American Health Information Community

Chronic Care Workgroup #12

January 18, 2007

**Disclaimer**

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

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

Okay, Karen.

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

I\'ll open it.

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

All right. Thank you.

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

Thanks, Matt. And welcome to the actual 12th meeting of the Chronic Care
Workgroup, and a Happy New Year to everybody. Just to remind that we\'re
being broadcast over the Internet and the transcript and the meeting,
summary minutes of this meeting will be available on our Website. And a
reminder also to make sure you speak clearly and distinctly and identify
yourself before speaking, so the transcribers know who to attribute your
words to.

So I think without any further ado, I\'ll ask Matt to introduce who's on
the phone and then we\'ll go around the table here.

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

Okay. Dr. Paul Nichol from the VA. Mary Ganous from Bearing Point.
Justine Handelman from Blue Cross Blue Shield. Brian DeVore from Intel.
Tony Trenkle from CMS. Madhu Agarwal from the Department of Veterans
Affairs. And Eric Larson from Group Health. Any others who I missed?
Okay, Judy.

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

Okay. And in the room we have \--

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

Karen Bell.

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

Jay Sanders.

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

Anand Parekh.

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

(inaudible) Flowers.

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

And Will Crawford from CMS.

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

Thank you, Will.

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

Not actually on the Workgroup.

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

Okay. I think we\'re ready to begin. Tony?

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

Good afternoon, I\'m going to defer any opening remarks because I think
we have a lot of business to do this afternoon, so why don\'t we just
move on to the agenda items.

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

The first of those is the review and acceptance of the November 8th
minutes. This is our last Workgroup.

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

Move their acceptance.

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

Second.

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

Was there a second?

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

Yes, there was.

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

Second.

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

Oh, thank you. Tony, is it all right if they are considered accepted and
we move on?

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

Yes, let\'s move on, Karen.

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

Okay. And I just wanted to clarify that we have today as the other
co-chair, from Intel, Brian DeVore. Thank you for being here today,
Brian.

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

You\'re welcome. I\'m supposed to be Craig or Colin today.

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

We\'re happy, and I promise I won\'t confuse your voices. I\'d like to
then just go ahead with the issue about refocusing for 2007. And I\'d
like to call your attention to the fact that this Workgroup has been
meeting for over a year, and it has had two charges. And I\'m going to
recapitulate on both of those for a moment.

We\'ve been spending quite a bit of time on a very specific charge,
which was to make recommendations to the Community so that within one
year widespread use of secure messaging, as appropriate, is fostered as
a means of communication between clinicians and patients about delivery,
about care delivery.

From the perspective of that particular charge, this Workgroup has done
a tremendous amount of work and in fact made some very strong
recommendations to the Secretary last May. All of which are moving
forward and we\'ll talk about that a little bit more, shortly.

However, there is also the broader charge, which is to make
recommendations to the Community to deploy widely available secure
technology solutions for remote monitoring and assessment of patients,
and for communication between clinicians and patients. So that goes far
beyond the secure messaging very specific charge.

As we move forward into 2007, I\'d like us to do a couple, I\'d like to
do a couple of things. First, I\'d like to thank you all and commend you
for the amount of work that has gone into A, the first set of
recommendations, and B, the ability to even think about the second set
moving forward.

Secondly, I\'d like to point out that much of this work, and your
ability to prioritize and think through where we need to be going in the
future, has led to the creation of some possible next steps through what
we\'re calling use cases, which I\'ll talk about a little bit more
later. But that\'s a very significant piece of work that we\'re also
embarking on, moving forward.

But thirdly, we\'re at a point right now where we really need, over the
course of the next few months, actually it would be helpful if we could
get some good recommendations for the next AHIC meeting, which is March
6th, to bring forward so we can keep the momentum going and to assure
that we\'ve addressed all of the critical concerns that we need to be
addressing in the recommendations format.

So the heart of today\'s meeting will be to think through all of the
presentations we\'ve had to date, the public testimony we\'ve had to
date, and to focus it on areas where recommendations may be appropriate
to set up for either the March meeting or perhaps even one later. So
again, most of the work will be in that genre today.

Once we have these recommendations, however, we need to also think very
clearly about what else we would like to do in 2007 and how best to do
it. Clearly, we\'ve met the specific charge, recommendations for the
specific charge. We are talking about the broader charge. We may need to
focus on some very specific issues in the broader charge to move forward
and then we would talk about how to do that. There are some pieces of
what we\'re doing that may actually dovetail with work that\'s going on
in other workgroups so we may want to acknowledge that and move it over
to those other groups. We really do need to think in 2007 how to use
everyone\'s time, resources, and expertise most effectively.

So I would just like to again underline that the outcomes that we\'re
hoping to get to today will be the beginnings of the formation for the
recommendations that will be coming forward in 2007 on the broad charge,
and also some focus on where this group, and how this group, should be
functioning moving forward.

Is there anyone else that would like to comment on that, perhaps the
co-chairs or if anyone has any questions, we could have a little
discussion on this at this point.

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

Karen, this is Brian. Do you foresee that the entire year of 2007 will
there be a need for the Chronic Care Workgroup through the entire year,
or I guess this kind of goes back \-- at what point do you think we\'ll
have enough information to provide recommendations \-- I mean, can you
kind of give us a chronology of \-- if we do provide recommendations for
a March meeting, and those are sufficient, and the Secretary accepts
those, are you planning, you know, additional work for the Workgroup? Is
it just taking the broad charge and expanding that into new and
different areas? If you can kind of give me your thoughts, that would be
helpful.

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

I think it\'s not so much my thoughts but everyone\'s thoughts on this
Workgroup. I mean, clearly if we feel that, or you all feel that we\'ve
pretty much wrested out, and I\'m using wrested with a W, every possible
recommendation that is necessary to move the broad charge forward, then
perhaps this Workgroup can come to an end. Or, if there are some very
specific areas that overlap with other Workgroups, it could be moved to
other Workgroups. We really do just want to make sure that we have in
fact met our mission. And if there are other pieces that this Workgroup
can do, under the guise of chronic care, if there are other issues that
anyone on board feels that we should be moving forward with, we can
bring these back, have them discussed with the AHIC and determine
whether or not the group should go into those areas. So it really is a
group discussion. We have a number of options on the table, and, again,
disband, and number two option is to really focus on some very major,
very big critical issues, perhaps we haven\'t addressed yet and really
focus on those. And the third option is to take some of the work that
we\'re doing and if there\'s overlap, move it to another Workgroup. So
those are the kinds of directions we should be considering.

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

Karen, can I make a couple comments, please?

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

Great.

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

Yeah, I think our focus for at least this meeting and perhaps next, if
we don\'t get it done this meeting, is to focus on the broad
recommendations. And perhaps after that we need to take a look at what
we have recommended so far and is there anything else that needs to be
done under the purview of this Workgroup, which has basically been set
up to make recommendations to the AHIC and to the Secretary, not to
monitor how these recommendations are being implemented.

So it seems to me that we, I agree with you in terms of the options,
because one of the options would be to look at what might be left to be
done if there is some major areas and decide is the best way to develop
new recommendations through this \-- by continuing this Workgroup, or is
it something that would be better left up to, say, the Confidentiality,
Privacy and Security group, for example, if it\'s something related to
that. Or is this something that should be better left to ONC staff to
do, but it seems to me that we have at least this meeting and next
meeting to focus on getting these broad recommendations, and then making
the determination if there is additional work that the group needs to
provide to support the Secretary.

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

That\'s correct, and I would only add that one of the recommendations
that this group can make is how it should move forward. So as we
deliberate everything else, one of the recommendations again could be a
statement about what the group has accomplished and what we feel the
next step should be for it.

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

Well, this is Jay Sanders. My remarks are not intended to try and
continue to increase my problems with the traffic in Washington in
coming to these meetings, but I have to say, my basic feeling is that
we\'ve only taken a single small step with respect to the broad charge,
in terms of the specific work that we have done relative to secure
messaging. The expanse of capabilities that exist today in terms of
off-the-shelf technology to enable a comprehensive evaluation of the
patient at home, and really substitute the majority of chronic care from
a doctor\'s office setting or an emergency room setting into the home
setting, is significant. And there are plenty of, there\'s plenty of
data out there and ongoing evaluations, particularly in the VA, that are
demonstrating the dramatic results in terms of the shifting of the care
to the home from the doctor\'s office using this enabling technology.

The only lubrication really that is needed in effect would be the issue
of how is that care compensated for? It\'s very clear from multiple
studies that have been done over the past ten years that literally half
of home healthcare visits that are done in the United States, up to
about 400,000 a year, half of those could be done utilizing what we call
today telemedicine technology. And the other specific fact is the a home
healthcare nurse can see only five to six patients per day when they
physically go to see the patient whereas they could see an average of 15
to 20 a day utilizing this technology.

To me, some continued emphasis and some discussions on more
comprehensive application of this technology I think would be very
warranted and is commensurate with what our broad charge has been right
from the beginning.

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

Well, that\'s been very helpful, Jay. I think that will be certainly the
beginning of a discussion on where we need to go moving forward. Anyone
else who would like to comment?

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

Karen, this is Jeff Rideout. I would agree with the comments that were
just made, and I do think, you know, it would be a shame to have such an
important and critical charter and only see a relatively modest pilot as
sort of the fruits of that. And I guess one question I would ask is
what\'s the Secretary\'s position on what this Workgroup should be
doing, especially in connection with other Workgroups, because I think
one of the challenges we\'ve had is how does our work integrate better
with some of the other Workgroups, because I think that\'s another area
that we\'re really missing.

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

I agree, you know, and I think I will jump in with a little bit of a
comment here. The Secretary has pretty much left this up to us. One of
the things that I think has been somewhat confusing to a lot of folks is
the name of this Workgroup, the Chronic Care Workgroup. In essence, the
broad charge is more about remote care. And how one receives care,
wherever they need it, whenever they need it, independent of having a
chronic illness.

And maybe that if we do move forward, we would do that, do so with a
very different twist. Not so much on the chronic care piece, but much
more so on the remote care piece, which would allow us then to bring in
many more of these other issues that you\'ve presented, Jay, and that
you\'ve commented on, Jeff.

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

This is Paul Nichol. If I could make two comments. One is that we have a
tremendous capability in the home telemonitoring within the VA, and it
would be very useful to bring Adam Darkins into some of the discussions
for additional details on that.

The second is, in terms of remote care, we just had a presentation at
our medical center by Ted Eytan from Group Health. And I was very
impressed at the combination of a personal health record, secure \-- and
secure messaging, used by an organization that has a fairly mature
electronic medical record. Really enables a tremendous amount of care to
be provided remotely, in alternate settings, more, and much more
efficiently. And those are sort of the cornerstones. Home
telemonitoring, personal health records, and secure messaging are sort
of the enabling technologies to do what we\'re talking about.

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

Just to support that comment, I\'m going through a little bit of a
odyssey myself. I\'m trying to collect all of my personal medical
information for the last 25 years, just to see what it would take. And
I\'m going through all of my health plans, all of my providers, all of
my hospitalizations, and you know, I\'m 45, I\'m not that old, and I
haven\'t had any major events. But it is a real odyssey to try to find
any of it. And to reinforce the last comment, could actually pull up all
of that information from my current medical group electronically,
myself, instantly. And it\'s just such a contrast when there are groups
that I\'ve been part of that don\'t exist anymore or the ones that
acquired them are basically saying it\'s archived, we don\'t even know
if we can find it. I do think there\'s a lot for us to continue to work
on.

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

Thank you, and that was Jeff Rideout, yes?

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

Yes, uh-huh.

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

Okay.

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

Karen, this is Mohan Nair.

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

Hi, Mohan. How are you?

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

Good, thank you. How are you? I\'m trying, attempting to answer your
question, which is what does the future bring for this Workgroup. You
have made certain comments that said maybe we would expand the charter
of some nature beyond chronic care, or you would say that our primary
objective is really on secure messaging. As I read and reread the broad
charge for the Workgroup, it has been the term "make recommendations to
the Community". And also to deal with what is available for remote
monitoring and assessment of patients. I think the broad charge didn\'t
say chronic care, as you had so accurately declared. But we did have a
specific charge of making recommendations specific to secure messaging.
And those recommendations are, in preparatory fashion, ready now. So if
you were to take this to the next level, I would ask us to consider that
the work is never done until the full recommendations around what does
it take to make secure technology solution available within the, within
our environment, our country. And to ensure that the accelerators are
available and discussed among us that forces this situation to occur
more rapidly than currently is being designed. So if you were to just
lay on top of our broad charge, I think we have what we need to drive
forward.

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

Thank you very much, Mohan. And I think you\'re absolutely right. We get
a little bit confused because our name is Chronic Care but it really is
about much more than that and that\'s a critical point. Thank you for
outlining that.

Is there anyone else on the line we haven\'t heard from yet?

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

You haven't heard from me. I\'m Eric Larson and I'm actually walking and
multitasking as we\'re doing this. But just to follow up on Paul\'s
comments, I think there\'s tremendous capacity in this topic of remote
monitoring, and I personally don\'t think it\'s a problem being focused
on chronic care, because it may help us. I think if we do go forward,
focus is going to be a challenge, because there really is a lot we could
be working on. But I\'m willing and very interested in talking more
about the stuff we\'re doing at Group Health, because it\'s very
helpful.

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

Okay.

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

Karen, this is Anand Parekh. Just one more comment just to add to the
pot. You know, I think one way we could certainly look at it in the
future is to broaden chronic care. But I think on the table should also
be the idea of potentially making chronic care narrower, or focusing on
a subset, if we think that chronic care is important and we think that
that should be a part of this Workgroup as we move forward, narrowing
chronic care to focus on multiple chronic conditions in individuals and
really looking at a subset of the chronic care population that indeed
has the worst coordination of care or the most medication interaction or
increase the cost to the system to the utmost, and how either secure
messaging or remote monitoring could help that narrow subset of chronic
care individuals could be another way to go. So I just add that as we
think about where to go next, we could broaden chronic care or we could
narrow it to a particular subgroup, or \-- there are a lot of ways to
take this.

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

This is Jay Sanders. And in followup to that comment, there actually was
and I believe is completed, a CMS-funded demonstration project from New
York with patients with chronic illness, solely diabetes, who of course
have a lot of co-morbidities, and if you take a large diabetic
population, you\'re fundamentally going to be dealing with most chronic
illnesses. And you know, I could be corrected if I\'m wrong, the results
of that three-year study at Columbia was quite dramatic. And that was
using telemedicine technology for these patients, both in an urban and
in a rural setting.

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

I would only add one thing and this is Karen Bell again. I certainly
like the concept of focusing on a very specific population. It certainly
helps us move forward. I would also say, though, that in many
situations, and this harkens back to what you said a little bit earlier
Jay, a lot of people can have a very significant acute problem, be
hospitalized for it, need a lot of home health support, and then they go
back to being healthy again. They really don\'t have that underlying
problem. So I think that there may be, again, very specific populations
that we want to hone in on. But we also may want to keep open the
possibility of really looking for where are those places where remote
care may have its biggest impact. That may be one of them. I also think
about situations where people are fairly isolated and the ability to
have some of the devices that are now available and have them cared for
through information coming through these devices could be another. So
there are so many different options out there. I\'m very excited about
those options. But our biggest problem will be focusing, I think.

So I would suggest that \-- and I\'m going to \-- we\'re going to try to
stay on schedule today. I\'m not always known for being able to do that,
so \-- we\'re going to try to stay on schedule. I would suggest, then,
that we take the comments that we have here and think about how we may
want to focus our recommendations really about ourselves, or what this
Workgroup can do in terms of moving forward. And also think about focus.
There's lots of different discussions here.

So we will help out by consolidating the discussion, some of the key
points that were made, and send it back to you with the thought that
your own way of thinking will help us craft a recommendation on what we
can do moving forward as we finish this batch of recommendation that
we\'re going to be working on today and next week.

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

Karen?

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

Yeah.

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

This is Brian. Just a quick question for clarity. Based on Tony\'s point
of making sure we do focus on the recommendations that we need to
deliver in the next month or so, because we only have one more meeting
after this. We\'re going to deliver some sort of recommendations, one of
those will be potentially a redefinition of scope moving forward.

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

Yup.

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

Okay, but for the next meeting or two we\'re going to focus on crafting
what that extension is. But that is not the main deliverable we've got
coming in the next month, so we need to kind of, you know, again prevent
scope creep here of, in ourselves and so we don\'t keep looking in the
future for the next month or so. If we can just nail these things down
right now, provide something of value they can use in the short-term,
just to kind to provide some parameters.

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

I would agree with you Brian. I think everything that we\'ve mentioned
is important and we need to look at, but our focus in this meeting and
next meeting really does need to be to hone in on these recommendations.

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

That is correct, and again if we were to go in a different direction, we
would want to make a recommendation about that as well. So we\'re just
keeping that one on the back burner, okay?

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

Gotcha.

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

Okay. Since we\'d like to keep on moving here, I\'m going to actually go
a little bit ahead of schedule, if that\'s all right with everyone. We
are going to spend a lot of time talking about the recommendations, and
with the papers that have been shared with all of you. So what I\'d like
to do now is ask Anand to present a little about the direction that
we\'ve gleaned from a number of folks within the federal government.
We\'ve been talking with folks from ASPE who do a lot of the program
evaluations here in the federal government. We\'ve been talking with
AHRQ, which as you know is the research and quality part of our
organization. And as well have gotten some input from our partners in
the private sector, from the American health \-- I\'m sorry, the
American Health Plans, and from the Blue Cross Blue Shield Association.
So Anand, I\'m wondering if you could just jump in and share with
everyone what the thought process has been.

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

Thanks, Karen. And just to refresh everyone\'s memory that this pilot
stems from recommendation 1.2 that the Workgroup passed as part of its
specific charge that public and private payors, including CMS, should
contribute to the evidence for and information based on reimbursement
strategies to direct reimbursement pilot or demonstration studies, et
cetera.

So this was really conceived from the recommendations that the Workgroup
previously passed, and, as Karen mentioned, various parts of the
Department contributed to develop this draft high-level proposal and
Cinyon Reed and Karen Bell put in the brunt of the effort here. And
I\'ll quickly go through it. I think the outline in your packet starting
from introduction, ending at timeframe is where I\'ll go, and I\'ll hit
some of the high points. It will probably take a few minutes. Karen,
feel free to jump in wherever there are gaps or if the thinking has
changed and then we can kind of launch into a discussion.

But the introduction here, I think all of you know, is the conceptual
data out there as well as some limited data from various payors that
secure messaging might in fact improve quality of care for individuals
with chronic condition, as well as potentially decrease the overall cost
of care. But again, the data out there is limited and especially when
you get into specific reimbursement models and how those reimbursement
models affect the return on investment or cost savings or improvement in
quality, the data is, can be considered somewhat murky.

So the hypothesis here is that reimbursement structures in general, and
there may be some specific ones that really do this, have a positive
return on investment in an environment that supports comprehensive
management of patients with chronic condition.

The saying that right now is being considered is in internal medicine
physician offices given that out of all the specialty groups really
internal medicine being broad, really see many individuals with chronic
condition. So the thought is that the pilots would take place in
internal medicine physician practices, in three areas across the
country. And this will need to be fleshed out a little bit more, but in
different areas there could be different reimbursement models that
we\'re testing, and so we could potentially test at least three
reimbursement models and those reimbursement models would need to be
determined by both the public, both CMS as well as the private payors in
those particular areas.

The physician practices we would want to be large, and here we have
written that at least 2000 patients, there should be at least 2000
patients in these practices. And we also want to select those practices
that have two criteria, specifically one that has the ability to monitor
individuals with chronic illness and so we\'re focusing really here on
those with chronic illnesses. And second, practices that have some kind
of operational setup where they can follow up with patients, either
telephonically or on paper. Otherwise, it will make it very difficult to
keep track of the communication information flow between patient and
physician.

The patients for this pilot would be all patients, and so we wouldn\'t
necessarily limit the secure online messaging to those with chronic
conditions, but however we would hope that we would have enough patients
so ultimately it would be a evaluation, we could do subgroup analyses to
hone in on those populations here, our main interest, those with chronic
conditions or those with multiple chronic conditions, and see whether
they benefit and which reimbursement structure allows the greatest
value. The intervention again are various reimbursement modalities. You
know, we considered fee-for-service capitation, pay-for-performance, and
some kind of bonus. So I think those are kind of the leading three or
four, but there are certainly others and potentially if we have three
different geographic areas you could potentially in each area have one.

The outcomes here, there are four that are listed, and these are all
kind of the best proxies we could come up with for cost and quality,
which is really what we\'re looking for. Patient adherence to care plans
and medication management, again, is somewhat of a good proxy for both
quality and cost, increased adherence could reduce costs. Decrease in
preventable hospital admissions and ER visits, another what we discussed
in previous Workgroup meetings, a good proxy for cost. And then improved
both patient satisfaction with care provider and improved clinician
satisfaction with care process, two other good proxies for quality. So
again, we\'re trying to come up with measurable outcomes that are good
proxies for quality and cost. Because given that this is going to be a
short pilot, in six months it\'s really going to be difficult to see
hard \-- you know, hard differences or changes in costs that we need to
come up with some proxies for some of these outcome variables. So this
is what we have so far.

The study design, again, is listed here as three cohort controlled
studies in three different areas. We would have, in each area, we would
have some practices with the intervention, with the secure online
messaging reimbursed and other practices that aren\'t applying the
secure online messaging, obviously not being, therefore, reimbursed. And
so each geographic area having its control. And I think that\'s the main
part of the study design.

The evaluations again we need access to various things, including
hospital discharge data, public and private claims data and satisfaction
surveys. Hopefully, the end will have enough power with the amount of
patients that we'll have.

The timeframe kind of puts things into scope. There\'s a planning phase
from January 1st to September 30th. It\'s nine months, and really that
involves writing a scope of work, contracting this out, figuring out the
technology or who can provide the secure online consultation. Choosing
the geographic areas, engaging the private payors in these areas.
Obviously, engaging CMS, and then doing an evaluation, or getting a
contractor to do the evaluation. So the first nine months of the
planning phase has quite a few things.

The intervention really wouldn\'t be until January 1st, 2008, for the
next six months. And then we would do the evaluation with hopes that
near the end of 2008 we could provide some kind of a report with newer
data. And that\'s really what the specific recommendation, 1.2, that the
Workgroup passed, really calls for, contributing to the evidence for
various reimbursement strategies.

So that\'s kind of where we are now, Karen. If you want to add or
clarify or \-- some of the points. But kind of a high level overview of
what some of our thoughts are so far.

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

Thank you very much, Anand. I really appreciate your doing that. The
only things that I might add are that the other Workgroups are going
through a somewhat similar process with other types of projects as well.
So that we are being fairly parsimonious in terms of how we are
approaching them, for instance, the issue of understanding patient
satisfaction with use of health information technology, here is around
secure messaging, but there are many other options, or opportunities,
for patients to be experiencing health information technologies.

So as we develop the surveys for this particular project we\'re also
actually capitalizing on a little economy of scale here, and we will be
working to develop a survey with, hopefully, standardized methodologies
for evaluating patient satisfaction with HIT moving forward.

So again, I just wanted to again underline that while this is a
stand-alone in and of itself, and the Secretary will be looking for a
very specific outcome here, as we move forward with this type of a
project we are also looking for opportunities to leverage what\'s
happening in the other Workgroups as well on their projects.

And the last thing I will say is that it is an incredibly tight
timeframe. And frankly, we have already started, we have a work plan
here. We have project management support to do this, moving forward. We
are somewhat limited right now because the budgets have not finally been
signed off, but as we understand better what our budgetary situation is,
then we will be prepared and ready to jump in full steam ahead.

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

Karen? This is Mohan.

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

Hi.

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

Hi. I have a couple of questions and then maybe a \-- one or two
suggestions. First of all, when you say that it takes between now and
September 30th for planning, are you, in the planning are you
considering a complete \-- how I do say \-- originated environment, or
are you leveraging off existing environments that may be three-quarters
or maybe one-tenth of what you\'re really expecting to build from there?
That\'s question one.

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

Yeah, and I think the first, and I think Karen knows more about this,
but I think the plan is to leverage, you know, in terms of, your
question which geographic areas would we select and can we leverage from
existing models or pilots out there that AHRQ, or other folks might be
doing?

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

Right.

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

And I think the answer is yes, that we would hope to build off what is
already being done in various parts of the country that CMS or AHRQ are
already engaged in and see if we can build off those platforms.

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

Right. And furthermore, being a, for loss of a better term, a payor, you
know I love that word, don\'t I? I would be look willing to look at
places where I can affect reimbursement rates even in my area in hopes
of assisting this pilot, because it\'s of interest to me to see whether
experiments of this nature really have positive impacts to patient as
well as physician behaviors.

So there\'s room for areas where you may find interested parties to
experiment. It may not be areas where you find the actual spot, but you
can actually design it. So you\'ve got both of those options available
to you.

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

Thanks, that\'s really helpful to know.

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

The other is, if you are looking at outcomes for this pilot, your
premise statement, hypothesis, is really \-- does \-- if I can
paraphrase \-- does reimbursement for secure online consulting generate
a positive ROI? That\'s what I read the hypothesis to mean. Correct?

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

That\'s correct.

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

Okay. If I were to take that hypothesis, what do you mean by a positive
ROI? Does it mean financial ROI, as in return on financial investment?
Or does it mean based on your outcome \--

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

Yes.

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

\-- measures, they\'re slightly different in terms of what you\'re
representing in the premise.

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

Yeah, no, that\'s a very good point. And ROI does sometimes I guess have
that financial connotation and here, and here we\'re, the outcomes are
kind of quality and cost. So we can, we can rephrase the hypothesis to
better reflect what we\'re going to look at ultimately.

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

Yeah, even though I\'m on the phone, I know Jay is going to respond in a
few seconds.

\[Laughter\]

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

And I like that. Because I think he\'s going to correct me. But allow me
to be stupid and then he can correct me.

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

He\'s smiling.

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

So my point is that there are certain ROI financial goals that
physicians have in their business practice. And it is impactful if it
does have a positive impact to them and also has a positive impact to
patient satisfaction, i.e., actual patient outcomes. So if we can find
the marriage between the two, it would be very powerful.

A physician, and I\'m speaking now out of turn because Jay knows better
than me and other physicians know much more than I, but being rewarded
for using the Web and the Internet in communicating with a patient is
directly \-- is sometimes indirectly proportional to making money
because they get paid for a visit.

So that contention, are you going to be addressing in this hypothesis?

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

This is Karen, Mohan, and again I thank you for bringing up the really
important points here. I think that as we develop the clinician
satisfaction survey, those are very important elements that will need to
be addressed. Satisfaction just isn\'t are you happy, did you get home
early, or was it easy. It really is what value has this brought to your
practice. And the value equation is comprised of many things.

So our hope and intent is that our satisfaction summary will certainly
give us information on what ROI would mean to the clinician.

And in the absence of the amount of time that it really takes to do the
kind of financial ROI analysis that we would like to do, we are
suggesting that decreased utilization, which translates to cost savings,
could be a surrogate for financial ROI. But we\'d have to make that
very, very clear.

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

Karen?

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

Yes?

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

This is Jeff Rideout. I\'ve done three studies on secure messaging, so
I\'ve got a few comments that maybe would help. If there are outcome
tools or measures that you want to use, we can provide those. But the
big worry I have here is you\'ve got a patient population that isn\'t
limited to those with chronic illness, and you\'ve got a very short
timeframe. And my fear is that the way this is designed in terms of
outcomes, we\'re not going to prove anything, because most of the
claims-based information will, in my experience, take at least a year,
if not two years, to show an effect, and that effect will be relatively
small.

There\'s also going to be maybe in the chronic care population this
notion of preventible hospitalizations and ER visits, a positive effect.
We did see some of that in a large PPO population. But I would start to
consider measures, outcome measures or process measures, that are
clearly going to be affected in the short-term. You\'ve got physician
and patient satisfaction, but another thing that we\'ve looked at pretty
carefully is employee presenteeism as well, which is, granted,
self-reported by those that are using the system, but it also shows a
very positive effect.

So I think one of the worries here is you\'re going to look for
something that we won\'t find in this time period and that will be the
reason why this is not promoted further. I just don\'t think you\'re
going to find much in the claims information in this short a period of
time.

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

Well, that\'s a very valuable comment, Jeff and I would very much love
to follow up with you in terms of any other thoughts that you would have
and work you\'ve already done in this area.

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

Anand, this is Tony. I just had a couple of questions for you. One, in
the planning stage, are you going to take into your planning, some of
the work that the Blue Cross Blue Shield Association and AHIP and also
Will Crawford from my staff have been looking at in terms of existing
pilots that are going on with secure messaging? I know Justine has
offered in the past and I know she\'s been working some with Cinyon and
Karen on this as well. Would that be taken into the planning phase?

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

I think most definitely. Whatever we can draw from, from AHIP or Blue
Cross or the ongoing CMS demos, that can, you know, that can strengthen
this, we would like to utilize all of that.

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

Okay. My second question on the study design, it says all public and
private payors within the design designated region will collaborate on
this pilot study. And I don\'t know about other public payors, but, you
know, CMS is limited by what authority they would have to conduct
various demos. And I\'m not sure how that would play in terms of tying
in to the rest of the study. I don\'t know if you\'ve given any thought
to that.

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

I think the biggest part of the collaboration would be, would need to be
some kind of collaboration, between, I think, CMS and maybe, let\'s say,
two or three major, major private payors in that region about deciding
how to \-- you know, one, whether to participate. And then two, how to
reimburse. Because, you know, there can\'t be a situation where CMS is
reimbursing as fee-for-service, and one private payor is doing it via
capitation. It\'s going to make it complicated.

So there would need to be some kind of conversation and, I mean,
that\'s, I think, you know, when I see that word collaboration, that\'s
what I was thinking about.

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

We might not even have the legal authority. It would have to be looked
at in terms of that. Even if we wanted to participate, or how we would
participate, would be limited by our legal authority to do so. That\'s
all I\'m saying. Need to keep that in mind when you\'re looking at \--

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

Right.

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

And absolutely underlining what Anand just said, Tony, we\'re really
talking here about methodology to be determined by the payor
collaborative. And there may be grant money, there may be other ways
that we can leverage monies to essentially assure that the reimbursement
occurs. And it would be through a third party, so no one payor would
actually be charged for it on an individual basis. So there are ways
that this can be done to move forward, even on patients that are CMS
beneficiaries.

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

And Karen?

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

Yup.

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

This is Jeff Rideout again. Another study issue you\'ve got to think
about is that you want to have patients or individuals that are assigned
to primary care physicians, which typically means a HMO benefit design
structure, or oftentimes it does. But to actually monitor the effect,
especially if we\'re going to carry this out more than a year, you need
those that are paid through a claims-based system to monitor utilization
of services or you have to have some surrogate for that that you measure
independently, like a survey.

So in terms of picking geographies, it would be important to think about
sort of the dominant structures for both benefits and payment as part of
why somebody gets chosen or not. If you did some of this, say, in
California, you\'re actually getting into some very, very challenging
issues around encounter data versus claims data that can be worked
around but create its own set of issues as well.

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

That\'s a good point.

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

It would be nice if there were a dominant payor in a relatively
self-contained environment where there was PCP assignment and people
were still being paid discounted fee-for-service.

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

That may actually exist in, particularly, a part of the country where
there\'s a very heavy penetrance of managed care in terms of CMS or
beneficiaries on Medicare, so those are the things that we really could
look at. But the question you brought to my mind, Jeff, is that very
frequently, because there are so many patients who are still on a
fee-for-service, in a fee-for-service environment, whether or not any of
the logarithms that have been used in the past to quote assign patients
to physicians I think would be workable in this situation.

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

You mean like an inferred primary care physician or something like that?

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

That\'s right.

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

And then the other thing, as I\'m sure people on the call understand and
have done this as well, you\'ve got to hit a certain threshold of use
before physicians will actually see this as part of their current
workflow. So if you end up \-- that\'s why the CMS piece is so important
to it. Because if you get below, say, 20 or 30 percent, people generally
don\'t see this as how they do business. They see it in addition to how
they do business.

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

This is Eric Larson. I\'ve listened to the discussion, and there are
lots of methodologic issues that are going to need to be worked out. My
only statement would be, I\'m glad that this is going to move fast
because I think you're going to have, in addition to the problems Jeff
mentioned about how long it takes to see benefit, you\'re going to have
contamination of your control group, because a lot of this is just
happening in an unstructured way, and in our work here, we find that the
group that uses it the most are the people that use the most medical
care and thus have the most chronic disease. So people are discovering
this, whether, you know, they\'re allowed to or not. So if we can get
this up and running by January, I think that would give a better chance
to evaluate this in a sort of quasi-experimental way.

I fear that if it drags on, we\'re basically going to be studying a
phenomenon that\'s kind of passed by, or is passing by, many
communities.

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

That\'s cheered me up a lot, Eric. I've been worried about the
timeframe, so thank you for the positive reinforcement.

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

This is Mohan, Karen and Anand. I mean, I congratulate the framework
that you\'ve put together in terms of the study. My only challenge to
your thinking is that in terms of what are you measuring? Are you
measuring behaviors shifts, are you measuring outcomes, are you
measuring the influence of reimbursement in a controlled environment,
which is hard to get because of all the discussion we just had. And with
\-- there\'s so much noise that can be introduced in such a pilot, I
fear that if we don\'t have a clear understanding of the premise
statement and the outcomes, in a very, very challenging environment like
we\'re discussing, we will get exactly what we ask for, which is too
many variables creating noise for non-decision.

Can you help us, and help me, get a stronger feel for that connection
between your premise and your outcome within a controlled environment,
or would we need, really, more planning to flesh this out as a team?

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

Well, I think, Mohan this is Karen again. I think you put a very
interesting premise on the table. Which is again, what do we mean by a
return? And that would be, you know, if we could have that discussion
amongst all of us right now, that would be very helpful as we move this
next step forward.

So I\'m going to open up Mohan\'s question to the group. What do we
really mean by this return? It is an investment being made in terms of
dollars, to the clinical office for this service, and clearly physicians
are making some investments in this, too and so are patients, in terms
of time. So what is the value? What\'s the return on this that we really
are \-- we think is most important? In a much more specific way than our
very broad categories over here.

I think maybe another way of phrasing the question. Virtually everyone
on the call is coming from a different stakeholder, a different group or
a different viewpoint. If you could each articulate what you see your
role as, and what you think the \-- what would really be valuable to
you, what would be the return on your personal investment in this. That
could be very helpful discussion.

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

This is Eric Larson. I\'ll jump into this because I\'m from a very
different system. But I think the metric ought to be pretty common.
First and foremost, I think, is some sort of measure of the true cost.
And my perspective would be that it\'s not just the cost to the payor,
but also the cost to the patient. And here we\'re talking about time and
opportunity costs, and other things.

So there\'s a broad array of issues that a trial like this could
generate answers to if at least some part of it involved some detailed,
you know, metrics of both costs of resources but cost of time on the
other side of things.

And a second domain that we think is pretty important is patient
activation, and extent to which people become, in the management of
chronic disease, so-called activated patients. And we believe that
there\'s a very good chance that secure messaging enhances that
phenomena which then leads to the third goal, which is some sort of
measure of chronic disease outcome, whether it be control of diabetes or
blood pressure or whatever it is that people are looking at. But you can
think of target conditions where there are discrete outcomes which in an
electronic environment anyway, you can actually collect pretty good data
on.

And again, I don\'t know how elaborate this study is going to be, but we
could share with you some of the methods we\'ve used to try to get at
some of these outcomes, albeit most of them we\'re wishing we could do a
better job measuring them.

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

Eric, this is Jay. Let me ask you a question. Have you been looking at
compliance as a metric?

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

We\'ve tried to. So the answer is yes. I\'m not sure I can tell you that
we have a conclusion yet.

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

Because to me compliance would be the hinge between the patient becoming
much more involved in managing their care as well as decreased
hospitalization.

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

Right. Yeah, we think that compliance is dramatically improved, but
there\'s a hidden variable here that\'s beyond secure messaging because
so much, I think the number one use of our secure messaging system is
for medication refill. And because we have a centralized system, it
really makes everything so much more convenient for people to stay on
their medications. And I can\'t imagine it isn\'t improving compliance,
just for that reason alone.

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

Right.

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

This is Paul Nichol. Eric, do you think there are organizations that
would help in benchmarking this process? I think the question about
reimbursement and incentives is a way of getting the system in place and
then measuring whether or not it is effective in improving outcomes or
making care more cost-effective, many health systems have a more mature
implementation of secure messaging, and I\'m wondering if applying the
same measures that would be used in the rest of the study to existing,
more mature systems would help establish a baseline of sorts for those
kinds of outcomes.

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

Well, that\'s what I was going to offer, Paul, is that we\'ve just
finished a report for the Johnson Foundation of a grant that went
through the Health Care Financing and Organization, and I think either
offline the staff that are working on this could talk to our Workgroup
and I\'m sure we could help out in terms of giving you some baseline
data and some diffusion curves and that sort of thing.

But again it\'s, my guess is it\'s probably happening to some extent in
communities already, and so picking the community and the practices like
you imply in your document, of trying to find one that isn\'t really
doing this, is going to be important. And I think you\'re just going to
have to sort of barge ahead very quickly on this project, assuming it\'s
funded.

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

This is Jeff Rideout. The other thing I\'d say, you\'re trying to prove
a lot of things at the same time so we have to be careful about sort of
what we do or don\'t want to end up proving. And I think, as was
mentioned, a general measure of patient convenience or satisfaction or
belief that this improves their access would be important, especially if
we\'re going it look at all patients, not just chronic care patients. I
don\'t think the ROI from claims is going to come through, so you need
to start thinking about other surrogates that interested parties would
want to look at, absentee from work, medication refills, or compliance.
I think some of the bigger measures like avoided ERs is probably not
going to show up either. So it just depends on what we want to prove and
how long we\'re willing to wait to prove it and what hasn\'t been proved
enough in other studies to actually make the reimbursement discussion go
a little faster.

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

One question I ask of you, Jeff, we certainly need to give a report to
the Secretary by December of 2008. However, if there were a possibility
of at least letting the study go for a year, doing the interim analysis
so we still get the report out on the six-month experience, but then
letting it go for a year, do you think that would be long enough to
begin to show some return on investment from a financial point of view?
Decrease in hospitalization or ER visits?

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

In one study we were involved in, that was enough because it was an
older PPO population. And I personally don\'t think that it\'s got a lot
of face validity to say that secure messaging decreases major
hospitalizations. You know, so I don\'t think you have to go there to
prove that it\'s valuable just in terms of avoided office visits and
some other more likely markers.

In the other study that I\'ve been involved in, it\'s a healthier
population and we can see trends in the right direction after a year,
but I don\'t think it\'s anything any of us would want to hang our hat
on yet.

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

Well, I\'m going to ask you a really hard question, then. One of the
comments that we\'ve heard many times over, and Anand made a little bit
earlier, is that we know a lot of work has done in this area but none
has been considered robust enough for there to be widespread acceptance
of the fact there is a positive return on investment with respect to
costs.

Is that because most of the studies just have not lasted long enough, or
because they were not designed to show the financial return on
investment? What \-- why do you think the current data is not sufficient
to meet everyone\'s needs?

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

For me personally, I don\'t know if I agree with that, step one. And
step two, you know, a lot of the studies weren\'t designed as either
case controls or prospectives. So in that sense there aren\'t as many.
But I don\'t know how many times we need to prove that this is valuable
to patients, valuable to clinicians, and actually avoids utilization
that\'s unnecessary.

So I just have a different perspective on whether they\'re robust
enough, I guess.

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

I agree with Jeff\'s general tenor there, that I think this study needs
to be done and I would predict that within six months there will be some
important differences that show up. One of the things that I think will
show up is productivity. And that is that physicians become much more
productive, however you want to measure it. But that can be fairly
dramatic. And I also think that it will be just important to chronicle
what happens in a practice versus a control practice, to \-- in the
indemnity, more fee-for-service kind of setting, and again I think if we
could get a six-month interim data analysis and then get a commitment to
continue this out for maybe 12, 18 months, and have some sort of
surveillance in the control group that looks at, you know, just secular
trends that are happening in the environment, at the end of the day
you\'ll have some very useful information.

But I think what Jeff said, my sense this is just going to happen. And
CMS has to figure out, you know, how are we going to have policies that
are rational when it\'s happening. And I think this kind of a study will
help you a great deal.

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

This is Mohan again. Karen, you asked from our perspective where we
stand with this and how would we define ROI. And I know I\'m the cause
of this question because I was also battling with what ROI meant because
in the office that I play in, Regence Group, which is the Blue Cross
Blue Shield affiliate across the four states here in the northwest, I\'m
always debating how we can transform healthcare. But I have to tell you
that the perspective I come from is not from the perspective of a payor
in this committee. My perspective is as serving government in terms of
trying to find a way out of this very, very broken healthcare system. So
it\'s very hard for me to think beyond \-- think to my position in terms
of what an insurance company would like. Because I\'m not \-- I\'m
refusing to think that way.

I think that as a committee member, we\'ve got to find a way to see if
reimbursement methods really do impact behavior shifts between patient
and physician. And I love the comments made prior with respect to we\'ve
already tested it so many times, why are we testing it again? And the
other comment which is the key element of this is activation on the
patient side.

Physicians are reimbursed in certain ways today. And if they\'re
reimbursed in different ways, will the behavior of the physician with
the patient shift at all? Or would it just not make a difference because
secure messaging may not be the choice method for them to shift
behavior.

So I liken it to three \-- I liken it to four things, and I know I sound
like a marketing guy, so forgive me, I\'m taking pills against that. One
of them is, is there a change in the affordability? Is it easier and
cheaper or less expensive, is there ultimate cost differentials that
shift in the economics of healthcare between physician and patient with
reimbursement for affordability of the patient reacting?

Number two is, is there change in access? Are they feeling more
accessible, and that\'s where patient satisfaction comes in. Can I get
to my physician in different ways besides having to make appointments?

Number three, is there more accountability on the part of the patient,
because that speaks to the real great words of activation, as I heard
prior. Is the patient becoming more accountable for their health
scenario, not just reacting to what the physician gives them orders to
perform? Which to me is very important, and may not be important for the
team, but I would propose that it is critically important.

So I would claim that affordability, accessibility, and then
accountability, which is part of the activation equation, are three
things that we should place into our hypothesis to measure in a
controlled environment, and like I said, I could be all wet on this and
all wrong, but those are the areas of interest from a policy
perspective. We need test cases to prove that essentially reimbursement
methods is one of the dependent variables in this equation.

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

That was very nicely articulated, Mohan. Thank you very much. We\'ve all
been very carefully jotting everything you\'ve said down so we\'re going
to run it by you to make sure we got it right.

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

Well, I may be completely wrong but this is from the perspective \-- I
got to tell you, from the perspective of the fact that the system is
broken and all of us who have participated in it have contributed to
that breakage, now we\'re going to have to look at other methods to make
this a different system than exists today.

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

I think your framework, though, of the accountability, the
affordability, and the accessibility is one that will resonate with
many, many stakeholders and policymakers. And so the types of methods
that we have, they can be more specific than the ones we have already
put forth. But could certainly all go in that kind of a rubric, which I
think could be a very good way of communicating about what this project
is designed \-- being designed to do.

So that was very helpful.

Tony, you\'re from CMS. How does that sound to you, the accountability,
accessibility, and affordability triad?

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

Yeah, I think that makes sense, Karen.

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

Okay.

Well, I\'m going to ask if there are any other comments about this part
of the discussion right now. Anyone has any other ideas, please, please
let me know, share them. And if anyone else from the public that\'s
listening in and has some thoughts on this, too we\'re more than happy
to hear from you, too. Either at the end of this call or, again, just
contact us online. And we will take this back, reorganize it, rethink it
through, and begin to start thinking about the next steps.

Before we do leave the topic completely, though, I know that we\'ve
tried to get information on what is happening with secure messaging and
reimbursement in a number of different ways. We have worked with Justine
Handelman from Blue Cross Blue Shield Association, and Jeanette Thornton
from the American Health Plan. We are still feeling like there\'s a
tremendous amount of data out there that we haven\'t had access to. And
one of the options that we may have is to basically try to arrange for a
metanalysis to be done which would include literally contacting all of
the possible payors in the country, asking what they\'re doing about it,
seeing if we can get information from them in an anonymized way and
pulling it together in a sort of metanalysis-type approach. And before
we leave completely, I\'m just wondering if anyone either thinks that\'s
a great idea or thinks it\'s a terrible idea.

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

Good idea.

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

Is that something that might be worth, in our planning phase, spending
some dollars on if necessary? Okay.

Well, thank you very, very much. We are about to move on to the really
meaty part. And \-- as if this wasn\'t meaty. I\'m feeling like I\'m
being very surfeited here with multiple entrees. But another very meaty
part of our agenda, which is to begin the framing, or the thinking about
how we might be framing, the next set of recommendations that may be
going forth. And again we did a particularly robust set in May. We\'ve
spent a lot of time talking about many issues since then. And we\'re at
a point right now where we really need to start thinking about moving
forward with the next batch.

A lot of effort has been put into consolidating the incredibly rich
public comment, public testimony and information that\'s come through
since then, and I particularly would like to thank Cinyon Reed for doing
a lot of background work and especially thank Will Crawford who came in
fairly recently, actually, and really did a, I think, a spectacular job,
not only pulling it together but doing so in a way that will hopefully
be easy for you to get a handle on where we go from here.

I would just start off by saying, before I turn some of this over to
Will, is that we learned from one of our other Workgroups and actually
from multiple other Workgroups, there really are these five big issues,
and we talked about them when we put together our vision statement, and
we talked about them when we were planning for where else we might go
for this, the AHIC meeting.

So we broke down literally all of the information that\'s come in and
parsed it out in these five different categories. So what you see here
may be \-- there may have been one comment about financing that was made
by a particular presenter, and he or she may have made a number of other
comments about other areas as well. We\'ve pulled that apart and
literally collected all of the information about financing, put it on
one page as best as we could, and the same with another areas.

So that\'s how we got to these five pages. They\'re not really white
papers. They\'re more summary more than anything else. Just so
everyone\'s clear that these are not policy statements in any size,
shape, or form. They\'re working documents to begin the discussions that
we need to start now.

So with that, Will, I\'m going to ask you to introduce folks to the five
areas, and walk us through them.

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

Happy to do that, thank you. And again Cinyon in particular did a
tremendous amount of work pulling together a lot of the testimony and
all the mechanics that went into putting this material together.

As Karen said, these are quite emphatically not white papers. In fact,
it was almost harder to do it that way because we wanted to come up
within these five buckets that were applicable across the different
Workgroups, summary of really two things. First, the core issues in each
area that the Workgroup has been grappling with and will continue to
grapple with in the future.

And then the main themes and the main points that came out of testimony.
We also were very, very careful and on some of them, we just made to go
not more than one page on any of these, which imposed a certain amount
of discipline in terms of keeping to the main themes and not hitting
things that may have only come up once or twice. So the expectation is
that everyone on the Workgroup has been on the Workgroup, has heard the
core testimony, and hopefully can use these as memory joggers and to
drive the discussion.

So what I\'m going to do is just run through \-- I\'m not going to read
these out. But we did, first paper in the packet on financial issues and
challenges. And this was in a way one of the trickier ones to summarize
because there was a lot of testimony and a lot of discussion, some of
which we just had. But we came up with three core issues.

The first, and I think we just spent an hour on it, is the sustainable
business models that can be developed using technology to support
chronic care delivery. And more generally, healthcare delivery via these
remote messaging technologies.

Major issues about the appropriate reimbursement for physician time and
expertise, when rendering services. Whether those are new services or
whether they\'re services that are already being rendered in some way
but are now potentially being delivered in different, through different
modalities, maybe more efficiently, maybe just differently.

And then particularly earlier on, there\'s been quite a bit of
discussion about accessibility, and affordability, in terms of pushing
the technical infrastructure out to more remote areas and what
implications that has for reimbursement. And a lot of discussion about
different reimbursement models.

And then also in these documents we have pointed out where some of the
previous recommendations have applied to some of these issues and for
financial models, in particular, again, the pilot study is looking very
closely, hopefully, at all of these issues.

Confidentiality, privacy, security.

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

Could we do them one at a time? Because I think that would be helpful
while we have people thinking about these particular issues,
particularly since we just had our previous discussion. And before we
jump into the discussion, though, I do want to just call your attention
to the three questions that we asked to you think a little bit about.
One is, is your recollection that you\'ve heard enough testimony in this
area that you feel that this group is ready to make some
recommendations, in addition to the ones we\'ve had before, or do we
need more testimony? And if so, what is it that you would like to hear
about?

If you feel that we\'ve had enough testimony, we can go forward with
recommendations, then think a little bit about some of the areas where
we might move forward. I\'m not saying we\'re crafting one today; we\'re
only thinking about what area a recommendation may be appropriate in and
we\'ll go through the crafting process later.

And just as an example, we've just spent a lot of time talking about a
sustainable business model for secure messaging. The question then
becomes, have we heard enough about sustainable business models for
other types of remote care?

So those are the kinds of things that we need to have a discussion on,
and I throw the floor open now for all of your comments.

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

This is Will Crawford again. The one other thing I would like to point
out is while we did a number of passes on it, the bucketing for all of
these issues is not completely unambiguous. So there may be some
cultural issues around financial models that we\'ve chosen to talk about
in the context of the cultural area, but may also have some implications
for finance. So, you know, don\'t necessarily limit yourself to just
what we\'ve summarized in these paragraphs, if you think there is
something that\'s come up within the Workgroup discussions that would
best apply somewhere else.

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

We\'ll give everybody a few moments to think. Don\'t feel too pressured.

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

Can we get some music?

\[Laughter\]

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

Helps me think.

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

Turn on your radio.

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

Well, I have the theme from Jeopardy I can sing if you'd like.

\[Laughter\]

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

Somebody put it on hold and we can get hold music.

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

If we do Jeopardy, you have to give your comments in the form of a
question.

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

We need a psychiatrist.

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

Right, where has my brain gone, would be the question I would be asking.

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

I think there\'s a lot of gaps we could probably have additional
testimony on. My only concern is you get these things bubbled up in time
to land on specific recommendations within the next two months. Given
that we only have one more meeting, is there enough time to get further
testimony and get that kind of vetted, in order it get that up to the
Secretary. Or are you asking questions about additional testimony for
the \-- what we talked about earlier. The broad, extension of the broad
charge.

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

If we feel we\'re not ready to make a recommendation, so on the broad
charge just yet, that\'s okay. I\'m sure we\'ll come up with other
recommendations in other areas. We don\'t have to have them all done by
March, but this is an opportunity in March to present some that are
ready to go.

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

Does it look odd, though, this next week you\'ll have Consumer
Empowerment \-- four or five report-outs from Workgroups with
recommendations, I assume.

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

The report-outs are not necessarily recommendations.

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

Okay.

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

There will only recommendations coming from two of all the groups that
are presenting.

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

Great, thanks for clarifying that.

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

So \-- and again, we will either have a report-out or recommendations,
but my thought was that we will probably be able to come up with some
recommendations at this point. And if we don\'t have all of them,
that\'s fine. We can do some more later. But we\'ve put a lot of work
and energy into this right now, so it\'s a time if we can do it, let\'s
do it.

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

This is Eric Larson. I think we could probably, in the space of a couple
of months, come up with some very strong recommendations about remote
monitoring modalities that are either proved to be valuable and prove to
be, you know, attractive to patients in terms of there being uptake, and
it would be a matter of getting some people to testify at our next
meeting, you know, and saying probably, you know, here are examples of
secure technology solutions involving remote monitoring, that we
recommend to the Secretary be more widely adopted because we believe,
and believe the evidence is emerging, that these improve care and
probably improve cost-effectiveness of the resources we use for care.

And I think diabetes, hypertension, possibly some work having to do with
chronic lung disease and peak flow. Other people will think of other
examples. But if we can get two or three people to tell us about their
work as testimony at the next meeting, my guess is the recommendations
will be fairly obvious.

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

Okay. We can certainly arrange for that. And in essence I\'ll work with
a number of you in terms of what groups to pull in and to make that
happen.

One of the things I was just wondering a little bit about as we get into
this model, we clearly are looking at different types of reimbursement
for secure messaging in the pilot that we hope to be doing.

There is a need to also look at reimbursement in some of these other
areas. So I\'m assuming that if we move forward with what you were
discussing, Eric, we could build some recommendations around financing
or reimbursements on these other models as well in the future.

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

I think that\'s an open question. And I think there are others in the
group that may know more about that than I do. Because I think we have
to listen to what these people are going to tell us, but I think what
we\'re going to end up concluding, and somebody else please, you know,
come in on here, is that if we use remote monitoring, you\'re going to
see patients more activated, you\'re going to see the patients saving
time from visits that they might have had to make to, for simple things
that are just kind of a waste of their time.

And how we translate that into a reimbursement formula that works in the
fee-for-service environment, I think it\'s just a huge challenge. You
know, in the VA and integrated delivery system, it\'s almost an easier
project, but when you\'re talking about management of diabetes, it\'s
going to be quite different. And I think some of the demonstration
projects that are going on around chronic disease management may help us
out a little bit. But I don\'t think any of them are \-- at least the
ones I know of \-- have embraced remote disease monitoring in the way
that it could be embraced as a management strategy that Jeff alluded to,
I think, earlier in some of the things that he said.

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

Thank you, Eric. I\'m getting a sense that the group isn\'t ready yet to
really start thinking about any recommendations in the financial issues
and challenges arena around the broader scope of remote care. Is there
anyone that would be in disagreement with that statement?

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

You know \--

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

Karen? \-- go ahead.

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

Yeah, Jay Sanders. We may not be ready, but in terms of some of the
things that we\'ve seen from the VA in which they\'re looking at the
financial issues as well as the outcomes issues, I think there may be a
very robust database that they have that could be translated into a
non-federal equivalent.

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

This is Eric Larson again. I don\'t know that it\'s fair to say that
we\'re not ready to think about the financial issues. I think we have
to.

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

Well, I think what I was suggesting, though, is that we\'re not at a
point right now where we have all of the information that we need \-- or
actually, I think the group actually has it and knows it in their own
experience, but we haven\'t had enough public testimony to pull together
a recommendation that we can move forward and advance at the March AHIC
on financial models for more remote care.

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

Let me pose an alternative. I agree with you, we probably wouldn\'t have
anything about financial models. But we could make a recommendation that
we work on this and by a time certain with you leading us we could come
up with something because we think it \-- we make a recommendation that
a recommendation is needed.

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

Okay.

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

This is Jeff Rideout. Aren\'t we really just struggling with the notion
of reimbursement for telehealth? Is that what I\'m hearing?

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

Telehealth in its full robust form.

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

Right, using different modalities, could include secure messaging, might
include video, might include simply phone consultation. You know, we\'re
looking at a lot of these issues and certainly in California there\'s a
very active dialogue between the governor and a number of advocates for
telehealth. And in my conversations with the Department of Defense, you
know, one of the questions I asked them is how do they deal with the
reimbursement or at least the coding issues, and I was told that
actually for a lot of these they actually use regular E & M codes and
just ignore the fact that E & M requires a face to face visit. Because
in their mind they don\'t feel that the quality of the experience is
diminished under those circumstances where they\'re using those codes
for telehealth appropriately.

So there\'s a whole series of discussions around the nature of
reimbursement for services based on guidelines that require physical
presence. And I think that discussion ought to be opened up, because a
lot of folks feel, and I would tend to put myself in that category, the
more we\'ve created specialized coding and circumstances for telehealth,
the more we\'ve kind of partitioned it into a special needs category as
opposed to this is just another way to deliver care under the
appropriate circumstances, you know, maybe as an analogy, like nurse
practitioners delivering care under physician supervision, in many
states and now without physician supervision in others.

So I\'m just wondering whether, you know, if we define the problem
we\'re trying to solve, then we can start working on what the nature of
the recommendations are, whether they\'re financial or the liability
issues, or those kind of things. We\'re stomping over ground that a lot
of people have stomped over for years.

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

Yeah, and this is Jay Sanders. I totally agree with you. And one of the
basic problems is inconsistency in the policy. We do have reimbursement
for telemedicine technology, if it\'s done in real-time and if it is
done in what is governmentally defined as a remote location, a remote
rural hospital. That same policy does not hold if the individual is in a
\-- in an urban setting and doesn\'t have access to the care from a
functional standpoint, as opposed to a geographic standpoint. There\'s
also the inconsistency that real-time is not applied to teleradiology,
which really makes up 70 percent of all telemedicine activity.
Teleradiology, wherever it occurs, is reimbursed, and yet ironically
telepathology is not. And that is, that decision, according to CMS, can
be made on a regional basis by the intermediary.

So there are a lot of inconsistencies, and we get caught up, I think
remote care needs to be less defined from the standpoint of saying that
it is remote because the individual is rural, as opposed to it\'s remote
because it\'s not in the doctor\'s office.

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

Tony, do you know if CMS actually has that definition for remote? I know
that they are very clear about where one can do telehealth. But is there
an official definition for remote, so as we\'re using it in the second
way, that Jay has just articulated here in this Workgroup, isn\'t
consistent with CMS terminology?

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

I\'d have to talk to the billing people. I don\'t know. I don\'t know
what that would be. Will, do you have any idea?

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

No, but I think we should find out.

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

We\'ll find out, yes.

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

Excellent points that have been raised.

So where are we with this one now? Are we with the point that we would
like to think about crafting a recommendation that we need to really
look at all of these issues associated with, and I\'m going to use
remote in the second way, remote care, that we can begin to start
thinking about that. Or do we want to wait a little bit more and then
gather more information before we go forward?

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

Well, this is Jeff. I\'d like to pick up on a comment that Eric made a
while back. Where I think a few very well-considered presentations at
the next meeting, perhaps from like the American Telemedicine society or
someone that\'s quite familiar with it in other federal agencies, would
be actually quite helpful on this specific topic. What\'s the nature of
the inconsistency and how much is that an impediment to actually wider
deployment and use. Because I think in the end that\'s probably again
going to be the major problem. If there\'s no consistency in payment,
nobody is going to implement it and use it.

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

Okay. Well, let us do that then. We will pull together the appropriate
people for the next Workgroup meeting and early on in the meeting, first
item on the agenda. And we will leave time at the end of the meeting to
talk about whether or not we want to move forward with a recommendation
in this arena. Is everyone okay with that? Okay. Thank you very much.

Will? Number 2.

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

Document B. Confidentiality, privacy and security which I believe is the
right order. I\'ve been writing it, seeing it privacy, security, and
confidentiality, and security, confidentiality, and privacy. CPS is the
kosher version.

A lot of early discussion about these issues, quite obviously, which
boil down to really the novelty of the way patient information is dealt
with in these remote care contexts. There\'s information that wasn\'t
necessarily stored electronically before. There\'s information that\'s
being transferred via different mechanisms and through different
intermediaries. And with telehealth in general, and perhaps even more so
with remote monitoring, there are a much wider variety of personnel who
are involved in the information exchange about patient data for chronic
care treatment and for remotely-delivered care.

One of the recommendations that came out of this Workgroup earlier, of
course, was to form the Confidentiality, Privacy, and Security
Workgroup, which has happened and has begun to, as Karen outlined
earlier, focus on particularly issues of identity-proofing right now and
will be doing their first round of recommendations to the AHIC next
Tuesday.

On this one we identified four points that had come up in discussion.
The first is what kind of new governance structures are required to
support remote monitoring and care? What circumstances should secure
messaging be used to communicate results and diagnoses to a patient?
That's more of a confidentiality issue. Should the results of the HIV
test be delivered online? How are patients enrolled in the remote
monitoring systems? And how are the risks and benefits of that
enrollment communicated to them? Example that stuck with me was someone
testifying about how patients enrolled in a disease management system
heard about it for the first time when the nurse called them up. And
knew quite a bit about their health status.

And then finally how does the involvement of those same non-physician
care coordinators, including possibly family care givers, home health
aides, geriatric care consultants, et cetera, impact the privacy
structures that are required to support remote chronic care.

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

There are several issues that I might just focus everyone on for a
moment. There are major differences between privacy and security. And
security, for instance, deals more with the technology and assuring that
it\'s secure. One of the, I think, pieces that the other Workgroup, the
Consumer Empowerment Workgroup has been grappling with, is whether to
move forward with a recommendation for certification of what they\'re
calling personal health records. Particularly in the area of security,
and also with disclosure and confidentiality policies. I don\'t know how
the AHIC will vote on that next week, but it is \-- it has been be a
very hot button. And one that\'s been very deeply discussed in the
Consumer Empowerment Workgroup. So when we\'re talking about governance
structures, we\'re also talking about the fact that we are now opening
the market to many, many different types of monitoring devices that are
going to be transmitting information to a number of different places,
perhaps to a patient\'s PHR, perhaps to a delivery system. So I think
one of the questions here is do we want to think about some sort of a
certification process or some way that we can assure that whatever those
devices are, or technologies are, they do meet certain standards for
security?

So that\'s point number one. And then the last point that was made here
is not one that the Consumer Empowerment Workgroup has been working on
to \-- I\'m sorry, the CPS Workgroup has been working on to a large
extent. They\'ve been working primarily on the issues that we asked them
to in the first batch of recommendations.

So these kinds of concerns about multiple other people having access to
information in the name of care coordination or disease management or
patient advocacy, are very real issues that the confidentiality and
security and privacy Workgroup haven\'t touched yet. And Tony, there may
be plans to do so. Do you know more about that than I do?

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

Yeah, they\'re supposed to examine a list of priorities for the next six
months or so, and there are some different \-- I don\'t have the topics
in front of me, but there\'s about a dozen topics that the workgroup
members are supposed to vote on in terms of what should be the
priorities. So we could certainly recommend priorities for them to work
on. If they\'re not on their list.

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

Thank you very much. I think that\'s going to be important. That\'s an
important function. Because we\'re looking very specifically at privacy
issues and security issues in a very unique environment here that\'s
just developing.

So recommendations in that area for the Workgroup, that other Workgroup
to take on, would be most helpful.

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

This is Will Crawford again. The current round of Confidentiality,
Privacy and Security Workgroup recommendations really focus on the first
half of the third bullet point, which is how are patients enrolled, and
of course just on the security and privacy aspects of that which is
really the identity-proofing process of determining that someone
actually is who they say they are. So lots of scope left.

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

Is this one where people would be in agreement in thinking about some
security and privacy issues that you might want to include in a
recommendation? We can talk about that more. Have we heard enough to
think that we might want to move forward with something over the course
of the next several weeks?

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

This is Paul Nichol, wasn\'t this the cross-cutting issue that the
Consumer Empowerment group was also looking at?

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

It\'s whether or not to certify public health records \-- I\'m sorry,
not public health records. Personal health records. Quite Freudian,
wasn\'t it?

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

That would violate the privacy security issues, I think.

\[Laughter\]

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

The certification personal health records was, I thought, a subset of
the initial cross-cutting issue, which was a broader concern about
security authentication, privacy, and confidentiality. So if only the
personal health record piece was addressed, then we\'re kind of back to
rethinking the issue, I guess.

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

In terms of what may or may not be a recommendation , it was just around
the personal health record. So I think the issue is whether or not we
would want to move forward. And I will be very honest. One of the issues
in the Consumer Empowerment Workgroup, is that, right now, the only
certification body is the Certification Commission for Health
Information Technology. Whether or not that\'s the appropriate body is
not so much the issue, I think, for us. It\'s should there be any type
of a certification body for remote technologies that provide information
from a patient setting into a clinical setting, or into a PHR?

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

There\'s two issues. There\'s the exchange application and there\'s the
database. And I think the most \-- and there are concerns in both. So it
may be useful to separate where is the data residing, how secure is it,
what are the privacy, confidentiality issues, who is in control. And
then is there a risk with whatever application is used to exchange that
data.

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

And I\'d add that there are additional technical and \-- there are
certification issues in particular that also are going to come up in the
technical challenges bucket, two papers away. And I guess I\'d also
finally add that some of the care coordination challenges will apply to
the Consumer Empowerment Workgroup, not necessarily in the current round
of discussions, but the personal health record as a virtual medical home
or as a tool for care coordination, is a very powerful concept. It\'s
been the subject of a lot of discussion by a number of groups, and those
issues of how one provides access and how one authorizes and certifies
other people to be participants in the care community around that record
are very important and certainly are not going to go away.

So there might be an additional opportunity for dialog with the Consumer
Empowerment Workgroup.

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

I think what we might do on this one, I think everyone probably wants to
have a little bit more thought on it. We\'ll pull together kind of a
high-level recapitulation of what could be the area, i.e., we may want
to be making a recommendation to the AHIC in March that the Consumer \--
I\'m sorry, that the Confidentiality, Privacy, and Security Workgroup
consider as top priorities, issues of security in remote care devices,
et cetera, something of that nature. And then you can all decide whether
we want to be \-- how specific we want to be, how broad we want to be,
and if we want to go in that direction. Is that okay?

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

Yeah.

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

We\'ll have a vote on this after the meeting. All right. Thank you.

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

Document C. Medical/legal issues and challenges. Again, this was an area
that didn't have quite as much discussion, but a couple of very
important points came up. I think first and foremost for everyone was
how the state licensing processes for medical professionals, which vary
dramatically, both in terms of who's allowed to do what, such as nurse
practitioners being able to prescribe, or not being able to prescribe,
and how, who is allowed to deliver particular kinds of care, might need
to be modified to support care that's provided by nurses and physicians
remotely, and possibly in a centralized environment that's over state
lines. And that triggered one of the recommendations back in May, which
has led to the establishment of the State Health \-- I'm afraid I can't
remember the acronym, but the new state \-- I guess it's the National
Alliance for e-Health, which is having it's first meeting, I believe,
next week. On the 25th, and will be addressing some of these issues.

Second major medical/legal issue, the potential for fraud and abuse.
There are new activities here, things are being done \-- the same
services in different ways, and new services. There is a fraud and abuse
potential.

And then finally, what legal limits prevent the distribution of home
monitoring equipment to particular populations from particular sources?
An example here is the Stark and Anti-kickback exemptions for hospitals
or other care coordination entities providing remote monitoring tools
for further use by patients, to partner practices, and so on. And Karen
may have something to add on this.

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

The only thing I have to add is information that was shared with the EHR
Workgroup last week. We had a very interesting panel of legal experts
that came in and talked about the medical/legal liability of having
information coming in from multiple sources, and a number of other
issues. That testimony is not yet available online. It's still being
developed in terms of a summary format, and will be available shortly.
But that may also be important information for this group to hear, as
well, before we do move forward in this particular area.

Does anyone see the possibility of any recommendation coming right now,
that we haven't already made, because we are dealing with state
licensure issues in another arena, as a result of the previous set of
recommendations, and we also have a fraud and abuse contract with RTI
International that is looking into potentials for fraud and abuse, and
in fact public comment on that \-- but this is just limited to
electronic health records \-- public comment on that is out right now,
so there is an opportunity to review that, if anyone has interest. But
again, that is very specific to fraud and abuse through the use of an
electronic health record, not through telemedicine.

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

Karen?

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

Yes?

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

Can you clarify also what the current contract is between HHS and the
NGA? I thought state licensure tort reform issues were on their plate.
Is that true? Is this something that we could make a recommendation that
the Secretary look to that group, or \-- can you kind of clarify that
for me?

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

It's not really so much tort reform, it's the licensure issue. It's part
of their contract to look into what possibly can be done with the State
Alliance to allow for health information and care to cross state lines.
So that's already there, and in the contract.

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

So we could recommend specifically on licensure, that the Secretary look
to that group, and not \-- I'm trying to understand \--

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

That's what we did last May. We've already, that, we made that
recommendation last May, and that group is already doing that, is
already under contract. So that piece is, we're moving along on that
piece.

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

Gotcha. So your question is, is there anything additional we need to be
recommending at this point.

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

Right. Or whether or not we'd like to wait a little bit, get more
information about things like Stark, Anti-Kickback, how that applies to
remote care, get a little bit more information from the legal team that
informed the EHR Workgroup. Probably not in time for March, but we can
certainly look at, in these areas. So the question is what's your
pleasure on this?

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

I think they have the critical charge. Let's leave it to them.

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

Okay.

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

It's the right group.

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

Yes, I think so. Is there anything else that anyone would like to hear
in terms of testimony on the medical/legal issues, other than the report
that we will bring you from the EHR Workgroup meeting?

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

Karen, this is Jeff Rideout again. What's been pulled, if anything, from
organizations that are already dealing with this? And, again, I mention
the American Telehealth society, but \-- I work with a California-based
group that does a lot of this, and it seems to me that there's a lot
that's already been pulled together on cross-border and licensing issues
for remote care. Is that something that's been pulled already?

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

Yes. They're in the process of working on that, our contractor is, so
they are moving forward in that direction.

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

So basically, the only kind of recommendation we would even be able to
offer would be to defer to that group and try to accommodate the
opportunities that exist for remote patient monitoring under those
recommendations, that kind of thing?

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

Pretty much.

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

Doesn't seem like we can do anything ourselves on it.

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

At this point, on that particular area, no. There may be some
opportunities, as I say, and I don't know \-- we haven't had any
discussion on this, but there may be some opportunities to explore
medical/legal liability for, particularly, clinicians, and whether or
not they feel that remote monitoring and remote care might increase
their liability, or decrease their liability. I'm just throwing that out
as a possibility.

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

Some of that's been done, informally, at least, and maybe if they aren't
doing it specifically, somebody on staff there could talk to some of the
major liability carriers, medical liability carriers, just to get some
sense of their policy on whether physicians use secure messaging, or
remote monitoring, what that does to their premiums and liabilities.
Because in our experience, actually, at least the ones locally have said
it's actually better if physicians are using secure messaging, because
there's documentation of the interaction. So they looked at it more akin
to would we rather them use this kind of system or the phone, as opposed
to we'd rather have them bring everybody into the office.

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

My comments are informal, not formal. This is Jay Sanders. But I can
tell you that this has taken a very interesting turn-around. When
telemedicine was first deployed, there was huge concern about its
liability, especially from the plaintiff attorney sector. The irony is
that now they are looking at this in the reverse way and are saying,
gee, if there was a screw-up in the diagnosis and the primary care
physician had access to a subspecialist with telemedicine, why in the
world didn't they use that access? And that failure to use telemedicine
provides liability, not the use of it. But as you indicated, the
American Telemedicine Association also has done a huge amount of work in
this area and could provide resource material and individuals.

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

So we'll need John to come, John Linkous to come and talk about some of
the previous issues, so perhaps we can (inaudible).

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

Right.

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

Okay. Okay, well I think at this point, we will not be moving forward
with any major recommendation right now, but we will certainly get more
input from the ATA and others and can think through whether or not we're
going to do anything further with this later. Okay? Thank you.

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

Okay. Number 4, cultural issues and challenges. This was a very broad
area, the group heard a lot of testimony on both cultural barriers to
adoption for physician and provider communities, and then also for
patient communities, which are somewhat different issues. Some of the
major issues around the provider community focused on simply modifying
physician workflow, but also perceptions of the effectiveness and the
burdens that would be created by a shift to a more remote-focused method
of care delivery.

And then for patients, obviously, concerns about patient education, the
ability to gain a sufficiently rich interaction with the provider that
more sensitive issues, particularly around medications and compliance
and ongoing conditions and bad news, could be dealt with in an
appropriate way.

We broadly, again, bucketed these into three major challenges. The first
is how can physician adoption of remote care technologies be encouraged,
and then what perceptual barriers to adoption currently exist within the
physician community.

One item that was cited quite frequently was the fear that patients
would abuse the privilege of secure messaging and overwhelm providers.
And a number of groups testified that that was probably not the case.

Second major bucket was what kind of a restructuring of the care
delivery model would be required to most effectively use remote
monitoring and secure messaging technologies. Is there an increased
benefit, for instance, to the scale that reports the weight back if the
patient has a medical home, has an assigned provider, has staff within
that provider office who is actually going to be looking at that data. I
think what that really boils down to is remote monitoring in particular
can generate a tremendous amount of information. Is anyone going to look
at it and use it?

The final bucket of course is how can patients themselves be best
engaged in remote care activities. And that includes a lot of education.
It includes the role of the provider, again, in acting often as the
ambassador for this technology. Or possibly the role of the employer.

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

This is Paul Nichol. This is an issue that we\'re looking at right now
in terms of our \-- the My HealtheVet personal health record and the
home telemonitoring and really it\'s a clinical adoption, clinical
integration, as more and more providers recognize the utility and
usefulness and patients are asking for these things. I think that helps
to promote the clinical adoption.

Again, Eric has, as I learned yesterday, 6 years and 120,000 patient
experience with this issue. And I was impressed that much of what Group
Health did was to emphasize the value from the patient perspective to
their clinical staff as an important means of getting them to accept it.
And Eric may be able to elaborate on that.

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

Yeah, I\'d be happy to, Paul. I don\'t know exactly what you heard from
Ted, but in this report that I mentioned earlier in the conversation,
we\'ve actually got some data, some surveys we did that that approach
worked with the doctors. You know, they said we\'re taking better care
of our patients now because of the increased access to information. And
that was a great source of professional satisfaction. At least it seemed
that way from the survey data. And knowing doctors and being one, I
think it\'s really right on as far as a good way to promote this.

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

Eric, this is Karen. Is the report available publicly yet?

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

Yeah, I think it is. I just wrote my colleagues while we were having
this conversation, but be happy to share it with you. It\'s been sent to
the Foundation and I think we consider it available to all comers. I
just have to check with the project officers.

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

That would be great. And if it is, we\'ll have the Web link online as
well. Thank you.

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

Eric, this is Jay. Is that Steve Downs, at Robert Wood Johnson?

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

I don\'t know, I\'m not the PI on the project. The PI is at the
University of Washington, and we just made it to the deadline, you know,
the usual rush. So the dust is still settling on the electronic version
of it anyway.

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

Okay.

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

Karen, this is Jeff Rideout. A related thing that we\'re involved with
with a number of safety net hospitals here is a virtual video call
center for remote translation services in a hospital setting so we\'re
doing that with a number of county hospitals in partnership with some
major foundations. And I\'m wondering whether that kind of example might
also kind of help people think differently about telehealth, because
it\'s truly a huge step up both in terms of quality and cost savings
versus using dial-in language lines, it does emphasize the remoteness
and the newer technologies that require video. But it\'s also
hospital-based as opposed to ambulatory-based. And it\'s all focused on
cultural competence and some new California state requirements that
hospitals and health plans provide culturally competent care at the
point of care. So that\'s another example that\'s out there, if you want
it.

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

That\'s very exciting, too.

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

It\'s all Medicaid-focused, at the moment, so that\'s another angle on
it.

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

It certainly sounds like this is an area where we could do a lot more
work. There is a lot going on out there, obviously, that we haven\'t
heard about. We know that there are problems, we\'ve heard about some
issues. We heard a lot about some of the issues around secure messaging,
not so much about the issues related to cultural adoption in patients
and physicians, or clinicians, for other forms of remote messaging. So
this could be a very important piece, because I\'ve really become a
believer of the fact that we can create the technology, we can even
figure out ways to finance it, but in the end it\'s the social change
that\'s going to make or break this.

So it certainly sounds like this is going to be a major piece of work
that we could concentrate on if we\'re going to get into this bigger
field of remote care.

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

Yeah, this is Paul Nichol. I absolutely agree with that and like I said
we\'re sort of in the throes of doing that in a couple of different
areas right now within the VA. I think what we\'ve identified is that
lack of familiarity breeds anxiety, and so much of what I\'ve been doing
recently is trying to educate my staff. Fortunately, I have some
excellent examples nearby, and good speakers, but a lot of it is
education and addressing and providing information about studies that
show secure messaging doesn\'t overwhelm doctors, and the benefits. And
you know, getting that information out there is going to be tremendously
important to sort of prepare the field for what we\'re trying to do.

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

Excellent. Thank you. We have one more to go.

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

I think we\'re even on schedule. So technical issues and challenges.
This was the final bucket focused more on, I guess for lack of a better
phrase, physical barriers to implementation. Some of which are
standards- and technology-focused. Some of which are a little bit more,
perhaps, structural. For instance, this is where we bucketed the
workflow issues for providers actually being able to do secure messaging
or to review the results of remote monitoring activities within their
EHR, or within an existing workflow that was most efficient for them
within the provider office.

Another area that came up here is standards, again, and the need
potentially for certification of standards. And we know there had been
some testimony early on from Continua on medical device and
consumer-oriented medical device, monitoring technologies. There was
some thought that could be extended a little bit to go to the next level
and determine perhaps if there are directives that could go from this
group to HITSP, about additional standards identification, for, for
instance, scales that report your weight, your weight to the doctor.

So we had again, four general buckets here. First was the extent that
adoption of remote care technology is linked with adoption of EHRs. And
that\'s particularly important when thinking about provider workflow.
Whether or not remote care can be fostered without widespread EHR
adoption is still something of an open issue.

Second bucket is what technical barriers to physician and patient
adoption remain. Again, fairly broad. That is an area where we want to
think about infrastructure.

Third, and we\'re just talking about this, is how the effectiveness of
these technologies can actually be evaluated both from a financial ROI
perspective but also from a patient use and clinical outcomes
perspective.

And then finally, what standards development activities are required to
enable secure messaging and remote monitoring infrastructure, including
more seamless integration into physician workflow. Some of that was
covered in the original May recommendations from the Workgroup.

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

I just want to \-- this is Jay Sanders. On that first bullet point, to
what extent is adoption of remote care technology linked with adoption
of EHRs and can remote care be fostered without widespread EHR adoption.
First of all, personally, my feeling is that they\'re in effect one and
the same. However, with that said, I wouldn\'t want remote monitoring,
secure messaging to be held hostage initially to whether or not there is
an existing electronic medical record. It\'s not because I\'m not
enthusiastic about it. I wish it happened tomorrow. But I think that\'s
going to still be a slow process. And secure messaging can occur right
now and I hope nobody remembers what I\'m about to say, but you can
print out the message and put it in your paper-based record.

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

This is Jeff. I totally agree with Jay, and we didn\'t share notes
before the call. And you can integrate, certainly, secure messaging
applications into EHRs. There\'s some that are already built in. It
would be horrible if we, you know, wait to do some of these things,
which actually in the remote patient monitoring world are much further
ahead than EHR adoption, certainly. Obviously, getting data into native
applications is a critical thing to think about. But it shouldn\'t be a
hurdle to everything else.

And I think the other question I have is, I apologize but is there
anyone on the Workgroup from Partners Telehealth?

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

There is not at the moment. But Joe Ternullo and Joe Kvedar did a
presentation here a couple of months ago.

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

Yeah, and again I\'m not doing an advertisement for them, but Joe Kvedar
may be a good source because I\'ve seen their methodology for evaluating
the implementation of new telehealth services in their group, which is
100 percent dedicated to telehealth. This is now called ConnectedHealth,
their group. And it would be nice to \-- I\'ve seen their methodology
and had it explained. It might be nice for the group to understand how
they have made their own decisions about which ones have the highest
value, the ROIs, the technical challenges of integration, just so,
again, we can see it in action as opposed to theorize about it.

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

Okay.

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

This is Eric Larson, just to agree with Jay and Jeff\'s comments. I
think that\'s an important point to make, that secure messaging is in
and of itself of value with or without an electronic medical record, and
\-- because I think there may be a misconception that you do want to
wait on some of these things until you have an electronic medical
record. And we know that that transition is hard for many small
practices and large practices.

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

One of the questions that this brings up, though, and I\'m just throwing
this on the table for ongoing discussion, is the degree to which one
needs interoperability of information between a remote monitoring device
and an EHR if someone happens to have it. I absolutely would agree with
all the conversations that they shouldn\'t be dependent. But if you do
have remote monitoring devices, should they be programmed and developed
and architected in a way that if a physician does have an EHR, then the
information should be interoperable, should be able to go from one to
the other?

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

I think \-- this is Jay. I think that\'s one of the primary focus of
what the whole Continua group is doing. I don\'t think that\'s going to
be a technological issue, given the makeup of the Continua group. I
think industry \--

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

You\'re breaking up. I\'m not hearing everything.

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

Could that be you, Eric?

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

No, this is Paul Nichol. That last speaker was sort of in and out.

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

There\'s a little bit of buzz on the line all of a sudden.

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

We\'re hearing it, too.

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

I was muted when this was happening. I\'m on a cell phone, though.

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

I was muted, too.

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

I wanted to comment that I think that this is more of a policy than a
technical issue. I think that information that\'s input into
telemonitoring devices and maintained in some database will have to
conform to standards for data exchange. And then the question is, how is
that data exchanged? We\'re going through that right now within the VA
and trying to figure out which of the data we put into our database and
which stays in a separate stand-alone application.

I think that one of the interesting things with personal health records
is whether patients should be in the middle of that to say yes, you can
have this information or no, you can\'t, and be in more in control. And
some of the health record bank models or personal health record models
would in fact allow a capability for the patient to determine who gets
what.

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

I\'m going to just throw out this question here, and forgive me if it
seems a little bit out of context. But in the same way we\'ve talked
about secure messaging as being a separate entity from electronic health
records, I think everyone is aware that we are moving forward, at the
Secretary\'s direction, with trying to create standards that have been
harmonized so that they can be used in an interoperable way. This is
going to take quite a bit of time.

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

We\'re talking about secure messaging separate from electronic health
records, because only 10 percent of the world has electronic \-- the
U.S. has electronic health records. Not that that\'s necessarily a
desirable state. And again, I\'m sorry I keep talking about Group Health
in such glowing terms, but they have a wonderful integration secure
messaging personal health records for patients and an electronic record
for their providers. And it\'s best done, again, personal opinion, I
guess, if secure messaging is provided in the context of a tethered
record with your primary health system is ideal. That can\'t always be
done and you need other options. But it certainly \-- I don\'t think we
should have a stance that it should be separate. It\'s separate of
necessity right now.

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

Right, and I certainly didn\'t mean that. I\'m just saying that we are
allowing them to essentially be (inaudible) either realize secure
messaging has value separate from the EHR. When we get into the device
monitoring, device monitoring again the market is so far ahead in that
particular area than where the market is with respect to electronic
health records. As you say, only 10 percent of physicians have them. But
we do have this very strong need to move forward at the Secretary\'s
direction toward interoperability of information.

So the real question I have in my mind is the degree to which we want to
encourage the development and the adoption of a remote care using a
number of different types of devices that at this point in time are not
going to be interoperable with anything else in the system, either
electronic health record or a large delivery system's health record, or
any of the PHRs. Or do we want to really be pushing forward with the
development of harmonized interoperability standards that the device
manufacturers and the monitoring, remote technology manufacturers can
start incorporating now?

Am I clear about that? In other words, should we be pushing for HITSP
standards now? For exchange of information between telehealth kinds of
products and delivery systems?

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

I thought that the Cconsumer Empowerment group had a recommendation for
exchange of information between personal health records and EMRs. You
know, in my view it\'s kind of a similar issue. There should be
standards for this kind of data exchange.

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

Just to add, there\'s two kinds of information exchange that are talked
about in conjunction with PHRs and EMRs. One, and this is what\'s
currently encompassed in the existing use cases, is clinical data,
registration history, medication summary, the continuity of care
document or record, for that patient. The other aspect, and this is not
been addressed yet, is the transactional messaging. Appointment
scheduling, the actual clinical queries, or two-way messaging, that in
some cases sits in what some people often call a tethered personal
health record and the EMR. And that area is not, to my knowledge,
currently on the HITSP agenda.

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

Well, you know, we\'re actually going to talk a little bit about what
could be on the HITSP agenda in a few more moments. But it would be
helpful to bring your thoughts to closure on this particular piece here
in terms of whether or not we should be thinking about crafting a
recommendation to the AHIC now, at least around interoperability of
monitoring devices and other types of medical information systems.

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

Well, this is Jay. If we\'re taking a vote, I vote yes.

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

This is Jeff. I think it\'s a good idea so long it is a doesn\'t get
interpreted as a hurdle, another hurdle. And I also, the caveat I have
is a lot of the best telehealth, you know, actually is simply a patient
talking to a nurse over a phone. Or it\'s a simple secure message. So I
think the device part of it is important and Cisco is part of Continua,
and we\'ve been involved in that. It may not be as important as simply
setting up the environment where people can communicate asynchronously
or in different locations and that communication may be something as
simple as a phone call.

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

This is Paul Nichol. I would agree with that. We set up our home
telemonitoring initially as, with a database that ended up being
separate from our electronic medical record, and then had notes entered
that summarized things. So it should be a target that we move toward,
but I would agree that we wouldn\'t want to make it a contingency that
would end up being an obstacle. I think they could \-- we could move
ahead in parallel with this.

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

This is Mohan. I ditto all the comments.

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

Eric Larson, the same. And I don\'t know that it\'s as easy to do this
without making it a hurdle. So what you need to do, I think, is to pay
attention to what is already out there, because a lot of people have
innovated and gone ahead and done things, and to somehow disadvantage
them would be a real shame.

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

So I think the real question is whether or not this should be a
recommendation that this type of activity should go on HITSP\'s road
map. That\'s really, I think, where we\'re coming down to here. And
going on the HITSP road map would mean that ultimately EHRs, both
in-patient and outpatient, would be using these same types of standards,
too.

And if there were \-- and I\'m just saying if \-- if there were a
certification process for monitoring devices or something bigger than
secure messaging, then obviously that would be included as well.

But yeah, it will take time, and question is when would it go on the
HITSP road map? And maybe this is the starting point for the next
discussion, actually.

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

Yeah.

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

And also, Karen, another thought about it would be maybe EHRs that
extend and have the capability of doing secure messaging, you know,
could be seen as preferred. So the direction is not from the tail, which
is the secure messaging, to the dog, which is the EHR, but the other way
around.

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

Exactly. And we certainly know that that model is in existence in a
number of places and works quite well.

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

If we\'re going to be pointing more at HITSP, can you clarify? They were
chartered for the two years, is this something that\'s going to
continue? Are we going to be tasking a group that somehow disappears in
not the near future, but \-- I mean, what kind of is the life of HITSP?
Does this become a permanent fixture at ONC?

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

I\'m not sure it will be a fixture at ONC, but I do think there\'s going
to be for several years to come yet HITSP, which will be defining
structural standards for interoperability in a number of different
areas. Our contract is a two-year contract, but it is anticipated that
HITSP would continue long beyond our contract.

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

Is that contingent upon funding of the office or \-- anything that would
throw a roadblock into that strategy?

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

I don\'t think so. I think that there is sufficient support to keep it
going even beyond the length of this contract. And there are a number of
ways that that could happen. But I don\'t think that\'s the thing we
need to be concentrating on here today.

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

This is Paul Nichol. I\'m sorry, I have to drop off the call. I hope
that doesn\'t disrupt our quorum.

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

No, but you\'re going to miss a very interesting discussion right about
now.

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

Guilt, guilt.

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

If you like, Paul, I\'ll send you an e-mail later, okay?

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

I would very much appreciate that. And I apologize for having to leave
early. I had forgotten how long this was going and I have a competing
group that's waiting for me here.

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

Thank you so much for your input.

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

I apologize. Thank you.

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

The rest of the meeting actually is going to be for your information so
I\'ll give it to you online.

Before I jump into the last item on the agenda, I\'m going to
recapitulate a little bit what our discussion was about. We talked about
these five major areas with the focus on whether or not we were ready to
begin to make some recommendations or think about recommendations for
the March AHIC, and those areas where we thought we needed more
discussion in order to make some decisions about recommendations.

So what we have at the moment are two areas where it is likely that we
will make some form of recommendation. One is in the area of
confidentiality, policy and security, in terms of directions that we
think the Workgroup, that Workgroup should go in. And the second one was
\-- actually, there are three.

The second one was a discussion we just had about technical issues and
challenges we may want to make a \-- and again, this depends on how we
craft it. We can always change our mind later. But at least go forward
with thinking about a reccomendation on interoperability, with some
caveats.

And then the third one was in the area of financial issues and
challenges where we will be making a recommendation to work through a
number of issues and also we will need more testimony in that arena.

We\'re also going to be hearing more testimony in the area of the
medical/legal issues, and we\'re going to be doing more work around
cultural and social issues with respect to the broader charge of remote
care. So that\'s where we ended up. And we will put together a brief
synopsis of this discussion. You\'ll have an opportunity to make
comment, vote yea or nay on moving forward. And then we will actually
get around to crafting some recommendations for you, some draft
recommendations for you, for the next meeting. Okay?

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

Sounds good to me. This is Mohan.

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

Everybody still with me? Can we last a few more minutes?

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

Yeah.

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

This is an update for you on use cases. There is going to be a
presentation at the American Health Information Community on Tuesday of
next week. And preliminary \-- this presentation has been preliminarily
been distributed to all of the Workgroup co-chairs, so Craig have will
gotten one, Brian. Tony, you should have gotten yours already. And there
will also be distributed to several Workgroup members that are
representing three different stakeholder groups. We have Blackford
Middleton from the EHR Workgroup that\'s representing the provider
stakeholder. Rose Marie Robertson from Consumer Empowerment is
representing the patient or the consumer stakeholder. And Carolyn
Clancy, who is the head of AHRQ and the head of the Quality Workgroup,
and John Lumpkin will be representing the interests of the stakeholders
that are not engaged in primary care. Or primarily in direct care. And
that would clearly be the quality reporting, the public health, the
research agendas.

Each of the co-chairs, every member of the AHIC, and these three
presenters, have been given a document that basically describes our
definition of a use case. A use case is primarily a pretty easy thing to
describe, but can be quite complicated, in that it\'s a description of
the events, the detail, how a system needs to achieve very specific
goals to meet the missions of very specific stakeholders.

The general concept is that these use cases lead to work that develop
specific software. That\'s been the traditional definition of use case.
We\'ve expanded it somewhat so that it not only meets that very specific
concept, but it also thinks through about all of the entities or
organizations that are interested in that particular kind of a what I
would call a priority or a particular area.

So what we\'ve done is taken all of the input that\'s come from all of
the Workgroups, including this one, and divided that input into these
three different kinds of stakeholder groups. The consumer or the
patient, the provider, and the population one. And looked at the options
for use case development that we could do moving forward. The American
Health Information Community is being asked to vote on these, and from
the perspective that their vote will prioritize these, what we\'re
calling use cases or priority areas, and that that prioritization
process will essentially lead to the road map that HITSP will work from,
that the NHIN contractors will work from, that a number of other of our
contracting partnerships will work from.

So what I\'d like to do with this particular group today, with all of
you today, is just to give you a brief overview of what those priority
areas are, because you have an opportunity to get to your co-chairs and
suggest to them the way you think that the vote should go. So that\'s
\-- this is an opportunity for you to give input, again, to your
co-chairs of this Workgroup, or to anyone else on the AHIC as they go
through this prioritization process.

Now, when it comes to the patient or consumer view, there are three
options here. One, thank goodness, is remote monitoring. It is
essentially recognizing that in order to move forward with this, whether
it\'s home devices or a number of other entities \-- and this is, this
was developed from all of your words, so I don\'t need to repeat it. But
it would essentially move forward with asking HITSP to come up with
standards for interoperability of vital signs, weight, blood pressure,
heart rate rhythm, pulse/ox symmetry, labs, glucose, that sort of thing.
Meanwhile, we would need to continue to work on issues related to
medical liability risk and some of the other ones that we\'ve talked
about. So that\'s the first of the three that are on that plate.

The second is remote consultation. And actually, this one was teed up by
not our Workgroup, but by the Consumer Empowerment Workgroup. And this
is essentially secure messaging. We\'ve already done a lot of work
around this, but the Consumer Empowerment Workgroup teed it up not quite
recognizing the degree to which we\'ve already done a lot of work in
this area. So the \-- I\'m sure that the American Health Information
Community will look at some way to try to harmonize the two.

But in the situation that the Consumer Empowerment Workgroup was
focusing on, it was also not just the communication. It was also the
ability to have reminders and get other information on how to manage
your care better. So it\'s a little bit broader than we initially had.

And then there\'s a third one, which again is from the Consumer
Empowerment Workgroup, primarily, which is the consumer access to
clinical information. And essentially that\'s the step to move forward
to making sure that any type of what we\'re calling the PHR, though we
don\'t really have a good definition for it yet, will have the ability
to share information not only with the entity that\'s providing the
information, i.e., a lab, but also would be able to pass that
information on to another one. So those are the three in that particular
area.

The second area is that of the provider. And here we have two options.
One is medication management, and really looking at all of the issues
necessary for that. And this goes beyond simple E-prescribing, not that
E-prescribing is very simple, but it certainly gets into the area of
monitoring medication, of assuring that there\'s good clinical decision
support, and that patients are taking the medications, even.

So there is that issue from that particular stakeholder viewpoint. And
the second one there is referrals and transfer of care, transferring
information from one setting to another, as the second priority area in
the provider perspective. And then the third area is population use,
population use cases. And here we have three also. One is in the area of
quality reporting. The second is in the area of public health case
reporting. And the third is in the area of emergency response
management. And I\'m not going to go into those in too much depth, but I
did want to at least make you aware that they are there and they will be
discussed as well.

So we have now a total of eight different possible use cases, or
possible different areas that we can move forward with for HITSP and the
NHIN, and everyone else to focus on. I would also say that there are
some enabling work that will need to be done in these areas as well. So
there\'s a tremendous amount of work that these priorities entail.

We believe that we can probably take on another three this year. So
we\'re going to have to winnow \-- not winnow, but we\'re going to have
to prioritize these down to three. So I would again just encourage you
to think through a little bit about what your priorities might be. Not
necessarily for the Chronic Care Workgroup member but as a consumer, a
provider, or someone who is interested in the population\'s health.
These decisions are going to affect how things are roll out across the
country.

So I\'m going to close by just going over that \-- those lists slowly,
one more time, and allow to you jot them down. And I do apologize. We do
not have this ready for public discussion yet. It will be, on Monday it
will be available on the AHIC Website. Monday or Tuesday? Tuesday.
Sorry. It will be available Tuesday on the AHIC Website.

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

How many times can we vote?

\[Laughter\]

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

Often!

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

Often, vote often. We should all join the AHIC here.

Okay, so \--

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

Paul gave me his vote after he left.

\[Laughter\]

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

I thought Paul gave me his vote.

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

You can tell Paul didn\'t want to leave.

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

Again, from the consumer/patient perspective, three possible use cases
or priorities. One, remote monitoring. Two, remote consultation slash
secure messaging, and a number of support services that go with it.
Three, consumer access to clinical information.

From the provider perspective. One, medication management. Two, referral
and transfer of care.

From the population perspective. One, quality reporting. Two, public
health case reporting. Three, response management.

And I will add that response management is very similar to a use case
that we are already working on, and that\'s the emergency electronic
health record recommendations about which were made to the AHIC, I
believe back in November and as part of an additional piece from the EHR
Workgroup. So that one is actually moving forward. So we\'re talking
about three others. You don\'t have to vote for that one.

Any questions?

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

So let me \-- this is Mohan again. When you say we vote. Are we to vote
between the choices within each segment, or \--

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

I think the bottom line on this one is that you actually don\'t get a
chance to vote. But your co-chairs have input here. So you need to get
to your co-chairs and tell them what you think are your top priorities.

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

Okay.

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

And they will move those forward.

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

Okay.

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

Mohan, I hope you realize throughout this meeting that I made a New
Year\'s resolution not to disagree with you.

\[Laughter\]

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

And by the way, my children consider me a payor.

\[Laughter\]

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

Even when we have adult children, it\'s that way, you know.

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

Right.

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

Could you tell us what the \-- again, what\'s in the bucket that you
called remote consultation. Is that really, you know, quote, just the
whole domain of secure messaging between a provider and a patient? Is
that what we\'re talking about?

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

I\'m going to read you the detail since you asked. Based on the
information provided through remote monitoring and other sources,
consumers could consult with their healthcare providers remotely. This
could occur through secure e-mail as well as real-time online
consultation. Patients could also benefit from reminders initiated by
clinicians that would be delivered via e-mail or other means to remind
patients of events and activities that are important to maintain their
level of health.

And then the kinds of things that, again, are being pulled out and
focused on here, that the HITSP, NHIN, et cetera would work on would be
structured e-mail, online consultation, and reminders, and what kinds of
interoperability standards can be developed around that and how would
that integrate into a health architecture, as well as what are some of
the Workgroup issues that would need to be talked about. The
medical/legal liability risk, for instance. And the degree to which a
PHR would need to integrate into this kind of a situation. As well as
the quality of any prepopulated data that might be available. So that\'s
the remote consultation.

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

Thank you.

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

Karen, this is Jeff Rideout. I guess I\'m just catching up with this.
Who is voting, and are we supposed to formally do this? Or is it just
sort of a \--

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

I wish you could formally vote. But the only real voting members are
going to be the AHIC members. And \--

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

So we lobby is what we do.

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

Exactly. But \-- and so you provide your co-chairs with information on
what you think is important in terms of your prioritization process. And
then you get to vote that way. It\'s a very \-- it\'s a little bit like
voting in Congress.

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

Just for clarification. The AHIC members, like Craig would represent all
of IT. He\'s going to be taking comments from those folks as well. And
also, I mean, I was part of the e-mail exchange that was sent out, so
I\'m probably \-- I\'ve seen some of the information that you\'re
referencing that a lot of folks haven\'t seen. My understanding is they
want comments back by close of business today.

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

I was going to say the same thing, Brian. That\'s the same message I
got. If anybody has any recommendations, they better get it to us pretty
quick.

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

Except this is just the preliminary vote on this, just to sort of make
sure people understand where we\'re going and what the priorities might
be.

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

Yeah, I understand \--

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

The full discussion is going to happen Tuesday. So there\'s no decision
being made today at all. The decision will be made at the AHIC after a
lot of robust discussion.

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

Back to my point, though. I mean, most of the folks on AHIC are fairly
engaged in their day-to-day activities. For them to get this information
\-- for me to get the information up to Craig in a way that he can \--
or even Tony can take this up to his boss, in a time frame that this is
going to be valuable and meet HHS\'s deadline is problematic to me. If
they\'re happy to take the voting until the morning of Tuesday, then I
think you\'ve got time to get input from everybody. Unless you want to
go on a mad e-mail lobbying campaign in the next two days.

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

I just want to underline the fact that there is no voting going on
today. And I\'ll let Judy explain why there\'s something that\'s due
today. The discussion is going to be had in full on Tuesday, and the
voting and prioritization will be on Tuesday. Judy, do you want to \--

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

Right. We had set out a ranking tool basically just to get a general
pulse of where people are on these various issues. And as Karen said,
the dust hasn\'t settled. It\'s just a way to kind of sort of see where
the higher priority might be. But we expect that there will be a lot of
discussion and, you know, hopefully leading to something that will be
beneficial.

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

And I think \-- and frankly, one of the reasons for sending out
something like this is that if we get something back from you, we know
that you\'ve read it, you understood it, you've thought about it, and
that the AHIC member will come to the meeting on Tuesday having had some
previous thought and discussion going into the meeting so that the
meeting itself can really be a really good thoughtful discussion. And
thorough.

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

This is Eric. Let me just throw in some \-- something to reach the
discussion here. As I read over the list I wrote down, and think about
our discussions on this committee, it seems to me like the remote
monitoring and remote consultation secure messaging are front and center
for us and for great value for patients. And they could almost be joined
together.

And then there\'s, I think, pretty good evidence now that referral and
transfer information for doctors and facilities is just a huge, huge
gain in the area of patient safety. And to improve quality. So just
picking three out of the air that I would argue strongly for in terms of
maximum benefit, those would be right up there on my list.

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

One of the things we could do in the next \-- I\'m looking at Cinyon
over here. Tell me no if you can\'t do this. We could probably, as we
come to a close, between 4:00 and 4:30, just get this list out to all of
you and then you can respond to all on the list and that will allow Tony
and Craig to see your thoughts. Would that be helpful?

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

Yes.

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

Okay, I heard one yes, so we\'ll \-- is that okay Cinyon? Okay, we\'ll
do that.

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

And will the list have the kind of detail you just read when I asked but
remote consultation? Or will it just have topics?

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

Yes, we\'ll send you the slide deck.

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

I guess I should thank you.

\[Laughter\]

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

I can go do that now. I have the e-mail so I\'ll go do that now.

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

Judy Sparrow is kind enough to absent herself, and she will do that
right now. Thanks Judy.

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

You\'re welcome.

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

Okay, so everybody\'s got homework. Some tonight and then a little bit
more when we do the second send-out on the possible recommendations. Are
we finishing on time today? Tony, Brian, I\'ve done most of the talking
today. Would you like to make any closing comments?

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

Do we want to take public comment?

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

Yeah, we need to take public comment. But before we do that, do we have
any other comments we want to make? I don\'t think at this point that I
have any additional comments. Brian, do you?

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

No.

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

Okay. I\'m being reminded that our next meeting is the 15th of February.
Again, we have quite a bit of work to do by then, so keep an eye out for
e-mails from myself, actually, probably not me, probably from Cinyon or
Will, and we\'ll get all this information back to you. But you can let
me know of any concerns or thoughts you may have, too.

Okay, well, thank you very much. We\'re now going to go to the public
comment period. The numbers should be on everyone\'s screen, if anyone
would like to contribute to today\'s discussion, please feel free to do
so now.

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

And as always, I\'ll remind anybody who called in earlier because they
were having audio difficulties with the Webcast, if you are already
dialed in, just press star-1 on your phone.

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

In the interim, I would like to thank everybody for doing a lot of very
good work today. It was very, very helpful to move forward with this and
I again particularly want to thank both Cinyon and Will, Will Crawford,
for the amount of work they did organizing all of this. I think we all
appreciate how much happens when we have a lot of different public
presentations, and the ability to collect it all in a way that we can
really synthesize something from it has been really, really very
helpful. So thank you, Cinyon, and thank you, Will.

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

Hear hear!

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

Anyone calling in?

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

Nope, doesn\'t look like it today.

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

So if I keep to a schedule, then the reward is we can leave ten minutes
early?

**[\>\>]{.underline}\
**The reward is send all your votes to Karen Bell.

\[Laughter\]

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

That\'s right.

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

Well, thank you.

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

Thank you, all. Good meeting.

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

Bye-bye.

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

Okay, thanks.

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

Thanks.