American Health Information Community

Chronic Care Workgroup #17

Tuesday, July 17, 2007

**Disclaimer**

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

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

Welcome, everybody to the 17th meeting of the Chronic Care Workgroup and
just a reminder that we\'re operating under the auspices of the Federal
Advisory Committee Act. The meeting is open to the public and there will
be an opportunity at the conclusion of the meeting for the public to
make comments. A remind to the Workgroup members to please speak clearly
and distinctly and identify yourselves as you begin to speak. And when
you\'re not speaking, those of you on the telephone, please remember to
mute your telephone. And let\'s begin with introducing the members of
the Workgroup who are present on the call. Jennifer, if could you do
that and then we\'ll go around the room.

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

Sure. On the phone today we have Craig Barrett and Colin Evans from
Intel. Paul Nichol from the VA is sitting in for Madhulika Agarwal.
Shannon Metzler in for Herb Kuhn for CMS. Joe Gifford is in for Mohan
Nair from The Regence Group. Anand Parekh from the Office of Public
Health and Science. Jeff Rideout from Cisco. And did I miss anybody on
the phone? Okay, that\'s it.

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

And here in the room we have \--

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

Justine Handelman with Blue Cross Blue Shield Association.

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

Sandeep Wadhwa, Disease Management Association and McKesson.

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

Hi. Jay Sanders.

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

Yael Harris, Office of the National Coordinator.

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

Karen Bell.

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

Tony Trenkle.

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

Okay, I think with that we\'ll turn it over to Karen.

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

To me?

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

To the co-chairs.

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

Okay. That\'s better.

\[laughter\]

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

Craig, do you have any remarks you want to make today?

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

Craig, do we still have you?

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

I\'m sorry, I was on mute for a minute. I was following instructions and
started to talk. The only comments I want to make are we made our
recommendations in to the full AHIC at the last meeting, our
recommendations were received, and Tony, is it appropriate to say they
were received with some discussion?

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

Yeah, I think that\'s appropriate.

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

But no rejection.

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

Right.

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

So I think our charter is still to continue to aggressively pursue the
areas that we\'re focusing on and this is everything from an aggressive
lobbying for a kind of a use case associated with communication for
chronic illnesses, as well as pushing on the other programs which were
associated with our recommendations to the full AHIC. Tony, your time.

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

I don\'t have any additional comments to make, Craig. I guess we should
next move to take a look at the minutes. Karen, do you want to go over
the action items? There\'s a few staff action items from the last
meeting if you can give us a status on them.

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

Thank you, I\'d be delighted to. I would, however, also like to make a
few clarifications on the minutes, if I might. On Page 2, I did go back
and check the regular minutes, and I basically asked various members for
their comments and their thoughts rather than suggest them. So I would
just like the last paragraph to read that Dr. Bell asked if the
co-chairs wished to comment on the need for, et cetera, et cetera.

And then a little bit further on, there\'s a reference on Page 5 to Dr.
Hunsberger who was kind enough to come and give us some guidance on some
of the legal issues with respect to the coverage. And I think it isn\'t
that Dr. Hunsberger was reluctant to give an opinion. I think it was
more that she was not prepared at this point given her background to
give an opinion on the breadth of the Secretary\'s authority. So I would
just suggest that we change that to Dr. Hunsberger could not at this
time give an opinion as to the breadth of the Secretary\'s authority, et
cetera, et cetera.

Are there any other comments or changes or corrections that anyone else
would like to make before I dive into the action items?

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

No.

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

Okay. Item number 1, we have an up-to-date Workgroup roster, we have
just put it together. And so it will be on the Web very shortly, and
will be distributed to every single one of you. And along with that, I
would like to take the opportunity to introduce the three remaining new
members of the group that we\'ve just signed on in the last short period
of time. One of them is here in the room with us. Sandeep Wadhwa from
McKesson Health Solutions. Would you comment a little bit on your
interest and background and your contribution to the Workgroup?

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

Sure, thank you. My name is Sandeep Wadhwa. I oversee care management
and disease management services for McKesson, and in particular have
been very focused on deploying disease management and care management to
Medicare and Medicaid populations and other vulnerable populations for
the elderly and the disabled. And have, prior to McKesson had done some
work with the Office of Policy Development at the White House and the
Congressional Office of Technology Assessment and so I\'m delighted to
bring to bear some experiences that we\'ve gained implementing different
chronic care solutions for commercially insured as well as fee for
service government populations. Thank you.

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

And we\'re delighted you\'re joining us as well. I think all of you will
remember that Sandeep gave a very informative and helpful presentation
some time ago, and it's great that he can join us. Second on the list is
and new to us is Joe Ternullo from Partners HealthCare, who is here
representing not Partners but Continua Health Alliance. I'm just
wondering, are you on the call, Joe, have you been able to join us?

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

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

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

Certainly can. And would love it if you could talk a little bit about
your background and interest as well.

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

Terrific, thank you. First of all, I want to thank you and everyone else
on the committee. I am really grateful to be a part of it, and I look
forward to helping out any way that I can. So let me start by saying
that I\'ve been with Partners HealthCare for 11 years and I\'m the
associate director of what is now called Partners Center for Connected
Health, was formerly called Partners Telemedicine. And in that role my
\-- over the 11 years my role has changed. At one time I was involved
with sort of day-to-day operations when Partners Home Care was formed
was very involved with working with them to help move them forward in
the area of technology. Now spend a lot of my time on Continua Health
Alliance and for an annual symposium that we have at Partners, I\'m very
involved with the American Telemedicine Association and its policy
committee and business and finance SIG as well. Just to round out a
couple other things I\'ll mention to the extent it might be relevant or
useful, I\'m a member of the Mass General IRB, and I also do a fair
amount of international work at Partners so, as an example, I\'m here in
California this week on business, next week I\'m going to Libya with the
U.S. State Department, we have Tripoli Medical Center is interested in
starting a connected health center and so I\'m fortunate enough to be
going over there to see if I can help with that. So a lot of interesting
things, I think there are some areas I can contribute, and I\'m looking
forward to working with all of you. Thank you very much.

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

Thank you, Joe. Welcome aboard.

And lastly, our last new member is Patrick O\'Connor from the American
Diabetes Association and I don\'t know if he\'s been able to join us or
not. Are you there, Patrick? I think not. He\'ll be able to join us
hopefully at the next meeting or if he comes on a little later in the
call we\'ll do a more formal introduction with Patrick also, but he\'s
clearly here representing the population of patients who have chronic
illness, with diabetes certainly being number one in many folks\' minds
and certainly one of the more prevalent ones that we deal with.

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

This is Joe Ternullo, I just want to say one other thing. Because I just
joined recently, the Workgroup, I didn\'t have it previously in my
schedule and I\'m going to have to drop off earlier today because I\'m
speaking at a conference in less than two hours. But going forward,
I\'ve put it in my schedule and I\'ll devote the full time to this.
Thank you.

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

Thank you. All right, well, I think that fleshes out our roster and
again we\'ll have it updated and on the Web within the next few days.

Item number two, draft recommendations emphasizing the importance of
making the secure messaging use case a priority for submission at the
June AHIC meeting. That recommendation did go forward. And you\'ll be
pleased to hear that there\'s going to be some discussion this afternoon
starting at around 3:00 of the use cases that we\'re contemplating
moving forward with.

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

Secure messaging and remote monitoring.

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

And remote monitoring. That\'s correct, thank you.

The next item was again to draft recommendations and those were, as you
know, drafted, agreed upon by the Workgroup, and were presented to the
AHIC as Craig indicated. And that actually took care of items 4 and 5 as
well.

So we\'re now here, needing to go over a few things. Number one,
thinking through what else we need to do on the previous work, moving
forward with some of the recommendations that we\'ve already been, that
have already been made. And number two, going into the area of care
coordination and how can we better focus on the population of patients
with chronic care. And we\'ll have quite a bit of discussion on that at
the end of the meeting. Dr. Yael Harris will be leading that, and our
thought was that we would begin to look at various models for addressing
the population of patients who have chronic care and really
understanding the different approaches that can be used and what are the
enablers and barriers to those approaches. And I also know there was a
very interesting meeting this morning that you, Craig, have been very,
were very engaged in setting up and it would be helpful to hear your
comments on this morning's meeting as well.

But before we do that, there is one other thing I would like to just
share with everyone. And that is the fact that there\'s been a
tremendous amount of angst and discussion and questions about the AHIC
successor, the organization that ultimately will come into being to
replace the current American Health Information Community. I think
everyone is aware of the fact that the AHIC\'s charter was
self-limiting. It was due to sunset in a specific period of time and
that the concept is that it would move into another space. As it goes,
as the public-private partnership moves in this direction, I think a lot
of Workgroup members who put so much time and energy and devotion and
passion into some very good work and wondering, well, what is the fate
of the Workgroups as we go forward? Everyone recognizes the importance
of the Workgroups, they really are the heart and soul of what moves
forward through the AHIC.

The agenda for this Workgroup from now and as moving forward is in the
foreseeable future is to continue to focus, to do exactly what you\'ve
been doing now, full steam ahead. There are issues that need to be
resolved, recommendations that need to be made. We will move forward
with those recommendations and move forward with that work. So as we
move into this new space about looking a little bit more specifically
around managing chronic illness, please bear in mind that this is work
that, again, is full steam ahead and we\'re anticipating some very
important recommendations coming forward from it as you all have made
very important recommendations in some of the other areas as well.

So I think at this point, before we get into any further discussion on
clinical decision support or any of the other items on the agenda, I\'m
wondering, Craig, if you could use this, if we could use this
opportunity for you to update us a little on the meeting that you held
this morning?

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

Before we do, we should move to accept the minutes.

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

So moved.

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

Second.

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

Thank you, Tony.

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

Go ahead, Craig.

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

The meeting this morning was really a series of panel discussions on the
topic of chronic care and aging. Really focused on the very simple
premise that the bulk of the spending in the healthcare industry is
really on the chronically ill or aged, and the 80/20 rule, 80 percent of
the cost absorbed by less than 20 percent of the people, and what can be
done about it, and frankly, the three panel sessions were almost a
rehash of what we\'ve been discussing in the Chronic Care subgroup for
the last year or two, from the standpoint of you need to move away from
disease management or isolated treatment to more of a holistic care
process. There was quite a bit of discussion that if you want to move in
that direction, what you need to do is move the compensation system in
that direction so you need to reimburse for the type of care that you
want to provide to chronically ill and not just a simple patient-doctor
office visit. It extended beyond just the doctor-patient interaction to
the influence of caregivers and how you integrate caregivers into the
patient-caregiver-clinician format, much as we\'ve talked about. It also
included, what\'s going on in the realm of I would call nursing home or
assisted living situations. But everyone came up with pretty much the
same sort of suggestions we\'ve heard presented to this group. And there
was a very strong emphasis as we have talked about as well that if you
want change to occur, you have to use purchasing power to make the
system change because the system is not going to change on its own.
Tony, you were in the audience at least for part of it. You may have a
different perspective. I didn\'t sense any new great revelations, I just
sensed a, really a seconding of the sort of discussions that we\'ve had
and the sort of suggestions we have put forward to try to move the
system to provide higher quality care for this class of people that need
intense care and whose intense care is a mixture of doctor care,
hospital care, nurse care, caregiver care, et cetera.

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

Yeah, I thought it pretty much echoed the themes that we had. I think
the theme that Jay has continued to make about the need for care before
a condition becomes chronic, the issues about coordination of care,
changing the payments, the issue about the use of technology and how
that can help, I think all these were similar themes to what we talked
about in many of our meetings.

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

Craig, this is Karen. Could I just ask one question? Did this group this
morning have some awareness of the types of recommendations that this
Workgroup has made, and did they have any comments about any of them, or
did you not get into that level of detail?

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

There was not a lot of that detail, Karen. I sense that they\'re aware
that AHIC is meeting and that we're focusing on the integration of
technology into the healthcare environment. By the way, essentially
every participant said exactly the same thing, which is information is
key, sharing of information is key, access to information is key. So the
whole issue of EMRs, PHRs, interoperability, is key for effective
healthcare. So they were just going down the AHIC bible almost chapter
and verse in that direction. They did all point out respectively their
limitations, a couple of people were forthright and honest enough to
suggest that golly I am conflicted a little bit by if I make this
investment, does this mean more revenue or less revenue, more profit or
less profit for me, what\'s the driving force to make me change? And the
medics context the discussion often came up that the reimbursement
scheme is terribly important to effect change, reimbursement from CMS,
reimbursement from the insurers, and purchasing power of ultimately the
people that are paying the bill are important to effect change here.

You almost walked away from the meeting with a feeling that everybody
wanted to do the right thing, wanted to move in the same direction, but
they were having a difficult time justifying that because that direction
didn\'t necessarily mean that they were going to be compensated moving
in that direction. So they were a little bit conflicted in terms of why
should I move if in fact my revenue is going to go down or the payment
schedule is going to change slightly. I think what they were all almost
hoping for was someone would come in with a strong hand and say this is
how we\'re going to change the reimbursement scheme. Now go get yourself
organized to accommodate that.

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

Right. Yeah, I think the other thing that you pointed out, Craig, about
the business community being AWOL and the efforts that Intel and others
have been making to get them to the table, the issue of how do we get
the patient more, I guess energized if nothing else, in terms of taking
charge of their own care. I think those were two other themes that came
out pretty well on that, that even if people have knowledge, they\'re
still not doing the things they need to do to take care of themselves.
I\'m sure Jay would have some comments on that.

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

I really do think that\'s an important is point. It\'s not just that CMS
needs to change its payment scheme or that the employers need to demand
change, but you need to get the third party, and that\'s the individual,
involved by having some skin in the game and some accountability for
their own actions. But all three of those things need to happen roughly
in parallel if you\'re really going to effect change in the system.

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

Yeah, Craig, that\'s why I\'ve always said we need a second pay for
performance methodology and that\'s pay for performance for the patient,
not simply for the provider.

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

Right. Right.

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

And you know, hopefully at least from the private sector side we can try
to do something in that direction by in fact providing a variety of
insurance schemes whereby you draw the individual in and make them more
accountable for some of their payments depending on their lifestyle,
their actions, et cetera.

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

And this is Jay. I think you actually have a framework for that, with
respect to the defined contribution plans, the medical defined
contribution plans, that industry has been developing. They just need to
be reshaped a little bit.

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

Craig, this is Jeff Rideout from Cisco. Was there any discussion of some
of the recent literature that puts a bit of a chilling effect on some of
the success of health IT, like the study that came out in the Archives
recently about the use of quality indicators with and without an EMR?
There\'s just been a few articles that have come through recently that I
think create some pause and I\'m wondering whether the committee really
is aware of those or how they play out in the thinking.

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

Well, I didn\'t sense any of that, Jeff. I sensed just about everybody
taking the same position which is if you\'re going to look at the
chronically ill medical records are terribly important, and access to
those records are important and continuity of those records are
important. And people were talking about the difficulty of treating
people without the detailed prior knowledge, and then combining that
with the whole concept of real-time acquisition of characteristics or
diagnostic data and putting that into the system for a real-time
doctor-clinician-type of \-- or clinician-patient-type of interaction.
But no one adopted the Nicholas Carr model of does IT really matter.
They were, I think, 100 percent in line with the basic technology is
there, the health community is not taking full advantage of it.

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

Okay, thank you.

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

Yeah, Jeff, this is Jay. I read that article and it didn\'t surprise me
at all because some of the things that we have been talking about
reflect an incredible amount of naiveté that exists out there, that if
we introduce the electronic medical record everything is going to change
and become good. The fundamental reality is if the information put into
the electronic medical record is outdated and wrong, it\'s still going
to be bad care except you\'re going to transmit that bad care
information a lot more efficiently with an electronic medical record
than a paper-based record.

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

I totally agree and I think there\'s some challenges with trying to find
a positive finding in what was probably going to end up being a negative
study no matter how it was constructed. I worry from a public perception
point of view that kind of nuance is a little bit hard to sell.

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

Absolutely.

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

Jeff, the parallel to that was clearly through the 1990s when everybody
kept saying that we\'ve spent all this money in IT and computers and
systems and interfaces and networks, and nothing has happened to the
productivity of the average worker. And then some day somebody woke up
and said oh, my goodness, the only reason the U.S. worker is still
amongst the most productive in the world is all the IT backbone they
have at their disposal. So we went through a decade of that. I suspect
there\'s going to be the same aura of denial in this area as well.

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

It\'s clearly not for the faint of heart and I think we\'re on the front
end of that, not the back end.

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

True.

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

This is Karen Bell. I would just add some information that\'s been
shared with the EHR Workgroup around these sorts of issues as well. And
the bottom line is an EHR is not an EHR is not an EHR. There is no
standard definition of an EHR. And it really does come down to what
functions are being used by clinicians. And that\'s why there\'s been
this general sense that 25 percent of physicians have EHRs. The reality
is only 10 percent of physicians are using four basic functions. Only 10
percent of physicians are using an EHR for progress notes, to order lab
results, to receive lab results, and to order meds. If you look at the
percent that are using any type of clinical support, and I do mean any
type, it\'s down below five percent. So I think that we just need to be
very careful when we read these kinds of articles, because in the end
they don\'t really tell us \-- they don\'t really get to that level of
specificity in terms of what works and what doesn\'t.

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

AHRQ pretty much said that, I talked to Jon White of AHRQ because they
sponsored the study. He agreed with that, he felt some of it was
misleading when it was \-- the way it was reported.

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

Karen and Tony, the other thing I\'d point out, thought, is our
inability to get CCHIT to review non-EMR type applications for
certification, especially around secure messaging and remote patient
monitoring means that we\'re riding that EMR tail or that dog pretty
much and that will have effect on success of non-EMR types of HIT as
well. So I\'m wondering how we can make sure those 2008 use cases really
do focus clearly on HIT in general, not on extensions of EMR or CPOE or
other things that are much more challenging in terms of implementation
and use.

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

Absolutely. That's a very good point.

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

Yeah, I think that\'s a good point, Jeff, I think that these use cases
are key. And I guess we\'re going to be talking about them a little
later this afternoon, right, Karen?

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

We will be.

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

Karen?

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

Yes?

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

I have a very serious question.

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

Uh-oh.

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

What room are you guys in?

\[laughter\]

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

We are on the fourth floor, what is it? 4090. And if you tell us where
you are, we\'ll come find you.

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

No, no. I\'m not there. I keep typing 4090 into my participant log-on
interface and I keep getting the room number you entered does not match
a record in our database for this event.

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

Are you looking for the Web \--

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

This is Jennifer. That room number is going to be 8285122.

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

Wait a minute. 82 \--

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

85 \--

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

122?

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

8285122\.

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

Thank you. I didn\'t know you had an 828th floor.

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

I wish we did, we\'d have a fabulous view. Thank you so much, I
appreciate everyone\'s input in sharing what happened this morning. I
know it was an important meeting. Should I go into the clinical decision
support system discussion?

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

Why don't we go ahead and move ahead, Karen.

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

Okay. This is not really a presentation, you won\'t see a slide deck but
there will be two questions for some of you to be able to see up on the
board at least here in the room, because in 2005 and 2006, ONC, in
partnership with AHRQ, the Agency for Healthcare Research and Quality,
as you know, sponsored the development of a clinical decision support
road map. The American Medical Informatics Association, AMIA, had
convened a group of experts in this area to essentially provide us with
a list of recommendations and a framework on how we could organize
efforts in the area of clinical decision support moving forward. The CDS
road map which is on their Website, as well as on ours, was presented to
the AHIC last summer and actually generated a tremendous amount of
discussion for those in the room who were there, who were present,
because there\'s such a close link between really good clinical decision
support and quality of care. And again, just to get back to the EHR
discussion, I\'m sure that the EHRs involved did not have any of the CDS
in it.

So as we move forward, we thought it would be important to pull together
another little bit of Workgroup, another Workgroup that, internally
here, and get input from all of the various AHIC Workgroups that may
have some interest in clinical decision support. So at this particular
point in time, Jon Glaser, who is the co-chair of the Personal
Healthcare Workgroup, is chairing a small group of co-chairs and folks
within our own office to really move forward and plan how we might
actually make the next steps with respect to clinical decision support.
So the bottom line is that I\'d like to spend a little time today just
hearing from all of you in answer to two questions. But before we get to
the two questions, I just wanted to underline those three areas on the
road map that are really critical for future use. One is access to the
best knowledge available and that doesn\'t mean just the data. It means
pulling a lot of data together and so that it\'s usable and can truly
present usable good information to clinicians or patients who will then
know what to do with it.

The second, and this is in the area of translation obviously, is to get
that knowledge and to be presented in such a way that it\'s widely
adopted and used. We all know that, in truth, reminders that pop up time
and time again in front of a physician get turned off. We also know that
there\'s clinical decision support systems out there that can provide a
phenomenal amount of information that's very, very helpful on all levels
of patient care and I think we actually saw a little bit of that when
Blackford Middleton presented, there was a very strong clinical decision
support system, but one of many.

So there\'s a big difference between those two approaches. And then
lastly, we need to continually improve our knowledge as more and more
information becomes available electronically, how can we use that to
feed our knowledge base so that we\'re consistently improving our
ability to provide ever-better clinical decision support, both from the
knowledge base and the user\'s point of view?

So given that, we\'re asking the various Workgroups to comment on two
questions. The first, for those of you who can\'t see it, is this. If
pilot projects were being funded to demonstrate the value of clinical
decision support, what kinds of things should be funded, i.e, on what
should these types of projects focus? So I\'m just going to just let
that settle for a little bit, and have \-- ask to you comment and think
through that and see what you would offer.

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

Karen, let me just ask you a question. With the CPOE efforts that have
clinical support built in that, are we including that in this, so that
the physician order entry \--

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

We can include anything. We can include that, we can include areas where
clinical decision support could be useful for patients, where it could
be useful for long-term caregivers. I mean, there are a lot of different
options here. So I\'m asking you to really think not only in terms of
what we now know about CDS, but also what it could be in multiple
settings.

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

In the could be realm, a question that I have relates to physician work
flow. Let\'s assume in the ideal world that in fact the technology that
we\'ve all been talking about to assess, evaluate patients in their
home, at their work site, all become real and used and there will be a
massive amount of data that will be emanating from the various types of
technologies in terms of real-time assessment of patients. More data
than any single physician provider could ever possibly look at even with
a very small, defined patient population. I view the clinical decision
support almost in a upfront, an upfront technology that is assessing and
evaluating all of the information coming in from various sensors, and
making a determination as to whether this is something that should be
viewed or is data that doesn\'t need to be looked at. Are we viewing it
from that standpoint as well?

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

We certainly can, absolutely.

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

Okay.

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

That's a very good point.

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

Hi. Joe Gifford. So decision support, CPOE, is part of a heavyweight
story for big systems that are installed in hospitals in their systems.
In the spirit of this Workgroup, we might want to look at more sort of
lightweight, widely deployable systems to be used within provider
networks that care for chronically ill folks. And I think that niche is
currently best served by private vendors, such as ActiveHealth or
Revolution Health, who, you know, their decision support is at the level
of kind of the low-hanging fruit. Which is, you know, you have diabetics
and which of those need retinal exams because we won\'t see any evidence
that there has been one, or you have asthmatics and we don\'t see
they\'re on a controller drug. That\'s a limited data \-- that\'s a
limited set but it\'s deployable today so I would vote something in that
realm that\'s deployable to a broad range of physicians in some pilot
project that would, some existing pilot project or coupled with a pilot
project that actually cares for groups of chronically ill folks by a
physician group.

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

Joe, could I just ask to you clarify a little bit? I\'m very familiar
with Revolution Health and ActiveHealth and they are geared toward
physicians for the most part. Do you have experience or do you know of
programs that are geared toward patients? Besides the VA, because we'll
hear from them later today.

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

Well, certainly, I guess the short answer is that it\'s not as
well-developed. But, for example, ActiveHealth and Revolution Health
both do have messaging to patients kind of in tandem with messaging to
docs, so if the first message goes to the doc, the diabetic needs a
retinal exam, then the second message like three weeks later or a month
later says, the message is to patients, we still haven\'t heard from
you, and copy the doc, but you need a retinal exam. And so those guys do
have that in their workflow.

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

Karen, this is Jeff Rideout from Cisco, picking up on that comment. I
used Revolution Health five years ago to providers, but they were also
doing pilot \-- and we did some formal RCT work around the effectiveness
and there was some that we could show. I know Verizon did a pilot on a
member-direct version with Revolution Health and I know ActiveHealth has
been doing that as well. So I would agree with the general comment.
Their is a lot that's already being done with some of the more simpler
things with decision support and there's actually been a fair amount of
work, study work, done on it as well.

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

This is Eric Larson from Group Health. And we have a number of decision
support around specific chronic diseases that are in the field or in
development, and I think the main issue is, you know, one, how effective
is it, and I think it will be proved to be very effective, both for the
traditional value of decision support, which is safety, but also for
effectiveness and efficiency. And I think that the main issue that
we\'re \-- I don\'t know if struggling with is the right word \-- but
the adoption by patients, you know, to sign on to our secure Website,
which is MyGroupHealth, is growing but it\'s not \-- it hasn\'t occurred
sort of in one giant step. But the group that is most likely to sign up,
to everybody\'s surprise, are those people with chronic disease. So I do
think that clinical decision support systems aimed at chronic disease
especially, not just reminders for prevention and so forth, has great
potential.

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

Thank you.

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

And Karen, to build on that comment and say that telenursing has really
embraced CDS as the modality of combining technology in CDS with the
teaching abilities of a nurse and the listening and empathy skills. I
think there\'s a lot of existing evaluations of those systems that for
the most part tend to be sponsored by payers directly to patients,
deploying CDS and most often telenursing systems to demonstrate value.
And I guess my question on this, can you just clarify, were these
projects to be evaluations of CDS projects that are out there, or are
these projects to fund a new CDS initiative?

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

The concept here, can be virtually anything you like. But the idea here
is if we\'re going to be \-- or anyone within our, AHRQ, ASPE, others,
were going to be funding projects, what should we be looking at to
demonstrate value of CDS? Recognizing, again, that CDS is a very broad
area and encompasses many things. So if you could tell us what to do,
what would you tell us? Because you\'re the FACA.

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

Karen, you know, there are two individuals if I had to go to to get the
best information on this, and people who have implemented these kind of
systems today, I would suggest, number one, it would be great if we
could talk to Dan Masys \-- M-A-S-Y-S \-- chairs the Department of
Medical Informatics at Vanderbilt, previously from San Diego. And the
other is Dr. George Hripcsak \-- that's actually spelled with an H, H-R
\-- who has been doing a lot of medical decision support and AI work at
Columbia Presbyterian in their Department of Medical Informatics under
Ted Shortliffe. From my standpoint, they\'re the leading figures in this
area. And I would like to offer, since I\'m going to raise my hand in
terms of a project that I would like to see and it may not be viewed in
the traditional way, and that is, I think the primary weakness has to do
with the history being taken by the care provider, that the history
being taken from the patient is not comprehensive and is not complete.
And therefore I would like to see the clinical decision support, one of
the demonstration projects focusing in on the whole area of the history.

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

That\'s a good one. On the list. Anybody else have any, if you could
wave your magic wand and tell us to do something? Anyone else have any
thoughts or ideas on clinical decision support? Justine?

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

Justine Handelman, Blue Cross, just building off of what Joe said
earlier, I think it\'s important to look at what are the chronic
diseases or conditions that drive the majority of costs and we know
it\'s \-- I believe it's congestive heart failure, diabetes, and asthma
are at the top of the list and do we focus in on some of those best
clinical practices of care in terms of diabetics, as Joe mentioned, a
retinal exam; if it\'s congestive heart failure, is it monitoring of
cholesterol and drug adherence; and I\'m not a physician, but you look
at asthma and again the protocols, drug maintenance and can you have
those tools that alert the doctor and the patient and you know, keep on
top of it and measure the quality of improvement if those adherences are
made to. I think it\'s important to focus in where we have to make a big
impact, especially on high cost and problematic diseases.

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

And given the fact that Adam Darkins just came in had the room, that\'s
exactly what the VA did about eight years ago, and just changed the
entire outcome for their patients.

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

This is Paul Nichol, that\'s the point I was going to make, thank you.
And we have a fairly large number of performance measures that we
monitor, you know, at various levels of organization, how a network is
doing, how a facility is doing, how individual providers are doing on
the performance measures. And for most of those there are clinical
reminders that help to promote adherence. I wanted to pick up on a
comment that was made that the VA is also at this point looking at
rephrasing our clinical reminders that we give providers so that we can
provide them to patients to make sure that they\'re aware of the
interventions that are appropriate for them and that they can
participate in the process of being sure that they get done.

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

This is a quick aside, Paul. Do you know if anyone is looking, within
the Federal Government at the relative effectiveness of CDS being
directed towards clinicians versus towards consumers or patients?

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

That\'s a great question and would be obviously a good research project.
We don\'t have the patient reminders in place yet, so that\'s one thing
we would like to explore, though.

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

Okay, thank you.

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

Karen, there may be another group within the civilian sector. The chief
medical officer for HCA, was former VA, Jonathan Perlin?

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

Yeah.

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

And Jonathan is introducing to the HCA group of hospitals what he helped
architect within the VA system.

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

Well, thank you all very much. Adam Darkins did join us but there\'s one
other question that I would like to throw out to everyone who may not
have seen it. And that is if each Workgroup or each one of you could get
one or more outcomes on a wish list of targets that CDS might affect,
what would those outcomes be, what would those targets be? So if you
think about clinical decision support and all the wonderful things it
can do, what is the outcome, what is the most important outcome you
would foresee?

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

Karen?

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

Yes.

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

This is Craig. Just to be relatively consistent, does it make sense to
analyze what our wish list looks like for CDS in line of our already
existent wish list? I mean, I think we should be looking for tools that
support the direction we\'re already moving in as opposed to kind of
opening up new frontiers.

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

I agree.

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

I would second that, Craig.

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

Craig, that\'s why I mentioned earlier we need to look at CDS from the
standpoint of beginning to, almost in an autonomous fashion, analyzing
the data that will be coming in from some of the disease management
sensors that we would like deployed.

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

And I\'m all for that and I just wanted to make sure that we don\'t
engage in one of the weaknesses of groupthink, which is every time a new
idea pops up, we go off in a new direction. I think we\'ve had some
really good deliberation on directions and priorities we\'ve set. We're
bringing a new tool into play, let\'s use that new tool to support the
directions we\'re already moving in.

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

Right.

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

This is Joe Gifford. In that spirit, Karen, I think my answer to your
question would be, the measurable outcome would be, do patients with
chronic, the typical chronic illnesses get evidence-based,
guideline-supported, consensus guideline care. Do they get the care
that's supported by guidelines? I don\'t think you could get to outcomes
very well. You could try. But I think, you know, reasonable low-hanging
fruit would just be on the usual measures, are they getting the
consensus guideline care.

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

Okay.

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

Karen, this is Anand. I think, I agree that probably process would be
easier to get to, but if we could get to outcome, I think that the one
that I would choose would be preventable hospitalization. Ultimately,
particularly for chronic disease and exacerbation of chronic disease,
what we\'re trying to avoid, from a quality perspective as well as a
cost perspective, are hospitalizations and if this is some way we could
go from process to outcome, I think preventable hospitalizations would
be something to target.

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

And I would \-- I\'d echo that comment as well, whether that's
hospitalizations or bed data, I think that\'s actually a nice marker of
utilization of resources but also morbidity. That reductions in
hospitalizations track, to me, the burden of suffering for this
population. So I really like that idea.

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

This is Jeff from Cisco. Karen, kind of go back to Craig\'s comment,
though, I think in the spirit of the Workgroup you\'d probably want to
shoot for how does the use of clinical decision support with and without
the remote patient monitoring or the secure messaging help or hurt
against those outcomes that are of greatest interest? You've almost got
three arms. You've got no remote patient monitoring or secure messaging,
you\'ve got remote patient monitoring, secure messaging with and without
clinical decision support, and which one offers the best for the patient
and I think we all have an assumption of what that would be, but I
agree, if we get a whole other area going especially one where there\'s
been a huge amount of both anecdotal and qualitative and quantitative
work done, we\'re going to spend a lot of time discussing that as well.

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

This has been very, very helpful. Thank you very much. All of us, we\'ll
get back fed to the folks whoare focusing on CDS, and we\'ll bring you
updates as we go along. Thanks again.

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

Our next presenter will be Adam Darkins from the Department of Veterans
Affairs. He's going to discuss evaluating the benefit of telehealth, and
I know the VA has been very successful in that area, so we welcome you
today and look forward to your remarks.

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

Well, thank you very much. Good afternoon, everyone. Please feel free to
interrupt if there\'s any clarification you want. I apologize there are
no slides. When I got the invitation, which I\'m delighted to come and
do, I was just about to get on a plane to go to the U.K. to give a paper
at a policy meeting at the NHS over the weekend. I just got off the
plane this afternoon, so I apologize I didn't get slides to you.

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

You picked up their accent very quickly.

\[laughter\]

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

You\'ll see as the meeting goes on, I\'ll pick up yours, Jay.

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

Don\'t you dare.

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

So, I mean, let me give you a bit of context. The VA has really
introduced telehealth for very good reasons, given the population base
it has, and so what I'll try to do is I\'ll cover thee areas very
quickly with evaluations that go with it on what we\'re doing and why
we've done it. Given the context of chronic care, let me talk about
monitoring of patients in the home. The VA has a population which is
aging, it\'s population is changing, it\'s numbers of aged over 85 will
go up from 680,000 to 1.4 million between 2000 and 2014. So that\'s a
very dramatic rise in that population, and with it comes a tremendous
need to provide services in terms of institutional and non-institutional
care. The requirements are between now and 2011, the VA is going to have
to find some 60,000 non-institutional care places. And 50,000 of those,
so out of a total number of about 105,000, 50,000 will be provided by
technology support using home to health technologies.

The context of that was, let me give you, was a pilot that began in 2000
and lasted until 2003 that was based in Florida. That presumed that if
you monitored people with chronic disease, namely heart failure, you'll
be aware, diabetes, the standard diseases, that if you monitor them
proactively at home, so monitor them with a view to picking up when they
got into trouble. So very simply, the person with heart failure, if you
detected their increase in weight, their symptoms and the reactive
changes, blood pressure, you could intervene early and prevent them
coming to hospital and ending up having a prolonged admission if they
survived. So the basis of what was done was to use simple technologies,
using telephone lines, to be able to monitor vital signs in \-- by way
of pulse, weight, temperature, blood pressure, blood glucose, being the
main ones. And also to ask very simple questions via some disease
management questions each day.

On the basis of that, be able to prioritize for a panel of patients, for
a care coordinator, who amongst that panel was getting into trouble and
getting into difficulty, and have that prioritization done on an
information system such that it was presented routinely and it means
that an outpatient appointment, a telephone call, or hospital admission
could take place.

The intervention was the technology plus the care coordinator. And the
evaluation that took place showed that in that population of patients
who were ones who had gone into non-institutional care, chosen on the
basis of utilization, disease specific measures, and cost, one could
reduce bed days of care and reduce hospital admissions, ER visits, and
affect \[inaudible\]. So in a group of 800 patients who were in that
study that took place as a pilot program, the findings were, more or
less across the board in those things, a 30 percent reduction in
utilization. With the exception of the outpatient clinic appointments.
There was an initial rise sometimes, of about 15 percent over 16 months,
but then came back towards normal, towards the baseline. The reasons for
that were A, it was reassurance on the part of the providers in terms of
managing, so they would see the patients; secondly, by coordinating the
care effectively, one was actually finding reasons why they should be
going into outpatient visits. So that made sense.

On the basis of this, between July 2003 and now, a national program was
instituted in each one of the 21 VISNs of the VA, done in a systemic way
in terms of the clinical process, the technology infrastructure to
support the patient, and the business processes. So it\'s possible for
us to be able to code this activity within our information systems. It
was rolled out and rolled out from about 1,200 patients in July of 2003,
to last week, as of Monday, it was 26,863 patients. I know it\'s 26, 863
because the data that we get is fed directly, by HL7 messaging, from the
devices, so it means that we actually know, week on week, when that is
updated, how many we\'ve got.

The evaluations that are being done at a local level have been ones that
are really substantiated. 21 VISNs, local VISNs, have done analyses to
check whether or not those same findings take place, and by and large
the answer is yes.

What would be nice to have, and we will be publishing, I hope within
about three or four months, the results of the national data. All I can
say is it largely substantiates that local data but we\'re in the final
stages of validation processes for it, and writing it up. So I prefer
not to be able to have this quoted at large because what I\'d like to do
is not have people floating around saying well \-- not that I\'m
suggesting people are necessarily floating around, but not have it
really out at large, quoting a figure like that, without people being
able to see essentially what the derivation of it is. Because the data
we\'re looking at is really before and after data. So there are
questions about, that could be raised about deviations from the mean and
other things. But essentially what I\'d like to do is substantiate what
we put. Implementation of this is not including implementation of staff.
I know there have been some performance monitors that provisionally will
be performance measures to encourage its use. Its adoption widely has
been done on the basis of the cost savings which have been found locally
that are really taking it forward. So we want to substantiate that in a
written paper which then could be looked at in detail.

Adjunctive things which have been done, have been looking at patient
satisfaction, which has been in the high 90 percents, and also doing the
VR-12, which is variation of the SF-12, the whole status measure, has
shown that health status doesn\'t appreciably change. You might say
well, that\'s something it should do. Effectively we\'re changing
location of care but we wouldn\'t anticipate necessarily that we would
see a diminished \-- an improvement to health status. Here are patients
with chronic disease and what we\'re really trying to make sure is the
site of care, which is home rather than the hospital, is not resulting
in a reduction in health status in people that are serving.

The automated systems we have to be able to do outcomes should on a
sequential basis be able to, once the final validations are done,
provide routine ongoing data for the utilization, currently that
utilization data will be bed data, hospital admissions. We\'ve been
doing some work which is to unify some coding \-- this is coming from
routine data systems. Local care \-- coding variations in ER visits
means we\'re going to be about six months behind in doing ER visits on
an ongoing basis. Similar things around data reconciliation for
hemoglobin A1c means it will be about 6 months before we can take that
forward on a regular basis. So on the basis, really, of the fact this
has been implemented in a very systemic way, it\'s shown the findings it
has done. The VA is going to use this to provide 50 percent of
\[inaudible\] institutional care needs between now and 2011.

What I haven\'t mentioned in terms of evaluations and which I think is
important, that in terms of evaluations which are traditionally done,
these are evaluations with scientific evidence in relation to the
delivery of patient care. Most of the pilots that have been done with
this previously, which have shown similar findings, have been with
relatively low numbers of patients, so additionally to that I think
there are important things we need to be able to \[inaudible\] which is
the robustness of the systems in terms of how this is delivered. I mean,
given that, providing care for people who are going to be in homes \--
in home rather than coming as they would be doing. And so we have also
done in terms of implementing this, put in place what we call conditions
of participation, which are essentially the forerunner of what would be
a Joint Commission inspection. The Joint Commission doesn\'t do, for the
moment, do routine evaluations for telehealth. The way in which we\'ve
implemented it is a way which is modular. It can fit either as a service
line or fit into a service itself. And as such it can either be that it
ends up interfacing with community-based standards or hospital
standards. And the way in which we\'ve implemented covers to make sure
there are no issues in terms of the Joint Commission.

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

What are some technologies that you use in this, Adam?

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

Use really three, four main groups of technology. Cameras, which were
originally Polaroid cameras and now digital cameras, to be able to take
pictures of wounds in the home. Use simple video phones, mainly for
mental health, in terms of managing people at home. Use messaging and
monitoring devices, which routinely do vital sign data and what's
important to mention in VA, in terms of qualifying for vital sign data
for measurements and performance measures, it has to be (inaudible)
cannot be taken, cannot be patient self-entered. So it cannot be entered
data from the home. But also the small \-- the disease management
protocols which are administered and done by these messaging and
monitoring devices. And then the higher end of the technology is into
the home which can also do the vital sign measurements and monitor \--
(inaudible). The spectrum of technologies, somewhere in the 85 percent,
have been the messaging and monitoring devices, according to the needs
of the patient.

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

So in essence, the messaging component is really an informal clinical
decision support methodology because the questions that are being asked
are consistent with the questions you would ask a patient with
congestive failure or a patient with diabetes. If I\'m not mistaken,
there are four vendors, commercial vendors out there now for the
national \-- Adam, can I ask a question, the original Florida demo, that
30 percent reduction that was inclusive of re-hospitalization? So that
was a hospitalization reduction as well?

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

Yes.

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

It was.

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

And it didn\'t specify causes, so it was all causes, looking at all
causes before and all causes after.

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

And were you able to assess what happened to compliance on the part of
the patient with respect to this?

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

Which terms?

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

In terms of taking their medicine, doing what they were \--

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

This was a reduction. We haven\'t systematically looked at this,
nationally it would look different in terms of what it would be, so I
hesitate to \-- I think it\'s interesting to see what my evolve.
Findings will be mixed. One of the findings of one of the early pilots
was a reduction in medication prescriptions. That was intended to be to
looking at compliance. So I think it would be totally wrong, I mean,
Jay, to say this is going to result in a reduction. But I think looking
at why it might be, I think there are a couple of things. One of which I
think traditionally with this group of patients, if they arrive in a
clinic and they see a physician who has not seen them before, and their
charts aren\'t there, there\'s a tremendous tendency just to treat
whatever is the obvious thing to treat, which might be the neck pain. So
you get prescriptions. The other thing, I think, is somebody
coordinating the care, because this is essentially using the technology
to extend care and case management, means that there\'s a
rationalization of prescriptions, some of these groups are on multiple
medications and somebody looking through them, particularly somebody who
is regularly talking with the primary care physician is somebody who can
rationalize that prescription medication sheet. It\'s not been
substantiated across the board in different pilots, so what we want to
do is work with pharmacy benefits, if you will, and look systematically
across the board so we have outcomes agreed looking at national data.

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

I'm smiling at the fact that, as you indicated, you\'re dealing with
populations with multiple medications and it\'s been clearly shown in
study after study over the decades that the number of drug/drug
interactions, frequency of drug/drug interactions, relative to the
number of drugs, literally becomes asymptotic at five drugs, so once
you\'re at five drugs or above, the likelihood of you having some type
of drug/drug interaction is exceedingly high, so anything that reduces
the number of drugs is good.

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

Dr. Darkins, did the information flow to a care manager primarily and
then get routed to the treating provider or did the information go right
to the provider who then acted upon any exception reports?

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

No, there\'s a care coordinator who is generally speaking a nurse or
social worker, but we've got instances of care coordination being
psychologists, occupational therapists, \[inaudible\] has been the care
coordinator. Now, they manage a panel of somewhere in the region of 150
patients who are general medical or 90 patients if they are mental
health patients. The idea is this is somebody who coordinates the care
and this is somebody who picks up on, in a panel of patients, who is
getting into trouble. They make the primary contact, that primary
contact they either work to existing orders from a provider, the
provider is aware that they\'re on this monitoring technology and this
is taking place, or else they contact the provider to be able to arrange
what may be necessary treatment so it\'s really there to try and avoid
the provider being the route through all decision-making. There\'s a lot
of work that's gone on in terms of the IT support for this, in terms of
linking it into the VA\'s information system and trying to automate the
process of providing information through to the provider so it\'s really
the least burdensome as possible in terms of what that is.

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

Is that new staff, when you add in the 26,000, is that ratio involving
whatever 26 divided by the blended rate is, or are those existing
resources that are able to do this in a part-time basis?

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

What we did \-- well, the organizational piece of this is complicated,
but I won't sort of go into all the details, but what we did is given
the fact that we anticipated \-- the funding originally was provided by
funding for technology, not for the staff. The presumption being that if
this provides the benefits it did, what we would see is staffing would
be redeployed from existing staffing. Now, we have not got data so I
can\'t end up giving you data across the board. I mean, as I said,
we\'re in a situation where numbers of patients are rising very rapidly
in this category, so there\'s going to be a need to take on new staff at
the VA, the health organization has quite a turnover of staff. And so
how much is being redeployment, but no separate funding is being
provided for staff. We\'ve seen growth in terms of the level of
patients.

In terms of staffing, one of the things that we did was to establish a
training center, with the realization that it was going to be necessary
to have a competent work force to be able to do this. The training
center was established in January of 2004. As of now it has trained some
four and a half thousand staff. Those staff have been largely trained
using virtual training techniques, it's a set curriculum, there is
certification with University of South Florida for those who want to at
the end of the training course, and it takes on average about three and
a half weeks to train a care coordinator. So as you know, most start-up
companies get into trouble when they end up going into the exponential
growth phase \[inaudible\]. So given the short amount of time there's a
lot of \[inaudible\], but essentially the principle behind it is I think
very simple. The devil is in the detail, and the details around how you
get this very firm so that it escalates, so you have robust processes
and have technology which is robust, and you also have business
processes. So it doesn\'t all shake apart, it just gets bigger.

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

I have a question on the staffing. Do you think the VA, I mean it\'s a
unique system to begin with, being a closed system, is getting to the
training, I mean can be more difficult, I would imagine on the private
sector, and building into the workflow, is the VA more so in a position
to tell their staff or their members this is what you\'re going to do,
in these pilots or as we expand it, so it\'s easier to put in place and
do versus what might be in the private sector given that \--

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

Well, there\'s some degree of turnover, so lots of people coming into
the VA have been in the private sector. So we\'re training up people, I
can\'t give you the figures or numbers, but certainly when we have
meetings and people come up there are many people that come up and say
look, I just joined the VA a couple months ago from the private sector.
I don\'t think there\'s anything specific about the background in terms
of knowledge of the organization. In terms of the VA\'s ability to
require it, we just required for this program, this is where it\'s going
to be done. The technicalities of how you might require a provider to do
that, seems to be about scope of practice, about skills and
competencies, and in terms of doing this, I would feel whatever
organization one was in, there is a set of skills and competencies that
they require to do it. And I think as such we\'ve been working with the
\[inaudible\] society, working closely with nursing organizations
elsewhere, that \-- so I would be interested to know if you see that
being a barrier but I can\'t see in that context why it would be.

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

Adam, this is Karen Bell. You had mentioned that a great deal had gone
into linking this information into the VA's EHR system. Does that mean
that it was linked up early on and that the care coordinators have
access to the entire clinical record or is this something that's just
now happening?

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

I mean, stop me if I go \-- it\'s quite complicated in terms of doing
this. I ought to just say that this industry is an emerging industry and
there isn\'t standardization amongst the industry, so what it was
necessary to do was in order to know that we would have something robust
was to let national contracts for this. Those national contracts enabled
us to be able to put HL7 requirements for the vital signs, the transfer
of vital sign data. It also enabled us to think about a strategy, there
needs to be some standardization around the disease management
protocols, they are somewhat crude at the moment, and how they become
more sophisticated is important. I won\'t say other than there are
fairly dramatic technical challenges in terms of how you end up doing
this. What we\'ve essentially resulted \-- we have at this moment the
Jewel \[phonetic\] system that communicates. What that\'s been very
useful for is it means we\'ve got sort of a system which is part VA,
which is also part vendor-driven. It means we've got a Jewel Circuit
Breaks \[phonetic\], which is sort of a backup system which has been
useful, but the communicating across the issue about \-- there are
technical issues which I won\'t go into, there are also data issues such
as a blood glucose being a lab blood glucose as equivalent to a
home-derived from one. It's not, so what are the requirements around
doing that? Making sure the HL7 requirements and vital signs are well
understood. So we are in the process and hopefully will be able to do
some of those things to finally integrate the vital signs. Paul Nichol,
if he's on, he can certainly amplify that, not necessarily going into
detail about what I've said, but would verify that the devil here is
actually in the details.

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

I\'m here, Adam, and agree with you.

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

The reason I say, a, is not in any way to be a damper on it but just to
say this is not something where the \-- the idea is very easy. So the
idea of just doing, it I don\'t think you have to gripe, wouldn\'t it be
nice to be managed at home with technology and monitored. But actually
making this so it's safe, so it\'s robust, so it will deliver care, an
awful lot needs to be done and put in place. Also I was saying
publishing, one of the reasons to wait until now to publish was also to
publish on what will probably be 14,000 patients. Gives a substantial
publication number, whereas, if we end up publishing some 2 or 300
patients. And I suspect that the changes in clinical care that have
taken place will show through. Because you don\'t necessarily change
clinical care when you\'ve got 100 patients or you have this number of
patients. We substantially change the delivery of care to be able to
accomodate.

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

Adam, this is Jon Linkous. It sounds like, correct me if I\'m wrong, but
the cost savings we\'re seeing at this point, at least a substantial
part of them, is in reduced hospitalizations. In terms of home care,
monitoring. That cost savings would be in, at least in many hospitals,
many healthcare systems, a completely different department than the home
care department. And I\'m wondering if that has been an issue at all
within the Veterans\' Administration in terms of calculating the value
of providing telemedicine or telehealth systems where the investment is
in one area but the cost savings may be accrued in some other part of
the system.

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

The answer is I don\'t know. But let me just give you some thoughts on
it and if there\'s a health economist in the room or on the phone let
them by all means critique what I\'m about to say. It seems to me that
the VA is no different than the other healthcare organizations in
principle, or the health system large. Even though it\'s an integrated
system, it has very considerable investments in hospitals and clinics.
Now, that investment is inelastic in terms of changing. So the real
difficulty that comes up in terms of either, in these kinds of areas,
whether it\'s in this country or other countries, is how you disinvest,
in a sense, in hospital care and how you reinvest in home care or this
kind of enterprise.

The VA has no difference \-- I mean, what we\'ve essentially done is
allowed the reinvestment in staff to take place of its own accord.
Rather than end up putting an investment in and saying let\'s create a
new silo, so instead of having hospital care and the other traditional
non-institutional care programs, and say let\'s fund another new silo
all the way down, which is going to be the staffing to do this. We've
essentially said it's what the change management should be able to do,
better fit from the hospital side. That Florida where it was instituted
to begin with is getting a big influx of patients as people move from
the Northeast particularly, down to where it\'s warmer climes. So
they\'ve been in a position not only to disinvest in hospitals, consider
how they may have to increase numbers of beds. So it's kind of taking it
from the other. The other thing, comes down to the idea of waiting lists
and actual waiting times, which means that by virtue of being able to
free up those beds and reducing length of stay. So essentially the
principles aren\'t a lot different but fundamentally it\'s the structure
of healthcare around hospital and home and clinic, that means you've got
investments in each. My personal opinion is just you need different ways
to approach it. You've obviously got problems in whatever system you
look at.

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

Any other questions?

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

You look puzzled. I probably said something which \--

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

No, I\'m just \-- I\'m thinking of the administrative systems, and how
in the healthcare systems, different department heads often get down to
\-- the reality of it is different department heads have investments in
systems of their own to make and they don't see the savings within their
department sometimes, it\'s very difficult to have them sell, or buy
into this investment.

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

I was at a meeting over the weekend, as I mentioned, and was there, it
was somebody from CMS but also somebody from Partners. So my own
personal wish, this is not in any way VA policy, but would be very nice
to look at some of the issues around how one would think about
allocating money for this in an organization like the VA, or reimbursing
something like this in something like Partners and would be very
interested to work with CMS, if I could put a plea out there for us to
do so. I mentioned we have \-- did I mention we have our own coding
system in VA? We use CPT coding just the same but the CPT coding for
this, in my opinion, please don\'t take this as an agency position, is
that it\'s certainly not adapted to be able to provide this at the
moment.

The VA, we have coded for this, so I systematically know, as well as
what activity takes place, and it seems to me and this is again my own
trying to sort of promulgate this talk in the agency, if you know
clearly what \-- who the patient is, in terms of their degree of
chronicity, their problems, you have a systemic way to treat them, then
rather than actually get involved in thinking about episodes of care,
what we should be funding for this is a program of care. Because often
episodes of care are used as a proxy, because you don\'t know about the
case mix. So you say because they \-- if they justify five visits, they
must be chronic.

Now, I\'m sure, though far be it from me to say so, that results in some
system some way. Someone might want to game it. So a logical way,
particularly because this is not providing direct hands-on care, so you
can fund it as a distinct program of care for which the costs are
discrete, it would lend itself to be funded as a program of care. For
that, that means having a start date and a stop date. Traditionally you
don\'t get such indices. Working to try to get those at the VA has been
\-- \[audio disruption\].

We\'re also doing work just in telehealth generally. On
teleretinalimaging, we have a program that was rolled out this year,
that program went to 163 sites. Those 163 sites are both acquisition and
\[inaudible\] meeting sites. This year to date just somewhere with, data
is coming in, somewhere between 60 and 80,000 patients been seen since
October 2006. We anticipate the steady state will be 200,000 a year,
which we will reach at the end of 2008. And we\'re providing in clinics,
via clinical video conferencing, this year we will provide something
like 35,000 consultations with telementalhealth.

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

Will you have data published on that as well at some point?

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

Yes. We're going for IRB approval to try to do some of those things, and
it's just really a question of hours in the day.

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

This is Paul Nichol. There was a comment made that I think is important
about departmental support for some of these activities. It\'s a
recurring theme that there are a number of interventions which will
improve patient care, but may not align under the current incentive
structure with the self-interest of the parties that need to be
involved. And that\'s a common theme in our current environment. The VA
is a little bit different because it\'s more of a, somewhat more of a
capitated model and it makes sense for us to do this. But that\'s
something we are going to have to struggle with as we look at how this
gets disseminated more widely.

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

I think Craig made that point early on in giving the summary of the
meeting this morning that there were some folks who were present who
were very candid about the fact that there might be a negative economic
incentive to them to improve the care system.

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

I would make a plea if we can do \-- I personally would be very happy to
work to try to look at some of the issues. Again, my personal opinion is
that if we were to look at some of the ways in which this could be
funded within the VA, certainly the funding is covered, but not directly
for this individually as a service, then if we were 1 or 2 percent out,
it\'s very different kettle of fish than if CMS is 1 or 2 percent out in
terms of something. So one might do some modeling around what some of
those things might be within a fixed system like the VA, and look at
though the incentives and disincentives may not be exactly comparable,
there are certainly ways there are some data one can use to look at
clinical behavior, one could look at other sort of \-- other things that
go on.

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

Craig or Tony, this is Jeff Rideout from Cisco. How did these findings
as they come out fit against the AHIC recommendation we just made? Can
we make that connection?

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

I guess we\'ll have to wait until they come out officially. When are
they coming out officially?

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

Our figures, or outcomes? I hope to publish in about three or four
months. That's depending on getting it \-- we have to get the data
privacy and security themes, IRB approval to be able to publish this to
the world outside. So that\'s going through. Then it\'s really a
question of writing it up and being accepted and submitting it. I\'m
thinking if we do this as rapidly as we intend to do it, if we\'re lucky
it will be about four months.

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

I guess the generic question is, you know, where do we go with the
recommendation as it sits now relative to some of the emerging
information that comes out from the VA, and other places. I\'m not clear
what the road map on that is.

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

Jeff, this is Karen Bell. I\'ll jump in a little bit here. I think that
one of the reasons we wanted to hear from Adam today was to really get a
much more robust understanding of the value of care coordination and
home monitoring. And that\'s actually again why we\'re going to be
hearing from Dr. Ferguson very shortly from Alaska. And that\'s very
specific to the recommendation, wanting to understand more about the
value store and forward technology. The concept that if we can get a
really good peer-reviewed approach and we can get good data and
information out there that this does have value, which is as you are
suggesting and hopefully we will see in print in the not too distant
future. The next step really is probably even a bigger challenge. We no
longer have to prove this works. We know that it works, we know there\'s
a return on investment, we know it saves lives, saves money. But we have
to then begin to figure out how do we make it happen in our fragmented
private system, as opposed to the integrated system that the VA enjoys
and frankly the integrated system that some very large delivery systems
enjoy as well? And that I think is really going to be the challenge. And
I think one of the things we\'ll talk a little bit more about today is
maybe thinking about what are the different models of coordinating care
and what do we need to look at and how can we think about bringing those
different models together, and perhaps supporting some of them, because
we have to get beyond the fragmentation. That\'s really what this is
about. But from at least, I think our point of view, hearing that this
truly does work, that it does bring cost savings, it does improve
quality is very important. You can\'t \-- that argument will now be off
the table and that is a very important argument.

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

Okay, because Karen you\'re saying something very important. I think at
the beginning of the meeting it was announced this is the 17th time that
we\'ve met. So I just want to understand the work that Dr. Ferguson is
doing, Dr. Darkins is presenting, that \-- we see that as kind of a
final statement on the question of whether these systems work or not.
And then the question for and the work for us becomes now that we know
that\'s confirmed, with both anecdotal and more RCT-type information,
the question is how do we go about implementing that in a reimbursement
and delivery system that\'s much more fragmented? I\'m trying to get the
road map.

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

I think so. I think that\'s exactly it. But I know that we have had a
lot of back and forth and discussion, does it work, does it not work.
We've heard some people say we really want to know that there is a
return on investment. I think that\'s really what we\'re hearing. There
is.

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

Again, I\'m obviously concerned, it would be very nice \-- an
organization like the VA cannot support activity like this, with all
this technology, in my opinion, because what it requires is many boats
to start the float. I guess the only thing that I would say in terms of
suggesting before everything races forward, is that to be very clear the
technology is only one piece of this. If it\'s not about \-- a, this is
defined patient need, define patient population is extremely important.
And the second thing is, unquestionably, it seems to me, this is how it
fits into care and case management. That again, I mean, meeting over the
weekend, there\'s a real agenda around the coordination of care and case
management. So the technology is there to facilitate it, but the
technology in itself, at the current level of sophistication, will not
do that. So there are people processes that need to be put in as well as
the technology processes.

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

I think that\'s critically important when you look at the private sector
given the different dynamics that are there and may not have the set-up
training you have in the VA and how it fits into the work.

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

So again going back to the recommendation, which I\'m staying fairly
focused on, you know, we talk a lot about mechanisms for control of
fraud and abuse. We didn\'t talk about the necessary clinical process
re-engineering and care delivery environments that are supported by
these technologies and will that be the next hurdle that we have to deal
with as a Workgroup in terms of moving the agenda forward for
reimbursement?

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

This is Karen again, Jeff. I think it is. And in essence that\'s why we
have a discussion at the end of the meeting today, which none of you
would have any idea that we have it there, except that it\'s on as a
next step for the Workgroup. We have a discussion about the different
models that could be deployed to do care coordination, to begin to think
through that next step, because if we are going to move forward, we do
need to understand better how we can do care coordination in the private
sector.

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

Thank you.

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

Karen, this is Mohan, I\'ve been on for a while, I didn\'t want to
interrupt the flow.

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

Hi there, Mohan. Welcome.

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

Thank you.

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

And this is Stewart Ferguson, I\'ve been on for a little while too, up
here in Alaska.

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

Are you out in the woods, Stewart?

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

I just came up from the river, fishing, so I\'m all set to present
whenever you're ready.

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

We better get you back to the river. Any more questions for Adam?

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

I would hope that we would send the first reprint to the Secretary.

\[laughter\]

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

Could I just say, Stewart, since you're on, I had a chapter to send
yesterday and it seems that some clarification is necessary, so my
apologies.

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

What\'s that, Adam?

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

I need to chat with you in the next day or to, if I may.

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

Fine, that would be wonderful. All right.

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

Adam, we can\'t thank you enough. This has been very, very helpful.
We\'re awaiting a report.

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

Do you mind if I hang out a few minutes?

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

You\'re welcome to hang around as long as you like, and for every
meeting, actually. So let us know. And we'll move forward right now.
Thank you again, and maybe, Yael, could you introduce Dr. Ferguson?

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

Sure. Dr. Ferguson apparently enjoys fishing, is actually the director
of the Alaska Federal Health Care Access Network, which has done some
really innovative things in terms of telehealth technology and
evaluating the value of their use of telehealth. Specifically we\'re
interested in store and forward technology because under the current
legislation store and forward technology is limited to use to Federal
reimbursement in Alaska and Hawaii. And Dr. Ferguson has done some
amazing things with store and forward technology and evaluating the
benefits of that technology. So thank you for joining us, Dr. Ferguson.

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

You\'re very welcome. Thank you. I just want to check, I know that I\'m
supposed to be done at 3:00 Eastern so do we want to \-- will I try to
shorten and be done in 25 minutes or do I have a little extra time?

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

You can have a little extra time.

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

Okay. I\'ll try to move it fairly fast. My goal of this presentation,
and I hope it\'s not misdirected, is to give you a sense what have
we\'ve seen in terms of our experience in Alaska. We\'ve actually been
kind of heads down and into production telehealth versus more
research-focused telehealth, and as a result I think the publications
are not at a level we would like to have although we have an incredibly
rich dataset and really one of the things that I hope comes out of this
or comes out in the next year or two is that we start to mine our
dataset, start to show value to the community. Next slide.

These are just a couple busy slides here to set the tone of what we\'re
facing in Alaska. We have both a lack of providers and a
mal-distribution of providers in Alaska. Fifty-nine percent of our
State\'s residents are underserved, medically underserved population. We
have 27 boroughs or census areas and 23 of those are in some portion
medically underserved areas or medically underserved populations. Next
slide.

One of the interesting things is, in Alaska, we have a greater
percentage of primary care physicians and a lesser percentage of
specialists. So while one in four physicians in the U.S. is typically a
primary care, we have one in two. We also have one of the fewest
doctors-to-residents ratios, and the doctors that we have, two-thirds of
them are located in Anchorage, which is about a 900 dollar air fare from
many of our villages, so we rely on kind of a primary care focus to
really deliver healthcare to most of our rural communities. The
information I\'m going to show you from our project for the last eight
years, you\'ll see about 75 percent of telehealth that we provide is
really primary care and about 25 percent is specialty care. Next slide.
Next slide.

We don\'t have managed care in Alaska. We have a mix here. We have a
Federal healthcare system which is Army and Air Force, we have Coast
Guard, VA system, and then a tribal system, the Alaska Tribal Health
System, which spans multiple organizations, and then of course we have
public health, community health, and private providers. There\'s a few
pictures here just to demonstrate some of the sites that we reach with
our network. The top left picture is the Alaska Native Medical Center.
But the top right picture is Kanakanak Hospital in Dillingham, Alaska.
And Dillingham has the auspicious record of having the highest closure
rate of its airport of any airport in the United States due to weather.
So these are facilities where they may be trying to serve 25 villages
and be trying to fly specialists in from Anchorage but one bad day means
that you don\'t have a specialist and you wait two more months to see
the specialist or all the people in that village cannot get in to be
served. We have serious issues both with access and weather-related
issues. Next slide.

So really because of this environment with lack of managed care, but
this Federal system, the AFHCAN project which is \-- next slide \-- the
proposal was made to Congress to fund an Alaska Federal Health Care
Access Network to improve healthcare to Federal beneficiaries throughout
Alaska. Next slide.

This was a fairly large project in concept. It has almost 250 sites
spread over half a million square miles. Perhaps makes it so difficult
is that we work with multiple agencies, multiple organizations. Each of
those organizations has its own database certificates, its own
electronic health record, its own security and privacy policies, we\'re
working with Air Force and Army, Air Force being one of the more
restrictive groups, as well as Coast Guard and then multiple Native
communities with varying ranges of technical and clinical support. Next
slide.

So we actually embraced store and forward in Alaska for practical
considerations, early on. We did not have the bandwidth that was
available in the Lower 48 and needed to find solutions that were less
bandwidth-dependent and we started to use store and forward. We now
embrace both real-time and store and forward because USF funding has
made video conferencing a reality in Alaska. The data I am going to show
you today is focused on store and forward. But please keep in mind some
of our organizations do as much live video conferencing as they do store
and forward. We actually don\'t look at them as old versus new
technologies, we actually look at them as two different technologies
that both serve a purpose in delivering clinical care and in many cases
store and forward is a much more efficient and reasonable approach to
access limited specialties, specialists. Next slide.

Store and forward can rely on lower bandwidth. And of course you think
of it as being images from digital cameras and scans, but you can
actually do an awful lot with short video clips, especially for therapy
sessions; temporal data: EKG, stethoscopes, tympanometry sounds; health
summaries. The advantages of store and forward, of course, is that you
can create cases on the run so essentially when the patient is there,
you create the case but then the doctor can respond when they\'re
available. And really it's because of this we see the efficiencies. Next
slide.

In the interest of time I\'ll skip this slide other than to kind of
point out the, two points. One is it\'s really about creating more
efficient healthcare with store and forward and the bottom point there
is that you need high quality, high quality data and images, many of
which are not available or capable of being stored within your
electronic health record system. Next slide.

So really we actually have these systems now where we have multiple
organizations and we have 43 that make up the AFHCAN family of partners,
these organizations with their own electronic medical or electronic
health records, have fairly large systems. The telehealth system needs
different data in many cases, multimedia data not available in the EMR,
and of course that overlaps with the billing systems and so you have
this fairly complex data concept of data sharing that we need to work.
Next slide.

So we developed in Alaska kind of a primary care tool. We focused on
primary care, really, for our telehealth, as I mentioned earlier, things
such as ear disease, heart disease, respiratory illness, and what we
developed was a fairly simple platform that took up no more than four
square feet in any of our village clinics but it could support up to 13
different medical devices and through the touch screen interface people
can capture data and send it anywhere in the State with which they have
a business relationship. Next slide.

One of the keys for us, of course, with over a thousand users spread all
across Alaska and it\'s so expensive to reach them to do training, was
to keep the system simple. We tend to use colored buttons, we kind of
almost hide the complexities of the interfaces to the devices. And we
find that many people can create cases in a matter of minutes. Next
slide.

I\'ll skip this other than to say that we now have 43 organizations in
Alaska and we have gotten around the firewall and technical issues. Next
slide.

The more complex issue is how do you serve the business needs and the
contractual needs of all the organizations that are going to deliver
telehealth services to each other, and do that within a secure
environment? And that is something that we\'ve worked on for many years
and we have a system now in Alaska that\'s quite robust. We actually
have 15 U.S. Coast Guard cutters that can send cases to Coast Guard
bases, that can forward them to Elmendorf Air Force Hospital, that can
then share them with the tribal system, their specialists there. We have
a fairly large network for \[inaudible\] that really cuts through and
spans firewalls and is consistent with all the security requirements.
Next slide.

I think one of the key things that we\'re learning with telehealth is
that we have yet to find a department that adopts telehealth and then
fails to continue to use it. It\'s a tool that once it\'s introduced in
a department we find it gets used and the usage grows. And really the
limitation for us is really just trying to find enough specialists
willing to take the cases. The primary care providers tend to adopt it
quite easily. This year we\'re seeing a 21 percent growth, that's that
small light blue bar on top of the other bar. So we\'re seeing a
continued growth. We have about 18 departments at the Alaska Native
Medical Center, for instance, that now use this system. Next slide.

So we\'re doing anywhere between 10 and 14,000 cases per year. I\'m
going to take you through some of the outcomes and the things that we
have seen over the years as we start to use this. I\'ll give you some
examples of where we think the telehealth is improving efficiency for
providing care in Alaska. Next slide.

The first example that I wanted to show you is data that we gathered
from point of care observations by our providers. So within our
software, since we wrote it, we have some \-- obviously the ability to
control the software, we actually ask evaluation questions to our
providers. We ask a different bank of questions to people that create
cases versus those that consult on cases. And programmatically we can
change the questions, we can have a whole bank of questions but we just
ask one every time somebody is working on a case. Next slide.

So one of the questions that we ask, and we ask this to people that
consult on cases, is did viewing this telemedicine case affect patient
travel for diagnosis or treatment. And we say compared to a phone
consult because this is really the way that this would be provided if we
did not have a robust telehealth environment. Now the interesting thing
is that, with over 10,000 responses, 10,000 telehealth cases, we find
that about half the time store and forward telehealth prevents patient
travel and eight percent of the time it causes patient travel. Next
slide.

The reality is that these numbers have been changing over time, and if
you go back to October, 2001, you would find that the cases that
prevented travel, which is the red line, were somewhere between 20 and
30 percent. And this is kind of an average window based, I think, on
every couple of months averaging the data. But you can see as we\'ve
adopted this system and used it more, I think our efficiencies with the
system have grown and now we find that on average 68 percent, so two out
of every three telehealth cases prevent patient travel. And as the
number of cases that prevent the travel grew, the percentage of cases
that had no effect dropped. So about two out three cases prevent patient
travel. Next slide.

If you make some really coarse assumptions and this where we haven\'t
really gone in and mined the data to really get a hard-core number, but
a round trip air fare in Alaska is somewhere around 600 dollars on
average. If you assume we do 10,000 cases, our savings, depending on
where the patient travels from and whether it\'s a child or an adult, is
in the range of 2 to 12 million dollars, which is an extremely coarse
range but you\'re into the millions of dollars in terms of travel
savings annually in Alaska. Next slide.

What\'s interesting and what we would love to go look at, because I
think this is an incredibly important point which is oftentimes missed
when we just try to focus on cost savings for travel, is what you\'re
saving in terms of catching disease states earlier or saving lives and
that's something that an economist could put a dollar value on, but it's
where we cause travel. And we find that about eight percent of the time
we cause patient travel. If a telecase employs an EKG, so we\'re dealing
with a heart patient, 12 percent of those cases cause patient travel.
Now, we\'d like to find out kind of what this really means, but we\'re
talking about a thousand cases a year that cause patient travel, most
likely because we catch disease states earlier. Next slide.

When we first started looking at some of our data, we actually looked at
the first \-- and Alaska state Medicaid started to reimburse for both
store and forward and live video back in, I think, 2001. We looked at
the first 91 cases for which Medicaid was billed, we found that in those
91 cases, which is a low number, Medicaid paid 6,970 dollars in claims.
Of those 91 cases, looking at them on a case by case basis, we found
that 79 of those patients we saved travel. Making a couple of
assumptions about the, those cases, we estimate that Medicaid which
would have paid for the travel, saved almost 55 and a half thousand
dollars. So really there's a multiplier here, that for every dollar they
spent on reimbursement for those cases, they saved almost eight dollars
on travel cost. This is one of the critical things that we find is that
as a system we believe store and forward can save money. But if you\'re
not paying for the travel cost, which is primarily where we\'re going
to, where we can document travel savings, it\'s kind of sometimes hard
to justify just actually paying for reimbursing the providers. Next
slide.

This is an interesting study. This was actually a self-motivated study
by an audiologist up in Nome, in Norton Sound region. And he has tracked
the number of referrals to specialty clinics and that\'s where somebody
is referred to see a specialist that will fly out from Anchorage about
once every three months. And what you can see is, beginning in 1999, the
number of specialty referrals has dropped almost uniformly, whereas the
blue bar, the number of telemed consults has dramatically grown and
really you can see that there\'s kind of been a drop in specialty
referrals as telemedicine consults have gone up. This audiologist has
tracked for every one of those patients on telehealth when he saved
travel exactly how much the Corporation, Norton Sound Health
Corporation, saved, that\'s the red line, and overall what the total
travel savings were. So he\'s showing that he, by himself, with
telehealth, is saving close to 200,000 dollars annually by using
telehealth for his patients for referrals to Anchorage. Next slide.

This is a different program. And this is something that we can do with
telehealth. We have a ubiquitous system now, throughout Alaska, so we
can begin to send allied professionals or mid-levels out to the village
to provide healthcare and because they have a uniform tool, they have
the carts and the software in every village, they can on the spot triage
patients and send referrals directly in to Anchorage. So we have used an
audiologist in this case, we\'ve traveled and seen over a thousand
patients of which exactly 500 we believe we saved travel on. It cost us
82,000 dollars to run this program and that\'s including travel,
lodging, per diem, and the contract labor for the audiologist, but we
estimate we saved almost 200,000 dollars in patient travel. Next slide.

What\'s probably much more important than the pure dollar savings,
though, are the outcomes for those thousand patients. We found that 27
percent of these patients, so almost a quarter of the patients, who were
waiting to see a specialist could be removed from the waiting list as
their cases were taken care of by the audiologist in the village with
the telehealth consult to the ENT specialist. We found that actually, if
you skip over to almost the last \-- the right side, 24 percent needed
to be seen and they did not need to be seen at a clinic, they needed to
be seen in Anchorage and scheduled for surgery. And so a quarter of them
were referred directly in to the specialist and cut out waiting time.
And we had some \-- we had five percent waiting, five percent of the
patients waiting to see the wrong specialist or needing to see somebody
else. And this kind of shows the power of using a telehealth environment
with traveling allied professionals, to provide care. Next slide.

I mentioned this earlier. What we have found is that as we start to
triage and use telehealth as a triage model to determine who needs to
see specialists and who doesn\'t, we find that waiting time for these
specialty clinics can drop dramatically. Nome is a good example, where
in 2002, as telehealth was only beginning to be implemented, we had a
waiting time of almost three-quarters of a year. It dropped to a few
months in 2003, and right now it\'s a negative waiting time, and I think
the quote on the right side is fairly interesting. This was an
unsolicited e-mail where with telehealth, we finally, for the first time
in memory, had open spots for specialists. The same thing has happened
in Bethel, which is one of our other large regional facilities. And
there\'s kind of a double thing that happens here. As you triage
patients with telehealth and either remove them from specialty clinics
or refer them directly to the specialist without them needing to be seen
in the clinic, at the same time then you open up slots for other
patients who were never directly involved in telehealth but now get an
earlier appointment so it kind of has a multiplier effect. Next slide.

We actually find that we\'re able to use telehealth sometimes to
schedule people directly for surgery. Now, this has a risk \-- or it has
a risk that we were worried about, which is, if you do not see this
person, if you do not have an in-person visit, can you predict not only
the procedure but the time required in the operating room for that
patient with a high level of accuracy? So we did a study where we looked
at 56 telehealth cases that led directly to surgical referrals, and
compared that to a matched set, so similar population and similar
surgical procedures, that never came through telehealth. And we found
that actually, if anything, the telehealth process was slightly more
accurate in predicting the procedure and the operative time, although
there was no statistical difference between these two populations. But
we do feel for lower-level surgical referrals, we can use telehealth
pretty accurately to predict both the OR time and the procedure. Next
slide.

One of the problems that we face in the rural setting is really just
meeting the standard of care. Post-surgical follow-up is a good example.
People will be flown in, receive surgery, go back to their villages, and
in many cases the specialists do not see that person again unless some
complication arises. The standard of care for, for instance, ear tubes
here is to see that patient every four months, and so we\'ve implemented
a process here where we do kind of a reverse telehealth consult. We have
specialists that ask health aides, nurses, audiologists, et cetera, to
provide them with information so they can provide the proper quality of
care to their patients. So we actually do post-surgical follow-up kind
of through a reverse model and this has been validated and we\'ve
actually been able to prove that we can use telehealth for post-surgical
follow-up. Next slide.

We ask questions to people that create cases. And one of the questions
we ask is we ask them to rate the statement that telemedicine will
improve the quality of care for this patient. So we have over one and a
half thousand responses and you can see that about 86 percent of the
time people that use our system to create a case believe it improves the
quality of care. Next slide.

In terms of increasing efficiency, we have some departments now that \--
well, all of the departments that we work with at the Alaska Native
Medical Center are providing telehealth support with no increase in
staffing. The most dramatic example, and it\'s dramatic because I\'ve
been doing it the longest, is our ENT department. They do about 2000
encounters a year. Now these are encounters that happen on top of
continuing the regular course load and they\'re able to do it, I think,
through the efficiencies of telehealth store and forward where during a
no-show or during administrative time they\'re actually able to clear
the caseload for that day. It also pulls in revenue, as well as making
obviously \-- becomes a bit of a feed as well because those patients now
can be scheduled for surgery and they can actually \-- that of course is
for, the department actually sees the revenue. Next slide.

So really this whole concept of being able to triage patients, that's
really all part of communications. And really telehealth is a
communication tool. In many cases what we\'re doing is replacing the
phone and the fax, which was used 10, 20 years ago, and when we asked
people to rate that statement, you\'ll see that 89 percent, so 9 out of
10 times, they believe it helps them communicate with the doctor. Next
slide.

One of the questions we ask is does it make your job more fun. And I
don\'t know how often you ask that with other technologies, but this is
actually an interesting question and we find that about 77 percent of
the time they believe it makes their job more fun. Well, the reason
that\'s somewhat interesting in Alaska \-- next slide \-- is because
it\'s so expensive to hire providers. This is a study that was done in
2005, I believe, by the University of Alaska, Anchorage. And you can see
that the cost of recruiting providers in Alaska is extremely high.
It\'s, on the average it's 38,000 dollars. If you have a hospital in
your system it jumps to 66,000 dollars just to recruit new physicians.
And then that\'s magnified if you have a high turnover rate, because you
keep spending that money on a fairly regular basis. Next slide.

One of the things that you can do with telehealth, it can be a powerful
tool to educate patients. And one of the little things that we have done
is we actually have created a fairly large, fat trigger switch that we
always give to our patients \-- and you can see the young boy here has
it in his hands \-- and we involve them in the taking of images, and
capturing of video, and other data acquisition, and there\'s been a
study by the Centers for Disease Control up here through the Arctic
disease prevention program in Alaska, that really documented that
involving the patients in the imaging, especially with ear images, that
you can reduce both the overuse of antibiotics and in some cases reduce
the resistant strains that are found in the disease. Next slide.

Overall, when we kind of summarize evaluation questions that we ask
people about telehealth, we find that two out of three providers believe
it played a role in educating the patient. Three out of four say it
makes their job more fun. Four out of five says it improves patient
satisfaction. Five out of six believe it improves quality of care, and
nine out of ten believe it helps them communicate with the doctor. Next
slide.

This is what I said earlier when you can triage patients and remove them
from waiting lists then you can open up positions for other patients not
served with telehealth who then see the benefit of telehealth. Next
slide.

We did a study a couple years back, we were trying to actually look at
the cost of delivering healthcare through specialty care models, some
that were kind of maybe specific to Alaska, versus telehealth models,
and I won\'t spend too much time on this. I really think the point to
take away from what I\'m going to show you is we have a tremendous
amount of data that we can start to look into cost, cost models, perhaps
cost-effectiveness models, and really it's maybe a bit of a plea on my
part to say this is data we really should start to use as a community
and we\'ve just not had the time or bandwidth to do it. I\'ll skip this,
go to the next slide.

This gives you a sense here of some of the parameters that we\'re able
to put into our model. We\'ve been operating so long we know a lot of
costs, that\'s not a question. We know about the travel, we know a lot
about our patient population, and so we can actually start to estimate
pretty accurately what the cost of delivering healthcare through
telehealth and traditional methods are. Next slide.

This gives you an example where we can show you a couple different
regions in Alaska and we can tell you how many patients we have, the
specific disease state, their average age, how many of them typically
would travel, we know the travel to the sites, we know the Medicaid
distribution, we actually even know the no-show rates on those sites, so
when you try to go out and provide care, you have a certain population
that you\'re just not seeing each time ,where telehealth of course, by
definition, does not have no-shows. Next slide.

And then this gives you kind of an idea of the model that we can report
from this. You can actually get a sense of the cost per encounter, the
cost per patient, delivering healthcare based on your annual, your
annual case load. The red line here with telehealth shows that it can
drop versus traditional healthcare under a variety of model scenarios.
Next slide.

I think some of the lessons that you can take away from any of these
cost models are not that surprising.

The cost, of course, extremely sensitive to how telehealth eliminates
the need for a subsequent in-person. If you always need an in-person
encounter after the fact, telehealth can still be effective in terms of
triaging and determining priorities, but it\'s going save a lot more, of
course, if you eliminate that. So focusing on that, of course,
telehealth, you really have to be careful about the specialties. You
look for specialties where you have the greatest chance of eliminating
that in-person, thinking throughout location of the patients and the
equipment. Really, the bottom line is almost every scenario that we run
through this cost model, the more care you can provide at the patient
location, whether it's with home health or portable systems or the
system in Alaska where we have clinics, or the equivalent system, you
have got the greatest opportunities to see cost savings. Next slide.

This is, from what we have been doing recently, trying to figure out
what is the actual burden on an organization to provide telehealth.
Burden being, burden really being kind of the sense of how much time it
takes a provider to really invest in their day, to provide a telehealth
consult or to create telehealth cases. This is a fairly busy slide but I
hope you can see it. The top left corner kind of shows this is the
number of cases per week at the Alaska Native Medical Center, going from
2002 to 2006, and you can see its gone from about 70 cases a week to now
they are getting on the order of 250 cases a week. The top right slide
shows the average time for a consultant to spend on a case, and the
bottom plot is the median time where it is 50 percent more, 50 percent
less. And what we've seen is with experience and with usage of the
system, the time to provide a consultation has dropped. And the average
time now for a consultation at the Alaska Native Medical Center is about
10 minutes. Next slide.

So this is kind of a table to compare both the consulting site, on the
right, and the originating site, and I think if you look at the average
time, you'll actually see that over the last four years the average
time ‑‑ and this is looking at eight and a half thousand telehealth
cases \-- about 11 minutes for a consulting site. But what you really
need to know is that the originating site, where we create telehealth
cases, it can take upwards, on average, 30 minutes to create a case. And
it takes that time because they are taking images, they are scanning,
they are doing EKGs. They are typing in histories. They are trying to
create a complete workup so that the specialist then can be efficient
and deal with the case effectively. And this is one of the things that,
I think, an issue that we have to address nationally, which is that we
do not really incentivize people for the additional time and the cost of
the equipment and the connectivity and the ongoing training and support,
which are big costs, out at the remote sites that create telehealth
cases. We are focused a lot on reimbursing people for providing
consultations, but it takes time to create that case so folks can be
efficient, and it's something that we probably need to be thinking
about. Next slide.

One of the things that\'s interesting is we went back and looked at
those questions about the job being more fun and patient satisfaction
and quality of care and we were curious that if a people that\'s
creating a case spends 60 minutes creating a case versus 5 minutes does
it make their job less fun, or the patient less satisfied? And the
surprising thing is that really the amount of time spent creating a case
has really no impact on any of the evaluation questions and if anything,
just looking at the ones I\'ve plotted here, patient satisfaction and
quality of care seem to kind of go up the longer the initiator spends
creating the case, that\'s the X axis in each of these plots. Next
slide.

I guess it is somewhat time insensitive. So if you summarize some of
this data is that consultant sites need very modest amounts of time to
review cases. That\'s the efficiency and that helps us take advantage of
the mal-distribution of providers by using telehealth. The time is
fairly constant, too. The variance is fairly small, and so it is fairly
predictable how long it will take to provide care through telehealth.
And they are being compensated for the expert opinion. So they provide a
lot of value, and it has a lower burden on the department to provide it
through telehealth. Those are all positives. At the initiator site it
does take additional time. There is no question about it that. It is
highly variable. When we actually, you know, there are several
components to the time spent on a case because an organization will
create a telehealth case, send it to a consultant, but then have to
review the consultant\'s recommendations when they come back. But about
83 to 85 percent of the time is actually in the case creation. And they
are really not compensated for the additional burden of telemedicine.
Next slide.

We are winding down here. In terms of reimbursement we have been very,
very lucky in Alaska. Of course we have Medicare that\'s willing to
reimburse, we also have a State Medicaid, a very, very powerful tool for
us because the majority of our patients fall into the State Medicaid
reimbursement. We also have a total of 34 other, so a total of 36
distinct payers that currently get billed and pay for telehealth by the
Alaska Native Medical Center. When we went back and reviewed a little
over a thousand claims, this is back in 2005, we found that the payment
rate was extremely high, about 91 percent. Of the ones that were not
paid, it is really because patients were not eligible or the deductible
was not met. So we have a process for submitting payments and we have
payers that are willing to pay. What I think we are missing in Alaska is
a disparity though between the payments for consultants but the lack of
payments for those that really bear the burden of creating telehealth
cases. Next slide.

In terms of future directions we are continuing to grow our system and
we are funded through the Indian Health Service now and we have received
funding in the past from Dena Puskin's Office for the Advancement of
Telehealth, the USDA, the Department of Defense. But we have now have
providers in our remote sites that are coming to us and requesting
technologies. They didn\'t used to do EKGs in the village. Now they not
only do EKGs, they want portable systems to be able to do these in
elders' homes. We are working with the Joslin Vision Network, and
similar to what Adam is doing with the VA, we want to move to a system
where we can actually work with diabetic patients and fly to the
villages, capture the images of the diabetic patients in their village
and send those for remote consult. And we tested this equipment, and
that's a picture of us testing it, when it was 50 below zero to make
sure the equipment can travel to our villages and it does quite clearly.
We are also expanding within the Indian Health Service \-- I don\'t know
if Mark Carroll is on this phone call or not but Mark Carroll is the
program director for telehealth for Indian Health Service and has been
instrumental in helping us take the technology now that was developed
with IHS funds and to share it with other sites. And we are planning to
be deployed at least with server technology in two-thirds of the Indian
Health Service areas this year and at that point it becomes an issue of
trying to build up the services, the protocols and start to put some of
the end‑user equipment out. Next slide.

We are also ‑‑

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

Stewart, I am on the call, just so you know.

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

Okay, great. All right, Mark, you can tell me if I say the wrong thing,
at least.

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

No, you have got it right.

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

Okay. We are also expanding within uniformed services. This is an
interesting lesson for us. We started off with a few Coast Guard cutters
in Alaska. We are now in all the Coast Guard cutters in the, I believe
in the Pacific and also a few ice breakers. And that's actually very
interesting because those Coast Guard cutters can be disconnected,
similar to people would be in our villages, if there is bad weather or
if they're traveling to an elder's home, or even in the Navaho area
where they travel to an elder's home without power, and they create
telehealth cases, and when they connect those can come back to the
Kodiak station or down to the Petaluma Training Center. And now I
believe all the medical officers coming out of the Coast Guard are
trained in our store and forward telehealth system and we are trying to
grow within the Army and the Air Force as well. It's available in Alaska
and we're trying to move to other locations. Next slide.

So I\'m going to just finish very quickly. We are getting close and I\'m
sorry if I\'m over time. Very quickly, the question that you would
wonder, I think, with telehealth is how do you know that you have
created value for the provider? One of our providers many years ago told
us you will know if you have created value if we use it. They don\'t
have time in their schedules to play with technology. If they use it and
they are still using it in a year, they think it has value. So the
continued usage, I think, demonstrates that. This is a good example.
This is a small clinic in Stebbins. Next slide.

It burned down in the middle of the winter. When things burn in Alaska
you don\'t have water that you can flow, so you bulldoze it over. But in
the middle of this fire they went running in to save one piece of
equipment. Next slide.

And that was our AFHCAN telehealth cart, and so it had value to
providers, that they were willing to rescue it from a burning clinic.
And they rescued it, they put it in a school, plugged it in, and it
worked, which really made us feel quite good. Store and forward
telehealth, for us, we know it works. It is not an issue as to how much
we have to evaluate it to know. We do know it works. But what I would
like to offer is we find a way that we can mine some of the data that we
have available on some of the experiences to help other people
understand how it could impact their delivery process with healthcare.
Next slide.

So that is the end of the slide show. Thank you very much for the
opportunity to speak.

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

Thank you very much, Stewart. Before we open it up to questions. I
don\'t know if you know that one of the recommendations this Workgroup
made to the Secretary through Craig was that our Secretary shall
evaluate the benefits of remote store and forward technology as
currently employed in Alaska and Hawaii to determine if these services
should be expanded beyond these two States, so we are going to be
knocking at your door to work with you very, very closely. Thank you
very much.

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

Thank you very much.

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

Questions? We have Jay Sanders \--

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

Hi Stewart.

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

Hi Jay.

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

Stewart, that was a fabulous presentation, as was Adam's fabulous data.
I implore you to mine it and to publish it. I recall being in Stebbins
about eight or nine years ago and meeting your health aide there. And
one of the stories, and I \-- it was just so funny when you showed this
slide. One of the things she said is that when they first brought the
equipment in, it was very experimental, nine years ago, and she said I
was very, very hesitant to use it. As a matter of fact, I really didn\'t
want it. And she had had it in place for about a year at the time that
we came up. And she said if you try and take it away from me, I will
kill you. Those were her exact words.

But the other aspect of this, and I\'m sure this would be of interest to
Craig because of his work internationally in terms of health, is the
incredible quality of your community health aides and how much the
telemedicine really supports their capability. You know, you ‑‑ I
remember meeting her in Stebbins, she had, I think, a 6th grade
education and she was the primary healthcare provider. She really was
the primary healthcare provider in that community and she did her
connectivity to Nome where there were, I think, seven primary care
physicians. It was quite dramatic. I think the other thing that I
didn\'t see which is would be interesting very interesting to look at is
how much the telehealth technology has improved the educational level of
the community health aide so that now, with another consult, she has
actually doesn\'t need to use telemedicine. She now knows how to take
care of that patient without getting a consultation.

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

Right. That\'s actually a really good point. We tried to think through
how we could measure it. I\'m not sure how we can or if we can. The
other thing too, Jay, that was learned is that we have a tremendous
database of, probably close to 150,000 images right now taken by health
aides about problems seen in Alaska. We are ‑‑ even to take that data
and try to turn it into an educational resource. We are going to focus
specifically on ear disease in the next year. But to use that data, to
provide educational content that can be shared with the community health
aide program, and we hope to actually put in kind of monthly or
quarterly kind of quizzes and tasks on that. And that would give us an
opportunity to really see if the, if they're learning through the
process.

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

Thank you very much.

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

Stewart, this is Jeff Rideout from Cisco. Obviously I'm fascinated with
the technology piece of it, but I came across a small company that does
automated pharmacy dispensing. And they do a lot of work with the Indian
Health Service and also with the Navy and the Army in Alaska. Are you
using that type of service, or them in particular, and how would that
kind of capability add to your service?

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

Yes, there is a fairly extensive telepharmacy program in Alaska. And I
should mention there is actually quite a lot going on in telemedicine in
Alaska besides AFHCAN. There's an article that was published in the
International Journal of Circumpolar Health about a year ago by Chris
Patricoski, clinical director, that outlined all the different programs
including telepharmacy. The telepharmacy, the way that works right now
is that, it is a fairly stand-alone system where we have the dispensing
units in our village clinics and they are wired directly into our health
records system and it ties directly into the pharmacy. So there is still
huge opportunities for improvement and we are working with the pharmacy
program right now because they still rely on phone calls and faxes to do
a fair amount of the documentation, and so they are actually looking at
implementing store and forward technology for the core communication
layer to be able to move data back and then tie that directly into the
dispensing units.

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

Stewart, this is Marc Carroll. I guess I might just add that we're also
using telepharmacy in other portions of the Indian Health Service. I\'m
on my way to a meeting up in Nevada right now, where there is interest
in that as well.

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

Stewart, this is Craig Barrett. Great presentation. Did I understand you
correctly at the start, that you used the phrase real‑time store and
forward.

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

If I did I didn\'t mean to. I apologize.

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

I was going to ask, are you doing any work which is real‑time?

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

Oh, yeah. Yeah, we actually ‑‑ and maybe I, if I said that, we do a fair
amount of real‑time now. Real‑time video, at least, for us, has been
grown at the regional level, by the regional corporations, mostly
because of network issues and support issues. We are now beginning to
move toward more of a Statewide video solution, but one of our
corporations, the Manilaq Association, with 11 village clinics does
about 3,000 store and forward cases a year and they do about 3,000 video
solutions a year. The other thing we are doing just from a technology
perspective is we are taking our 300 carts that are out there in the
village and we are trying to move them to the point where they are video
enabled and take all the devices on the cart and through a touch screen
interface any one of those can actually integrate store and forward live
video and it really just becomes up to the user to pick the right
technology for the clinical needs.

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

So I presume the users are \-- can pick and choose depending on their
schedules and their timing, some instances they can fill in slots, other
times it makes more sense to have a real‑time conference.

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

Exactly. And every corporation does it differently. And some of them
have, for instance, a provider that\'s available on call, in a room, all
afternoon that you can actually do a live video. Some other places it is
done on an as needed basis so the video becomes a little more difficult
to make that work. So different solutions for different corporations as
well.

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

Thank you.

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

This is a fabulous presentation, Stewart. This is Mohan Nair. I really,
really appreciated the level of detail as well as the acuity at which
the presentation was given. I have two questions, if I may.

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

Sure.

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

One is I heard on a continuous basis in your conversation, and maybe it
was just me hearing my own voice, that there was, time was not a factor
in input of data as well as use of the system as a deterrent to the
value of the systems that were being used. That\'s correct, right?

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

In other words even though it is taking time to create cases people are
still doing it.

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

Right.

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

Correct.

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

They said it is more fun as well, the fun quotient was, what, very high.
Strongly agreed, 36 percent

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

Yes. M\'hmm.

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

What was really interesting was when you moved towards ‑‑ so the value
proposition for using a system of this nature, both makes the patient
feel good because of the accessibility and the factors associated with
that. The physician feels good because the physician has, or the
caseworker or whoever you wish, because they are getting amazing
comments about how parents and patients are enjoying this.

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

M\'hmm.

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

So all of the factors seem relatively positive, and we are all holding
hands on the value. Why, then, is the discussion of reimbursement a
factor?

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

That\'s a very good question. It really comes down to opportunity costs
I think. The best example I can give you is, again, in Nome, the
audiologist there, who has done an incredible job, that was the one plot
where he documented the drop in specialty clinic referrals and the
growth in telehealth. He can show his corporation he is saving them
160,000 dollars a year, but every single year he has to explain to his
administration why he is spending time doing telehealth instead of
spending that time seeing more patients.

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

Therein lies the ironic dilemma of value. It seems like you can prove
that there is significant financial gain from the activities he is
performing, and yet has still to justify the time and access points he
is using that is not patient-centric.

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

Right.

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

In the minds of the administrators.

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

This is Adam Darkins. Can I just make a quick point? What I was going to
say is that, in terms of what needs to be done, it is necessary to
justify it to be able to describe what it is and to find a way to
reimburse for it. The other way it makes sense is to really describe
what it has done in detail is because of the risk of fraud and abuse
with this. Because if things which are currently being done on the
telephone, which are not reimbursed for, are put on to telehealth, there
is a real risk of something going out of control. I think there is a way
in which it is really important to describe exactly what these things
are.

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

For the layman, can you describe to me why there is any greater chance
of fraud and abuse using telehealth or any electronic medium as opposed
to supposed face‑to‑face visits?

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

Well, because it is a more complicated deal to be able to doing.
Firstly, it is not easy to describe what it is. Secondly it is taking
place at two places at the same time. And how you transfer something
that legitimately could be done on the telephone into something which is
now done on video conferencing. Again I just ‑‑ this is not a \-- I\'m
not trying to put this up as a barrier to doing it. It just fits into
what one is naturally trying to do in terms of describing these
services. But if somebody who would have done something on a telephone
which is not reimbursed says, why should I, if I just do it by video now
or just do it in another way, and they get reimbursement. You\'re not
going to end up doing the things you want to do. You're going to create
a huge amount of unmet need. But the ability, since we're using
information systems, and the beauty of information systems, particularly
from my perspective, as you think about using, if this is done over IP
you can describe what this is. This is all very easily soluble. It is
not as though it's a huge problem. But I put to Jay whether he ‑‑

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

If I may, my question is driven around a continual concern and confusion
over the, what I term to myself is the way out, which is pay for it and
everybody will have it. Because in my model, that doesn\'t work in the
long‑term. Unless people see continuous value and can fight and win for
it, because they think it is an integrated part of their business, we
will always have this natural conversation about it. If people would
have it they would just see the value. That\'s why I\'m asking the
question. I think I got an answer that\'s more direct, which is they are
spending time and people are not seeing the value, and you have to
justify the value continuously. It is not part of the business process
that\'s been truly accepted by either the hospital or the physician or
things of that nature. It is not common process. So therefore it is a
new activity.

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

Right.

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

Hence has to be justified. Therein lies the root of one of the
challenges we face. Even if you reimburse, you\'re only changing
behavior, you\'re not changing culture.

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

This is Karen Bell. Could I just ask, Stewart, how are the communities
of providers reimbursed? Are they on salary or is it fee for service?

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

Yes, the staff are salaried.

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

Okay. So it is not, reimbursement is not really an issue for them.

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

It is not individually, but it is at both the departmental and then
obviously the corporate level.

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

Yes, I thought I heard that. Forgive me, Karen, if I mistook the
comment.

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

I was not clear about that, so I just wanted to clarify.

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

The other question, if I can sneak in one, there is the issue of quality
of care and the issue of quality of care you said that quality of care
has gone up. How do you measure quality of care in your environment?

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

Well, when I said quality of care went up I was actually saying that the
people that create cases believe that telehealth has improved the
quality of care. It is really, it is very subjective in that case, I
don\'t have hard parameters to prove to you that the quality of care has
improved. There are a variety of indicators we could implement and look
at. One, it is always a little bit difficult because you can mix quality
with access to care. And somewhat related, I think in, our environment.
The quality of care suffers when we cannot get people to the providers.

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

Absolutely. I mean, our gut says that, I mean, probably our unified gut
believes that. The concern is how do we get clarity on that because it
helps on this whole idea of value.

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

Can I \-- quality of care, there were substantial increases in quality
of care, in terms of the home telehealth, we had increase \-- there's
been reductions in hemoglobin A1c of up to two points in patients. In
terms of the teleretinalimaging, we've seen a benefit in terms of
providing health promotion, very much stresses diabetic control,
benefits in terms of many more patients seen in terms of access to
screening very much earlier.

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

And Stewart, I would suggest that you do have, you do have data to
indicate improved quality of care. As you said in your demonstration,
and as we saw eight, nine years ago in Stebbins. That community health
aide knew when a child came in with chronic otitis media what the
antibiotic gram was and not to give antibiotics. So antibiotics were not
being given, drug/drug interactions were not occurring. And drug
resistant, non ‑‑ and bacteria that had become resistant to all
antibiotics was not occurring.

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

Yes. There are probably a lot that we can actually show, Jay. I totally
agree. I just don\'t have a lot of hard core data at this point to make
a strong statement.

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

I really appreciate that. This is Mohan again. I really appreciate that.
I don\'t mean my question to be pulling down the overall value of your
presentation at all.

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

Oh, no. I guess I wanted to make one statement about the fraud and abuse
aspect, which has really been a perennial concern, I think, especially
with store and forward. And I think it goes back to when people think of
it as being an e‑mail system, that you can e‑mail a Durham consult to 20
providers in 20 states and probably get away with it since a lot of
those systems are not tied together and they won\'t track interstate
issues there. In many respects I think a store and forward technology,
properly done, has a much higher level of ‑‑ should give you a much
higher level of confidence than many live video systems because it is
very highly auditable and highly trackable. In our system we track every
user that touches any piece of information in a system and it shows up
whenever you look at a case. It's pretty hard, you may not be able to
stop the fraud and abuse but you are certainly be able to audit and
track it after the fact.

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

Stewart, this is Jon Linkous. Do you store your images that are used in
store and forward?

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

Yes, we store them right now in our system because in the Indian Health
Service system we don\'t have a system capable of supporting images. But
we are moving to a system where we can actually move those wherever they
appropriately should exist, whether it's a PAK system or whatever.

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

This is Karen Bell. I really hate to jump in and bring this conversation
to a close.

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

Then don\'t, Karen. Let me ask a question.

\[laughter\]

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

It's all yours, Craig.

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

And then I\'ve got one too, Mohan.

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

I want to make sure I understand this. If, Stewart, if I looked at all
the data, the patients love it. The individual doctors love it. We
convinced you that they are getting better care in this last little
discussion. The administrators don\'t like it because they don\'t get a
big enough budget. Is that what I understood? You can just answer yes.

\[laughter\]

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

Can I make one addenda? The administrators would love it more if there
was more money in it.

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

More money in it\>

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

Well, no, I think if the business case were clear to administrators it
would be easier to justify. But generally, yes, we don\'t have any
trouble getting support for the system.

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

So let me rephrase my question. The patients love it, the doctors love
it, but the system doesn\'t love it. System being the administrators,
and the reimbursement, fixed costs, et cetera, et cetera, because the
system is more efficient.

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

Yes, I think ‑‑

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

Just say yes.

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

Okay, yeah.

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

Thank you.

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

Okay.

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

Okay. If I may sneak in one more question before Karen verbally slaps me
on the phone here.

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

I will be quiet.

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

You have in one of your slides IHS expansion.

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

Yes.

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

It describes location of which, some of which I live in. So could you
tell us a little bit more about how we would connect with you in these
specific areas to see how you\'re doing?

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

You mean ‑‑ I don\'t want to miss the question. You want to know
physically how this will, the connections will be established?

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

Yeah. What are you doing? It says IHS and there is a list of ‑‑

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

Yes, expansion ‑‑

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

Yes.

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

Yes. Well, what we are doing, we are actually doing telemedicine in some
of those areas but we are actually building up capacity in most of those
areas. For instance, in the Portland area, we actually have a system in
Yakima, for instance, Washington where they are sending regular
consultation requests to the Alaska Native Medical Center and doing ENT
healthcare that way. The Native American cardiology program in
Flagstaff, Arizona is taking consults and we are taking consults, I
don\'t know if it is back up and running again, but they are taking them
from Catawba, in South Carolina. So there are isolated places where we
are actually providing care, but the bigger picture is that we are
trying to establish fairly large servers with capacity to add sites. So
I think we are looking at a longer term project here over the coming
years to build up, to basically, to match services with the needs.

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

Thank you. Thank you.

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

Well I guess my jumping in a little bit earlier put a damper on any
further discussion which is unfortunate, because this has been a very,
very good, lively discussion and a wonderful presentation, both Adam and
Stewart, thank you very, very much. And you\'re not off the hook,
Stewart, we will be following up on you because we need to get into your
database and work on \--

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

No pun intended about the hook.

\[laughter\]

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

You\'re welcome. Okay.

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

I think we are going to have to make a minor change in the agenda. There
is going to be a discussion at the very end of our next steps. I will
tell you in about 25 words or less that our next steps, I think, unless
anyone has a major problems with this, would be for us to start thinking
about the different models for care coordination for patients with
chronic illnesses and we will begin to pull together some public
testimony on those different models and we'll start moving forward and
we can discuss that more at the next time. But we really do need to
spend the rest of our session together and you have probably up to 20
minutes.

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

Okay.

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

Ken Gebhart from Bearing Point is here to discuss our approach to use
cases. Take it away, Ken. Thank you.

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

Thank you. My name is Ken Gebhart, with BearingPoing. I support Dr.
Loonsk with the development of the use cases. If we could go to the next
slide. I\'m going to try to move quickly but not to exclude
conversation.

This slide, may be, as I look at it, a challenge to read. A printed out
version will be simpler. This is the roadmap slide that I have \-- thank
you \-- I've got this one memorized, burned in my brain. This is the
roadmap slide which Dr. Loonsk introduced at the last AHIC meeting. And
what I wanted to share with you is on the left in the blue boxes are the
use cases that we finished. And as you know, January we went to AHIC and
asked for priorities among the candidate use cases we had put on the
table. We received those priorities for medication management, quality,
and consumer access to clinical information. We had already finished the
emergency responder use cases in December. We have now finished those
three that I just mentioned and we are beginning development on the next
six.

So what I wanted to share with you is that we are at the beginning
stages of defining the scope and the edges, if you will, for the next
six use cases. The first two up there, remote monitoring, remote
consultation, obviously resonate with the entire conversation you had
this afternoon. Also up there is referrals and transfer of care, which
does fit into the chronic care world in a variety of ways; personalized
healthcare; public health case reporting; and response management.

On the right side of this chart, in, to be honest, deliberately small
type, is a long list of needs that were identified in October of last
year by each of the Workgroups and not prioritized for the initial work
this year. We know that those need to be prioritized, they need to be
refreshed. We know that the Workgroups have, in some cases, gone deeper
into those needs, in others they have discovered new needs, and in some
cases the needs have changed over time. So while I\'m going to talk
about how we are starting to move ahead with the use cases in the middle
there. I want to also share with you that Dr. Loonsk will introduce at
the July AHIC meeting a process for asking the Workgroups to help
reframe the priorities for what\'s on the right, refresh the needs and,
in December of this coming year, bring that back to AHIC.

So that\'s two things going on. I want to focus on the use cases that my
team is doing research on and beginning to scope right now.

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

Do you know how many use cases they will accept this year?

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

Our hope is that the six that are in the middle, we are going to write
all of them.

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

Oh, okay.

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

We are staffing up now to do that. We are doing research on all six
right now. We obviously need to get feedback from the AHIC members and
Workgroup members, and I will draw your attention in a minute to an
e-mail that Judy sent out yesterday asking for some of that input, that
will help us better inform those decisions. But our charge, as the
Secretary told us in January, was to move forward and get them done so
we are preparing to do that now.

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

Would these six be done all together and go to HITSP or would they be
broken up as they have in the past in a batch of three and then later in
the year a batch of three?

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

My comments are going to be about when I deliver use cases for AHIC.
Okay. The question about what happens with HITSP is one that we will
have to ask Mr. Loonsk to answer. HITSP has interesting challenges about
capacity and things that I\'m not qualified to speak about. But I do
know that the Secretary asked us to lean forward, get ahead of the
curve, get these done so that there was a backlog, if you will, ready to
go as HITSP is able to take them. So I would suggest if you would like
more information from John about that, we tee up a question for him.

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

You may be clarifying this. But in the remote consultation box, the
third bullet, online consultation, is that inclusive of store and
forward or is it just real‑time synchronous?

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

Both, actually. I have learned a lot from just the conversations you've
had this afternoon. I was listening for a while before I came in, as
well as here, and the frame of reference for that term store and forward
expanded for me in that conversation. What we just finished talking
about in Alaska, for example, put some new twists to what store and
forward means, you know. So for me, it is open for, you know, the
scoping conversation.

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

Right.

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

Let me go to the next slide briefly, here. I'm trying to manage the
time. The next slide talks about our development process for use cases.
Just wanted to share with you, we are obviously starting our work now,
we have a high-level draft description of each of the use cases which
I'll walk you through some of in a few minutes. We expect to develop a
prototype use case which is our first cut at the use case, it is not
fully detailed, doesn\'t dive into all the details that we think will
need to be there in the end. We will send that out for public comment.
This is a process we have used for the last use cases. In this instance,
we will be moving to a standard of four weeks of public comment to give
organizations more time to respond to that. Yes, we know that you were
challenged this last cycle with the need to get something to HITSP so
they can work on it and deliver standards at the end of this year. But
we are committed to this, and we are anticipating getting the prototypes
into that public comment process probably mid-August.

So we will take the feedback, we disposition it. We build a detailed use
case, in draft form. We send that through another round of public
comment process. And our experience has been that we can generally turn
around the final, detailed use case in three to four weeks. So our
intention is that by the end of this calendar year those six use cases
would be there as long as they are committed to a process that the
feedback says go.

So if that\'s all right, I would like to spend just a minute walking you
through one piece of what was in the e‑mail from Judy. I have handouts
from those of you in the room. I didn\'t know if everybody had it.

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

I sent it to everybody.

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

But just for convenience, let me put these down.

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

Yeah.

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

What I\'m going to call your attention to here \-- I'll kind of watch
the time \-- is the draft descriptions of use cases. The third page in,
the title, cover page looks like this. What I wanted to do is just go
through the use cases as we have currently drafted them. We are sending
this out deliberately looking for the feedback. What we are going to do
with your feedback is assemble it into themes at the end of next week
and bring the themes of that feedback, along with our thoughts about the
best way to disposition those comments, to the AHIC meeting at the end
of the month. So I\'m going to suggest just in the interest of time that
I walk you through two of the use cases that are most prominent for this
group based on what I\'ve heard. The first one, which starts on page 2,
is the remote monitoring priority area.

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

Can you just, for the 2008 use cases, that will be done at the end of
2007?

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

That\'s correct. There is the ‑‑ if the label of \'08 versus \'07, is
that confusing?

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

A little.

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

Maybe, if I could just jump in for a moment, for our newer members. The
process that we have developed is that the use case is the first step
\--

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

Okay.

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

‑‑ for the entire interoperability process and beyond. So the use case
is sent to HITSP where they develop the interoperability standards. It
is also sent to the Certification Commission so that the certification
process can be linked into the NHIN contractors and the privacy and
security contract as well as others. So the use cases are really the
first step that we are using to develop the work of our other
contractors.

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

So the 2009 use cases are going to be on a ‑‑ very quickly.

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

Well ‑‑

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

Prioritizing the needs. Prioritizing in those areas ‑‑ we will literally
after the July AHIC meeting send you a formal request to help define
those needs and ‑‑

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

Got it.

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

All right. So I\'m going to look at remonitoring, page 2 of the e‑mail
from Judy. The highlights obviously are directly at the heart of what
you have been talking about. Prioritized needs that are derived from,
I\'ve got two documents here. I will just wave them in the air. The
October, 2006, prioritized needs that the Workgroup developed also was
summarized, some of you may remember this wonderful diagram. That\'s the
gray and yellow priority chart from last fall. This is, between the two
of them, those are our Bible, if you will, as the starting point for
what was prioritized for development.

We know that some Workgroups will go beyond those needs. Some have
clarified extensively what they need. What I've listened to in the last
couple of hours has helped immensely solidify for me the aspects that
you\'re looking for. What we have tried to do is turn that into a short
page and a half description of the use case and get your feedback on
that before we start, end up with the development of the prototype.

Just a couple things I want to hit on here that I really would welcome
your feedback on. One of the things that has come up is whether or not
secondary use of remote monitoring data should be within the scope of
the use case. And I don't know the answer to that, I know it is a
question, if you will provide comments on that thought, that would be
real helpful.

Down at the bottom of this page are some working assumptions which I
think are crucial for the feedback that we are looking for. The first is
that we are focused, in remote monitoring, on devices in the home care
setting. I want to think about that. We have seen schools mentioned and
we have seen other things mentioned as we have talked about telehealth
here. It suddenly, where is the boundary going to be for this use case
becomes a challenge.

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

Eventually it will be wherever the patient is.

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

Right. So geography, physical location may not matter. May matter more
in the nature of what\'s occurring. We've also, a working assumption
that the focus of this is on patient-to-clinician communication of these
physiological measures.

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

Clinician being defined very generally.

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

Yes.

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

And you ‑‑

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

Absolutely. As you mentioned in earlier discussion today there is
frequently most commonly a care manager, a case manager, some role in
the middle sort of watching stuff day by day. Whatever the primary role
makes sense for the situation. And then escalating concern or whatever
makes sense to a provider based on what\'s happening. Okay. So we are
trying to build that, deliberately into the use case. What we are
suggesting is that one of the edges here is that the telemedicine
capabilities, particularly provider to provider, would not be in scope
of this use case. Now, when you think about what we just listened to for
Alaska, okay, we need to think about, was that provider to provider? Was
that telemedicine? I\'m looking for your feedback to this process of,
you know, where do you think the right boundary is for this use case.

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

Do you want the comment now? I would say that the ‑‑ if you\'re thinking
about the intermediate personal care being a clinician broadly you have
to think that person may need to refer on what this is to a specialist,
either in primary care \-- so you need to consider clinician to
clinician certainly in there because I think you will find there is a
continuum of care. If you don\'t do it, it is not really going to do
what\'s necessary.

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

Then I think the third comment. We would welcome that feedback.

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

One of the questions that frequently comes up \-- Karen Bell again \--
is when we talk about scope. What is the timeline on scope? And clearly
there are some things that would be necessary and be used within the
next year. There are some things where the scope might not be ready for,
for instance, you know like the HIE NHIN piece. That might not be ready
for another three or four years. So when you talk about scope are you
talking about the timeline that goes on ad infinitum, so you build it
now, you scope it now for all time, or are you thinking about a more
time-limited scope?

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

Well I think it's more time-limited but this is, in some ways, in
the eye of the beholder. What we generally say is we want to be sure we
have accounted for the as-is, what happens today, to the extent that
that makes sense to do. That we have accounted for the near‑term to be,
which in your description is probably the three to five years, as HIEs
take off, as we have the ability to move this data, you know, through
those mechanisms what are the capability that are necessary to
accomplish it? Thinking through the timeline for, we do the use case,
that\'s the start of a long process as you described for HITSP and
others, certification and vendors that deliver products, those products
to be implemented and operational in the market, you know, we are
probably talking the five-year planning horizon. But we need to sort of
hit that target. I would welcome your comments on that as well.

We also need to do, one other thing which Dr. Loonsk always mentions in
this, which is to think about the longer term and at least where it is
necessary, put the beginning elements of what might be necessary longer
term if we know what they are. So I think, that\'s the best frame that I
have for it right now. I\'m just trying to watch the time.

We have a couple things here that I wanted to make sure we also touched
on. The last bullet point on page 2. The impression is that the key is
to get the data from the patient to the clinician. There may be
situations where the data can be delivered in some means other than a
device connected directly. And so we are assuming right now, working
assumption, that this use case needs to include the scenario or the
provisions for a patient who is doing, you know, writing their weight on
a clipboard and either keypadding it in or calling it in once a week or
whatever. The key is get the data to the clinician. We are interested if
that\'s your perspective as well.

I\'m going to not spend much time on the scenarios except on page 3 we
have described three candidate workflows that we think capture these
ideas. Welcome your comments about them.

Then on page 4 is the remote consultation use case. New ‑‑ I think we
have heard \-- and I\'m playing back some of the conversation you have
had today in my mind as I say this \-- the ability for consumer to
communicate with a provider and, again, caution about provider and
clinician probably needs to be calling clinician broadly and provider as
an example of it, but also the ability for a provider to initiate
communication the other way. The criteria around secure and so forth is
all a key part of this thing.

We have included in our assumptions about the scope of this that we feed
to incorporate family members or other key members of the support team
who may have needs or, need the ability to help monitor the patient. The
personal case is one in which my father is a congestive failure patient
and it would be very helpful for me to be aware that he had not logged
his weight for three days in a row, and find out why. So those are the
kind of things we are thinking of here.

We have added one other thing which we think fits into the use case and
that\'s, loosely, the concept of reminders. This could be a health
checkup reminder, this could be some other form of reminder, but it is a
provider-to-patient form of communication. It seems to fit this model of
interaction. So we have put that in this use case, as it came out of the
consumer empowerment use case originally, but it seemed to be one we
could read right in here.

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

Can I interrupt on the priority area, remote consultation page the first
line where it says remotely using computer technologies. I would
probably not put computer technologies. I mean there are devices out
there that do it interactively right through the TV, you don\'t need a
computer, so I wouldn\'t want to keep it restricted.

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

I think that\'s a great comment. Welcome your feedback.

Additions, the bottom of page 4, this may be fairly generic but we want
to make sure we are calling your attention to the question of whether we
should be weaving in the provider workflow issues in this particular
area. That can be tied to the reimbursement conversations you have been
having. We are trying to find a way to tee that up.

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

Could I ask a quick question?

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

Sure.

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

You \[inaudible\] in more acute patients \[inaudible\].

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

We are \--

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

Seems to me you would be very wise not to specify \[INAUDIBLE\] the
legal issues associated.

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

If you are thinking acute as in a hospital based ‑‑

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

I think once you get caught up in the minefield of your
monitoring people having MIs at home, you then get into, if you\'re
dealing with acute situations, about providing acute services to deal
with what we find. If you're dealing with chronic disease, you'd be
wiser, in my opinion, you'd end up dealing with things that will not
require acute interventions ‑‑

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

Yeah, but what \-- I understand exactly what you\'re saying. But the
problem is, that you may be, you have a patient with chronic illness
like diabetes who is having strange chest pains.

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

And you make sure what you do is they use 911 and they go down the
traditional route.

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

Yeah, but the problem with that ‑‑ once again, totally agree if it was
that clear. The difficulty is fifty percent of people in the United
States who die of a heart attack die outside the hospital and the reason
for that is they've delayed their care because they didn\'t understand
their symptoms.

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

\-- experience with 26,000 patients. And the advice going through, that
exactly what you say, but who is therefore responsible, because you\'re
monitoring. That care coordinator who's monitoring, you have a very
complex raft of services you have to start doing. You end up creating
something which is fiendishly complicated. Much easy to tackle acute
care later, once you've got chronic care worked out ‑‑ just in the
short‑term make sure they to do 911. What I\'m saying, it would have
been ‑‑ you bite off more \--

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

Built in.

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

But I understand. This is an offline ‑‑ we are having offline ‑‑

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

That\'s right.

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

Thank you.

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

These are definite ‑‑

\[multiple speakers\]

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

Unbelievable.

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

Baseline nature of the feedback we frequently get in public comment
process is I would expect to hear a fair amount about that point. I
think this is probably a place for me to stop and ask questions given
the timeframe.

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

That would be great. Thanks very much.

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

I just want to reiterate, in the letter that was sent out, that comments
are due back by July 25th in order to be incorporated into the
presentation on July 31st. I know that\'s a very tight time frame. I
think with this Workgroup pushing forward, I think it is critical we do
take a chance to review them and provide feedback. All feedback should
be sent to the following e-mail address. It's usecase, one word, at hhs
dot gov. You also should have received this e‑mail in your inbox, so
feel free to just refer to that as well.

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

Are these first two, have they been sponsored by this Workgroup or ‑‑

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

They have been promoted by this Workgroup, yeah.

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

We recommended that this be a priority for the AHIC to develop these use
cases.

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

Judy?

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

Yes?

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

This is Jeff Rideout. Given that the use case as proposed is relatively
short is there any problem with putting our edits right on that and
sending that in?

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

That\'s fine.

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

As opposed to that separate form?

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

That\'s correct.

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

That\'s fine.

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

Okay.

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

This is Eric Larson here. I\'m trying to put these ones that are coming
from our group in the context of the ones that wouldn\'t be coming from
our group. I was struck by the public health case reporting and this
notion of bi‑directional communication. Is it assumed that, in our, in
all of our use cases, bidirectional communication is a given? Or do we
need to specify something like that?

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

I would say that bidirectional communication has a very specific intent
in the public health arena. Different, largely different, than what we
have just discussed.

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

Okay.

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

There are some variations on that that we could get into it. But it is a
different kind of intent for the most part. So I wouldn\'t use the
generic label ‑‑

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

Thanks.

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

Go ahead.

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

I was going to ask, not as detail. Maybe it is not appropriate as part
of this or does it fit into the comments of ‑‑ it is not clear to me is
we have very few cases from 06 and 07 going into \'08. How they build
upon each other and build towards the broader vision we are working for
and is that something that goes on then behind the scenes of these use
cases and how, how these fit together and fit into that larger vision of
promoting Nationwide Health Information Network and health information
exchanges and I know the focus now is just on getting the words around
the scope of these use cases, but how does that happen and should
comments come back to that regard as well if there are connections
that ‑‑

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

I think any comments would be welcome. I will say a portion of this.
Dr. Bell may have other things to contribute for this one. We are
working internally with the use case team to build this vision of, this
visual, if you will, of how, what have we addressed of the needs that
have been identified through the Workgroups in AHIC? What\'s remaining
to be done? The question of how to tie it to, broader goals, that ‑‑

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

And I think you\'re also talking about priorities. You know we certainly
have some, and how do we determine the priorities moving forward? And
again, I think, and I'll echo Ken\'s comments, I think the feedback from
the Workgroup, from the public will be very helpful in terms of moving
that forward, so definitely we welcome that comment.

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

Thank you.

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

Ken, thank you very, very much. I'm sure you'll hear lots of good
feedback from this group.

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

Looking forward to it.

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

We actually have not a huge amount of time for public comments but we
have some. I guess we are ready to open the lines, if the chairs are
willing to call the meeting to a close.

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

Yes.

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

Yes.

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

Thank you.

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

This is Jennifer. I've just put a slide up. People who have been
listening over the Web can call the number there. People who have been
listening over the phone just need to press star 1 to alert the
operator. There is an e‑mail address there if anyone would like to write
in comments after the meeting. I will check back with you in about a
minute or two.

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

All right.

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

And in the meantime, this is Karen Bell again. I will just announce that
our next meeting \-- what number is that going to be, our 18th?

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

Eighteenth.

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

Our 18th, my goodness \-- is September 27th. Everybody has got the month
of August off. Enjoy it. But you still have to do the feedback.

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

After July 25th you have a month off.

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

That\'s right. Anyone interested can certainly tune into the July 31st
American Health Information Community \--

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

Karen, did you just say September ‑‑

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

27th.

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

27th, thank you.

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

And the American Health Information Community on the 31st of July is the
one where the use cases will be discussed and prioritized.

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

And that will begin at 9:00 rather than 8:30.

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

That\'s correct.

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

And that's over at HHS.

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

Right.

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

Karen, Eric Larson here. If you\'re looking for discussions on the
different models for care coordination, I could help you maybe get
somebody like Ed Wagner or somebody like that if his schedule would
permit. I think he would be a good discussant.

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

You\'re absolutely right. Thank you.

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

Okay.

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

We will work with you on that.

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

Yes.

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

This is Jennifer. It doesn\'t like we do have anyone calling in today.

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

All right.

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

Craig, do you want to move to adjourn?

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

You just did.

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

Okay.

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

Well, thank you everyone.

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

Thank you.

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

Very good meeting. Appreciate everyone\'s input and time.

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

Bye‑bye.

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

See you in September. Bye‑bye.