American Health Information Community

Quality Workgroup Meeting #2

October 11, 2006

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by speakers and moderators at DHHS-sponsored conferences do not
necessarily reflect the official policies of the DHHS; nor does mention
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by the U.S. Government.*

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

Okay, we are live? Yes.

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

Good afternoon, everyone. This is Carolyn Clancy and welcome to the
second meeting of the Quality Workgroup to the American Health
Information Community, which hereinafter we will refer to as AHIC. Rick
Stephens, are you on the line?

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

I am.

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

Terrific. One these days we\'ll actually get to meet in person. I\'ve
been very impressed by the capacity of the workgroups to get work done
virtually. And I want to thanks all the folks, we have a number of folks
here with us in the Office of the National Coordinator who are part of
the Workgroup. I have Margaret van Amringe. Helen Darling, Jerry Shea
who I believe also has brought some colleagues with us and we have a
number of our presenters here with us as well. Kelly Cronin is also here
with me. Do we know who else is on the phone from the Workgroup? Take a
roll call?

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

Matt?

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

Certainly. On the phone, right now we have Susan Postal from HCA. Carol
O. from the National Quality Forum. Denise S. here for Abby Block today.
Jonathan Teich from Brigham & Women\'s Hospital. Anne Easton from the
U.S. Office of Personnel Management. Reed Tuckson from United Health
Group. And are there any other Workgroup members or designees that I
skipped?

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

Jane Metzger.

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

Okay. Very quickly, for call-in procedures for the Workgroup members
participating over the phone, please keep your line \-- keep your phone
muted when you\'re not saying anything. And when you do have a comment,
say your name so members of the public can follow along. And if you\'re
on the Web cast interface, please don\'t touch or advance any of the
slides while we\'re going through the presentations today.

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

Great. Well, just by way of introduction before we get into such
important parliamentary maneuvers as accepting the minutes and so forth,
let me just say that I think all of us, certainly speaking for myself; I
think we had a tremendous sense of excitement and potential during our
first Workgroup meeting. I must say on my end of the phone, three hours
flew by like rapidly. And frankly, I want to thank all of the Workgroup
members for teeing up very important issues.

I think that you will see in the lineup of presentations that are
scheduled for today; we\'ve tried to be responsive to many of the
critical issues that you\'ve brought up. I think we also recognized
throughout our discussion at the first meeting that we will have to
struggle with the tension between our broad charge and specific charge.
But I think that will be a very, very healthy tension. And the other
thing I can say is I particularly want to thank Rick Stevens and Helen
Darling for being part of this group because they\'re going to remind us
about the sense of urgency that we desperately need not to forget.

And I have to just reflect that since our first meeting I have been part
of a number of very important conversations that only underscore and
reinforce the importance of the work that we\'re undertaking here. So I
want to thank the Workgroup members and others who are participating,
because your assistance and your best brain power are urgently needed,
in order to get us to a point where we can not only figure out what we
want to get in health care and how we want to buy it and buy right and
buy smart. But also figure out how it is we can scale that measure and
enterprise in a way that is not possible today.

Rick, do you want to add anything?

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

Carolyn, I would like to echo the comments you made. I think they\'re
spot on. Lots of moving pieces in this particular space, and getting
alignment about the language, our motivations or expectations are
critical if we\'re going to be successful with an output we can all use.

The second comment I\'d like to make, yes, I won\'t be bashful about
reminding us about the urgency and also the sense of value that we need
to create in terms of the output. Getting \-- this is an awful lot about
getting a process in place so we have data that we all understand to
allow us to go forward. But ultimately the output is really improving
health care and taking advantage of the opportunity to really assess our
cost quality so that we can make the right improvements in the right
direction. While enhancing health care in this nation.

So thank you very much, and I\'m looking forward to this meeting today.
And I think as a clear reflection of the sense of urgency, I want to
thank in advance the presenters who have made themselves available
today. Before we get to the presentations, and I can hear people holding
their breaths on the phone, I\'d like to ask if we can approve the
minutes which the Workgroup members should have gotten. And I believe
the others can see them posted on the Web site?

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

Yes.

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

Yes. So moved and seconded. Any objections from the members of the
Workgroup? Then we\'ll consider the minutes approved, and let me start
out with the presentations. The first two presentations we\'re going to
hear are from Francois of Bridges to Excellence, and from I think
Phyllis Torda from NCQA, lot agenda says Greg Carlton. They\'re both
fabulous people so whoever tunes in to make the presentation will be
terrific with us. Both of these are speaking to different aspects of the
business case for automating quality reporting, and Helen Darling, this
was a point that I heard you very specifically refer to so I think
you\'ll find there\'s terrific work done but there is also big areas
where we have important gaps to address.

Let me introduce Francois. I think many people are probably more
familiar with the product of your genus, Bridges to Excellence and some
of the newer initiatives you\'ve been working on since then than they
might be with you personally. Which actually I think is a good thing. It
speaks to an enduring initiative and so forth. But without further due,
if it you wanted to tell us, start your presentation.

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

Thank you for giving me the opportunity to share a few remarks. Is
someone piloting this or \-- excellent, okay. So let\'s start with the
first slide. Great, thank you.

The topic today, business case for automating quality reporting,
obviously suggests that there is a business case for quality reporting,
and that\'s what I\'m going to try to focus my brief remarks on. And in
particular, focusing in on what are the subsets of performance measures
that we have been able to determine, have a fairly significant impact on
the cost of care and therefore act as a good predictor for the case
around quality reporting.

Let\'s start first with everyone\'s all-time favorite. And so in
diabetes what we have found in a number of different studies is a
consistent amount of data that shows that physicians that can
demonstrate that they manage A1c\'s, blood pressure, and lipid levels
for patients who have diabetes, have episode costs of care that are
lower than physicians that are just randomly selected in a community.

And I emphasize that these are physicians that demonstrate that they can
manage patients with diabetes by controlling their blood pressure,
hemoglobin A1C's and LDLs. And it is that impact on the intermediate
outcomes that is the higher predictor for cost savings.

The next slide will show us a little bit more detail, not on diabetes,
but everyone\'s second favorite which is cardiovascular disease. And
what we have asked actuaries to do is really look at the data that
exists in clinical trials as well as in other studies, about the
potential impact on the cost of care of various performance measures.
And in this particular instance what they did is they looked at the
ability to save money if in fact you have patients with coronary artery
disease whose blood pressure, lipid levels are appropriately managed,
but they also went so far as to valuing other performance measures that
are usually considered part of an initial start of set of ambulatory
occasion measures, such as completion of a lipid profile.

I think what\'s important to note is the process measures, while
certainly important, do not have much predictive value in terms of the
cost of care. And I think \-- and again, it\'s \-- this is a specific
area which is cardiovascular ambulatory care. And the data are pretty
clear in showing that the completion for example of the lipid profile
does not in any way result in actuarial based savings, however the
control of blood pressure does.

So you now start seeing a fairly recurring theme which is if it you can
measure intermediate outcomes and feedback that information to
physicians to help them control intermediate outcomes, you can generate
cost savings in health care.

Our next evolution in this effort was really to look much more
comprehensively on the next slide at a series of ambulatory care quality
measures that \-- all of which I think are on the AQA starter set. And
to determine the potential both clinical impact and financial impact of
a lot of these measures. And in a fairly comprehensive effort that
included looking at all types of data analyses, we ended up with a group
of performance measures again not completely surprising, that had a very
high clinical and financial value associated to them, which include
blood pressure management, A1c management and LDL management. And so \--
just so that people don\'t think that out of the ordinary, if you look
at the way the national health services in England weighted their
ambulatory care measures, you will note that the weighting on
intermediate outcome measures was significantly higher than the
weighting on certain process measures. Not that process measures are
unimportant, but they\'re actuarial value have a tendency to be lower
than the actuarial value of intermediate outcomes.

So what this kind of leads us to, and I think this has been a thrust
certainly of what we\'ve tried to do is to encourage the adoption and
use of health information technology because you can imagine that these
data are difficult to get in normal circumstances, some of them are
actually impossible to get off of claims information.

And so unless we find a way to automate the collection of these very
important data, we will continue to be frustrated by the limitations of
clinical information. And so on the next slide I just \--

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

Can I ask \--

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

Sure.

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

What does the score refer to here in this chart?

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

That\'s a good question. The score refers to a kind of a multiplicative
between the aptitude of that performance measure to impact clinical \--
the clinical outcome patients and the ability of that performance
measure to impact financial outcomes. So the multiplication. And we\'re
publishing a study that will show all of this information in much more
detail, as well as the actual financial savings.

The reason it\'s not in here is because we\'re in the process of
publishing so we are precluding from being able to \--

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

That\'s helpful.

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

So a couple of words on this importance of finding ways to integrate
clinical information to claims information and it\'s a fairly simplistic
chart. As you think about three probably biggest limitations of claims
data, it includes attribution, which is a very significant limitation,
or \-- and when I say attribution, it\'s the ability of claims to
accurately attribute claims to physicians. There are very significant
limitations to being able to do that with great accuracy in claims data
and on a highly consistent fashion.

Think about a very simple example of group practice that bills under one
ID number. You cannot attribute to the individual physician.

The second one is in what you can measure. There are limitations in
claims data in what you can measure and as reminded at some time we need
to stop torturing claims data to get them to do things they were not
designed to do in the first place.

And finally, even if you solve both of those things, you still have the
issue of timeliness. And there is a fairly significant time lag between
the moment of bill is issued, the moment you can re-aggregate amongst
multiple payers and score it and create a report card, the purpose of
which shouldn\'t just be for the dissemination of information to
consumers but to facilitate performance improvement on the part of
physicians. So we have to find a way to massively speed up the
performance feedback loop both to consumers as well as to physicians and
in clinical information derived from electronic health records in some
way, can create those much more rapid feedback loops than claims
fortunate or unfortunately never will.

Thank you.

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

Thank you very much. And thank you in particular for reinforcing the why
a time lag with claims data is a challenge. It actually is an important
barrier to getting information back to clinician to improve care that in
essence were not just about report cards, notwithstanding a very strong
focus on transparency. A person getting information months to years
later isn't quite as helpful if it\'s close to real time.

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

They may have improved in the interim.

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

Right.

One question I had for you, Francois and then I\'ll open it up to others
in the Workgroup. Of course, if all those people would just adopt
electronic health records, interoperable CCHIT, electronic health
records immediately, we would be in a different world. And one can make
different guesstimates about how likely we are to get to that world. My
favorite is the minimalist, by 2010; I think 50 percent of physicians in
practice will have electronic health records. Interoperable CCHIT
approved.

But between now and then and even a bit past, that I think we\'re still
going to be talking about some use of claims data potentially enriched
by clinical IT elements. Lab and pharmacy in particular. Have you and
your colleagues given any thought to that at all or was that part of
bridges?

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

Yeah, I think it\'s a core component, and the reality is that you can\'t
stop and nor should we stop in any way, the move towards public
reporting and score carding until everyone has an electronic health
record. I think the issue is they are data that exist and some of these
are available in physician offices and large group practices and I think
we have to continuously find ways to integrate those data and to give
those physicians and physician groups the opportunity and the right to
submit those data as part of their performance scorecard and not exclude
it because it\'s simply not consistent with the rest of the data. My
thinking is if you want to accelerate and put pressure on the system,
then give kudos to the guys who can give you more timely information and
willing to do that. And reward them at a higher level if they deserve
that and that may encourage others to adopt electronic health records
than otherwise. If we continue to take a one size fits all then the one
size that fits all is claims data until such time that we have EHRs for
everyone and I think we have a way of blending that solution so that
self-reported either through chart \-- manual chart extraction or
electronic chart extracted data ought to be a core mix of any public
report card.

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

Let me pause to welcome Peggy O\'Kane and Phyllis \[indiscernible\] who
just joined us. Do you have anything to add?

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

I\'ll hold off, then. I\'ve had the personal opportunity to hear a lot
of insights from you and your colleagues about what you learned here.
Questions from any other members of the Workgroup?

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

Carolyn, Rick Stephens. A question I\'ll go back to is the measurement
impacts. I understand that it\'s fairly new but give than we have I
guess at best volatility about people\'s understanding when you get down
to quantitative measurements as opposed to qualitative, where are we in
the process, do we believe, about people accepting this sort of
measurement and what you believe will be the recommendation going
forward on the formula for computing the number?

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

Now, are you talking about quality measures in general, or the ones that
Francois was \--

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

This is the one Francois was talking about and under his measures
impact.

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

Yeah. And you are asking me if I \-- I\'m sorry.

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

So the question is, what\'s your sense of what I\'ll call the universal
acceptance of this, because I\'ve not seen too much measurements yet
where there\'s a formula used where there\'s acceptance of that on a
wide basis.

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

It depends on \-- I mean, I think there are two parts to the question,
if I may. The first one is, is the quality measure itself an accepted
measure. The second one, is how do you score that measure and include it
in a scorecard.

I think on the former, there\'s no doubt that blood pressure and blood
pressure control and lipid control and A1c control and all these others
are well accepted measures and in fact they\'re part of the AQA starter
set as well as the set of performance measures that were bubbled up to
the NQF, by the AMA physician consortium and the NCQA. So I don\'t think
there\'s any doubt physicians accept those as being valid.

How you end up by scoring them in a scorecard is obviously highly
debatable.

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

And that\'s what I\'m referring to.

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

Yeah, and I think on that side, and I know Peggy and Phyllis are going
to get into it, we have not had any pushback whatsoever from the
community in the scoring mechanisms to date in a physician recognition
program. I don\'t think there\'s one physician that I\'ve met yet that
has told me that they think that having more than 20 percent of their
patients uncontrolled for A1c's is in any way acceptable.

So I do think we have a lot of empirical, good empirical and other data
that show that you can create score cards that are valid in the market.

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

So \-- and I guess the pushback would be because we rolled out with the
intention of our health care for 60,000 employees in the Puget Sound
area, got significant pushback from the WSMA, the Washington State
Medical Association.

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

Yeah.

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

So being sensitive to, that I was trying to get some sense, and I think
we have a lot of work to do in that area. So we\'ll look forward to
seeing when the paper comes out that actually publishes what those \--

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

Yeah and I think you need to segment the pushback that comes from
raising issues around attribution, the depths of the method you\'re
proposing and methodology from potentially other issues which is the
acceptance of the measurement itself.

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

Phyllis, do you want to chime?

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

Yes.

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

Can you come over to the table?

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

Particularly at the individual physician level. I think there\'s some
features to the way we score and you use our scoring that make it
particularly \[indiscernible\] and one is the measures. And we\'re
looking at performance across the seven measures, not on performance on
any one issue. And in order to get an acceptable score, you don\'t have
to clinical path every individual measure, 75 out of 100 points. And
that makes it much more acceptable. I have these conversations with
physicians every day.

The other is even to get credit for any one measure, as Francois alluded
to, you\'re looking at for a percentage of the patient population,
sample and it\'s not 100. When you tell them it\'s not 100, you get this
huge sigh of relief.

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

It\'s a representative of \-- not a sub-sample.

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

Right, so I mean those two features taken together, not 100 on any one
measure and you\'re looking at performance across a set of measures, a
composite, you don\'t have to pass every measure and we\'re not
reporting granular results on each measure at individual physician
level, which makes it more acceptable and doable at the individual
physician level.

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

So again, this is Rick. I\'m optimistic and want to be, but I\'ve yet to
see anywhere where a health care plan provider and the medical
practitioners and the physicians have agreed on this. So I\'m looking
for one where it\'s actually working.

**[\>\> Peggy O'Kane:]{.underline}**

Well, I mean, I think we\'ve built on \-- this is Peggy O\'Kane. We\'ve
built on a lot of work that\'s been done by the American Diabetes
Association, and the American Heart Association, to create consensus,
and remember this is a voluntary program. So that means these people are
stepping up voluntarily. So that\'s different from something that gets
rolled out maybe in Washington State where maybe people that wouldn\'t
have come forward if it were voluntary.

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

I wasn\'t sure I heard you use the word 'volunteer', Rick.

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

It was not 'volunteer', but eventually if we\'re going to be successful
when I go back to the 1.9 billion we spend across aerospace, it will be
8 or 9 billion dollars. It does have to get to the point it goes beyond
voluntary to everyone participate. Some will say I don\'t want to go
play.

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

We agree with, that but I think we have to realize the dynamics are
going to be a little different.

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

Yes, and I don\'t think it diminishes your point at all that we\'ve got
a long way to go.

One thing I will say is your results, at least on the clinical side,
seem to me to correlate very well with David Eddie\'s models about the
intersection of managing diabetes and cardiovascular risk factors. That
to me seems like independent validation.

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

And we\'ve \-- \[multiple speakers\]

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

We actually adjusted our scoring to give weight to measures that \--

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

Helen?

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

I have two. One, the point about 50 percent of offices have an
electronic record, I guess was \--

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

By 2010.

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

By 2010. The question, do we know about what volume of care that is?
Frequently it is the higher volume placing that is more likely to have
them. Maybe 50 percent of all practices, but it could be 80 percent of
all care.

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

We can check on that. This was actually derived from a study that was
done to figure how we build a nationwide health information
infrastructure. What does it cost, by a team from Harvard? You know,
essentially what they did was to come up with a estimate of what happens
if nobody does anything. And so it\'s that nobody does anything,
estimate that says the by 2010, 50 percent of physicians. You\'d have to
believe based on what we know now with adoption that would be torched in
favor of larger groups.

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

Right. So it would be a higher percentage of care. That was what I
wanted to \--

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

I think it would be important to state that.

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

Yes.

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

Otherwise it sounds grimmer and we know it\'s grim enough. \[Laughter\]

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

The second question and maybe this is \-- I know I was on the first
call, so I know this \-- I didn\'t miss something, I don\'t believe,
it\'s not clear to me from the dialogue so far whether or not a decision
has been made when it would be made about a, if you will, transition
strategy versus the end game. And that gets so important because if you
take steps that slow down one thing, obviously, especially if that\'s
what you\'re trying to get to, we may not want to do that. We may want
to decide early on what the transition strategy ought to be. And then
talk about what it takes to get there. So we don\'t undo accidentally,
or delay something accidentally, or frankly with scarce resources which
we all have, spend money that we don\'t have on something that is not
going to be the end game.

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

No, I think that\'s a critically important strategic issue and one I\'d
like to come back to when we get to the part of the discussion about
what we bring back to the community. Because my guess is that they would
want to weigh in on that as well. And how different that looks in
different parts of the country. I think it\'s going to be an interesting
calculus.

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

I agree with that, that they will want to weigh in. But if our \-- if
you will, subject matter expertise is quality, and we know
disproportionately more about quality than maybe somebody who is working
on \-- in another area, if we could advise at least.

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

Yes, I would agree.

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

Given what we know about quality metrics, what would you then advise
ought to be the transition and the endgame.

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

Yeah.

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

Other comments or questions?

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

Or anyone from the public? Well, then, Francois, let me thank you
immensely. I think you did a fabulous job distilling that and now I\'ve
been looking forward to the presentation from NCQA. So Phyllis, I\'ll
hand you a microphone.

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

Sure. I\'m not Greg. His name is on the slides. But I\'m vice president
for development at NCQA, and I\'ll \--

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

I\'m going to walk through this and Peggy\'s going to provide the color
commentary.

I\'m moving to the slide that \-- the next slide that says why measure.
This slide \-- \[indiscernible\]

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

This slide just reminds us regimen plays a dynamic role in the
marketplace and it\'s not a question of accountability and public
reporting versus all the improvements. There\'s a dynamic relationship
between those and I\'m not sure I understand the subtleties of it, but
we believe that public reporting and accountability leads to quality
improvement and you don\'t need to \-- it\'s not either/or.

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

Showing the two pathways and model of the professionalism driving
improvement. Showing these are not necessarily in conflict.

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

Next slide. I want to use the next slide to talk about the types of
measurement currently used in use for valuation. What the sources of
data are. And what a little about what they might be in had the future.

Currently used clinical performance measures to tell us about quality
and utilization and related to utilization is cost. And currently we
collect those measures at the health plan level through two different
methodologies. And one is what we call the administrative data method.
And that\'s basically a claims and enrollment data combined. It is
electronic data. And because it\'s electronic data it can be reported
basically in the universe, not pulling sample. You\'re reporting on your
full population.

The alternative method, which is the more common in many cases for many
measures, is what we call the hybrid method. And the hybrid method
involves taking a sample of members, seeing if you can get the
information for each member from administrative data, and if not, so you
can get a positive \-- so your sample of members is your denominator.
Usually 411.

If you can then get the information necessary to qualify for the
numerator of a measure that the member had a mammogram, for example,
then you can get that from administrative data. And if not, you chase
the charts. You go look for the data in the paper chart.

So it\'s not just that it\'s electronic and paper information, the point
I really want to emphasize, if you have electronic information you can
get information on the full population. And if you don\'t, you go to a
sampling methodology. That\'s where the work comes in.

We collect patient experience of care measures, and we do have a program
that operates at the \[indiscernible\] level that we created in
conjunction with Bridges to Excellence, and Francois initially called
Physician Practice Connections, and that program is process measures,
but it\'s process measures about how practices, physician practices, are
using electronic information to deliver care.

So it\'s not about what electronic capabilities they have. It\'s about
how they use the electronic capability to deliver care. And it is based
on research that shows a relationship between managing information and
improved care.

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

At this point you might tell the anecdote about the people that came
forward that had EHRs, you know, kind of full capability EHRs and kind
of \--

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

One of the most common comments we\'ve gotten from participants in this
program is until they looked at our requirements and started to try to
meet them, they hadn\'t made the jump in their own minds \-- they had
paper records that they put and they made electronics. But they didn\'t
go beyond that in their thinking. They just went from a static paper
document basically to a static electronic document. Our program asks
them, did you count across those records? Did you do population based
management based on counting out what the each one of the individual
records? And the story that we hear over and over is I never thought to
turn on that functionality.

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

Some of this is with the design of the records themselves, which are the
electronic shoe box, you know, so you can\'t \-- if it\'s not coded
going in, you can\'t access that.

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

Right.

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

To pick up on a point that Francois made about sort of a trajectory of
electronic information, the most common \-- we have now enrollment forms
and claims forms, and actually making those two talk is not always a
simple endeavor in and of itself. And it\'s the same thing \-- that\'s
at the health plan level but same at a practice level. Practice
management system, that has certain information, and they have an
electronic health record. They may need to make those two talk and those
two don\'t necessarily have the same information. So even the most basic
levels there\'s need to enter that information.

The next level we\'ve been able to go to with electronic information is
integrate \-- is sort of beyond claims and enrollment, is lab results.
Somewhere between 20 and 50 percent of health plans are now getting lab
results electronically. That\'s 20 and 50 percent of health care. We\'ve
made some inroad there and that enables more measurement and enables us
to get to the outcomes Francois was talking about. But even at a health
plan level we don\'t have that. And most physicians are not getting that
retrievable form.

Then kind of an in-between step that\'s kind of interesting, and seen
emerging is the use of registry. Which is sort of electronic health
record but it is a way of creating a database with retrievable
information so it\'s \-- as patients' diagnoses, some information about
care and service that they have. It is certainly disease specific and it
does allow management of care.

In California, for example, at the approved level, the physician group
level where there\'s been a pay for performance in place for three years
and that demands electronic data, there\'s been a market growth in the
creation and use of such registries.

Finally, electronic health record and come back to this theme in a
couple of slides but the electronic health record for a primary care
practitioner is not the same as electronic health record for a
specialist. And you know, I think we really need to \-- the data
elements, what you want, the data elements, all of what we would like to
see baked into it, really needs to differ for the primary care
specialties from the other specialties. And that\'s kind of a level that
needs more attention.

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

These days that also is going to include specifically for surgical or
procedural, the issue of data. Or sites, I should say.

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

Yeah. Yep. Exactly.

Next slide, please. I think what we want to \-- the point we want to
make is a point Carolyn made earlier, and that is the real point is to
improve care at the point of care. And as Peggy said, we talk about
quality measurement, talking about the tail of the dog. The dog is
improving quality of care at the point of care. The first question to
ask is what do we want physicians or other providers to be doing? Then
we\'ll measure them on how well they do them. But the first question is
what should they be doing and that gets back to the point of the
diabetes program, the heart-stroke programs. Those programs couldn\'t
exist if they\'re not well accepted guidelines from the American
Diabetes Association, the American Heart Association, and those are the
guidelines that we built the measurement off of and they really need to
come first. They can\'t \--

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

This is a huge issue. As we know well, working now with on spine care
program, where it\'s kind of \-- there is a lack of evidence and
there\'s nobody that\'s harvested the evidence and turned it in to
guidelines pretty much across the board.

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

When you mention the associations, are you also wrapping in NQF
processing or is that distinctive?

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

That\'s distinctive. \[Multiple speakers\]

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

These predate.

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

I know something about the diabetes stuff because I hear the \-- so
there were some adjustments made. Are those reflected in what you now
do? Are they up to NQF?

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

We\'re keeping ourselves aligned.

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

They are aligned. And it is true that going from a guideline to measures
is not a no-brainer.

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

Yeah.

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

So here\'s where the performance \-- off goal of getting all patients to
LDLs of below 100. What does that mean in measurement terms? And that\'s
where we \-- our measure in the diabetes program is percentage of
patients with LDLs of 100 but we don\'t require it\'s 100 percent. A
realistic thing. You know, in terms of goals, don\'t translate well into
measures that have to be absolute.

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

But I think the takeaway point here is we have very uneven platforms for
building measurements. And that\'s a reality and it\'s something that is
going to take a while to correct, when you get into specialty care.

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

Next slide, please.

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

This is where they say all the money is.

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

It is.

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

The next slide illustrates what the point Carolyn just made. Which is
there are a number of sources for data that can contribute to quality
measurement. And they\'re kind of arrayed on this slide.

In many cases, true quality crosses these boundaries. So you need a
system for not just getting data out of one of these little geometric
figures, but for getting data across. I think that goes to the
recommendations and the \-- to focus on measures of continuity of care,
by definition those cross settings. These are the most challenging areas
right now. Do you want to say anything else?

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

We just have, because we\'ve built our performance measurement first in
primary care, I think we tend to have thought models that think we can
kind of replicate what we\'ve done in primary care, and it gets much
more complex the more physicians involved, than when you have really
sick patients that are crossing into different settings and so forth. So
just to say I don\'t think it\'s an additive process. So we\'re going to
have to be very strategic. We\'re going to really move down this road in
a coherent and rapid enough way.

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

Can I ask a question about that? So would an example of the points you
just made be something like every discharge has to have a contract
between something that is a particular measure, theoretically has high
value if it\'s done right? It sort of captures a lot of problems that
theoretically \-- there are different ways of thinking of solutions, but
your example of somebody coming out of a hospital is a good one because
you might have somebody that has a primary care physician, but if the
primary care physician doesn\'t know the person was coming out of the
hospital, then that \-- that\'s a real opportunity for somebody to crash
and burn. Right?

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

And if the information isn\'t followed. That\'s why there\'s been a lot
of energy focused on reconciliation which on some level is a huge
opportunity really important but its fruit on the ground. Not low
hanging.

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

This again brings up the idea of what is a reasonable way of thinking
about entities that are big enough you\'re going to capture these kinds
of transitions.

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

This is case for automating; I think Francois went into this really
well. I think there\'s \-- we\'re really talking about two kinds of
costs. We\'re talking about costs related to how care is delivered, so
eliminating medication errors. And the costs related to how care is
delivered or getting services in a timely manner, which reduces
hospitalizations. Those are costs related to care delivered. And then
there\'s cost of measurement. This can also be saved through electronic
data. I think that the point that Peggy just made a minute ago, that we
need to be parsimonious and strategic about what we measure. We don\'t
want to overwhelm various providers with measurements steps that are
really a distraction. An example of sort of what you hear perhaps gone
too far, is the system \-- is prescription alerts where you have lots of
complaints if they\'re too sensitive, the physicians get overwhelmed and
just ignore them and don\'t act. So that\'s an example of how not sort
of strategic you can undo the good work you\'re trying to do.

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

I have a question on issues.

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

Uh-huh.

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

Have you looked at the cost of the quality of data in looking at data
that comes from the medical record versus data that are coming from the
administrative data? Because I\'m assuming you have to audit both to see
where they\'re \-- make sure the data be whatever credible standard \--
is there \-- has there been in your \-- if you\'ve done that any
different from the findings data are more accurate when they\'re coming
from the medical record than the administrative?

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

Whenever we introduce a measure that requires administrative data,
testing process is to compare it against chart data and be comfortable
with the quality of the administrative data. That we\'re getting. So we
would not have a measure that requires administrative data unless we
were comfortable based on a testing process that actually compared it to
chart data.

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

I\'m sort of meaning if you were going retrospective assuming you said
some people were using a hybrid model and some people were obviously
have an electronic health record. Do you go back and audit those data to
make sure the data is actually getting in are accurate and see any
differences in those using the hybrid versus those using \--

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

Well, because I think we catch it up stream.

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

You have to pass the audit to report the data.

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

We actually haven\'t looked \-- if you flunk the audit, we don\'t report
the data.

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

I don\'t know if anyone from CMS is on the phone but Lou Metra (ph) in
California worked with Paul Tang on this issue and they have publication
pending, we\'ve been trying to share some kind of summary with the
group, so we can get up to speed on this because there\'s not only a
measurement bias when you go from claims to EHR but I think there\'s a
differential quality and probably cost implications, too, and I think we
just need to dig into it a little more based on some real world
experience.

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

Yeah, because I\'d definitely like to look at that issue.

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

The ability to report measures from EHRs today is a real problem. People
are really \-- \[multiple speakers\]

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

That\'s a different question than I heard you ask. So anyway, okay.
Based on the testing we would have done, any measure for which we\'re
getting administrative data, we\'re pretty confident that\'s good data.

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

And we actually certify software that goes into the claims system and
extracts data, so you know, there are all these kind of little solutions
that people dream up once you have a system.

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

Yeah, I don\'t know where \-- I don\'t know where it comes up in the
presentation but there are different issues that get raised with EHRs.
And we\'ve heard anecdotally you can get the situation with EHR data
where the defaults that are turned on in the system indicate that
certain services were provided. Those are the defaults.

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

In other words, so you can have a thing in the chart that says a foot
exam was done that automatically trips as soon as you would pull that
patient\'s record up. You don\'t want that, right?

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

Right.

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

You want somebody to affirmatively have to input that.

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

Right. So there\'s \-- because the EHRs make our lives easier and you
want to create systems for reporting, you can take it too far.

Let\'s see. Where are we? Are we on the \-- the next slide, I think?

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

This is probably not news to any of you. We think there\'s a big
hesitation out there because of the initial investment and because of
the need to reengineer your processes within the practice. And I think
there\'s also this 'What if I buy the wrong one hesitation out this big
time?"

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

And then you can speak to the technical issue.

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

Some data, you know, we mentioned the data not being coded, and
therefore it\'s kind of in there just hard to access in a paper record.
And then this whole knotty issue, it might be that you could have a
simple solution for measurement but not the right solution to have it
accessible at the point of care. So just something to keep in mind.

And then this interoperability issue, I know you\'re very aware of this,
but we have been regaled by somebody who has a electronic health record
and who has to have his staff manually input lab data and comment from
the outside so the center for interoperability is huge.

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

That also gets to the continuity of care issue, how to get the data from
the hospital to the physicians or the \-- so the physician can follow up
on the patient.

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

That really also I think speaks to the point that we need, or the
Workgroup figuring out a transition plan or how we\'re going to approach
the broad charge, how we\'re going to look not only at the capabilities
in electronic health record whether it\'s inpatient or ambulatory but
network services necessary to get the information from point A. to point
B. or aggregate it as you need it.

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

Right.

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

For the purposes of doing analysis, and public reporting or feedback
back to the providers. We\'ll have to drill down on that. And bring it
forward.

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

Okay, the next set of slides, I\'m going skip through them, but I\'ll
tell you what they say. I mean, you can just have them for reference. It
really gets to I think Francois\'s point about how do you \-- how we
a\-- avoid those of greater electronic capability right now. And so for
the programs that Francois talked about, these programs are heart-stroke
programs, we are putting into place electronic interface where the data
can be uploaded directly from the electronic health records over the
Web, into our systems and we can score the physicians and grant the
recognition for our program. And this is in place on a pilot basis,
we\'re testing it in two locations. Right now. But it\'s been received
very well. And we expect that what it\'s going to result in is the
recognition of being able to acknowledge much larger numbers of
physicians than we ever have before, and in these programs and they\'re
going to be the ones that you can do also. Buying EHR systems, that have
the reporting capability built in, their data can easily be uploaded,
transferred to us, scored and publicly reported. So it\'s going to
result in a real advantage to those physicians. And right now, we have
the diabetes \-- we\'ve operated the diabetes program since 2001, I
think, the ADA founded in 1997, and we have about 2500 physicians
nationally recognized \-- you know, they\'re not spread out evenly
across the country but those physicians, every one of them, some are in
groups but basically either they or their group have had to go in groups
and abstract and no matter how much pay for performance we can put
behind it, it\'s really hard to get that program to grow. But with the
ability to do this electronic information exchange, I mean, we\'re
looking at probably I hate to say, this but you know, being able to
double the number in a year or two. We have bigger goals than that. But
it will be \--

\[Laughter\]

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

You\'re taking the 2,300 participating \--

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

We have 500 in the diabetes program. These are physicians or groups.

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

2,500 in physicians, either as \--

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

Good.

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

So there\'s one place you can go.

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

I would tell them about, this is really sort of interesting, I think.

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

You know, basically this is this is a program that GE asked us if we
could certify the ability of centricity to report these results to us,
and we\'ve done that with GE now, and ran a test with a group in Maine
and we\'re about to do it \-- are we allowed to say? Okay, in Southern
California this is going to bring 1,200 physicians into the program.

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

Has the potential.

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

I think they\'ve been doing chart reviews.

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

It\'s important \-- it\'s important to say, that as a precursor to this,
we do certify now the electronic health records system for being able to
calculate and report the data. And that\'s an important component of
this. You can go upstream to the electronic health record, certify the
capability of it, and then the data has to be entered for the individual
physicians and passed and validate it again. It\'s a two-step process.
But we are now certifying the reporting capability in the diabetes area
for some electronic health records.

Maybe we can skip all the way to \-- 14?

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

Let me \--

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

Can I ask a question? If I am running a plan, a small plan in New York
State, and we\'ve been reporting using administrative data and we just
took the plunge and now we have an electronic health record. Which may
or may not have the functionality, probably doesn\'t have the
functionality of reporting to you. We\'re not ready for the provider
recognition program today with NCQA. Am I still stuck with the
administrative data? Okay. \[Multiple speakers\]

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

Most of the pressures \--

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

A lot of clinical measures are hybrids.

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

But until such time there\'s a broad scale formula and the vendors have
come up to actually building in what can be built in, my en investment
in electronic health records is not helping me be \--

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

Well, it\'s helping you probably get your performance levels up.

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

That\'s correct, but in terms of the reporting. I\'m just trying to get
\--

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

Well, we\'ll get into these issues in a second. But you said, if I have
a plan. It\'s important to note that except in the situation with Kaiser
and a few others, most plans don\'t own EHRs.

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

Right.

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

The practices in their network.

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

Yes.

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

So if you have a practice in your network that has an electronic health
record, you could \-- I mean, that\'s the issue we\'re addressing here.
So the health plan uses the hybrid methodology, they pick a sample and
see whether they have the electronic data in their system to give you
some \[indiscernible\] if you don\'t, the health plan\'s current option
is to send a staff person to the office to abstract the data from the
chart. If the practice has an electronic health record, there\'s really
no reason why that practice can\'t transfer that information to the plan
in some way to satisfy the \[indiscernible\].

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

Who reconciles? Hybrid methodology?

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

This is a different hybrid methodology.

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

Okay.

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

It\'s a hybrid between claims and EHR.

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

That would be the plan\'s responsibility done by the auditor is okay,
the plan \-- you actually have a pathway.

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

Yes.

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

Okay.

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

But Carolyn, I think you\'re pulling on the right thread. And that is,
the incentive that would cause people to head down this path. You talk
about Kaiser and I\'ll go back to Boeing again, so in St. Louis we have
8,000 employees, BJC probably handles about 80 percent. If I was to talk
to Steve, the President of BJC, I mean, and said, "Hey, Steve, this is
probably something you want to get involved in " because they do have
electronic health records, what\'s the incentive or motivation for him
to go do this if he\'s already using electronic health care to manage
what he\'s got as a plan?

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

Do they have a plan?

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

Well, BJC, they\'re using electronic health care records.

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

Yeah, but they\'re a provider organization, right?

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

No; they are health care provider. They have doctors.

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

But they\'re not a health plan in that \--

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

We\'re talking about health insurance plans here.

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

Okay, but they feed in to \-- and I don\'t know who our plan provider is
down there. But again I\'m trying to make a bridge. And everywhere I go,
and it may be united health care.

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

Yeah, it is, we are.

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

Okay. Everywhere I go, I see this chasm between what practitioners do,
what health plan providers want.

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

Well, I think part of the answer \-- Reed Tuckson from united. What most
people \-- a lot of people are banking on here, is the certification
commission of health information technology. Certification of electronic
health record. Can you all speak in terms of how if it all you all are
going to connect into CCHIT in?

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

Yes, let me just say that a driving rationale, or one of the driving
rationales for creating this Workgroup was to make sure that including
the functionality for public reporting on approved endorsed quality
measures would be on the radar screen of the CCHIT. Understand that the
products they\'ve already endorsed they have not addressed this
particular functionality. You have to start somewhere and so forth. But
you know, Rick was asking the right question. If docs have made the
investments and don\'t have bridges to the community is a powerful
incentive to work through these issues, you\'re not going to lower the
risk of investment which is the primary rationale for having a
certification commission.

If you think to the executive order, the potential is it kind of sends
mixed message. You order a \[indiscernible\] and you ought to be
reporting on quality in a transparent consistent fashion, but by the
way, one won\'t help without other. It\'s that disconnect that is our
specific charge.

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

Right, and that\'s the point that \-- so Rick, in terms of sort of how
we look at it, it does have to be some mechanism that you\'re asking the
Barnes-Jewish folks to purchase an electronic software or reconfigure
their systems to be compatible with national standards both for
interoperability across the health care system, as well as for
performance measures which is what we are trying to do here.

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

Yeah, Francois, do you want to get in here?

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

I want to make a point there\'s no, I think and Phyllis and \-- talked
about this, which is if you think about the \[indiscernible\] the NCQA
is doing with centricity, to expand on that because I was part of the
discussion in the early stages, and what happens with those electronic
health records users, they do not have themselves in their electronic
health records, any capability of reporting performance measures at all.
But what happens is their data gets uploaded into a central server that
itself does the work and the manipulation of the data to look at and for
the measures. So to bring that to Barnes-Jewish, even if their chart
systems don't have the inmate capability of reporting measures, there is
the potential for Barnes-Jewish to do that on behalf of the physicians
that are using their electronic health record to the extent they are
doing some level of clinical data aggregation within the system.

So you can see how an intermediary, an information intermediary can act
as an organization that can in fact score those data without having the
electronic health record, to use your terms, Carolyn, having a magic
\[indiscernible\].

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

This is Jane Metzger. May I make a comment?

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

Yes.

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

This problem of the assumption that some day the CCHIT-certified vendors
will be able to do all of the things we\'re talking about, I am on the
commission and there are some real barriers that potentially this
committee could address to including some of these functions on the road
map for certification. And I\'d like to recommend that we hear either
from Mark Leavitt or from the Chair of the Ambulatory Workgroup, because
they\'re all really some decisions that somebody needs to make about,
you know, what quality measures are going to finally be agreed upon and
widely used. But also on this problem that was just referenced about
will the EHR be submitting data to some data intermediary or not?
Because that has huge implications for the EHR. That\'s one
recommendation. Another is that the Karen and others at the AMA have
engaged in quite a number of experiments now involving a lot of
different EHR vendors. Many of these have actually been funded by ARC.
And I think it would be useful to hear from her team, you negotiation
maybe not the ins and outs of what made it so hard, but what kinds of
concrete action of the sort that this group recommends would help in
that process.

And a third recommendation is I think this group needs to understand the
current state of prompting, alerting and medication checking in the EHR
industry. It\'s at a very low state. And if we want to think about the
first goal is to have the practice improve, need the tools to do that
and then hopefully when they report it out, we\'re looking at
encouraging progress. I would recommend that maybe one of us from the
leap frog team report on briefly and in one of our meetings about what
we found about the sort of state of the practice.

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

Jane, having had a little \-- first of all, the points are excellent,
and to some extent when we hear from Dr. Eisenberg a little bit later
this afternoon, I think some of your issues may be at least recognized.

I take your point that this is sort of a critical fork in the road, as
Yogi Berra once said. Fortunately, I don\'t think we need to take one. I
think most people would probably prefer that the market decide that. On
the other hand, as we\'re teeing up options and recommendations, I think
we\'re going to have to be cognizant of the specific pathways that are
available. I mean, and to say more directly, I don\'t think we\'re going
to be saying to the community, you should adopt a recommends that says
everyone\'s got to be partnered to a regional health information
organization or health information exchange or you can go away. That is
not the only dynamic in play here in any case. I think there are
physician practices that would prefer to be able to hit because of some
perceived sense they\'re closer to the action. The others will be in a
place where it will be much easier to partner with an intermediary and
we haven\'t talked about the intermediary.

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

It\'s very easy to think about California. In California, partly because
of the pay for performance project, Phyllis, you should listen to this.
\[Laughter\]

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

I\'m sorry.

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

She\'s the one that\'s out there all the time.

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

What\'s going on in California is because of the IHA project and
probably also because of the Kaiser commitment now to an EHR, the
medical groups in California are investing in a massive scale in EHRs
and it seems that it\'s kind of going to be an Allscript and an Epicare
world out there and one of the groups said to me that, you know, these
are \-- they\'re kind of thinking of them as maybe private RHIOs how
they\'re going to relate to Cal RIO, is something that\'s being puzzled
over at the moment.

So I can\'t think of other markets where this kind of dynamic change is
happening on this scale. But it\'s an interesting point to consider, how
does a RHIO relate to something that has a lot of system capability? And
where there are other vendors.

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

In California you have the dynamic, I mean these are groups. Fairly
large groups for the most part. You have had 3 years of pay for
performance on performance results, administrative data.

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

Right.

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

And it has driven change.

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

That\'s correct.

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

And you also have people getting caught in the crosshairs between ones
that have data, doctors that have electronic health records and the
plans and charts.

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

No, in California you can be a self-reporter or choose to be a
self-reporter and report your own data at group level or take the
planned data and get whichever is better.

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

Carol?

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

Yes.

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

I\'m realizing we\'re having a fabulous conversation but also
recognizing that we have some terrific people to hear from.

Yes?

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

This is Jonathan, a quick comment on the certification. It seems like if
we do nothing else, we\'re hearing from many different people who have
different programs that have done things. It seems like our charge has a
lot to do with trying to unify. This if I was an EHR vendor, I think
I\'d be concerned saying well, I can make a report and a data model for
sending in this data. But whose data? Is it the bridge\'s data, the
Cal-RHIO, and so on. So perhaps one of our most useful functions can be
to try and get all these different players to have some sort of
agreement on where these measures come together. On having sort of a
common list from which everyone can choose, if full. Because I think
only then can the vendors probably feel confident in saying okay we can
go ahead and do this development.

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

I think that\'s important, Jonathan, and I mean I think Jane\'s point
about which measures, the really good news about where we are right now
is we\'ve actually got some starter sets. And I think I should also
remind us that most of our discussion pertains to ambulatory care right
now. We haven\'t even touched hospital care, which for the most part
actually lags behind in terms of EHR capability.

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

Carolyn, this is Reed. Could you be more explicit \-- just in terms of
the ground rules of the sums that is we are making. Isn\'t, I thought,
that a lot of what we are doing assumes, especially given the role of
Leavitt, and government throughout transparency initiative in terms of
CMS\'s relationship to the AQA, and the ambulatory care measures moving
beyond ambulatory as AQA is doing to specialty. Aren\'t those
essentially considered to be the core measures that we would be assuming
would be used?

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

There is a sum that we would be looking both at AQA and HQA measures.

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

Right.

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

And that that would be \-- now, none of which, by the way, of course,
are specified at this moment at a sufficient level of detail. But that
would be the starting point, yes.

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

Because I think that what\'s important, I think as I listened to my
colleagues on line, I think we\'re all sort of recognizing that there
needs to be \-- we cannot possibly solve for a quadratic equation of 18
different performance assessment and dueling initiatives. The AQA seems
to be \-- I mean, where this is moving and the AQA is moving forward. So
I was hoping that we would be more explicit about that assumption and if
that is not the assumption, I\'d just want to make sure we\'re clear
about that not being the assumption.

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

That is the assumption.

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

And Reed, my question wasn\'t so much about avoiding AQA. I think
that\'s the way to go. It\'s about getting different tools and systems
to comply with that in a common fashion, how you get them.

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

Thank you.

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

So where are we?

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

I can finish up real quickly. Because I think we\'ve really made the
points for both of these next two slides. This slide says that at the
health plan level the conversation is about how to get data transferred
from electronic health records that are in the provider\'s office, to
the health plans. Really an auditing data transmission issue. You know,
we\'re working through those issues right now at the health plan level.
But that\'s the conversation. Transferring data from the providers to
the health plan so they can use it for their HEDIS reporting.

The last slide, to make the point that was made, on the phone, that
NCQA, the AMA, and CMS actually have had a conversation with the vendors
and the vendors are looking for identifications of standardized measure
sets to incorporate in the products. And I think we were just
emphasizing again to date the focus of the measures and much of the
activity is really primary care-related and specialty conversation
versus just begun and that\'s a whole different animal. It\'s not just
one set of measures but what measures are appropriate for primary care
practitioners versus the various measures.

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

Yeah, and I think that in this Workgroup we\'re trying to steer a little
clear of getting into the issue of appropriate measures. But I think the
point is well taken and it underscores what I thought was the brilliance
of our earlier slide so I may call to you borrow. Where the data are
coming from multiple sources. Because ultimately for the stuff \-- the
part of medical care which really costs a lot and which is potentially
both high value or high waste. That\'s where it gets really, really
hard. Now, clearly we\'ve got to start from where we are and move
forward, but nonetheless we can\'t lose sight of that fact.

I mean, we could automate and do everything perfectly for immunizations
and that would actually be very, very important for public health. It
wouldn\'t touch the other domain.

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

So Carol, this is Reed again. I just want to again \-- so as we listen
to this very excellent presentation and the conversation, do we have a
growing sense of any consensus that you are hearing emerge? I\'m trying
to understand then as the data comes from physician offices to plans, we
also have simultaneously \-- on one level we have the CCHIT, and other
\-- this \-- this deliberate effort to try to provide a coherent set of
rules, or guidance around how electronic records will \-- what will be
built into the software so that there will be some consistency and we
don\'t have to jerry-rig 18 different solutions to this enormous
problem. So there\'s that reality that I think we have to deal with and
decide whether or not that is something that is fundamentally relevant
to our work. And secondly there are the data aggregation initiatives
that are part of the AQA activity. And the things the Secretary has been
calling for in terms of the pilots of data aggregation.

If the data aggregation activities are to organize a variety of data
from plans and from clinicians, organizing those together, how does that
activity relate to the presentation we just heard?

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

What I\'m thinking I\'m hearing are a couple of key points, Reed. First
of all, the delivery landscape is really, really complex. And I think
weak all heave a human sigh of relief we don\'t have to address that
issue, or celebrates its richness, however you prefer to look at it.

What we are here to do is identify the critical fundamental steps to
move forward to address the specific charge. And the purpose of today\'s
presentation was really to address the business case issue and to
actually illustrate just how embedded that is in many other issues, but
I thought we needed to be very responsive to that.

And secondly, to actually get us familiar and up to speed with some of
the complexities here on what people have been dealing with. So I
thought the presentation from Phyllis and Peggy was really, really,
terrific because I always knew you were mired in lots of these details,
but now I have like a fuller understanding.

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

I soar above them.

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

It\'s incredibly important stuff. I\'ve just had a request that I\'m
going to honor since I\'ve had to spend some time in airports. We\'re
going to just change the order of presentations, and move now to Floyd
Eisenberg, who I think is either about to get on a plane or something
like that.

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

I\'ll revisit my question after this presentation.

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

That would be perfect, Reed.

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

Thank you.

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

Dr. Eisenberg?

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

Yes, I thank you very much. I\'ve been uncharacteristically silent
although part was because I was on mute during the first part of the
call.

But many of the items and questions that came up related to EHRs and how
they can and would comply. I think I\'ve addressed in some of the slides
that are here, and I am presenting on behalf of the EHR Vendor
Association. As well as an employee of Siemens, this creates electronic
records for hospitals, et cetera.

So I\'d like to go to the second slide, if that\'s okay, to address the
areas I\'ll talk about. And one is the problem space and market demand
from this end point of a vendor, the standard reporting issues. Factors
for achieving quality and pay for performance. Parallel efforts. And
interoperability issues.

Just to explain where I\'ve been, I have practiced in mostly a private
practice, and individual practice association, HMO. I also worked for a
short time, 4 years, in a managed care plan, and am familiar very much
with the HEDIS efforts hybrid and otherwise. And I have been working in
the IT space now for eight and a half years.

So if we can go to the next slide, I\'ll start with the problem space
from the vendor\'s perspective. When we do talk to our customers,
traditionally what they have been looking for is efficiency of process
in making their processes work quicker. Until more recently, with
efforts like bridges for excellence, and pay for performance, there has
been less attention to asking vendors to provide function to get there.
And it\'s also been a major concern that if we provide so much what we
would call feature function, by providing pick lists for our clinicians
to put in what is necessary, so everything is efficiently coded. And we
avoid copying and forward, so that I know that all the items that I\'m
supposed to do are there and I can remove those that weren\'t there,
using the example of foot exam, if we leave that out, then there\'s
additional work on the practitioner side. I\'m not saying it\'s right to
automate defaults. I\'m just saying there are concerns with the ease of
use to clinicians.

And in fact as one example from my health plan days, when we were
working on implementing a clinical guideline, regarding HIV, which is
the way out of date because that was over eight years ago, but based on
existing guidelines and EHR AHRQ work, we created a form, like many had,
for our clinicians to use, our practitioners. And I was actually very
encouraged when one of our physicians called me and said she liked my
form and use it is all the time. Until she said to me, she uses it in a
slide presentation to explain how hard things can be if health plans
provide new forms for clinicians to fill out and it\'s mainly because we
don\'t have the data. So that was a very rude awakening when in fact the
whole process was to improve quality in a special HIV program.

Next slide. The next slide is really related to standardized methods for
reporting and mostly as we look \-- the effort currently is looking at
the ambulatory space, but if we also look at the inpatient space, we
have many of our customers telling us they need reporting and they want
help on quality reporting for magnet status, for nursing qualifications
and quality. And also for physician quality. And when we look over the
measures, many of them are very similar with slight changes. And every
difference in a measure makes it more complex to try to pull those
measures out, standardize data entry and standardize methodology. The
closer they can be, the easier it will be. The methodology of report
something also not necessarily standard. Also the issue of some
initiatives that require the clinicians to fill in a form to submit,
actually can be contradictory to early adopter efforts to try to report
electronically, when in fact they have to find a method to fill that
form electronically or manually create it. So that\'s where that bullet
came from.

Next slide. Some of the factors that raised concern that I think are
important to bullet here, and many of these issues came up, is that
performance measures do need to be independent of care setting. If
we\'re working in a hospital physician network, the \-- and there are
different physicians caring for the patient, whether or not it is a
health plan, it would be helpful from the patient\'s perspective if
there was independence of care setting, independence of practitioner
type that\'s addressing the nurse versus doctor versus other
practitioner measures. Coordinate willing terminologies. We \-- I\'m
currently one of the Co-chairs of the Biosurveillance HITSP Technical
Committee, and we constantly have comments about semantic
interoperability, which is not necessarily a near term effort for full
interoperability. We have addressed SNOMED and LOINC and other
terminologies. But full interoperability on the same SNOMED concept ID
for the same concept to be incorporated into measures is not there
today. And is a complex process, especially when data entry is off then
free text and has to somehow be adjudicated into the appropriate codes.
If not, we would end up with too many pick lists and nobody would use
the systems. We also see there are measures related to high impact
disease but there are also some that are less high impact, high cost
related, and we believe EHR perspective, that the greater impact is
important.

Let me go to the next slide. There are specific factors that will help
integrate these measures. And I think there was discussion about
guidelines and guidelines often have some very interesting elements
where there is a clinical decision required, which is very nice, and
there are also elements which are sometimes based on consensus not
totally on evidence. Trying to implement those and deal with metrics
around those and deal with capturing those metrics within existing EHR
in some way not intrusively so the clinical user doesn\'t have to worry
about the words they\'re using but that it\'s managed in the background,
and those terms are codified appropriately. The more atomic level say to
which SNOMED, which LOINC codes are applicable would be very helpful as
we \-- so we could bill to a more incremental build of semantic
interoperability to allow data entry and reuse of data. And
understanding denominator becomes another issue. It\'s clear when it\'s
a health plan who is a member, usually clear, from beginning of one year
to end of that year. It\'s not always easy and I know some of this is
addressed for the fire departments population but not always easy for
physicians or hospitals to know who their population is. And
clarification of that would be very helpful in these measures as well.
The concern I have as well and I\'ve heard this frequently in our
biosurveillance committee is we now know what it is we seed. It\'s up to
the vendor to provide an easy way and I\'ll address that issue of the
quick pick list so they\'re all codified and we know what it is up
front. It\'s the same issue that comes up if we provide too many
medication alerts, doctors stop listening, all nurses won\'t listen, if
we provide too cumbersome data entry, people just will not use the
system and they won\'t buy it. And so the more prescriptive that
certification is, the more complicated it will be for vendors to
actually differentiate themselves, where a better ease of use to get to
the same outcome will help. And also the ability to where some might
require pick lists, some might have a good standard way to use the data
secondarily, and map it to the appropriate codes, in a clarified format.
Allowing vendors to have that ability to differentiate is very important
because that\'s where innovation will come from.

So excessive prescription is not productive.

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

Well, Dr. Eisenberg, I will take your point about physician skills, but
\-- or learning curve might be a better way to say it. I don\'t think we
need to actually address that directly. And nor do I think worry
interested in being overly prescriptive. I hope I can assure you on that
front.

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

That\'s good. I do know in other settings, I\'ve heard that in many
committees, so just wanted to make that point.

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

Thank you. Next slide. And this, as far as adopting interoperability
standard for guidelines, again I\'m seeing \-- bringing semantic
interoperability terminology based standardization to again build
incrementally. I believe the reason we have not seen a lot of full
adoption of SNOMED LOINC, the return on investment is limited as we see
more pay for performance initiatives that require standard reporting. As
we build on more and more measures over time so that \-- that have these
terms, they can be reused. And it will build that way. Rather than
expecting all at once.

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

Dr. Eisenberg, this is Jerry Shea. I don\'t understand when you say
incremental terminology based standardization. Build semantic
interoperability in pay for performance. I don\'t get anything out of
that phrase. So just explain it to me.

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

Sure. We have had requests and many, many vendors have, do you deal with
SNOMED, is SNOMED incorporated in your system, is LOINC incorporated in
the system? And when it comes down to real operability of the system,
which components actually use SNOMED, and use LOINC. I\'m using those as
examples. And which local terms are mapped to them are fairly limited.
Because the return on investment for actually doing that mapping at each
site for the local terms they already have, they\'re not de novo sites
that were all on paper, and are now electronic. So the actual mapping is
a complex process. So if there are specific measures that identify
specific mappings, that can be done some this year, some next year, and
add on to those and maintain consistency, that would build on the
overall mapping. And build the return on investment for doing the effort
and the work effort. Does that help?

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

Dr. Eisenberg, could I try to simplify this a little bit.

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

Sure.

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

This derives from the fact that there\'s been an inconsistent demand
from reporting on performance. This would therefore create a business
case and demand from customers for you to do which parts of this are
necessary. Is that correct?

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

That\'s correct.

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

Okay. I mean, because you know, on some level we\'ve got to address all
the technical details, at the same time keeping the bigger picture in
mind. So thank you.

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

You want to continue?

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

Sure. The other was consistent with the HEDIS process, as testing
measures are developed and released for pay for performance continuing
the ability to test the measures \-- quality measures in real time for a
period of time, perhaps a year, to determine the effectiveness and help
local facilities and local EHRs to comply, would be very valuable. And
so advance notification so that compliance and local testing can be
performed.

Going back to a comment, I meant on the other slide which I had
forgotten, are comments came up early in this meeting that report
something but what we really want to do is improve performance. And in
order to determine how to get the measures and know what workflow
components are important to improve performance locally in each office,
is important. There are some standards but each office; each facility is
going to have different workflow issues. So to identify the key items to
help provide feedback as we\'re sending information to NCQA, to CMS,
that also provide feedback concerning workflow components that could be
improved every week, every month, depending upon the measure, rather
than waiting until your report is out and you\'re being compared, but
it\'s already 6 to 12 months into the next reporting period, and now you
have to fix it. That incremental internal reporting and embedded
measurement for improvement would be helped a lot by having these
measures in advance and also that capability should be something that
vendors have the ability to differentiate on and not be prescribed in
detail.

Go to the next slide. This was the comment concerning what would \--
came at the end of the NCQA presentation, and that is there is a
collaboration for performance measurement integration into EHR systems,
and this is basically repeat of the fact that there is such an effort,
there was a conference on June 22. There\'s a new meeting on November
17, there are now two workgroups set up to look at data capturing
internal reporting, extraction and external reporting. To help standards
like in the ambulatory set and hopefully in the future move toward
inpatient measure. And internal reporting as well.

And I believe these kinds of efforts are helpful. Concern is not to have
competing efforts in the industry but to collaborate between that effort
and the Workgroup.

I believe there\'s one more slide, which again is referring to the EHR
efforts and relate somewhat to some of the other AHIC efforts. There are
a lot of the HITSP efforts at this point which will be submitted to the
Office of National Coordinator at the end of this month, are related to
clinical data sharing among physicians with the EHR, between physicians
and patients for consumer empowerment. And collecting data for
biosurveillance. From the same mechanisms. What\'s very interesting in
that is that we\'re asking physician groups, and here\'s where you see
document sharing, dynamic information management, and transactions,
we\'re asking physicians groups to have capability for document share so
that information can be shared between doctors and with patients, and
we\'re also asking them to have information in their formats that can be
used for biosurveillance which is a form of secondary data use. I think
it\'s important that we be cognizant of the fact we\'re asking physician
offices, vendors, implementation and there\'s cost to development,
implementation and to each office, to manage all of these efforts, and
standardization of secondary use, whether for quality, biosurveillance,
or otherwise, should be based on the same document \-- or the same data
sharing that\'s required for the individual patient clinical care. Just
concern that comes up sometimes there where the document share is
wonderful, but there\'s not a clear mechanism for how to do aggregate
reporting out of that, or for instance what we identified in HITSP is
there\'s no published. And \[indiscernible\] mechanism yet. So there are
infrastructure capabilities that need to be developed to make this more
\-- and it also has to be a combined effort, not separate efforts.

So that\'s the overview for the vendor perspective of what the \-- what
our customers can see and the issues of trying to incorporate multiple
initiatives at the same time. Hopefully that helps as an overview?

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

Thank you very much, Dr. Eisenberg. Helen Darling has a question.

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

Thank you, Dr. Eisenberg. This may not be \-- I may not be asking the
right person, but a number of large employers now provide usually with a
vendor like WebMD, the capability for their employees to have access to
their own medical information. In some cases they\'re now able \-- the
health plans are able to download and Reed may be able to talk about
this, too, down load information including claims and even in some
instances lab results.

Now, if that\'s \-- is that just a great rarity, or is that some
indication that at least we\'re moving towards a world in which those
kinds of functionalities will be available? Because this is already
operational?

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

Actually, I think that\'s an excellent question and a very important.
We\'ve actually looked at the issue of employer provision of data. Very
often, what we hear is the employers can provide data but for
appropriate care and for employee privacy, it\'s best that that data be
coordinated with the providing clinicians. But we do see where \--
whether it\'s electronic through the Internet or an Intranet or whether
it\'s a smart card, to provide the information to be reused and there
are efforts like that in New York City and other places. For smart
cards, so patients will have their medication list.

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

I\'m sorry; I didn\'t mean to suggest that employers had. It\'s usually
through the WebMD, or some other portal like that. So the employer never
sees the data. It\'s to the employee or to dependents from the \-- in
some instances the health plan and in other instances it\'s through
WebMD or another portal like that. So it never gets to the employer. I
don\'t know any employer who would want that.

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

Well, actually on the business continuity side, there\'s certain
elements they might want but that\'s going to be complicated.

But I totally agree that needs to be incorporated and hopefully some of
the efforts that are going on between consumer empowerment and EHR, will
help with sharing that data, whatever the PHR that\'s being used.

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

Helen, this is Reed and you\'re right for the need for speed on this.
There are a number of players who are moving rapidly, I mean we already
have about 20-some million people who have access to that personal
health record here at united, and so I think the thesis behind your
point is that there really does need to be some quick organization of
coherence at this space as well if there\'s going to be any true
interoperability or transport of this data once it leaves the individual
health plans.

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

Great, thank you.

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

And when it comes down to medications, on med reconciliation, one of the
issues is terminology is different and the ambulatory space is often
NCPDP, and that\'s agreeing to a granular level you probably don\'t want
to deal with here.

On the inpatient level it\'s \-- so just being able to communicate is
not as simple as it sounds.

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

Thank you. I\'m sensitive to our time here together. So I think I\'d
like to keep moving on. I do have to do one little time check, though.
Dr. Diamond has a 5:00 appointment out in Rockville. So I\'m thinking it
might make sense for him to go next, then followed by Christine Anderson
and Terry Colin. Terry, are you on the phone?

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

Yes.

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

Okay. I prefer to think of this as us saving the best for last, of
course. But apologies, if in any way this interferes with your schedule.
I think these conversations are richer and more detailed than we had
anticipated. But frankly, they\'re very reflective of our sort of
internal staff discussions about how do we move this forward, what are
the most important issues as well. So I think they\'ve been incredibly
important. With that, I\'m going to turn to Lou Diamond.

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

Thank you and I appreciate the switch. Hopefully, traffic will allow me
to get back to Rockville in time.

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

There\'s a slight problem with Mr. Diamond\'s presentation slides so he
can get going and we\'ll try to pull them up in the meantime. There\'s a
technical error on the back end and we\'re attempting to fix it.

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

Thank you. I will talk about two kinds of infrastructure issues.

\[Captioner break\]

Do they support the various quality measures that are needed? And I\'ve
shared with you two mapping exercises here. We\'ve taken some of the
diseases that currently have quality measures associated with them and
mapped them against the various, in this case lab results so that we
could get a sense of what kinds of lab results do we need that\'s psycho
clinical data to support the diseases with measures, you can then dig
deeper and actually have each measure specified in the mapping exercise
and identify what the data element are for those particular quality
measures.

So it seems to me that the bottom line is that to move this process
forward, and I think it piggybacks a little bit on the presentation
immediately, how \-- immediately preceding this. How do we identify the
priority areas that we need to pursue to identify the data elements and
identify the coding that is needed to facilitate the input \[audio
interruption\]

Going through these recurring mapping exercises, is going to be key
going forward. My final slide has to do with \-- before I get into the
summary \-- what are the criteria, overarching criteria we should be
thinking about? We need to obviously understand the uses of the data,
and I\'ve shared with you some of the uses, even though \-- we need to
know what the data is. And what they\'re getting at is clearly in the
hospital, we usually know where the lab data is. It\'s in Building 9,
Room \-- and so on and so on. In the outpatient setting we often don\'t
know where the lab data actually resides and also issues about how do we
access this because it\'s kind of capturing data from multiple sources.
We need to know whether the data elements have been clearly defined and
classified and whether they are or are not code-able. We need to know
whether the collection is effective from a cost point of view. And we
need to clearly understand what the value of the measures is.

Final couple of slides to kind of provide approach to slide 13, I guess
it is. To \-- so how do we \-- one strategy called administrative data
with clinical data. The one approach is to do what is described \--
displayed in PowerPoint 13, is to begin after going through a mapping
exercises, name what the quality measures are, what the data elements
are and all the dimensions that I\'ve mentioned. Sequentially access
that data, and put it into a format that can be used to construct the
measures or construct the kind of reports. And you can see there are
various ways of doing that. You can capture the data? \[indiscernible\]
you can do stuff in the hospital setting by attaching various kinds of
additional data elements at the time of admission and rather than at the
time of discharge. You can use ICD 5 and expand the CPT coding system.
And there\'s a lot of value and in a lot of the new code systems
including IC10.

And clearly the parallel and alternative approach in displayed in
PowerPoint 14, speaks to the direct access and to clinical data from the
EMR and personal health record and constructs the registries that the
NCQA folks discussed earlier. The data connection tools in the physician
office.

It\'s clear that the \-- that the electronic health record is electronic
medical record per se, are not enhance data collection to support
quality measures. It has to be in such a way that data elements are
captured at the front end and as you well know in the U.K., I believe
all of the PCPs had electronic medical records to support their new
3-year program of pay for performance and reporting but none of those
from what I understand from reports, was able to support the measurement
system. Or very few of them. Also put in place systems to collect. And
the going forward strategy displayed on PowerPoint 15 is to identify the
data element we need and do this through a systemic approach of
definitions whether it is or isn\'t code-able and goes through the
various mapping exercises. Short-term, it would be prudent for us to
improve something called claims data, and its accessibility and merging
across plans, and Medicare and Medicaid, and add clinical data, and
clearly we\'re going to have to explore further as we discussed earlier
today, how the electronic medical record can explicitly support quality
measurements.

So thank you for your team.

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

Thank you very much, Dr. Diamond. I want to just hit on one point, which
is incredibly basic except I hear people getting confused about it in
meetings. Your first appendix chart you showed us where you talked about
the distinction between information collected manually that can be
transmitted or converted into electronic form is really crucial, because
I hear lots of people say no, we submit the data electronically. They
sure do. That\'s after the nurse has gone through a huge pile of charts
and entered it into some sort of software program and created the right
file. So I think that that\'s a very important distinction as we think
about this moving forward.

I think the other 90 your presentation implicitly brings up, which is
very, very important; there is no single pathway and in any world we\'re
going to need both clinical and administrative data. Because a free
floating hemoglobin A1C, or pick your test result, isn\'t that
meaningful if you don\'t have a date and time on it. And that\'s even
more important for acute care.

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

I agree. If we in addition are going to be measuring efficiency, you
need more than the data \-- the discrete element that support a quality
measurement \'system.

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

Right.

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

So all the negative comments about so-called claims data, we need to
figure out how do we \-- we can improve the claims data for multiple
purposes.

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

Questions from members of the Workgroup?

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

The last point is so important, when you think about the projection that
the health industry will be twice what it is today just in a few years,
and the size of the government sector alone will be the size of the
current health industry. And if we don\'t have opportunity through a
claims system or however we do it, to efficiently deliver information,
and to do it in systems that people know if they\'re going to either get
paid or how people are going to be paying attention, they\'ll be
counting, so when times get tough, it is going to be harder to eliminate
certain systems than others, which \-- so we have to think about the
future, not just the present.

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

So that gives a lot to have billing data. Le me just tell you.
\[Laughter\]

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

Other comments or questions before we move on? Let me move on with a
quick comment. If any of you are hearing traffic in the background,
that\'s because we have the windows open. We have our choice of going
deaf or suffocating at the moment we\'re choosing hearing dysfunction.
If it becomes unbearable for those on the phone, let me know.

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

Is it code-able? \[Laughter\]

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

We\'re looking for the right ICD code.

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

That\'s the next PowerPoint presentation, or maybe there are two of them
on that, I\'m not sure.

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

Christine Martin Anderson.

**[\>\> Christine Martin Anderson:]{.underline}**

Okay, I think some of you have heard me talk about this topic but I\'ll
give you the expanded version. That doesn\'t mean in time.

\[Laughter\]

Because you can only deliver what people can absorb so I\'m going to
assume you can absorb a lot.

This presentation is a result really of some learning over four separate
efforts. One was an effort that David Brailer and I embarked on in 1995
or so to try to create an episode-based claims system-based clinical
decision support system to try to rate physicians. So we use claims
data, ground into episodes to find treatment failures, et cetera, and
ran into a lot of problems with claims data and just concluded that was
just a road we couldn\'t go down.

And then started to do clinical support with hybrid data because we use
everything electronic and add in lab results and everything and how far
would this take quality improvement efforts and still sell short? The
third effort was around trying to think about a \-- that product was
successful but the effort fell short. It was trying to define a \--
design system to impact quality at the point of care. And the appendix
that I have here is related to some steps we\'re taking \-- this is
after David was no longer working with me but we were trying to say
let\'s figure out if we can find the data. And then I think about it
point of care and quality reporting. We look two separate places. And
the fourth was rationalizing charge masters which had resource level
data across a hundred different health systems. Using \[indiscernible\]
the unified medical language system from national library of medicine to
try to figure out if we could do process level benchmarking, and that
was successful, but painful. In fact nobody would pay for it every time
we had to go through it because it was so painful. Charge master is so
specific.

This effort I\'m going to talk to you more, is then in the midst of all
that we had the core measures, being launched in the same time line, and
looked at looking at organization that is were doing less quality
improvement and more quality reporting, because they were doing more
charge instruction with their quality improvement nurses. And so tried
to go \-- worked with at least one organization and expanded to others,
around how \-- if we go to slide 2, I think that\'s the best place to
start. How was it that electronic health records could help get us out
of this problem? Because we read the draft inpatient rule and it said
things like we can expand measurement because we\'ll automatic them with
health records and we\'re trying to understand that. And found that the
numerator was fairly easy. The next slide.

It was it seemed doable to know who got for instance the data blocker.
And certainly there were systems between standing orders and e-mark
systems, and electronic medication reconciliation, and administrative
and reconciliation efforts. To get to the numerator. But the part that
was really hard was the denominator, to find which patients were
supposed to receive the particular therapy and which were not.

If you go to the next slide on contra indications, it was really the
biggest challenge. If a patient had allergies, couldn\'t have a beta
blocker. And medical record data sources were enormous. Because there is
no standard station around where you write something. Let alone where or
how much you write about it. It became really difficult to think about
those problems. So we embarked on an exercise which he gave you in the
handout as a separate handout. With one organization that was willing to
go through a very painful process, a multihospital health system, and
they figured they would already invested over \$100 million in their EHR
& understood from their EHR vendor that it did quality reporting and
actually saw some demos of that. So they wanted to really understand how
does it really map out in the end. So we took this process with their
nurses, the 100 people implementing the EMR, and they had a lot of staff
to peel off for. This they had the vendor, CMR vendor, and then some
people on a consulting team that I was managing, and we looked to see,
if we went data element by data element through the joint commission and
CMS, specification guide, how could we mind that their implementation, I
think what\'s really critical about this, their implementation. So this
\-- my slide deck isn\'t about that but the handout is about their
implementation. Because the commercial electronic medical records are
extremely customizable. There\'s nothing that tells you where you have
to put something. Or in many cases what format you have to store it in.
And so what we did was we took all the data elements and the summaries
on the first page. We found 60 percent of the data elements that we
looked at could be automated. They weren\'t currently but they could
have been if the implementation was done right because we\'re doing this
upstream. But if you look at the list of what they are, they\'re pretty
obvious. Some of them come from the financial system, right, admission
date, birth date, ICD9 codes, discharge status, et cetera. The others
are extremely specific. You know, get them from allergy lists which
aren\'t uncomplicated but could be done. Then there were another 17 ½
that they could partially automate. And partially automate meant they
could get some signal which record to pull. It doesn\'t mean they knew
for sure.

If you look at that list which I think starts on page 6, you\'ll see the
first eight \-- it becomes really important what did you know on
admission or around admission, or what happened prior to arrival, or
what happened \-- you know, before you were admitted or what happened in
the last 3 months or things that just were not well suited to the way
that their EMR was designed to try to look \-- and then others that are
about they could know there was a blood pressure date and time but they
had a hard time relating that specifically back to when other events
occurred and a particular result. And then they had a list, another I
think it was 22 percent that they could not automate at all and started
on page 10, largely due to the order they were implementing or
\[indiscernible\] wherein and of themselves very customizable text based
systems that they didn\'t have a good idea even for when they were going
to implement them, how they could actually make it occur. So that\'s why
I included the comments columns, because you get some sense, if you look
at the second one, about how complicated it gets. Only use this data if
this is \-- and really much farther beyond what their data system could
use. After that experience, \[indiscernible\] and some of my colleagues
started interviewing other health systems people, I wanted to know is
this is a pretty advanced organization, but they had one vendor, so what
about the other vendors. And so what about the VA, sort of we want down
the list and talked to a lot of folks, and found that everyone sort of
had the same resounding story, which was that we as an industry have
demanded so much in terms of flexibility and customization that we\'ve
designed ourselves right out of any kind of system and \--

\[train going by\]

part of the decision is there\'s a huge amount of culture involved here.
We have worked \-- we can have standard order sets but God forbid you
mandate them. You have to be able to skip them in some way. And you can
have alerts but you have to be able to bypass them. Not to say those are
bad choices but they represent the way we deliver medicine today and not
thinking about how do we redesign the system and it\'s about the current
system. The health systems that we talked to, of the ones that really
understood the issue, and I\'d say about \-- I\'d say about a third of
people didn\'t know what we were talking about. They thought it was
going to happen when they bought the EHR. Automatically. About a third
was really trying not to think about it because they wanted to get
through their CPOE implementation. And then the last third assumes it
will be all things when it comes to systems, really understood they had
a big problem, they weren\'t sure how to solve it or how to send \-- not
only the vendors the right message but the medical staff the message and
there were enlightened leaders. The rest of this presentation really
represents that larger group of people. That we\'re interviewing. Saying
what the problems are, what are some possible solutions. And I think
there were two critical \-- slide 4, the next slide, talks about the
documentation issue we talked about that we really need to think about
what we need out of clinical documentation. But it need to be structured
in a different way but we also then have some challenges around culture
and we also need to think about standardize the nomenclature in a much
better way than we have and I\'m not suggesting we should be
prescriptive about how that happens but definitely at least agreeing on
a nomenclature would be immensely useful so it\'s not vendor dependent
and/or organization dependent. On the next slide, I think we need to
think about this issue of data exchange because the linkage is a problem
for not only measurement but care.

What you know when someone presents in the emergency room about what
happened, is really important. And I think it gets less focus in the
inpatient environment because we\'re not as worried about accidentally
tripping into OEs because these are if you can\'t find the EKG, you just
do another one. No one is worried about overuse as if you hold
physicians accountable for the same outpatient record. It doesn\'t get a
lot of attention, but it\'s still critical. It comes up a lot in the
time-based measures. Things you need to do within a certain number of
hours or minutes from arrival. And if you just have that information you
could be timelier rather than repeating a test. That\'s where the
sensitization comes.

Slide 6, this is meant to say doesn\'t mean we have to showdown
electronic health record. It is a quality because it is a secondary use
because the same changes will help clinical decision support. We need to
keep drawing the bridges. You know, across the line and being clear on
what we want. In slide 7, talks about some of the issues again, the
quality specifications in general are insufficient for IT coding. That
doesn\'t mean you can\'t write an algorithm around them and pull data
out and advise them. It\'s just that in general, if you wanted to build
them into the system itself, for the data capture, a lot of these
measures, I mean these data elements we\'re calling are actually more
than one data element in and of themselves. If you\'re saying for
instance there\'s one \-- easy to see, if you look at the third list or
even the second list or if it says prior hospitalization within 14 days,
that\'s not really a data element. I mean, it\'s a data element for
purposes of an algorithm but not in the EMR. That\'s the result of a
algorithm. Of some sort. And so I think I talked about a lot of these
other components. And one thing that I\'ve been struggling with a lot in
this area is how much should we want from our EHRs? Should we just want
them to capture the data or should we want to press F7? Because there\'s
issues here around competing for performance time, if you\'re trying to
do something population-based versus something for care. There are
issues around whether or not the competency really is likely to exist in
certain organizations about the coding the algorithm for the performance
measures and you want to make sure they get the data in a structured
format and out. But we don\'t really need to prescribe whether they or
someone else runs the algorithms on that data. Because the algorithms
change so frequently, as we know, evidence changes so frequently, that
we have challenges around whether it\'s going to make sense to try to
keep forcing to the top of their development agenda to change the
algorithm again. And how many releases you can have. And then someone, a
very astute chief medical officer said to me I\'m really worried if I
change my standing order sets so often, but I\'ll induce errors because
things that used to be four lines down are an inch down and now two
inches because I keep changing that form, and we need to think about how
much the dynamism of quality measurement and evidence and clinical
decision support might actually bring new kind of errors into the system
and we need to be thoughtful to that. I don\'t have the answer to the
question but it seems to me it\'s something that\'s worked pondering and
figuring out. At least let\'s get the data in and out.

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

I don\'t think we want to prescribe that.

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

Right.

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

That\'s a very important open question. This has lots of small political
associations I might add. In terms of who is controlling.

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

Right.

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

The aggregation of data.

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

Then one other comment about this table that I \-- it came out of this
Excel spreadsheet with the measures across the top and the Xs that tell
where \-- and I want to emphasize it\'s an organization, one commercial
product. So it is not \--

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

It\'s just a direction. But it\'s also something that I think that any
\-- I have the permission of the organization, anyone can use it as a
starting point. If anyone wants a copy of the master, it\'s okay to use
it. It\'s not definitive. Of another organization could look and say I
could automate that or can\'t automate another one. The automation, 60
percent of the data element could be automated only allow them to
automate at the end for quality measures because of the
interdependencies across the data elements. So the net result with this
particular customer they stopped and said we really need to rethink how
we\'re approaching documentation because that\'s not acceptable. We need
to figure how to go forward.

My understanding is they\'re restarting next month. But with eyes open.
Better than eyes closed.

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

Exactly.

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

I thought that was very helpful because particularly because it links
the two issues we want to keep front and square related to the specific
charge. It\'s both of those what has become known as the F7 but also
about clinical decision support about how do we use electronic
information to enhance improvement care. At the end of the day, all of
this has to be about documenting how badly we\'re doing. Actually has to
help us get to a better placed or misplaced set of energies. Questions
or comments from the Workgroup? Peggy?

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

One question is how much should we be going into that area to try to
look under the hood and make sure it\'s working well under the hood and
how much should we be trying to design an accountability system that\'s
going to drive this kind of change? Because as you heard from this great
presentation, there's a whole world of hurt out there. I mean, if we
design the right kind of accountability system, I would hope the market
would work towards solutions. Realizing how complex that is. But I just
worry that us trying to design something both that works at the delivery
system level and the accountability level.

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

If we design the right kind of measurement, having been sobered by these
realities, then I think people will row engineer their practices,
reengineer the kind of standardization of what goes into the medical
records. The things that will then lead to better performance. If we
embed ourselves in that problem set, I\'m afraid we get completely
overwhelmed by the complexity of it. And never really get anywhere.
That\'s the question for me. How far do we want to kind of stand on the
outside and say this is what we want you to be accountable for?

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

It seems to me, and I\'m just trying to because it may be something
we\'ll have to discuss more before we are prepared to bring a specific
recommendation forward. It does seem in another workgroup I\'ve
participated in adopting electronic health records, continually run up
against this diffusion spectrum challenge, right? You don\'t want to do
anything to slow momentum for folks who are on the leading edge. And
want to take these problems with their eyes open. At the same time
recognizing that a minimalist solution, significantly advance us from
where we are now. This would lower the risk of investing in electronic
health records and so forth. I don\'t think we want to get into areas
wherein theory the market \-- I know the Secretary doesn\'t want the
community making decisions. It would be up to the market even when he
has a fairly rare in his own mind about what might be a preferred
strategy. How to walk that line I think is something we\'re going to
have to struggle with a little bit.

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

And I wonder if you have a point of view on this.

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

One thing I learned in this process, it\'s too big for \[indiscernible\]
to track he will on their own and too much specialized knowledge. I
think they had the right kind of people together but the second is,
it\'s hard for a vendor to tackle. I don\'t think they \-- 100 percent
got it until the very end what we were trying to get at. And get over
the defensive posture. And we intend to some day eclipse the quality
industry and don\'t want to tell you too much now. There\'s
competitiveness and forcing them and also getting them to work together
but sometimes collaboration is better than competition, and you can \--
there\'s a lot of competing to do on workflow, right in let\'s not
compete on standard.

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

Right.

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

My viewpoint is if you can take people down a path of knowledge without
prescribing how they solve it and for instance, don\'t have to solve for
the health care organization, each health care organization how to
handle their physician implementation issue but it does help for those
who want to tackle, here\'s an option of a way that might work.

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

This is Jane Metzger. Along those same lines, and without getting into
exactly prescribing solutions, it seems to me that certification needs
to ensure that organizations have the basic IT tools they need to
improve on the front end, and report on the back end. And this is now a
mechanism that is in place and subject to direct guidance from the AHIC.
So it seems to me that even following this philosophy of we\'re not
going to prescribe the exact solution, we have a responsibility to think
through where certification can make a real contribution here. As I said
both on the front end and back end. And it seems to me, if we stick with
just this issue of accountability, which I agree is a huge one, we\'re
really leaving a lot on the table that needs to be said.

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

Yeah, I mean I don\'t have a fixed point of view on that. I think I was
just kind of appalled to hear of the complexity of what\'s going on even
with advanced delivery system. You know. And so the question is, how do
we not get ourselves completely tied in not here. But I think what you
said was useful is I think your formulation was very helpful, Jane, and
crystallizing where our focus needs to be in the short-term. Recognizing
that we can\'t \-- that ultimately we have to embrace a whole array of
challenges.

I, for one, am a little uncomfortable focusing only on accountability
mainly because what I see it\'s doing to hospitals, from what I can tell
it is taking the energy and resources into reporting on the report card.
And now they\'ve got a pretty strong \-- or they perceive it as a pretty
strong incentive to comply with every aspect of it. I\'m not
recommendation they don\'t. But what I\'m saying, given fixed resources
today, that is going to drive their whole agenda and it\'s completely I
think upending internal efforts to think about \[indiscernible\].

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

It\'s Nancy Foster, if I could get in.

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

Yes.

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

First of all, I thank you for the comment you\'ve just made. It is in
fact an issue of great concern to many hospitals and health care
systems, how do we get beyond just collecting data and making reports?
But I also wanted to comment on Christine\'s report to us. I thank you
so much, Christine, for highlighting the fact that we really need to be
thinking not in terms of how do we collect quality measures as they
exist today, but how do we collect the data elements that are going to
allow us to build to the quality measure as it exists today and as it
will exist 6 months from now, which is going to be different than the
way it looks today. And that is very different take on what we\'ve been
talking about, and it speaks to something that Janet Corrigan had talked
about before, which is this need to get from standardization in how we
define the elements of the measures, so that we can build the
standardization and the data collection. It\'s a very complicated issue,
but something we can\'t forget.

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

Did you want to get in?

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

I wanted to just echo Nancy\'s comment because it seems to me a focus
could be legitimately \-- probably quality measures that
\[indiscernible\] have. Of the standards data elements. AQA has
articulated both some standards for the aggregation, and it seems if we
do that, the right direction and we don\'t have to get down to what the
details are. We are providing standards based system. But in this case
focused on quality metrics, focused on any number of priorities that we
need to drive the standards. Data elements are different, for the
quality metrics. That\'s one of the projects we need to explore. And I
think your presentation highlights that.

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

Can I follow on that?

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

Yes.

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

One of the questions that came up in my mind, and I would start by
agreeing with Lou, tends to be important in Nancy\'s comment about the
standardization. But one of the questions in my mind is there anything
in the experience to date which would advise that standardization
process? Because in my experience, in a variety of settings, there\'s no
explicit consideration of what does this mean when we get into the
electronic format. There\'s so much effort and such desperate need to
standardize metrics, and the question I put maybe Christine you\'re the
best to answer this, from what you\'ve seen, are the things that are not
being thought of in the standardization process or the measure the
development process now that get to be thought of before we go too much
further along, what would enable electronic translation into electronic
format?

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

I\'m a little nervous to suggest it sometimes because we\'re going maybe
farther a field from the data can support. But I think the \-- and I
know the joint commission paid a lot of attention to this. But back and
forth between what is needed from that evidence perspective in order for
a measure to be credible and accepted by providers, and what is feasible
from a data perspective, so that you\'re not feasible from a data
perspective so you\'re not forcing back into the charts. Weighing those
two in the balance, in the measured development process, I think at the
beginning stages of public reporting we\'ve weighed it entirely toward
let\'s make sure it\'s so scientifically valid and a provider can get
behind it and there\'s no way to poke a hole in this algorithm, without
yet the sensitivity to, because lack of knowledge, around what would
ever be automatable? And so that only becomes an issue of escalating
effort. Then you start to realize that maybe \-- what\'s the impact of
removing data elements. It seems too critical in the evidence, but if it
wasn\'t there, what would it have done to reliability of the measure?

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

We\'ve looked a little bit at that and I think you have it right. You
can standardize the measure, the numerator and denominator but unless
you have a data dictionary, you can get the same measure could be
corrected and looked 12 different ways. So that\'s a data element
there\'s still a lot of work to be done. From a joint \-- we
\[indiscernible\] those silos. There\'s your silo, AQA, others. If we
could come up with a way to look across the data elements that people
are using to different measurement projects, and come up with some \--
as much as we can, some standards to the data elements, a long way to
helping vendors decide what to embed in the electronic health records
that could be used for multiple purposes. I think that work still needs
to be done.

But you have to get down to the very granular level, the data element.
And I \-- he also agree with what you said, Christine, a lot things in
this are not really data elements. They\'re a composite of a number of
data elements. But there are still a lot of people use different
definitions for some of the most basic things you wouldn\'t think there
would be a lot of controversy over or only lock at it one way.

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

So I hear harmonization of measures. And I think we ought to always
think of harmonization of data first. And then this issue of electronic
\-- I love \-- based on electronic versus clinical because people often
think of a diagnosis as clinical information and it only really exists
many times because of billing. And we call it diagnostic code. People
call that sometimes clinical but it would fall in the administrative
column and then we say what the parallel to that is. And in an
electronic health record. A problem? Is it a problem \-- and off he
times they link it into their financial system to pull the ICB9 codes
back in, which is required \-- they\'re not available real time in most
organizations. So you can\'t do real time physician support with them.
Some are doing concurrent coding and that\'s the right way to go. But or
finding another answer \-- the other the admitting diagnosis. And four
hours of arrival for pneumonia. So that starts on arrival, not on when
you realize it was pneumonia. So we wonder why these numbers are so low.
There are a lot of issues. I\'m not saying that\'s not wrong. People
don\'t always know it\'s pneumonia in the first four hours. True
confession.

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

They give the antibiotic anyway.

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

Right. Then we\'ll have the other measure, got overuse of antibiotics.

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

So I\'m looking at Kelly about a time check here. So by the clock here,
it\'s about 4:32. I definitely need to be out of here by about 5:05.
We\'ve teed up a whole array of issues, and I know that we still have
some outstanding questions left. And we have Terry\'s presentation.
Terry, how long do you think you might take, and I ask this in the
spirit of we would like to give full justice to your presentation and
the question is do we defer it for the next Workgroup meeting, or tell
me what you think.

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

I can probably do it in ten minutes but not shorter.

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

Okay, go.

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

I\'m Terry Cullen, a physician, but I\'m the CIO for Indian Service. The
next slide talks about what we are, which is an agency that provides
care to 1.6 million people, in 600 health care facilities in 36 States.
Next slide. And what we have is health IT system that we\'ve had for 25
years, called our mass resource and management system. We call it really
powerful at measuring stuff.

Next slide. What you\'re going to see on next slide is the reason why we
can do electronic quality reporting. If you look here and you look at
the middle, the PCC patient database is basically functions as a health
data repository, it wasn\'t designed that way but it\'s working that
way. Next slide.

So what we do with that database is we measure performance and I\'m here
to tell that you this has been a six-year process. We started in 2001,
electronic measuring only doing electronic reporting. There were lots of
business process changes that had to occur. But it\'s 6 years later and
we\'re pretty successful. What we use to do that is a clinical reporting
system called CRS. This allows for local, regional, national tracking on
the fly, clinical data, quality reporting. There are 350 clinical
quality measures; the vast majority of sites only use 30. The reason
there\'s so many I\'m going to show you later, a desire to drive in
consistent logic. We obviously believe we saved a lot of money. We no
longer do any chart reviews other than when we\'re releasing the
software to verify it when we first started this we did 20,000 chart
reviews to make sure that we were accurate. And what you see on there is
just a little screen shot of the GUI. The one thing you can see, within
what we have to report to Congress, we do a HEDIS equivalent, an elder
care report, a CMS performance report. The one thing I want you to know,
though, is that what we have learned on the back end is that if you
don\'t pay attention to certain things, you can really deal with a
metadata registry, you need a logic model, you need an appropriate data
architecture so that you don\'t have the impact on performance people
talked -- we can run a report on 100,000 people in a local database in
20 minutes have everything else run what they\'re doing. We\'re not
seeing impact on performance right now because of the advances in
technology.

The problem, I totally agree with whoever said this, the definition of
what\'s in the denominator is huge, and usually your numerators are easy
to design. It\'s everybody saying they\'re not in my denominator,
they\'re in yours. It\'s a major focus on us to really ensure there\'s
program logic.

This is run at those 600 sites, there\'s an aggregate report developed
that can be used locally, exported, can export into excel, into fast of
the there\'s a macro in excel. Lets it autograph it. If they don\'t know
how to use excel and we update the logic twice a year. One thing 2005,
2006, codes that may have been terminated. In 2006, but we\'re still
active in 2005. Still need to be included because you\'re getting your
baseline there. So the updates in our software logic incorporate the
knowledge even if they\'re retired may not have been retired 5 years
ago. Next slide. And the next slide shows you what we look at, we do
really push for standardization and what you\'re going to see here is
that what we\'ve done is standardize things that aren\'t currently
standardized. Patient education codes sets are not standardized. Health
factor code sets. You can screen for tobacco use or not but there\'s
many gradations in tobacco and alcohol use. We\'ve developed
standardized code sets that are semantically interoperable within our
system to enable us to be able to retrieve that data in a consistent
manner. Those are developed released and locked at a national level.
However, to accommodate this whole issue of local, but I call my lab
Terry\'s lab, even though it\'s an LDL, but I picked a name 4 years ago
and I still want to use, it we also put another filter in there which
allows us to \-- a local site to populate a local taxonomy. So for
instance, what you\'ll see is a hemoglobin A1c taxonomy will have the
standard LOINC codes but may also have Terry\'s hemoglobin A1c because
that\'s what I always called it in my lab. That\'s the way we adapt to
what the local needs are.

Next slide.

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

A question. Who populates those local taxonomies?

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

They\'re populated by the \-- we give guidance to the local sites of how
to do it, but it\'s done locally.

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

Okay, okay. This is a list of the CR measure topics. We also submitted
on the Web site a list of or performance measures and CRS fact sheets.
The performance measure list has all the requirements and the definition
of our numerator and denominator but these are examples. One important
thing is we\'re really pushing into comprehensive care measures, so we
now have a diabetes, a CBD1 and elder care, with the recognition we
really want to get into intermediate outcome measures.

The next slide is an example just a really brief graphic of the CRS
logic looks like and what you\'ll see here is attention to what is the
denominator, how do you define diabetic and I\'ll tell you, this is a
very refined definition that we use internally based on that 16,000
chart reviews of who really was a diabetic and who really was a medical
home for us. Unlike managed care, once you\'re an Indian in our system,
you\'re always our patient. What we really wanted to do was not harm
physicians because we got a ton of feedback, I only saw them once how
can you think of I did everything. This was developed.

The next slide is a copy of a sample report and what you\'ll see is the
\-- this is what we give to the providers that enables them to see what
we\'re looking at, so poor glycemic control. A1C documented, and then it
tells you exactly what occurring, so you don\'t have to reference the
book that has it all in it. The next slide is a brief sample report that
shows you that we give you the base period, the previous year and the
current report period and we give them a percentage change from the
base. Or percentages change from the previous year. And that\'s really
to make sure that we are tracking improvement over time.

The next slide, briefly shows you that the users who are defined at the
local site, anybody can get what we call the key to this application,
you can run patient lists, you can do all this cool stuff, you can use
it for case management, you can use it to know who is screening, clearly
we use it at a national level so say are we providing adequate and
quality care to our parents the but at the local level you can parse and
dice the data set however you want, by patient, provider, population,
community, by age, or by gender.

Next slide. And the next slide gives you a sample patient list. What the
patient lists tell you how the provider \-- how the patient met the
measure, and I\'m not going to go into this but you can see the little
definitions UP, AC, and then the numerator, how do you happen end up in
the denominator for this measure and what did we hit electronically in
the numerator that made you meet that measure. Because it may have been
a procedure code, it may have been a V-code, a ICD code, lab code, and
we want to be able to show the provider what that is.

The next slide is really the last one, and I just bring this up because
we know the whole concept what have data is granular and what is
management and interoperability. Our patients have a very high \-- many
behavioral health issues, we need to pay attention to them. You guys
that are familiar where the behavioral health data sets are not very
standardized at this point. So these are both examples of screening for
domestic violence much there\'s no code for that. We developed an
internal code and taught people on it. Same for alcohol screening and
women of child bearing age. And this is just an example of the impact of
those on there. The one they think I forgot to mention even though it\'s
in one of the slides is the logic that we use to do the quality measure
is the same logic that prompts the health maintenance reminder for the
patient. So there\'s not a disconnect, and that\'s done through a
knowledge management coupler that is geared to give the most
conservative recommendation so if you\'re diabetic and have coronary
vascular disease and you have conflict conflicting blood pressure
recommendations, you\'re going it get the most conservative one show up.
So you may make it in the diabetic measure and it may not make it the
CVD measure but the only remained certificate CVD, because that\'s more
conservative than the diabetic one.

And the one other thing is we do try to stay abreast what is going on
with data field. Injection fraction, never used to be in anybody\'s data
set, and we entered it in our system about two years ago at the data
field.

The opportunity that I think the federal sector brings to the private
sector, isn\'t that anybody is going to use RPMS, or use this
application but that our requirements are SRS, and our system design
documents are STDs from a technical perspective are fairly robust and
granular at this point and available for anybody to use.

With that, I\'ll close. Thanks.

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

That was astoundingly efficient. And for those of you who have not had
an opportunity to hear about the work that Terry and her colleagues are
doing, it\'s a big risk here is profound underestimate made on the care
of American Indians. So thank you very, very much for that.

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

This is Rick Stephens. As a Native American, I think probably we need
more MDs who are CIOs.

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

If we could replicate Terry Cullen, I think many of us would have tried
to do that already.

Thank you very much for that presentation.

So in our remaining minutes, I just wanted to summarize some key themes
we heard as we go to next steps. And Reed, are you still on the line?
He\'s not, so we may need to follow back with him. He had a question
about where some of this work fit with the AQA data \--

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

I was on mute, I apologize.

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

Oh, you\'re back.

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

I know you\'re rushing for time and but yes, the question I was simply
trying to make sure that at this understood was how it is that we\'re
going to use the building blocks that are currently available to us as a
template to advance the work of this committee and those templates
we\'ve talked about being \-- building blocks being QA data aggregation
initiatives and are we sort of trying to explicitly put those as folders
that we then leap our work off of?

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

No \-- yes, we are going to try to build that work. So let me state
where I think we are at the moment. I think that some of you may be
exhausted by the granular detail. Let me just assure you this is only a
small sample of it. But the point is not to immersion you in all of
this, but a lot of these details turn out to be really, really
important, in terms of making progress. And frankly, I think reinforce
the need for this particular Workgroup. If this were easy, I\'m sure
NCQA, JCAHO and a few others would have involved it already. I think
we\'ve also learned if we were starting the quality enterprise from
scratch, we would probably have a different script than the one we got
much that\'s easy.

However, having said, that that\'s not actually our starting point. Our
starting point is where we are right now. And it seems to me that we
want to figure out how do we use the power of IT, and the power of
collective power of the community to drive some progress forward without
slowing down the momentum we got going right now within AQA, HQA, what
NCQA id doing, so forth. That is the hard part. Positive momentum from a
very flawed imperfect place that we are right now, is exactly where we
need to focus our effort. So I think we heard some very key themes here
that I just wanted to articulate.

A fair number of folks came back to the importance of standardizing data
elements. And what wasn\'t said at Dr. Eisenberg\'s presentation but I
think we could come back to, is what is sort of potential overlaps
between what works for us and what is actually going to be moving
forward for the Biosurveillance Workgroup and others. Because I think
there are going to be some critical issues and critical opportunities
there. Able on Reed\'s point, I think we clearly have a starting point
of starting with the current measures we have for AQA and HQA.

Now, that alone turns out to be a little tiny bit challenging only
because AQA is supposed to tee up more later this month. But that\'s
okay. Now is the time to be thinking about that.

We heard about a couple of presentations that we\'re going to be hearing
from I think as well. Another \-- two other key things \-- let me assure
\[sirens blaring\]. Reminds me of one of those Woody Allen\'s movies
where he grows up living next to a subway on Coney Island. Let me assure
everyone the unfortunate person is not someone in the room and we closed
the windows again.

Another key them is we don\'t want to prescribe solutions but we do want
to focus on where the certification commission can make a difference,
and make sure \-- help reassure physicians and others making investments
in electronic health records, that they will actually be buying a
product that will help them in terms of reporting on quality
improvements. And another theme I think we agreed on this is not just
about accountability. Accountability is actually a means to getting
better value from health care. It is not the end goal of itself.

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

Well, I mean that\'s clear.

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

Yeah, well \--

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

Be clear that maybe you misunderstood what I meant.

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

No, no, no. But I\'m really thinking more about the hospitals than
anything else. Because in HQA meetings it becomes very clear that I
think in some many institutions given their available resources and
capacity, it is the end game. Because that\'s all they have the capacity
to focus on. I really wasn\'t keying on your point at all.

So given that, there are still a number of items that we\'ve got to work
on. Let me say that I think Christine has given us a very nice sort of
set of lists of recommendations that we can build on. I think some other
areas where we heard \-- where we need to hear from is what specifically
is happening with the VA right now. We have reached out to Tammy C. I
think is how you say her last name, and they had a conflict over there
today, so we definitely need to hear from them. Because after all,
sitting around the table we have VA, we have defense, we\'ve got OPM.
And when we reach out to somebody at defense I think is an open question
in terms of what they\'re doing.

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

I know the VA has obviously a pretty significant performance management
system. Not quite as advanced at this point in time, I think of any
health service in terms of full automation, what Terry describes, they
can physically automate over 60 measures, and I think there\'s more of a
hybrid approach than VA but it would be great to hear more about that
from Tammy so we can understand. I think DOD has spoken less on that
specifically.

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

Well and since the feds are speaking with one voice now, I mean actually
that contrast might be very, very helpful. I think it was Jane and I may
have the attribution wrong, who suggested hearing from the leap frog
group.

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

We had a chance at ARC to hear about a demo, the bottom line of this
demo would suggest that many people have CPO systems. It\'s a small
minority that where the doctors are using them. A small subset. I\'d
guess 5 to 10 percent. My colleague is indicating 10. So we\'ll take the
upper number. But of those hospitals, even of those that are way out
there, okay, a lot of them probably don\'t have \-- are not getting the
full value out of the CPOE systems. It\'s the one bottom line. But
hearing about that I think also does tee up some issues for the
certification commission. That\'s the scope of what they can do. Based
on that, I think we\'ll need to come back to you with some specific next
steps. But I think that we\'ve got a fairly robust menu from which to go
forward.

In terms of our next group, so we will get an interim summary that
we\'ll put on the tail end of the minutes or as a separate note to
members, that will be available to all eventually. This is time
management for today.

I had another thought that just escaped me. Kelly?

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

I wanted to bring up that we are expected to present on October 31 to
the Secretary and the community. And really it\'s for the purposes of
the community having a full understanding of what this general priority
area is around our specific charge. So with the core set of inpatient
and ambulatory measures, what do we think is important to communicate to
them at this point based on our two meetings and assessment occurred and
what we all know collectively, in trying to describe this priority area.
And I think between Christine and Michelle and I, and John and a few
others, we could take what we heard today and with the last meeting as
well, and try to highlight some of the consideration, because I think
across the workgroups, trying to describe to the extent feasible, some
of the issues around data and workflow and capturing the right kind of
data, any policy or regulatory consideration. I think today we heard a
little about maybe a need for incentives for reporting electronic data.
And I know data stewardship and control has come up a lot, not only
within the AQA data aggregation group but the AQA steering committee but
touched on some of the data ownership issues, too.

And then we\'re also trying to draw any considerations around the need
for stored data or to access data from a repository and while we still
have to discuss that a lot more as a workgroup, if there\'s anything
that we heard today that we\'d like to raise to put out there as an
issue that needs to be determined or considered, and as you know a lot
of our work continues, but also if this ends up being a priority for the
Health IT Standards Panel, the certification commission and the
Nationwide Health Information Network Consortia in 2007. They need to
know enough from us to get started.

So we can certainly provide more detail as we get along, but to the
extent we can draw from our first two meetings and collectively what we
know to lay out some of those issues on the 31st, that would be helpful.

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

Would it \-- it might be helpful, maybe I\'m the only one who thinks
this simplistically, but if we could take the original charge and put
that on a chart essentially as the framework because one of the things
that keeps happening as I listen, we are literally going down dozens of
paths simultaneously, and with that tight time frame, if we could step
back and just see \-- maybe even every time we have a discussion, then
say what part of that framework are we filling in, what gap are we
resolving. What question are we answering? So it\'s more like a \--
somehow combination of framework and frequently he asked questions. But
this happens to be by the AHIC.

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

No, I think that actually makes perfect sense. And I just wanted to
clarify the dealings I\'ve had with what happens next. And then it went
out of my brain. We are not making recommendations on the 31st. We are
actually presenting more of a progress report where we are and we had a
fairly lively debate about what kind of time lean we wanted to be on. On
the other hand, I think that if we\'re focused with potential synergies
with biosurveillance and others we\'ll be well on the way of keying up
recommendations for the December 12 meeting.

Rick, I have been doing all the talking here. I didn\'t mean to exclude
you from all of this. You have to anything else to add?

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

Lots of moving pieces. I just sent you an e-mail maybe we can talk one
or one tomorrow morning.

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

That would be great.

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

Then I think another issue that you and Rick can \-- at what point do
you want the visioning process? Because I think in many ways we were
looking at that visioning process where we start with a really good
accurate description of our currency, which I think we have from what we
heard, and then where do we want to get to ultimately, what does that
look like? And then try to focus on our enablers and barriers and how do
we make short-term progress. Understanding it\'s not just going to be
one path. We have parallel paths and serve the needs both the inpatient
and ambulatory perspective. I think if it you want to start getting that
in November that could be what we tee up in November, to create that
framework.

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

I think that would be helpful. Because I think visioning process will
help coalesce what we\'re talking about.

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

Yeah, and I guess the other issue that we\'ve got to keep our eyes on
all the time is our unique opportunity in this nexus of fairly dynamic
enterprise. One piece that we\'re taking on at ARQ, as of next month,
which should be interesting, someone made the comment that getting from
a guideline to a measure is not a no-brainer. We\'re actually going to
be sitting down with guideline and measured developers because one of
the problems that people who do write decisions support for those
systems that are like way out there on the leading edge have is the
guidelines are not written in such a way to make either creation of a
measure easy, or \-- and to say nothing of physician support. They
include lots of language like consider.

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

Right.

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

We don\'t have an electronic code for consider. Or a way to actually
assess whether someone has considered unless this, a little balloon over
their head. \[Laughter\]

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

It\'s that kind of thing that we\'re going to \-- we recognize that\'s a
critical input, and because the existence of of a guideline,
particularly developed by a professional organization, has become de
facto, gets back to Rick\'s earlier question, a stamp of legitimacy
almost required or implicitly required for measures. Measures are not
purely developed from what we know. But often it\'s what we know as
it\'s filtered through clinical judgment and so forth. We think this is
going to be an important opportunity. So we\'ll be keeping you apprised
of that.

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

Input we had earlier if the DOD comes to present, we have a
\[indiscernible\] weave that into their presentation.

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

Right. So the next call, Kelly, is?

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

November 2?

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

November \--

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

November 1.

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

Right after the Community meeting.

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

The Community meeting is on Halloween.

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

Right.

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

So just all kinds of possibilities. Terry we may need your template for
the slides. \[Laughter\]

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

And November 1 is going to be our meeting. Is that right?

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

Well, no \-- people want to come, they \--

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

This is why that day is always open.

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

Again, let me just say this has been a fairly intensive afternoon. One
that I think has been very instructive, and I don\'t know that future
meetings will be less intense, but they\'ll be intense in a different
way.

\[laughter\]

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

I want to give a really, really profound thank you and sense of
appreciation to all of our presenters. I think this was incredibly help.
For those traveling, safe travels. For those just going back to
multitasking \--

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

Carolyn, I think we need to give the public the opportunity to call in
and make comments.

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

Thank you, I forgot that important piece.

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

Okay. For members of the public who are on the Web right now following
along, you\'ll see a call-in number and instructions to make a comment.
I think we have a few people on the phone already. If they would like to
make a comment, just press Star 1 on your touchtone, and that will put
you through. We\'ll give it about 45 seconds for people to get through.
If not, there\'s an e-mail address to send your comments.

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

We don\'t have anybody on phone yet. Maybe just 20 seconds, make sure
nobody has hung up on the operators and then I think we\'ve given people
ample opportunity.

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

Good point.

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

I\'ll just say while we\'re waiting. George Isham. A great meeting.

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

Thank you.

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

Thank you, George.

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

I\'m fairly impressed how clear it came across, today\'s generation of
automated medical records, is inadequate to the task of pushing F8, and
putting out a quality measure.

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

It doesn\'t look like anyone is calling in. Again, there is the e-mail
address up there if people would like to submit comments that way.

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

Thank you very much, Matt.

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

Bye-bye.