American Health Information Community

EHR Workgroup Meeting #8

August 15, 2006

**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}**

You can go ahead, Lillee.

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

Good afternoon, everyone. Good morning to those on the West Coast, and
good afternoon to those on the East Coast. Today is Tuesday, August 15,
and this is the Electronic Health Records Workgroup of the American
Health Information Community.

I\'m Lillee Gelinas, I\'m Vice President for clinical performance and
chief nursing officer at VHA, and I will be your Co-chair for the day.

I\'d like to begin, perhaps, with just a roll call so we know who has
joined us. Matt, if you would be so kind as to take a roll call now.

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

Sure. On the phone for today\'s meeting, Ken Waldbillig from EMC here
for Mark Lewis today, Howard Isenstein from the Federation of American
Hospitals is representing Chip Kahn. Bart Harmon from the Department of
Defense. Daniel Morreale from AtlantiCare is representing George Lynn.
John Tooker from the College of American Physicians \-- American College
of Physicians, excuse me. Jim Sorace for Barry Straube from CMS. And
Robert Kolodner from the Department of Veteran Affairs. Is there \--
Karen, anybody from the Workgroup with you at ONC today?

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

No, there is not. At least not at the present time.

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

Just quickly, reminders of call-in procedures for the Workgroup members.
Please keep your computer speakers muted and keep your phones muted when
you\'re not saying anything. When you do have a comment to make, please
say who it is before you start speaking. If you\'re following along on
the Webcast, don\'t touch any of the buttons to advance the slides. For
members of the public who are listening in, you will be given an
opportunity to ask questions or make comments at the end of the meeting.
Lillee, I believe that\'s it.

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

Matt, thank you so much. I\'d like to bring your attention to the
Department of Human and Health Services Website there is the Workgroup
agenda. We\'re going to be reviewing the call in procedures for FACA
guidelines in just a moment. We\'ll also hear testimony today from
practicing physicians and others as to some of the cultural barriers and
other components that we need to consider as we look at what is it going
to take for large-scale electronic health record adoption.

I\'d like to now call on Judith Sparrow to review for us call-in
procedures and the FACA guidelines. Judith?

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

Thank you, Lillee. This is Judy Sparrow, the AHIC Director of the Office
of the National Coordinator in Washington, D.C. I have sent out to each
of you a shortened version of the FACA, Federal Advisory Committee Act.
And just to briefly remind you, this is a public meeting, it has been
announced in the *Federal Register*, so we are operating in something of
a fish bowl here, and we do keep detailed minutes which will be
available on our Website after the meeting, a few days after the
meeting. And to remind you that our role is advisory, we advise the AHIC
which in turn makes recommendations to the Secretary. So I think Matt
has reviewed the call-in procedures, and just to remind you again that
only Workgroup members may speak during the meeting, and then at the end
of the meeting we will have a period of time for public comment. Thanks,
Lillee.

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

Judy, thank you so much. We really appreciate the leadership you\'re
exhibiting as AHIC Executive Director.

I\'d like the Workgroup members to look at some of the Workgroup
discussion we will be holding right after our formal testimony, when we
really need to talk robustly about identifying the next priorities for
creating value in electronic health record systems. But we also want to
make sure that we spend some time on the critical issues with respect to
legal considerations that frequently are barriers to adoption.

So before we begin with our testimony, I\'d like to ask if the committee
members have reviewed and been able to look at the minutes from our July
Workgroup meeting, and are there any additions or corrections we should
consider.

Hearing none, I\'ll declare a consensus, and submit the minutes from our
previous July meeting are accepted as presented.

Karen, it would be great if you could introduce our first speaker as we
are looking at some of the testimony that we needed to hear and
consider, in order to make our discussions more robust towards the end
of the call. So I\'d ask you to please introduce Dr. Ralston.

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

I would be absolutely delighted to. Dr. Fred Ralston is actually coming
to us from the coast of Maine this morning, but he is a regent and chair
of the Board of Governors of the American College of Physicians. His
comments today really will be coming to us as those of a practicing
physician who has used an electronic health record for over two years,
and is clear about the needs for information that\'s coming in an
interoperable sense, the need to acquire information from multiple
sources. So without further ado I\'d like to introduce Dr. Fred Ralston,
who will be able to speak to us for about 15 or 20 moments \-- minutes,
and we will then have an opportunity to ask questions. Dr. Ralston.

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

Thank you. I\'m a general internist, I work with two other internists,
four family physicians, a pediatrician, and a nurse practitioner. I\'ve
given some background information in interest of time about our practice
and the specific products that we use, and I just would remind everyone
I have no financial link with any company.

I\'d like to give some perspective, because I also talk about this with
other members of our group and at medical meetings, those who are
considering taking the plunge. And what I tell them and what they
certainly know is that they have to balance their individual risks and
benefits of adopting an electronic health record in much the same way
that we as physicians consider the risk of bleeding when we place a
patient on blood thinner for a specific medical indication.

The risks certainly are obvious to this group, the financial costs
involved, the software, hardware, maintenance, and support costs. But
certainly, as a practicing physician, the opportunity cost is something
that has to be focused in, because it becomes the absolute be-all and
end-all of your practice during the selection practice, the transition
from paper and during initial period of use. There are many areas that
are going to get less attention.

One of the things that I\'ve continued to say when I talk to other
people, when our group researched the purchase of our electronic record
we asked every group we visited the same question: Could you ever go
back to paper and charts. And the reassuring answer that we got was no,
in every case. This was not the same when we talked to people who had
had more budget-based, Internet-based systems; they often had gone back
to paper.

One of the bigger things that we see in talking to others this group
size, is eight physicians, I guess we\'re sort of medium at least in
some universes. Smaller practices certainly allow easier consensus among
the group members, but lack the economies of scale. And one of the early
adopters in Tennessee is a fellow internist friend of mine who shows the
slide of the camper his family uses at the beach, when others stayed in
nice vacation homes, he calls that the house that electronic records
built. But he loves EHR in any case.

In larger groups the dollars are less of an issue but it\'s harder to
come to a decision, and a key decision seems to be whether to mandate
participation. A yes can cause physicians to leave, and a no can delay
or prevent complete participation by all physicians. We exempted one
senior family physician in our group simply because we couldn\'t afford
to lose him. But that\'s obviously going to be a decision that\'s going
to be made in different ways. We know when we were interviewing \-- or
selecting a record, another group lost a physician because he didn\'t
want to take the plunge. Then the group he moved to adopted the same
record some six months later, and he saw the handwriting on the wall.

Other variables that we\'ve seen, the technology comfort factor, whether
people use computers at home, and their typing skills.

One of the big things that we see, and this certainly echoes American
College of Physicians\' testimony before Congress, is that it\'s harder
to make a business case for the record when the physicians are paying
most of the costs, but the benefits are being shared in large measure by
others. And that\'s one thing that certainly would change the direction
of the equation.

That really, to me, is the single biggest road block, the payment
disconnect. If every party was paying for proportional costs of the
electronic record, the business case would be a slam dunk. If the
physician continues to pay all or most, then the economic case is a bit
more marginal.

Just giving our group perspective, and moving on to the functionalities,
in our group we knew that we would have an electronic record eventually.
We knew it was the right thing to do, we felt strongly it would improve
efficiency because we saw too much paper floating around.

The money part scared us to death. Even though the quality improvement
organization in Tennessee and the former chairman of medicine there have
both cited us as one of the most progressive groups in the State, we
always feel like we\'re one bad decision away from going out of
business. And that\'s something that I think when you look at your
targets in primary care, general internal medicine, family medicine, and
pediatrics in particular, you have to remember the challenging financial
environment that they live in. Five percent Medicare cut would lower
income probably by about 13 percent.

So that was why we didn\'t do it sooner. But why did we do it? And I
think with every group there will be a different trigger point, there
are probably a lot of people on the verge of doing it. We did it because
we needed a med-peds doctor to continue to have OB care in the
community. If we couldn\'t run a critical care nursery we couldn\'t have
OB in our small town, so this was simply part of the package that we
offered to attract her.

And the year that we recruited her, we got the only med-peds graduate
who didn\'t have previous obligations finishing in the State of
Tennessee.

So in our selection process, what did we do right in picking the record?
We counted on our professional societies and personal contacts to get
advice, and the selection process was logical and was not driven by the
vendors. We had excellent professional IT support locally, which was
crucial.

In the selection process, our team included both physicians and the two
top office staff members. Managers and physicians each had input, and
essentially veto power over the final selection, and this process ended
up helping us pick a product that works both clinically and from a
management standpoint. And in visiting other places, we\'ve seen records
that were stronger in one regard than the other.

We did some wrong things, we tried to design a system that was perfect
from the start, when our paper charts weren\'t perfect, and it probably
cost us a little bit more money than it should have.

We also learned from a company trainer who dealt with all specialties,
and that was simply wrong. We wasted a lot of time and effort in doing
that.

Okay, the function that is we love about our office record, everything
is where it should be. If the lab gets entered in the computer
appropriately, there are no lost reports, there are no lost charts,
there are no charts in disarray because it was copied, and scheduling is
linked to the record. Those are all things that we would never give up.

The integration of the office lab is absolutely crucial. Without extra
dictation or flow sheets that never seem to be filled out, it\'s easy to
see when I ordered the last microalbumin on diabetics, the last
chemistry on patients on an ACE inhibitor. If you have a patient going
into renal failure, it\'s easy to document the changes. And \--

\[phone ringing\]

\-- are others there? I hear a ringing.

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

Hold on one second, I\'ll try to get that muted.

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

I thought that was your phone.

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

That was happening earlier I think.

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

Is that you?

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

It\'s definitely a phone call coming in.

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

I guess the main option is to talk over it.

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

Let\'s give 20 more seconds see if we can identify it, or if even if we
can\'t mute it.

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

Dr. Ralston, this is Lillee Gelinas. You were beginning to really
concentrate on things that you liked about your system.

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

Yes.

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

And those are things we are enormously interested in, is what were the
aspects that really facilitated you liking it so much. When we get to
discussion I just wanted you to think about it, because we frequently
hear nothing but the bad.

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

Right.

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

Sounds like you can continue now.

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

Okay. If I have a hypertensive patient, for example, whose kidney
function is deteriorating, it\'s easy to print out a flow sheet when I
refer to a nephrologist. In the past that involved often scurrying about
for various papers from a lab, and I love that functionality. I think
one of the biggest things that really saved us time from the very
beginning was the ability to do asynchronous communication. We can send
and receive messages even to my nurse who is two feet away without
interrupting workflow. If she\'s in the middle of something or I\'m in
the middle of something, I can have something sent that I know is going
to be dealt with. There\'s no worry of lost pieces of paper or post-it
notes, the patient chart is attached to the message. And in particular,
triage nurses, schedulers, both nurses and physicians, can all access
the chart directly, rather than having to search for a chart that\'s
been pulled by somebody else.

That\'s probably one of the functions that is inherent in all systems
that is an absolute gem. I only now vaguely recall the havoc wreaked by
pulled charts that can\'t be located and an urgent patient message
associated with them.

Also another nice little byproduct is just that Internet access is
always easy and available, simply because you have technology to do
that.

We love the prescription refills. They could be better, but boy,
they\'re a lot better than the old system. They\'re always, at least the
way that we do the flow in our office, easily accessible with the chart
at hand. You can quickly view the missed appointments, you can document
the refills.

Ordering of outside tests is a godsend. Mammograms, you can quickly view
when the last mammogram was done, two clicks and you\'ve ordered a test
with the demographic information already attached. The order is
documented.

The things that we don\'t like, it sounds like you\'ve heard enough of
this, we hate scanned lab. The whole idea of interfaces, which I
understand you\'re trying to work on, has been a real nightmare. Our
private reference lab that we work with, we\'ve been able to set one up
so that the data they provide is just as good as if we did in our own
in-office lab. Unfortunately, one private insurer came along and decided
to use a different reference lab owned by the same company, it\'s now
scanned data, they don\'t care, they wouldn\'t let us use the reference
lab or our own lab. That kind of thing is frustrating. I understand
you\'re going to make some changes that improve that.

There are lots of things about our hospital record that tell us what we
do like about our office record. It\'s cumbersome and slow, it\'s
underutilized, but in particular it was not selected with physician
input and there\'s no champion driving for, A, better understanding of
how it already works, and failing that, better updates. Significant data
in the hospital chart can be buried in text fields, and virtually
nothing in the office, at least where we have anything to do with it, is
lost in a text field. You can have a critical vital sign, and have no
clue unless you read every aspect of the record.

But what I tell people about our electronic health record, the first
thing I say is we never could go back to paper, it's just isn\'t an
option anymore. There\'s a logic and natural order of care that \-- with
EHR that makes sense, and would only improve with time. It already is
better than paper, and our gut feelings is it\'s going to continue to
improve. There are many things that we learn about the system that
we\'re not fully utilizing, and many ways that others can improve the
system that we have to make it better.

I think in what we would suggest to you, to make electronic health
record better, would be better interfaces with the connected world. All
the lab that we order, we would love to have interfaced with our system
as real data. And the second step, which I understand you\'ve been
working on, is to have all lab ordered by others available for download
to our system as real data. So that we can simply add what incremental
lab we might need, or have the benefit of the lab that someone has
recently obtained.

We would like our reports to come to us by e-mail rather than fax or
mail and then have to be scanned in, and it makes sense that there could
be some kind of universal coding where a mammogram is labeled as a
mammogram, and there\'s a patient identifier so that it could come to us
review, and then to file in the appropriate place in the chart.

We would love some improvements in the electronic prescribing and refill
management. There needs to be more space for comments, pediatric doses
often won\'t fit. Messages which I tend to use regarding the use of
medicines for my patients won\'t fit in the data field allocated. I like
to put in my older patients for heart and blood pressure, for example.
Or if I\'m responding to an electronic request, needs appointment before
additional refills will be authorized. And there\'s simply not enough
room in the text field, you can only accept or reject and only have
limited comment. One dream wish would be a Palm type reconciliation
between different systems.

Currently, our office and hospital systems don\'t talk to each other. I
have to fax a med list when I admit the patient to the hospital, and on
discharge from the hospital I do get a nice form where I can reconcile
it by hand, but I would love to be able to synch that the way I do my
Palm and desktop, where any discrepancies and information either follow
predetermined rules, where the most recent is accepted, or I get to
pick. I think that would make a big difference.

It\'s hard to hand off a patient, and I know that\'s one of the quality
functions that the joint commission has focused on, and then when you
start getting into different physicians it makes it even harder. So
having the systems speak with each other would make a real difference.

The bottom line, as far as efficiency, we feel that it\'s already
helpful, but it\'s getting better over time, and that interaction among
people using the system can make it better. There\'s a feeling of
professional satisfaction, although there is a feeling that we\'re
making sacrifices in doing that, at least at this level.

There are probably two business cases that you can make for electronic
records. The strong case I\'m not willing to make, and I don\'t think
you would want to hear, because there probably are some opportunities
for the doctors who were going to weekend seminars to add gimmicks to
see more episodic patients and code aggressively. The case I would be
willing to make, and you might want to hear, would be that it would
appeal to the doctors who are really trying to do the right thing for
their patients, and are always looking for the best ways to keep up and
improve the quality of care that they give.

There is probably a financial opportunity to correct chronic undercoding
when caring for complex patients, and I think in our instance, there is
an opportunity to recruit new physicians and primary care from a very
limited pipeline.

There\'s a time I\'m sure in every system where ongoing costs are likely
to be more than offset from savings. It\'s going to vary, depending on
the individual practice. Most vendors will give you figures that are
unrealistic. And the business case would be much stronger if there were
shared costs in setting those systems up.

I\'m glad our practice did it. Right now, there still has to be a
component of altruism involved in the decision to adopt that. And I\'ll
be happy to make any comments or answer any questions.

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

Dr. Ralston, that was very enlightening and exactly what the Workgroup
needs to hear. Are there any questions from the Workgroup members for
Dr. Ralston?

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

This is Howard Isenstein from the Federation of American Hospitals.

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

Welcome, Howard.

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

Two questions. The first one is when selecting out of the scores of
products out there, did you get any help from your local medical
society, or what advice would you give to other physician groups of
where to find sources to \-- which vendor to select.

And then the second question I have is, as you may know, the HHS just
issued regulations giving hospitals and others safe harbor and Stark
anti-kickback exemptions to give health information technology to
physicians. Would that have helped you in any way if your local
hospital, the hospitals you are on, you have privileges, were to have
partnered with, would that have helped in any way, or would you have
been interested in getting it from them?

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

Well, in answering the last question first, the particular thing that we
would have very much liked would have been a better interface. And I
live in a small community, we have wonderful relations with our
hospital, I was a board member there for eleven years. But the
functionality for individual practices right now seems to vary among the
product, so I\'m not sure that any hospital right now would be able to
offer a product that would be best suited for an orthopedic practice, an
internal medicine practice, or an ear, nose, and throat practice.

I think it would be certainly helpful to explore, and these systems may
morph as companies acquire each other, where a number of vendors can
provide products that are appropriate for multiple specialties. I see,
and once again, I\'m a big advocate of the medical society, I\'m a
former chairman of my State medical society, but I think the specialty
societies here play a key role. Because there are records that are
clearly wonderful for internal medicine that are not suited for surgical
specialties, and vice versa. And so we got advice, and then I\'ve worked
in my leadership role in the American College of Physicians in trying to
help improve that process from ACP. There wasn\'t as much as a formal
process when we went through that, we\'re trying to improve that
function. But I certainly got a short list from a trusted speaker at the
annual session of the companies that were solvent enough and had a
reasonable number of users. And that was where we started the short list
from.

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

Thanks very much.

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

Any other questions?

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

Doctor, this is Ken Waldbillig from EMC. A quick question relative to
any functionality or desired functionality in the area of decision
support. And then secondly, were there any financial incentives that you
think might be helpful to \-- maybe from a tax advantage perspective, to
offset maybe some of the depreciation cost of your acquisition?

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

I think that any assistance financially would be quite beneficial. I
think there\'s a tremendous fear in practices that are really on the
edge right now in adding additional debt. So while a tax incentive would
be beneficial, it\'s that fear of signing at the bottom line that has a
real key part. And I forget the first part of your \--

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

Decision support.

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

I would love to have that embedded. I used a peer from the ACP, and I
simply have to have it set up in a separate screen, but I would love to
have a link from \-- you know, from the diagnosis into an appropriate
tool.

But, you know, once you have the Internet access there in your lab, if
you have a question or an issue, it\'s pretty easy to use your other
tools. But I do feel that in an ideal world later that will be
integrated.

And I will say that we are cooperating with QSource, the Tennessee
Quality Improvement Organization. We\'ve been an advocate, we\'ve talked
with a number of other physician practices, and we\'re starting to
gather the data and help in the quality improvement process. But the
first priority in setting up a system like that has to be to make it
work, and to have the practice not melt down in the process. So we\'re
probably not nearly as far along in that as we would like to be.

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

Thank you.

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

This is John Tooker. Thanks very much for doing this on your vacation.
Thinking of your relationship to your hospital and the relaxation of the
kickback requirements, do you think that if physicians now are thinking
about a relationship with their hospital which would make it easier for
them to acquire health information technology in the maintenance, that
the hospitals would expect a certain quid pro quo for providing that
service?

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

Of course, I live in an unusual world, as you know, with really
essentially no outside ownership of any of the medical providers in our
community or the hospital, and so we all are collegial, but we all
pretty much are stuck with each other. I\'m going to admit my patients
to their hospital, and they know it. So there might be a different
answer in a different city.

In particular, though, I would advise any physician who was considering
getting a, quote, free or reduced-cost record from a hospital to talk
with a physician in a similar practice, in the same specialty, who has
used that system, and make sure that it works in the real world.

There are too many of the cookie-cutter systems that simply don\'t work
in certain specialties.

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

Thanks. If you have any trouble with that phone in Maine, let me know.

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

Thank you so much.

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

Doctor, this is Karen Bell. You mentioned a little bit earlier that
you\'re very much looking forward to having the interfaces so you can
capture laboratory data without having to build a lot of interfaces.

If you were to think about which other interfaces would be most useful
to you, what would those be? Would they be vaccines, would they be
radiology results? There are lots of things that you might want to share
with other clinicians or obtain from other providers. So could you just
take a moment and think through maybe the top half dozen or so, or top
three, that you would next like to see immediately available without
special interfaces?

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

Okay, well, I\'m assuming the lab is in the pipeline.

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

You\'ve already got lab.

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

Okay, I think that radiology is certainly something that would be very
helpful, although the volume still is small enough on that that we can
handle that coming in by hand.

I mean, in an ideal world, I would love a report from a rheumatologist,
for example, who sees my patient, to come back not in a faxed letter,
but with a series of diagnoses that I could either choose to add or not
add to my list of ongoing problems. Same thing with the medicines they
prescribe.

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

Okay. And would you like to comment at all about vaccine history, or
about family history, or anything else, or \--

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

That would be something that would be wonderful. We\'ve had some basic
functionality problems within our record, and that\'s probably peculiar
to the particular company that we use, that in particular have made
vaccine data entry a bit of a challenge. And so we would like an
improved standard format on that, where you automatically are able to
enter a vaccine and know that it\'s going to be identifiable in the
record. Or if there\'s a pneumovac that is given a patient of mine in
the hospital, that when I do that reconciliation between the hospital
and the office, I\'d love for that to be automatically entered. So when
they ask the question two years from now, and it wasn\'t given in the
office, I don\'t have to speculate. And the family history the same.

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

Thank you very much, Fred.

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

Doctor, this is Ken Waldbillig with one more follow-up, if I may,
relative to your comments around communications, both intra and
extra-system communications. You mentioned you used a messaging system
inside the system that you have today. I\'d like to hear maybe a use
case regarding that messaging inside of the practice, and then
extra-system, is there any instance in which you\'re using e-mail in
order to correspond with a patient?

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

I have done communication with patients when they lived outside of my
community, I haven\'t set that up. I had a patient who had a boat in the
Atlantic, and I have people who have moved out of town, but we haven\'t
really had it practically set up. So most of our communication is going
to be within the practice. For example, I just turned my switches over
to my screen, and I have my office record at home, I\'ve regulated some
Coumadin doses, not during this talk but earlier today, and authorized
some electronic refills which wouldn\'t show up to my partners because
they were sent to my account.

And we use that a lot, and it gives us essentially a do-list, it gives
my nurse a list of ten e-mails from me that she has to deal with and get
rid of.

The largest cardiology group that we referred to told us they weren\'t
interested in setting up secure e-mail to communicate with us. That sort
of blew our mind, but they are the dominant carrier, at least to the
south of us, and so we simply have to reconcile their fax into our
system.

But, you know, there are some people who are early adopters, and there
are some people who drag their feet. So we can only control our
universe.

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

Thank you again.

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

That you so much. Is that you all\'s phone, Karen, that keeps ringing
like that?

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

Turns out not to be, we\'ve been muted.

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

We\'re still working on it, Karen.

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

Thank you very, Dr. Ralston, because that was an outstanding
presentation and helped forward our thinking. I just want to make one
point that Dr. Carolyn Clancy, head of AHRQ, has also joined us for this
call. Welcome Carolyn.

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

Thank you.

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

Karen, are we ready to move on to our next presentation?

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

Thank you, and I will exit stage left.

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

Thanks again, Fred. I\'d next like to introduce Dr. Marc Williams, who
is from Intermountain Health. He\'s joining us today because he also has
some ideas perhaps a little bit different to add on to what we heard
from Dr. Ralston about the types of information that\'s critical to have
the standardized format, and the value of use of electronic health
record. I believe you\'re on the line, Marc?

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

I am.

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

It\'s all yours.

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

Thanks very much for taking the time to add me in at the last minute,
here. Let me also just say at the outset that I don\'t have any
financial interest in any companies or vendors. I also want to give you
a little bit of background. I\'m a medical geneticist and pediatrician,
I\'m currently the director of the clinical genetics institute at
Intermountain in Salt Lake City, UT. I came here in the beginning of
2005 and prior to that time I practiced in a large multi-specialty
clinic in Wisconsin. I\'ve basically had about 12 years of experience
using electronic health records, because both my previous place of
employment and Intermountain have taken the lead in terms of developing
home-built EHRs, that incorporate both inpatient and outpatient records.

So a lot of the things that Dr. Ralston was just talking about, I\'ve
been able to use for the last 12 years, and I can tell you that all of
the questions that you asked, would it be useful, the answer is yes.

You know, to be able to pull X-rays right up on my computer screen in
the office and do the image viewing and interpretation, to be able to
connect with the statewide network of immunization, so if a patient got
an immunization in school I still have that record through, in that
case, the Wisconsin records. All those sorts of things are incredibly
useful.

So with that as a prelude, I really want to drill down a bit in terms of
focus. And this relates to the issue of family history, and a question
that we asked of Karen Bell, which is, is family history on the
Electronic Health Records Workgroup road map. And the answer that we
were given is not really, we\'d like to hear more about it, and so
that\'s why I\'m here.

We\'ve been hearing so much about personalized medicine and genomics and
things like that that I think we tend to forget that we probably have
the best tool already in our armamentarium, and that\'s family history.
And the reason for that is family history not only captures genetic
susceptibly, but it also captures family, shared cultural, shared
environment types of things. So it\'s really a very powerful tool in
terms of identifying individuals that may be at a unique risk.

There\'s also been a lot of work done over the years to validate family
history, to be able to determine who in fact is at risk, and in some
sense what should be done differently in an individual based on their
family history, than in individuals who don\'t have a family history.

So where this intersects with the electronic health record relates to
how we capture that information. And essentially, family history is
entered into any medical record, including electronic medical records at
the present time, in free text. And because we don\'t have any coded
information that is in an electronic health record, it doesn\'t allow us
to do any analysis of that data. And so what we have been working on
here at Intermountain and what other groups have been working on is can
we develop a way to standardize and code family relationships, and
disorders that are present within a family, so that we can maintain that
information in a coded database, where we can apply, then, analytics
behind the scene to be able to do risk stratification.

The way we\'ve kind of been looking at this in terms of where the
utility would be for our practitioners, is that first of all, they\'re
already taking a family history, that\'s part of the standard medical
evaluation. So it\'s work \-- this is not new work, it\'s work that\'s
already being done. But even though we do it, for the most part we
don\'t really know what to do with that information. So ultimately, if
we could enter this information in the standardized coded fashion, and
perhaps ideally even develop a patient-entered interface where the
patients would take the time to enter their family health information
that would then be encoded and available, which would actually save
physician time, then we could look electronically through that
information that was provided, and the first step would be to
risk-stratify. Which is to say based on the family history and
information that\'s provided, is this individual at extraordinarily high
risk for any specific condition.

An example might be if a patient enters that both of their parents had
asthma, then we know that there would be a \-- that that patient\'s
relative risk for having asthma at some point in their lifetime is seven
times that of the general population. So that would allow us to say
okay, this is an individual where we need to pay special attention to
whether or not they are developing symptoms that could be consistent
with asthma. And you could carry that over in a number of different
areas.

The next step, after risk stratification, would be then to be able to
take those individuals that are at higher risk, and say are there health
messages that could be developed that could go back to the physician, or
other provider, to alter care for that patient based on their family
history. So this would really be the issue of clinical decision support.

So we take that patient, where we\'ve identified that high risk based on
family history for asthma, and we could look through the electronic
health record and say, well, has this individual had coded episodes for
things like bronchitis or pneumonia or things that we know are sometime
euphemisms for asthma. In other words, does this patient have asthma but
we haven\'t made the diagnosis.

If those instances were found, then a message could be sent back to the
provider saying, you know, this individual is at high risk for asthma
based on family history, and has had three episodes of lower respiratory
infection within the last five years. Suggest doing pulmonary function
studies to assess for asthma, and then depending on results, initiate
appropriate treatment.

So that would be an example of how you could actually close the loop in
terms of taking best advantage of this family history information.

In the State of Utah, we\'ve had some experience with this. There was a
project that was initiated about 20 years ago called the Utah Health
Family Tree, which was run through the school districts where high
school students obtained information on their families, this was fully
consented. That information was then deposited into a database, and
validation was run against medical records, and then these families were
reevaluated after ten years to see if some of the individuals that were
reported had in fact gone on to develop some of the diseases that were
reported in the family.

So in particular the cardiovascular disease, the family history
information that was provided was validated and we were able to develop
predictive information. That information that was then used to do risk
stratification, and through a project run through the Utah Department of
Health, public health nurses went out to families to discuss this high
risk information with them, and talked about health behavior changes
that could be initiated to possibly slow or prevent the onset of
conditions such as cardiovascular disease or diabetes. And although this
data is in the process of being submitted for publication, I don\'t
think I\'m letting any cat out of the bag to say that there was some
evidence that this type of an intervention did in fact change health
behavior, so that there does seem to be some utility for using this
information the way that we\'re describing it.

I\'ve essentially placed all of this in a very condensed form in the
document that you have in front of you or on your computer screen, and I
also just wanted to note that this little message that I\'m giving you
has the endorsement of a number of genetic professional societies and
large health care systems who are also involved in doing research on
electronic health record.

So this has been \-- the document that you have has been reviewed by all
of the individuals listed at the end, and basically we\'re all in
agreement that this is an important thing to do.

So again, while this is a very sort of small piece of the overall
electronic health record, I think it\'s a piece that\'s very important
to be intentional about including, and would also point out that it\'s
something that there are a number of individuals who are working on this
right now. And at a relatively modest investment, I think we could have
standardization at least of this particular part of the electronic
health record relatively quickly.

So with that, I\'ll conclude sort of my formal remarks, and be happy to
answer any question.

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

This is Howard Isenstein from the Federation. Sorry, I want to ask a
question entirely irrelevant to your comment, which is the recent
announcement of Microsoft\'s with your organization. Maybe you heard the
previous speaker talking about the problem of disparate information, and
wanting sort of to aggregate it in one place. And I\'m curious, I mean,
the system that MedStar developed, now you\'re collaborating with
Microsoft, does it really accomplish those aims that the previous
physician was having issues with?

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

Now, when you\'re talking about collaboration with Microsoft, you\'re
talking about Intermountain?

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

No, I\'m sorry, MedStar.

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

Excuse me just a moment. I just wanted to let everyone know, this is
Karen Bell, that Peter Basch is in the room with us now, and he actually
is working with MedStar. So perhaps if you would like to answer that.

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

Let me direct that to him, yeah.

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

Certainly, and good afternoon, everyone. The system that was developed
at MedStar Health as a results viewer works quite well for taking
information from disparate systems and presenting them in a
clinician-friendly patient-centric manner. And I was not involved in
developing the system or fortunately or unfortunately benefiting from
the sale. I\'m not running Microsoft, either. But I\'ll tell you it\'s a
terrific system, and I think I can only speculate as to Microsoft\'s
interest in terms of what they\'re planning to do. But I think that you
kind of hit the nail on the head, they\'re hoping to look at the current
state of disarray, and put in a data organizing tool, some of them call
it data exploration tool, until we have more meaningful
interoperability.

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

Thank you.

The previous speaker, I\'m sorry, I wanted to add one other thing. Do
clinical decision support systems have in them algorithms regarding, you
know, risk profiles that you were talking about before on family
history?

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

In limited applications, yes. I know that in \-- Kevin Hughes at
Massachusetts General has been using algorithms specifically relating to
identification of individuals that may be at risk for certain types of
familial cancers, like breast, ovarian cancer, colorectal cancer, that
sort of thing. I\'m not aware that anyone has a system up and running
that is doing more generalized risk assessment, although there certainly
are \-- the CDC has, I think, four pilots where they\'re working with
clinics to try and see whether a system like this is workable, and how
it could be used. We\'re obviously working on things here at
Intermountain. But there\'s not an existing system that I\'m aware of
that\'s up and running in a more general term for family history.

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

Thanks to both of you, appreciate it.

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

This is Lillee Gelinas, I do have a question for you. As you know,
Secretary Leavitt gave this Workgroup a challenge to make
recommendations and develop a use case around a first responder
emergency medical record.

Have you been able to look at this decision? Because frankly, the notion
of family history was not one of the critical elements that was
originally put forward that needed to be in a first responder EHR. And
specifically, this is addressing the Katrina After Action Report
Recommendation 62 around developing the first responder EHR. So could
you just comment a bit on your thoughts of whether family history should
be part of that mission critical essential element component of a first
responder EHR?

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

Yeah, this is going to be completely off the top of my head, because as
far as I know, none of the family history work has been done has been
done within that context. That being said, I can certainly envision
scenarios where family history information available to a first
responder could be extraordinarily important. An example that just kind
of came to mind, wearing my pediatrician\'s hat, are certainly disorders
that can be identified on newborn screening, where we may have a sibling
who also has the disorder, but because they\'re older and weren\'t seen
through the newborn screening program, could be a potential risk. So
there are certain disorders called fatty oxidation defects where when an
individual becomes ill they can become profoundly hypoglycemic, can have
seizures and then go into a severe metabolic crisis. Whereas if this is
recognized early and the individuals can be given a high dose glucose,
that situation can frequently be avoided.

So you could imagine the scenario where if the first responder that was
seeing an individual who was unconscious and seizing had information on
the family history, that that\'s something about a family history
positive for fatty acid deposits, with a recommendation to do a point of
care glucose and prepare to administer D25 or D50, that there could be
value there.

I\'m sure there would be other ways that this could be exploited that I
just haven\'t thought of, but that would be one scenario.

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

This is John Houston.

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

John, welcome.

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

My apologies for being late. I\'m on vacation, so I had some other
things I had to get done.

I had one specific question, maybe I missed it in the testimony, but has
there been any attempt, or any thought of trying to, as we become more
automated with our EHRs, is trying to link family history actively
between patients, so that rather than me giving you my family history, I
tell you who my father or my mother are, my grandparents, whoever might
have an electronic record, and then use that as the basis for populating
a family history?

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

John, are you sure you\'re not from Utah?

\[Laughter\]

We\'re actually very interested in that question, being the home of
genealogy. There actually are ways that one can use informatics to
construct a genealogy or family history, if you prefer, and then link
those individuals to medical records which can, you know, could then
basically, as you say, build that family history without having to have
a patient \-- to obtain that information from an individual patient.

There are a couple of different ways that that can be used. One could be
to just, you know, construct the family history. The second would be to
validate information that the patient gives.

So for example, this is a scenario that occurs all the time, where you
have a male patient in the office, and I say, well, what did your mother
die of. Well, female cancer. Us guys are kind of uncomfortable talking
about all the things that reside down in that female area. So we could
then \-- if his mother was represented in the electronic health system,
we could say oh, this was an ovarian cancer, and that would potentially
have a very different risk message than if it was an endometrial cancer.
Because ovarian cancer would suggest this could be a BrC family, whereas
endometrial cancer would suggest this could be, could be, this a
colorectal family with HNPCC. So I think that is highly useful, and
actually has been done through the Utah population database, which
Secretary Leavitt I know is quite familiar with. This was basically
genealogies that were constructed using publicly available information,
birth records, death certificates, et cetera, and that can then overlay
on electronic health records such as that at University of Utah or
Intermountain where the individuals can then be identified to see if
they are represented on the dataset, and then additional information can
be mined out of that.

Now, the biggest issue for using that type of an approach is
confidentiality, privacy issues. Because when you do that, you are of
course then \-- you\'re not just saying, well, the patient\'s mother has
this, but you\'re \-- at some level, you\'re identifying who that
specific individual is, using PHI.

Now, one of the thoughts we\'ve had is that if this is done at a very
deep level of the informatics system, and then that personal health
information is scrubbed as it resides back up through the system, so
that what you are left with is a pedigree that does not have PHI, but
does have that validation, that that may meet HIPAA requirements. But
quite honestly, this is something \-- this is an area that has yet to be
explored.

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

Interestingly enough, one of my responsibilities is privacy, and
obviously I recognize the pitfalls of it. And I\'m sure there\'s ways to
engineer an environment at least where people could authorize the use
of \-- you know, the access to information related to them for family
purposes. But I think there\'s also an enormous amount of power, as you
said, because we often don\'t necessarily completely understand some of
the conditions that our family members have, and yet the more
information you have, I would think, as a physician, the better off you
are in trying to provide a complete and accurate diagnosis.

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

Absolutely.

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

This is Ken Waldbillig from EMC. I\'d like to ask if you would comment,
please, on the direction overall that you believe the addition of family
history at a genetic level will take.

Some detail is regarding the genotypes and the alleles, serious genomic
information being added to the family history and required over
generations to become a very powerful predictor of disease and the
expression of clinical phenotype. So if you can, it sounds like it\'s
not for an emergency responder application, but more of a future of
health care as an important insertion into maybe some of the standards
that we have emerging today.

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

Yeah, and I think you know again, we tend to bandy about the term
personalized medicine, and the idea that we will have information
available to us that will allow us to, rather than giving just sort of
generic preventive messages to individuals, that we can give much more
specific preventive messages to individuals, whether that relates to
traditional preventive care, whether it relates to use of certain
medications and avoidance of others, whether it relates to altered
surveillance for certain diseases given that information.

There\'s no question that family history just sitting by itself can
provide a lot of that. But if that is enhanced as we begin to understand
some of the genomic level information in what \-- how that contributes
to risk, then those can be overlaid.

I\'ve heard people express, to say well, geez, once we understand the
genomics of the family history, we\'ll sort of be an arcane relic of the
past and we won\'t need it anymore. And I think that\'s a bit
unrealistic, for a couple of reasons. The first is I think it\'s going
to take an extraordinarily long time to actually sort out all of the
genomic stuff. My apologies to my colleague, Francis Collins, who said
we\'ll all have our chip by 2010, but I think we\'re all realizing it\'s
going to be much further down the road than that. The little pieces are
going to emerge, but that sort of overall concept of health from
genomics is not going to emerge for quite some time.

Second of all, clearly, your genome is not absolutely deterministic.
Your genome interacts with environment, interacts with culture and other
things that we probably don\'t even understand at the present time.
Family history captures that information. We don\'t know how it does it,
you know, at a basic level, but you share environment with other family
members, you share cultural values and diet and other things with family
members, and so it has a richness to it that the genome itself will
never be able to have. And again, if we look at the interactions, the
basic interactions to genome environment, et cetera, to understand the
ramifications in a predictive way of that level of complexity is a long
ways down the road.

So, you know this is really, I think, an opportunity to take strong
advantage of what we have, and can use, and understand currently, as
opposed to waiting for that ideal situation down the road when we really
understand what the genome is telling us.

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

Thank you.

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

Karen, this is Lillee. Could you do a time check for us, please, at this
point?

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

Yeah it\'s about two o\'clock, so we really need to move on if there are
no further questions for Dr. Williams. Is that all right?

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

If I could make one further comment, and nothing specific, but just
to \-- I understand that are you dealing with cultural barriers. I do
want you to be aware that relating specifically to family history, we
and a number of other groups are partnering through the Genetic
Alliance, looking at cultural issues relating to family history. And our
specific part of that task is looking at issues of how culturally
specific information that\'s obtained might be able to interact with
electronic medical health record. So that may be of some use to you down
the road as you deal with these issues, as well.

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

Thank you very much, we very much appreciate your input on a very
important topic, Dr. Williams. Before we move on to hear from Dr. Basch
in great detail, Dr. Peter Basch, I\'d like to invite any of the
clinicians on the line, specifically those from the DOD or VA who are
working on interoperability, particularly between the DOD and the VA
right now, in terms what are the elements that are most important to
clinicians to be able to share information.

So I offer the invitation, and wonder if either if Dr. Kolodner or
Dr. Harmon would like to respond.

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

Karen, this is Bart Harmon, I\'d be happy to respond.

Based on conversation in the last meeting, I did forward in the list of
data elements that the DOD and the VA have prioritized as being the
highest priority to be shared. And just to briefly read through that
list. Number one was identifying patients, because you can\'t put it in
the correct person\'s record on the receiving end without that. Not
really clinical information, but necessary.

After that came medication list. With medication allergies. Lab results.
Then problem list. Clinical encounters, and clinical notes. Anatomic
pathology results. Vital signs.

And then a grouping which we termed family history and health factors,
largely because the DOD and the VA have a slightly different focus, but
it\'s a lot of the same information. So actually, our eighth priority
would have been family history, which actually came just ahead of
radiology reports. Which is a little bit interesting, in light of
today\'s discussion.

And just one comment, we actually, in the DOD, started with a commercial
version of the \-- many of the Intermountain Healthcare tools as our
starting point, and we added in a third-party commercial terminology to
help us with some of the additional areas. And one of those areas was
the family history, but also fairly heavy structured documentation
within the subjective and objective part of clinical notes. And it\'s
interesting to hear Intermountain Health moving in that direction, also.
I would guess they\'re probably building it internally with their
concept identifiers. Interesting to see how that all comes together.

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

Thank you very much, Bart. Could I just ask you what \-- if there was a
particular schema that was applied to the prioritization process. I
think one of the things we heard a little bit earlier, that radiology
results are critical, but they do come to the small percent of the total
workload, and wondering if that may be one of the reasons that radiology
reports are low.

So the real question again is there a particular schema that you applied
to the ranking of priority?

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

No, we just brought together \-- we convened a group of clinicians that
work in physical locations where there are DOD and VA facilities close
to each other, and they deal with patients moving back and forth across
our health enterprises on a regular basis. Sometimes because we have
administrative sharing agreements between the DOD and the VA, and we
just ask them, based on their clinical judgment, what would be the most
helpful. And this is the sequence they put it in.

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

This is Jim Sorace from CMS. I was just curious, to clarify, radiology
results, we\'re talking about just the text of the radiology report, and
not the image? Or are we talking about both?

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

That\'s correct, this is just the report, the text report.

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

This is Rob Kolodner. We are working on the other, on the images, but
because that\'s a higher intensity, and would take longer, the
prioritization of the report was placed much higher.

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

Thank you very much, I think that was helpful, Bart, we\'ll certainly
put it in context of the larger discussion.

I\'d just like to sum it up a little bit by saying we\'ve heard from a
clinician in a rural practice, we\'ve heard from an integrated delivery
systems, probably one of the premier ones in the country in
(indiscernible) health, we\'ve heard from the Federal system. And we are
about ready to hear a fairly robust discussion about some of the real
barriers for EHR adoption from Dr. Peter Basch. But before we jump into
that, I think it\'s fair to ask him his thoughts on those clinical
elements that are most important for interpretability. I\'m going to
turn this over to Dr. Basch.

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

Thank you, Karen. And again, good afternoon for the Workgroup and
guests. I\'m not going to spend a lot of time seconding what other
people have said, but I think it was Dr. Ralston made the suggestion in
terms of structured problems, meds and allergies, that it\'s important
to have a view accept-reject functionality, because we need to remember
the principle of garbage in, garbage out. Without that, we may find our
systems being overwhelmed with duplicative entries, similar names used
for the same processes. As many electronic sources for medication do not
yet have the ability to remove them or change them, we may end up with
problem meds and allergy lists that are so long that they become
unusable.

I think the idea of using anything structured, and that is structurable,
and having a unit set feature is very important. I would apply to past
medical, past surgical history. I agree in principle with the concept on
family history, but being a practicing clinician, not an active
(indiscernible), I want to make sure as we do so we are not creating a
new standard of care, such that an office visit becomes a multi-hour
venture as we\'re examining and trying to dissect, deconstruct, and then
move to future generations what family history holds.

And let me say that I agree with the potential value, but if I were to
have to sell that concept to the doctors in my health system, that would
probably stop them from adopting the electronic medical record.

In terms of using information regarding radiology reports and
procedures, one of the interesting things we found as we get these now
is the unstructured text mostly scanned into our system, is that a text
certainly is used to describe, and in the case of many medical reports,
dance around diagnoses. It\'s hard to turn that into using any kind of a
semantic interchange into something meaningful without getting all of
this (indiscernible) sometimes without having a conversation with the
originator of the text.

So we are still struggling with a concept of what we want to capture and
structure it. What we do is we capture a meta-tag structure. For
example, X-ray done or mammogram done, or in the case of procedure,
colonoscopy done, and then link to the full text and perhaps annotation
on (indiscernible) rather than trying to capture the structure of it. I
think the argument when it comes to the numeric lab value is certainly
much stronger.

One of the things that wasn\'t mentioned that I\'ve been very interested
in capturing, is structured primarily in the interface between
clinician, has to do with consultations. I am convinced as a primary
care physician that much of the tremendous value that my specialist
friends provide to me in the way of consult gets completely lost on a
very busy day in the midst of very wordy consultation notes. And one of
the things I would find exceedingly helpful is to have a structured
section within a consult note that contained very clearly what was done,
and what is recommended to be done.

When I\'ve gone back and done an informal study and reread consult
reports, which is \-- I don\'t think a typical for the standard of care,
we typically read through them very, very quickly, I found that there
was as much as a 50 percent difference between what I thought had been
done by the specialist, and what the specialist actually said using very
indirect language and a recommendation that I should get.

I think we are having substantial leakage within the resources that
we\'re using.

Okay, and that was it in terms of my suggestions in terms of what we
need to structure and move between clinicians.

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

That\'s great, thank you very much. And what I\'m going to suggest in
the interest of time, so we keep on schedule, is that any questions that
our members may have for Dr. Basch be held until he goes through with
his formal presentation.

And so without further ado, then, I would ask you to move into that now,
Peter.

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

I\'m not used to doing a presentation where I can\'t actually drive the
slides, so I apologize if I get a little out of synch, I do have
some slides so I\'ll be saying \"Next\" more frequently than I\'d
actually like to. But anyway, with that in mind \-- next?

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

There\'s a slight delay.

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

Oh, okay, is the full slide visible or is it cut off \--

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

I don\'t know.

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

I think it\'s fully visible.

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

It\'s visible.

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

It\'s possible, as I look at this, that the build that I put in my
slides isn\'t operative anyway, so maybe I won\'t have to say \"next\"
as much as I was referring.

Anyway, it was interesting that I was listed as testifying on legal and
cultural barriers. I am a clinician, I have a small practice here in
Capitol Hill in Washington, DC, I am an early adopter of health
information technology, it\'s been about ten years since we\'ve been
using a full electronic medical records in my practice. And it was very,
very ugly a decade ago, but I would echo the comments of Dr. Ralston,
that as ugly as it was back then, we would never go back to using paper.
We use e-prescribing even though it\'s not quite legal in D.C., and I
use e-mail and secure messaging with patients.

I\'m also \-- our practice is the first practice in Washington, DC,
within the (indiscernible) pay for performance program. My other hat
that I wear, at least that I get paid for, is as Medical Director of
e-health for MedStar Health, which is the largest health system in the
Mid-Atlantic area. And my primary area role is expanding EMR
implementation among other physicians within MedStar Health, and at this
point we\'re focused on employee physicians. And one of the things I\'m
very proud of is in the years that it took me as a primary care doctor
to get hospital residents caring again about ambulatory care, I\'ve
gotten 100 percent volume on the concept of implementation focused not
on creating digital documentation, but on enhancing quality and safety.

On the right of the slide you can see I\'m involved in other \-- a bunch
of other activities, and I have a disclaimer at the bottom that while my
comments are probably consistent with a mission of most if not all of
those organizations, I\'m speaking today on behalf of myself and not for
these organizations. Next slide, please.

All right, I mentioned this about the legal and cultural barriers, and
in case anyone is wondering, if there are lawyers on the call, you\'ll
figure it out very quickly. As my wife, a lawyer, reminds me, you are
not a lawyer, be careful what you say. I\'m also not a sociologist and
my comments on cultural barriers are going to be more focused on
structural barriers. My viewpoint of EMR adoption, having been in this
for over a decade, is shaped by being a practitioner, early adopter, and
looking very much at how the EMR after you get through the first couple
of areas of gee whiz, I\'m actually doing this, everyone is doing this,
it works, what does it really mean.

That\'s why I like to ask the question what could or should an
interconnected HIT health care system look like, and what are the
implications for clinicians who participate in such a transformed
system.

And that\'s where I look at cost and benefit, that\'s where I look at
workflow, and I\'ll also use the term care flow. Because really what
we\'re talking about is changing how we care for patients. And also, one
of the things I\'m very concerned about is unintended consequences in
terms of unintentional expansion due to (indiscernible) liability, and
the potential for the likelihood of errors.

Next slide, please. To talk a little about my practice, I\'m sorry, I
had a visual joke in the build slides. A little over a decade ago when
we were considering an EMR, I had actually a very nice picture that sits
underneath that garbage picture of a nicely organized chart rack, a
Norman Rockwellian picture of what an office may look at. And actually
what you\'re seeing on the screen is I think an actual shot of what my
office file room looked like.

We were drowning in paper, we were truly struggling to survive in an
atmosphere of declining reimbursement and increasing responsibility. And
notice our decision to get into EMR was based not on any of the ideals
I\'m preaching now, nor on any of the concepts put forward by the
Institute of Medicine, but they were quite colloquial. What could we do
to increase physician productivity, what could we do in an office that
had two locations to get the same information at both locations.
Weren\'t even thinking about multiple other uses at that point. And what
could we do to simplify compliance with emerging E and M documentation
requirements. Those are drivers for the EMR.

And as you move over to the right, 11 years later, you\'ll see we
doubled the number of providers, we consolidated offices. We kept the
same amount of support staff.

As opposed to drowning in paper, we\'re drowning in information now. And
all of our processes intra- and extra-office are enabled by the EMR.

In terms of outcomes, one of the things I\'ve found that\'s surprising,
but I think it\'s confirmed by most research, is we were not able to
increase productivity. Probably that\'s a good thing. If you make an
argument to a physician that you\'re going to have to run faster on the
hamster wheel if you use EMR, that\'s a turn off to technology from the
beginning. But the fact that we were able to increase clinicians and
keep the same number of support staff I think is quite persuasive.
Certainly, we were successful in mobilizing information securely, not
just obviously between offices, but anywhere.

And yes, we were successful in simplifying compliance with the E and M
documentation guidelines, but we discovered not just what the world of
digital garbage was, but unfortunately that we were adding to it.

Next slide, please.

Okay, impact on patients, and certainly I think these statistics have
been seen by many of you before. We were flying by the seat of our
pants, at least part of the time, in terms of safety. It was basically
what we knew, how we were working, whether we were paying attention, and
if a text reference was close by, not too outdated, and we had the time
to pick it up.

In terms of quality, very uneven. And I\'ll say this as a
self-criticism, I don\'t know if any of my partners would agree with
this, but was limited by what we knew and what we thought of at the
time.

Next. And if you can move a bit to the right. And where we are now,
well, we always evaluate patients in context. Visits, phone calls, and
on call. This is important when you think about phone calls, e-mails, or
being on call. These are also important clinical encounters, and in the
paper world is it feasible to pull charts for those. Well, if you can\'t
find a chart a third of the time, you can\'t even pull it for an office
visit, it\'s typically not done. Within EMR it certainly can be.

In terms of improving safety and quality, I\'m sure this has been
discussed many times by other speakers, one of the points that I would
like to highlight is the system we use is filled with decision support.
Not just for physicians, but for staff and patients as well. Next.

And over to the right, if you would, please. All right, unfortunately
the color doesn\'t display very well here, but this is the first of my
\"yes, but\" slides. In 2006, while we can access the chart every
patient a calls us or on call, it\'s probably not all we\'ve done. And
I\'m not sure these are new slides or builds, why don\'t you go next.
Okay, we can stay right there. And in terms of the features for quality
intake, I\'ll say they\'re not always used. And the question I\'m
raising here if the benefits are so clear to doctors and patients, why
is it not regularly or always used to provide benefit, and why is EMR
adoption so low and so slow? Next.

Okay, now, this will probably come across very \-- not particularly
elegantly without build. So I\'ll try and describe this to you. You\'re
actually not supposed to see text behind the IOM's crossing the quality
chasm, so pretend for a moment. To some people as they look at the
chasm, it is clear the answer is computers. Have no idea what happens
when we go next, a little crossing the quality chasm should move out of
the way, so you can actually read the text. Actually has a quote from
clinicians, in responding to those particular messages about the chasm.
And if that doesn\'t work, I can tell you what\'s behind there.

What do you expect from a seven minute office visit? In terms of the
comments on preventive services, I\'m surprised it\'s done that much of
the time. If you really cared about prevention, maybe somebody would pay
for it. Regarding chronic care management, much of the same. Surprised
that it\'s done as well as it\'s done even 50 percent of the time,
because of the lack of focus.

One of the other comments there was from clinicians. If we didn\'t have
to focus on meeting documentation requirements or drug prior
authorization maybe we could actually devote more of the seven to ten
minutes to things that really count like diabetes and congestive heart
failure.

So the answer from clinicians tends not to be why computers, it\'s not
an anti-technology message, but it\'s one of a broken process. It\'s one
that calls forth you really are functioning in a fragmented system, and
we\'re functioning in a system which doesn\'t value information
management.

And really, what we\'re talking about here is paying more attention,
more focus, and evaluation of information management. Next slide.

All right, so again, if crossing the chasm means reducing the barrier to
computers, then we have these analyst discussions about how do we reduce
costs of IT solutions. What kind of incentives should be in place for
adoption of computers? How can we get physicians to retrain their
workflow so that they will use these? How can we make them more usable?
And even create the focus on what I call HIT and HIE enablers, to use
organizations, RHIOs. And even ONC and the AHIC are really focused in
their titles and missions on reducing barriers to computerization. Next
slide, please.

If this focus is on resolving healthcare fragmentation, which honestly
in my view means waste, redundancy and inefficiency, which we\'re all
opposed to, is improve to the system profit to another stakeholder that
is I\'d say it\'s the 8,000 pound gorilla in the room.

And outdated, out of synch reimbursement policies. What procedural
medicine has been doing is relatively \-- my procedural friends say,
don\'t say generously \-- so I put in relatively generously reimbursed,
visit-based medicine relatively poorly reimbursed, and the activities of
information management not reimbursed at all. Next.

Now, in case people have not seen enough screen shots of EMRs, let\'s
just go through this quickly. What do I mean when I\'m talking about
focusing more information. Here is the health system we\'re using, and
no, Napoleon Dynamite is not one of my real patients. I wish. But this
is typically a diabetes visit what you might see. Something like patient
states he\'s feeling well, sugars have been okay. That\'s typically how
medicine is practiced now.

Next slide is in advancing EMR we\'re trying to focus on \-- let\'s move
to the right a little bit, this is a screen of extra questions that
probably should be asked regularly with diabetic visits. Next slide,
please.

And as most of my patients with diabetes also have hypertension and
hyperlipidemia, similar enhanced focus on hypertension. Next slide.

And hyperlipidemia. These are complex. In fact, when you present this to
clinicians, they say wait a second, this is not apples and apples. No,
it isn\'t. We\'re not trying to do bait and switch, but we\'re telling
our doctors the purpose of EMR is not to provide a repository for
digital documentation. It is to improve what we do with conditions that
sorely need improvement. Next slide.

So what we\'re looking at here is if the maximal value of HIT is
improving the value of visits and improving information management, you
have to address the fact the digital-based medicine is poorly
reimbursed, and information management is not reimbursed at all. Which
leads to two disturbing conclusions. One, the more HIT is optimally
used, the worst the financial ROI for physicians and hospitals. The HIT
purchasers. And this really called into question strategies for what if
we made HIT cheaper or what if we provide incentives to get it.

Second disturbing conclusion, without a concomitant resolution of
healthcare fragmentation and dysfunctional reimbursement policy, HIT use
will be suboptimal and dysfunctional.

My next slide, I apologize, I had another visual joke which probably
won\'t come out. We\'ll see what this does. Oh yes, we see our friend
there.

Someone much more eloquent than I did. Looking at the two disturbing
conclusions, Dr. Brailer \-- and I\'m paraphrasing because I couldn\'t
find the exact quote. If you go a little bit to the right, please. And
David has said this on a number of occasions. \"The question should not
be why is the rate of EMR adoption so low, but rather, why are
physicians adopting them at all.\"

And this is the rest of the disturbing conclusions. If you go back to
the left a little bit. and my own further disturbing conclusion,
strategies to reduce cost, risk, and improved interoperability.
Essentially what we\'ve been focusing on for the last several years may
be largely irrelevant, unless we deal with the problem of worsening
financial ROI for optimal use of HIT. And in fact, unless we deal with
outdated reimbursement policies, my second doubly disturbing conclusion,
success in HIT, HIE adoption may be irrelevant. In other words, we may
actually \-- and I believe we\'ll get here, with everybody using them,
but will it provide benefit to the American public. And it\'s those
questions that suggest a need to reframe the broadened specific charges
of this Workgroup. Next slide.

These conclusions I don\'t believe are just mine, I think they\'re
supported by the literature. If you refer to Robert Miller\'s study in
*Health Affairs* last fall, that looked at physicians being successful
in generating a financial ROI in their small practices, but doing so in
ways that made sense to their business cases. Elimination of
transcription in some cases, and in some cases reducing staff, and in
all cases getting financial benefits from right coding. The disturbing
thing he found at this time, quoted as a footnote, was no evidence of
improved quality, safety, efficacy. So if we look at these as examples
of success, I would say examples of success of what.

Of course, a recent article by Sidorov in *Health Affairs* that called
into question benefits of HIT. (Indiscernible) implementation outside of
a couple of geographic areas that I won\'t mention for fear of offending
those on the phone, and academic institutions, those kind of benefits
are rarely seen. And I looked at the Sidorov article not as an article
damning HIT, but one that supports the notion that without aligning the
business case, HIT will be used, I\'ll say dysfunctionally, from the
public perspective and quite functionally from the physician purchaser
perspective. Next slide, please.

There is a bright side to this, which is if we can create a solution
sequence which is along with our work on improving standards, usability,
interoperability, so forth, we work on defragmenting healthcare \--which
I wish were as easily as hitting control-alt-delete \-- and a new
reimbursement schema which is aligned with the IOM goals of STEEEP care,
HIT and HIE will serve as enabling infrastructure. You couldn\'t do
without it, it would be impossible.

Adopting advanced and even expensive HIT would be seen as a smart
option, and a good business decision. And plus, I believe in that
setting that most of what we see as barriers today for IT adoption would
vanish. Next slide, please.

Okay, so let\'s assume that we could do this. Okay, big assumption, but
I am still practicing, I am still working in this field, I am quit
optimistic. I also think that you really don\'t have a choice but to be
optimistic that we can do this. Let\'s assume this happens, and let\'s
assume then that the IT is in place and the reimbursement schema is
aligned with using every available opportunity to optimize care \--
which in my view would be enhancing reactive care, adding proactive
population base, and adding self care, and e-care, adding key base care,
utilizing virtual group practices. I\'m not suggesting as some have, I
see, or data, solo and small-group practice is over, but there does have
to be some virtual integration, and creating a care model based on
interconnectedness. Next slide, please.

Assuming that, those are big assumptions, what do I see then as the
barriers for this optimal use of HIT? And there are plenty.

There are barriers within workforce. There are lots of barriers within
how the software actually works today. While we are achieving some
success in the data interconnectivity, I don\'t think we\'ve actually
begun to look at clinical protocol for interconnectedness.

There are mostly unresolved and I\'ll say mostly unasked medical legal
questions concerning the use of HIT and HIE. I also think that we need
to address an out of date, and I\'ll say even foolish documentation
schema that is being \-- intended to be applied to 20th to 21st century
technologic driven medicine, and also barriers involved in new areas
caused by HIT, HIE. Next slide.

Within the workforce I think these barriers are easiest to address, but
they have to at least be honestly looked at. Probably most if not all
physicians in practice, most if not all residents in training, and most
medical students have learned a reactive medical model, which is we deal
primarily with patients when they\'re sick.

To really use HIT optimally, and think about proactive and population
based care, and also some of the other ideals contained in the IOM
vision, such as reducing or hopefully even eliminating inequalities in
care and moving more toward patient-centeredness, we really need to
retrain from \-- not just from those in school now, but those currently
in practice. And I\'m pleased to say that there are plenty of groups now
working on this model of optimism of if we could make this happen, what
could we do. And I think ACP, AAFP, AMIA, and eHealth are some of the
groups that I would single out as doing excellent work. Next slide,
please.

In terms of software immaturity, again let me state from the outset
I\'ve been using EMR for over a decade, I love EMR, I would never
practice on paper again, so I\'m giving this criticism as a friend. Most
EMRs are fair-to-excellent for documentation support and representation
of episodes of care. Few, or maybe no, EMRs, or I\'ll say no if we have
all this list, few if we look at some of them, have really good
embedded, granular, actionable clinical decision support; robust tools
for determining, aggregating, and reporting performance measures; forms
and structures for following episodes of care. One of the other speakers
talked about this, in terms of analyzing family history.

We don\'t even have it in our EMRs now if we\'re looking at episodes of
urinary tract infections or hematuria or sinusitis, things we should put
two and two together and say this is something more than someone coming
in for the 50th visit with the same acute problem.

There are, at least in the vendor world that I see, no forms to enable
care coordination. This is all done by the seat of your pants.
Meaningful interoperability to share information \-- and also, one that
I\'m beginning to work on with a couple of vendors, a creation of
dashboards sitting on top of an EMR for monitoring preventive and
chronic care adherence. Next slide, please.

Clinical protocol for interconnectedness. You can go to the right a
little bit. I made this point before, technical interoperability does
not result in interconnectedness. And I think that one of the things
that we need to do as we\'re putting forth a system that intends to
interconnect, is think about what interconnectedness means, and think
about what is there that might not be necessarily talked about in
point-to-point data transmission. Which is context, the notion of
responsibility, whose lab is this to respond to before it gets sent off
into the ether, and what\'s involved in handoff.

I am very concerned, and I\'ve seen this as someone who lives now in a
world of data excess, that without defined protocols for
interconnectedness, broad availability of information can readily result
in information overload, bad decisions made on information out of
context, and even care confusion.

One example that still haunts made happened quite recently. I try to be
a careful physician who responds to all data that comes to my site, and
because I have an electronic system I sometimes get a copy of the report
before the ordering physician got it, and I try to notify my patients of
results. And one of my patients, a young woman, had a pelvic sonogram
\-- not ordered by me, ordered by a gynecologist, and I saw the result.
And I\'m embarrassed to say my GYN skills are probably not what they
were in school, but I made a judgment based on the report, I gave the
patient some advice. She got actually quite upset with me and said,
well, you didn\'t order this. And I actually just got a call from the
gynecologist who gave me the exact opposite advice. Thanks a lot, I
think what I\'m going to do is nothing, until you guys talk it out to
get your signals straight.

This is completely unintentional, but I think will happen more and more
as we move data without context and meta-tags.

One of my other concerns, as I discussed with some of my colleagues, who
have highly functioning HIE sites, when I\'ve asked them questions about
protocols for interconnectedness, even among the best of them the answer
is typically, well, we don\'t know. We leave it up to physician
preference. What do you mean? If a physician wants to pull everything
based on what they feel like pulling, that\'s fine. If they want to be
pushed information, because someone is identified as being in their
patient panel, we\'ll push it to them. But there\'s really been given
very little thought about what it means when data moves more broadly to
people other than the ordering clinician. Next slide, please.

Medical/legal challenges. Ones on the top I think are kind of basic.
What\'s it really mean when we start talking about using EHR in
practice. I think the answer to all of these is who knows, we have to
wait for case law to determine it. But I think clinicians are very
concerned. Once we get their hands on a keyboard, have they suddenly
entered into a new world with elevated standard of care?

One of the things that we do, and this may or may not be a good
decision, is because some of the forms that I showed you are highly
advanced and difficult for the users, is we turn off the decision
support for new users, and turn it on incrementally as people get
familiar with the technology. Well, are we actually creating risk by not
allowing the full benefit of the clinical decision support to be
activated from day one? Lawyers might say yes, you are. Clinician
implementers and those trying to get other colleagues to use this and
not run out of the building might say it will never work. And certainly
this is one that we started thinking about a couple of weeks ago, with
the Stark and Anti-kickback exceptions, is we are in many systems
thinking about co-hosting an ASP solution for our affiliated medical
staff. But in doing so, might we as a co-host now become responsible for
quality of care for physicians who are not under our direction or
employ?

Other questions regarding health information exchanges. Will the
availability of health information exchange add a new duty to use it? If
so, is that a duty that is shared by all physicians? For example,
physicians in an emergency room who might think this is something that
would be extremely useful, might say this is great, I can look things up
when I need them, and not use it when I don\'t want it. If you\'re a
family physician or general internist, one might find this burdensome.

And of course, another big question, what does this health information
exchange or patient-centered aggregation of information mean? Does this
become a second medical record? Is it the record of records, or is it
just an aggregation of information? Next slide, please.

I won\'t dwell on this, but as you can tell by my prior comments, I am
very concerned with (indiscernible) progress has gone in the three
decades that I\'ve been in practice, and I\'ll say that by and large
they\'ve been made much worse by electronic health record, and much,
much worse by (indiscernible) documentation rules.

One of my concerns is we\'re very worried about sharing progress notes.
I would say probably at this point in time they\'re not worth it. They
don\'t contain all that much value. I think we do need to think about a
new documentation schema based on enhancing quality and longitudinal
care. And for those who don\'t remember, section 941 of the MMA of 2003
actually called for this. Wasn\'t done, but it was called for. Next
slide.

Potential unintended consequences. New errors we have to think about. If
a physician who is multitasking all the time, one of the things that
we\'ve noted is that multitasking when you\'re handwriting information
rarely leads to mistakes. Multitasking when you\'re using an electronic
tool, where you have dropdown lists and pick lists, frequently leads to
mistakes.

Clinical decision supports. When there\'s too many of them and you\'re
multitasking, you miss a lot of them, and the concern is you miss the
important one. And of course, as we are focusing more on outcomes
because our system \-- or focusing more on outcomes, one of my other
concerns is we get too narrowed in our focus and not be
patient-centered, and that we don\'t practice medicine in a way that
allows us to be good physicians to all of those patients. Next slide.

So in summary, I would say a major problem with health care delivery is
not a lack of HIT or interoperability, but system fragmentation,
outdated reimbursement schema. You will not be able to resolve these
without an infrastructure of interoperable HIT.

I truly believe that what we are now so focused on as barriers to HIT
adoption would diminish or disappear if a sustainable business case was
developed for information management and quality.

And even in that environment, there are barriers to optimal use of HIT,
but I think they\'re all very much resolvable.

Thank you very much, and I realize I\'ve probably gone a little bit
over, but I am available to stay for questions at your discretion.

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

Thank you very much, Peter. The floor is open for questions of
Dr. Basch.

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

This is Carolyn, can you hear me?

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

Yes.

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

Peter, that was really quite an incredible and comprehensive overview. I
guess I have a couple of comments, and a question. One is, I have been
impressed by some of the negative studies by two issues. One is a kind
of funny publication bias, because I think there\'s been so much
excitement about IT that, you know, a study that shows it actually can
help in some circumstances accelerate the usual errors we make, perhaps
almost becomes a kind of man bites dog story. I don\'t know if you had a
comment to that effect. I actually think it would be hard to sell an
article to a journal that says we had astonishing successes. There
clearly have been some, but right now because there has been so much
focus on IT as an answer, I think there\'s a unique interest in studies
that show, you know, that within a short period of time not all problems
were solved, for all of the reasons that you articulated.

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

Well I think you\'re right, Carolyn, and I think from the vantage point
of those in publication they do make the more saleable article. On the
other hand, for those of us who are living in the world of using HIT and
have been using it for awhile and gotten over the wow factor, we\'re
beginning to see more and more instances not with the HIT is bad, but
because we have not thought truly of the implications of what we\'re
using, that we\'re seeing more of these errors.

The articles about HIT leading to propagation of errors doesn\'t mean
HIT necessarily caused the errors, it means there are systems in place
typically because of duplication \-- let\'s say a doctor and a nurse,
you know, both looking at the same order and saying, did you write this?
Yes, I wrote it. Did you mean this? Yes, I did. It\'s the same kind of
thing that pilots and co-pilots go through before takeoff. There is
value to that.

In one of my other roles is the chair of the Maryland EHR Task Force,
I\'ve had some extremely edifying conversations with a clinical
pharmacist who is on the task force, that told me something that as a
clinician I had never thought of before. Which is that for physicians
who are using electronic tool sets to e-prescribe and have bought into
this notion of efficiency, they believe it so much they no longer talk
to the pharmacist. And when errors come in \-- and I\'ve done them, too,
from pick list errors \-- a pharmacist can do a couple of things. And
typically call the physician is one of them. And the pharmacist was
telling me that he is having trouble returning people to the concept
that asynchronous and electronic is great, but synchronous is also
necessary. One of his concerns, and he\'s a very thoughtful
(indiscernible), is that many of his colleagues mistakenly believe when
things come in from a system into another system, that they must be
right even, if they don\'t make sense. The clinician must have meant
that, because it came into my system.

So that is something that I think we can work through with our HIT
implementations, but I think that we can\'t ignore them.

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

Karen, it may be astute at this point to move on.

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

I believe so, and if we have any other questions, I know where we can
find you, Peter. So thank you very much for an excellent presentation.
Very complete.

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

Thank you very much, good afternoon.

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

I know Peter has to catch a plane also, so we\'ll let him go. We have
one more presentation today, and again, it is focusing on some of the
issues that physicians face with adoption.

Chuck Parker, who is with the QIO in Massachusetts Masspro has been
working very intensively in a number of different areas, including
helping over 500 physician practices make a decision about moving
forward with EHR adoption.

And so Chuck, I\'d like to turn the floor over to you, if I may.

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

Thank you. You actually heard a little bit about the QIO program with
one of the previous speakers, and the overall aspect. But I want to give
you an oversight of what this is. The DOQ-IT project is a CMS-funded
initiative, (indiscernible) adoption of electronic medical records
today. And what we\'re looking at doing here is help the small- to
medium-size physician office get the appropriate help, and helping them
assist in moving the process of EHR adoption, move forward. We are one
of four pilot states \-- it was us, California, Utah and Arkansas \--
that started this project back in 2004, and as a result of that we\'ve
been moving forward with a significant number of practices.

We recognized it\'s something we needed to take look at, because
realistically small- to medium-size practices had no way of effectively
gaining true consulting help or at least right information to help them
make the decision to move forward. That\'s one of the issues you heard
today with some of the other practice types, is making those decisions
effectively in the vendor world, making sure you have appropriate
decision-making factors out there in place when you start to move
forward.

It\'s DOQ-IT\'s mission to reduce these initiatives, and we are there to
primarily focus on the small to medium size physician office. Basically
our population consists of practices that represent ten or less
physicians practicing at a single site across the overall spectrum.

It\'s important to note here that we are focused on the Medicare
beneficiaries, which in this case is primary care, internal medicine,
and some of the subspecialties that do serve primary care roles in
chronic care disease states. Such as cardiologists for CHS and
potentially endocrinologists for diabetic care. Those are our primary
care workgroups, so understand that\'s where our focus is.

However, because of the work that we do and the way we\'ve created
efficiencies, we do assist the entire community of practice. On the next
slide I do want to talk a little bit more about our individual program
here and some of the successes we\'ve been able to achieve, and that we
are currently working with over 1,400 physicians across the \-- inside
of Massachusetts, that represents 300 practices.

Now, that 300 practices is a specific amount of number that we\'re
actually funded to work with through CMS. In reality, we\'ve had over
700 practices apply to our program, in the two years that we\'ve been
around assisting the physician offices out in the field.

That 43 practices is actually 56 practices to date that have already
adopted technology that we\'ve assisted in moving forward in that
process.

We\'re currently working with 33 IPA/PHO organizations, and there\'s a
specific reason why we do that, it provides us a sense of
leveragability, and a sense of trying to create \-- we\'ll talk a little
bit more about the reasons why, but a leveragability. They have
basically \-- in the State of Massachusetts, most physicians are
organized in at least one of these types of organizations for managed
care contracting. And it does provide us a little bit level of
efficiency, in the sense to be able to reach out and work with
infocommunication strategy. Also from basically an organized strategy of
saying, you know, here as a community we\'re going to move forward with
this type of activity.

Once again, since CMS does pay for this, there are no fees for the
physician offices to take advantage of our services. So there is no cost
to the independent physician out there.

The services that we do offer are education \-- in the sense of how do
we actually move forward, I\'ll actually describe it a little bit more
later on. We do offer consultation, and that helps with the EHR
selection process. But one of the areas \-- two of the primary areas
that I would say we focus on that vendors don\'t. This is an area where
practices tend to fail if they do not pay attention to these aspects
prior to installing the electronic health record, is in the workflow
analysis and redesign. And helping physicians understand where their
problems truly are, what is it that you\'re trying to actually fix by
using EHR.

Electronic health records is only a tool, and it\'s a tool that can only
really assist you if you understand how to actually implement and use
that tool. So we truly go through a full-blown workflow analysis with
each practice.

Other piece of that puzzle is also cultural change and implementation
planning, and the fact we also have to make sure that the practice
understands what\'s coming about, as well. Inside their organization, as
well. So you need to be very clear in communicating that aspect.

Here\'s kind of what we talk about when we talk about the DOQ-IT road
map in and of itself. And that is that we take a look at how we start
with them, we assess where they are, we help them actually plan that
process. We take a look at the cultural change that needs to take place.
And we focus on the staff, and that\'s the key critical issue here.
That\'s one of the areas where we see those practices that relied upon
vendors only to help them implement EHRs get into trouble, is that the
vendors have typically relied upon ROI that says you\'re going to lose
staff. Well, when you say that to somebody in the physician office,
somebody is not going to be happy with the fact that this product is
going in and they\'re going to lose their job. So we have to be very
clear and cautious about how that actually is presented from a return on
investment standpoint. And we typically never bring that point up that
somebody is going to lose their job; that this is an opportunity for you
to learn new environments and also learn other application.

We help them with the vendor selection process. We can help them from
setting up a true RFP down to the level of actually contracting to a
single solo physician. So if they understand and truly understand what
they\'re getting from the aspect of the electronic health record \--
and, you know, most vendor contracts when they\'re handed to small
physician office are written to favor the vendor. So we provide a
valuable assistance in that contracting aspect. Bottom part of that is
organizational redesign. Once again, workflows. Taking a look at
clinical, operational and financial workflows.

We help them through the implementation process once they do get working
with a vendor, then we get to the evaluate and improve. That\'s the area
I think that\'s important with this program is we don\'t go away. The
vendor typically is there for basically three to five weeks after the
install starts, then that\'s it, they never usually see the vendor again
onsite. So the practice never truly gets to engage the full aspects of
how their electronic health record can help them.

That\'s one of the things that we do in that planning phase is we say
okay, here\'s problems one, two and three, this is probably all you\'re
going to be able to accomplish during the implementation phase. but what
we do is we come back and evaluate and improve. Did you get your goals,
did you truly improve. Now let\'s take a look at how we continue on with
four, five and six on your list. So we truly continue to create that
cycle so we get out of that phase of only using 25 to 45 percent of the
electronic health record.

The latter part of that is we truly want to get into the area of care
management. This is where CMS sees their cost savings in driving this
program, in that the longer-term aspect of those people with chronic
conditions is a significant cost to the system itself. If we can manage
them better early in the process, then we significantly can save dollars
in the longer term, by making sure we don\'t end up with those people
that have overall chronic conditions affecting the system immediately.
It gets into chronic care areas, but this is also where pay for quality
programming becomes a very key aspect in this portion of it, as well. We
heard Dr. Basch talk a little bit about that specifically as well in his
program, that this is something we\'re starting to pay attention to. And
so we\'re here as a part of this program to help instill that activity
as well.

On the next slide what we have is a little bit \-- you know, some of the
content education services that we do provide to our \-- out into the
field itself. This is the level of efficiency, and a piece of puzzle we
find very key in working with physician organizations. In the sense
that, you know, these are \-- we are actually in the process of
automating these and making them available via Web content. But it
provides the physician the base level of understanding. And not only the
physician, but the physician office staff, which actually we find more
critical in the overall implementation phase of this, some basic
understanding of what the process going to look like. And we take them
through these detailed levels of education series.

The next slide addresses some of the areas, we\'re talking about pay for
quality programs. In Massachusetts we\'ve worked with Bridges to
Excellence here as well, it\'s one of the pilot programs for the
physician office link program, and developed a methodology by which we
can actually work with the physician office to get them into Bridges to
Excellence through the DOQ-IT initiative. Since we are truly feet on the
street, if you will, in the physician offices, Bridges to Excellence
recognized that we can actually help them in that process to achieve the
goals that they\'re looking for, as well. So we\'ve actually designed
programs in the pay for quality initiatives working with aspects that
fall along in the DOQ-IT program itself.

In addition to that, MCMP, the Medicare Care Management Performance
program, is another program that CMS will be rolling out. This was
something that was also legislated under MMA, the section 649
demonstration. This program is ready to roll out, we\'re just awaiting
OMB funding for it at this point.

Those two pieces of the puzzle are very key in the sense that they\'re
drivers in helping physicians look at this and say there is a light at
the end of the tunnel, I\'m going to make this investment.

Now, some of the information from the field itself, what are we hearing
from physician offices. This is kind of where we want to provide a
little detail today, and go into more discussion later on. Is that
physician offices, that cost is still a factor, particularly for those
small- to medium-size physician offices. Because they really don\'t have
leveragability with the vendor community itself, how do we actually get
them together to make purchasing \-- or get that purchasing power.

Well, within the DOQ-IT program because we can actually kind of
aggregate at a community level, we have been able to create some
organizational structure around some of these smaller practice types.
And again, leveraging the IPA or the physician hospital organizations,
we can also leverage those organizations.

In conjunction with that, we are \-- my organization here is actually,
as a parent-child relationship with the Mass Medical Society, and we
work specifically with the Mass Medical Society to try to create
opportunities for these practices to purchase software as well in
reduced format. So we\'re still working on that, cost still a factor.

In the two years of this program we really truly haven\'t seen a cost
drop in the industry with any particular vendor. We know what their
ceiling is and we know what their floors are at this point, so we know
when we are helping a practice get a good deal, but we don\'t
necessarily \-- aren\'t seeing a significant drop in any price across
the continuum.

Staffing for these small offices is also very much still an issue. They
have a need to pay overtime in making sure they choose the right adopt
pathways. It requires education, and requires either the practice send
their staff away for education theories, or that they have to pay them
overtime, once they start to actually roll the project out itself.

So, you know, these are very small offices and some get taxed in that
sense in that you may only have three people supporting a physician in a
solo doc practice, so how do you leverage that to make sure you get the
activities done appropriately.

There are negative reports on the EHR adoption that slow or stop this
progress, and Dr. Basch specifically mentioned one that I listed here as
well, that kind of show and demonstrate out there, or at least put out
in the field, that there really isn\'t any value to the electronic
health records. Well, we know that there is value, that we can
demonstrate a return on investment. Even Dr. Basch has specifically said
he\'s seen a return on investment.

So, you know, these types of reports that come out specifically, you
know, lend credence to the opposition in saying we shouldn\'t go there.
But realistically, most of the points that are within that report we\'ve
actually created an analysis and said here are the answers to each one
of these points. (Indiscernible) the research that\'s out there, and
provide education to these physician offices that say yes, this still is
the right thing to do, and here\'s why. In spite of what you may be
reading out there.

The fourth area here, lack of technical knowledge permits bad selection
practice. This is one of the areas where physician offices tend to let
the vendor take over the process. And if you don\'t have somebody who
can help in that process, with either consulting with them, or taking a
part of a bigger broader decision factor, that they don\'t have the
technical knowledge, it\'s not their skill. And so, you know, there are
many decisions that have to be made above and beyond just electronic
health record, as well. Do I go wireless, what are the decisions about
going with wireless? What is \-- do I need to upgrade my equipment? What
does the network look like, what kind of security do I need to put in
place, what is the disaster recovery that has to be put in place as
well?

So, you know, and a lot of these decision-making factors, the physician
office can be taken advantage of. This is something that we do offer
assistance in that program. But it is something that\'s still very
relevant out there, and one of the reasons why we see a slower selection
process, a slower adoption process. It\'s just not their comfort zone,
and they don\'t have areas where they can turn to effectively get that
information.

Next slide. We have, you know, as I mentioned before, the vendors can
create these issues. They have volatile return on investment and
modeling. And what I mean is that, here again, they talk about fact that
you\'re going to have to lose staff. Significant amount of the cost
savings is based on staff reductions. And, you know, here again, that
(indiscernible) actually can cause sabotage in some cases we\'ve seen.
Where you have staff who know that at some point that this thing is
going to affect their job, that they start resisting and start causing
problems with the system as well. So you have to be very careful and
cautious on how we approach that issue and how you structure that
conversation with the individual staff, communication in that area.

One of the things that we\'ve also seen is that stuck or failed
implementations can be addressed. One of the things is that we \--
within the DOQ-IT project, that helps us in the sense of being out there
in the field, is we understand how to communicate with vendors. Doctors
still don\'t. They\'re still \-- that\'s not their forte. Vice versa, we
also can then communicate with the physician office and tell them when
the vendor truly is telling them they can\'t get something done here or
that really is an issue. So in a lot of cases we become an intermediary
and can help them and move forward these stuck and failed
implementations.

This is something that\'s key and critical today. As we start to see the
ramp-up of electronic health records, we\'re seeing more and more
vendors run into issues with implementation staff. They simply don\'t
have enough in the field to cover the amount of installs that are coming
and contracted for throughout the organizational structures. Even within
my program here, you take a look at 1,500 physicians coming in the
marketplace. Well, even if we split that amongst ten vendors, those ten
vendors don\'t have that kind of resource here in Massachusetts to
handle that amount of implementation coming to the marketplace.

So how can we address that so that we don\'t get our individual doctor
offices stuck in certain places because the vendors can\'t actually also
meet the implementation guidelines, as well. And so helping them in that
process, making sure that they\'re able to move forward, even
independent of the vendor, as well, is the key and critical factor.

One of the things that we also see, you know, that kind of stopped
physicians at some point is to say how do I participate. You know, there
are a myriad of choices here in Massachusetts now at this point of how
do I go about doing this. Do I go through my IPA? Do I now participate
with a hospital, because of the Stark exceptions do I wait for that type
of activity?

We\'ve got a RHIO here, we\'ve actually got three RHIOs here in the
state that call themselves some form of that. Do I participate as part
of the RHIO, and what does that actually mean? And the last area is do I
just do this by myself, do I figure it out and make my own separate
decision? So for those physicians who are interested in participating,
it\'s how do I join into this ball game, and what do I need to be paying
attention to. Here again, we\'re adding more choices to that overall
decision-making factor by using the things such as the RHIOs and health
information exchanges.

Key areas that we see here is that workflow redesign is key to
improvement. We need to understand what it truly is that a physician
office is trying to improve, and help them focus on that. Set the goals
up front, so that they understand when they go to make a selection from
an electronic health record vendor type, what it is (indiscernible) to
improve upon. So that you truly have a guideline of making an assessment
when you\'re doing that EHR selection process.

And the last piece of that is culture change is very key to the adoption
process. You want to make sure that you\'ve created the appropriate
culture within your physician office to make sure that everybody is on
board and wants to actually utilize the tool itself, as well.

The next slide, some of the things that we\'re starting to see here as
well are some of the legal issues that are facing the physician offices
in the industry.

And a lot have these are going to kind of be reiteration of what you
just heard Peter talk about in his standpoint, as well, but we are
specifically running into these immediate now. The RHIO and LHIO permit
additional data that may have legal implications for the
decision-making. One of the things we\'re hearing physicians today talk
about is now are you asking me to rely upon somebody else\'s data?
Because this information is available, are you going to make me assess
my patient based upon additional data that I would have never had in the
past? So now I\'ve got to take time out, I\'ve now got to review a whole
slew of additional information that the RHIO may be sending to me from
an exchange standpoint. And how do we actually account for that from
either a time billing factor or, you know, under the current model, or
realistically in the future, if we\'re looking at switching billing
models to a pay for quality initiative, how do I make sure that\'s been
accomplished so we can actually get paid for that type of activity?

Another area we need to look at is community record creates issues
around who updates the record. This is something we\'ve heard very
plainly is realistically the goal of a community, once you take a look
at these electronic health records, the ultimate goal, or ultimate
strategy is to get to one patient, on record. (Indiscernible) as opposed
to our physician-centric models that we have today with electronic
health records. Once you start to deliver on that promise, the community
record itself takes precedent, who updates the record, who has the right
to update that record? And more importantly, who has the legal aspect to
look at that record? And what parts of the record can be looked at?

EHR vendors today truly don\'t support multiple levels of security, when
it comes to a community health records standard as well. So taking a
look at that longer term strategy, which is our goal of where we want to
get to, is something we\'re going to have to pay attention to, as well,
with our EHRs.

We still have a problem with controlled access within the EHR and RHIO.
Not only do we have that issue with the community record, but once you
get to extending beyond that to passing information to another resource
that may not even be in our community of practice, what type of access
do we have and what type of limitations do we need to put in place?

One of the things that we\'re also seeing here in Massachusetts is that
too much information creates data blindness. We literally can overload
the physician with too much information now, in the fact of some of it
becomes counterintuitive or counterproductive, to the point of how do
you make a medical decision when you may receive two pieces of
conflicting information on a particular patient? And that these varying
models also don\'t provide data quick enough. How long do you wait
before making a decision? Most of the NHIN models today typically return
data within about 30 seconds. That\'s still relatively slow for
physician office standards in being able to return information to make
medical decisions on. So, you know, we have to be able to figure out how
to account for that when we take a look at making these interoperable
records part of the overall scheme of how we move forward with this
community of practices.

It is something that we have to take a look at, in that, you know, how
long do we have to wait. You know, if by chance I had to make a medical
decision as a physician, you know, by way, a minute later a piece of
information popped up because now the system finally returned the right
information, you know, do I have to go back and correct for that, or am
I going to be held legally liable for that piece of information as well?

I think on the last piece of this, on the legal issues that we\'re also
seeing, and this is something around the LHIO and RHIO. Next slide,
please. Is that on the local \-- in the LHIO and RHIO stratification
we\'re starting to see a differentiation between what is called
(indiscernible) which is basically a larger interconnect system for what
we call local health informations or health information exchanges, HIE.
What we see is that at the HIE standpoint, we need to have a much higher
concentration of data transfer, and that\'s typically within the
community of practice. So the people I work with on a regular ongoing
basis, the hospital I work with, the labs that I work with, the
radiology companies that I may be working with, we have a community of
practice that typically is defined fairly well. And I need to be able to
exchange information amongst that relatively easily and very well.

Whereas with a statewide RHIO, we realistically don\'t necessarily need
to pass all that level of information. We only need basic level context
about the patient to make the medical decision-making in emergency care
or tertiary or quaternary care methodologies. We\'re starting to see
some differentiation or stratification in that this community of
practice, what I call community of practice, are looking at \-- you
know, when they try to drive down to that individual one patient, one
record aspect. And being able to pass that information more effectively.

You know, one of the things that we also heard is that, something we
want to talk a little bit more about, is stratification of practices
between the have and have-nots. We\'ve heard that specifically today,
from our first speaker, is that being able to acquire that information
from a physician who doesn\'t have a system becomes actually time
consuming for the physicians who do have the electronic health records.
So over the next few years, the next 14 to 15 years, if we go through
this adoption cycle, we\'re already (indiscernible) where we have \-- it
becomes an issue for a practice who has an electronic health record, to
actually have to deal with a practice who doesn\'t. And being able to
transfer that information back and forth. Because truly, if you want
to \-- if you\'re going to move to a pay for quality based system,
realistically you have to have those discrete data elements in your EHR.
So do you have to pay somebody at the physician office to take that fax
transmission so you can necessarily load into it the information chart
appropriately?

So I think that\'s one of the things that we\'re starting to look at
here, and using some technology around secure messaging, and creating
structured text messages from those physicians who have versus those who
have not.

The other thing we\'re seeing too that physician offices are concerned
with today is the difference between patient portals and personal health
records, in that patient portal is defined as an activity where the
patient has true connectivity to the physician office and the electronic
health record itself, the specific health record itself. So the
difference here is that the personal health record relies upon the
patient to load the data specifically in the system, versus the patient
portal which is actually driving from the true medical record itself.
And we\'re seeing a concern of physicians in saying, you know, am I
going to have to be relied upon \-- do I have a legal liability if a
patient tells me I have a personal health record, and I don\'t assess or
don\'t use that tool, am I going to be held legally liable in that
sense. Whereas part of a patient portal, I know it\'s part of my system,
that information, I\'m already making medical decisions on that already.

The last piece of this is that the LHIO and RHIOs are \-- what are the
data streams needed to be flowing out of this. Physician offices are
somewhat interested and concerned about what are other aspects of this.
Obviously pay for quality is going to be a big concern, we know that
Secretary Leavitt has a strong desire to move into transparency, and
that this is an initiative where CMS is also looking at moving their
payment methodology.

Other concerns include biosurveillance, there is a whole legal aspect
that goes along with this, with biosurveillance. What is the difference
between the greater good of the community and knowing what the
(indiscernible) is versus personal privacy. So physician offices are
very interested and actually very concerned about that aspect of, you
know, you\'re going to use my electronic health record now to transmit
information about my patient population, and do I still have some HIPAA
requirements around being able to maintain that individual patient
security, when it comes to biosurveillance and the greater good of the
community.

There will also be community needs as well. When I talk about community
needs, this is more towards the transparency in the reporting, being
able to rank your physician, if you will, in the longer run. And there
are other data streams that will eventually come out in that sense, too,
eventualities are we do anticipate there will be some level of physician
office credentialing that could actually take place in this methodology
as well.

Kind of a shotgun approach to a lot of activity that we see here, but
realistically we kind of have our fingers on the pulse of a significant
number of physicians population here in Massachusetts at this point.

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

Is that it, Chuck?

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

Yes.

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

Great. Thank you very much, certainly we\'ve had a lot of information
presented today that heretofore has not been on our plate, and you\'ve
done a fabulous job of pointing out some of the issues that you
discovered with all your experience.

We are a little late on time, but I would like to open the floor to a
couple of questions, if anyone has some.

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

This is Rob Kolodner from VA. I think the last two presentations have
been excellent and have pointed out, you know, that all is not positive
with anything. It reminds me of some of the comments that Secretary
Leavitt made at the AHIC meeting, when he used the analogy that we want
to build a go-kart right now, and that we ultimately want to race a car,
but we don\'t want to start out in a race car because of the dangers of
it.

I think we\'ve heard a number of the issues that \-- a number of
comments that the electronic health record, while being beneficial, can
also be \-- cause harm if it\'s misused.

The issue of information overload, I think, is an example where
ultimately, we do want the clinician to have all the information they
need, but we may not yet have the understanding of how to organize that
data for the high volume that might be there. So that the important
things stand out, and the unimportant fade to the background.

I think it argues for why we need to have that ultimate vision,
understand some of the challenges of getting that vision, and start by
taking small enough steps that we can succeed, and not overstep the
current understanding of informatics and how you interact within a
health care delivery system.

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

Hello, this is Ken Waldbillig, I\'d like to ask a question. Relative to
the number of deployments you have, can you give us a sense overall of
what percentage have been onsite implementations with hardware, software
and services, and training of people on the ground, versus more of an
ASP, where the physicians pay for it kind of \-- you know, by the
transaction?

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

I\'m going to actually break it up by two different ways of talking
about an ASP. There is the vendor hosted ASP, then there are community
based, typically run by the hospital ASP initiatives as well. Then
there\'s the solo. Of our 50 implementations we\'ve worked with, fully
I\'d say 40 of those have truly been \-- it\'s in the physician\'s
office itself.

I would say the remainder \-- well, another 14 of those would have been
hospital-based ASPs or community-based ASPs, and two of them were
basically the vendor-supported ASPs. Now, that\'s our current
deployments.

I would say the significant amount of deployments we\'ll be providing
over the next 18 months will actually be community-based ASP model, in
which the community is deciding to take a look at, you know, whether
it\'s the hospital or the hospital and IPA organizations
collaboratively, are looking at creating a single source record using an
ASP model. So I would say fully 70 percent of the upcoming installations
over the next 18 months will be using an ASP model driven out of the
community as opposed to a vendor.

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

As a followup, this is a cost- and staffing-based driver?

**[\>\> CHUCK PARKER:]{.underline}**\
Yes, because most physician offices, going back to that knowledge, lack
of knowledge at the physician office level, they want to remove the
technology, that disaster recovery, that network support, that making
sure doing the backups every night on my tape drive kind of issues. They
don\'t \-- that\'s not what they do, and they want to try to remove
that. And they see that there is benefit in providing that in a
centralized location. You know, and having that done in a more robust
manner that can be achieved in an ASP environment.

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

Chuck, this is Lillee Gelinas. Given that Masspro is one of the QIOs,
and you\'re the chief technology officer, how many other QIOs have a
role such as yours and are as far along in this work as you are?

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

I don\'t know of any other QIOs that have a chief technology office role
at this point. Somewhat relatively new because the QIOs are just now
getting into a significant amount of technology.

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

So you\'re it.

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

I\'m not saying I\'m it, they just may not call it that yet today. The
other aspect of it is the other three pilot states are fairly far along
as well. California has had initiatives as well that are ongoing. Utah,
being with Intermountain Health there, they\'ve also been very effective
in moving practices forward. And Arkansas, you know, here again, we were
chosen for very specific models and representative organizations within
our States. You know, Arkansas here is a very much so fee-for-service
driven organization, yet they have been able to achieve a success rate
as well.

So I think that the pilot programs have a little bit more attention paid
to them, and that we\'re \-- you know, a little bit more collaboration
overall in the sense of how we actually had to move stuff forward. Every
State that has a QIO program has now taken on this role, this activity,
so obviously there are varying levels of deployment based on, you
know, higher in the marketplace at that time to be able to help with
this type of programmatic of a system. So we\'ve taken grade pride in
the sense we\'ve actually created an organization around consultants and
went out and tried to find the best really organizers, as it were,
consulting based organization.

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

Given Masspro\'s work here, who would you recommend to the Workgroup
that we also hear from? Should also hear from the other three pilots, or
do you think what we\'ve learned today gives us enough food for thought
for the recommendations we\'re going to have to make?

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

I think that, you know, each one of our states has differences, very
unique differences, and I think at some point I would encourage you to
at least listen to the other three pilot states, as well. Because, you
know, obviously Arkansas has a different structure than we have,
California has obviously a significant amount of \-- you know, basically
programmatic focus on this area for the last three years as well. So,
you know, I would suggest at some point, you know, conversing with them,
because they do have unique differences in the way that their state
operates.

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

Judy, are you still there?

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

Yes, I am.

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

I know that Dr. Bell got called to the Secretary\'s office, but could
you please just make the note that perhaps for future Workgroup meeting
we do need to hear from the other three pilots? Because I thought the
Masspro presentation was outstanding.

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

I agree with you, and I\'ve done that.

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

Great. Chuck, thank you very much. Good luck in your endeavors, and
please let us know how we can assist you, because you have certainly
assisted us today.

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

Feel free \-- I am here and available to the program, and certainly as a
sister organization can provide support in this area, as well.

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

I\'d like to call the committee\'s attention to the fact that it\'s
currently about 3:22 Eastern Standard Time, and we have to cut loose at
4, and we have two key agenda items yet to discuss. But the testimony
from Dr. Ralston, from Dr. Williams, Dr. Basch, and Chuck Parker have
really helped us with trying to deal with some of the conundrums and
recommendations that we\'re trying to deal with.

Our Workgroup discussion was meant to be centered on two major themes.
The first, identifying the next priorities for creating value in EHR
systems, as we construct our road map.

And Judy, maybe you can help us, as well, but I know that road map needs
to be coordinated with the other AHIC workgroups. And secondly, some of
the critical issues with respect to the legal considerations. However, I
have to tell you I think the discussions today really helped advance us
in that area as well. So \--

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

This is Dan, excuse me.

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

Go ahead, yeah.

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

I just want to make one brief comment.

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

Sure.

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

The discussions today were wonderful, but they really centered around
the physician\'s office. And if we take a little bigger look, we\'ll
realize that hospitals are facing many of the same barriers. The
fragmented systems, integration, reimbursement, and all that. And there
may be an opportunity to find those solutions in looking at both the way
some of the hospitals have approached it and some of the individual
practices have approached it in the future.

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

That\'s good caution. I know that throughout this process we\'ve been
talking about the differences in the primary care setting versus the
acute setting versus other setting. So your caution is well heard and
noted.

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

Lillee, hi, this is Pam Pure.

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

Hi .

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

Hi, how are you doing?

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

Good.

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

I found today very informative, and I\'m just a little bit confused
about how we\'re going to take this information. Because if we had 20
more speakers, we\'d hear 20 more variations on how people are doing
this. You know, that all have I think some common threads and all have
some, you know, differences and different challenges based on the
regions, the size of the physician office, and their existing technology
infrastructure.

So it may be helpful if we could talk a little bit about what the
deliverable looks like.

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

I know, and Karen has just been called away. Judy, maybe you can help,
but I can give you this perspective. We could listen to presentations
and testimony until the cows come home here.

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

Right.

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

And it\'s all boiling down to some key areas, and that\'s why the
testimony today was clustered around the clinician\'s view, legal
barriers, cultural barriers, et cetera.

So remember that our role is only advisory to AHIC, and that we need to
review, comment, and be as supportive as we can to the staff, who has to
formalize a great deal of the work in this area.

So Judy, I don\'t know if you want to comment more about that, but we
were just trying to seed \-- seed the thinking, as we say.

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

Right, I would echo that sentiment. I think the more we can hear from
the various points of view and collect the information, it just helps us
in forming our recommendation and our advice to the AHIC.

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

Help me \-- when you say forming advice, I mean \-- I\'m just a little
bit confused here. Like I said, I think there\'s great variation, and
Lillee, I think you hit on the three similarities. I\'m just not sure
how we go from where we are to the September meeting.

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

I think the staff \-- again, I don\'t want to push on the staff, but the
staff takes what we do in each of the workgroups, and that\'s why
there\'s so much work that\'s done between times. Our role here is to
make sure we\'re giving the staff the right advice.

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

That\'s right. And I think the adoption of EHR is sort of taking root in
across the country. We just need to hear about what the positive and
negatives of what\'s going on.

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

Then I would suggest there\'s two models that we haven\'t covered that
are probably different, or would potentially lead to different
conclusions. I think this was suggested earlier about there\'s the
hospital piece, but there\'s also the view of what it\'s like to be a
hospital and sponsor the roll-out and deployment of these systems.

And since you know the pending changes to Stark were announced, there\'s
tremendous uproar and discussion at the hospital CEO level, in terms of
what this means to them, and do they need to quickly provide this
technology for the physicians in the community before their competitors
do, and where do they get the money, and how do they support the
roll-out.

So it may be worthwhile to understand the perspective of the health
system in a competitive environment, in terms of how they believe they
will be impacted by Stark, both in terms of opportunity and risk.

Because I do think it\'s very significant, I mean, there are consulting
practices coming up around this to go help and advise hospitals in
terms \-- and large health systems, about what to do, as a byproduct of
this change.

So I think it\'s something significant that we should introduce to the
staff.

The other thing that we haven\'t discussed, I think maybe appropriate to
go through, is we\'ve kind of talked about these EMRs in terms of an all
or nothing, and that you turn on the entire EMR.

And there\'s I think a lot of confusion in the marketplace, is there a
rational way \-- this gets back to Secretary Leavitt\'s desire for, you
know, immediate progress, even if it isn\'t perfect. Is there a rational
way to recommend incremental deployment of the system? So if you looked
at 100 practices that had implemented this technology, very few would
have the entire system up.

And I think there\'s some key learning in the marketplace for what\'s
enough to turn something on, to have value, so we can kind of set some
realistic expectations for phase one that may make phase one more
affordable and more successful, without getting into some of the
complexity.

So, you know, it\'s something that I know a lot of people are talking
about and looking at in the vendor community, and it\'s probably
relevant to the recommendation.

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

That\'s a very good point, Pam. This is Ken Waldbillig. I\'d like to
support your question with just a brief comment. I believe that we\'re
going to come to a place where because of the diversity of
subspecialties, it\'s going to be difficult for us to make other than
high-level recommendations, you know, a waterfront kind of a
recommendation, to AHIC.

So it might be useful for us to take the perspective of what is the
minimum target, ultimately the target, for a first phase. For example,
if we were to take primary care physicians \-- and I\'m just using this
as an example, I\'m not recommending it specifically in that area \--
but as a way to further segment essentially the value, so we can get
something up from a delivery perspective recommended.

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

You know, Pam, this is Lillee, just want to address one key thing. We as
AHIC had recommended to the Secretary that one of the barriers to
adoption was this Stark issue. And in the last 12 to 14 months have been
trying to help get that barrier off the table.

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

Right, and I \--

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

It\'s been very interesting in the private sector, I can\'t comment \--
I always give a caveat and disclaimer, I cannot comment for the
government or VA sectors, but I would tell you what\'s really
interesting is that up to this point we would say we can\'t buy IT, we
can\'t do this, we can\'t do that, because we can\'t afford it.

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

Right.

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

All right. Well, guess what, some of that debate just got taken off the
table.

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

And please don\'t misinterpret, I think this is absolutely great for the
industry, and I think it\'s huge, and very positive, and, you know, I
think it\'s great. So now we\'ve taken that issue off the table, and I
think, you know, hospital CEOs don\'t know exactly what to do, and what
they need to provide to be the, quote, partner with the physicians in
the community. And I think this ties into what\'s the Phase 1.

And where I was going with my comments, so I apologize if I wasn\'t
clear, Lillee, because I think this is \-- I actually think it\'s a
watershed decision in health care IT, and I\'m very, very excited and am
very supportive about it.

I just think that, you know, we talked about Masspro and physicians
supporting this themselves. I think there\'s a whole bunch of things
that hospitals have to think through, in terms of how to support it, how
to fund it. You know, what to do now that they can provide it, where are
they going to get the money from, what\'s enough technology. You know,
and okay, so now they have the green light, I think they\'re all sitting
in the car, they have the green light and they\'re not sure where to go.

So I was just thinking that talking to some of these folks that may have
either made decisions about how they\'re going to go, and now they have
the green light and can go faster, but I just think we need to give that
hospital segment more direction on how to drive now, and drive down a
path that really takes us where we want to go.

So it\'s a positive thing, it\'s just they don\'t know what to do. They
don\'t know how to set up the infrastructure, they don\'t know how to
support the physicians. And I think to be honest, it happened a lot more
quickly than all the naysayers thought. They thought this would just
take a lot longer, and so I don\'t think they\'ve put plans in place.

So I think part of the recommendation for, you know, that we can take to
AHIC is in a hospital-out strategy. Here are some tips for success, this
is why it\'s a good way to look at it, and this is the way it can be
done and be successful. Kind of the same thing we heard in the other
environments, earlier.

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

Right.

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

And I think when we start talking about that approach, where we\'ve
given a large health system now the green light to send this out to
their affiliates, and you look at some of the affiliates, some people
have six or eight hundred affiliates, in a large community. So now if
they give the technology out, what\'s enough. What\'s a good first step.

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

Right. You\'re suggesting perhaps having some testimony from that
hospital point of view.

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

Right, from the hospital point of view, and then also having some
recommendations come out in terms of what is enough to be a valuable
Phase 1. You know, is just getting the world up on e-prescribing, would
that \-- would we consider that a home run for Phase 1?

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

Yeah, what does success look like?

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

Yeah, I think we\'re all in agreement that ultimately success looks like
interoperability, and the whole record, and the whole history and
things. But I think if we could put a boundary around the Phase 1, that
people could do very quickly, and I think we could \-- I think with
Stark and with clarity around Phase 1, we could move this industry
faster than it\'s ever been moved before.

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

I agree. Any other comments?

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

Yeah, this is John Tooker from ACP. I\'d like to offer a related
comment.

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

Great.

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

You know the Certification Commission for Health Information Technology
has recently approved its first phase, if you will, of electronic health
records. And those functionalities are now specified. And they are
moving, of course, to Phase 2, which includes the hospital electronic
health records, and specifically CPOE, and clinical decision support.

And my sense is that we may want to follow the progress of the CCHIT in
terms of helping to make recommendations about what a certified
electronic health records are ready for adoption. And I think we should
be really cautious about making recommendations for adoption of certain
functionalities that aren\'t aligned with what CCHIT is now doing,
particularly since CCHIT is one of the contractors for the AHIC.

Regarding the hospital adoption of electronic \-- or helping physicians
adopt electronic health records, although we have the green light, I
don\'t think we know a lot about what this really means. And I\'m
mentioning back to some earlier work, this was the case of WellPoint,
when they made electronic health records available free, free, to
physicians, and the rate of uptake was really quite small. As Leonard
Schaeffer was prone to say, you know, free isn\'t free enough. And a lot
of this had to do with how physician practices were prepared to adopt
electronic health records. And what was really critical, and mentioned
in the testimony today, the importance of a practice transformation when
you get an electronic health record. It\'s not the widget, it\'s how
your practice is going to be changed.

And I\'m worried, if we focus too much on if you make the widget
available, the electronic health record available at low cost to
practices, that physicians should go ahead and adopt.

And I think there\'s also some critical recollections from the prior PHO
days, the physician hospital organization days, in which hospitals did
provide a lot of resources to practices. But \-- and the question that I
asked earlier, is oftentimes with a hospital there was a certain quid
pro quo. That if they were going to provide you services, that you were
going to be expected, either subtly or explicitly, to give something
back to the hospital. And I\'m not saying that\'s what would happen
today, but that was an experience with the PHO data.

And I think that one thing we ought to do is encourage bona fide,
well-structured pilots to see really what does happen when hospitals are
able to make these resources more readily available to physicians.

And I think the previous speakers have outlined very clearly how
complicated this is. That if we are going to get into those physicians
who are eventually going to be reporting under the Medicare fee schedule
on quality, we\'re talking about in the nature of 160,000 practices that
are four or less. And in relationship to the hospitals, we\'re talking
about four to five thousand hospitals out there that could potentially
be involved with their physicians.

I think one of the messages that we may want to help provide to the AHIC
is not to underestimate the complexity of this, but to propose solutions
that are based in an evidence base, and are tried through a trial
process, or a pilot process, to see what best facilitates not just early
adoption, but sustained adoption that leads to better health care
outcomes for those involved.

And I don\'t really know whether this is going to be a watershed time
for adoption, but it should be, if it is, it should be very carefully
planned so that it doesn\'t result in yet another failure of promises of
adoption that don\'t end up in reality.

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

Right.

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

This is John Houston, I wanted to sort of dovetail some of those prior
comments. I think there\'s also a general misunderstanding of what
providers \-- hospitals will actually provide, and whether the physician
office is actually going to benefit from it. Because if all you\'re
doing is the hospital is providing access to their own EHR, then in
theory, there\'s going to be a certain patient population for which the
physician will have access to. And it really isn\'t akin to a
physician\'s own EHR within his or her practice, but rather, it\'s a
view into the provider\'s EHR.

And so the functionality, as well as the data on the physician\'s
patient population, can be very limited. And so the benefit that the
physician receives can be very limited, as well it can actually
complicate his trying to practice medicine.

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

Right, and you know, one of the features I think \-- and that\'s very
helpful of the relaxation of the anti-kickback is that the hospitals
will help with maintenance of these systems. And this is critically
important, but as far as I know that\'s not well defined what that
really means. And where hospitals who are at a certain level may have
the \-- have 24-hour services for maintenance of computers, practices
who begin to depend on them are going to have to have that same level of
support. So I think we just need to plan this very carefully, and do the
best we can to make sure that adoption is going to be successful.

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

Right, and that\'s also \-- and John, I\'m totally supportive of using
the CCHIT phases, I just think that that needs to come back to this
group and made official. But I think Phase 1 deployment is actually
critical to figure that out, and then I think the rest will be figured
out after we get some scale in Phase 1.

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

Agreed.

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

This is Rob. I think also in an area like this, the idea is to empower
the local providers. And if they\'re admitting to two or three
facilities, what they really need is access or support for a record that
they can use for their entire practice, and not have to fragment that.
And not necessarily just be a subset of \-- or view in on the hospital
system.

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

This is Ken. From a practical perspective, we heard from Masspro that
fully 70 percent of implementation moving forward is going to be this
kind of community based ASP model that will likely have some involvement
with the hospital. So if we take that kind of an approach, from a
practical perspective, we\'ve got to look at the reality, that this is
what a lot of the physicians are going to do.

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

I agree with that. This is John again. But I think one thing we need to
remember is that hospital practices change dramatically in that a very
large area of ambulatory care right now, which most of the care in the
country is provided, these hospitals offices have very little to do with
hospitals, particularly as hospitals are providing more and more of the
care. So lots of physicians don\'t really have the same relationship to
the hospital as they did in the past.

And when you talk about surgical practices, which are going to be I
think as important, the surgical practices are used to a relationship
with the hospital, and oftentimes a lot of their overhead is paid for by
the hospital. And they\'re going to have a lot of learning to do, to put
health information technology into their ambulatory settings, in which
they\'re going to have to begin to acquire, manage, and report data from
those practices. All good things to do, but I think it\'s going to be
pretty complicated.

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

I think the simplest solution will be the one that people will gravitate
to. And if it includes a services relationship with an existing IT
infrastructure that does not include then the requirement for a local
physician\'s practice, large or small, to make that investment, I think
that will be the path of least resistance regardless of the
functionality.

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

Judy, I\'m assuming that the great note keepers are doing their task,
and this is a dynamic conversation that really will help us.

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

Yes, indeed. I appreciate all the suggestions.

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

The cautions are right on.

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

Right.

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

Can you give us some guidance, Judy, how far Karen wanted us to push on
this identifying our next priorities?

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

I think we\'re actually running out of time, we need to get the \-- any
public comment in. She didn\'t really brief me, she just left rather
quickly.

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

Abruptly? I would just ask the Workgroup, then, knowing that probably in
September we will need to continue to push on this notion of the next
priorities in creating value, we have to construct this road map, and
how we coordinate that with the other workgroups is going to be
extremely important work for the staff.

I think the staff has heard at length how we have talked about linkage
and alignment, and don\'t want to create silos, want to be assured that
all this finally comes together in one nice woven piece of fabric, not a
bunch of disparate threads, so to speak.

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

I think focus on our September meeting we\'ll continue, looks like from
our notes from the last meeting, continue discussion about how to make
the EHRs valuable to clinicians, and developing a business model for
health care professionals.

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

Right.

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

We were also mentioning health information support in disasters, which
ties in with the recommendation made at the last AHIC.

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

Right.

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

Do we have a prioritization of value to whom, so value to clinicians,
value to patients, value to \-- you know, emergency, or value to payers,
do we have any \-- do we rank that at all or what do we \-- I\'m not
sure how we should go about that.

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

Good question. I haven\'t got to the ranking.

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

I think that\'s a great way for us to chunk the work, though. And you
can also chunk the barriers to adoption, if it\'s broken down that way.

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

Right.

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

The barriers for acute care EHR adoption piece can be quite different
than the outpatient piece, et cetera.

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

We were just talking about that, right.

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

But I don\'t want us to miss the fact that the Secretary asked us that
our number one, very quick deliverable here was the first responder EHR.
So we are, by his direction, needing to focus on the outpatient setting,
first. Or the I would say external to the hospital setting first. And
then talk about how that connects to the emergency department.

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

Okay.

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

Okay. I want to thank you all for your comments. If you can hold on just
a little bit longer, here. Matt, we need to see if we have any public
comments, to be able to bring the public into the discussion.

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

Yeah, the information is up on the screen for anyone following along on
their computer. If there\'s a member of the public who has already
dialed in, you can just press star one to be connected. We\'ll wait one
or two minutes for people to get through, and after that we\'ll leave an
e-mail address up for e-mail comments and questions.

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

In the meantime let me remind you that the next meeting is scheduled for
September 19, which is a Tuesday.

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

The next Workgroup meeting.

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

Correct.

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

And the next AHIC meeting is \--

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

The 12th. One week before.

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

Right.

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

What\'s the time of the September 19th currently scheduled for?

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

1:00 to 4:00.

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

I have 1:00 to 4:00 Eastern Standard Time on my calendar, Rob.

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

Thank you.

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

And Judy, do you have a definitive time for the AHIC meeting?

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

8:30 to 1:00.

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

Okay, thank you.

Matt, any takers there?

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

Not as of yet, let\'s give it maybe 20 more seconds. If nobody is
calling in then I can \-- end up doing it. Sounds like somebody is
trying to beep in on your phone right now, we can hear you, which means
your line is unmuted and you can go ahead and talk, if you\'re trying to
ring in with a comment. Please announce yourself first.

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

Hi, this is Chuck Parker again. Just wanted to let you know that one of
the activities \-- today, I presented specifically on the physician
office, but we have very well-coordinated with the hospitals as well on
this activity. We\'ve created a working group with the chief information
officers here in this area to work at the community level, and they\'re
very engaged in this process of finding ways to adopt the technology and
help out in the community processes. I would say that primarily yes,
there are some issues still around the trust of, you know, providing
that information, providing those resources. But realistically, the
physicians see that there\'s a need necessarily to have them provide
that activity, and leverage that group purchasing capability of a larger
organizational structure.

So \-- and specifically I was talking today about the physician office,
but we have a significant amount of experience in working with
communities here as a whole, and with the hospital community setting as
well. In organizing these activities, to tie it to not only from the
community base structure, but also the inpatient CPOE systems as well.

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

I\'d just ask you while you\'re still online, since the regs were
announced by Secretary Leavitt, have the hospitals become keen on
pushing this out to physicians?

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

We actually had seven organizations that were headed down this pathway,
and we\'re just literally waiting for the Stark legislation to come
through. So yes, it\'s in full anticipation that something was going to
happen.

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

Looks like we have one more comment. Operator, can you open up Chantal
Worzala\'s line, please.

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

Hi, this is Chantal Worzala of the American Hospital Association. Thank
you for a very interesting session today, learned a lot. Just wanted to
make a couple of comments. First, I would definitely agree with those
who said it\'s also important to look at the barriers to hospital
adoption of EHRs. I know you\'re taking a phased approach, but wouldn\'t
want that to fall off the agenda.

Second, I thought that the discussion about the Stark rules was quite
interesting. Just wanted to remind folks that what those are, are fraud
and abuse regulations, and what they\'re really doing is giving
hospitals flexibility. There\'s nothing about those regulations that say
that hospitals must work with community physicians to provide IT
services. There are certainly some hospitals that are in a position to
do so, but not all hospitals are.

Although I think some of the suggestions for, you know, what are ways to
start are quite interesting.

I would also note that there are still quite a few uncertainties about
how exactly to interpret those rules and where you can and can\'t go,
given the rules as they are. So I think it will take some time to
address some of those ambiguities and uncertainties in the regs. And
determine, really, what the reaction and impact on physician adoption of
EHRs will be.

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

Well, thank you, everyone. Judy, I would expect it\'s time for a close
here?

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

Yes, thank you all very much for joining in. Appreciate it very much.
And we\'ll be back on the 19th.

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

Thank you, everyone. Matt, thanks always for the technical support that
you provide to us. Hope everyone has a great rest of the week, and I
want to continue to thank you for your tremendous commitment to AHIC
work.

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

Thank you.

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

Bye, all.