American Health Information Community

Chronic Care Workgroup Meeting

April 24, 2006

1 p.m. EDT

**Disclaimer**

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

\>\> Matt: Okay, Craig and Tony, I think that Karen is going to call
back in, but we\'ve got the public listening now, if you would like to
start with some introductory remarks. (00:10.1)

\>\> Craig: I think our introductory remarks are that we have a rather
hefty agenda. We have five recommendations which we need to discuss in
some detail and make sure that the clarification of the exact charge
direction, the background information that we are trying to pursue to
carry out our task \-- and that should consume the majority of the
meeting. Tony, I don\'t know if you have anything different that you
would like to say than that. (00:40.0)

\>\> Tony: No. That pretty much covers what we need to cover, which is a
lot in the next several hours. (00:49.4)

\>\> Matt: Okay. While we wait for Karen to call back in, I will quickly
run through a roll call of the Workgroup members on the line. And just
to remind everybody who is called in as a Workgroup member, you have an
open line, so you can speak whenever you need to. Please mute your phone
when you\'re not speaking. And if you are following along with the
Webcast, please don\'t touch any of the controls on that. (1:09.0)

Joining us on the call today, in addition to our Co-chairs, Craig
Barrett and Tony Trenkle, we have Brian DeVore, Dan Jones, Paul Nichol,
Eric Larson, Jeff Rideout, Joyce Dubow, Mike Crist \-- and Vernette,
could you please remind me who is live in the room at ONC with you?
(01:28.8)

\>\> Vernette: Jay Sanders. (01:31.3)

\>\> Matt: I\'m sorry, so that was Dr. Jay Sanders? (01:35.9)

\>\> Vernette: Yes, as far as a Workgroup member. (01:38.8)

\>\> Matt: Okay, thank you. Since everybody does have an open line, I
would just like to issue one additional reminder: please identify
yourself before you begin speaking so we know who is who. Karen, are you
back on the line with us? (01:57.6)

\>\> Tony: Matt, it would be helpful if you could say who is there from
the Workgroup and also who they represent a little slower, because I
didn\'t get all of the names, and a couple of them were unfamiliar to
me. Could we kind of go through them again while we are waiting for
Karen? (02:13.8)

\>\> Matt: Absolutely, and I might not have some of the affiliations
correct, so if I do get somebody\'s name wrong or their organization
wrong, please step in and correct me. We\'ve got Brian DeVore from Intel
\--

\>\> Tony: Right.

\>\> Matt: \-- Dan Jones from the University of Mississippi Medical
Center, Paul Nichol from the Department of Veterans Affairs, Eric Larson
from Group Health Cooperative, Jeff Rideout from Cisco Systems, Joyce
Dubow from AARP, Mike Crist from LabCorp of America, and Jay Sanders
from the Global Telemedicine Group. (02:56.1)

\>\> Andy: And this is Andy Mekelburg from Verizon. I have joined, too.
(02:58.8)

\>\> Colin: This is [Colin Emms]{.mark} at Intel also. (03:01.9)

\>\> Matt: Any Workgroup members on the phone that we missed? (03:07.6)
\[Silence\] Okay, that looks like it for right now, Tony. (03:13.7)

\>\> Tony: Okay, thank you, Matt. (03:13.8)

\>\> Matt: Uh huh. (03:13.9) \[Silence\]

\>\> [Craig]{.mark}: Did we lose Karen? (3:40.9)

\>\> Matt: I think Karen was switching to a different phone, so she is
going to be back on in another minute or 2, and then she will begin with
the first agenda item. (03:51.6)

\>\> Mohan: Good morning; this is Mohan Nair. I joined a little late.
(03:52.0)

\>\> Matt: And joining us: Mohan Nair from the Regence Group. (4:00.8)

\>\> Mohan: Thank you. (04:02.9) \[Silence\]

\>\> Craig: Tony, while we are waiting, do you want to perhaps give the
group just a brief summary of Brailer\'s status and how he will interact
with us as we go forward? (04:52.2)

\>\> Tony: Well, I was waiting for \-- actually, Craig, for him to come
and s\-- he was going to personally come and speak to each of the
workgroups, and Karen was just saying that he \-- she anticipates him
coming on at some point in the call. But pretty much what you saw in the
news release is what I have been able to ascertain. In other words, he
is going to be a Senior Advisor to the Secretary as well as the Vice
Chair of the AHIC, and I guess he will provide more details as to what
that would encompass. He will be leaving his current position, I
believe, May 21, which is about 4 weeks from Friday. (05:36.4)

\>\> Karen: Hi, this is Karen Bell and Herb Kuhn. We finally were able
to get the star phone working, so we are with you now. My apologies.
(05:47.7)

\>\> Tony: Okay, Karen we just finished with the introductions. I guess
it is time for you to review the call-in procedures and the FACA
guidelines. (05:57.9)

\>\> Karen: I will do that and then move into the goals for today\'s
meeting. Just wanted to clarify to everyone that the participants on
this call are the workgroup members. This is a public process, so anyone
can stream in and get information from the Workgroup. And there will be
a time at the end of the meeting for public comment, and we would
welcome anyone on the call to offer public comments at that point. It is
a FACA process, a Federal Advisory Committee, so that all participants
are free to represent their points of view to the full extent
possible. (06:38.3)

The goals of today\'s meeting \-- and I am going to jump right into that
now \-- is to essentially wordsmith and craft the next version of the
draft recommendations that will go to the American Health Information
Community on May 16. We have had a bedding process where individual
Workgroup members have created first-draft recommendations which have
been vetted by other Workgroup members in a process to bring them to the
public comment phase now. The full intent of today\'s meeting is to work
through these recommendations \-- again, the format of full discussion
\-- so that they are crafted as a next draft, and there will be more
work that occurs between now and the next Workgroup meeting to get them
into their final form. In order for that to occur, we have put together
each recommendation; it will be available on the screen. And there are a
couple of preliminary discussion questions that are there just to get
discussions going on how these might be crafted in a way that will be
consistent with other recommendations coming forth as well. (08:06.3)

In addition to the recommendations, we will be soliciting comments on
the supporting documentation and the writing, again with the
understanding that it will go through several iterations as well prior
to the next Workgroup meeting, where we will be eliciting final comments
and sign off. So, with that, I will turn the discussion back to the
Chairs to go through these recommendations, because they really are the
only intent of today\'s meeting. So thank you very much. Any other
questions before we jump into it, though? (08:45.1)

\>\> Tony: I guess, just from a procedure standpoint, I \-- Craig, I
think we also had the review and acceptance of the minutes from last
meeting. I guess we should ask the Workgroup if anybody has any comments
on that. (08:59.4) \[Silence\]

\>\> Eric: I suggest we accept them. This is Eric Larson. (09:07.5)

\>\> Craig: Hearing none. (09:07.5)

\>\> Tony: Okay, we will go ahead and accept them, then. Craig, did you
want to start with the recommendations? (09:18.5)

\>\> Craig: Well, does everyone have a copy of the information that was
sent out with the recommendations and background material? If you
don\'t, holler out. I guess we \-- I'm just looking \-- I guess we have
it up on our screen as well at this point in time. The challenge today,
I think is, to go through the five issues that we have: reimbursement,
liability and licensure, consumer access, workflow, the standards for
embedding this type of information into EHRs and the standards for
patient ID authentication and security. I believe what we have up on the
first screen is the series of recommendations for reimbursement. And
each one of these follows a fairly standard format, which is in fact
a kind of a description of the issue, and then a series of suggestions
on information to capture and reconcile, and the timeline associated
with that. The reimbursement issue, which is up on the screen, I think
\--

\>\> Karen: Craig?

\>\> Craig: Yes. (10:36.3)

\>\> Karen: It\'s Karen. Would you like to maybe make some comments
about why this is an important recommendation \-- some of the background
information that goes with it for the public audience? (10:45.8)

\>\> Craig: Well, the \-- I think the key issue associated with
reimbursement is, in fact, that most of the audience should be aware
that reimbursement is a physical interaction association, not a virtual
interaction association today. Therefore, reimbursement for secure
messaging \-- secure e-mail-type messaging is not reimbursable in most
instances; it is in some instances around the world. The challenge is to
figure out how to facilitate reimbursements and facilitate usage of the
technology. (11:30.5)

But, I think more importantly, underlying that is how to facilitate
reimbursement where there is, in fact, a measure of success or measure
of improvement in medical care delivery through the use of the
technology. So it is not just a question of reimbursement; it is a
question of reimbursement for quality of care associated with the
technology. (11:59.5)

\>\> Gloria: Can I interrupt for just a moment? This is Gloria. I think
that because not everyone may have access to be able to see these
recommendations on a computer, that it might be good to just have us
read the recommendations at the beginning of each \-- of the discussion
of each one. Would that be okay? (12:25.1)

\>\> Karen: That may \-- that would probably be a very good idea.
Perhaps even \-- what about the introductory paragraph that sort of sets
up the discussion for the recommendation? Would you recommend that that
be read as well so that everyone is essentially thinking up to speed?
(12:44.2)

\>\> Gloria: Sure, I would be happy to do that if you would like me to.
(12:51.2)

\>\> Karen: Alright, why don\'t you start that process then, Gloria? And
then the Chairs can get back into leading the discussion again.
(13:01.6)

\>\> Craig: Well, can I just \-- this is Craig Barrett \-- can I ask how
much of this stuff are we going to read? I find it terribly interesting
that we are talking about just using electronic communication and we are
going to end up verbally reading all of the documentation. (13:19.7)

\[General laughter\]

\>\> Karen: Agreed. I am just a little concerned that not everyone has
all of the information. (13:26.4)

\>\> Craig: Well, yeah, but I\'m looking at the pile of paper that I
have in front of me, which I happened to print off. Now, are we going to
read all of this, or are we going to pick selected segments of it for
verbalization? (13:39.3)

\>\> Karen: I was thinking about perhaps one brief paragraph to set up
the discussion around the recommendations and then the recommendation
\-- each one itself, and then the discussion goes for each
recommendation. Would that work? (13:55.0)

\>\> Craig: Let\'s give that a try with reimbursement and then \--

\>\> Karen: Okay.

\>\> Craig: \-- we can modify it if it doesn\'t. All right? (14:02.0)

\>\> Karen: Okay. (14:02.9)

\>\> Gloria: So, Karen, for the paragraph that sets things up, are you
thinking of the paragraph that begins \"While up to 80 percent of the
\--\" (14:13.2)

\>\> Karen: Yeah, maybe just that one paragraph. (14:13.2)

\>\> Gloria: Okay. I will read quickly. "While up to 80 percent of
chronic care management takes place outside of the practitioner\'s
office, he or she is only reimbursed for time and expertise if the
patient makes the effort to make and keep an appointment for an office
visit. Explanations on how to best manage the changing pattern of atrial
fibrilla\--" I can't say the word \--

\>\> Craig: "Fibrillation."

\>\> Gloria: \-- "fibrillation" \[laughs\] \-- I'm trying to go too fast
\-- "advice on how to modulate insulin in a brittle diabetic, monitoring
the blood pressure, and titrating with medication all require office
visits in order for clinicians to be compensated. Much of this
information and guidance could be provided through direct communication.
(14:56.8)

"Lack of reimbursement for clinicians hired and expertise rendered
outside of the office setting is a major barrier to widespread adoption
of the use of secure messaging between clinicians and their patients. In
situations where lack of compensation is not a barrier, salaried
clinicians or fee-for-service reimbursement has a positive return on
investments, and improved quality of care has been noted by eventually
holding responsibility for the cost of care. (15:22.9)

"So the first two recommendations on reimbursement read, 'HHS should
develop the evidence base for informed reimbursement policies with
respect to secure messaging between clinicians and their patients.' The
second one reads, 'HHS should be charged to develop a description of
reimbursement methods visible for secure messaging. These methods would
need to address the \--'"

\>\> Craig: "Heterogeneity."

\>\> Gloria: "'\-- heterogeneity'" \[laughs\] \-- I'm sorry \-- "'of
practice settings from traditional fee-for-service to a variety of
capitated systems, ITA, and integrated staff models, as well as newer
innovative proposals like the American College of Physicians Advanced
Medical Home. The timeline would be 6 months. To develop these
descriptions, HHS should utilize the experience of existing secure
messaging systems to learn different reimbursement strategies and to
identify current best practices regarding existing specific and
auditable guidelines for reimbursement of secure messaging, concurrent
for 6 months.'" (16:31.4)

\>\> Gloria: Now the Chairs are ready to take it over again. (16:35.4)
\[Silence\]

\>\> Karen: We had suggested a coup\-- this is Karen Bell. We had
suggested a couple of preliminary discussions based on the fact that
perhaps the second recommendation actually adds specificity and clarity
to the first one. So the types of questions that we felt that we could
ask to get the discussion flowing is, is this truly two recommendations,
or could it be one, and how could it be worded to add more clarity to
exactly what can be done moving forward? (17:19.0)

\>\> Tony: Karen, this is Tony. Based on the last discussion at the
previous Workgroup meeting, I thought that the group had talked about
the first one as being different because the first one \-- the second
recommendation for reimbursement presupposes that there will be
reimbursement, whereas the first one is looking at the evidence base to
discuss reformed reimbursement policies. This does not make a judgment
as to whether or not reimbursements specifically for secure messaging
will occur. So I think they are somewhat different. The second one is
more of a discussion: if there is reimbursement, what are the types of
reimbursement methods that should be made? (18:04.5)

\>\> Eric: Hi, this is Eric Larson. I was part of the group that wrote
these, and I think it is important that two exist separately, because
they are different, and they also ask that the work be done not just
around "How much do you pay per message?" or "Is that the way your going
to do it?" It says, "There are many ways of doing this. Let\'s
understand how they work and then adapt ideally one or several ways to
make this part of the cost of care, because there is a cost associated
with it." (18:46.5)

\>\> Tony: I think your explanation actually makes it a lot clearer,
Eric. It may be somehow that can be folded into the two recommendations
to kind of clarify the difference between them. (19:05.3)

\>\> Craig: But just so I am clear \-- this is Craig \-- the first one
effectively says, "Develop the evidence base associated with the
technology. Where is it being used? How is it being used? What are the
results of its use?" And then the second one is, "From that evidence
base, develop a description of methods which, whether they are best
known practices or the best techniques for using the technology to get
measurable improvement of quality of health care, come forward with
those recommendations." Is that effectively what the subgroup meant by
the two? (19:53.2)

\>\> Tony: That is correct. (19:55.1)

\>\> Joyce: Well \-- this is Joyce \-- except that it \-- if I
understand the first one, it is not referring to a technology so much as
a practice. (20:05.3)

\>\> Craig: I may be misusing the words. (20:09.8)

\>\> Joyce: Okay, I just want to be clear that I understand it, because
as I understand #1, there is an agnostic tone about #1 to determine the
evidence base, to identify the evidence base, to be sure that this is an
effective tool to encourage secure methods. Is that correct? (20:30.4)

\>\> Tony: That was my interpretation of what we talked about last time,
Joyce; this is Tony. But I think that the only difference is, #2 is a
little bit more descriptive of the \-- of actually developing a
description reimbursement method. But I agree with you: the way we
talked about #1 last time, there was a premise that we had not
determined whether there should be reimbursement with regard to secure
messaging, but the evidence base needed to be developed be HHS.
(21:05.0)

\>\> Eric: Yeah. This is Eric Larson again. I think what this means
practically is that we would recommend a very rapid deployment of
probably a survey of what people who are using secure messaging are
doing and what the evidence is as to how that affects what they are
doing and ideally if they know anything about how it's affected the flow
of patients, satisfaction of patients. It is probably premature to know
anything about actual outcomes, but in our conversations, we thought,
"there is enough people using this technology, if you will, that we can
develop an information base that describes how it's being used, and then
that would be what informs the development of reimbursement methods or
description of reimbursement methods under Recommendation 2. (22:05.7)

\>\> Joyce: I am sorry to be dense. Eric, do you mean \-- when you say
"what is being done," do you mean how or whether it is being paid for,
or do you mean that \-- (22:13.5)

\>\> Eric: That is correct. (22.15.4)

\>\> Joyce: Okay, so when you say that if it is being used, whether or
not it is being paid for, and how \-- what methodologies are used to
pay. (22:23.8)

\>\> Eric: Correct. (22:24.7)

\>\>: Joyce: Okay. (22:24.9)

\>\> Tony: So you are looking across the universe then, Eric, of all of
places where secure messaging is being done, whether it is being paid
for or not, to develop this evidence base. Is that where you are coming
from? Whether it is being paid for specifically or if it is being paid
for as part of an overall outcome for care? Is that \-- (22:24.4)

\>\> Eric: That is correct. (22:47.3)

\>\> Tony: Okay. (22:47.3)

\>\> Jeff: This is Jeff Rideout. Eric and I were working on this
together. I have maybe a couple of examples. There may be examples where
people are paying for the specific secure message when there is clinical
content. There maybe other examples where this is bundled as part of an
online communication tool that includes secure messaging but may include
lab lookup or other things. And it maybe bundled as part of a tool
that\'s available through capitated payments as part of the
per-member-per-month service. So this was an attempt to say, "We know of
examples where this kind of secure messaging is being used in all of
these settings. Let\'s catalog those things first and understand the
range of its use and how it's being reimbursed." (23;27.8)

\>\> Craig: So Jeff, this is really the "how, what, where, when" \--
(23:31.2)

\>\> Jeff: Yes, exactly. (23:31.6)

\>\> Craig: \-- summary of the technology and how it's being used in
different practice settings? (23:35.6)

\>\> Jeff: Correct, and how people may or may not even be paying for it
at this point. (23:40.6)

\>\> Karen: Okay.

\>\> Craig: So the outcome of this study would be basically a catalog of
what is being used; how it's being used; and what are the results, as
best we can determine, from its use. (23:57.1)

\>\> Jeff: Correct. (23:58.6)

\>\> Mohan: This is Mohan Nair. If I may, you just mentioned something,
Craig. You said the outcome is a catalog of what is being dis\-- of what
is out there. Is the outcome of this recommendation that we follow that
which is described in this list of choices we have and, within this list
of choices, to come up with what we think is a best choice, or is this
recommendation to find a new way in which to do this, based on the
evidence? (24:33.8)

\>\> Jeff: Well, I think there was recognition that reimbursement takes
a variety of forms, depending on the delivery system and the financing
of that, and it wasn\'t to say, "There is one best form." It was to say,
"Are there ways that this service is currently being either incorporated
into the financing and reimbursements or not?" And if we know what those
ranges are, then we have a better chance of saying which ones might be
preferred. (25:03.7)

\>\> Mohan: I see.

\>\> Eric: And this is Eric again. The operative recommendation is to
identify current best practices regarding. (25:11.4)

\>\> Mohan: Right. (25:11.6)

\>\> Eric: That\'s \-- to me, the bottom line is that would be, then,
the basis that the field or the \-- or CMS could use to develop whatever
payment system they are going develop, given the heterogeneity of
providers. (25:31.9)

My guess it will be systems, not just one type only. (25:37.5)

\>\> Mohan: Yeah. Again, I am not communicating effectively. So let me
try again. (25:43.1)

Is it the assumption in this \-- in the Workgroup that we will design
something based on what we see working, or is the assumption of this
Workgroup to look at what is working and create a new environment of
reimbursement within an infrastructure they may have to change?
(26:00.3)

\>\> Eric: I don\'t think that \-- Jeff, just speak up, too \-- I
don\'t think we presupposed that that would be the outcome. We didn\'t
specify that much detail. (26:20.2)

\>\> Tony: Yeah, I don\'t think you \-- well, it doesn\'t look to me,
from what we are reading, that you went that far. You were just getting
to the point where somebody would take that as the next step, then.
(26:28.5)

\>\> Eric: Well, yeah.

\>\> Karen: I think one thing just to keep in mind \-- this is Karen
Bell \-- is that these are recommendations to the AHIC. The Community
will have a lot of discussion on these and will probably shape their own
recommendations, based on the information we provide to them so that \--
I think that the hope is that we can provide enough good information,
either now or to the AHIC, where they can subsequently make future
recommendations. (26:57.1)

\>\> [Mohan]{.mark}: Okay. (26:58.2)

\>\> Jay: Hi, Tony. This is Jay Sanders. I thought I understood
Reimbursement 1 before all of this discussion. The way that I understood
it \-- and obviously, I think I understood it incorrectly \-- was that
the evidence base that we were looking for was evidence base on "secure
messaging improved the quality of care or was a critical part of the
care process" and that, in parallel, Reimbursement 2 would allow us to
look at the various types of reimbursement methodologies, if the
evidence base proved that the secure messaging improved the quality of
care. (27:44:3)

So if I am wrong, my only suggestion would be that we perhaps rephrase
Reimbursement Recommendation 1 so there wouldn\'t be this confusion.
(27:59.5)

\>\> Paul: This is Paul Nichol. I would agree. I think that the lack of
reimbursement is a significant barrier to expanding the use of secure
messaging and that they \-- I thought the goal of this evidence search
was to confirm that there is sufficient evidence to make a
recommendation to remove that barrier by offering ideas for
reimbursement and potentially not just reimbursing for the service, but
perhaps offering incentives for its use. (28:34.2)

\>\> Craig: I guess we can all read whatever we want into the phrase in
the first recommendation, which is \"informed reimbursement policies\":
whether that means \"informed\" as such that you are getting results for
payment, whether there is increased quality associated with use of the
technology, etc., etc. Is that part of our challenge? We are all reading
what we want into that statement? (29:06.9)

\>\> Jeff: This is Jeff. I think we can read as much or as little as we
want in. I think \-- Eric, jump in here too \-- the main goal is just to
catalog an inventory of where secure messaging is being used and where
it is being reimbursed, and my assumption would be, in those areas where
it has been documented, we would catalog everything else too. Is there a
documented impact on productivity, on quality, on process? And so there
would be essentially a single body of information that says, "This is
what people are doing in terms of payment, and this is what they may be
getting out of it \-- out of the system." That is just really what we
were trying to get at here. (29:47.0)

\>\> Tony: Yeah, that was my interpretation as well, Jeff, as to what
you were looking for there. This is more the universe of what is out
there, and this is where it may impact outcomes of various types,
whether it be quality or other areas. (30:03.5)

\>\> Eric: And just \-- this is Eric again \-- it was our assumption \--
and this is for AHIC \-- when you work through these, if we approve them
today, you are going to find, as you probably already know, that there
is a lot of information out there. And we are saying as a subgroup
of this project that we think, within 6 months, you are going to be able
to come up with, or whoever does this work is going to be able to come
up with, some description of best practices. And that should allow us to
begin to move on this, because we were told at one time that this was
off the table, and it\'s our strong recommendation, based on what Paul
Nichol just said, that it really shouldn\'t be off the table if we want
this to start happening in the management of chronic diseases. (30:55.8)

\>\> Karen: This is Karen Bell again. So, I think what I am taking from
this is that the next \-- the kind of language we are looking for, in at
least Reimbursement 1, is a little bit more clarity about what we mean
by "informed" and what \-- I am sorry \-- what we mean by "the evidence
base," so that it includes not only reimbursement methodology but also
the kinds of outcomes that could be associated with looking at secure
messaging. (31:34.3)

\>\> Craig: Yes. Karen, I was looking at the last bullet on page 3
of the material that was sent out; I will read it for the folks who
don\'t have it: "HHS should monitor and report on ongoing electronic
communication experiences in various practices and in pilot studies to
determine the effects of online communications on cost; quality,
especially for chronic disease outcomes; medical/legal concerns; and
patient/caregiver satisfaction." (32:05.5)

\>\> Jeff: That is kind of \-- when I read that, I was okay with the
first recommendation, Reimbursement 1, assuming that that\'s what it
does, that it has all of the issues of cost, quality, satisfaction
embedded in it. If that is what we mean by "informed reimbursement
policies," I am cool with this. (32:31.2)

\>\> Karen: So basically, then \-- that is a very good point \-- so we
take this and do a study to see where we are now. That would be the
first one. And then a second recommendation would be that the same type
of evaluation would be conducted in an ongoing monitoring fashion.
(32:51.8)

\>\> Herb: Well, this is Herb Kuhn. I think what that leads to is what
these demonstrations are all about \-- is to prove a concept. And
can you deliver a higher-level care, more efficient care? And that is
the kind of information we hope to harvest from those, so how can all
that be integrated into this process as you evaluate this Recommendation
#1? (33:12.5) 

\>\> Eric: Okay. I think the \-- Eric Larson again \-- I think the
recommendation, as it stands, is well-supported by the appendix
information, I think, that is out there, and I do think that works. But
the second recommendation is really to move to that sort of
best-practices reimbursement, and eventually that will have to be
somehow codified, I presume, at the Federal level anyway, and the
private sector will have its own opportunities. (33:53.8)

\>\> Jeff: This is Jeff Rideout again. So those are the easy ones.
(34:09.1)

\>\> Karen: Do you want to take a crack at trying to \-- Karen Bell here
\-- do you want to take a crack at trying to change some of this
language now, or do you want to direct us to go back and take the meat
of this conversation, work with the original crafters \-- Herb, Jeff
Rideout, and Eric \-- to clarify the language a little bit, and then we
will continue the vetting process among all of the Workgroup members?
(34:41.1)

\>\> Craig: You know, Karen, I would be happy if you just could get into
the first one, just the concepts of cost quality, you know,
and satisfaction. (34:58.0)

\>\> Karen: Okay. (34:58.3)\
\
\>\> Craig: Patient and caregiver satisfaction. (35:01.0)

\>\> Karen: Yeah, I have that as a \-- as \-- I have it as two different
things: #1, to find out the state of the art right now and have a really
good evaluative study done in terms of where we are today, and then,
clearly, we need to be monitoring it moving forward. (35:21.6)

\>\> Craig: And then, I presume from the tenor of the conversation that
once we have that \-- the database in place, then it's the subgroup \--
the recommendation is to effectively develop a description of methods
suitable for different settings that is all drawn from the best-known
practices in the database above. (35:49.0)

\>\> Tony: That was my understanding of it also, Craig, but I do agree
with you on #1, that we do need to develop the overall evidence base,
but I think it does need to be tied to some of the various outcomes that
are discussed in that last paragraph. I guess \-- I think that was the
point you were getting at, that it is one thing to catalog, but secondly
to really point out areas where it has shown effective improvement. And
I think it's \-- that does need to somehow get into the first
recommendation there. (36:27.3)

\>\> Craig: So Karen, perhaps if you could \-- if we could just embed
those concepts into Reimbursement 1, the first recommendation \--
(36:37.5)

\>\> Karen: You\'ve got it. (36:40.1)

\>\> Craig: \-- and then, with the rest of the background material that
goes behind these recommendations, I think \-- at least I had the sense
from the group that the background material further clarifies and gives
a little bit better job, just because it uses more words, to get us
where we want to go. (36:58.7)

\>\> Karen: So in terms of the second bullet, where HHS should be
charged to develop a description of reimbursement methods, is \-- we
agreed that would be a separate one. We would pretty much keep that as
is? (37:19.4)

\>\> Craig: Well, I think the \-- if anything, the second one is the
action item to make the list of, quote, \"suitable methods.\" Those are
suitable methods to, in fact, fulfill the charter of this group, which
is, "Hey, if you really want to make wide spread use of this capability
available, these are the suitable methods to do that." (37:45.8)

I understand the subtleties involved here, whether we are supposed to
make absolute recommendations to do this and do that. But we do have a
charter to \-- AHIC has a charter to promote widespread adoption of this
capability. Is that correct? (38:02.8)

\>\> Karen: Mm-hmm. (38:03.9)

\>\> Craig: So I think our Reimbursement 2 should be basically, "HHS is
charged, or we are charged, to develop and provide the description of
the methods which are suitable to give this improved care, cost, quality
\-- is that good sense? \-- and then all that stuff underneath that is
just kind of how we are going to do that, what time frame we are going
to take, and whose proposals we are going to look at. Maybe there are
others that other people have that we should look at as well. But a lot
of that can be included in the package. (38:44.5)

\>\> Karen: Jeff, Herb and Eric, does that make sense to you? (38:48.7)

\>\> Eric: Yeah. I think that is exactly right. That first sentence is
the key sentence there. I am glad that you picked up on the word
\"suitable\".(39:02.1)

\>\> Jeff: I think the way you described one feeding into two; I mean,
one is an input for two, so the action is in two, and one is how we get
informed about, how to define what suitable means.(39:14.8)

\>\> Herb: Yeah, this is Herb. This works for me as well. The only thing
that I keep thinking back, in the back of my head, and I think we used
the word \"cost\" in here and is that interchangeable for efficiency?
What I am also looking at is whatever payment systems that we have, they
really drive a higher performance in terms of great efficiency, and I
was wondering if somehow we could capture that thought or whether we
think that is captured enough in the term \"cost.\" (39:40.9)

\>\> Karen: Won\'t that come out when we determine best practices?
(39:45.1)

\>\> Herb: That could, but I am just wondering if we want to be just a
little bit more directional there? (39:48.9)

\>\> Karen: We want to use \"utilization\" in addition to \"cost\"?
(39:53.9)

\>\> Craig: Well, don\'t you get it with \"cost\", \"quality\",
\"patient," and "caregiver satisfaction\"? (40:01.07) 

\>\> Herb: Yeah, and that can be one and the same, but I think that if
is obvious to everybody, I just want to think the obvious and if it is
not, I just want to make it clear. (40:10.1)

\>\> Karen: Maybe we could include that in some of the explanatory
language.(40:20.3)

\>\> Herb: Then we could bring it out there. (40:19.2)

\>\> Karen: Okay. (40:22.6)

\>\> Herb: Okay, thanks Karen. (40:22.7)

\>\> Karen: What about the third one down now: The opportunity to
leverage existing programs? (40:33.5)

Shall I read this one? (40:47.4)

\>\> Craig: We have people who are not online; you\'d best read it.
(40:54.7)

\>\> Karen: Okay. (40:56.2)

This was a third recommendation related to reimbursements. HHS should
identify opportunities to leverage existing programs using secure
messaging between clinicians and their patients. Two, reflect the
diversity of current physician practices. Reimburse only for
Internet-based physician-patient encounters that qualify under CCT code
074T used in accordance with guidelines as developed by the American
Medical Information Association, the American Medical Association, and
the Massachusetts Health Data Consortium to secure messaging, and
coincide with existing or planned HHS demonstration programs designed to
promote health, IT adoption, consumer-directed health care, and/or
pay-for-performance efforts. (41:51.9)

There is a lot in this one.(41:56.0)

\>\> Craig: Um-hum.(41:56.1)

\>\> Jay: Karen, can I ask you a question? This is Jay Sanders. In the
opening paragraph, opening sentence, you said between clinicians and
their patients, there are nurses clinicians as well, and yet in all of
the bullets, you are really referring to physicians. Which would exclude
the nurses, so I would like some clarification there.(42:21.2)

\>\> Karen: Well, I think that the crafter, I would have to go back to
the folks who actually crafted this, I think the intent was clinicians.
Is that correct?(42:33.7)

\>\> Eric: The word \"clinician\" was meant to be inclusive because we
did get some feedback on that point in the process of developing that.
(42:42.2)

\>\> Karen: Okay. (42:42.3)

\>\> Jeff: This is Jeff. The only thing I would add is that, as I would
understand it, at this point the reimbursement could only be between a
physician and patient encounter even if a nonphysician clinician were
involved, is that correct?(42:55.4)

\>\> Jay: I don\'t believe so, no. Nurse practitioners can be reimbursed
(43:04.1)

\>\> Jeff: Well, the nurse practitioners work under the license of a
physician, so I guess what I am trying to make sure that I understand
is, are we trying to suggest new reimbursement or new caregiver
categories beyond the physician and their extenders? (43:16.1)

\>\> Karen: I think it is because, in some States, nurse clinicians can
function independently, and have their own prescriptive powers.
(43:25.2)

\>\> Jeff: Okay, then it was definitely always meant to be inclusive, so
\"clinician\" would be a more appropriate term to use. (43:31.8)

\>\> Karen: It was designed to include the nurse practitioners.
(43:36.3)

\>\> Jeff: When legally appropriate. (43:37.3)

\>\> Karen: Yes. (43:38.1)

\>\> Joyce: But, if I could make a more general comment, it seems to me
that these bullets amplify what you would use in determining what the
best practices were, and if that is not correct, then I need to
understand their purposes better, but it seems to me that we are making
some predetermination if this stands alone. The alternative is that, if
it is amplifying how you would determine a best practice, then I am okay
with it. (44:11.9)

\>\> Craig: It seems the way it is worded is that, to go back to the
nesting of these three, the first is to develop the database, the second
is to kind of look at the description of the methods suitable for this
technology, and then the third one is leverage existing programs. That
is kind of the nesting I see. (44:38.9)

\>\> Joyce: Well, it sort of prejudges, if it is nested that way. You
know, if we are taking the lay of the land, and then trying to identify
what we think is the best of the best, then\...(44:57.2)

\> Craig: I am reading carefully what this says. It says "should
identify opportunities to leverage existing programs, such as\..." It
doesn\'t say that you have to, it just says look for opportunities to
leverage. If you found in reimbursement, that is the second
recommendation, the best known method is something that is not
leveraging off an existing program. I presume you could follow that
best-known method. (45:30.3)

\>\> Paul: This is Paul Nichol. I had the same reaction to that. I think
we are wanting to leverage the experience from existing programs into
new environments, rather than literally leveraging existing programs.
(45:47.6)

\>\> Craig: Again, the phrase \"identify opportunities to leverage
existing programs\" is so broad and general, you could read it in about
three different fashions, at least. Do it when it makes sense; don\'t do
it when it doesn\'t make sense. It may be 50/50 if it almost makes
sense. (46:08.6)

\>\> Eric: This is Eric, and Jeff, please chime in here. I think when
this originally was written, we had the idea of demonstration projects
in here, and the language got changed to be broader than demonstration
projects, but would include using demonstration projects to leverage off
of existing programs. (46:36.2)

\>\> Craig: That certainly is in the last subbullet under this one.
(46:40.8)

\>\> Eric: Yeah. (46:41.0)

\>\> Karen: That is correct, Eric. I would say that there was
significant feedback from CMS to modify the demonstration project's
leverage of existing programs, so that is how that language was changed
by other Workgroup members. (46:58.4)

\>\> Eric: Okay. (46:59.2)

\>\> Jeff: This is Jeff. I had the same reaction as Eric just expressed,
because the flow of this was really \-- the third recommendation was
really about: Okay. Now that you have collected the information, you
have developed best practices, and come up with what we think are the
right ways to reimburse. Then we actually test them in demonstration
projects and leverage these other things that would inform the best
practices, so this is kind of turned and, I think, in some ways,
minimized the role of the demonstration project idea in this
reimbursement. (47:35.3)\
They are referenced in the last bullet, but you could interpret this
last bullet as basically if one exists, then apply these principles, or
leverage these programs, but it doesn\'t actually recommend that one be
created to do that, and I think that is the difference. At least in my
mind, it would be that, you know, it is important for CMS to actually
test these ideas in some way that is formal and specific to their
particular reimbursement environment. (47:56.9)

\>\> Tony: This is Tony. I guess the reason I changed these is because
we didn\'t know why it would need to be specifically CMS. I think the
idea would be, if you are going to test reimbursement, it could be
tested in a variety of programs and leverage existing work that is going
on, not necessarily CMS demonstration programs. It could be tied to a
lot of other factors besides just reimbursement for technology or secure
messaging. (48:32.3)

\>\> Jeff: This is Jeff again. I think that is fine, so long as there is
actually a commitment to do that tying in, and certainly, this doesn\'t
say that CMS would be the only one that would be responsible for showing
that this can be done, but clearly, as the largest payer, if they don\'t
set the stage, it is a lot harder for either other payers or employers,
or physicians to get excited about this, and the whole thing about
adoption isn\'t just that someone is paying for it, it\'s that your
biggest payer is paying for it, because otherwise, it makes much less
sense, especially for physicians working in environments where there are
multiple payers, if their largest single payer isn\'t doing anything in
that way. This, again, is my personal belief, but I think something very
explicit, whether it is tied to an existing program, or the creation to
a new demonstration program, is absolutely pretty critical to whether
this actually flies or not. (49:28.6)

\>\> Tony: Herb, I don\'t know if you have any thoughts on it. I know
Mark was very much not supporting something specifically in this area.
That is why I tried to make the language more general. (49:36.8)

\>\> Herb: No, I think you have shared your thoughts pretty accurately,
Tony. We kind of were thinking on it. (49:46.4)

\>\> Karen: Well, you know, one of the things that can be done here\...
We have recognized that we may not get absolutely consensus on every
recommendation and every workgroup. I mean, there is the possibility
that this can go to the community as an issue that needs further
discussion by a larger venue. I think the issue of how this eventually
gets teased out may not be resolvable within this Workgroup, if we
can\'t come to consensus. So, what would be your thoughts on that?
(50:24.8)

\>\> Craig: Could you just reword the opening statement? Just say
something: HHS should identify opportunities to leverage existing
programs and/or use existing or planned HHS demonstration programs to
use secure messaging between clinicians and patients to A, B, C. I was
just trying to basically put, in the first opening sentence, that what
we want to do is leverage existing programs inside or outside of HHS, to
demonstrate that the process works. That is kind of what it says now,
but if we just separate \"leverage existing programs\" at the top from
\"existing or planned HHS demonstration programs\" at the bottom.
(51:29.3)

\>\> Karen: So, are you suggesting, Craig, that we have "HHS and other
private entities"? (51:38.0)

\>\> Craig: HHS should identify opportunities, parentheses, whether they
are external or internal to HHS, end parentheses. (51:48.8)

\>\> Karen: Okay. (51:49.5)

\>\> Eric: And I think that\...this is Eric Larson\...and Jeff should
comment too. I think that would work in opening the door at least what
we were advocating in our original version, and hopefully be sensitive
to what David and others may have been concerned about. (52:10.1)

\>\> Jeff: This is Jeff. I hate to be a pain, but I don\'t understand
the process then, because what I am hearing is that, as a member of this
group, I am part of a consensus process, but I am not sure that we have
defined where our consensus is on this issue, and I am also hearing that
certain members of this group may be able to take things out of the
scope of the recommendation and we are working hard to kind of create
flexibility, but in the creation of that flexibility, we will
essentially give everybody the right to opt in or out of the
recommendation. (52:42.9)\
If that is what is happening, I would just like somebody to confirm
that. Maybe, Craig, you can confirm that, or somebody? I do think, at
this point, if we, as a group, not just as individuals, but if we as a
group feel strongly about a particular point, like a demonstration
project, we ought to be free to at least put it in the recommendation.
I, for one, would like to know at least by verbal vote where our
consensus does or doesn\'t lie on this issue. (53:09.9)\
I don\'t sense I have a feeling for that, being on the phone. (53:16.1)

\>\> Craig: Well, you threw a question to me, and I am not aware that
anybody has the right to veto or opt in or out of the group consensus.
Tony? (53:34.2)

\>\> Tony: I don\'t think anybody is opting in or opting out of the
group\'s consensus. We were just expressing the opinion that, what Mark
had said, if the group comes up and says that the consensus is that this
should be included, I think then the language should be included. Then,
it is up to the AHIC to determine whether it should be forwarded on, and
then the department needs to discuss how that can best be implemented. I
think that is pretty much what we are talking about. (54:02.3)\
We are not suggesting to take in or take out. I was just expressing why
we had recommended some changes in that, based on what Mark McClellan
wanted, that we wanted to expand it beyond just saying the CMS
Demonstration Project originally had said. (54:20.6)

\>\> Craig: Let\'s take that and then, as far as group consensus\.....
is the consensus is that we think that we ought to leverage existing
programs wherever they reside? Or we should leverage existing programs
just within HHS? That is a simple, kind of black-or-white approach.
(54:49.0)

\>\> Jeff: Craig, this is Jeff again. I guess my point is, I would say
leverage wherever they reside, but make sure at least there is a
commitment to one program within HHS, whether it is an existing one or a
new one, so that the recommendations can truly be tested in the
environment that we are talking about, which is the largest payer for
most physicians. So, I don\'t know whether narrow or broad really
answers that question, because, you know, there is a lot of flexibility
still left within that, and I would like to see something fairly
specific recommended. (55:22.3)

\>\> Craig: If you go back to the overall charter, which is to make this
capability available widespread, it almost has to include an HHS
component. (55:34.7)

\>\> Jeff: That is my feeling. (55:36.0)

\>\> Eric: Yeah, I agree \-- Eric Larson. (55:37.9)

\>\> Jeff: I think we always come back to being a subset of that
overarching objective, so whatever we do here has to just kind of feed
into that. (55:45.7)

\>\> Tony: Yeah. And I think the point is that the recommendation would
be that, anything that is going to be widespread has to include HHS and
specifically CMS, because CMS is such a big share of the marketplace. I
think, you know, just to say \"leverage existing programs, including HHS
programs, as appropriate\", or something of that sort, could be
something that could cover it. (56:12.5)

\>\> Paul: This is Paul Nichol. I am wondering if perhaps HHS shouldn\'t
take the lead in establishing a model for reimbursement within the
programs that HHS is responsible for, as a way of really encouraging the
appropriate reimbursement, where secure message is used in accordance
with these guidelines. The four bullet points here are restrictors on
the use of secure messaging, and I think the overall goal is to support
its use when it is done appropriately. (56:45.6)

\>\> Karen: This is Karen Bell. I would just suggest perhaps that there
be some discussion on different ways that HHS might be able to move
forward. I mean, demonstration program is one way of doing it. There are
other ways also of testing out the way that reimbursement might be done
within HHS. I am just wondering if the problem around consensus is
around demonstration programs, and there may be other ways that the same
objective could be realized. (57:23.5)

\>\> Jeff: Karen, this is Jeff. I like that idea. What about an idea
around coverage with evidence development, because I know CMS does,
although that is a much broader\...it is not a geographically target
approach? (57:38.4)

\>\> Karen: Or some language. I am looking at Herb right now, who
happens to be in the room with me. Some language that allows CMS to
develop a program to evaluate reimbursement within the Medicare setting.
(57:58.5)

\>\> Herb: You raise a good point, but you know, the principle one is
through the demonstration. I am trying to think how the CED process
would be applicable here, and how that might work. Most of the CED
process is worked around device-specific or drug-specific items, not a
process like this, but that would be something we maybe could explore
and look at. (58:27.0)

\>\> Karen: Do you have some language that we might be able to put into
that? (58:30.1)

\>\> Herb: I am trying to think about how we could maybe rephrase that.
(58:38.7)

\>\> Tony: Craig, might this be a recommendation that maybe we get
further wording provided to this? It sounds like we are coming close to
an agreement on it, but I would hate to just put language up there that
we just come up with in a hurry. Maybe Herb, Jeff and Eric could up with
some better language that could cover this. (59:05.1)

\>\> Craig: I am all for that, under the assumption that we are all in
agreement that what we really want out of this is that HHS has to lead
the way with the capability under the banner of things that they
reimburse for (you know, that 50% of the market, or whatever it is);
they have to have the demonstration vehicle there, and whether it is
co-opted from somebody else, whether it is plagiarized from somebody
else \-- it has to be leveraged back into the HHS world. I think that is
the tenor of the conversation I am hearing on this call. (59:43.5)

\>\> Tony: Right. Yeah. I can understand that. (59:45.5)

\>\> Craig: If that is true, and everybody is happy to say, \"All right,
that is our intent\", let\'s let the wordsmiths go back and wordsmith
this. I\'m fine. (59:55.5)

\>\> Eric: Eric Larson. I agree with that. (59:57.6)

\>\> Jay: I agree \-- Jay Sanders. (1:00:02.8)

\>\> Jeff: This is Jeff. I agree. (1:00:06.3)

\>\> Dan: This is Dan. I agree. (1:00:08.4)

\>\> Colin: Colin \-- I\'m fine with it. (1:00:09.5)

\>\> Mike: Mike Crist \-- I agree. (1:00:11.7)

\>\> Craig: Well, we ought to adjourn the call; everybody agrees.
(1:00:15.4).

\>\> Joyce: Well, actually, I am going to demur; I have to see the
language first. I mean, you know, I think when we see the language, I
guess we can have another discussion. (1:00:24.7)

\>\> Matt: Who is speaking? (1:00:25.2)

\>\> Joyce: It is Joyce. (1:00:27.2)

\>\> Karen: I think we are agreeing to the process, not to the actual
recommendation, Joyce. (1:00:31.0)

\>\> Joyce: The process is fine. (1:00:35.0)

\>\> Karen: Okay. Great. Then we do have consensus. (1:00:35.2)

\>\> Suzanne: Suzanne, I am in agreement too. (1:00:41.6)

\>\> Karen: Okay. Now, the fourth reimbursement recommendation, we
essentially referred back to the first one, so I think that we have both
developed the current practices and monitoring reporting on ongoing
experience, using the same criteria. So, are we in agreement that that
is an acceptable collapsing of two separate recommendations? (1:01:14.4)

\>\> Jay: Jay Sanders \-- yes. (1:01:17.6)

\>\> Eric: Yes \-- Eric Larson. (1:01:20.2)

\>\> Karen: Okay. (1:01:21.3)

\>\> Jeff: Yes \-- Jeff Rideout. (1:01:23.:1)

\>\> Craig: Agreed \-- Craig. (1:01:24.6)

\>\> Paul: Yes \-- Paul Nichol. (1:01:25.2)

\>\> Tony: Agreed \-- Tony. (1:01:28.9)

\>\> Mike: Agreed \-- Mike Crist. (1:01:28.8)

\>\> Andy: Andy \-- Yes. (1:01:30.6)

\>\> Dan: Dan \-- aye. (1:01:34)

\>\> Karen: Thank you all. Craig, Tony\... should we move into the
medical liability and licensure one? (1:01:03.8)

\>\> Tony: I think we are ready to move into that. Craig, it is one of
your favorites, so do you want to do this section? (1:01:51.7)

\>\> Craig: Following our best-known method, I guess somebody ought to
read this. Karen, you do such a good job of that. (1:02:00.7)

\>\> Karen: I am not going to read it all, but I will read a little bit.
Since the use of communication technologies, such as secure messaging,
to exchange medical information between a patient and his/her care
provider is a critical and essential component of the health care
delivery process, which can impact the diagnostic and therapeutic
decisions for the patient \-- this is a very long sentence; we are going
to have to fix this one; sorry \-- as well as provide a convenient,
cost-effective means of accessing that care, any barriers need to be
addressed. (1:02:35.4)\
One such restriction or barrier is based on existing State licensing
laws, which prohibit a practitioner licensed in one State from giving
advice, care, education, to his/her patient, using a communication
modality, if that patient resides in another State. So, in essence, what
this recommendation is about is to address the need for reciprocity or
some other type of approach, so that there can be clinical practice
across State lines. (1:03:20.9)\
The recommendation itself reads as follows: Given that existing State
licensing laws did not anticipate secure messaging as an integral part
of the health care process, it is recommended that the secretary of HHS,
working with such stakeholder groups as the National Governors\'
Association, the Federation of State Medical Boards, and the National
Council of State Boards of Nursing, explore new licensing alternatives
to address the ability to provide electronic care delivery across State
boundaries, while still ensuring compatibility with individual State
requirements, in terms of licensing fees, CME, etc. (1:04:04.3)\
It goes on to describe some alternatives which could include licensure
by reciprocity, similar to what exists between States and Australia, or
utilizing a model comparable to a driver\'s license in which, if you
have a valid license from one State, you are permitted to drive in any
other State. Key stakeholders to include in discussions might include
the American Medical Association, the American Nurses\' Association, and
the American Bar Association. (1:04:39.2)

One of the preliminary discussion questions, actually, is, "Should we be
a little bit more focused in the key recommendations, and have some of
the discussion about rationale and examples included in some of the
explanatory paragraphs, or shall we keep it as is?" (1:05:05.1)

\>\> Jay: So Karen, what are you thinking? Is your recommendation that
the secretary of HHS, working with the stakeholder groups, explore new
licensing alternatives? (1:05:21.0)

\>\> Karen: Uh huh. (1:05:22.3)

\>\> Jay: Okay. (1:05:22.6)

\>\> Karen: We could make is very crisp, or we could leave it with the
rationale and examples included. Or, take the rationale and examples
out, and put them in some of the supporting paragraphs around it, and
just keep the recommendation, as you say, Jay, from the secretary of HHS
down through perhaps "licensing fees, CME, etc.\" (1:05:52.2)

\>\> Jay: Yeah, I think that is good. Let me just say, the reason I went
into medicine was, of course, I wrote long sentences in English class.
So yeah, I think being brief and concise would be much better.
(1:06:06.8)

\>\> Craig: So, Karen, just following your proposal here. If you went
down to where it says \"CME, etc.\", period, suppose you just deleted
everything? (1:06:22.1)

\>\> Karen: I moved all of that to some background material. (1:06:23.9)

\>\> Craig: Move \"some alternatives\". All of that could be in the
background material. (1:06:27.7)

\>\> Karen: Right. (1:06:27.9)

\>\> Craig: I have no problem with that. (1:06:31.6)

\>\> Karen: Okay. (1:06:32.9)

\>\> Tony: I think that makes sense. (1:06:34.3).

\>\> Andy: Karen, this is Andy Mekelburg. I guess while you are doing
that, should you take a look at the stakeholder group, whom you are
recommending to be included? Because I see that you have them sort of
split up top and then down below. (1:06:43.1)

\>\> Karen: Okay, so we should put all of them together in one place?
(1:06:47.3)

\>\> Jeff: I\'m not saying whether you put them in the front or in the
back. (1:06:49.6)

\>\> Karen: Okay. No, I think you are right. (1:06:51.5)

\>\> Tony: Maybe you could take the stakeholder groups out and just say
\"key stakeholder groups\". Then put information in the supporting
documentation about various groups. (1:07:03.4)

\>\> Karen: Right. (1:07:04.0)

\>\> Andy: Yeah, probably because the ones that you don\'t name are
probably going to be upset that they weren\'t named anyway. (1:07:08.8)

\>\> Tony: That\'s right. (1:07:09.8)

\>\> Craig: Alright, that is a good suggestion I think. (1:07:11.5)

\>\> Karen: Okay. (1:07:14.2)

So everyone is comfortable with that, and we will go back and clean that
up as agreed to. (1:07:22.9)

\>\> Andy: Karen, this is Andy again. Just sort of a side question about
this. It is probably related to the reimbursement issue as well. When
you going across State lines and you have Medicaid populations, I don\'t
know how that gets impacted at all. I don\'t know the answer. I just put
that out there just as a thought going through this. (1:07:51.2)

\>\> Karen: All right, so I think that is a very good thought, and we
will put in there the reference to the fact that Medicaid is State based
as well. Okay. Any other comments? (1:08:06.0)

\>\> Paul: This is Paul Nichol. I just had a question in the key
stakeholder. Do we have a good list of groups that represent patient
perspectives as the key stakeholders? (1:08:19.3)

\>\> Karen: The consumer \-- and we are actually going to get into
fairly robust discussion on that shortly, but I will start it right now.
The Consumer Empowerment Workgroup has been broken into three subgroups,
one of which has identified a lot of key issues with respect to the
consumer. In fact, and we will talk a little bit more about this when we
get into the security privacy recommendations, we will be looking for
your support and permission, and direction to move forward with the
formation of a separate entity that would be comprised of members of all
of the workgroups that would focus on all of the key issues related to
privacy and security where the consumer\'s voice is so important. The
issues of how one defines a unique patient, how one links that patient
to his or her information, how one does authorizations, what level of
authorization is necessary, what level of authentication is necessary.
All of those elements would be looked at in this other, very robust
grouping, because it is really the heart of consumers\' acceptance of
any of the programs we are talking about. (1:09:58.1)

\>\> Paul: Okay, well thank you. We don\'t have to belabor it here. I
think that it is important to address it, and it sounds like there is a
lot of thoughts about that. (1:10:04.8)

\>\> Karen: We\'ll go into it more, but you asked, so I had to jump in
and offer. Thank you. (1:10:10.0)

Are we ready to go on to the next one? (1:10:20.0)

\>\> Tony: I was just going to say that myself, Karen. (1:10:21.0)

\>\> Karen: This is the consumer/clinicians\' workflow. Here we are
looking at ways, and I am going to read a little bit of some of the
background from this one. As we consider enhancing the
consumer/clinician experience, via communication beyond face-to-face
interaction in traditional care settings, we begin by addressing the
question of consumer value. Key areas of value include time savings,
improved access and an unquantifiable piece of mind that patient users
get from the system. (1:11:03.8) \
There is a sense of social interaction that secure messaging provides
patients, especially elderly patients. The value proposition for
clinicians to secure messaging with their patients includes office
efficiency, clinical productivity, revenue potential if reimbursed,
patient satisfaction and interoperability with other IT systems.
(1:11:28.7) \
So, in general, the concept here is that one can\'t separate the
workflow issues from the reimbursement issues for the nature in which
physicians are reimbursed drives how they perform. In particular, if you
do not get to a secure messaging use rate among patient of at least
20-30%, it creates additional workflow. (1:11:53.6) \
I think that the background here, and I am going to stop reading right
now, is for these recommendations to enable clarity around the
intangible value to both consumer and the value to physicians in the
consumer/physician workflow. Understanding that, we would need to
investigate value to both parties, and also what type of workflow
changes would be necessary to maximize that value. (1:12:32.0) 

As written, the recommendations are: 1. Enable clarity around intangible
value to consumer/physician workflow. 2. EHRQ should investigate the
impact of secure messaging on improved workflow by identifying
successful patient care models that leverage secure messaging, and EHRQ
should quantify and qualify tangible return on its investments; that is
to say, or for example, piece of mind for patient within these usage
models. (1:13:16)

And to tee up the discussion, we had a couple of questions: 1. Is there
a need to further clarify intangible value? 2. Do we want to be a little
bit more specific about factors that enhance and optimize workflow in
physicians offices as well as factors that enhance in a sense the
patient\'s use of secure messaging with their clinicians. (1:13:37.4)

\>\> Craig: Karen? (1:13:40.2)

\>\> Karen: Yes. (1:13:40.2)

\>\> Craig: This is Craig. These are two way, way different
propositions, aren\'t they? (1:13.46.4)

\>\> Karen: I believe so. (1:13:48.5)

\>\> Craig: One is how in different practice settings do you use the
capability. Then the other is an intangible, which I noticed with some
interest that we are going to figure out how to quantify an intangible.
As soon as you figure out to do that let me know, will you. (1:14:13.2)

\>\> Karen: I am just nervous that someone is going to direct us to do
this. (1:14:21.0)

\>\> Joyce: I would like to suggest that we don\'t try to define
intangible, and not use the term. I think you can make determinations
about consumer preferences and consumer \"satisfaction\". Whether they
like it or not or whether they find it useful, by surveying patients?
Then it becomes something that is very tangible and quantifiable. It
seems to me that is how would be accessed anyway. Just the way tax
surveys access consumer experience with various health care settings or
providers, we could also make determinations as many other surveys have
already done. (1:15:02.7) 

So I think we shouldn\'t tackle defining intangible. I don\'t think
that\'s necessary to use it. (1:15.07.9)

\>\> Andy: This is Andy Mekelburg from Verizon. I would actually agree.
I think just using the word \"value\" would be good, because one
person\'s intangible and tangible tends to be
[\_\_\_\_\_\_\_\_ (inaudible)]{.mark} you can avoid have to go out of
their house and go to the doctor\'s office, maybe you don\'t have a true
value that you can put a dollar amount, but you know the hassle factor
is major plus. I guess that is a major plus. I guess that is where you
are trying to capture, but there may be some indirect or direct costs
like avoiding a taxicab ride, those kinds of things. (1:15:41.8) 

So the extent that you could paint the picture of why this is good for
consumers, I think you are right on, on this recommendation. I would
take intangible probably out. (1:15:51.9)

\>\> Joyce: Actually, excuse me, I was just going to say I don\'t think
we should predetermine that. I think we should ask them whether they do
find it useful. I mean, they\'ll tell us. You can structure a survey to
find out how they experienced the use of this stuff. Either they find it
useful or they don\'t. We may learn from that. (1:16:10.3)

\>\> Craig: I\'m trying to find out what is the difference between this
recommendation and the recommendations back in 1, 2 and 3, where we
basically said we were going to catalog on the basis of cost, quality
and care delivered. All of these things, and that would presumably
include not only workflow in different settings, it would also include
quality of care from both the clinician and the patient. (1:16:43.2)

\>\> Jay: I agree with that, Craig. (1:16:44.9)

\>\> Tony: Right, I agree with that too. I think that it\'s mostly a
subset of number one in some ways. If we keep it separate using the word
\"consumer\", I think that it should word \"patient\" to be consistent
with the language that you used in other venues with this. But, I agree
with Craig; it seems like workflow has to be part of the review or look
at methods of reimbursement in number one, and part of that certainly
should look at some of the non-\...what you\'d call \"intangibles\" as
far as the patient is concerned. (1:17:25.6)

\>\> Mohan: This is Mohan Nair. I was part of creating this
recommendation. I failed in being able to make it a recommendation
prior, because I wasn\'t articulating it well at the last meeting. I
tried to come back with some energy to convince the committee that this
issue of workflow between consumer and clinician, or between clinicians
for the sake of the consumer in a care episode, is not just a
transactional relationship between one clinician and a consumer, but
it\'s between many consumers and may clinicians communicating about a
care episode. (1:18:03.2) \
I would like us to consider, and I am willing to bow to the committee\'s
thoughts that this be not highlighted under just "Reimbursement."
Reimbursement does include workflow, but not to the extent where we
really truly understand what work is different or how activities are
changed in the process of providing care using this element of
technology. (1:18:29.5)

I believe that if we do not have a strong, highlightable understanding
of this, not just under the context of reimbursement, but in the overall
context of value, that we may fail to provide the community with a
rounded view of the changing relationship between the consumer and the
clinician. (1:18:48.1)

\>\> Joyce: I agree with that. I think that you could understand
recommendation one in the context of whether it\'s reimbursed, or not,
or the nature of the reimbursement. All of the subsets of that in terms
of patient satisfaction and improvements could assess in the context of
the reimbursement methodology. This one seems sort of a more overarching
recommendation that assesses this process with respect to workflow in
and of itself. Is that what you are trying to say? (1:19:26.9)

\>\> Mohan: Yes, ma\'am. Furthermore, the industry we serve has always
been talking about who pays for it, and hence, we will do it if somebody
pays for it. When really questioned about the concept of value, and I do
respect communications regarding intangible verses tangible, and that
may just be an error on our parts. The fact is value over cost has never
been fundamental in our industry. If we are to look at these sort of
technological implementations, we have to look at value, tangible or
intangible, in a context wider than reimbursement. (1:20:05.9)

\>\> Tony: I think I see what you are getting at, Mohan. I think what
you are looking at is more of an overarching look at how this adds value
to the patient\'s experience basically. (1:20:18.9)

\>\> Mohan: Right, and I believe that, if I may one more time put my
thoughts into this if you allow me, I see this happen in the marketplace
constantly. I see colleagues challenged in this context, which is, "If
you don\'t have tangible and intangible value at the consumer and
clinician levels, which doesn\'t just take all the technical abilities
as values, because that is just the benefits of using it, we will have a
challenge in terms of adoption." (1:20:49.7) \
If we don\'t understand what the key value propositions are and
highlight those propositions, and really measure those propositions, we
will fail in the adoption cycle. We would have implemented an efficient
process, but forgotten that value propositions are what people use this
for. (1:21:09.7)

\>\> Craig: I\'m not so much arguing with the issue of the value inherit
in the process. I\'m only trying to provide a logical sequence of
events, and get items where they might logically be collected. If we
are going to talk about the cost, quality, efficiency, and customer
satisfaction up in front under "Reimbursement.' Does it make sense to
then readdress that as separate line item later? That was my issue.
(1:21:53.6)

\>\> Mohan: I totally respect that. I would recommend that the committee
consider that this be a broader issue, not under the logical perspective
of reimbursement. The medical world and the health care world seem to
look at things in the reimbursement perspective. We need to look at the
world in terms of a consumer value and clinician value perspective. That
is highlightable enough that it is not just one slide in a long
presentation. It has to be considered larger, in my opinion, and in the
opinion of some of the people that I have been challenged with.
(1:22:34.1)

\>\> Craig: Do you want to take another shot, then, at putting this in a
value recommendation, as opposed to a workflow? (1:22:45.2)

\>\> Mohan: I see what you are saying, Craig. That in positioning as a
workflow it would be more of an efficiency play versus a value play. Is
that what I am hearing you say? (1:22:55.8)

\>\> Craig: Correct. (1:22:58.9)

\>\> Tony: Can\'t you call consumer relation value? (1:22:59.4)

\>\> Eric: Yes, I like that idea. This is Eric Larson. This whole
discussion is something that I think highlights something that is and
probably should be missing from the reimbursement issue, but needs to be
in the report. It just doesn\'t flow, excuse the words, as a workflow
issue. I think that if we framed it as value and we are much more
explicit about what the recommendation is, and why it is different. It
would fly. (1:23:31.8)

\>\> Mohan: I assume that the workflow issues are being addressed under
"Reimbursement," which is the effectiveness of the change of workflow,
and people knowing how to interact with each other to optimize their
office visits as well as their Internet visits, shall I say? That was a
rich discussion in the last meeting we had, where some of the protocols
were evident in our discussion. (1:24:02.4)

\>\> Andy: This is Andy Mekelburg again. I think I agree with you Mohan,
because we talk a lot about, I guess we don\'t call it intangible value,
we talk about enhancing quality of life for these consumers using these
kinds of technology. I think it sounds like that is where you are going
on that. (1:24:20.7)

\>\> Mohan: Yes, and you are right. You\'ve caught me on the two of
them, and I didn\'t mean to sneak it in there. I actually didn\'t even
know that I was doing it. The two factors, the one is improved and
changing workflow between the Encare models associated with this, which
is one of the rules of engagement, given this new model. Can we give
guidelines or at least understanding on the new rules of engagement? If
that\'s fit under reimbursement, I\'m okay with that. As long it\'s
really established with that level of highlight. I think that when we
talk about workflow we tend to brush through it. (1:24:53.6)\
I am concerned that we may send the wrong message to the community in
terms of priorities. I believe shifting workflow is where costs are. If
we don\'t understand how those workflows are understood, costs will
merely be passed from one part of the segment to the next. That has to
be a detailed work in any context. If you want to put that in the
reimbursement, that\'s fine as long as it is highlighted. The other area
which you sort of coached me through, is really in speaking to consumer
and clinician value, and dealing with the tangible and intangible
measures associated with that. (1:25:29.8)\
That I take. I can accept that. If you wish a rewrite on that, I will
take the actions to do that. (1:25:36.1)

\>\> Craig: Let me muddy the water a little bit more, if I could. If we
assume that the workflow issue has to be inherent back in the
reimbursement or that whole data-gathering or sample-gathering exercise
is up front for the moment, then we say that in addition to that there
has to be value here for both the clinician and for the consumer. I am
wondering, is it possible \-- Karen, I\'m looking ahead a little bit to
the last cross-cutting AHIC workgroup recommendation, which is kind of
consumer access in the health care digital divide, which is inherent in
it has a little bit of this\... that is, of what value is this
capability to the consumer public at large? Are there subsets of it
where you could get this value? Are there subsets where you do not get
this value? Are we providing value to the consumer? Is it
possible\...this is the confusing part\...is it possible to combine what
Mohan is talking about here in terms of value? With that value we are
talking about later on? (1:26:56.0)

\>\> Karen: You know, I think that is a very good point, Craig.
Initially, we were mostly concerned about access. Given the fact that
there are literacy issues, not just in terms of computer literacy, but
language barriers as well that could create problems with patients
accessing information electronically. I think you are absolutely right
that no matter what we do, we have to bring value equations into
overcoming that barrier of the digital divide. (1:27:35.7)\
I think we could clearly articulate it, include in that, and make it a
cross-cutting workgroup recommendation. (1:27:47.6)

\>\> Craig: Mohan, understanding what you say about value to
the consumer, I presume we are interested in value to every aspect of
the consumer population. (1:27:58.2)

\>\> Mohan: Yes, as well as clinicians. (1:27:59.5)

\>\> Craig: And clinicians. We are really talking about the totality of
value in the system, and that has to include subpopulations, as well as
the mainstream population. (1:28:14.3)

\>\> Mohan: Yes. (1:28:14.9)

\>\> Craig: I am just looking for a coherent way to pull all of this
together. (1:28:17.5)

\>\> Mohan: Right, and I challenge the team at AHIC to not include it
under consumer access and visual divide, because it is framed. I am
sorry that I am doing this; I don\'t want to waste everyone\'s time, but
it\'s under the context of the ones that are not privileged in the IT
world, either through access or through knowledge. I believe that in the
current base of users, patients as well as doctors, for communicating
with each other today, there is no body of work except for a few that we
heard over the presentations that really talk about how we work
together. How efficiently can we work together? (1:28:54.7)\
If you have a bad process, and you automate that process, all you get is
cost transfers. You don\'t get a net reduction in cost, because value
has not been understood. So you can have communications, and you may
also have no tangible value in that communication. The rules of
engagement were discussed in the last meeting, where two presenters
talked about how they would speak. I\'m just talking about being
highlighted somewhere without having it submerged into one slide.
Because I believe that if we don\'t understand that well, it will
destroy secure messaging as a methodology. (1:29:37.7)\
For example, if you talk to some doctors, they actually recognize that
patients do not talk about very serious issues by e-mail. They speak on
the phone or they actually communicate live. They tend not to trust
e-mails for very serious illnesses that are personal in nature. How do
we know what is communicative, what is not communicative. What is the
process were you use not just secure messaging, but the phone as well as
the interaction with the office that allows for an effective use of
value and cost? (1:30:13.2)\
I don\'t want to go further, because I think I will be leaning on my
soapbox in a few seconds. (1:30:18.2)

\>\> Paul: This is Paul Nichol. I think this is a very important
discussion. This is a transformational technology just as the electronic
health record is. The workflow reimbursement methodologies have not yet
caught up to the changes in workflow. When you implement this, it
creates new opportunities for workflow that are slow to be reimbursed. I
think that this is a fundamental issue. It is not a technology issue.
I\'m not really sure where to take it. It changes the workflow and yet
the reimbursement methodologies want to be able to be in-count, and
encounter or a procedure, and have a hard time with the concept of
measuring value. (1:31:02.1)\
It becomes a little slippery. There is concern about gaming the system.
We stay with what is comfortable to measure, which may not be the
appropriate things to reimburse. (1:31:11.4)

\>\> Mohan: Correct. I believe that fundamentally if you do not
understand this flow of value and the workflow associated with it, that
if you implement technology without that, you will automate a bad
process. (1:31:28.4)

\>\> Craig: Let me go back again to my suggestion, which was not to
subordinate this discussion of value back to consumer access, but to
perhaps raise the issue of value to the top line and subordinate some of
the other activities under that. (1:31:50.9)

\>\> Mohan: I see what you are saying. (1:31.51.7)

\>\> Craig: Consumer access and workflow are totally tied in to
underrepresented fractions of the population who don\'t have IT views.
They don\'t get the value. That is one aspect of it. Other aspects of
the value are the process of communication between clinicians. Perhaps
what we could do is have a value-oriented recommendation, which has a
number of subsets under it. (1:32:22.1)

\>\> Mohan: Yes, I would go for that. I would support that. (1:32:24.8)

\>\> Tony: Yeah, I would agree with that too. I think it makes a lot of
sense. (1:32:29.4)

\>\> Karen: Alright, so perhaps then, Mohan, maybe you and I
offline could do a next pass at that? (1:32:40.4)

\>\> Mohan: Yes, ma\'am, yes. (1:32:40.4)

\>\> Karen: Okay. (1:32:40.8)

\>\> Mohan: Yes. The workflow has to be reflective in reimbursement
somewhere, and I would still believe that the workflow issues are
critical to effective flow of value. I wouldn\'t put it under the value
equation because of what Craig just recommended. I would put it under
reimbursement, but it has to be pretty highlighted in terms of, don\'t
talk about reimbursing an existing process, talk about how
workflow changes, and reimburse for that change first. (1:33:06.5)

\>\> Craig: Yes, in a sense, looking for the best known methods or best
known practices using the new technology has to incorporate the total
discussion of workflow, and how the change of workflow accommodates to
that new technology. (1:33:23.8)

\>\> Mohan: Correct. (1:33:23.8)

\>\> Craig: I do think we can direct that back to the reimbursement data
gathering and discussions. Then let\'s try to set up this separate
value-oriented recommendation, which includes in it some of these
cross-cutting issues, Karen, like you have at the end. Also really look
at the inherent value associated with the process to the user and
provider. (1:33:56.2)

Alright, Mohan, you have a lot of work for yourself. Thank you.
(1:34:04.3)

\>\> Mohan: I don\'t know how I ended up with this, this way, but I will
try. (1:34:05.9)

\>\> Karen: The good news is that you are on the west coast and I\'m on
the east coast, so we can do this late in the day. (1:34:12.1) 

Okay, Thank you very much. Very good discussion. Might I move on now to
the invading the status for imbedding secure messaging into the EHRs?
(1:34:30.9)

\>\> Craig: Sure. (1:34:31.1)

\>\> Karen: The opening paragraph here talks about secure technology
solutions for communications, about chronic care delivery between
clinicians and between clinicians and patients, and the remote
monitoring and assessment of patients must be based on standard
transactions before they can be widely deployed as a means of chronic
care improvement. Clearly, the certification of secure message
transactions and portals by recognized certification body has the
potential to encourage more widespread utilization, as does the
formation of standards for the text and for the communication itself.
(1:35:18.4)\
We therefore have 2 standards or 2 recommendations that come forth. One
was that the office of the national coordinator work with HITSP, the
Health Information Technology Standards Panel, to prioritize
harmonization of standard relevant to secure messaging that could be
used by the Certification Commission for Health Information Technology
and certification criteria for system supporting secure messaging.
(1:35:47.2)\
Then the second was that ONC needs to also work with CCHIT to establish
certification criteria for patients and physician\'s secure messaging.
Our questions released on these are that it seems as if they were two
very separate recommendations. One about standards formation, which
would be the requirement of HITSP, the Health Information Technology
Standards Panel, and then the second recommendation would be specific to
the certification commission establishing criteria for
interoperatability of secure messaging into electronic health records.
(1:36:34.6) \
I believe that was the intent of these recommendations. (1:36:39.8)

\>\> Mike: Hi, this is Mike Crist, and I was the lead on the subgroup
that worked on these two. I can see where these would be a little bit
confusing. At the heart of the matter, we were trying to get at two
concerns. One was secure message transactions, and the second was
certification of the systems that would use those transactions. What I
would like to do is suggest rewording of both of those, and if you could
follow along with me? I think it would greatly simplify the two
recommendations. (1:37:13.0)

\>\> Karen: Okay. (1:37:13.0)

\>\> Mike: Okay, in the first one, it would read: The office of the
national coordinator for Health Information Technology needs to ask
HITSP to (and delete the rest of that sentence starting with the word
\"prioritize\" all the way through \"message\") and insert \"define
standards for secure message transactions\". (1:37:42.0)

\>\> Karen: Okay.

\>\> Mike: So it needs to ask HITSP to define standards for secure
message transactions.

\>\> Karen: And just to clarify, we do have a contract with HITSP. So we
can direct them through our contractual vehicles. (1:37:50.0)

\>\> Mike: Yeah, I was going to ask, Karen, if we said remove the word
\"ask\" and use a more forceful verb. (1:37:56.6)

\>\> Karen: And, it would be? (1:37:57.6)

\>\> Mike: "Direct." (1:37:58.5)

\>\> Karen: Yeah, "direct." (1:37:59.3)

\>\> Mike: That\'s even better. (1:38:01.9)

\>\> Karen: Okay. (1:38:02.5)

\>\> Mike: Great, and on the second one, the rewording would be, "ONC
needs to direct CCHIT to establish certification criteria for," and
delete "patient/physician secure messaging" and insert \"systems
supporting secure messaging\", which is the last four words of the
previous recommendation. So it would read, "ONC needs to direct CCHIT to
establish certification criteria for systems supporting secure
messaging." (1:38:43.5)

\>\> Karen: Okay. (1:38:44.8)

\>\> Mike: That gets at the transactions themselves and the system that
use the transactions. Then we can reword the titles of each of the
recommendations as appropriate. In fact, I have actually done that. The
first one I would reword as "Standards for Secure Messages," and the
second one would be "Standards for Certification of Systems Using Secure
Messages." (1:39:10.7)

\>\> Karen: Yes, okay. That is very helpful. Is everyone okay with that?
(1:39:15.2)

\>\> Jay: Yes. (1:39:17.2)

\>\> Craig: Yes. (1:39:18.0)

\>\> Jeff: Yes. (1:39:18.6)

\>\> [Eric]{.mark}: Yes. (1:39:20.4)

\>\> Tony: Yes. (1:39:22.2)

\>\> [Paul]{.mark}: Yes.

\>\> Dan: Fine. (1:39:23.8)

\>\> Jeff: This is probably \-- I had another question. I got some
feedback on this particular item that suggested we should think more
broadly. This recommendation address electronic health records, and that
is frequently used as a term for the organizational electronic record
that is used by health system. The question that I received is,
"Shouldn\'t we be thinking personal health records and in fact going
into the future? Won\'t there be an eventual migration to personal
health records as the authoritative repository of patient information,
rather than fragmented electronic health records across
organizations?" (1:40:09.2)\
The difference is one of how much control the patient has over the
information, and I would think that we at least need to specify that we
are considering patient health records in the discussion. (1:40:24.5)

\>\> Mike: Jeff, Mike Crist. I completely agree with you. You notice
that I went to that more general wording of systems supporting the
secure messaging, instead of just saying EHRs. I totally agree with you.
(1:40:38.1)

\>\> Tony: I would keep it with systems. Not with personal health
records. Because there are a lot of different meanings of different
meanings for personal health records as well in this. (1:40:48.9)

\>\> Mike: You could go to the baggage issue. (1:40:50.1)

\>\> Tony: Right, exactly. (1:40:50.2)

\>\> Mohan: I would agree as well. This is Mohan. (1:41:14.4)

\>\> Eric: This is Eric Larson. This recommendation refers back to
Appendix 5, which is having to do with interoperability. That is not
mentioned here. Is that just assumed or should we have mentioned this
here. Or is it not referring back to Appendix 5? (1:41:20.4)

\>\> Karen: I think it can go back to Appendix 5. We haven\'t really
gotten very much into the details of the language around the
recommendations, but certainly can go back and put Appendix 5 to make
sure that it supports it. (1:41:30.9)

Okay. (1:41:40.5)

\>\> Tony: Are we ready to move on to the next one then? (1:41:44.1)

\>\> Jeff: I had a couple of other questions. One is this appears to me
to be neutral as to what device this interface is on. There is
increasing move to using cell phones or other means of communicating
other than computer to computer. So we\'re pretty much neutral in terms
of what device this is sent on? (1:42:09.2)

\>\> Tony: I think it should be. Otherwise it becomes too directive. I
think the key point that you are trying to make is interoperability?
(1:42:20.7)

\>\> Jeff: Right. (1:42:20.7)

\>\> Karen: And I think the other piece is that, as different systems
come online, right now ONC's contract with CHCIT is that it worked with
ambulatory EHRs. Then we will go into hospital EHRs. Then there were be
criteria around interoperability. It is highly likely that there will be
discussions around PHRs as well. I suspect that there will be a dynamic
process here, and I agree simply by making sure we have standards and a
vehicle to certify their use and their functionality is the critical
first step. (1:43:02.4)

\>\> Jeff: Then the last question I have was perhaps a more difficult
one, and that is are we getting technical standards out ahead of
national policy? Is the national policy that this is going to support
clearly articulated? (1:43:18.5)\
The inference was that we are trying to solve a policy problem with a
technical standard. (1:43:28.2)

\>\> Karen: Well, I think it depends a little bit on which policy you
are referring to perhaps. Clearly, interoperability is a national policy
or Federal policy. We are trying to assure that any electronic
information can flow, it can do so in a way that can be interoperable
given the fact that we do need to pay attention to privacy and security
issues, and a lot of policy around that. (1:44:00.8)

\>\> Tony: Yeah, I would concur with Karen. I think is really does
depend on the policy to talk about. If it speaking of interoperability
as she says, that is already a policy. I\'m not sure. Are you taking
more policy around secure messaging? (1:44:17.8)

\>\> Jeff: I think around secure messaging, yes. (1:44:20.6)

I didn\'t want to belabor; I just thought I would raise some interesting
questions that I got, that I thought I would bring to the group.
(1:44:34.5)

\>\> Mike: I don\'t think that is was supposed to imply that the
standards were over the policy, just that these standards would help
support the success of using secure messaging for the chronic care
patients. Portability as discussed. (1:44:51.5)

\>\> Karen: Any more comments on this one? (1:45:02.4)

\>\> Eric: I just think that in the first paragraph we need to at least
put the word \"interoperability\" or the concept in there somewhere,
because if people just read this I don\'t think they will make the
connection necessarily, if they don\'t. (1:45:16.3)

\>\> Karen: Okay. Definitely we will put that in. Thank you. (1:45:19.4)

Is everyone comfortable with this one then? (1:45:27.6)

\>\> Jay: Yes. (1:45:30.7)

\>\> Craig: Yes. (1:45:31.5)

\>\> [Mike]{.mark}: Yes. (1:45:31.5)

\>\> Tony: Yes. (1:45:31.6)

\>\> Mohan: Okay too, Mohan. (1:45:34.5)

\>\> Karen: Well, in that case, let\'s just move right along here into
the cross-cutting recommendation. We\'ve already had some discussion on
the fact that we need to find ways to improve consumer access to this
information. We\'ve had this discussion focusing around the fact that
value needs to be included in this cross-cutting recommendation as well.
Ultimately, since this is something that is important to all of the
workgroups, there may be some changes in how this gets described. I
would just ask all of you to comment on the substance of this
recommendation, which is as follows: (1:46:22.9)\
I will read it for everyone. HRQ should conduct a synthesis of current
knowledge from existing studies of computer use by the elderly and
undisturbed populations, including an analysis of barriers and drivers.
The barrier and driver analysis should elucidate for which
subpopulations barriers can be overcome and how they can be overcome.
Again, to that we were going to add, studying how patient would define
value and realized value from the use of this technology. (1:47:01.5)

\>\> Craig: Did you just turn it around, and not add to that but mixed
value on the top and one of the subbullets is intact to make sure that
subpopulations. Will you look at the barriers to all subpopulations from
having access to this value? (1:47:19.2)

\>\> Karen: Okay. (1:47:22.6)

\>\> Mohan: This is Mohan Nair. While you were talking I was editing. I
wonder if it is okay for me to make a recommendation right here.
(1:47:26.5)

\>\> Karen: Please. (1:47:28.5)

\>\> Mohan: In looking at this recommendation, I would add to what Craig
said. I would add the words \"Consumer/Physician Value\" instead of
\"Consumer Access\" as the title. I would add a paragraph, which is
really the paragraph that we started the consumer clinician workflow. If
this is going too far and is too confusing, please tell me, team. It
is the first paragraph of consumer/clinician value, add that into this
recommendation very easily. Add also the second bullet under enable
clarity around value to consumer and value within consumer/physician
workflow, add that second bullet that says quantify and qualify ROI,
etc. as the second bullet within this recommendation. (1:48:32.3)

\>\> Karen: Mohan, this is Karen. My only concern is as I said before,
this is going to be a recommendation that is coming out of four
workgroups about assuring that the barriers to consumer access are
addressed. If we start getting into reimbursements and workflow then
that becomes much more of a recommendation that is specific to our
Workgroup. I thought that was why we had included a lot of the issues
around workflow up in the reimbursement one. (1:49:08.0)

\>\> Mohan: Okay. I may have miscommunicated. I didn\'t mean to imply
anything associated with workflow into this recommendation. (1:49:12.7)

\>\> Karen: Okay. (1:49:12.9)

\>\> Mohan: Maybe I should draw it up and show it to you first before I
start opening my mouth. (1:49:16.3)

\>\> Karen: Okay. I was under the impression that we were going to
include workflow and ROI, and that sort of discussion in the
reimbursement seat. (1:49:25.3)

\>\> Mohan: Oh, okay. (1:49:25.3)

\>\> Joyce: But Karen, I would like to reinforce you suggestion that
there would be a cross-cutting consideration of some of the consumer
issues. I think that makes a lot of sense. I doesn\'t confine it to one
area. So I think that you have come up with something that is very
workable. (1:49:45.3)

\>\> Mohan: Okay. Well, I don\'t know whether this is the forum for us
to display to you in such a raw form? Maybe we will go back and add to
it. I also see a way in which we can take some of the subparagraphs in
the consumer/clinician workflow write-up and apply it to
the reimbursement write-up. I think it is very possibly workable.
(1:50:04.3)

\>\> Karen: Okay. Well, then, I will bring back to you over the course
of this week, and for the next discussion a recommendation that
essentially harmonizes this concept amongst all the workgroups. So that
it will be one that has a similar language for the secretary,
independent of the workgroup. With that in mind we are also putting
together, with information from the other 3 workgroups, recommendations
on patient\'s identification, authentication, authorization and linking
the patient information to the unique patient. That actually has quite a
bit of specificity and I thank the original drafter of these workgroup
recommendations because they help inform that piece of work a great
deal. (1:51:07.0)\
Thank you very much for that effort. Before we go forward with that I
really want to make sure that everyone on the workgroup is comfortable
with going this next step, so that we can have this harmonized
recommendation that I will bring to you again over the course of this
week. (1:51:25.7)

\>\> Jay: Karen, this is Jay. Is one subset of the access issue, which
I\'m not sure is addressed or maybe I\'m misunderstanding it. It
addresses consumer access, but one think we need to recognize is there
physician access barriers as well, in rural communities in terms of cost
of having an Internet. (1:51:53.7)

\>\> Karen: That is a very good point, Jay. I\'ll add that. (1:52:00.3)

\>\> Jay: Especially where there is no broadband. (1:52:04.5)

\>\> Karen: Okay. How does everyone feel about the harmonized
recommendations on privacy and security? (1:52:19.4)

\>\> Tony: Karen, I do have a concern on one of the things for the
privacy and security. I guess the requirement of initial in-person
authentication as a requirement of e-authentication. I think that
in-person proofing is a product that is tied to risk levels, and types
of information. To make that just a general overall requirement could
create a lot of problems. Let alone the fact that most places don\'t
require in person proofing today. When you go into a doctor\'s office
they generally ask you for you insurance card. They don\'t ask you to
provide proof that you are who you are. (1:53:12.5)\
So I am wondering how this in-person proofing became an issue that was
in this second recommendation? I\'d rather have it tied back to more of
a risk-based approach. (1:53:24.6)

\>\> Karen: Okay. (1:53:34.4)

\>\> Eric: This is Eric Larson. I thought I wrote that this was a
problem for me, and I can just speak from experience at Group Health
here. We started out with in-person for what proved to be very naive
reasons, and very quickly abandoned it as being really not feasible and
not worth it, and a barrier for persons to use secure messaging. We now
have got over 100,000 people, all of whom have been authenticated by, we
think, very secure means, and have not had any security issues that
would have been any different had in-person authentication have been the
standard. (1:54:12.6)\
I think we really have to take this one out.(1:54:15.7)

\>\> Karen: Okay. (1:54:16.1)

\>\> Paul: Hello, this is Paul Nichol. That perhaps reflects the
experience that we though we had heard as the VA gears up to expand the
range of information that patients can access, which would be to access
more specific information from our electronic record, in addition to
creating their own personal health record. If others have found an
acceptable means to do that, I think that makes sense. It was my
understanding that many organizations require some initial in-person
verification, but it sounds like there is experience to the contrary.
(1:55:09.3)

\>\> Karen: Well, I think again, as we move forward with these
recommendations, there will be a tremendous amount of input for the
consumer community on how to frame these up. One of the things we have
been talking about is different levels of authentication. In-person
clearly is one, but there are many others as well and we would work with
the consumer group to help get their thoughts and feedback on
that.(1:55:34.1)

\>\> Craig: If you don\'t need in-person presence to get a passport, I
don\'t think you do. Do you? (1:55:41.9)

\>\> Jay: No, you don\'t. (1:55:43.2)

\>\> Craig: It seems to be an overburdening requirement then in this
area. (1:55:48.2)

\>\> Jay: Let me just point out information. Last week I participated in
New Orleans in a disaster preparedness conference. One of the problems
that came up related to the fact that all of the volunteer first
responders that came down who would introduce themselves as Dr. so and
so, Nurse Smith and such. There was no methodology by which the people
in the infected areas could actually authenticate whether these people
were who they said they were, and in fact there were a whole bunch of
problems in the fact that many of these people were not who they said
they were. (1:56:35.2)\
One of the conference participants was a Mr. Craig Wilson from the
Department of Homeland Security, and also the head of the
Anti-Bioterrorism Passport at the Pentagon. They have a very, very
interesting card identification system that they are now developing,
that most people at the conference were very impressed with. I will just
give you that contact information, Karen; you may want to talk to them.
(1:57:05.3)

\>\> Karen: Thank you so much, Jay. I appreciate that. (1:57:08.1)

\>\> Jeff: There was a second aspect to this that is kind of buried. I
wonder if it is worth mentioning? That was the concept of the use of
secure portals rather than common e-mail. In some of our previous
discussions, I had talked about concerns over regular e-mail for this
purpose. I am not sure whether we want to still capture that concept in
some way? Or is that for the organizations to decide how they set up
communication with patients? (1:57:41.6)

\>\> Karen: That is a very good point. Perhaps in the paragraph that
accompanies this we could go to that in more detail. Pull it out of the
discussions that we have already pulled together. I\'ll add that in the
write-up. (1:58:00.2)

\>\> Tony: I think one of the issues you run into, if you don\'t make
something based on risk analysis, is that everything gets tied to the
gold standard. So I think if it\'s a safe secure messaging portal for
exchange of information I think it depends on the type and kind of
information you are exchanging. I think that gets back to a risk
analysis and to become to prescriptive here could create more of a
barrier then something that helps accelerate it. I think we just have to
be careful how we write this up. (1:58:35.3)

\>\> Jeff: Well I guess the question then is are we removing this
recommendation in its entirety, or are we saying that the initial
authentication should be at least as secure or verifiable as in person
authentication.? Or acceptable alternatives. (1:58:59.8)

\>\> Karen: I\'m thinking that the recommendations that will come out of
all four workgroups will essentially create, as I said a little bit
earlier, a fifth body that would really look at these issues of
authentication/authorization, identification and linkage in great
detail. Bringing in privacy and security information from multiple
sources. So I think we might do well to move in that direction for a
more widespread and robust national approach. (1:59:39.7)

\>\> Joyce: So you are suggesting that we punt on this now and not make
any predetermination. Is that right? (1:59:44.4)

\>\> Karen: Except for the discussion around secure messaging verses
e-mail. That was very specific for this Workgroup. (1:59:56.7)

It was only a short-term punt, to use your expression. If we have your
permission to move forward, the other workgroups are meeting tomorrow
and Wednesday. By the end of this week, we should be able to come forth
with an essentially harmonized recommendation for your review. If you
feel that is not adequate, we can always go back. The intent is that we
should have by the end of this week something for you to react to prior
to the next draft of this letter. (2:00:34.8)

\>\> Eric: This is Eric Larson. It seem to me that one of the guiding
principle wouldn\'t want to ask HHS or HITSP to set a requirement that
would be essentially a step backwards for systems that we know to be
performing with good security already. To me, that is a place where we
just can\'t go or we will be creating problems for people. (2:01:06.3)

\>\> Karen: Right. Absolutely, good point. (2:01:06.3)

Well, we do have a little bit of time. (2:01:18.0)

\>\> Jeff: Can I then raise just a question? There was a second piece to
this standard. Maybe it was on the previous slide. (2:01:29.6)

\>\> Karen: Which one was that? (2:01:33.3)

\>\> Jeff: It was the patient identification. (2:01:39.6)

\>\> Karen: Right. (2:01:40.3)

\>\> Jeff: Just one minor point. That is, and this came from someone who
works in the VA, we mentioned the HHS, but we didn\'t include other
Federal health providers that should probably be in there. It\'s a
fairly a specific HHS that is to be in the private sector. I don\'t know
how you want to word that. Whether it be the public and private sector
or whether it would be HHS and other Federal health care systems would
be included in that. Then the second question that I had. The initial
recommendation that went in actually included some very specific issues
that I think reflect concerns that it is not clear again exactly
(2:02:34.9)\
how much patient input is in this. There was one of the comments was it
the methodology for identifying and authenticating patients. Must be
constructed as such a way to promote patient trust in the process,
transparency in the use of information provided and adequate patient
control over who may or may not access this information. In some of the
other groups I have been involved with at a State level, when there has
been a discussion about creating a statewide data repository for
interest. (2:03:07.6)\
For instance these issues have come up and a more local control of the
data has been raised. I am just wondering whether we need to somehow
preserve or articulate the need to have direct patient involvement in
this process? (2:03:29.0)

\>\> Karen: Thank you, and your comments are ones that we are hearing
from all of the workgroups. Clearly the need to have, and the discussion
about local verse more national has also come up a number of time over.
I think you are putting your finger on some core critical elements. That
is why again we thought it would be helpful to work with all of the
workgroups. To take all the information that we have heard on these
issues, and again try to harmonize them in a way so that by the end of
the week you have something that is a little bit more substantive and
essentially brings together all of the concerns that all the workgroups
are voicing around these very specific issues. (2:04:14.1)

\>\> Jeff: Okay. That sounds great. I wasn\'t sure which version of the
recommendations was going forward to those cross cutting groups, whether
it was the more truncated one or the earlier one. (2:04:31.1)

\>\> Karen: They will have everything in great detail. So they will pull
it together and see what you\'re all saying, if that\'s okay.
(2:04:39.3)

\>\> Jeff: Great. Thanks very much. (2:04:41.0)

\>\> Karen: Thank you. (2:04:41.4)

Well, I think I have everything I need to get you another pass in the
next couple of days. So with that I\'m just going to warn everyone that
we\'ll probably have pretty quick turnaround, and we will highlight
through \"track changes\" or something else, all of the comments from
today. Hopefully we\'ll be able to work with you all over the course of
the next week or so until we get something that is a little closer to a
final draft. Both on recommendations in the supporting write-up. If
there is any direction that you can give us on the supporting write up,
we\'d be delighted to hear it. (2:05:36.2)

\>\> Eric: What is the timing on when you need that? (2:05:38.9)

\>\> Karen: As soon as possible. (2:05:40.4)

\>\> Eric: That\'s what I was afraid of. (2:05:43.0)

\>\> Karen: We are doing iterations daily here. (2:05:50.8)

Well, this is what known at the moment. The next steps are for us to
these changes and get them back to you in the next 24-48 hours. So
please stay tuned everyone. (2:06:12.7)

\>\> Eric: Okay, thanks. (2:06:14.5)

\>\> Karen: Bye.

\>\> Matt: Karen, we need to have some public comment here before
everyone signs off. (2:06:20.1)

\>\> Karen: Yes we do. (2:06:20.8)

\>\> Tony: Say that, Matt, thank you. (2:06:23.6)

\>\> Matt: If there are members of the public who are on the phone right
now and would like to say something, please press \*1 on your touch
tone. If you are following along on the Web you will see that there is
now a slide up with instructions to call in and make a comment. We will
wait about 2 or 3 minutes for people to get through the operators, and
if we don\'t have anybody then, we will leave up an e-mail address where
you can e-mail questions or comments for the Workgroup. (2:06:47.3) 

\>\> Gloria: Matt, this is Gloria. We have a member of the public here
in the conference room who would like to say something. (2:06:55.1)

\>\> Matt: Okay, why don\'t you let him/her go ahead. (2:06:57.6)

\>\> Gloria: What information do you need? Name and organization?

\>\> Matt: We just do name on the phone; if she wants to provide the
organization, that\'s fine as well. (2:07:08.6)

\>\> Gloria: Okay. It\'s open to you. And the microphones, by the way,
are here. (2:07:12.0)

\>\> Tracey: Thank you . My name is Tracey Moorehead, and I am the
Executive Director of the Disease Management Association of America. I
wanted to first express my high regard and utmost respect for the
incredible robust conversation that this Workgroup has undertaken in the
past couple of months, and also to mention the extraordinary amount of
time and energy that you all have put forth into some very intensive
recommendations. I appreciate the opportunity to attend today, and to
review the draft recommendations that Karen and the others have worked
on. I do look forward to reviewing the final product. (2:07:33.3)\
Understandably, the Workgroup has not yet completed development, but its
recommendations to the broader AHIC. I would also like to say that a lot
of the questions that I had about the recommendations have been answered
through today\'s discussion. However, there are a couple of questions
that I would like to pose to the Workgroup for consideration as you work
to finalize the recommendations that you are planning to put forth to
the broader AHIC within the next couple of weeks. (2:08:16.4) \
I was very pleased to hear the discussion today that there does appear
to have been some coordination between CMS and the AHIC and chronic care
group, groups. Stating from the experience of the more than one dozen
demonstrations and part of the project currently ongoing with CMS on
chronic care management. I have been concerned in fact that there had
not been coordination there, but I was wrong. (2:08:42.0)\
Secondly, I wanted to question the extent to which the Chronic Care
Workgroup has considered the very thorough and thoughtful process
conducted over a period of several years by HHS and others in developing
a very broad definition and regulations regarding HIPAA compliance.
Specifically I was concerned that there seems to be a far more narrow
definition of provider that was being considered by the Workgroup, and I
was hoping for clarification on that issue. (2:09:15.4)\
Finally, I do believe that the efforts of AHIC and their chronic care
workers specifically are incredibly important in moving forward the
effort to expand the use of electronic health records and other
interoperable technology to improve the delivery care in this country. I
do see AHIC as a funnel through which a lot of this is happening, and
also in efforts to push forward the implementation. However, I remain
concerned, and my members remained concerned, that there needs to be
consideration of other parallel efforts that are underway in other
agencies, particularly the Department of Commerce and [MIST,]{.mark} and
some of the work that they have ongoing within technology deploying and
efforts. I am curious to what extent the Chronic Care Workgroup and Apex
have coordinated with these other agencies and efforts? Again I have
nothing but the highest regards for the work that is going on here, and
I hope the MAA and our members can continue to serve as a resource for
the staff and members of the Workgroup. Thank you. (2:10:19.4)

\>\> Matt: Thank you, Gloria. Is there anybody else in the room who
wants to say something? (2:10:35.3)

\>\> Operator: No, not at this time, Matt. (2:10:39.1)

\>\> Matt: Okay, I just got a message from the operator that no one else
is trying to call in. I think that we have given ample time for them to
do that. Again if somebody is following along on the web and wants to
submit a comment via e-mail there will be an address left up until about
4 o\'clock. So you will be able to do that. Tony and Craig, I will leave
it to you to adjourn. (2:10:58.5)

\>\> Tony: Craig, are you ready to adjourn? (2:11:06.8)

\>\> Joyce: Have we mentioned the next meeting date? (2:11:05.8)

\>\> Craig: It was in the material. (2:11:11.1)

\>\> Karen: Larry, do you want to suggest a date and time? (2:11:16.7)

\>\> Gloria: Yes, the materials that we sent out several weeks ago by
now indicate that the next meeting of this group will be Tuesday May 2,
2006, also beginning at 1:00 o\'clock. (2:11:34.6)

\>\> Karen: For the benefit of the public, thank you very much, Gloria.
(2:11:36.9)

\>\> Gloria: Wait, wait, wait, wait. Let me double-check that. May 2 or
May 3? (2:11:42.6)

\>\> Jeff: I have May 3rd. This is Jeff. (2:11:44:7)

\>\> \[Male voice\]: I have May 3rd. (2:11:47.5)

\>\> Gloria: Okay. I am really sorry. Wednesday, May 3, 2006, beginning
at 1 o\'clock. (2:11:52.5)

\>\> Karen: Thank you. (2:11:56.4)

\>\> Gloria: We have so many Workgroup meetings going on almost
simultaneously. (2:11:58.3)

\>\> Karen: Well, thank you very much. This is Karen Bell. I have wanted
to really express our appreciation for all of the effort that the
Workgroup members has put into drafting these recommendations, and
betting them and working with them yet again. Everyone has done a
phenomenal job, and thank you all very much. (2:12:19.1)

\>\> Craig: Thank you. (2:12:24.0)

\>\> Tony: Thank you.

\>\> Mike: Thank you very much. (2:12:24.9)

\>\> Karen: Bye now. (2:12:26.7)

\[Many "byes"\]