American Health Information Community

EHR Workgroup Meeting

May 2, 2006

1 p.m. EDT

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

Okay, Lillee, you can go ahead.

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

Okay, sir, ready to begin.

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

Good afternoon, everyone, and welcome to this May 2 Electronic Health
Record Workgroup conference call. My name is Lillee Gelinas, and I have
the privilege of co-chairing the EHR Workgroup with Dr. Jonathan Perlin,
who is the Undersecretary for the Veterans Administration. Matt, if we
could please run through a roll call that would be very helpful, so we
know who is on the line, and hopefully our colleagues at ONC have been
able to join.

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

Sure. Joining us on the call today, Dr. David Brailer; Howard Isenstein
from the Federation of American Hospitals; Colonel Bart Harmon,
Department of Defense; Connie Laubenthal from the American College of
Physicians; Dan Morelli from AtlantiCare, Pam Pure from McKesson; James
Sorace from CMS; Chantal Worzala from the American Hospital Association;
we have Jason Dubois in the room at ONC along with Co-chair Dr. Perlin.
Is there any other Workgroup members on the phone who I failed to read
off?

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

This is Jon Houston, I\'m on the phone.

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

Any others? Okay, Lillee, that looks like it.

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

That\'s great. And Matt, do we have a live feed into the ONC group,
where I can call on Dr. Perlin?

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

I believe so.

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

Good afternoon, Lillee. Good afternoon, members of the Workgroup, this
is Dr. Jon Perlin. Appreciate everyone joining today. Here also Karen
Bell of the ONC staff, with a number of other individuals who have been
participating in the calls, as well.

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

And Jon, as I understand our charge for today, really, just so everyone
knows, we do not have a formal agenda. So if you\'re speedily going
through e-mail looking for one, there\'s not one. That\'s because we
wanted to spend the majority of our time on two very important topics.
At our previous call we asked for some presentations around first
responders, so that we could begin to address the Secretary\'s charge to
us around creating a first responder system as soon as we could. And the
second most important topic for today\'s call is the letter to Secretary
Leavitt considering the background and discussion and our
recommendations. Which we really do need to have good and robust
dialogue around. I know our expectation is at the end of this particular
meeting we would be able to achieve consensus around those
recommendations.

So with just that bit of intro, Karen, would you like to get us started?

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

Thank you very much, Lillee. Actually, if we had an agenda the very
first thing on it would be some comments from Dr. David Brailer, who is
on the line with us right now. So if it\'s acceptable with you and
Dr. Perlin, then perhaps Dr. Brailer could make comments at this point.
Thank you.

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

That would be wonderful.

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

Okay, thanks, Karen, and thanks, Lillee. Let me just try to frame some
of the discussion for you all where you are today. By doing that, first
I want to thank this Workgroup in particular for some very, very hard
work. I think this group has really been our benchmark of making
exceedingly good progress, exceedingly thoughtful progress that balances
policy and technical issues and long range and short range. It\'s really
been just remarkable, I just wanted to thank the members, but also
Lillee and Jon for just the outstanding leadership.

May 16 is a major event. That is when we\'re really going to move from
the thinking phase about what we should do to the very specific action
phase, and your work is going to be very much part of that. At the
American Health Information Community we\'re going to do three types of
things with respect to your work. First, we\'re going to listen to your
recommendations. Which will be things, as you know, that are motivating
the specific charge, the near term breakthrough around lab data. I know
you\'ve been looking at draft recommendations, and those are far along.
But whatever recommendations you put up and present and submit via draft
letter, we\'ll have time reserved for substantive discussion by the AHIC
members on a line item-by-line item basis.

I.e., they won\'t just listen to your discussion and say thank you.
We\'ll present each recommendation, and we\'ll ask the AHIC to discuss
it and to take action on it, if they\'re able to, and actually could
include consensus endorsement to transmit it to the department, could
include modification, it could include sending it back for further work
in the Workgroup. But we do expect to have a substantive discussion on
that topic.

Secondly, I\'d encourage the group if there are any issues that are
major issues that you\'re seeking guidance on, if it either hasn\'t come
to the point of a recommendation or if it\'s an abstract issue or
something that\'s really helping move you towards the longer goals,
we\'d ask you to present this. A topic that requires the AHIC to help
you break a log jam, be able to understand directionality, to get good
people thinking about a topic.

And then finally, to get a glimpse about where you\'re going in the
future, meaning after May 16. And this is an important transition,
because while we\'ve been working very, very hard to get specific
recommendations through and underway so they can pass through the
department and other government agencies, private-sector entities, in
enough time to have something material occur by the one year deadline we
set for ourselves for the short-term breakthrough, we\'re going to then
turn to a slower, more purposeful, more meaty activity around the
longer, the broader charge, the broader issue. Which yours is obviously
quite broad.

And with that, we do want to recognize you all have been working very
hard, so we\'re going to step back and pace this a little bit more
thoughtfully, add more time for hearings, for deliberations, for fact
finding, and give you time before you come back to the AHIC the next
time.

Now, you might want to come back earlier than a few months from now, but
we want to make sure the work fits your capacity to do this, and the
magnitude of the issue that\'s at hand.

So I think we will stop being so much the taskmasters and let you really
dig into the topic that\'s at hand.

With that, again I just want to say thank you all very much again, it\'s
really just been a remarkable experience here, and we\'re looking
forward very much to some hard-hitting and very specific recommendations
that I know you\'re brewing, to let the AHIC really put this into high
gear as it moves into the department. Thank you all very much.

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

Thank you, Dr. Brailer. And you may have heard well wishes from Jon and
I on our last call, you were unable to be with us, but the announcement
about your change had just come through, and we had wanted to thank you
immensely for your leadership. Because the way we look at this, I
suppose you could use the analogy of the railroad. You laid the tracks
down, and we put the train on it.

So thank you for that, because you created the environment, the venue,
and the avenues in order for us to succeed. And Jon, I certainly want to
you weigh in, but I have to tell you this has been an enormous privilege
to serve with Jon, the capabilities have just been incredible. Where I
fail, he shores me up, and hopefully vice versa.

It has been a tremendous opportunity, and you were brilliant in the
Co-chair appointments, I think. And that with the incredible brain trust
of our Workgroup, who we trust, who we have very open dialogue with, who
we deal with tough stuff with, we\'ve been able to achieve some
remarkable progress in a very short period of time.

Jon, what would you say?

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

Let me say simply ditto. First, let me thank you, Lillee, for your
leadership, and all the hospital self-systems providers that you
represent. Again, endorse just the thanks to the Workgroup membership,
to the ONC office, Karen Bell in particular.

But David, it\'s been a privilege having you in this capacity. I know
that we will have the great privilege of working with you in an ongoing
capacity in your new role, and continuing role with the AHIC. And so I
would on behalf of our Federal colleagues thank you for laying the
track, representing the President and Secretary Leavitt, in terms of
something that will forever improve the health care that we\'re able to
provide.

So many things for that. The task, as we all would agree, is not over,
and we look forward to the continued work ahead.

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

Thank both of you, it\'s really very kind. And you\'re right, I\'m
hardly going anyplace. So I think AHIC will continue to make great
progress, and I\'m certainly eager to be there to participate, and to
make sure the revolution we\'re trying to brew is going to move forward.
So thank you, that\'s very kind.

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

Lillee, I should let you know I have the advantage today of being in the
ONC offices and their new space in the Switzer building. I know people
who have not seen it in person, let me describe it. I suspect the ONC
staff will not miss the unfurnished cubicles of the Humphrey building.
So a pleasure to be in this new space here.

As Karen said, there are really three items today, and we appreciate
Dr. Brailer offering some opening thoughts, and also giving us some
insight into the road ahead and the expectations before us. Not only as
a Workgroup in terms of presenting our recommendations, as consensus
recommendations at the AHIC, and being prepared to both discuss, defend,
amplify, as may occur with the community discussion.

We have two additional tests that are ahead. First, we need to come to
closure on our document. I would note that I would want to take that up
as our first item of business. Because the other item, which is very
important to our country, to Secretary Leavitt, in terms of sort of
nailing down the form and content of the necessary first provider, first
responder information, for disaster preparedness, is something that has
a number of fairly previous presentations associated with it. But I know
that four absolutely phenomenal experts will be able to join us. But
they\'re schedule for later in the meeting, they had some time
constraints.

So I think in terms of making sure we have the privilege of their
insights, their thoughts, which we\'ll really need to grapple with
whether these are discrete elements that are pulled out of an electronic
health record, or what the form of making these data available to first
responders might be, we\'ll need to come to that as the second item of
business.

Thus, in preparation, we want to begin really making sure that we can
come forward with full confidence and full consensus on the
recommendations that we would offer to our colleagues on the broader
AHIC and to Secretary Leavitt.

We appreciate, David, the comments you\'ve made on the Workgroup
deliberations thus far. It is reassuring that there has been the ability
to channel the broad, the specific charge, into some actionable items,
particularly as they relate to the area of laboratory information.

Obviously, this has been an interesting and complex area. There are many
different parties to the transmission of information, the interchange of
clinical information that really embrace all the players in the health
care environment. There are many issues that conjure up some important,
sometimes challenging, relevant policy issues. Some of those policy
issues are regulatory. Some of those issues are actually statutory. Some
are State and some are Federal. But despite all the challenges, I think
we have crafted before us a set of recommendations, a framework that
allows traction, and meeting the intent of the charges.

I should let you know that maybe Dr. Bell, Karen, may want to comment on
this further, that we should reserve our discussion to the intents of
the recommendations, not necessarily the wordsmithing. I don\'t mean
words that, you know, have substantive meaning, but all the documents I
understand will be professionally edited so that there is no loss of
clarity, and that they\'re all consistent among the workgroups. So we
should reserve our time for content discussion, not getting bogged down
in these sort of formatting issues.

Karen, would you like to make any comments to that, or anything else?

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

Thank you, very much, Jonathan. I would like to call people\'s attention
to the fact that what you are seeing in this letter is a little
different than what you saw in the last one. We took the comments and
the permission that you gave us to try to craft these recommendations a
little bit more consistent with the formatting of the other workgroups.
But we also had the benefit of getting more information, particularly
around CLIA and HIPAA, so we were able to focus a little bit differently
on the CLIA-HIPAA recommendation.

We also again, as I mentioned earlier, are working carefully and closely
with the other workgroups on privacy and security, so that
recommendation has changed quite a bit. And a good number of the pieces
that were in it were actually incorporated in the body of the preceding
paragraph.

The first recommendation also changed a bit, and I would go on basically
to say that there have been some changes in the crafting of all 10, and
there are 10 recommendations, that you will be presenting to the AHIC on
the 15th. And they do fall in the six categories that are on the first
page of the letter.

We do have a standard formatting for the letter as well, so each letter
from each workgroup will be set up the same way, with the broad charge,
the specific charge, and the major areas that the recommendations
address. A background discussion, and then diving into the key
recommendations, with a short paragraph, perhaps a little bit longer in
some circumstances, before the recommendation explaining it.

There will be references at the end of the letter for further
information, and as you all know, these have been very public meetings,
and so they are available in the archives on the Web.

So again, as you approach the recommendations, they will look different
than the last time. And we would very much hope that we can get
consensus on the content of the recommendations. And again, the
wordsmithing will be done professionally afterwards.

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

As we would dive in I would ask everyone to again keep the big tasks in
mind, what the desired outcome is, which is improved health care. For
those who woke up in the city of Washington today you\'ll see in *The
Washington Post* in the Health section there was something entitled
nurses\' manifest. From the perspective of the health care provider,
rendered somewhat disabled by a broken femur in an acute care setting.
It\'s really a tragic indictment of the shortcomings in all elements in
health care today.

Putting aside the physical infrastructure, many of the issues that were
problematic were issues that in electronic health record, exchange of
health information, would have overcome. Issues such as consistency of
medication, knowledge of allergies, privacy in communication, coherence
of clinical intent among different care providers, knowledge of
preexisting conditions. And germane to our discussion today, laboratory
information.

And I thought as I read that article, wouldn\'t it be nice to flash
forward to that 10 year window that the President imagines when most
Americans have the benefit of electronic health records. And to achieve
this, we all need to think broadly, and I would hope that each
individual on this call would tap into not only your professional
expertise, not only the organizational vantage point that each of us
comes from, but that inner voice that attaches to the kind of health
care that you\'d want for yourself and your family. Or that your wife,
your sister, your daughter, your mother, who was \-- were offering these
words in today\'s *Washington Post*.

With that, why don\'t we actually turn to the letter. And why don\'t I
just introduce \-- perhaps take up some discussion on the first
recommendation. But just by way of background, it starts off again
reiterating what is the focus, the broad charge, the specific charge.
And six key issue areas that are identified.

And maybe for the sake of everyone, I have the documents on hand.
Including the public who have called in, or are following online, I\'ll
just read the six areas, just ask for agreement that this reflects the
body of the letter.

Item 1, necessary steps in migration from provider-focused system to a
patient-focused system, with respect of \-- with respect to the flow of
laboratory information.

Two, the urgent need for endorsed, adopted and interoperable vocabulary
messaging and implementation standards for laboratory results and data
exchange.

Three, CLIA and HIPAA regulations which present potential barriers to
electronic laboratory results data exchange in a patient-centric manner,
particularly in more stringent States.

Four, technical considerations relating to privacy and security, with
respect to patient and provider authorization and authentication,
including accurate patient identification linkage to patient-specific
information.

Five, line business cases for the multiple stakeholders involved.

And 6, assessment, monitoring and research of early adopters\'
experiences and identification of best practices.

I know that was a large piece, this is meant to capture the scope of the
recommendations. Let me just ask if there\'s anyone for whom this
articulation is a do or die issue, and feel it either omits or
overstates any particular area.

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

This is John Houston. The first specific charge, I don\'t remember it
being couched in those terms. Is that still the same?

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

The specific charge for the Workgroup itself?

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

For #1.

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

Are you talking about \--

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

You read off the six items, you read #1, necessary steps in migration
from provider focused system to patient focused.

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

This is an enumeration, these six statements are an embodiment of the
scope of the recommendations contained within the document. Not the
specific charge itself, they are the areas that the recommendations seek
to address in order collectively to support both the broad charge and
the specific charge.

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

I understand that, but are these \-- so these are \-- were these stated
this way before, though, is my point, on our last meeting.

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

I believe they \--

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

Yes. 

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

I\'m sorry? The fifth bullet, the line business cases for multiple
stakeholders involved, was an addition. But the five remaining charges 1
through 4 and #6 are verbatim.

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

And I remember, I was the one that brought up the business case as an
issue, as well.

But perhaps just to get to the targeted \-- and I know we\'re not
supposed to wordsmith, but I was confusing just with the question, when
we say specific charge, I was back up the specific charge for the
Workgroup, that language has never changed from \-- in the past 6
months.

In terms of the necessary steps in the migration from provider-focused
system to patient-focused system, yes, we have talked about that in many
respects in many venues in a number of different ways. We also, on a
call probably two calls ago, talked about this issue in relation to the
Consumer Empowerment Workgroup. We just wanted to make sure we
weren\'t \-- I don\'t know any other way to put it other than stepping
on toes, so to speak. But I\'m sure we could look back in the archives
and get you some of the good dialogue we had around this issue.

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

When I read it, when I look at it again after it having been read here
today, I just \-- I did not \-- maybe I was focused on other things when
I was reading the \--

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

Maybe I can ask, is there a particular concern that you\'re trying to
highlight, having understood that these are identical to what they were
at least in the last iteration, last conference call. Is there something
that you want to get at?

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

No, there isn\'t, I just \-- I\'m looking at it again, and I just \-- I
guess my thought is the word "patient-focused" versus
"provider-focused." I guess it\'s in terms of \-- not in terms of who
owns the information as much as how it\'s being structured.

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

And John, maybe I \-- my interpretation \-- and this is a nit, but I
think meaningful, it talks about the evolution from a provider-centered
model to a patient-centered model. I personally think both will continue
to exist.

There is always going to be a provider-centric model of information
based upon what that provider is doing in the patient\'s life. I think
the patient-centered view is an additional view, or another option, just
like there\'s a nurses\' view and physicians\' view. So my reaction
after going through this \-- and I don\'t know if this is the same point
that you were on, John \-- is to me, the patient-centered model is
incremental as opposed to instead of. And when you read this, it looks
like it\'s an evolution to something else, as opposed to incremental.

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

Okay, maybe that\'s my concern. I know that there is \-- there are State
laws that make it very clear that the providers, you know \-- at least
in Pennsylvania at least, is the custodian of the record. And I think
that at least as it relates to information that the provider collects
and creates on behalf of the patient.

So I just want to make sure that we\'re not \-- I just want to
understand whether we\'re advocating for this system to be one for which
the patient has total rights over, or one for which \-- is structured
simply so that it allows the information to be available for patient
care \-- patient \-- for purposes, really, to the patient regardless of
where the patient is.

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

Jason, you wanted to make a comment.

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

Yeah, and I think we talked about this earlier, we realized that
physician adoption of health IT was particularly low, and we wanted to
help both intentivize increased adoption, but with physicians. Kind of
looking at it from the physician\'s perspective. And then would kind of
help achieve the broad charge which we talked about being more like a
RHIO model. That it was this evolutionary model where, you know,
provided we get more physicians to plug and play, with the
physician-centric, that eventually you would be able to move toward the
RHIO. And I think this talk of the migration from provider focus to
patient focus is just \-- you know, perfect, quite frankly.

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

What? I didn\'t hear the last thing you just said. It\'s what?

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

A perfect way to spell that out, about how we\'re going to be trying to
move that way, but they need to do more to help get more of the
physician-centered perspective in, especially with adoption, at least to
date, particularly low.

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

Right, but are you saying \-- what I\'m saying is a little bit different
than a migration to. I\'m suggesting that in addition to. Because the
physician is always going to make a decision or in many cases are going
to make a decision when something is ready to be sent to a patient, or
the patient\'s record, is likely to be a subset of the overall
information available to the physician or to the hospital, or to the
home care provider.

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

Maybe I can offer a friendly amendment here, let me try this out. Is it
necessary steps in the evolution \-- I\'m sorry, necessary steps in the
development of provider-focused systems, and evolution to a
patient-focused system \-- I\'m trying to capture \-- if I\'m hearing
what people are saying, it\'s that we need to embrace and support the
evolution of the current system, including uptake of electronic health
record use, at the same time the broad focus is to become more of a
patient-centric system.

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

But I guess my only point is the provider model never goes away. So the
patient model is incremental. To the provider.

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

But you know, from our very first meetings the discussion was that, you
know, one of the challenges for \-- when you think about the nurse in
*Washington Post* today, the issue was the information didn\'t follow
her.

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

I\'m not saying the information doesn\'t follow \-- doesn\'t get to the
physician, but there is a provider view of data and, you know, a patient
view of data, and there will always be two different views of that
information.

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

But is that the same as a patient-focused system, or \-- are we talking
about a view of the information versus the ultimate goal for the
trajectory of both the health information and the system? I ask that as
a question.

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

I understand your point, Jonathan. I think I\'m in agreement with your
point, and also I guess, you know, I guess what I\'m \-- what I\'m
trying to communicate, and not very well, because you\'re correct in
your view on this, is that having a patient-centric system doesn\'t
eliminate the need for a provider system.

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

Maybe actually \-- I think you\'ve just provided the answer, then. I
think the broader system is \-- the goal of the broader system is to
become more patient centric. But the view that \-- you know, one we\'ll
never eliminate nor would one desire to eliminate, the provider view to
the information.

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

That\'s right.

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

That said, would a better phrasing here, necessary steps in migration to
a patient focused system with respect to the flow of information,
laboratory information?

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

Can I \-- or \-- is what we\'re really talking about is making sure we
have a more holistic view of the patient\'s health information, and one
that is not, rather \-- is not rather stored and managed on a provider
by provider basis.

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

Exactly.

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

That to me then is missing in the way this thing \-- this is worded.

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

I think you\'re right, I think that\'s what we\'re struggling. I think
we all are thinking the same thing, but it\'s not coming out as clear as
I think it needs to.

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

Maybe instead of a phrasing like provider focused we use a peer to peer
system, to a \-- you know, whole system. To a whole system of some sort.

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

It\'s really not provider focused right now, it\'s really encounter
focused, right?

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

It could be provider focused.

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

I think we want to make sure we don\'t miss the major point of the
meeting, which are the recommendations themselves. I hear the intent
here, and I think we\'re going to have to work on the phraseology. The
provider view is not mitigated by a patient-centric world, and that\'s
really what we want to capture. And do we have consensus, but that\'s
the concept we want to capture?

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

Yes.

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

Yes.

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

Yeah.

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

Terrific. Karen, can we task that, and if there\'s a sentence by the end
of the call, we\'ll come back to that. But I think we\'ve got the
intent. I also don\'t want to undermine what was the work of the group
ands actually was captured verbatim, looking at the note that was just
provided to me, of a previous call, that in fact was the consensus
phraseology previously.

It may have been the consensus, but I think we\'ve captured the
consensus spirit, if not the words, and we\'ll come back to that.

Background discussion I think is simply recitation of history, and it\'s
very well done. Let\'s move to the key recommendations, and I would ask
my esteemed Co-chair, Lillee, to take us through recommendations \--
I\'m sorry, Jason, you have \--

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

Just one more thing, and I brought this up the last time. You
certainly \-- I talked about \-- it\'s in the last paragraph of page 2,
there\'s a piece most labs will only provide results to ordering
clinician. You did add a piece in there that did say many States
prohibit labs from providing results to anyone other than the ordering
clinician. I think that can stand alone, and we can take out the
previous piece. Because I don\'t think that \-- I think they\'re saying
the same thing, and \-- I think it\'s (technical difficulties) to say
the labs will only provide results to the ordering clinician.

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

You know, let me just challenge this on sort of \--

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

It\'s both the ordering clinician and his or her designee.

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

Let\'s say conceptually I don\'t disagree with you, but if I\'m someone
trying to read this who doesn\'t have the luxury of the context and
background we all have, would I understand that.

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

Well, at least worded this way, then, Jonathan, what it\'s suggesting is
the labs refuse to do it, and I don\'t think it\'s a refusal on their
part. It actually speaks more to the latter statement, in that it
states, "Don\'t provide them the ability to disclose this information."
It prohibits them.

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

If we inverted that after the colon had many States adopt \-- or the
word "clinician," comma, and most States will only provide \-- and most
labs will only provide, would that remove your objection? So it\'s now a
dependent clause clarifying many States prohibit?

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

Maybe that could be changed to change "will" to "can." Most labs can
only provide results to the ordering clinician.

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

Or allowed?

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

\-- the words were there but that is an important \--

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

Good pickup.

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

I think we\'ve got concurrence on that. All right, let me \--

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

Ready to go?

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

Recommendation 1.0, time to go.

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

Jon, just as a point for time, should we read the supporting paragraph
or just the recommendation?

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

I think just the recommendation, if people \-- again, if these are
do-or-die issues. But \--

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

Yeah. I am noticing just on our call today that the majority are \--
were present for our last call, so we should \-- that helped us with the
wordsmithing of the recommendation, so I\'m hoping we can just think
back what some of our thoughts were, but the first recommendation had to
do with laboratory results as they related to provider and
patient-centric models.

Recommendation 1.0 is that HHS should take immediate steps to facilitate
the adoption and use of endorsed standards and incentives needed for
interoperability of lab results within the current provider-centric
environment. ONC shall work with multiple stakeholders to develop a
detailed workplan to achieve patient-centric information flow of
laboratory data in 2007.

So with that, let me open it up for discussion. And one key piece I do
want to point out in the description paragraph, we do \-- the very last
sentence does talk about the patient-centric model does require
addressing both technical and legal privacy and security issues.

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

This is Chantal, just a clarifying question, since unfortunately I
couldn\'t be on the last call.

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

Sure.

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

This recommendation doesn\'t spell out what it means by incentives. Are
those the incentives that you\'re thinking about further on, with
Federal delivery system in recommendation two, adopting the standards
and maybe putting that into contracts, or were other incentives also in
mind?

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

I\'ll respond to that, Chantal. It\'s Karen Bell. The reason we set it
up this way was to assure that we would take immediate action to
essentially facilitate physicians currently getting access to the
information that they order electronically. However, we do also
recognize that we will need to make a lot of changes in order to move
forward with a patient-centric model. So this is essentially our \--
recommends to the Secretary that we attend to the current situation as
well as develop a clear, concise workplan for moving to a more
patient-centric model in the future. It is not more specific than that
at this point because the specificity resides in future recommendations.

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

Future recommendations in this document, or just coming down the pike as
we continue our work?

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

The document. For instance, there are 10 recommendations altogether. A
little further on there are recommendations about incentives related to
the business case, for instance.

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

Okay, I just wanted to clear up if that\'s what you were pointing to or
if it was something else. That\'s great, thanks.

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

Good discussion. More? Just a couple key words, here, to point out to
you, remember the word "adoption" is clear in our broad charge, no
matter what we do. And the concept of addressing the issues of multiple
stakeholders. Across a very detailed workplan that\'s yet to come. But
we wanted to capture the spirit of all the different stakeholders that
were involved, here.

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

Lillee, Carolyn Clancy has joined us.

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

Great.

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

Hi, Lillee.

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

Hi.

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

I just had a quick question, again I\'m responding to the sense of
urgency I\'m hearing around the AHIC table, and there\'s a couple of
possible answers to this. Do you want to put a date on that, in \'07? A
skeptic might say oh, great, we\'re going to develop a workplan. I\'m
just pushing a little bit here.

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

And we have until December 2007 to do it?

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

That\'s what I mean. I guess if we went by the fiscal year we\'d say by
the end of September. But I guess I would suggest a date certain. Even
if we push back on that, even if we have to extend it, at least it gets
people\'s attention that this isn\'t like oh great, breathe a sigh of
relief, we\'re not really doing it again.

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

I think that\'s very true. And we can live with pretty much any date
that the Workgroup thinks is a reasonable time frame. What about June?

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

Go for March.

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

Match? Will you help us?

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

Yes.

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

We can do March.

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

This is Jon Perlin. I absolutely like the specificity.

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

Karen, are you saying you can do March?

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

Yes.

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

Really. Notification for \--

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

We are hiring staff. 

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

If you can do March, then, March 31, I guess.

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

You all are going \--

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

You all are going to have to help, though, you realize?

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

Yes.

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

We\'ll put down March 31. Thank you.

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

Thank you, Carolyn. With those comments, are we done with recommendation
1.0?

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

I think so.

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

Okay. Jon, do you want to take the next one?

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

Sure. Maybe we\'ll take \-- we\'ll see how it goes, take them
individually, and then if it\'s easier we\'ll move block. Recommendation
2.0, HITSP should identify and endorse vocabulary messaging and
implementation standards for reporting the most commonly used laboratory
test results by September of 2006 so as to be included in the CCHIT
interoperability criteria for March 2007 certification. HITSP must
consider CLIA and HIPAA regulatory requirements as appropriate.

Any discussion, any do or die? We\'re fairly specific and technical on
this recommendation.

Okay, let\'s take recommends 2.1. Amplifies, Federal delivery system
should develop a plan to adopt the HITSP-endorsed standards for
laboratory data interoperability by 2006. Any comments?

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

I think that needs to be clearer about what is meant by "Federal
delivery systems." I assume we\'re talking about systems where the
provider \-- where the Feds directly provide the care as opposed to
contract. Am I correct? We would be talking about DHIS, VA, Bureau of
Prisons, DoD, I think we\'d have to be clear whether community health
care systems are \-- I think that\'s more like a grant program.

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

Would you like to make that more specific in the recommendation,
Carolyn?

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

Yes.

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

"Federal delivery systems, parentheses, providing direct patient care,
closed paren"?

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

Yes.

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

Okay. Okay, good. I think I just signed up for some work.

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

I was looking at you while I said that.

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

Well, if Karen Bell at the ONC office can identify March 31, we can
identify December 2006 for a plan.

Recommendation 2.2. Federal agencies and departments with health lines
of business should include the use of HITSP-approved standards and their
contracting vehicles where applicable.

Jason, you have a comment?

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

Yeah, I think in here it should spell out that this should be incentive
driven, or there should be a positive incentive to drive adoption versus
a mandate driven, in this particular section. Especially as people \--
adoption, much like health HIT adoption in the first place has been
slow, that if you mandate it you\'re going to have more problems than
benefits, so that would be the clarification that I think should be
included there.

It\'s \-- Teddy Roosevelt was the stick versus carrot, I like to think
more carrot than stick here.

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

Should we put it in the paragraph above, or do you think it needs to be
right in the recommendation itself, Jason?

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

I think 2.2 is more about Federal purchasing, for example, that\'s why I
think it should belong in 2.2 as opposed to \-- well, they are kind of
alike, frankly 2.1 and 2.2, but if I had my druthers.

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

You have a sentence there already, and I think because some people will
read the bold print, that actually having it in \--

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

Include and incentivize, does that get your point, Jason?

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

Or simply a positive incentive as opposed \--

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

May I ask you as a question? Even though we\'re a health delivery system
we also purchase a good bit of care. There\'s a difference between us
incentivizing doesn\'t really me on the hook. It\'s a little bit softer,
I think I feel less on the hook with that if you include incentivize,
where I want to express it as a positive by incentivizing it, but it\'s
not optional for me not to include it. What are your thoughts on that?

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

I just think anytime you\'re trying to drive behavior, Jonathan, that
the examples they have, be it physician behavior, laboratory behavior,
what have you, I think the best way to get there is by putting money
there. And that\'s how they found physician pay for performance, where
they\'re paying for better care, and I think that\'s the take I\'m
taking away with it.

It kind of reflected somewhat in the last recommendation we have, I\'m
actually in 5.0, should address \-- should assess and develop the
business case for historical lab results, where there\'s a need and
alignment of incentives for all stakeholders, that\'s also taking a
position of a positive incentive to help drive how that information is
being delivered.

So it\'s not enough to say well, I want all the hemoglobin a1C results
for the patient in this \-- (telephone ringing) \-- saved by the bell.
But instead say I want it in these patients and I want it in HL7 format
and I want it to be presented to me in this way, so you\'ll get people
to rearrange their systems to match yours.

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

Jason, this is Howard. Are you talking about financial incentives here?

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

Or \-- yeah, certainly that could be one way.

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

A fairly simple way of approaching this at CMS where we have a quality
improvement program we\'re working physician adoption is simply to try
to have our program try to work to foster the adoption of certified
systems that adopt these standards.

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

I would agree. I don\'t know about the monetary incentive thing. I
don\'t see where the money is on the table here at all.

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

Well, there may be cases where it is, but I\'m just saying \-- actually
there are probably several examples of both.

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

Jason, let me \-- I heard this discussion, and agreeing with your point
on incentives being useful to drive behavior, and agreeing that
recommendation five, Lillee\'s addition previously really gets to the
heart of this change, has to be in there. Would we get that if we change
the language or \-- Recommendation 2.2, with the health lines of
business, should include the adoption of HITSP-approved standards.
Instead of include the use. And go back to the recommendation five, is
the incentivization.

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

The only difference is 5 is specific only to historical lab results, it
doesn\'t mean people changing their existing laboratory information
systems for \-- ongoing incurring information.

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

Maybe we could modify 5, that\'s a possibility. The other possibility is
in the paragraph above, the very last sentence, basically talks about
positively incentivizing. We could add, rather than use regulatory
action.

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

Right. I don\'t think that\'s for all time, quite frankly, don\'t get me
wrong. My only concern here is in the early periods of transition by
mandating it you might be creating more problems than you are benefits.
Obviously over time you\'re not going to need to do that. So I\'m okay
with this.

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

\-- the question \-- when to \-- how they would adopt. The \-- 

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

So maybe there\'s an option here that gets at \-- which includes, slash,
incentivize, and reinforcing the concept and we get to Recommendation 5
as well.

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

I can live with "slash, incentivize."

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

\-- they\'ve done a lot to publicize \-- 

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

Terrific.

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

We can add the part about not using a mandatory approach.

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

Excuse me, this is John Houston. For some reason somebody\'s phone is
dropping out and I\'m only hearing half the conversation.

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

Is it from ONC, from here in Washington that you\'re not hearing things
well, John?

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

Sounds like they\'re may be at the end of the table where the mike
isn\'t picking up well.

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

That\'s I think part of it.

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

We\'ll make sure people come around to \--

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

And while you\'re playing musical chairs, this is Chantal. I want to
understand whether or not Recommendation 2.1, and 2.2 are targeting the
same delivery systems. Specific about Federal agency and departments
with health lines of business, is that the same as delivery systems
providing direct patient care?

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

No it\'s not Chantal. It\'s Karen Bell again. Federal delivery systems
are those that are actually providing direct care under the auspices of
the Federal Government. The Federal agencies and departments with health
lines of business use their contracting vehicle, so that this would
include a very different delivery \-- a very different delivery system.

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

Are we thinking here with the contracting vehicles, this is FEHBP, is
this \--

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

Exactly.

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

Is this Medicare and Medicaid, what \--

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

Yes. All of the above.

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

And what is a contracting vehicle under Medicare and Medicaid? I\'ve
seen this in legislation, as well.

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

I believe that every provider that has \-- that does business with the
Federal Government has essentially a contract. There\'s an agreement
that, at least I as a practicing physician had with Medicare in order to
get paid by Medicare. So that constitutes the contracting \--
contractual entity.

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

So we\'re envisioning under this recommendation that Medicare and
Medicaid would require, for example, physician offices that produce lab
results to use HITSP-approved standards?

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

Or incentivize.

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

Incentivize.

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

I think that\'s a pretty \--

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

Let me, Chantal, set your mind at ease. We\'re not talking about the
bedside tests, we\'re talking about the laboratories that go back and
forth with another organization such as a laboratory services provider.
We felt it would be absolutely impossible, in the office, with, you
know, the essentially testing equipment now that is equivalent of home
pregnancy tests, you know, little cards that \-- you know, provide an
amount of data that is not within this immediate purview, that we\'re
not going to be able to capture that. So this is the sort of thing that
I would order in an office from a \-- you know, laboratory provider,
services provider, and we\'d expect that transaction to be HITSP \--
using HITSP-approved standards.

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

Right, I\'m just thinking about the small docs transferring over to
LOINC, for example, which is required for that data to move from one
place to another.

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

Actually that\'s a very good point, Chantal.

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

Yeah, it is.

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

At the last meeting we agreed that one of the open issues was we do
about \-- what do we do about small physician offices. And as Jonathan
suggested, we agreed they\'re off the table in this discussion. So we
need to make that clear in this document.

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

But it would provide to hospitals who provide more than 50 percent of
laboratory services under Medicare. But again, I think the important
distinction here is whereas we\'re not going to be asking, you know, all
the hospitals the entire country to have HITSP compliant results
reporting, that there would be incentives here to help drive adoption
and transmission of that information in the HITSP-approved standards.

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

This is Jim Sorace from CMS. I was just going to say we are applicable
to give you some degree of latitude on this. Because I mean you
obviously can\'t phase this in nationally overnight.

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

Thank you, Jim.

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

Into provider contracts with Medicare, when vendors are supplying
product that allow you to do it, isn\'t a very \-- you know, it\'s just
not going to happen.

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

But then there will be a market for it, because the \-- if there\'s an
incentive for it, and then they\'ll be demanding it from the vendors.

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

It doesn\'t mandate the use of it.

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

It kind of helps the adoption, because there will be a market for this
to happen, there will be a push for it.

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

And there are other venues like we have through the quality improvement
organizations and some of the work we\'re doing at adoption that we
could use to sort of try to help get these standards implemented that
aren\'t directly financial. Which is the point I was trying to make
earlier.

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

Okay, appreciate the excellent discussion on these. Added clarification,
I think also adoptability, if you will.

Anything else that people want to put forward before we go on to the
third group of recommendations? Terrific, let me turn it back to Lillee,
to 3.0 group.

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

This is great discussion, Jon, exactly what we need before we get to the
May full meeting. Let\'s go to CLIA and HIPAA. Recommendation 3.0. ONC
should review the possible models for the exchange of historical lab
information and determine which would require CLIA/HIPAA guidance,
regulatory change, or statute change.

Now, do you think this is too vague or does it get \-- is the spirit of
the matter here?

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

It\'s too vague, if you ask me. This is John Houston.

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

This is Karen Bell. Let me describe what the intent was, and then
perhaps we can clarify a little bit. There are multiple models for
getting historical laboratory information to providers. Some may require
just guidance, some may require complete statute change. Just as an
example. Right now, having talked to \-- at length with our CLIA
experts, the language is such that there is no definition about time
frame.

It is very clear that a provider who is using the information for
treatment purposes can access that information. It has been interpreted,
because the language in CLIA is vague, and doesn\'t say a time frame,
that that means that it\'s the lab that\'s immediately ordered and
reported on.

However, the law is quite interesting here. If it\'s vague, you need
guidance to interpret it. One just can\'t interpret it on one\'s own.

So that if we simply wanted, using our current peer to peer system,
physicians to be able to access historical data, then CLIA guidance
alone would allow them to do that, in a specific time frame.

If we were to make greater change, if we were, for instance, to involve
a RHIO, if we were to prove a Web-based portal, then we may need
regulatory change, or maybe even statute change.

And so in order to really understand how we can move forward here, we
need to look at all of the various models that exist for both
peer-to-peer, and for patient-centric flow of labs, historical lab data,
and then we need to bump that up against HIPAA and CLIA to determine
whether it\'s guidance, regulatory change, or all-out statute change,
which will take several years.

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

And all are needed here, quite frankly, Karen. Because CLIA was created
in a time when laboratory data exchange, at least at the electronic
level, really wasn\'t off the ground yet.

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

So again, the thought was that this would recommend that ONC, we would
go offline with our CLIA experts and with anyone else we can pull
together, to look at these models, and really get a very strong opinion
about where we could get buy with guidance, where we could do regulatory
change, and where our back is to the wall we have to start a statutory
change process.

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

We talk about it in the next set of recommendations, the issues of how
far authorizations will get us to some of these types of things, though,
also.

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

That\'s true, but we still need to have the HIPAA and CLIA either
guidance reg change or statute to support whatever technical changes or
technical systems are built.

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

Well, since we want our Co-chairs to look great, because they are great,
at the next meeting, I\'m struggling here with the context. Now, we\'re
talking about breakthroughs in the context of the year, the
recommendations are coming to the AHIC in a very short period of time
now, 2 weeks, literally, then the question is, when do you bring this
back. And are we talking about something that\'s here, or will we be
bringing that back to the AHIC at some certain date?

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

It\'s here. We need to do this quickly. We\'re talking about doing this
in months. Yes.

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

Yes. I guess I am also \-- how would I say this, reflecting some
internal conversations I\'ve heard to the effect of that I don\'t want
lawyers telling me I can\'t do what I want.  But the point, again
urgency is \--

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

Right. The intent here is for our legal support to tell us the best way
to get this done. Either through guidance, regulatory change or statute.
But it does need to get done.

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

And I think there are, we\'ve been talking obviously with Dr. Brailer\'s
office, I think there are things that can be done in an incremental
fashion that can get at some of the problems that \-- like for example,
Lab Core and Flex Diagnostic lab was providing laboratory data
information for some of the Medicare health support programs which under
State laws and because of CLIA aren\'t permitted today.

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

This is Jon Perlin. Two things. I\'d ask people to please state your
name, so everybody online can follow. And second, I appreciated Carolyn
Clancy\'s comments on this being somewhat open ended, I just \-- that
just flashed before me the image of Secretary Leavitt really telling us
that we need to give ourselves a deadline here. And I think we need to
attach to it a date certain at the end of the sentence.

Let me ask Dr. Bell, you were particularly \--

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

Ambitious?

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

Ambitious, inspirational, I appreciate that. You\'re putting down
September 2006. Terrific.

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

Are we ready to move on?

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

Good.

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

Okay, Recommendation 3.1, ONC should engage the National Governors
Association and other State-based organizations to resolve variations in
authorized persons under various State clinical laboratory laws as a
resource for clinical laboratories seeking to define access rights to
electronic laboratory data.

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

Could we go back about what we need to resolve?

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

Resolve variations?

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

Yeah.

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

We talked about the different laws at our last call, although I\'m
not \-- this is Lillee, I\'m not totally versed in that. We did want to
call upon, at one of our AHIC full meetings, the Gulf States Governors
Association presented to us the experience after Katrina, and offered
their assistance to us because they see the urgency around this job
getting done. And then we considered the resource that we have as well
in the National Governors Association. To help us.

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

In our ideal state what we\'re saying here is NGA, you guys meet, and
come up with \-- you know, model language on what authorized persons
mean, and then go to your legislatures, and have them change the laws to
adopt this one definition. Is that in our ideal world what we want?

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

This is Karen Bell. I think it may not necessarily be exactly the same
language, but I think the bottom line is that the intent would be the
same. So that there could be the recognition that disease doesn\'t honor
State boundaries, and care doesn\'t either, so that we need to find ways
to assure that care can be consistent across State boundaries. And one
of the ways that that can happen is to address this particular issue in
terms of who is authorized in various States. To receive laboratory
information. Because we do know that there are some States where only
the ordering physician is authorized.

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

This might be a little radical, but can we say to resolve variations,
including \-- you know, legal, statute, State statutes, including
changing State statutes, comma, in authorized \-- something like that,
to just where we\'re trying to go?

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

This is Carolyn Clancy again. I\'m not clear, Karen, from your earlier
description of what you sort of revealed or had revealed about CLIA,
that the issue isn\'t a State statute so much as it is kind of commonly
accepted practices. We here in Virginia, for example, have simply \--
this is hypothetical and mythical \-- have come to accept the language
of CLIA to mean that if Dr. Perlin ordered this test and that, are we
authorized to get the results. That\'s clearly not written in the
statute. I\'m not sure you need a State statute to overcome that,
necessarily.

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

Jason, what would your members be comfortable with?

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

I think both are important, because I think one is kind of low-hanging
fruit. And Dr. Clancy is right, that there isn\'t any clear
understanding \-- or isn\'t any clear case law, quite frankly, that
explicitly says that that\'s a permitted exchange. But it\'s kind of in
a lot of situations generally understood that\'s \-- but I think as an
incremental approach we need to help address some of the variations in
our State that would be beneficial. For example, in Georgia or in
Florida, that, you know, to the extent that they could change or define
authorized person to include entities such as, you know, a disease
management organization or a chronic care improvement program, or, you
know, any \-- a primary care doctor, or even I guess managed care
contract, where they\'re collecting this information to help do \-- you
know, to help address health care needs where it\'s not permitted today.

If that\'s clear, Howard.

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

I\'m just wondering, if you go to the general council of one of your
members and, you know \-- lawyers are paid to say no, but I mean, you
know, so in other words, having some \-- you know, executive branch of
the State say this is what we mean, that would help them say yeah, we
can give it to this, that and the other entity.

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

Howard, this is Karen Bell. One of the things I\'m wondering is in terms
of the language at the top of page five, someone suggested here that it
read under various State clinical laboratory practices. As opposed to
laws.

Because in some States it is a practice, in some it\'s a statute, some
it\'s a regulation. It does vary State to State. A practice could be
broad enough to encompass it.

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

I either have those three or four things, or the catchall practice, I
think that would help.

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

Okay.

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

Besides clinical laboratory laws, many times the authorized person is
defined in the medical licensing law of a given State. That the State
itself may have no clinical laboratory laws, but in the medical
licensing it says that the physician is the only person authorized to
order laboratory tests. And so forth. And that the laboratories are only
allowed \-- and it will basically go on to say that only the physician
may receive these results that they ordered.

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

This is Jon Perlin. If I could just play devil\'s advocate. I appreciate
the intent of the word \"practices,\" but to me that\'s a little
ambiguous in fact it\'s a lot ambiguous. I appreciate you\'re just
giving the example of State licensing \-- essentially creating the
regulation or policy that limits. In other instances we believe it to be
statutory, and probably in most instances it\'s commonly accepted belief
or practice. So would it be worthwhile and desired to help \-- if we\'re
going to ask National Governors Association to assist with this, to
resolve the issue, if we\'re going to give them a task, to be very clear
in our task, would be to resolve inconsistencies in statute, regulation,
policy, and practice. As the four, there.

And the other, just in the thread of specificity, that \-- you know, we
embraced earlier and I appreciate particularly off the \-- the national
coordinator willing to take this on, suggested adding by December of
2006, at the end of this recommendation, which I think is terrific in
terms of if we\'re going to task another entity, we\'re going to task
ourselves, to have some clarity on \--

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

This is Carolyn, I have a clarity as opposed to reality check. My
assumption is \-- and I want to check intent \-- is ONC would get help
from others in 3.0, and then engage the NGA. And it seems sort of
logical to me they would be sequential, because you should \-- you know,
the governors have enough ambiguity to deal with, the less \-- the last
thing they need is a new source.

So it seems to me I\'m not sure where to put language here \--

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

We have by March.

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

We have September.

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

September and then December.

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

We have September and December, some of it will be concomitant, but I
think they\'ll have recommendation in September they can really chew on.

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

Based on Recommendation 3.0?

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

Yes, based on findings from, yes.

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

Right. Thank you for that.

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

And this is Jason. Jonathan, I think one way we can address your
specific concerns is just maybe parenthetically after laboratory law
spell out, you know, including regulation, et cetera.

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

I appreciate it. I wasn\'t quite sure who made the comment earlier \--
this may be more than we want to specify, but, you know, National
Governors Association is going to be looking to, just as Dr. Clancy
identified, the product of Recommendation 3.0 to provide some
information. And whether this actually goes in the document, I would
believe our expectation, where there are statutory issues, would be some
model statutory language that could be consistently used to consistently
resolve some of the issues, so that we didn\'t inadvertently confuse.

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

I\'m wondering if that wouldn\'t be brought up more narratively or
verbally for the discussion \--

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

Exactly, that would be a good point.

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

I just have one comment on the preamble for this section. I know we\'re
anxious to keep our momentum going. The last sentence of the first
paragraph is accurate. I\'m wondering if we couldn\'t add something to
the effect that \-- and are silent on disclosing results to other
clinicians or others involved in the care of the patient.

In essence, what we\'re talking about is the situation where \-- which
is incredibly common, especially for sicker patients, where patients are
seen by four, six, eight doctors and we don\'t have a clear pathway. I
mean, the law kind of thinks it\'s in this very binary, almost
two-dimensional world. I ordered the tests, result comes back to me.

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

We don\'t cover all the consulting physicians.

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

Right, or the Disease Management Team or the \-- for that matter or a
whole array of actors. But for people who don\'t think about this a lot,
I\'m just looking for some clarity.

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

This is John Houston. I still think we\'re missing the boat on some of
this stuff, and I said this before, but I still think that \-- and I\'ve
said this before today \-- there\'s still the concept of getting
specific patient authorization, I think cures a lot of this. And it\'s
not \-- it\'s either deleted or missing in all the discussion here, and
I think it\'s probably the most practical case in a lot of the States
where we can resolve this issue.

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

Actually, John, we have had that discussion with Lynn Egan, here, who is
the CLIA specialist for the Federal Government working on it with CMS to
begin with. And unfortunately, it really is not a simple issue, because
we tried to go in that direction, of patient authorization.

The CLIA and HIPAA \-- CLIA, actually, supersedes anything on patient
authorization right now. So again, that might be something that we could
address through CLIA guidance, but it still would be CLIA guidance.

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

I thought CLIA deferred especially under State law to the idea, concept
of patient authorization.

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

This is Jason. CLIA actually says in the event that the State takes any
action, be it more stringent or less stringent, the State law applies.
But absent it, CLIA applies.

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

Right, exactly. And CLIA is silent on the patient authorization piece,
which means without guidance it does not recognize patient
authorization.

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

If it\'s silent on patient authorization.

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

That means one cannot assume patient authorization is appropriate
without CLIA guidance.

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

Say that one more time, I\'m misunderstanding all this.

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

If CLIA is silent on something, my assumption was that \-- I won\'t say
anything else \-- my assumption was that one could pretty much do what
one thought was appropriate, if CLIA was silent.

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

Right.

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

What I came to discover is that if CLIA is silent, that means you can\'t
do whatever you think you want to interpret it as. You have to go back,
and CLIA has to have very specific guidance on something.

Absent direction, is not permission. And I know that I\'m fond of saying
that I\'d rather beg forgiveness than ask permission, but in this
situation, it would not do me very much good. It would probably get me
in jail.

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

Okay, because I think there\'s an enormous misunderstanding here, then.
At least with regards to people I speak to, and what people are doing in
a variety of States with regards to release of lab information. And I
would think that the cornerstone of a lot of this is the patient
ultimately has the rights to authorize the release of his or her
information to whom he or she decides.

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

Not unless there\'s specific State either regulation or statute that
allows that. But at this point that doesn\'t exist.

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

I think the physician can provide that authorization. Maybe that\'s the
difference, here. John \-- this is Jason speaking, first of all,
Jonathan, I apologize. But under CLIA the physician and his or her
designees is actually the verbatim language from CLIA. So the physician
could make it \-- you know, could make the decision on whether or not to
provide that information to the laboratory, or \-- you know, another
partner.

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

Now, for my own understanding, because I must have missed this \-- or
just totally forgotten about this conversation. But the HIPAA
authorization language. Why is CLIA \-- does CLIA trump that?

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

I thought we said CLIA trumps State laws.

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

You also have HIPAA that describes the fact that information could be
released pursuant to a valid authorization.

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

Well, I think \-- CLIA was 1988, so that was \-- I mean, that went in
place first. And CLIA has language about use. HIPAA language is
different in terms of treatment purposes. And all I can tell you is that
I can\'t answer your question specifically, we can go back to Lynn Egan
and ask her to sort of talk about how one relates to the other.

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

I think we\'re going to need to. Because again, I believe HIPAA is very
clear as to what it says can happen pursuant to patient authorization.

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

Yes, but HIPAA \-- this is Connie Laubenthal. HIPAA does not override
State law, CLIA does. And State laws are the ones that are the problem.
State laws that say only the laboratory can only give the data to an
authorized provider, then the provider has it, and the provider can give
it to anybody the patient says under HIPAA, but the laboratory cannot
give that information to the patient directly.

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

Okay, I remember that part of the discussion. I thought that was only a
defect in a certain limited number of States, though. Or am I
understanding \-- are you saying it\'s a much more wider-scale problem,
then?

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

I\'m saying that it\'s a problem in many States, and if you\'re looking
at a national provider, like LabCorp, et cetera, of laboratory data,
that they don\'t want to have a patchwork of policies in place. That
they\'re going to do the same thing in all States that will meet the
requirements of all States. And many \-- and that was some of the
discussions that we were having in the ELINCS group that I\'m a part of
is that they\'re not going to agree to do anything that they can\'t do
in all States.

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

This is Jon Perlin. I appreciate this discussion, and I think based on
the information we have, which Lynn Egan has provided before, that
we\'ve come to certain conclusions. Obviously there are certain other
ambiguities that are out there. You know, the interesting thing \-- and
John, I particularly appreciate your comments \-- I think the
recommendation themselves actually not only give us license, but charge
the answer to these questions. And if it\'s helpful, perhaps in the
supporting text above that, without it being a specific recommendation,
we can \-- under the group process that way as well we can put a
sentence that says encouraging appropriate patient authorizations to
facilitate the recommendations.

And then within the charge, we have a do-out to ourselves, and ONC has
the do-out which is to provide the information about the extent to which
the patient authorization would supersede any of the ambiguities.

So I think it\'s been a good discussion, but the recommendations
themselves I think force us to resolve that specific issue.

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

But why can\'t one of the recommendations be very \-- I understand
Recommendation 3.0 discusses \-- you know, CLIA guidance. I mean, I
would say why can\'t we have a very specific recommendation that says
CLIA guidance specifically related to permitting patients to be able to
authorize release of information.

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

Because right now we don\'t know we can do that. And this was intended
to allow us to explore all of those issues about where guidance
would \-- could be helpful, where regulatory could be helpful, and
statute could be helpful. And the intent is that by September, we will
have resolved all of those issues. And we can come back to the Workgroup
in September, and the Workgroup can then go to the AHIC with something
much more specific.

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

I think there needs to be more discussion \-- I mean, I think there
needs to be something more. I understand what Jonathan is saying about
putting something in the paragraph before the recommendation. Just want
to make it \-- I think it just needs to be clear that this is one of the
focus areas, and be very specific as to one of the things we were \-- I
think architectural, one of the things could resolve this issue in its
entirety, and try to make sure it\'s clearly on the table so nobody
misunderstands it.

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

Would you feel comfortable, John, if in terms of possible models \--
our inclusion was that everything related to the architecture, the
authorization, et cetera, was in this possible model. Would you be
comfortable with that, with the understanding that in the paragraph
above it we could describe a little bit more the patient authorization
piece in the possible model?

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

I think so. Jonathan, is that what you were referring to, also?

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

Essentially we\'re putting a marker on there that one of the do-outs is
the full exposition of this. And we have certain information that I
think there\'s no debate about, and I think there\'s certain ambiguity.
These recommendations in fact charge us not only to resolve that
ambiguity, but resolve the specific issue.

I think Karen has brought forward I think a very good suggestion which
is that the words "possible models" also include understanding \-- or
facilitating full authorization to support appropriate information
exchange.

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

That would \-- I\'d accept that.

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

This is Jason. I just want to interject for a second. I think this is a
problem for a couple of different reasons. The patient authorization,
that laboratories don\'t want to get into, quite frankly. First of all
is the fact that patients have to see their physician first, when
they\'re getting a result back. And, you know, that they can\'t be
making these interpretations or getting their test results without
seeing a physician. That\'s part of the problem.

The second part of the problem is laboratories don\'t want to have to
take on the administrative responsibility of providing an authorization
every time that information moves around. That was \-- and we kind of
touched upon this a little bit, you actually took out in the next
section, lab results, privacy and security, the opt-in, opt-out piece,
which I think is not wholly divorced from what we\'re talking about now.

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

Okay, you\'ve raised some very good points that we don\'t want to
inadvertently confuse the playing field.

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

I don\'t think we\'re necessarily talking about patient authorization
for the release of the lab tests to the patient. I think what I\'m
referring to is an authorization related to the inclusion of the
patient\'s lab test within some type of \-- you know, repository and/or
environment whereby the lab test could be called up.

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

Let me just throw an aside in here, not a hypothetical, in VA, with the
patient\'s personal health record. For critical values, we are creating
business rules so that a patient never finds out of a new diagnosis of
cancer without appropriate counseling. On the other hand, for normal lab
values and for routine sort of abnormals, patient has direct access to
those.

So there is a new world coming. But Jason, I think you put some very
practical points on the table. We don\'t want to inadvertently create a
barrier to wrap it up in the next year.

John, I think your points are extremely well taken. I think we have to
find a way to identify including authorization in the supporting text,
but not obfuscated to the degree that someone takes that as a new set of
tasks for laboratory providers, service providers, to take on. That in
fact is not part of the intended deal.

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

I think it could be practically accomplished, I think there are ways to
deal with using an authorization vehicle as way to solve a lot of our
problems. But \-- you know, that\'s just my opinion.

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

Okay, we appreciate that. Lillee, back to you.

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

I\'m just thinking, do we \-- should we move on here, or \--

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

John, can you live with the \-- with this as written, with the
commitment that this is the scenario that we\'re obviously going to
continue to grapple and work with?

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

I thought we were going to add something to the paragraph above, though.

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

Yes, we are.

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

That\'s what Carolyn was talking.

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

Okay. I remember, Jon, you said as written \--

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

We\'re not going to call the possible models, because that takes it
afield from the lab providers. But we\'ll specifically acknowledge
including understanding how patient authorization may facilitate more
efficient sharing of information.

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

I\'m fine with that.

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

That work for you, Jason?

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

Okay.

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

Everybody okay?

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

State laws are going to prevent it from happening anyway but \-- I think
the way it\'s written, actually, is the right way to take it in the
first place. It is very overarching and gives the authority to ONC to
get into it.

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

John, just as a point, those of us on the phone we do have a hard time
hearing everyone clearly. So if there\'s a pause we\'re stretching our
ears. Was that Jason who said that he was fine?

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

Yes, it was.

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

Okay. Are we finished? The CLIA/HIPAA options, recommendations?

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

I think so. Okay, I\'ll pick up on Recommendation 4.0. And this
recommendation is a consumer empowerment subgroup, comprised of privacy
and security members, and members of all AHIC breakthrough workgroups
should develop a consistent set of recommendations on patient
identification, authentication and authorization.

Just by way of context to be cross-cutting, and thus the nature of the
recommendation, and I want to thank Howard Eisenstein and John Helstin
for volunteering to participate as part of the group that is charged
with this recommendation.

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

This is Karen Bell. I would like to just clarify this a little bit
further. Yesterday, the Consumer Empowerment Workgroup agreed to add
five elements to really specify this a little bit more. And those were a
message of patient identification, message of authentication, message
for controlling access to personal health information. Policies for
breaches of personal health information confidentiality. Guidelines for
secondary uses of data. And a scope of work for a long-term independent
advisory body on privacy and security policies.

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

Can you read the first one again, please?

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

Methods of patient identification.

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

I think it\'s more than just patient identification. I think we also \--
well, I think authentication would deal with provider side. Or the other
individuals who would be getting that information.

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

That\'s what we thought.

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

Okay.

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

And these will be spelled out on a version that we\'ll be putting
together as we clean all this up today, we\'ll try to get it out
tonight, Alicia?

Yes, we can get this out to you in another format tonight so you all can
review it in the next day or 2.

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

Karen, this is Lillee, that\'s actually very helpful. And then the
paragraph above, the one sentence, it\'s the last sentence of the entire
paragraph that I think really sums up some of the conundrums we\'ve been
dealing with for several months now. I like this language, the resulting
cacophony of State law is fundamentally inconsistent, which is mandated
in one State, is prohibited in another. It\'s that tolerating insanity
part we talked about on the private sector. 

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

I hear pages turning, I appreciate the work on that one. Let me turn
back to you, Lillee, for 5.0.

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

I just have one question for Karen, because I\'m very anxious to hear
the recommendations of the other workgroups since we\'ve all been
submerged in our own silos, so to speak. Was there any recommendation
that came out of the Consumer Empowerment Workgroup or any discussion
that was going to be easy, anything that can inform our discussions
where they said this is the low-hanging fruit and is the easy part?

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

I don\'t believe there was anything easy coming out of the consumer
empowerment. Around the table everyone is in agreement.

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

Darn.

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

And again, this goes back to what was said earlier, I think this
Workgroup has really turned those big gears, in a way that the rest of
the machinery can actually start going into play. Everyone has done very
hard work here, and it\'s much appreciated.

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

I look forward to that.

Okay, the next set of recommendations address laboratory results, in
terms of advancing adoption. And if we go back to our broad charge, that
word "adoption" is front and center for us.

And some language that appears to really get to the meat of the matter
is in the first paragraph that talks about it is imperative we address
the unique needs and impact on all stakeholders. Therefore,
Recommendation 5.0 is that ONC should assess and develop the business
case for historical laboratory results data sharing across all adoption
models, considering the unique needs and alignment of incentives for all
stakeholders.

And I know just to start the discussion here, this is one aspect that in
talking to my colleagues in the private sector we talk about where is
the economic and operational business case. Both. It\'s not just the
economic case, it\'s the operational case.

And there is the business case for the impact on the patient, as well.
And it just seems like much that we\'ve seen in the past haven\'t been
very able to crisply and succinctly address the business case. Because
if we could address the business case, adoption would fall into line
much easier.

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

Lillee, this is Karen. Having stepped up to the plate on a couple things
before, I\'m willing to back off a little bit on this one, and I\'m
wondering if the group would allow us to change this to HHS working with
the private sector. Because as we reread this, I think clearly we\'re
going to need input from the private sector, and also to work in
collaboration with other parts of HHS on this.

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

I think that\'s a viable recommendation. I\'d also ask \-- maybe it is a
small subgroup, but you may recall at one of the AHIC meetings we
distributed the HFMA document, the Healthcare Financial Management
Association document, on facilitating adoption of EHR in the private
sector.

HIMSS has also done some outstanding work. Jason, your association has
done some outstanding work on adoption, and just the business case that
outlines the conundrums we have to face. But I would say I wouldn\'t
back off the recommendation that the business case has got to be made.

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

The suggestion as I hear it is to broaden it to include HHS by working
with private-sector partners.

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

Do we have consensus around that?

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

This is Jason Dubois. Earlier we talked about it not just being
historical laboratory results data, but the current and historical
laboratory results.

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

There\'s an implication, that the \-- implication that is backwards
compatibility, but not forwards. Lillee, I have a question, just \--
I\'m trying to include the \-- the concept is to include stakeholders,
both in development, and I don\'t want to omit either \-- just disclose
personal VA interests here, but I\'m looking across the table, I think
DoD and all the other Federal partners as well, so something that
includes Federal, or more broadly stakeholders, and Karen perhaps you
have some proposed language to encompass that.

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

Yeah, we\'ll work on that broader language for sure.

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

Thank you. I\'m comfortable with it.

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

I think it works.

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

Okay, Jon, back to you.

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

I feel somewhat strange looking across the table at Dr. Clancy with the
next two recommendations. I\'m sorry \--

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

I\'m looking at you, Jon, with your fine Ph.D., not your M.D. Is it the
business case or the value proposition? They\'re a little bit different
here.

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

You know, I think that\'s a very good point, because the value
proposition is what will make it sustainable.

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

Wow, yeah.

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

There may be case where is we need \-- there may be nuances or
dimensions where we need to figure out how to create the business case
to get the value we want. But I think it\'s the value, here.

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

I think that\'s terrific.

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

I do, too.

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

My Ph.D. is in pharmacology. Molecular neurobiology.

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

This is Chantal, and I keep coming in with these comments, I think
we\'re talking about the business case not the value proposition.
Because I think that\'s the conundrum we\'re in, is that we understand
the value proposition but we can\'t make the business case. Because the
financial value goes to those other than those that need to make the
investment. So it\'s the business case for those who need to make the
investment that we really need to understand, and augment. The value
proposition I think speaks more broadly to, you know, this is idle good
for all of this, which I think we all understand are committed to
achieving, it\'s just a question how to get there, which involves
developing business cases.

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

I appreciate that, Chantal. It\'s Carolyn again. What I\'m struggling
with, in the world of quality where I spend a lot of my working time, we
end up doing these analyses that I struggle with that basically say
there isn\'t a business case for improving diabetes care. You know,
according to how we pay right now, that\'s actually correct. Because you
run into all the same problems.

When I think the real question ought to be how do we create a business
case.

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

Exactly.

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

That was really the sense I was trying to get at. I\'m not trying to
ignore the business issues, I think they\'re critical, and without them
we don\'t get to a value proposition. So I\'m not sure what I think is
the appropriate wordsmithing. Maybe it\'s value proposition including
the business case.

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

Let me ask you would this work, should assess the value proposition and
develop the business case?

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

Yes. Yes, I like that. Chantal?

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

Yes, that\'s fine. Actually I think \-- yeah. I guess I get a little
frustrated because you hear things like, you know, all of the
contractors will develop the business case, and I think what we really
need to do is you are suggesting on the quality side is, you know,
develop the methods to build the business case. Because what we have
right now seems pretty clear, you know, as if developing the business
case, it\'s there, you just haven\'t seen it. But I think we understand
what the barriers of business case are, so what are methods for getting
beyond it. And really creating a business case.

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

This is Jason. I think that actually both the value proposition and the
business case are likely two different parties, because you\'ll have the
laboratories, be it hospital laboratories, independent laboratories, or
physician office laboratories, who are \-- you know, in the way that
they\'re operating in those scenarios, indirect providers of laboratory
data information. And then you\'re providing it to another entity, be it
a physician, a hospital, or disease management organization that\'s
actually going to be translating that data into the \-- you know, the
value they\'re hoping to reap from it.

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

Terrific. I think your comment, Carolyn Clancy\'s comment, hit a very
resonant chord with people, and I appreciate the discussion around that.

Do you feel very strange reading these recommendations, Dr. Clancy,
across the table? Should we ask to you perhaps comment on these and
initiate the discussion?

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

No, what I will say, it probably reflects time in government, I think it
should be AHRQ in collaboration with CDC and CMS. Which is not to say
I\'m walking away from accountability, but I know people don\'t like to
be excluded. CDC and CMS are on that AHIC and obviously have waivers
that we don\'t necessarily have, so I\'d like the opportunity to include
them.

And again, I\'m not stepping away from our stepping up to the plate
here, but just I want to recognize that there is this whole lab group at
CDC. I don\'t precisely know what they do, but I know they feel very
strongly about it.

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

I think that\'s a good point. And I think just one of the overriding is
the inclusiveness that we hope to develop here. Let me read the
recommendations, take that as an amendment, unless there is someone who
wants to come at it specifically. AHRQ, CDC and you said CMS? AHRQ, CDC
and CMS should develop a proposed study methodology to measure the
extent and effectiveness of the adoption of the first stage of HITSP
standards as well as the adoption and utilization of aggregated
patient-centric data as it becomes available.

6.1, AHRQ, CDC and CMS should research best practices in the
implementation and utilization of patient centric-laboratory data stores
and how to disseminate this knowledge.

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

Carolyn, would it be better to have AHRQ in collaboration with, because
that would \--

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

I think it \-- a little less confusing, I like that wording a little
better.

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

Puts you in the accountability position.

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

Yes. If I were hearing that it wouldn\'t sound like oh, God, I just
heard 100 people who are part of a big party, and I\'m not sure who to
call.

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

Okay.

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

And Carolyn, this is Lillee. If we\'re successful in developing the
study methodology, and I\'m confident we will be, or you will be and
colleagues, and it addresses the first stage of adoption of HITSP
standards, is it intuitive that it would be transferable to the other
aspects of adopting the EHR that we have to address, or is this really
just specific to measuring the extent and effectiveness of the adoption
of HITSP standards?

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

That is probably one of the key questions that I would ask a study team
to address.

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

Because I don\'t want to address one piece, and we still didn\'t get to
the endgame.

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

Well, right, so I think a very reasonable deliverable to ask of some
very smart people who think about this a lot, is to what extent are the
issues here generalizable to other HITSP standards.

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

You\'ve been so good about reminding us the timetable, and I realize
this is somewhat sequential development. Methodology can occur
concurrently, but ultimately the assessment of progress has to trail
behind the actual implementation.

With that in mind, should we attach a date to the end of these
statements?

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

Sure. January 10, 2010.

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

I love it.

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

Within 1,000 days.

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

I\'m trying to track. First HITSP has to actually adopt the standards,
right? So we\'re talking about September 2006. And the real question in
my mind about time frame is we can propose a study methodology. That\'s
relatively straightforward. So I could make that deliverable early
calendar year of \'07. 

The issue of best practices I think in a sense has to trail the
inclusion of those criteria. It seems to me. Which doesn\'t mean that we
wouldn\'t thinking about it and planning what\'s going to happen.

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

That\'s why I asked the question, because the methodology may be
concurrent, the other trails, by definition.

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

Yes.

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

Okay, maybe we\'ll put the date on it.

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

Jon, do you think \-- I like your word "concurrent," just spurned me to
think of something. If AHRQ should identify best practices, it seems,
after some of the presentations we\'ve had in the past to the Workgroup,
that there are, for instance, in terms of RHIOs, there are best
practices that are already in place, that we necessarily wouldn\'t have
to wait for the best practices related to HITSP standard adoption.

And then recommendations on how to disseminate the knowledge. I wish
that that sentence could have a little bit more punch, because I\'ve
seen a huge number of professionally done, outstanding tomes, come out
of government entities, and they land in the dark hole of private-sector
adoption, and nothing happens to them.

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

How about "implement"?

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

That\'s better.

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

Because I agree with you.

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

Good.

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

And I sure would step up to the plate and help with you that one,
Carolyn, I\'ll tell you.

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

Fine.

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

I think it would be very interesting.

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

Good, good, good.

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

That one and the business case.

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

Terrific.

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

Any other comments on 6 \-- or the Group 6 recommendation?

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

March 2007, Carolyn, for the first one?

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

Yes.

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

And no date for the second.

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

Right.

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

Not yet. Stand by.

Jon, I would say just having gone through these, just some compliments
to the ONC staff. Because this is much crisper than what we first
considered. You recall you and I had asked for the Cliff Notes version.
And I think a great deal of work has been done to help get to us this
point.

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

Absolutely. Many, many things.

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

I would echo that. Really lovely. This is great. Actually just to get
back to 6.1, certainly we could give a report by the end of \'07. Which
may even be the \-- you know, CCHIT got held up, therefore our plan is
to do X, Y and Z. But I think there ought to be a date there.

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

Terrific. We\'ve attached date, we\'ve gone through \-- Karen,
methodologically at this point \-- I think we said at the beginning,
this will be professionally edited, not to change meaning, but for
consistency with the other documents. You actually believe you\'ll have
a document up in \-- let me propose that \-- we\'ve gone through this in
a fair degree of granularity, and \-- we get the document up, and if
anyone feels that the ultimate document grossly distorts their
boyfriend, bring that to the attention of Karen, to Lillee, and to
myself.

Other than that, I think we have consensus document. Remember, this
is \-- what we\'ll be putting forward, we\'ll have the opportunity for
the discussion with our colleagues at AHIC, ultimately, the process will
evolve. And so a number of the points that are implied by what we did
today, and particularly discussion around CLIA and patient authorization
or issues, that invariably we will be coming back to refining, learning
more about, and pushing forward.

So let me agree with Lillee, and thank everyone for your hard work, your
thoughtfulness, the research that you did, the skills you bring to the
table. And again, amplify just our admiration for the ONC staff on
making this cogent and coherent set of recommendations that I believe we
can bring forward proudly to Secretary Leavitt.

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

I would just add that we\'re going to be briefing him tomorrow morning,
so he will be hearing the first of this in the morning, so thank you
again from our side, as well. Karen.

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

Terrific.

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

We are going to change gears.

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

I just had one question I keep asking myself how we come back to the
original recommendation. All this is great stuff, and it\'s really come
a long way, but nothing has happened in a year. Other than potentially
some workplans, and some guidelines. And when we got together we said
gosh, we want to see action in a year. And, you know, as great as the
recommendation is, that continues to just really kind of stick with me,
and listening to Secretary Leavitt get it done type attitude, you know,
I see a year from now, if all these recommendations are accepted, where
will we be.

Maybe I\'m just too impatient. But, you know, I don\'t see any impact on
the country in a year, based on this letter going.

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

Pam, this is Karen Bell. We had the privilege of hearing Secretary
Leavitt\'s announcement yesterday which I know he\'s going to be talking
about at the AHIC meeting, and that was around the next thousand days.
He has nine top priorities for the next 1,000 days one of which are
these breakthroughs. So he\'s giving us now until \-- he\'s very
specific \-- the 20th of January \-- hello? Okay. To essentially make
sure that we meet very, very specific deadlines and timetables. And in
fact, we\'re going to be starting the day after the AHIC to put those
deadlines and timetables in place.

He recognizes that to have widespread implementation of any of these
charges requires these major changes that we\'re putting on the table.
And in fact, he even talked about his experience with his 5-year-old
daughter and the watchmaker \-- or clockmaker that came to the house to
repair his grandfather clock.

The child couldn\'t move the small or medium-sized gears, and the reason
that they couldn\'t is you can\'t address those issues until you take
care of those bigger gears. So he\'s really asking us to put our hands
on those big gears, because if you move those, then all those little
ones will fall into place.

So he\'s recognizing that we need to essentially address those gears,
and those are those six areas that we talked about on the first page of
the document. And these types of recommendations are really the ones he
needs to make now in order for anything to happen in a shorter time
period.

So while yes, the specific charge was within a year, but it\'s within a
year make sure you have everything in place, all of those big gears in
place, so that the other smaller ones will start rolling out, and start
moving.

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

And Karen, this is Lillee I would add I just want to emphasize the
urgency that was just placed forward, and I don\'t know what will be in
the cards for us, but let me assure you in the private sector we are
enormously concerned about the next hurricane season as well as bird
flu. And we want to make sure that our thinking, our readiness, and our
alignment is going to be in concert with the crystal ball that we can\'t
read.

So it is up to us to make sure that we are making recommendations that
are actionable. And if you can communicate that to the Secretary \--
that\'s why we need the tremendous brain trust of everyone that\'s on
this Workgroup to help.

But, you know, sometimes there are external forces that really put
gasoline on the fire. And who knows what those may be going forward, but
we are in a little bit better shape today than we were this time last
year, which is the way I measure some progress.

And if anyone has any recommendations as we go forward on how to speed
this process, I know we are all ears.

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

This is Jason, I think we started to do some of that today by putting in
deadlines for a lot of the recommendations we put in our report. Or
letter.

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

Good.

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

I heard the urgency earlier this week.

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

Okay, Pam, well, thank you for that charge. I know it feels fairly
amorphous, and policy oriented, but, you know, I \-- again, and part of
I think the luxury of being in VA, whether a system is \-- you know, a
system that others would want to use or not I think is beside the point.
But the point of optimism for me is we\'re a system that\'s electronic,
we have the luxury of this, and I hope that serves as a point of
optimism that this is achievable.

What I think is so gratifying is that we\'ve had discussion today where
we\'ve brought a lot of people from different parts of the community
together, public and private, regulatory and operational, vendor and
provider. And had a dialogue about some of the things that need to
happen. To use Secretary Leavitt\'s metaphor that Karen just related,
will really make the gears turn. I think this is tremendously powerful
groundwork. And Lillee, I think your points on the urgency of H5M1, the
avian influenza, I would also note the urgency of the emerging
MRSA epidemic and hurricane season that\'s upon us in less than 30 days,
really a great segue to the next set of presentations, one I know
Secretary Leavitt very much wanted us to attend to in terms of looking
at how \-- even build beyond what was done heroically and urgently last
year in terms of Katrina Health and some of those activities, to be able
to make essential information immediately accessible to first
responders, and for the care of patients, should there be \-- not only
these natural disasters but, you know, challenges that confront us in a
world that includes, sadly, manmade disasters, as well.

And we have four terrific presenters, here today, or online, some of
whom are here, to talk about what they view as the essential information
for providing care to patients. These individuals bring a variety of
perspectives, including from the affected area of New Orleans, from an
academic perspective, a direct delivery perspective, from a population
health, health policy, public health perspective.

Let me introduce first Edward Barthell, who is a physician with the
American College of Emergency Physicians. He\'s put together a
presentation that I think should be in everyone\'s mail-ins, and I know
for those that are online it\'s been teed up online. And Dr. Barthell,
thank you for joining the group and agreeing to present today.

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

Thanks for having me, it\'s a privilege to be able to speak to the
distinguished group that\'s on the phone here today.

I am responding on behalf of the College of Emergency Physicians, I just
put some of my affiliations on the first slide. Brian Keaton, who is on
the AHIC group that\'s been looking at particularly biosurveillance,
asked me to respond since he\'s tied up doing \-- or testifying at a
Senate subcommittee.

But we do have a few ideas that we wanted to go through with everyone,
if you want to skip to the next slide, I just have about four or five
slides that I\'ll go through very quickly and talk for 5 minutes then
answer any questions.

I was asked to talk about first responders, and what type of information
they would need, both discrete data elements and what mechanisms we
might be able to use to provide that data to first responders.

And I guess you have to first talk about what is a first responder. My
background is I\'m an emergency doc, but I\'ve done a lot of infomatics
and worked a lot with fire departments, police departments and EMS
services, and depending on the situation any or all of these personnel
may be the first responders, when there\'s a disaster.

And I\'m not even including obvious other first responders in some
situations which might be primary care physicians and other clinicians.
But if you go to the next slide, please.

If you look at the sarin gas attack in Tokyo, over 90 percent of the
people jumped in private cars and drove to their nearest emergency
department, and they all crashed the doors of the emergency department
and said they couldn\'t breathe. That\'s an example where the emergency
department ended up being the first responder more than the police or
fire. There are certainly situations where alternative groups that
become the first responders, but in any case, it just shows that
flexible systems are needed. The systems need to be able to provide the
background information on patients to all of these different groups, and
preferably simultaneously.

If you move on to the next slide. What we tried to do, and again, this
is Brian Keaton and I reviewed this, so it\'s our first thoughts done
very quickly, but derived from some research that has been done in this
area, is tried to create a grid where we talked about kind of routine
operations, and then disaster operations, and what are the discrete data
needs that one might think we would need.

In the mid-90s we had a program sponsored by DARPA that looked at it
specifically for emergency medicine, and DARPA was particularly
interested in how to take care of soldiers. And the reality was there
isn\'t a whole lot of background information you need on soldiers to
take care of them when they get injured, because they\'re generally all
very healthy.

But in the day-to-day operations of emergency medicine now, it\'s
becoming increasingly a geriatric practice, where we have lots of sick
elderly folks that can\'t be cared for in primary care doctors' office,
so they are referred to the ERs. They have multiple medical problems,
multiple medications, then it\'s capped off by the fact they have
dementia and can\'t give any kind of history to us.

When you go through these kind of situations, and we did a number of
observational studies, the types of routine pieces of information we
need in emergency medicine tend to boil down to these list of items that
are in this grid. With demographics including which physicians the
patient routinely works with in the past. It may be a primary doc but it
may also be a specialist.

Medications and allergies was the single highest priority. Problem list
would be the next priority, although most of us have also learned to
just synthesize the problem list based on the medications the patient
takes.

Advanced directives are something that we have more commonly now. In the
old days we used to almost never have that in advance. And a copy of
previous EKG. Although that\'s for a minority of patients, that can make
a big difference in how aggressive or nonaggressive you need to be in
treating cases of chest pain.

The hospital emergency providers also want to have a sense of what\'s
going on around them in the world, so what\'s coming, meaning what kind
of other cases are being \-- are rolling in. Are there special breakouts
or certain breakouts in the community of unusual diseases or unusual
injury patterns they should be looking out for. That tends to be a
problem, in not knowing that, all you know about is your own four walls
and you don\'t know what\'s going on outside.

There are some systems coming through that are helping with that.

The other big problem in emergency departments is where am I going to
put the patient if they need to be admitted. Because so many of the
hospitals are \-- have bed problems, so emergency departments across the
country are boarding patients for long periods of time just waiting for
their destination for admitted cases.

When you go to the routine data elements for prehospital, again there
are some demographic issues, but the prehospital providers have a more
limited set of interventions they\'re going to make, and so they just
need the data that is going to drive whether or not they need to make
those interventions. So they need to know whether the patient is
diabetic, and that\'s why they\'re confused, but then again they\'re
going to do a finger stick and give them glucose if they need it. The
advanced directives are important for prehospital, too, because they
don\'t want to be rushing and doing CPR on an elderly patient with
cancer who is preferring not all of that done to them.

And then the other important issue for prehospital is again to do with
crowding conditions, is where can I take this patient. In the routine
setting it\'s where should I take this patient. They may think it
through in terms of where the patient would prefer to go, where their
primary doctor is located, et cetera. That may change in a disaster
situation where it\'s not where should I take them, but where can I take
them. Because there may not be availability in the places that are
nearby, and they need to know if they need to divert to more distant
locations.

EMS during a disaster tends to focus on is this a regular patient, if
they\'re really in a true disaster mode, and that just helps categorize
where they\'re going to try to take the patient, which order they\'re
going to take them, to the various facilities. EDs, hospital EDs in a
disaster setting, again, you test the need of smaller amount of data,
and you\'re just concentrating on medications driving a lot of your
decisions in terms of what that patient may need. And you\'re much more
aware of what\'s coming and what are the available destinations for the
patients after they get processed through the emergency department.

I think we tried to just on a very high level pin down what were the
discrete data needs in these various situations.

If we move to the next slide. I tried to also come up with a list of
some of the mechanisms for making data available. I think people need to
know what systems are currently in place, in the prehospital industry,
and hospital emergency departments today. Radio notification from
dispatch centers is still the primary way that EMTs in the field have
any kind of communication or get any kind of information.

A lot of them do carry pagers or cell phones. Paper-based charting still
predominates in the field, although there are increasing numbers of
electronic charting systems that are starting to be used.

Patient tracking systems are also starting to be investigated in a
number of areas of the country.

Part of the issue is getting good wireless network access, which is,
again, it\'s evolving, it\'s an infrastructure that is needed by
prehospital.

A lot of development that\'s ongoing using CDMA and other types of
technology trying to get data feeds that can be ongoing between the
field and either base stations and/or hospital emergency departments,
but a lot of that is in early stages and it\'s not \-- has not
penetrated the market to a great degree.

In the hospital emergency departments almost all of them have some kind
of a registration or ADT system, where patients are registered, because
that\'s how they send out the bills. And most of them now have Internet
access. Five years ago I would have said that\'s about 40 percent, but
now we can say that most hospital emergency rooms are going to have
Internet access.

There are a lot of Web-based capacity diversion systems in place, in
over half of the hospitals, and that can serve as a messaging network
for messages between public health and emergency departments.

Electronic tracking systems, you can think of this as kind of an
electronic version of the big grease board that\'s traditionally been
used in emergency departments listing the patients that are in the
department right now and which one is in x-ray and which one is waiting
for lab tests, et cetera. Those kind of electronic tracking systems are
becoming much more common. But physician charting, where the physician
is walking around with a portable tablet or going online to do all the
charting on all their patients, is still not \-- has still not
penetrated the industry very far. So if you want to be able to have
something that\'s immediately in front of the physician in the emergency
department, it\'s not going to happen through a physician charting tool.

So I just wanted to give people a framework of what kind of systems we
might be able to use to get data delivered to these workers.

Last page is just some references and some of the standards activities.
I am on the HITSP Workgroup that\'s working on biosurveillance issues,
but it\'s been trying to track on the EHR side as well. So I guess
that\'s about all I wanted to say briefly here, and then entertain any
questions.

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

Thank you very much for a very lucid presentation. I think you were in
some of the sort of pragmatic field experience following Katrina.
Relocating patients, medications, allergies, problem lists, disposition,
were some of the key and essential pieces of information.

As we try to look forward to what support would be immediately
available, I think your dichotomy between the routine and the emergency
needs is extremely useful. I think one of the questions that you\'ve
raised that we didn\'t really consider previously was the issue of kind
of contextualizing the patient and see what\'s coming or what\'s
happening to the \-- at least local or regional population in terms of a
disaster.

Let me open for questions, or comments, further discussion. 

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

Or maybe we could have all them after all four presentations.

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

We\'ll do that. Lillee, we have an order, there are some time
constraints on some of the folks. I\'ll introduce here the second one.

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

That\'s fine. I just have one quick question, I didn\'t know what DARPA
was.

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

That\'s Defense Advances Research Programs.

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

Defense Advanced Research Projects Agency.

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

They brought you the Internet, Lillee.

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

Al Gore did that.

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

Keep us moving, Jon. I don\'t have a time constraint, but keep us
moving.

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

Okay, coming to item \-- the second presenter, is Lieutenant Colonel
David Parramore, and \-- I\'m sorry, is that where you wanted to go?

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

Yes.

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

David Parramore, Department of Defense, with Faith Devoe, and they\'ll
be providing a DoD perspective.

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

Good afternoon, this is Dave Parramore calling in. Just a little bit of
background. Last year, during OIF, Operation Iraqi Freedom, we delivered
electronic health systems in the deployed environment. And really, you
know, looking over this previous discussion, our requirements are
essentially the same.

You know, we\'ve got several systems that are being used out there,
we\'ve got hand-held devices, we\'ve got electronic health records
systems. But, you know, looking at these requirements, really,
essentially nothing to add.

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

Okay, well, thank you very, very much. Appreciate the brevity. Very
useful.

Let\'s go now to Dr.  Regina Townsend from Louisiana Department of
Health and Hospitals. I believe members of the Workgroup are probably
aware that the overall community had a presentation from representatives
of the Southerner Governors Association that gave a very compelling,
moving articulation of the needs of what the front line practicing
clinicians would very much like to have had in the midst of disaster.
Dr. Townsend.

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

This is Dr. Townsend. How are you all doing, thank you so much for the
opportunity to speak with you. I guess my perspective is maybe a little
bit different. I had the opportunity to brief the AHIC group when I was
there with the SGA. And when we look at emergency room response EHRs,
it\'s a different feeling down here in Louisiana, now, because of the
impact that Katrina had on New Orleans and all of the evacuees. From my
perspective, I absolutely agree with everything that came before, about
the essential elements, and in an emergency response, electronic health
records. And I guess the thing to keep in mind for your group as you\'re
considering things, is how do you make these things portable. Especially
when at the time of whatever crisis you very well may not have access to
any of the methods of communication that you talked about here.

Because I can tell you, in the Superdome, we had some emergency power,
but the cell towers were knocked down. The only thing that worked,
because we had the gambit, we had Nextel, we had Cingular, occasionally
you could get a sat phone to work, not very often. And sometimes, the
800-MHz radios would communicate. And that wasn\'t really reliable,
either.

So I guess that was the big thing that we found, was how do you \-- how
do you create an electronic health record to give you emergency response
when it\'s very likely that in \-- at the time of the emergency you\'re
not going to have access to any of those things.

And I think it was very clear, too, during Katrina Health one of the
physicians who was originally from Mississippi went down there to help
and she said, you know, Katrina Health was all well and good, but she
was in a room with no electricity, so she said nothing helped her.

But the communication aspect is very important and needs to be kept in
mind.

Now, when I went from the Superdome to the Pete Maravich Assembly
Center, I think that\'s when as we set up the field hospital, you
realize just how important some sort of electronic access would have
been for a lot of these patients. Because as they came in, many
couldn\'t give a history. So I agree, the central information really is
can you get allergies. As you know, there\'s not a standard way to get
that electronically. Obviously medications and a problem list would be
great.

You know, those are the bare minimum I think that anyone would like to
have.

The lessons that we have learned here, as we developed the Health
Information Exchange that is actually being funded through a contract
with the Office of the National Coordinator there at HHS, is we know
that we can\'t have a fully robust system up by the time hurricane
season starts, which is less than a month away. But we do know better
now what the inventory is of electronic information that we could
gather. Who has that information now, in the hurricane-prone areas.

So that\'s one of the lessons that we really learned. We know that
between claims data, as proven in Katrina Health, with a lot of the
electronic information that\'s available at some of our major hospitals,
including big charity that was knocked out, we still had that electronic
information available.

So we can sort of recreate and reconstruct some of the medical
information for a lot of the evacuees, and that\'s the project we\'re
working on.

But short term, knowing where that information is. A lot of providers
have gotten much better making sure they have backup. Like the VA
system, you know, their backup isn\'t local, so they had their
information, even though their hospital went down.

So the other things that we\'re doing here, to be kept in mind, Arcadian
Ambulance Service actually has computers on all of their ambulances
statewide. And so from their command and control center, they can
actually feed out information to the ambulance at the point that someone
is being picked up. It helps them with GPS technology, it helps them
with any information that a caller can give to them, or that they can
share with the hospital on the way.

And then finally, there\'s the Louisiana emergency response network that
is getting a little more attention now since Katrina. And that speaks to
needing to know where you ought to take a patient. Because they\'re
trying to build a system where the emergency response unit knows what
hospital is capable of taking care of the level of patient, whether
it\'s red, yellow, green, and getting them most quickly to the most
appropriate place where they can be taken care of.

So like I said, we have a unique perspective down here since we\'ve
lived through a lot of this stuff, but you know, you guys have
identified the elements, we just have to figure out a way to make them
available during the time that they\'re needed.

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

Dr. Townsend, thank you very much for your comments appreciate both the
perspective from Louisiana as well as really a very thoughtful review of
the infrastructure and some of the challenges that electronic health
records and other information technologies would face in the particular
environment, then some of the essential work-arounds such as computer
units on squad vehicles.

Our last presenter in this discussion, actually provides a very nice
segue to this, is Aaron Reinhart, who is executive director of the Lakes
Region EMS. He comes to us from North Branch, Minnesota, and is actually
here with us at the HHS offices in Washington, DC. Aaron, thank you for
joining us today.

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

Thank you. Thank you for the invitation. We really appreciate the chance
to be here, and hope this can be the first of many conversations. Just
to briefly tell you a little bit about myself, because I think it would
help frame up some of my comments. As you mentioned, I serve an
administrative role for rural ambulance in Minnesota. Spent eight years
in the military, serving as a nuclear biological chemical warfare
officer, something I never thought would come over into the civilian
world. But recently spent a month in Texas as the EMS commander for all
the ambulances that were deployed by FEMA in Texas. And four of those
days actually served as a hospital administrator.

And so a lot of what Dr. Townsend was mentioning as far as the
information, lack of it, resources, really rang home to our experiences
in Texas.

Prior to speaking today we brought together a group of stakeholders for
EMS to be able to present ourselves as a consolidated voice. Those
groups are groups like the North Central EMS Institute, a benchmarking
group; the National Association of Offices of Rural Health; the National
EMS Management Association; National Rural Health Association; and the
National Association of EMS Officers, which used to be the Association
of EMS Directors.

So as a group, we wanted to share with you what we thought our primary
needs were when it came to electronic records, both in the emergent
situation as well as day-to-day.

And I think the EMS agenda for the future really kind of frames what we
try to accomplish, and what data elements would come out of that. This
is a document that was put out in 1996 by NTSA through a consensus
process such as this, and it\'s really been updated by a newer document,
the rural EMS agenda for future.

And essentially it says EMS will have the ability to identify and modify
illness and injury risk, provide acute illness and injury care, and
follow up and contribute to treatment of chronic conditions and
community health monitoring.

So I think it paints that picture of that larger role EMS has the
ability to play both in the emergent and nonemergent environment.

We act as a safety net in many situations, we\'re the first call for
individuals that either are underinsured or uninsured. We play that role
in the continuum of care both prehospital as well as interfacility, in
returning the patient to home or to other areas, as well as the role
that was mentioned, disaster management.

Today, EMS has a lot of things going for it that was already mentioned.
We have the national EMS information system in place, adopted by all 50
States and the six Territories. That dataset is a very comprehensive
dataset. It encompasses 500 some data elements, it\'s really three
concentric circles. The largest of circles being every and all data
elements that an individual provider would want to gather. The next
smaller circle is data elements that would be reported to a State or
regional level. And finally, the smallest circle is one that would be
reported to the national level.

That dataset is in place, and actually I\'m participating in a group
that will do benchmarking activities to test how well it works in
practicality. It\'s one thing to publish a dataset, it\'s another thing
to put it into place.

We are actually till also in the process of certifying our vendors that
produce our electronic charts, our data systems, as well as States'
compliance to it.

One of the things I\'ve also done in a previous life is developed a
State data collection repository called Minstar Minnesota which is now
the data example for seven other States across the Nation.

So specifically, we really hope today rather than talking about specific
data elements, though I think many of them have been mentioned so far,
we really hope to have the ability to talk in more detail down the road
about specific EMS needs.

But some that were mentioned by several of the speakers would be things
like medications, patient\'s history, demographics, allergies,
laboratory values, et cetera.

To try to illustrate why both in a day-to-day operations as well as in
an emergent operation EMS might need those particular data elements,
I\'d like to share with you two possible things that EMS can do in the
event of a disaster.

And this was a lesson we learned very hard in Texas. The first is what I
call the FedEx model. Give us 1,000, 10,000 patients, whatever it
happens to be, and using kind of the red, green, black, yellow model
that the other speaker mentioned, we can very quickly prioritize those
patients and transport those patients to destinations and be home in
time for supper.

However, I don\'t know that that does the incident a lot of good.

What we learned in Texas was EMS\'s role probably should be treating
those patients, and managing them in the field, and taking only the
smallest of the smallest set of those patients to the hospital. And
managing that hospital in Texas for four days, we could take one x-ray a
day, because we had enough power to power a few things, and not cooling,
and the x-ray would overheat.

So only the smallest number of patients could get that x-ray, not the
sprains and strains that we might typically have seen in the past.

The greatest need \-- and again, many of the other speakers spoke to
it \-- is connectivity, EMS\'s ability to access high speed Internet,
whether it\'s through satellites or whether it\'s terrestrial or both,
we have the ability to exchange information already, we already have our
dataset, it\'s been defined. And then similarly as important, the
ability to exchange that information.

H7 is something that\'s in place for hospitals and hospital type care.
Would there be something similar that would allow patient demographics
to seamlessly move up and down and sideways throughout the continuum of
care.

So in summary, again, thank you for this opportunity to speak. We see
the ability for data in this electronic patient record to help us both
in the disaster sense, but in everyday case. We see 80 percent of our
patients to be cardiac. And things that we might do to be prepared for a
disaster, manmade or not, will benefit us every day in being able to
help, for example, those cardiac patients and getting them to definitive
care quickly. Thank you.

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

Thank you very, very much for that perspective, and four complementary
perspectives on emergency needs both in terms of the patient level and
the population level. Let me turn next to Dr. Karen Bell for your
perspective, and perhaps also to refresh us on some of the Secretary\'s
expectations in terms of how we can best support being poised to
respond, if necessary, in time of disaster, and build on what we\'ve
learned from Katrina.

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

Thank you, very much, Jonathan. I think all the speakers have been very
clear that some things are well known, but there\'s opportunity to
really move forward. And again, in the same vein \-- and thank you all
for participating and listening to our previous discussions, as well.
Because in the same vein that we\'ve been off as a Workgroup to provide
recommendations on lab and EHR, this particular Workgroup will be making
recommendations on first response, as well.

And as articulated a little earlier, it is around what are those data
elements that are most important for first responders. And I think that
discussion has been quite focused, and I think there\'s virtual
agreement on that.

But the bigger piece, which I think everyone else has alluded to, is how
do we make that communication occur. Where does this data reside, how
can it be easily extracted and made available. I believe is the real
work that will need to occur.

So I will turn back to all of you who have presented, and ask if you
could respond back to the Workgroup in terms of your own experience,
what would you \-- if you were Workgroup members, what would you move
forward with in terms of recommendations on how we may go about making
this information available to first responders when they first need it.
And since you\'re in the room with me right now, Aaron, and you talked a
little bit about the 500 data elements, maybe you could discuss in a
little bit more detail about how perhaps that could be made available to
your network.

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

I think very easily. The data elements themselves, whether they are
collected today by paper, and then subsequently put into some type of
electronic system, or collected initially at the patient\'s side
electronically, within the structure of NEMSIS, the XML structure allows
for that data to seamlessly move, whether it\'s within a region of a
State, within a State, or within multiple States. Minnesota and
Wisconsin, now, because of this, can regularly exchange information.

I think the key to exchanging that information is how do we get these
disparate platforms to communicate. How do we get the NEMSIS data
dictionary that all EMS providers will be using, to be able to talk with
the hospital, or be able to talk with public health, or to be able to
talk with fire or any number of other responders.

And I think it goes back to what I mentioned before is first we need
connectivity. Regardless of whether we can make the platforms talk to
each other, without the connectivity it doesn\'t make a difference. And
I think the second piece is that ability to have that universal exchange
platform.

I\'m hesitant to say it should be in one large Web-based repository
someplace. In EMS\'s case we\'ll have that, and we do have that today. I
think we need the ability for it to move all throughout the system,
whether it\'s at that particular disaster scene or whether it\'s at a
particular region, or at the dome in Louisiana, or at the hospital in
Texas, it needs to be able to move back and forth.

If I would have had Internet access in Texas, I would have had full
access to all of my patients\' medical records in our information system
back in Minnesota, all I needed was Internet access. And I was able to
get it occasionally when I hacked into the military satellite. Until
they figured out my IT and locked me out. So I would have it every once
in awhile.

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

Well, I\'m wondering, you made a very interesting comment here \-- and I
think we heard it also from Dr. Townsend, Internet access is a very
critical piece.

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

Absolutely.

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

So if we were to think about ways \-- and you made the comment about the
military satellite, there may be ways where we could make military \--
Internet access \--

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

For the record, I never hacked into the military satellite.

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

Having worked with the DoD on their communications capabilities \--

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

This is Lieutenant Colonel Parramore again, I could probably speak to
some of that. I was the Chief Information Officer for the Medical Task
Force in Iraq, and I can tell you that delivering technology or
transmission path for Internet is really a challenge. But I would echo
the comments that I heard earlier that it\'s exceedingly important to
deliver Internet to your hospitals. What becomes really difficult,
particularly in a combat zone, is delivering Internet to the point of
injury, or your EMS first responders. So you rely heavily on your voice
networks to accomplish that task of evacuating the patient from the
point of injury to the hospital.

The good news in our case is that most often from point of injury to
that trauma care is minutes, if not less than an hour. So that\'s the
good news, the voice networks work very well. But at least from the DoD
side, those electronic health record systems that we tap into on the
Internet are available worldwide, but the documentation begins
electronically in earnest at that hospital.

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

Appreciate those comments. I think it ties together all of the
presenters in another theme, and Dr. Barthell, you spoke to most
acutely, which is situational awareness, knowing what\'s coming. And I
just interject from the VA perspective, that in fact we often knew much
more situationally and broadly than some of our folks at ground level.
We ultimately had some high-powered satellite systems delivered with
broadband capacity, and it allowed not only a transmission of medical
data, but it provided the communication the rest of us fairly much took
for granted.

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

This is Ed Barthell. I agree with all these comments that preceded me,
that if we can get Internet access to the hospitals, and then have at
least voice communication out into the field, that\'s a nice way to
start. And that\'s still the backbone of the current system.

If you look at the types of data that are in this big NEMSIS dataset,
there\'s kind of two things. One is reviewing past history data on
patients, the other is data ailments that have to do with documenting
that specific encounter. It\'s certainly feasible you can document that
specific encounter on a local device that synchs up later when you
don\'t have connectivity out in the field, but I think by the time you
get to the hospital it\'s going to be very useful to have the
connectivity.

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

This is Lauren Tillary. Having had experience before of working with the
Department of Defense and deploying assets for with \-- medical
triaging, and humanitarian assistance to Africa and to other places
including Antarctica, one of the things I would recommend is also for
Internet connectivity is exploring the possibility that \-- of putting
into place a contract possibly with using commercial satellites during a
national disaster, or the Natural Disaster Management System goes into
effect, that could take advantage of that at a point in time.

The other part is that we \-- and the Department of Defense had also
realized the need to be able to store and forward information, so that
when communications did become available, that you could forward the
information on at the point of injury, out ultimately to \-- for
situational awareness and for electronic recording of the information.

One thing that we did also find out in our experiences in Iraq, and even
previously, in Kosovo, was the need for having a standardization of a
patient identification. When the patient is noncoherent, or you\'re in a
natural disaster, you need some way of having a standardized way of how
you\'re going to identify that person, and then later going back and
changing that record to reflect the actual patient\'s demographic
identification in the future.

So I would encourage you as one of the items that you\'re looking at for
patient identification is you consider that in a natural disaster.
Having a standardized format across the emergency medical system, or
looking at patient identification.

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

Great, a convergent points in terms of going forward, very consistent
with suggestions made previously, and standardized approach to a unique
identifier, that is particularly useful when no identification can be
made, and be able to be replaced with appropriate identification when
that becomes available.

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

Jon, this is Lillee. Can I ask a question?

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

Absolutely, please.

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

Because I \-- you know, I think I\'ve shared with you many times that in
the private sector I\'m struck with the system that\'s in the DoD and VA
sector. We have a nonsystem on the private sector of connectivity.

Are there any recommendations that you could make? Because you know
the \-- the real world in Katrina was that we lost medical records in
physician practices and in hospitals that went under water. And you
could have the best Internet access and try to access someone\'s
records, but they were flooded and gone. The hospitals were closed, the
physician practices were closed.

I\'m wondering if there\'s not some experience or something that could
be done that perhaps bridges into the Consumer Empowerment Workgroup,
where there is some type of accountability, personal accountability for
Americans to have some type of common \-- just very basic medical record
that is present medical condition, allergies, you know, the key things
that the first presenter presented that I thought was very helpful, and
substantiated what we\'ve discussed previously.

But is there a way that we can jump-start some of what the Secretary is
asking us to do, knowing that we\'re bearing down on another hurricane
season, appealing to the average American and the \-- you know, common
sense, here. Because we can talk about access all we want to, but if the
records are gone, what are we accessing.

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

You raise a great point, maybe I\'ll take the liberty of just a quick VA
perspective. Ironically, while Veterans had full access to electronic
health records, VA employees by and large use non-VA health care
providers. We\'ve taken two approaches, one definitively low tech, and
that\'s a personal preparedness document that lists just those things,
that\'s prepared for each member of a family, and copies are made and
securely stored. But the other is the point that I think is really
relevant to this group, not only the Electronic Health Record Workgroup,
but the consumer empowerment and AHIC, which is the nascent personal
health record. There are any number of personal record sites starting
up, certainly VA has one for individuals that don\'t happen to use VA,
for care My HealtheVet, just to name others \-- maybe I shouldn\'t name
specific organizations, but there are any number of organizations that
are beginning to stand up these entities that provide secure and
obviously offsite location of electronic health information.

And I think that you offer the seeds, it would be interesting to hear
some discussion and comments on that on something that we could offer to
Secretary Leavitt as something that would serve as a de facto repository
for some basic information that would be secure and provide some of
these key elements. The basic demography, medications, allergies, the
major past history. That\'s \-- that would be available broadly, with
proviso of some modest connectivity.

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

So Jon, your system, then, it\'s a veteran- or consumer-centric system,
so to speak, because they are the ones that populate my "e-vet," so to
speak.

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

Exactly. The My HealtheVet, a little pun there, very difficult to spell.
But in fact we actually \-- for those that are involved, the district
care will prepopulate with their entire health record. But for any other
veteran, or frankly for that matter any other individual who were so
inclined, but really getting to veterans that log on, and they can use
it as their sort of personal health space. Education, health assessment,
and that sort of thing.

For example, if I wanted my dad to have a secure set of basic health
information, the items we mentioned previously, I could recommend that
he go sign up. And, you know, should there be a disaster, say, "What
medications are you on? I don\'t remember." And say, "Go access My
HealtheVet site," and it would be there.

I\'m not recommending that it\'s the specific solution, but I think an
idea that emerges is that truly, you know, responsibly empowered health
consumers could establish a basic account of information that could be
widely accessible.

And that\'s \-- you know, back to the point about action this year,
that\'s \-- that\'s not a high hurdle.

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

We\'ve had a family meeting, John, and my family, you know, we\'ve got
26 members of my family who are stuck in my house and no access to
anything. And elderly family members with no access to drugs or
anything. And I can just tell you, seizing on where we were, I think if
we empower Americans to self-populate information, there\'s a sense of
urgency out there that \-- you know, even last year did not exist.

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

Let me just note that for the members of the Workgroup, I had the
context of not only know but Lillee was actually from New Orleans, so
this was not theoretical, this was \--

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

No.

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

This is Bart Harmon, if I could make a quick comment from the DoD
perspective.

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

Please.

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

One lesson learned that might play into the consumer empowerment group
or maybe even some of the certification types of activities is that we
focus a lot on system reliability, system availability, system
survivability. And you may want to consider trying to get this into some
of the system certification types of discussions and requirements that
systems that are made available to consumers have to be capable of
surviving a disaster.

For example, within the DoD our data repository that supports electronic
health record actually has a fail over backup site that\'s remote
enough, that\'s in another State, so that if even the primary data
center were to be hit by a nuclear weapon we could fail over to another
site and continue operating. That might be the extreme, but the result
of that was when our hospitals were shut down in the hurricane zone, we
evacuated our patients, for example, to Fort Smith Naval Hospital and
continued their chemotherapy from that central data repository.

That may be a lesson learned that\'s helpful, and might avoid, for
example, some of these companies that are standing up, PHRs, maybe we
need to push the bar of how survivable and available those PHRs are.

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

This is John Houston, why \-- maybe even a more low tech solution to all
of this is the question came up, is what types of things do we need to
have sort of in an essential dataset. Why can\'t that be mimicked,
frankly, in a very low tech fashion in paper at least this year, and
build upon that, develop an electronic record, and in subsequent years
develop on that data.

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

This is Jon Perlin. That\'s exactly what we encouraged the VA employees
to do, particularly in some of the disaster prone areas, also after 911
in New York and Washington, two sites employees are very interested
about how do I put together, and be happy to contribute what we consider
personal health record. But maybe there\'s nexus here which is the goal
is electronic, and rapidly. Bart Harmon makes some great points about
survivability, transportability of information, so it\'s not just
localized in one site. But maybe we actually build as the immediate task
the sort of basic dataset, that if we\'re actually on the right sort of
form, maybe there\'s a standard that could be developed so it actually
could be input in some either automated or semiautomated fashion.

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

In the very first year, we all sort of talk about what is the essential
dataset. Even when you answer that question and say people, go out and
get your essential dataset. And then you say okay, in subsequent years
we\'re going to deal with how do we automate this and make it something
that\'s supportable over time.

But you\'ve got a month until the next hurricane. Or to the next
hurricane season, I should say. You\'ve got a whole group of people and
a lot of areas that are frankly \-- you know, potential targets for
those hurricanes.

If you tell them what they need to gather, and then say this will be
useful in subsequent years, as we develop systems to support this, then
it all works together in some type of long-term plan.

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

This is Jim Sorace, I have a question. If you\'re faced with the
retrieval question, so you\'re a first responder and you\'re trying to
find out the information on the patient, how would you index the
databases so that they\'re searchable? I mean, in other words, do we
need some sort of national repository for these things that you would
turn to, or is there a way in which it could be \-- in which the data
could be made available to an agency running a disaster for a certain
set of geographical area, as needed?

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

This is Ed Barthell. And these are all questions that we tried to
address with the NIIA-HIN program back in the 90s, and the essential
medical dataset we created is trying to do exactly what you are talking
about. In terms of the distribution we talked about having a State-based
system where each State, or sometimes substate and regions, which is
very close to today\'s RHIOs, would be the mechanism that you\'d keep
this essential medical dataset registered with a local RHIO, rather than
having it printed on paper, because people forget where they left the
paper, they lose it, they get their wallet stolen, whatever the
circumstance. We\'d rather have it be something you could access over
the Internet.

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

My health system a few years ago looked at using smart cards for
essential datasets. Frankly, if an ambulance service could issue smart
card readers with some small portal device, it could be very
inexpensive. Frankly, as long as you keep that smart card up to date,
you could plug it into a reader an ambulance and you wouldn\'t need
anything other than the smart card and a reader.

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

Let\'s not try to engineer the solution in entirety today. I think this
is terrific discussion, for a number of things. First consensus on a
number of key data elements that are absolutely necessarily. Second,
that timeliness is key, and getting those key data elements on paper as
a first step is essential, and a good takeaway. Third, there are any
number of solutions for consolidating personal health information, be it
PHR, smart card, or other technologies.

The fourth that \-- you know Dr. Bell is here with, she has a list in
front of her of some of the data that exists electronically right now.
Like pharmacy that was so useful in Katrina Health, from which one could
infer certain disease States and know how to provide continuity of care.

Like laboratory data as an additional example. Like some of the hospital
information, administrative datasets that are available.

I think our first mode is to identify these categories of information,
and I think we\'ll come back to some of the questions on engineering
some of the other. But Karen, let me ask a point of order, here, and
what your recommendations are as to our best structural approach to
making good on deliverables of some of the things that would potentially
have immediate high yield.

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

Well, it certainly seems to me, and tell me if I\'ve heard differently,
that the group has identified those critical elements that should be
available at the time of the first response. So we could certainly \--
this Workgroup could go to the AHIC on the 15th and say that those have
been identified.

That further work would need to be done over the course of perhaps the
next meeting in terms of how we put that in a paper form or
recommendations about the format that it could go in. And then thirdly,
we would explore ways in which existing electronic information could be
made available at the point of contact. And I know that some of that
work has already been done as part of the work that this group has done
for the specific charge.

So we could take what we\'ve learned on the specific charge based on
those recommendations, and apply that to some of these other issues, as
well.

And perhaps that three part approach would be appropriate for the AHIC
meeting on the 15th. As a first step.

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

Maybe ONC can bring back what sort of electronic information might be
available, and particularly tapping into the HHS resources around
Katrina Health, and learning from that.

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

Great idea.

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

I think we\'ve \-- Lillee, you and I can probably find some volunteers,
judging from the excitement in the conversation.

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

Uh-huh.

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

Kind of a mockup of the basic paper personal health records that would
feed into the other, and then our subsequent discussion to talk about
how to have \-- how to achieve indexed personal health records that
would be available under disaster circumstances, certainly available to
individuals, and interface with consumer empowerment groups.

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

That\'s right.

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

This is Jason Dubois. Can I offer just two comments? One is as you do
this work on the PHR, I would encourage you to talk with the American
Health Insurance Plans, because they\'ve developed \-- they\'re
developing \-- and I don\'t know how far along they are, but they are
developing a universal personal health record with the intent that if
you\'re with Blue Cross Blue Shield of Illinois and often move to
Wisconsin to use Aetna there that you\'ll be able to take along with you
your health information to the new plan, that that will be easily
recognizable with the other plan.

The other thing that I didn\'t know we\'ve made a lot of talk today
about the need to do something, and this is just \-- you know, stream of
consciousness notes, so take it for that.

But I didn\'t know whether it was the potential for creating some kind
of offering by HHS on their Web site to the people who elect to enroll
in terms of a PHR that\'s offered by HHS, that they could \-- or there
would be some kind of a Web portal that they could input their own
prescription information, and immunizations, I think those are two big
keys that people could selectively elect to put in there, thereby
authorizing its inclusion and use, and have the government as the
database for that. And those people who \-- you know, my parents are
getting ready to move down to Florida off the coast and, you know,
hurricane alley, this fall. And, you know, they might elect to \-- you
know, sign up on the Web and say, "Okay, I don\'t have any place in
house on paper," God forbid something happened to the house but that
would be one repository where they could have it and, you know, God
forbid anything happened, it could be touched into later on. It\'s just
a thought.

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

It seems to me when we start moving into electronic arena we\'re going
to dealing with again similar type things as we here. We\'re going to
need to standards for defining all of these elements, standards for
interoperability. So I think if you allow us, we\'ll take what we\'ve
come \-- put together here, and work it through the Workgroup over the
course of the next week or so, and come up with some very broad
approaches that we can bring to the Secretary on the 15th, start
bringing the workgroups together.

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

That sound good to people?

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

Fair.

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

We have reached the point in the conversation where we should open up
for any public comment. We\'ve covered a good deal of territory, and
again I thank those of us who were with the entire conversation. So
let\'s go to Matt and anybody who has any comments from beyond the
Workgroup membership itself.

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

Sure. If there\'s members of the public on the phone who want to speak,
you simply need to press Star 1 on the telephone. And if you\'re
following along on the Webcast, you\'ll see the instructions up on the
screen. And as always, we\'ll take about two minutes to see if anybody
gets through the operators, and if not, at that time we\'ll leave up the
e-mail address to submit comments that way.

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

In the interim, while we\'re waiting let me turn back to Lillee for any
final comments you might want to make this part of the conversation.

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

I think it\'s been a great meeting. I want to thank members of the
Workgroup, because you really do roll your sleeves up and get the job
done. I hope you are as comfortable as I am with the recommendations
that are now going to the AHIC. I think you have paved the path for us
in terms of the types of questions we may get and the types of
discussions we may entertain. And I really am glad that Secretary
Leavitt has given us the additional charge around first responder EHRs,
because we really have a great opportunity to show the way.

I would really be intrigued, when Jason gave the recommendation around
an HHS voluntary scenario that would be on the Web site, I\'d be curious
to know, for instance, on pandemicflu.gov, how many downloads there are
of the personal planning and business planning check lists and plans,
those types of things. So if I do think if we can reach those that are
proactive and really want to be part of the solution, reach a tipping
point, and be able to do something. So Jason, thank you for that.

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

Let me just take this opportunity to thank our presenters today,
Dr. Barthell, American College of Physicians. Aaron Reinhart, Lakes
Region EMS, I appreciate the broad experience you also bring. David
Parramore from the Department of Defense. Appreciate also Dr. Harmon\'s
comments on backup and Dr. Regina Townsend from Louisiana Department of
Health and hospitals. Matt, do we have any input at this time?

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

Doesn\'t look like we have anybody calling in. The e-mail will be left
up on the Webcast for a few minutes if anybody wants to make comments
that way.

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

Again, I thank people for spending time this afternoon. Karen, any last
administrative comments? Next meeting information, other logistical?

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

Next meeting is going to be the American Health Information Community
meeting on Tuesday the 16th of May. Subsequent to that we will have more
workgroups, and the times for those and dates will be posted.

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

Again, to the ONC staff, Dr. Karen Bell, Alicia Bradford, new executive
director, Katy Barr, many thanks to the entire team, great support and
work. And we\'ll see you next time.

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

Thanks, everyone.

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

Thank you all.

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

Bye.

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

This concludes today\'s conference. Thank you for your participation.