American Health Information Community

Chronic Care Workgroup Meeting

July 26, 2006

1 p.m. EDT

**Disclaimer**

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

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

You can go ahead, Craig.

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

Welcome, all. This is our monthly meeting of the Chronic Care Workgroup.
As you recall, in the June meeting we had a lot of discussion between
the broad charge and the specific charge, basically how to use secure
messaging and how to use secure messaging effectively. That meeting we
had a number of discussions about collecting data, looking at
alternatives and then deciding how to move forward. Today we should have
a lot of that information presented. Tony, I don\'t know if you want to
add anything to that.

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

Craig, let me just add a couple of things. I had an opportunity just to
talk briefly with Karen before the meeting, and one of the items we felt
was not addressed enough in June was really the critical components of
the broad charge, and where we move to next. So we thought that after
the discussions on the secure messaging reimbursement, that Justine and
Jeanette are going to describe, and then the HHS physicians'
perspective, we thought it would be good to move to a more general
discussion to kind of lay out where we need to go. Does that feel good
for you, to go that direction?

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

Sure, that sounds good.

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

All right. Matt, are you going to do a roll call, or is there any
additional information? Judy, are you going to lead the procedures on
the call-in for us?

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

Matt usually does that, right?

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

I\'ll do a quick roll call and review the procedures. Joining us on the
phone today, we have Don Horton from Laboratory Corporation of America,
he\'s filling in for Mike Crist today. Herb Kuhn from CMS, Eric Larson
from Group Health of Puget Sound, Andy McElberg from Verizon, Mohan Nair
from Regence Group, Paul Nichol from the Department of Veterans Affairs,
John Rother from AARP, Jay Sanders from Global Telemedicine Group. Is
there any other Workgroup members on the phone whose name I didn\'t
call?

Do we have anybody else in the room at ONC?

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

Actually, the Workgroup members that are here are Tony Trenkle, who has
filled a couple different roles, and Karen Bell. And other than that, we
have some guests and the public.

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

Just a quick review of the procedures, which should be routine by now.
Please keep your phone muted when you\'re not speaking, and when you do
make a comment please say your name first so we all know who to
attribute it to. And if you\'re logged into the Webcast as well, don\'t
touch the controls to advance or change the slides. For members of the
public who are listening in, you\'ll be given an opportunity to ask
questions or make comments in the last 5 minutes or so of the meeting.

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

Okay, Craig, do we want to move for acceptance of the minutes from the
June meeting?

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

Are there any corrections or additions? Do I have a motion for
acceptance?

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

So moved. Eric Larson.

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

Second?

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

Second. Paul Nichol.

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

All in favor?

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

Aye.

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

Okay, I\'ll turn to Karen next to discuss the followup meetings \--
items from the meeting.

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

Thank you very much, Tony, this is Karen Bell. Tony and I had previously
discussed the fact that some of the summary document work that you have,
from the environmental stand, and information that you have in your
packet, we thought we would leave and postpone to the next meeting,
where we may be able to actually flesh it out a little bit more for you
all. So that I\'d just like to concentrate on two followup items right
now. One is the Privacy and Security Workgroup.

As you recall, or you may recall, among the recommendations that went to
the American Health Information Community from all of the workgroups,
there were a series of issues related to privacy and security. And that
led to the recommendation for the formation of a Workgroup that would
include all work group participants \-- not all the participants, but
representative participants from all the work groups, as well as others,
and it would be a long and thorough vetting from the Community in terms
of \--

That Privacy Workgroup is being formed as we speak. Tony Trenkle is the
representative from the Chronic Care Workgroup, as well as
representative from representing his own expertise in privacy and
security. And at this point, the group is still being formed, and if
there\'s anyone else on this Workgroup that would be interested in
joining, then we can certainly add him or her to that list. And so I
just would like to leave that open for the moment to see if there is any
interest among the Workgroup members.

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

Karen, can we go over what the objectives of the Workgroup are?

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

Absolutely, thank you. I think the issues that were identified are
patient identification, authentication, authorization, and the types of
technical structures and policies that would be consistent with the
directions that the Policy Workgroup \-- I\'m sorry, that the Privacy
and Security Workgroup recommend.

So it is a group that\'s being formed, again, with a lot of public
input, to address primarily those issues that we talked about and were
recommended a little bit earlier to the American Health Information
Community.

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

And the timeline for that group?

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

Judy, do you remember the final deliverable?

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

I think the first deliverable is sometime in the spring of 2007.

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

This is Paul Nichol from the VA. Could I ask whether members of that are
restricted to active Workgroup members, or whether it would be
acceptable to suggest someone else from the Department of Veterans
Affairs who deals with this on a more regular basis?

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

That would be more than acceptable, they don\'t have to be absolute
Workgroup members.

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

Thank you.

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

Thank you. But I wanted to \-- but we certainly wanted to give all
Workgroup members the right of first refusal. So hearing none at the
moment I would just suggest if anyone is interested to please get back
to either Tony or myself, and we will assure that your name is added to
the list. Otherwise, I will assume all of you are very busy with other
chores and work, thank you.

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

I think they need to get back to your office, Karen. Nice try.

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

Well, you\'re Chair.

The second issue is about State licensure, and there\'s just a small
brief update on that.

Our office actually did meet with the Federal State Medical Board, and
they were actually very open to considering some options around
reciprocity.

There will be, as I indicated earlier, a meeting with the Secretary,
with the National Governors Association and we\'re looking at all of the
issues that we think he ought to bring to that meeting in August, with
this being one. So we are making some progress in this area, it\'s still
on the agenda for him to discuss, and we should have a little bit more
information on that as the work with the State medical board rolls out.

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

When is the NGA meeting?

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

MGA meeting is August 8. Not MGA, NGA. We should have more information
for the next Workgroup meeting.

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

Karen, this is Jay. Can you hear me?

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

Yes, I can.

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

One, I want to applaud the fact that you met with the Federation of
State Medical Boards. The only caution is that the Federation of State
Medical Boards has always been receptive to addressing some sort of
change in the individual State licensure situation that exists today.
But unfortunately, they have very little to say, and very little
authority to deal with the problem. So while we may be an advocate,
they\'re not going to be an authority or decision-making group.

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

That\'s helpful to hear, Jay. Actually, it\'s not \-- doesn\'t help us
in the long run, perhaps, as much, but it\'s helpful to hear and I think
that\'s why it\'s going to be very important that Secretary Leavitt
weigh in.

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

This is Craig Barrett. Just out of curiosity, where is the holdup?

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

It isn\'t so much a holdup, it\'s our ability to meet with NGA through
the Secretary, that is in his time frame.

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

The question about holdup is if the State licensure boards are for this?

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

No, the State licensure boards, that\'s the issue. The federation
represents simply a federation, but has no authority to change any
individual State laws. It still remains the medical boards of each
individual State that has the authority to make the changes.

The reason that the National Governors Association meeting is important
is that in the majority of the 50 States, the appointment to the State
medical board comes out of the Governor\'s office. So it\'s really the
governor, and then as the ultimate authority, from an appointment
standpoint, to determine who is on the State medical board. But the
individual State medical boards at the present time make their own rules
and regulations.

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

If there are no more questions before we move on to the next piece of
the agenda, I\'d also like to mention that Dr. Anand Parekh has just
joined us and he will be leading a discussion a little later on the HHS
physicians perspective with respect to a possible demonstration.
Welcome. Glad you could join us.

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

Thank you, Karen.

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

Karen, one final note on that one. So the meeting is on August 8, which
is less than two weeks away, so what is going to happen between now and
then for the Secretary? They\'re going to \-- is he giving a briefing,
or what exactly is he going to do for the NGA?

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

Actually, there are several steps that are being taken right now. There
are a number of major initiatives that are on the Secretary\'s agenda
for the next 900 \-- and I think it\'s now eight hundred days. And those
of us who are in charge of those nine initiatives have been discussing
all of the entities \-- or all of the important issues that he might
bring to the governor\'s association. So that information should be
pulled together this week, by the end of this week, or early part of
next week at the latest, and then he will be briefed on these issues and
make a determination on how to address them moving forward.

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

So this will be a one of a number of issues he\'ll bring forward to \--
okay.

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

Yes. Yes.

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

Okay, anything else on the followup items?

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

Nothing at this point. Any questions?

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

Okay, so we should turn to the next item on the agenda, Justine, are you
ready to give a presentation, and Jeanette, as well?

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

I wanted to thank you all for having us here today. We don\'t have any
handouts as we\' going through the data, but I wanted to present what we
have found and what we did do, and collectively, Blue Cross Blue Shield
Association and American Health Insurance Plans (AHIP) work together on
this survey.

And just so you all know, I\'m sure you\'re familiar with why we did
this, but as you all know, this Workgroup made recommendations to the
full AHIC, one of which was to help develop an evidence base for secure
messaging. And as part of that, we were asked if we would go out and
survey our plans to find out what was happening out in the field, and
that\'s what we did.

When we went to our sample members, we defined using a definition you
had included in your material, so we defined secure patient messaging as
communications between patients and clinicians that have an explicit
measure of responsibility for the patient\'s care, and may include but
are not limited to online consultations, prescription refills,
scheduling appointments, referral requests, sharing test results,
receiving care reminders and instructions, et cetera.

Also want to you know that the plans that we did survey, and that
responded are very representational I think and run the gambit of all
the insurance plans out there from State-based plans, regional plans,
large national plans, Blue plans, commercial plans, offering a whole
line of products from HMOs, PPOs, fee for service, and Medicare and
Medicaid business. We had two plans that were integrated path models,
and we did get responses from all.

At a high level at our overall response, we didn\'t have an overwhelming
return on these surveys. From the Blue plans I had the easier task I\'d
say than AHIP, because we only have 38 Blue Cross Blue Shield plans, and
they are all independents and locally operated. AHIP has many more plans
and different lines of health insurance as well. We did receive about
half of our Blues did respond to us. And I can let you know we did
follow up with those that didn\'t respond, and they didn\'t respond
because they aren\'t doing anything in this area. So we have a good
sense of how many Blue plans are doing something.

Together we received a total of 37 health plans responses. And of those
37, only 11 are currently offering secure patient clinician messaging,
with 10 of those 11 offering some form of reimbursement. And when they
do reimburse, they reimburse for, and I put in quotes, eligible
services. One thing I just wanted to say, is that those of us at least
the Blue plans that I talked to, many of these are very small projects,
still very much pilot projects. So almost a word of caution, if you
will, in looking forward, because we\'re still learning what it is
that\'s appropriate to be paid for, and a lot of work going into looking
at what is an eligible service. And we didn\'t delve into that in the
survey.

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

So you didn\'t get a standard sense of what the criteria might be, then?

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

Not from this survey, but that is something as a followup I know
Jeanette and I have talked, and our plans are very interested working
with you going back, now that we know which plans are doing things, and
surveying them further. So we don\'t at this point. I should point out
one respondent is piloting, of those I mentioned, a 10-R \-- thank
you \-- 10-R reimbursement. (Inaudible) the eligible. One is not
reimbursing at this time, but it is piloting.

And then I did speak to one plan, a Blue plan, that actually responded
that they are not doing this right now, but they had in the past, and in
fact interesting for this Workgroup, they had a pilot that focused
solely on patients with chronic conditions. And they did that for a
year, and what they found is they weren\'t getting enough critical mass.
Well, they were reimbursing and they had eligible criteria and they were
trying to get to their population with chronic conditions, they\'re
looking at diabetes and heart disease, they couldn\'t get enough
physicians. Finding a way to fit this into the workflow to make a sense
to keep it going. So it was something that they found wasn\'t providing
enough value to keep going, so they actually stopped that.

So one thing at least, in discussions I\'ve had, that critical mass is
really a key thing to this.

Overall, what we did find is that, as I mentioned, few plans are
currently reimbursing for secure patient-clinician messaging. And while
not everyone had responded, I mentioned that some calls did show that
those that didn\'t respond, some of them at least on the Blue side are
just not doing this. And of all the plans that did respond that they
weren\'t doing it, only four said that they were planning to offer these
services and some reimbursement, perhaps, in the next year.

The health plans that are reimbursing, as I mentioned, are not
reimbursing for everything. For the most part, they are only reimbursing
for online consultations. And for this, it is based on meeting certain
eligibility criteria. But again, we didn\'t delve into that.

The plans that we surveyed are not reimbursing for things like
scheduling appointments, requesting prescription refills, responding to
referral requests, transmitting test results, care reminders,
educational materials.

Interestingly, one plan that I did talk to a little bit further about
this, when I said so what is \-- you know, you have this whole platform,
they\'re offering all of these services, where are you getting the most
hits. And even though they are reimbursing for eligible Web visits, as
they call it, that is one of the lowest used functions. It\'s really
the \-- the prescription refills that are being used, appointment
scheduling very high, and new patient information. Those are really the
highest areas.

Another key take-away from our survey is that reimbursing for security
messaging is relatively new. We asked our plans how long have you been
doing this, and most of them have been doing it for less than 3 years.
With only 2 health plans out of the 11 that are doing something having
been in this for more than 3 years. But it\'s still less than four. So
no one that we surveyed has been doing this for longer than 4 years.

And most of our plans do require a patient copay for the Web visit.
However, the amount of that copay varies dependent upon the contract
terms and all the variations in those plan designs.

So let me stop there, and turn to Jeanette is going to go through more
of our findings.

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

Let me go into more of the detail of some of the questions we asked our
plans during the survey. When we looked at sort of \-- a little bit on
sort of when reimbursement occurs, and it was after each episode, it
wasn\'t on a regular basis \-- done on a regular basis. One of the
health plans did have it as part of their negotiated contract with
providers. Again, this stresses the importance to have strong criteria
defining what \-- when reimbursement occurs.

We asked about the integration with disease management programs, which
many health plans are rolling out to their consumers. And a couple of
the plans did say that it is incorporated in their disease management
plans, or they plan to do it. Another interesting thing was \-- is that
as plans roll out personal health records, some of these services are
going to be included in the personal health records, but it\'s a little
bit too early to say right now.

Let\'s see. There wasn\'t much difference in the product line in terms
of determining when reimbursement occurs. It was more based on an
agreement with an employer, or an agreement with a specific \-- you
know, HMO, et cetera.

We asked about the vendor that is used, and RelayHealth was the most
common vendor. However, another four health plans said it was part of
the provider on electronic health record product, so they didn\'t list
the specific vendor.

Another important piece of the survey was how are the \-- where does the
cost lie or who is paying for the service. And most health plans are not
paying for the physician cost. A few did initially for a short trial
period, but that cost is being on the physician themselves.

Surprisingly, the return on investment question, most health plans left
that blank, which to us just shows that it\'s really a little bit early
in many of the health plans implementation. However, many of these
areas, you know, we\'re very interested in doing followup work with your
committee to go back and dig deeper on a lot of these questions. We\'re
willing to call our top 50 members and get some additional information.
More than happy to do that on working with your committee.

Another thing that we asked about was, you know, how is outreach
occurring. And mostly this was done in direct physician communications,
as well as member communications via a Web site. So they were pretty
consistent in how they\'re doing those, that outreach.

So with that, I\'ll open it up for any questions for Justine or myself.

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

One thing I do want to point out is when we did undertake the survey we
decided to go \-- we worked closely with HHS staff to develop the
questions, and to go at a high level to find out what\'s really
happening, and from there follow up and see where can we delve deeper
and learn more.

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

This is Karen Bell. Jeanette, you didn\'t give us a sense about how many
plans you were able to survey, and what your response rate was. And I\'m
assuming it\'s a very different set of plans from Blue Cross Blue Shield
groups, so I want to make sure \--

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

Right, we received 19 responses.

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

So we made sure we separated that out.

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

Out of how many surveyed?

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

We only did a sample of our total membership. We have 230 non-Blue
members.

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

Right.

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

So your sample size was how big?

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

I don\'t have that, I don\'t remember how many it was e-mailed out to,
but out of the 230, right. Unfortunately with the timing of this, we
were originally going to do this for the AHIC meeting, so we had given
them a very short turnaround during our annual meeting and Board meeting
the same week. So it\'s kind of unfortunate, but doesn\'t neglect our
willingness to work with all of you.

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

Out of the payers who were reimbursing, was there a \-- generally
similar reimbursement structure in terms of need for service or
capitation or pay for performance?

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

Most of what we got, and we didn\'t delve and ask a lot of questions in
high level, but we did learn most are paying in some degree of fee for
service, but it\'s for a service that they have criteria to make sure
it\'s for \--

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

Eligible?

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

Right, an eligible visit. Or there are some plans, there are a few that
were doing a fee for episode of care. So for example, if there was flu,
it would \-- and multiple questions or contacts came in over the course
of the period there would be one payment for that episode of care versus
payments for each contact. And only one, as Jeanette mentioned, that
actually built it into a capitation contract with its providers.

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

And the plans that I talked to that actually are reimbursing, it was a
mix, it was one large national plan, but there are some State-based
plans that were reimbursing. And a large national plan who was
reimbursing did so because of employer demand, and large employers were
asking for that service. So we thought that was very interesting.

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

I should point out here at least in the Blue plans we talked to,
there\'s only one Blue plan that has been doing this for a long time and
has some experience, but they are the one that says the Web visits is
very low. And the others most of them this is still very new, very
limited population, what they say to us is really trying to get critical
mass is difficult, and how this fits into the workflow. The physician
office.

So I think our plans have said, well, they are testing this, you know,
it\'s still with a cautionary note of we don\'t know or we haven\'t been
doing this long enough to see are we getting real returns on the
investment, are we getting the critical mass to do this. And they\'re
gathering results and beginning to do \-- measure outcomes at this
point.

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

This is Craig Barrett. All your comments are reference to the insurance
companies\' perspective. Do you get any feedback from the patients\'
perspective?

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

No, the survey focused solely on our health plans that are doing this,
so we did not go out and do that, that would be something I think our
offices, I don\'t know if you\'re equipped to do as much as you know our
plans may \-- research and focus groups, but we did not take that angle
on the source-level approach.

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

And you weren\'t asked.

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

Right, we weren\'t.

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

I think Craig brings up a good point, that\'s certainly an area that
needs to be looked at in terms of consumer response.

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

Absolutely. And I could say I mean anecdotally when I talked to our one
plan that I mentioned who stopped doing this \-- I was really interested
when I heard they were focusing on chronic conditions, and they said it
was a mixed \-- they couldn\'t get critical mass. Some physicians, it
was hard to get workflow, some of the patients felt it was a little too
much, for lack of a better word, Big Brother come in to check on them.
There was a bit of uncomfortableness or discomfort among some of them of
doing this, and feeling comfortable with this new medium is something
they weren\'t used to doing. Some of those patients didn\'t quite feel
comfortable. I don\'t know what kind of patients they were, whether they
were not computer literate, what were the factors.

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

Actually at tomorrow\'s Consumer Empowerment meeting on the personal
health records we\'re going to talk a lot about the focus groups that
AHIC did last year. And one of the things we found \-- we found that
consumers were very interested in personal health records, and security
was a number one concern. So that\'s, you know, an important thing. But
we\'ve tried to reach out to consumers a lot about at least our personal
health record project that we\'re going to talk more about tomorrow.

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

This is Craig Barrett. The stories are legion about people who will give
their credit card to any restaurant worker in the world, but won\'t put
the credit card number online because of security reasons. There isn\'t
always a great degree of rationality in some of these responses.

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

Let us know if there\'s any additional work you\'d like to us do or
followup you\'d like to do with our plans, we\'d be more than happy to
help out the committee in any way.

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

Craig Barrett again. From your perspective in getting feedback on these
surveys, admittedly it\'s a pretty small sample, but what\'s the general
direction or trend?

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

Well, in talking to some folks, we have four additional plans that are
considering doing it within the next year. So that\'s \-- and a couple
other plans that are working with employers to do some other pilots. So
in that \-- with that small sample size, we do see a positive trend, but
these, again, are very small pilots in terms of just getting some
information, getting started. I don\'t know, Justine?

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

On our side we didn\'t have any plans that responded they were thinking
about doing this. We had the seven that were already trying this, the
others that weren\'t thinking about it. And when we\'ve talked to them
on other issues of where they are headed in terms of a trend, most of
our plans or many of them, I should say, are focused on personal health
records, on helping in their communities to \-- for collaboration for
regional health information exchanges, adoption of electronic medical
records in the physician office, e-prescribing. That\'s where I think
we\'ve seen from some of our plans some of the trends back in their
communities.

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

There may be an indirect measure of the trend in that RelayHealth was
just bought by a much larger corporation, and they must have done some
market due diligence before they made that purchase.

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

I have a question. You suggested that perhaps you\'d be willing to work
a little bit more on this, and one of the things that I think we\'re all
suffering from is an inconsistency of value measures. Whether they\'re
quality of care, cost measures, whatever. Would both of your
organizations be willing to work together, with or without input from
the Federal Government, with respect to developing a core set of value
metrics that are addressed? Quality, cost, patient satisfaction,
provider satisfaction \-- just throwing that out as sort of the four big
areas, that plans who are moving forward with pilots or plans that are
doing this would agree to, so that we may have more robust ability to
evaluate, even if there are some small numbers, and a number of small
plans? You know, I don\'t necessarily know that you need to make a
commitment, but I\'m just wondering if that\'s something that we could
think about and talk about moving forward.

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

Sure, we can do that. I think the challenge will be how much data and
information some of our plans, especially when you look at many of them
not having been in this too long. Certainly we\'re committed, I know RCO
is a member of AHIP, I know AHIP is committed to helping and doing more
in this area, so certainly.

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

I think that makes a lot of sense, Karen. Because part of the problem
we\'re finding here is getting consistent information. And I guess if we
could pull together some criteria and some consistency, I think that
would help in terms of assessing a value proposition.

I just have one other question. Is the survey that you did, some of
them, you said most of them were pilots. There were several that were
full-blown implementations or \--

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

From our plans, some of them, well, they might not be pilots in the
sense they\'re still testing to see if it works. Most of our plans are
on a limited population, whether it\'s employer driven. For example, one
plan has a large employer in their area that really wanted this for
their employees, so it was something that they worked out in the
contract.

Others are focusing on certain geographic areas, or looking at certain
physicians that they may focus in on. But I didn\'t see any of our plans
that are actually offering this to all of their members, if that\'s what
you\'re asking.

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

Well, I guess part of what my question was, is this something that you
see growing along with personal health records, as a \-- you know, as
part of a personal health record system, for want of a better word.

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

I think that\'s hard to tell at this point from what we\'ve gotten back
from our plans. I think most of them are still assessing, internally, as
to what they\'re doing, is there a value, are they getting a return. I
think in terms of the appointment request, the prescription, new patient
information, where they\'re seeing higher uptake in numbers, there may
be more. On some of the others, I think they need to see more work, and
will there be more critical mass coming to use this.

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

And we had two plans both in the upper northwest that do have a pretty
widespread rollout to most of their members. So we can get you the
contacts for those plans, if you\'d like to follow up with them.

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

That may tie in.

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

Thank you very much. This is Karen Bell, and I really want to underline
how much we all appreciate the effort and energy that you\'ve put into
doing this, and very much enjoyed working with you on the process. And
thank you so much for the presentation today.

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

Thank you.

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

Thanks a lot.

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

This is Karen Bell, again. What I would just share with you \-- and
there will be a document that will be posted after this meeting, to our
Web site, but if any of you have access to your computers, there was one
that was actually e-mailed a little bit \-- I guess about an hour or so
ago, just for people who might like to focus on a piece of paper while I
do a presentation.

This is very much like Justine\'s, it\'s just a discussion about some
fact finding that our office did with respect to secure messaging
solutions. And a number of different models.

And right up front, I\'m going to indicate that the model that\'s being
excluded in this discussion is one where secure messaging occurs through
a patient portal on a delivery systemwide electronic health record.
There are a number of places where large integrated delivery systems
have an electronic health record that all of the providers have access
to and use for each patient, and patients do have the ability to access
that information and communicate with caregivers in that environment,
through a secure system.

We\'re eliminating \-- again, just to underline, we\'re eliminating that
particular model and we\'re presenting you a little bit of information
about three other models that exist essentially in the vendor community
at the present time.

One of those is \-- and as it was mentioned a little bit earlier by our
agent representative, was RelayHealth. And in fact, RelayHealth did come
and give a presentation here several meetings ago. And as you may
recall, that is a very structured, secure message model that occurs
between the patient and his or her clinician of record.

Its business model can be any one of a number of things. It can be a
patient copay or the equivalent of a copay, so the patient essentially
pays the same amount and the physician receives some reimbursement for
that. It can be insurer, which could be either plan or employer based,
with reimbursements for the license to access the service, and a fee for
service. And thirdly, it can be reimbursed to the physician or clinician
as part of a basket of care management services, i.e., as part of a
capitation fee or something of that nature.

The content of this particular model, as we\'ve said before, is very
structured in order to capture key clinical information in a way that it
can be used most effectively by the clinician, and the instigator of the
encounter is clearly the patient.

The value to the provider \-- and I think we\'ve heard this already \--
is going to be dependent on workflow management, and the financial model
that works for the provider.

As far as the patient is concerned, there have been studies to suggest
that the increased access brings value along with greater compliance.
But this has not been demonstrated in our more vulnerable populations.
In our older patients, nor in, for instance our Medicaid population.

In terms of demonstrated value to payers, I think we\'ve heard before
that in a very limited number of studies, I think one or two, there
appears to be a positive return on invest from decreased EHR visits and
hospitalizations and visits, but again as we heard today there are a
very limited number of short term programs out there, so that this
clearly would need to be validated in moving forward.

And then lastly, in terms of market penetration for this particular
model, we heard about a number of plans mentioned today, and I would add
that in at least a dozen States and national plans there are at least
18,000 physicians covering 600,000 patients as of now in this particular
model.

It is interesting that in some States there is significant overlap, with
multiple plans in the same area covering the same service. We identified
four of those. There could be more, but at least in Florida, parts of
Florida, California, New York City, Massachusetts in the Boston area,
there are two to three or more plans offering the similar service.

A second model for secure messaging is actually much more limited. It\'s
a model where the secure messaging system is actually imbedded in an
electronic health record.

In this situation, the business model is essentially from the physician
office \-- the clinician office. Because a number have found this to be
a more effective and efficient alternative to paper mailing and multiple
telephone calls that go back and forth. And also it\'s far more HIPAA
compliant, because the message is secure as opposed to leaving the
message on a voice mail at someone\'s telephone address.

It can also be offered to patients who are willing to pay either a
monthly fee to their physician\'s office to use this, somewhere in the
range of maybe about \$40 a month, or it can be fee for service
somewhere in the range of what would normally have been a copay.

In this situation, the content is not structured, it\'s free flowing.
And the value to the provider, as I articulated a little bit earlier,
comes from cost saving from administrative efficiency. There is also, as
I indicated earlier, value from HIPAA compliance when one is leaving
messages, and the ability to track and validate that communication has
occurred.

When one focuses on the provider in this situation, as the essentially
primary business component, or consumer, then the provider can make this
available to his or her entire patient population so it\'s very easy to
include it in their workflow.

Again, it\'s essentially, in terms of market penetration, very limited
to providers who have electronic health records, and electronic health
records in which this can be imbedded. So that when one actually starts
looking at measures of values to patients and possibly even payers,
it\'s fairly limited at this point in time because of that model. But
it\'s essentially growing on a regular basis. So that\'s the second
model.

And the third model that I\'d like to share with you today is one
where \-- again, it\'s patient and clinician focused. One where both can
access a network, a secure network for the purposes of personal health
management. Business model here is that patient would be willing to pay
a copay or the equivalent of a copay for accessing services with
their \-- or accessing communication with their clinician.

And in many situations, or actually not many, I take that back, in
several situations, perhaps as many as four health plans are sponsoring
this as an alternative to a plan generated personal health record.
Because most recent publications and studies are indicating that it\'s a
very low uptake amongst the membership community with respect to
plan-sponsored PHRs. So in this situation, where a clinician is
providing the service, patients appear to be much more inclined to be
engaged.

And the content here, actually, is multiple. It isn\'t just the secure
message that is the communication vehicle around each specific clinical
situation, it\'s also the ability for physicians to send reminders to
their patients, to ask them for followup if the patient hasn\'t
responded with followup, and to provide them with patient-specific
access to health information that may be critical for them at any point
in time in their clinical process.

The value to the provider is similar to what I mentioned earlier about
the imbedded EHR. Because it\'s a provider-based system it\'s available
to his or her entire patient population, and leads to more
administrative efficiency as well as more timely feedback from their
patients, and patient satisfaction.

The demonstrated value to patients is actually in progress. The company
that\'s doing it right now has defined the process measures that it will
be using to demonstrate value to patients and to payers as well. And as
I mentioned to you earlier, it is beginning to move into the payer
market, looking at payers who may be willing to reimburse for these
types of services, as physicians become more and more engaged with it.

So just to recapitulate, we have here three very different models. One
where the secure messaging system is imbedded in the electronic health
record; second is where the secure messaging system occurs through a
network, and a lot of information can flow back and forth through that
network; and then the third is a very structured portal that patients
can use to access their clinicians and the clinicians can respond.

Most commonly used has been the last one I just mentioned, but these
other two I think certainly merit some investigation as well. And I just
put them out there in terms of \-- in terms of your information, so you
have some sense of really what the market is doing around secure
messaging at this point in time. And I\'d be happy to answer any
questions.

And if you would like to hear directly, in terms of public testimony, in
terms of what these various groups are doing with respect to their
research, their outcome studies, I\'d be more than happy to provide that
to you at your discretion.

And again, this will come to you in written format after this meeting is
over.

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

Karen, this is Craig Barrett. You mentioned up front that you were not
including kind of the vertical integrated model, sort of the Kaiser
Permanente model, is that correct?

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

I did not include that in this analysis. These are strictly the vendors'
models that are available to anyone.

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

Okay, thank you.

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

\-- vendors that are only available in a specific delivery system. We
could certainly go back and look at those as the next go-around.

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

Karen, this is Mohan Nair.

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

Hi, Mohan.

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

Hi. This is excellent work, this is very good breakdown. I might say
this is a good framework for discussion, actually. And it breeds a
question in my mind. From your exposure to this, and your research into
this, which one had the biggest \-- largest traction to patients and the
least process shift for physician?

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

I can tell you that the one with the least process shift to physicians
is where physicians are already using an EHR, and it is integrated into
that workflow.

If physicians are paperless, this becomes a wonderful way of
communicating with patients. But again, it does assume that physicians
have that EHR system in place.

And I am happy to underline the fact that many of the \-- several of the
EHR vendors that have this imbedded are certification commission
certified, so just wanted to underline the importance of certification
commission \-- of certification processes.

In terms of the second one, it would be where you have the network,
where again all of the patients are eligible for the service. And the
one that\'s toughest to include would be the structured remote
encounters, because there you have to have some form of reimbursement
for the most part, and it does change workflow. And there\'s not been
enough, I think, study work to be done at this point in time on really
what is the greatest value to the patient.

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

Thank you.

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

This is Eric Larson. I think it was Craig or \-- that asked a question
about the perspective of a Kaiser Permanente group. I think it would be
worthwhile making sure that that perspective is included in our thinking
about this. And I agree, this is very nice work.

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

Thank you. So I take away from this that we will then go back on the
large delivery systems that we know are doing this, and see if we can
get some of their value measures. And understand their business model
content a bit more as well.

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

Right.

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

Thank you, we\'ll do that. Any other questions or comments on this?
Other than thank you for your added homework?

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

Yeah, absolutely.

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

Okay. Well, what we\'ll do is we\'ll do that added homework, and then
we\'ll present this as a package for the next Workgroup meeting. We\'ll
put it all together in one report.

Do you want to go into this?

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

Okay, I guess we\'re ready to move on to the next topic, then. Karen,
would you like to introduce?

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

Absolutely. Dr. Anand Parekh is an internist who is currently working
with HHS in the Secretary\'s office and with the office of emergency
preparedness, public health and emergency preparedness. He\'s offered to
give a brief overview of some of the discussions a number of the
clinically oriented physicians in HHS have had over the course of the
last several weeks. So a small group has come together from CMS,
actually we\'ve had some input from AHRQ, from this office, and clearly
from the Secretary\'s office, to really think through some of the issues
and questions around a demo. And our hope is that we present this today,
and Anand is presenting it today, and it will stimulate some discussion
about some guidance that we might consider if we do move forward with
the demo.

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

Thanks Karen, thanks for your leadership on this topic. I\'m going to be
speak probably for about 5 minutes or so, and hopefully I can summarize
where we are. I don\'t want to call these recommendations as yet, but
maybe current thinking among a small group of us. We\'ve all heard about
the theoretical benefits of secure messaging to potentially improve
quality and reduce costs, but actually to translate this into a
potential demonstration project that CMS could use was our task. And
I\'d ask if you have in front of you, to follow with me. One of the
attachments for today\'s meeting was a document entitled AHIC chronic
care guiding demonstration, it\'s a two page document which goes through
seven or eight major points which I thought I would highlight, and I\'m
just going to take it from the top.

I think the first point in terms of a demonstration is defining what the
services could be in a demonstration under secure messaging. And some of
the possibilities where online consultation, which we know;
administrative functions, which we\'ve heard about as well a little bit
today; a third is patient viewing of EHRs; and fourth is remote
monitoring device data.

And we considered really four options that a potential demonstration
project could evaluate. The simplest option being defining security
messaging for these purposes to be just online consultation, structured
tests, a structured text. And the reason why I think we were \-- we had
a favorable impression about this one is unlike the current
demonstration projects that are a part of MMA, secure messaging here
wouldn\'t be bundled and we could potentially see a cause and effect of
a specific service, here.

So one of our thoughts was potentially in a demonstration project to
compare, is to have an experimental and a control group, one group
having online consultation physicians and patient, and then a control
group.

But we also had a favorable impression of the second possibility, which
is defining secure messaging as not only online consultation, but also
adding these administrative functions which we talked about just a
little while ago. Allowing a patient to have referral requests, to
schedule appointments, to get prescription refills, et cetera. And the
idea of having, again, one experimental group and one control group for
this one, we thought that might be a good recommendation, as well.

The third and fourth options here include patient viewing of EHR and
remote monitoring device data. And as much as we all \-- you know, would
like to see EHRs flourish, and that\'s really one of the \-- you know,
the central pursuits of AHIC here, given the scope of this demonstration
project and the fact that EHRs right now still have a very low
prevalence, especially in small provider groups, we just thought that
having a requirement of patient viewing of EHR, as we define secure
messaging for purposes of this demonstration project, might be too
restrictive of a requirement. And I can get into that a little bit more
later on.

So I think in terms of the first point, here, how we might want to
define secure messaging for the demonstration project, I think our
preference right now is to evaluate the idea of online consultation, and
also evaluate the idea of online consultation plus administrative
functions, and compare it to a control group, to see if there is a
benefit in terms of quality and cost and satisfaction, and the other
outcomes we might want to study.

And I\'m just going to run through these and then open it up for
questions and discussion.

The second point we considered is what the care model or the
reimbursement model should be. As we all know, both fee for service and
capitation, and the broad models have their own pros and cons. I think
for fee for service, obviously this would be the most attractive for
physicians, but the worry I think CMS and we would have is what do you
do about fraud and abuse. And what do you do with the situation where
physicians and patients are consulting 20 times a day, and who will then
justify whether these are \-- whether these services should be paid for
or not. And so the fraud and abuse issue is something that we need
to \-- you know, to further discuss.

In terms of capitation, this structure probably makes even maybe better
sense. The problem with capitation is how do you deal with risk
adjusting and how do you differentiate some providers who put in a lot
of effort with this, and others who just do more of an average kind of
job. So the ability to do a good job is the problem here. Certainly a
copay or something like that in addition to capitation could be \-- you
know, could be utilized in a demonstration project. I think what we
concluded after a couple meetings is we need more input maybe from CMS,
and maybe ORDI just on details of some of the different reimbursement
approaches. We looked at some of the approaches in the demonstration
project under MMA that dealt with this topic, but I think we\'re
probably going to need a little bit more input from CMS in terms of what
direction to go from there.

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

And who from CMS was on your team?

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

It was David Humps.

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

David Humps?

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

The third kind of broad area is how do we choose the physician
population, and the workflow issue is really the key here. And the first
point is that, you know, anecdotal data tells us that physicians need
probably about 30 percent of their patients to be eligible for secure
messaging reimbursement to get them to really change their workflow, to
be able to do this. If there\'s just not enough patients in their
practice who are going to engage in secure messaging, it\'s probably not
going to be worth the physician\'s time, money or effort to actually
will go through with this. So the ability for us to attract physicians
who are potentially already engaging in secure messaging, who are
working with different payers in their geographic region, who are
already getting reimbursed for providing these services, might be the
way we want to go.

I think we\'ll probably have to do something regionally as well, based
on the limited data that we\'ve heard. Secure messaging has grown more
in California as well as the northeast as opposed to particular other
regions, and we might need to, just because of the reality of the
situation, focus on a regional basis for a demonstration project.

We could consider segmenting by specialty, as well, even though I think
there\'s scope here for both primary care physicians and specialty
physicians to get involved if we\'re focusing on chronic illnesses. You
know, your CHF, COPD, diabetes, things that both primary care physician
and specialists see. Hopefully that will broaden our physician
population there.

But I think the key point on this number here is our feeling right now
that we probably cannot focus just on physicians who have EHRs, as much
as we want to, just because of the low prevalence out there in terms of
physicians who have EHRs. One of the problems then is then what we would
be recommending to CMS, not necessarily contrary to AHIC but not really
going in the direction we want. It also brings up the challenging point
for CMS of in terms of audit purposes. And gosh, you know, if we don\'t
incorporate this in EHRs then somehow each office would then have to
print out each of these, you know, information flows, print out, and
then put in the chart, and you\'re adding kind of a volume to the
already large paper record. And it\'s not really ultimately the
direction that all of us want to go into. But given the low prevalence,
I think right now the recommendation would be not to restrict it to
physicians who just have EHRs.

The fourth point is how do we choose the population. And here, I think
the main considerations were should we take the similar approach to a
lot of the CMS demos that are currently underway that is focusing on
high cost chronic illnesses, CHF, COPD, diabetes, potentially including
cancer as a fourth eligible condition, or should we focus on individuals
who have multiple chronic conditions, since that\'s really where
potentially the most gain can be made with improved coordination in care
and improved IT in their care.

So I think this is something that we probably also need to talk to CMS
about. I think there are advantages to both of these specific
approaches, as well as an approach that takes into account multiple
chronic conditions. I think consideration should be made to potentially
follow the same pattern that was followed in the Medicare 721 demo,
focusing on CHF, COPD and diabetes. There\'s good data that tells us
actually elderly individuals who have one of these conditions also have
multiple other conditions. So we probably will, if we focus on three or
four disease-specific areas, probably get those individuals who have
multiple chronic conditions as well.

The fifth area is again this idea of how would secure messaging in a
demonstration project change the workflow for participating physicians.
And, you know, there\'s a limited data out there from RelayHealth and
Kaiser and folks that potentially this could increase productivity of
physicians and increase their relative volume units and free up some
more time for them to see patients, other patients in person. However,
there\'s limited data there. And then the second question about how this
gets incorporated in the EHRs I alluded to earlier is a problem.

The sixth issue is how we assess value. And we talked at length about we
need to define success here. At the end, if CMS engaged in a
demonstration project, what is success in the end, and what will \--
what might make CMS decide to go forth and establish this as something
more than a demonstration project. And, you know, obviously there\'s
cost and there\'s satisfaction.

But the way we broke down cost was, at least for CMS purposes, the cost
to CMS for sure would be potential reimbursement for each secure
message, quote unquote, visit. Whatever that \-- however we define
secure message. And the other cost to CMS would be all those
administrative transaction costs. That\'s collecting the information,
doing the auditing on the claims, and all of that. And those costs will
hopefully have to be offset by the expected reduction in costs from
reduced cost to provider visits, reduced hospitalizations, reduced cost
of associated illnesses by engaging in secure messaging.

So that cost balance will probably be something that CMS will be very
interested in. And I think obviously then patient and provider
satisfaction will be big items in terms of assessing value here. So
that\'s kind of where we are with that.

I think the seventh is actual implementation. CMS\'s big keys are
reimbursing those services which are both appropriate and necessary. And
actually, you know, as I alluded to earlier, trying to figure out
exactly which part of secure messaging is appropriate and necessary and,
you know, how you differentiate what could be fraud or what could be
abuse from things that are not, is going to be important.

We talked a little bit about the length of the demo, will be something
that we\'ll need to decide, whether it\'s three years like some of the
other demos. You know, there is some consideration to be made that
something longer than just a year, maybe two or three years, might give
more time to see some cost benefits and quality benefits, but again,
that\'s debatable.

And I think the last point I want to make is whatever we decide to put
forth to CMS as a recommendation needs to be aligned with CMS\'s vision
for the future as well as AHIC\'s vision for the future, in terms of
improving care coordination for the Medicare population as well as
promoting EHRs as AHIC is trying to do.

Again, I\'ve probably not called these recommendations, and more kind of
where a few HHS physicians who have thought about this for the last
couple weeks, a few areas where we\'ve come into agreement, and some of
the thought processes that have gone along there. But I\'d be happy
to \-- we\'d be happy to engage in further discussions with this.

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

This is Eric Larson. On your demonstration project, and this patient
viewing of EHR, I agree that you wouldn\'t want to make this a
requirement for the demonstration project, but would it be an option for
part of a demonstration project?

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

I think that\'s certainly a good idea. I think the key is do you get
enough physicians to participate that at the end of the day, when you
evaluate and you do an analysis, your N is big enough to say something
about the outcomes that you\'re interested in.

You know, I think we can \-- I think CMS could consider it, it\'s just a
matter of how useful it would be.

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

I guess the reason I ask is I\'m trying to get my hands around, is this
going to be a single demonstration project of a sort of single way of
accomplishing secure messaging. Or is it going to be structured in such
a way that you will see the heterogeneity and learn both from the
demonstration project but, you know, sort of some of the questions
we\'ve asked as a group, as well as be able to make observations about
how different ways of doing things result in different outcomes or
different costs or different benefits and so forth?

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

I think certainly the thought process was for a demonstration project to
really evaluate two parts of the secure messaging. One would be just
simply the online consultation, since we agree that\'s really the \--
you know, one of the core features of secure messaging. But also, then
to evaluate online consultation plus some of these administrative
functions. I think the thought was within a demonstration project to
evaluate a couple different either services or bundles of services, if
you will, and compare them to a control group, and then look at all of
the different outcomes that you would like. And certainly I think that
probably gets to a lot of the questions I think the broader Workgroup is
interested in.

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

I have a question, this is Kelly Cronin at ONC. I\'m wondering if there
was any consideration given to the scope of the demo, given that there
is authority to do demonstration projects under the Social Security Act,
and you can actually do pretty large-scale demos that go beyond what is
typically done by ORDI, if there was a will and a way. And if in fact
there\'s a desire to target physicians that might have up to 30 percent
of their patient population impacted, so that workflow really would not
be as much of an issue.

Perhaps you could think of going in regions where there\'s not already
some level of reimbursement, but also regions where \-- or physician
offices where they have at least 30 percent of their patient population
being reimbursed by Medicare. So that you wouldn\'t just limit it to,
you know, areas where there\'s an ongoing \-- there\'s a plan that is
already currently reimbursing.

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

This is Tony Trenkle. I think this has to be vetted in CMS. I don\'t
know who the gentleman was that was on the Workgroup, but he doesn\'t
represent the areas that would be doing the demos. And I think we were
planning to have some internal discussions on this. This is a good
document to provide some background, but I think we have to look at this
more closely.

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

Hi, this is Jay Sanders. One comment, and one question. The issue of
fraud and abuse, you know, obviously should not be minimized in any way.
But it\'s an apples and oranges issue, and shouldn\'t be used as
something to block the need to do this. You just put in the safeguards.
I mean, look at our present system, it\'s got \-- it\'s got lots of
opportunities for fraud and abuse in it. And there are certain flags
that you can put in, into the system, to flag a situation that seems to
be one that falls outside the two standard deviations. So while it is
important, it is an apples and oranges issue and shouldn\'t be used as
an excuse not to do it.

The question that I have is relating to the demonstration project and
the reimbursement. There are so many times that a patient\'s question to
the care provider could be adequately answered not by the physician, but
by a nurse within the office in terms of how to take the medication,
when to take the medication, et cetera. And would there be any attempt
within the demonstration to broaden who might get reimbursed within that
physician\'s office?

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

I think \-- in terms of the first point, I completely agree with you,
and I think the fraud and abuse was just brought up as really just to
talk about program integrity. But I think we all completely agree that
just as long as the safeguards are there, it\'s something that we all
realize we need to address, you know, it shouldn\'t really be an
impediment to a demonstration project.

I think the second point you made is a good one. We didn\'t really get
into talking much about how health care providers, nonphysician health
care providers could potentially be the providers who could interact
with patients. But I think you\'re absolutely right, you know, some if
not the majority of maybe the questions that patients might have might
probably be very well \-- you know, the responses will be as good if not
better from nonphysicians as opposed to physician.

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

Right, and it also might address some of the obstacles that exist from
physicians in terms of workflow.

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

Yes.

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

This is Karen Bell. I think the issue of scope that we\'ve been talking
about is a very big one. We were thinking from the perspective that
clearly there are integrated delivery systems where secure messaging
does occur as part of patient access to electronic health record, and we
mentioned that a little bit earlier. But that most of the country
basically still is cared for by physicians in small practices. So in
that situation, the large integrated models may prove to be providing
better care, and have better structures and processes, and I think in a
recent ARHQ report demonstrated that.

So really I think we\'re concerned about the patients who are receiving
care, again, in these small physicians' offices.

The second thing is as one looked at the secure messaging, that\'s
clearly the most common mode that\'s available right now. Which if I go
back to my chat a little bit earlier on these various models, it\'s one
that multiple payers are using, and that is well known, and I think we
could probably develop some pretty consistent outcome measures around.

There is growth in the area of the essentially network access, where a
number of these other services are available, so that I think it
would \-- that\'s why we thought about adding those on. But to a
nonpoint, there really are not that many physicians who have EHRs right
now, so that the EHR-embedded model is one that probably would not give
us a very robust response in the end.

So I think it really \-- you know, my original question to you all,
then, does come back down to scope. Does our approach here, where we\'re
thinking about scoping it to secure messaging, because that seems to be
the easiest way to develop a demonstration, an appropriate approach? Or
does the group think that we should actually broaden and much, much more
diverse?

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

Demo for \-- meet Recommendation 1.1, or is it to deal with the broader
charge?

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

1.1.

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

Which says secure messaging.

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

Right.

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

Karen? This is Craig Barrett. How would you define an incredible
success?

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

I think I\'d have to leave that to CMS.

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

I\'ll mention \-- Recommendation 1.1 says public and private payers
including CMS, Karen. And who are the other public and private payers
who are involved in this? Maybe they should be speaking now, as well.

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

I\'ll be bold enough to answer. This is Kelly Cronin. I think if we
could end up with an evidence based reimbursement policy in the several
years we will be making a significant advancement. And I think that most
of us in HHS are all for evidence-based decision making when it comes to
setting policies. And if there\'s a very strong evidence base to suggest
that there\'s a clear return on investment, there\'s clearly value
added, it\'s going to improve the efficiency of the program and keep the
program integrity, that it would be hard to say no, this is not a
reasonable service to reimburse.

And I think that actually gets back to what we were beginning to discuss
a little bit earlier when we were talking with Justine and Jeanette
about the possibility of coming together with a consistent set of
measures that would lead to a more robust analysis, I think that would
be incredible success. Where everyone agrees to the right value
measures, that demonstrate improvement in the cost structure \-- and not
just the visits, but the overall cost structure \-- the value in terms
of quality of care, patient satisfaction, provider satisfaction, I think
that we will have what I would call incredible success.

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

And even the anecdotal evidence out there about the theoretical benefits
about this \-- you know, data that really helps and folks have provided,
that patient group is a younger group, average age of 38. Healthy group,
you know, computer literate. It\'s a very different group than the group
that we\'re trying to engage, the over-65 with multiple chronic
conditions group. And so I believe that evidence based, I think Kelly is
absolutely right, it needs to be built to figure out what the best
reimbursement model eventually is.

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

This is Paul Nichol. I would agree it would be best to focus only on
secure messaging at this point. I would hope in doing so that we could
understand the context in which it\'s being used so that we don\'t
exclude systems in which patients also have access to their electronic
health record or other sort of Web portal functions.

But I think secure messaging can be separated out and stand alone in the
evaluation, as long as we understand that context in the evaluation we
need to ask some questions to understand what other information and
functionality patients may have access to.

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

Yeah, this is Jay. I agree with that also, but I\'m not sure that the
results with secure messaging, whether they\'re good or bad, necessarily
will preclude our moving on, for instance, and doing a demonstration in
terms of remote sensing.

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

This is Eric Larson. I\'m not really responding to Jay\'s point, I
don\'t have an opinion on that, but I\'m going back to I think what was
Karen\'s original question, should this be broad or focused. And in
response to Craig\'s question about definition of success, your answers
indicate to me that this should be broad. If you want to achieve that
kind of success around reimbursement and quality and so forth.

I don\'t think you\'re going to learn as much from a very narrow focused
demonstration around secure messaging as you would from a broader
demonstration which included heterogeneity of the way practices are
organized. I agree most practices are small, but within that small
practice there\'s innovations, like we\'ve talked about, the advanced
medical home which essentially tries to provide an integrated service
for people with chronic disease, and as you move up you get into the
more organized integrated systems.

And I think the way we\'re going to learn from a demonstration project
is to have a breadth of experience contained in that demonstration
project, so that at the end of the day you\'re going to be able to
unfold the results and say that this is what we know about secure
messaging, depending on how it\'s used.

And I suspect there will be things that are self-evident today that
we\'ll learn, plus things that we haven\'t thought of.

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

Eric, this is Jay. You know, I \-- philosophically, I agree with that
point. But specifically, since so much of hospital readmission relates
to noncompliance on the part of the patient, or just lack of
information, I suspect there will be a significant impact with secure
messaging that we\'ll really be able to measure.

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

I agree.

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

I think the other issue was whether to restrict only to those situations
in which broader access was available. And the point I was trying to
make is that we don\'t want to restrict it only to health care systems
that provide that kind of access. We want to focus on secure messaging,
but understand that it can be used in a variety of different
environments, and that we need to capture the context in which it\'s
used.

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

Yeah, this is Mohan Nair. I\'m challenged with a couple of questions, if
I may ask the presenter Dr. Park as well as Karen Bell, specifically
what are we demonstrating, or are we really creating a test case? What
are we attempting to demonstrate, specifically?

And the second is, the second question is, from my experience, however
limited, when we deal with chronic versus acute care environments, there
seems to be not just a patient-physician relationship, but a referral
relationship between the patient to other physicians in the episode that
they encounter. So it\'s really a network of caregivers that the patient
deals with. How is this demonstration going to articulate the careful
relationship between multiple physicians or caregivers, from primary to
specialty to physical therapy, to \-- and it goes on and on, in the
particular non \-- I use the word "episodic," but it\'s really \-- one
of the problems with our health care environment is that things are
transactional now. And they really are relationship in reality, between
multiple physicians \-- I mean, Jay Sanders will absolutely agree with
me on this \-- in the cycle of care.

How is this demonstration project or investigative project reflective of
reimbursements in that kind of arena?

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

Reimbursement to \-- I\'m sorry, what was the last part of that?

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

How are we \-- what are we demonstrating in the context of what I just
said? I\'m sorry I\'m being so confusing, but it\'s the morning over
here. There are two questions I\'m asking. One, what are we
demonstrating. Number two, are we taking into account the multiple
transactional elements between physician and patient, multiple
physicians and caregivers and patients, in the course of a chronic care
episode?

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

Mohan, this is Karen Bell. I may have misunderstood, but are we really
asking how we look at overall utilization with respect to a given
patient with chronic illness in both a situation where at least one
physician is the primary point of contact for secure messaging, versus
overall utilization where perhaps a \-- the control patient has no
access?

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

Well, let me give you an \-- yeah, exactly. Let me give you an example.
Diabetic A is doing his primary care concerns with a primary care
physician on a number of issues, including kidney and maybe his heart.
And he\'s being sent to a cardiologist for his heart, but he\'s also
being sent to a diabetologist for his hemoglobin A1c exam, and his \--
you know, evidence based exams that he is usually asked to perform. He
is now connecting with multiple physicians, really being the point of
reference. Maybe his primary care is not the point of contact in a PPO
kind of environment.

Is your demonstration project acknowledging that level of
interrelationships, or are we just connecting one physician to a chronic
care patient?

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

Well, I think in the evaluation piece, where we have access to full
claims data, or payers have access to full claims data, utilization of
these other services can be tracked.

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

Yes, it can.

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

And I think that could be how we could address it in this situation. An
alternative could be to do patient satisfaction surveys, which are
obviously much more costly, but I think that there are ways that we can
look at how patients utilize services other than those of the primary
point of contact, clinicians with whom they could have structured e-mail
contact.

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

I think coordination of care, as Mohan, you alluded to, is essential,
and there are maybe ways we can get to that. But, you know, I wonder \--
you know, maybe this demonstration project might not address that, you
know. And as important as coordination of care is for this population,
you know, there are other ways that I think, you know, we\'re trying to
pursue that improvement in coordination of care of this individuals.
Whether it\'s paying physicians to coordinate care, or interoperable
medical records of the cardiologist and endocrinologist has, the same
data as the primary care physician about this chronic diabetic. There
are probably other things we need to do to improve that very important
aspect you alluded to, coordination of care. Secure messaging, this
demonstration project, might improve that, it might not. But I think
that there are enough potentially other outcomes or ways to define
success or value that could be gained, both costs as well as quality.

Even if, you know, even if we can\'t show specifically how coordination
of care is being improved here.

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

I agree. I just wanted to make sure we bounded our demonstration, and
you just helped me actually bound it. Thank you.

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

This is Karen Bell. I\'d like to just make an offer. I always find
myself frustrated after I\'ve done this, but I\'m going to do it anyway.

There\'s a lot of rich feedback that I think all of you could provide us
with, or actually the CMS and other private payers, in terms of how to
go about structuring this and outcome measures. And what I\'m going to
suggest or offer is that we can pull together just a simple template
that essentially begins to address some of the questions that Anand has
set up for us here, and perhaps could ask you to take a little bit of
time to respond on that template. We will then put it together and tell
you what all your responses were at the next meeting, so that we might
be able to move this forward, taking advantage of everybody\'s
experience and expertise in this area.

Is that something everyone could live with?

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

Sure.

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

Yeah, I\'m fine with that, I actually encourage it.

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

All right, well, we\'ll move ahead in that direction. And before we
leave this topic, because we do need to spend some time on our final
topic, I just wanted to share with everyone that we\'ve actually had
several meetings with a statewide cancer group in Georgia, and I have
here, and it\'s available to everyone, a report out of the Institute of
Medicine, and the national research council that was essentially funded
with \-- primarily by Georgia\'s tobacco settlement money, where they
did a major analysis on really patient-centric measures of quality for
cancer care. And they\'re very interested in looking at different models
for managing cancer as a chronic illness as well.

So I just wanted to share with you all that that\'s actually one of the
reasons that we added \-- a little group added cancer as a possible
fourth chronic illness to the list of patient populations to be
considered. Because there are some very good outcome measures in terms
of quality of care for this population that go far beyond the types of
measures that are available for diabetes and CHF; and secondly, because
this is apparently a group that is very, very interested in clearly
managing their illnesses, a chronic illness, and are very interested in
whatever it takes to communicate better with their caregivers, and make
sure that they are following the appropriate care plans and protocols,
et cetera, et cetera.

So I just wanted to bring your attention to that report, and not only
IOM but AHRQ is involved, and the usual cash cows, so it does give us an
interesting avenue.

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

This is Craig Barrett. When you come up with your matrix of options,
could I get you to revisit the question you dodged earlier?

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

Of course.

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

Because whatever we propose should I think fit the Secretary\'s
description of basically low-hanging fruit and being a credible success.
And a lot of the discussion is kind of \-- free-ranging discussion is
very good, but a lot of it tries to be all encompassing and all
inclusive and look at the very, very broadest view of things, as opposed
to what demonstration can you do in the near term, which is an
incredible success, which shows the value of this technology, which then
by its own success draws the rest of the system into it.

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

That\'s very well articulated, Craig, and we\'ll certainly concentrate
on making sure we go in that direction.

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

Karen, this is Jay. Just an add-on, on the whole question or the
definition of success. Just recognize, we\'re going to have to deal with
the situation, like with a lot of new technologies, what happens if
we \-- if the demonstration shows significant improvement in care,
improved quality of care, with an increased cost?

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

Oh, you bummed us out now.

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

That\'s supposed to be an oxymoron.

I think what it really comes down to is, you know, your definition of
quality of care. It may be higher quality in the short term, and the
improvement in the cost structure comes a little bit later on. I think
the real issue here is the timing of quality and cost, and how the two
are married together.

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

I don\'t know if we can sell it to L&B, Karen.

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

I know, I think it\'s a timing issue. I\'m a firm believer that if you
do improve your quality you will get a better cost structure ultimately,
the question is how long. All the preventive measures go in that
direction. It\'s going to take us a very long time, might be 20 years to
really see the cost value of a lot of the quality measures we now have.

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

Totally agree.

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

If I can bring you guys back to reality for a minute, it\'s 17 percent
of GDP, it\'s inconceivable to me that you\'re not going to be able to
have an incredible success, which gives higher quality of care at lower
cost.

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

I hope you\'re right.

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

If that\'s not the case this discussion is just hypothetical, anyway.

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

We\'ll certainly make that a high priority item, and that\'s a very
helpful comment.

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

Well, and to just \-- this is Eric Larson. To amplify that, this is why
going back to my point about, if you can make this a broad demonstration
project, you stand a much better chance of finding that conclusion. If
you place it in a very narrow context, where it\'s less likely to
succeed, or it happens to be a context that\'s less likely to succeed,
you\'ll miss that very important finding, I think. You could; I don\'t
think you will, but you could.

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

This is Mohan. And hence my \-- again, I\'m retreading what we\'ve
already retreaded, but forgive me. It is very important we know what
we\'re demonstrating. There were a number of issues discussed, and when
you\'re controlling variables that really are uncontrollable, because
there are so many inputs coming for patient-physician communications, we
do have to exactly view what slice of that communication we think is
value, and how we want to see that value to be costed. And I do believe
that dramatic shifts can occur, if we know how deep and narrow we need
to go. Versus looking at multiple variables and not seeing any one \--
everything correlating to a chain, or a transformation. So I would
highly recommend that when we offline discuss this, that we pursue this
idea of depth, and then view of how we want to make secure messaging
effective. Which is what Recommendation 1.1 is requesting.

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

Is there any further discussion on this topic?

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

Karen, you\'ll get that matrix out?

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

I will, and I\'ll even give us a date certain, by next Friday.

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

I\'ll look forward to the definition of incredible success.

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

Thank you, Craig.

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

Craig, do we want to turn to the next steps at this point, to tie in to
what I mentioned earlier about the priorities discussion, moving to the
broader charge that we\'re supposed to \-- I guess tackle in the June
meeting? The critical component to the broad charge, and the process to
address them?

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

Yeah.

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

You didn\'t sound too enthused about it.

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

I think we\'ve got a whole lot of very valuable information put on the
table today, and there\'s probably more \-- bigger database behind it,
which is what is \-- what\'s been happening with the current systems,
what experiments have been run. Even though we had kind of a cursory
survey, because of the time constraints, there are systems out there
that are using the technology.

Using that, and then I think the real critical issue is exactly what we
were just talking about. What sort of experiments can you to set up to
run the potential of this technology, this capability, to get higher
quality care at lower cost. Not taking money away from anybody, but
bringing higher quality of care at lower cost. And it\'s just I think a
matter of kind of biting the bullet and deciding what course of action
you take. What experiments do you run, what models do you pursue, what
part of the 80-20 distribution do you look at. I presume, and why I keep
going after Karen about incredible success, is I presume we\'re really
looking at the 80 percent of the cost model here, not the 20 percent of
the cost model, and that 80 percent of the cost model is concentrated in
a relatively small number of patients, as we all know.

So it\'s defining the experiment, and then demonstrating that the
process works. That in my mind is the whole critical hinge that we\'re
focusing on.

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

Craig, this is Karen. I think one of the things that would be helpful
for us here, and for our contractors, would be for this Workgroup to
help articulate what really are the options we could be looking at, and
then to prioritize those, so that what you described can actually move
forward. We spent a lot of time on the specific charges, secure
messaging, and we will continue to spend time on that charge, obviously,
as we move forward. But there are so many other options that are
available to start thinking about and pursuing. And there are new
and \-- please forgive me for making this comment directly to you,
Craig, but it\'s really to everyone. There are so many exciting new
things that are on the horizon that we could be looking at with respect
to remote monitoring of clinical indices, at home and at work, and many
other ways of getting \-- essentially providing remote care. That it
would be very helpful to really get a handle on what it is that\'s out
there now, what it is that\'s coming in the next several years, and
begin to prioritize where we need to go next in our thinking about
collecting information remotely and providing information remotely.

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

I couldn\'t agree more. But eventually, the body has to make a
recommendation for HHS, and I presume our recommendation has to be
comprised of a relatively narrow and small set of tactics or approaches
that you take, maybe two approaches that you take, and then you put all
of your energy behind those two, as opposed to a very superficial
broad-brushed approach.

That\'s why I always come back to let\'s go to where the money is,
let\'s define an incredible success on the basis of the 80 percent of
the cost. And if that\'s what you chase after, then it seems you chase
after chronically ill remote diagnostics and messaging \-- secure
messaging between the chronically ill and their caregivers and the
collection of information remotely. But I mean, that\'s just one
person\'s opinion on this topic.

But I would just suggest we continue to go back and focus on
fundamentals, which are the total cost of the system, the influence of
technology to impact that. That then takes you to where the total \-- or
the great bulk of the cost is incurred, and then you see how technology
can impact that. And it\'s remote diagnostics, and monitoring, and
messaging between physician and caregiver.

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

And I think what we may be looking for is exactly that, but perhaps with
greater specificity. When we\'re talking about remote diagnostics, are
we talking about storing for telederm, are we talking about other forms
of telemedicine, are we talking about home health based transmission to
clinicians, are we talking about devices that the patient uses and then
automatically sends information back, or devices that the patient uses
and then sends information back when he or she chooses? There are so
many different \-- frankly, very exciting potentials out there. And
while I think we\'ve all agreed that there are some major enablers and
barriers that have to be addressed for all of these technologies, and we
spent a lot of time on reimbursement and on State-based models today, I
think that if we really are going to be moving forward with the broad
charge, we need to consider those in the context of the gambit of
technologies that are available. And perhaps even prioritize those that
we should be thinking about next.

And I just \-- I just mentioned a very few of everything that\'s out
there, and, you know, perhaps we just need to hear more about what is
available in the way of remote technology right now.

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

Yeah, and there\'s obviously a ton of stuff which is not in the
marketplace yet, which is just being developed as we speak.

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

Right. And that would be even I think perhaps more important. So does
that resonate with where you were thinking we need to go, Craig?

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

Yes. Assuming that we \-- this is a building block approach, which is
the building blocks are that secure messaging is a very key part of
this. Reimbursement for value is a key part of this. And then the array
of technologies that you can use is the secure parts, is kind of a three
step approach.

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

This is Paul Nichol. But one technology I haven\'t heard mentioned that
actually is going to overtake all this is the personal health record. We
are fairly focused on electronic medical records, and I think we need to
keep that perspective, as well.

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

Well, the \-- this is Jay \-- the personal health record or electronic
medical record, either side of the coin, will have to integrate or be
the framework in which all of the information, data gathered by whatever
the technology is, you know, is put into. That would be number one.

But I\'d like to go back to Craig\'s point and Karen\'s point. Craig is
looking for the 80 percent of the cost factor based upon the 10 to 20
percent of the population that it\'s costing us that. And Karen used the
term evidence based multiple times throughout this entire discussion.

I think our focus has to be on what is the condition, and what is the
need in terms of monitoring and taking care of that condition. And then
you find the technology that provides that functionality, as opposed to
focusing on what types of technology.

For instance, you ask any cardiologist what technology do you need to
take care of a patient with congestive heart failure, and he\'ll tell
you it\'s a scale. Okay, so maybe we ought to be looking for a digital
scale that automatically, when the patient steps on it, you know, sends
that patient\'s weight in. It can be as simple as that.

I would not like to focus on the technology as much as what the need is,
and then define the functionality that\'s out there that provides us
information on the need.

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

Yeah, this is Tony Trenkle. I\'d agree with you, Jay, I think that\'s an
important approach. I think to focus the other way takes away from the
outcome, potentially.

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

So that basically, this is a very good guideline, because as we think
about moving forward, then, one of our top priorities is to focus on
need with respect to what is it that\'s costing us dollars, and what
conditions lend themselves to better management remotely through
technology.

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

Right.

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

By the way, this to me is a very different question than whether a given
insurance plan saves administrative money or not. I think this is where
you\'re talking about the big bucks, it\'s where you\'re talking about
keeping people out of the hospital. And minimizing the cost from that
standpoint, and maximizing their quality of life from that standpoint.

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

Right.

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

Right.

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

So Karen, I\'m really looking forward to your matrix.

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

And Karen, we\'re supposed to get that next \-- what day?

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

Friday, because I understand that there\'s a little bit of staff help in
the wings, so we will definitely get it to you next Friday. We just have
to get through next Tuesday\'s American Health Information Community
Meeting. So you can all work on it next weekend. Thank you. Not this
Friday, next Friday.

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

Well, that should be the basis of the meeting on the 16th, then, which
is the next \-- our next Chronic Care Workgroup meeting.

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

That\'s right.

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

Our next meeting is the 16th?

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

I believe so, yes.

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

It\'s Wednesday, 16th of August.

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

Right. Got it.

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

Now, Karen, what do we need to accomplish between now and the 16th of
August, dealing with the next steps issue?

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

I think the most critical piece is to essentially provide everyone
feedback on this, the matrix document. So we can then pull that together
for you, and that can be the basis of discussion moving forward.

And I think at the next meeting what we\'ve heard is that we need to
think a little bit about bringing information to you for that meeting on
high cost cases, and possible technological solutions for those high
cost cases, with the hope that all of you will then be able to provide
us with more information about where that actually could go.

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

Craig, a number of months ago, I guess, Brian pulled together some
preliminary information with regards to that. Is that something we can
build upon for the next meeting?

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

Yeah, I hope so.

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

We can work with Brian prior to the next meeting to try to focus that
discussion a little bit more, if that would be helpful. I just
volunteered you, Brian. Thank you.

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

Sure.

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

Okay, any other comments?

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

I am presuming our discussion here, what we propose is not at odds
with \-- you know, personal health records, the standards that should be
required or put in place to interface PHRs with the clinical data and
with other applications, and all this other stuff.

I just think we have a whole series of efforts in parallel. Our charter
is basically looking at where we can have the biggest impact, where we
can define incredible success by gathering the right data in a real-time
fashion, and using the communication channel we\'re talking about to act
on those data.

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

This is Kelly Cronin. I\'ve been playing a similar role to what Karenis
playing with this group on the Consumer Empowerment Workgroup, and we
have had a lot of discussions around the interoperability or portability
of data with EHRs, and have started to also explore some of the priority
functionality. But we have an all-day meeting tomorrow, plan to get a
lot of testimony from various stakeholders on a lot of issues regarding
interoperability and potentially certification. And I think we\'ll
probably have a more informed discussion on this over the next month as
we start to identify some of the critical components or some priority
areas for the next rounds of use cases.

So I think we\'re just going to have to stay connected and make sure
we\'re not tripping over each other. I think there have been previous
meetings where people have identified the \-- this rather natural
overlap here as it relates to secure messaging and interoperability
between EHRs and PHRs. And certainly I think a lot of what we\'re
hearing and within the literature so far really supports the model of
having a PHR be a subset or be connected to an EHR. And I think that HL7
and other organizations are already starting some work to ensure that
some of the standards are already being developed, and that could be
easily fed into the health IT standards panel.

But we\'re still sorting through a lot of those issues, and I think that
there\'s little that\'s really fully understood about, you know, what\'s
most important to consumers at this point with respect to PHRs.

We have, you know, some survey data, some anecdotal data, we\'ll look at
a lot of testimony on this tomorrow and at other meetings. But I think
it\'s going to be sort of a challenging determination for us to do some
priority setting for us at this point. Because the market is moving so
quickly, there\'s a lot of innovation, but not sort of a definitive
evidence base yet about what consumers really want out of these tools
and what\'s really going to drive adoption.

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

Just as a point of information and totally consistent with that, you
ought to take a look at the RFP that Robert Wood Johnson Foundation just
came out with with respect to PHR. Very, very interesting.

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

Yeah, it is. We\'ve talked to them about that a lot. They unfortunately
have their call scheduled for tomorrow during our all day hearing, but
it\'s going to be a really innovative program, and we expect to see
interesting progress from that.

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

Right.

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

Before we go into public testimony, it\'s Karen again, I\'m just
wondering if there are \-- I\'m sorry, public comment, whether there\'s
any public testimony that this Workgroup thinks might be important for
the 16th, next month. I mean, we\'ve talked a lot about what is
happening in various venues, but there may be some value to bringing in
some public testimony. So I\'m just wondering if anyone has any thoughts
about that right now, so that we can begin to arrange for same as
necessary.

And again, if you can\'t think of it right now, then you can certainly
get back to me and we can include it on the agenda.

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

Okay, before we get into public comment, Karen, I want to make sure we
bridge this next meeting, then, properly. One item we had on earlier
that we didn\'t get into was the summary of the previous Workgroup
discussion, and you said you would do additional work on that to bring
that up to date.

Secondly, we just talked about the matrix that\'s going out next Friday
and that will be used to provide feedback from members that will be used
at the next meeting. And thirdly, I have information on technology that
will build partly on what Brian had previously pulled together, and
maybe some additional speakers as necessary.

Is that \-- Craig, does that tie in pretty much to what you have seen
from this meeting?

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

Yeah. And I would just encourage us all with that as additional
background information to focus, focus, focus on a few definitive
proposals to come out of that next meeting.

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

Okay, so the final thing should be, then, to focus \-- as a part of next
meeting, then, is to begin focusing on a few definitive proposals. Okay.

Any comments from members, other members?

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

No.

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

No.

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

No, I\'m okay.

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

Okay, can we move to public comments then, now, Matt?

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

Yes, there\'s information up on the screen. We\'ll give it a minute. If
nobody has called in I\'ll let you know, and we can close up.

It looks like nobody is trying to call in.

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

Okay, Craig, do you want to move for adjournment?

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

I would so move.

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

Second.

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

All in favor?

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

Aye.

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

We\'re adjourned.

(Meeting adjourned.)