American Health Information Community

Quality Workgroup Meeting #6

February 7, 2007

**Disclaimer**

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

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

Looks like we\'re ready to go.

\>\>:

Okay, thank you. Good afternoon, everybody, and welcome to the sixth
meeting of the quality work group. Just a reminder that this meeting is
being webcast live, and for those of you that are members speaking,
please remember to speak clearly and distinctly and identify yourselves
before talking. And also, when you\'re not speaking if you could please
mute your telephone lines to reduce some of the background noise. I know
we have a busy meeting today, so I\'ll ask Jennifer if she\'ll introduce
the members on the phone, and then I\'ll see if anyone is here on the
line that\'s a member. Okay, Jennifer?

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

We\'ve got Margaret van Amringe from the Joint Commission on
Accreditation of Healthcare Organizations. Jerry Osheroff from Thomson
Healthcare. Pam French is in for Rick Stephens from The Boeing Company.
Mary Beth Bigley from the Office of the Surgeon General. Janet Corrigan
for the National Quality Forum. Sunil Sinha, CMS. Michael Kaszynskifrom
the Office of Personnel Management. Susan Postal from H \-- I\'m sorry,
Hospital Corporation of America. Carolyn Clancy from AHRQ. Nancy Foster
from the American Hospital Association. And Helen Darling from the
National Business Group on Health, as well as Carol Ostrowski from the
National Quality Forum. Did I miss anybody?

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

Jonathan Teich.

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

Okay, Judy?

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

In the room we have \--

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

(Inaudible) from ONC.

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

Kelly Cronin, ONC.

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

Charlene Underwood, Siemens Medical Solutions.

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

I think we\'re ready to start, Carolyn.

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

Thank you very much, Judy and Jennifer. Welcome, everyone. Our first
official order of business is to accept the meeting summary from our
last meeting. Do I have a motion for that?

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

So move.

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

Yes. Thank you. Anyone have anyone have any objections to accepting the
summary? Good. Then we can \-- that was five minutes, that was really
terrific. Just by way of a brief update since our last meeting let me
mention that the next meeting of the American Health Information
Community is going to be March 13th. It was originally expected that it
could be March 6th, and we will be bringing forth recommendations for
our future scope of work to the community at that time, which is going
to be the bulk of our agenda today.

At the last meeting, which was on January 23rd, I actually had a brief
presentation, two presentations, one in the morning was to talk about
quality being one of the potential use cases, or one of the options for
use cases for the next round of NHIN contracts.

I should tell you, as well, I\'d like to attribute this to my
brilliance, but after all, but in fact there was a sort of prevoting
process and everyone wanted to have quality on the list of potential use
cases. So the good news is I didn\'t blow that great sense of
enthusiasm. In the afternoon I had an opportunity to present the vision
that we have been working on together, and I would say by and large
people seemed very enthused about that. Although it was after lunch. No
one had any objections, a few people came up to speak to me afterwards.
So I think that\'s a tribute to the work that we\'ve been doing
together, so let me thank you for all of that.

Pam, anything that you\'d like to add at this point?

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

No, I think we have a good agenda, and to walk through the
recommendations letter.

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

Terrific. Let me also let you know in advance that I have to get off the
phone at 2:00. Where I\'m speaking at a conference out in Minneapolis, a
place you only go to at this time of year because you really like the
people, it\'s about that cold. And so I will be bragging about some of
our collective work together as part of the talk I\'m giving but. But
Nancy Foster has agreed to step in my place, so thank you again for
that, Nancy.

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

Glad to do it.

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

The next item in our agenda talks about THE AQA measures, update on AQA
measures. And I think what this speaks to specifically is since this
group was formed and we began our work together, there has been a new
development, of course, in the world of physician reimbursement, and
that is that rather than getting a 5 percent cut that they were
originally slated for, physicians will now actually get to break even on
what they\'re paid by Medicare. And starting July 1, they can actually
get an increase of 1 and a half percent, if they report on a subset of
measures by physician specialty. They will get that in a lump sum for
the period of time between July 1st and the end of the calendar year.

This is good news because needless to say, it has the attention of lots
and lots of physicians on quality measurement. It\'s a huge challenge
for my colleagues at CMS because it is a very, very short period of time
to implement something that would be affecting the vast majority of the
nation\'s 700,000 plus physicians.

What this has meant is that when the work group was first \-- our work
group was first created and we were talking about a core set of measures
that had been approved by the AQA, initially we were talking about this
sort of starter set of 26 measures. Since then a number of other
measures have been adopted. Some of them have been in use for awhile,
for example those used by the Society of Thoracic Surgeons. Some of them
are very new and are introducing lots of I think much needed discussion
within the physician community about what it is we\'re measuring with
quality measures. Are we measuring competence or are we measuring high
performance, or some combination of both. Needless to say the timeline
has people working very rapidly.

Some of the measures that will be in use by July 1st are going through
the national quality forum consensus development process now, some have
a commitment to do so in the future. I would guess that some of them are
likely to be transitional and improved upon in the future. Trying to
keep the hope out of my voice for that one.

The reason this is all important isn\'t to give you an update from the
inner workings of doctor politics, but more to talk about the fact that
as we move forward in our work, trying to focus on a set of AQA approved
measures as part of our core work in terms of building that
functionality into electronic health records, in figuring out a hybrid
strategy for data aggregation on the other hand for those who don\'t
have electronic health records, I think we would be well advised to
focus on a subset of those measures. And that becomes very relevant in
one of the specific recommendations.

Let me just pause and ask if there are any questions.

Great. I think then that we can move specifically to the letter, and
specific recommendations. Some of this \-- much of this should look very
familiar to you. Although as with the vision, there have been continued
tweaks and improvements. So for those of you who have made specific
suggestions, thank you very much for that.

Let me ask if there are any comments on sort of the preamble before we
get into the specific recommendations.

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

Are you talking, Carolyn, about the preamble to the letter?

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

[Yes]{.mark}.

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

Looks great.

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

Carolyn, it\'s Nancy. Just one comment. While the sentiment that\'s
embodied in the paragraph right after the specific charge is certainly
something to which I can subscribe, I think the language may be a little
bit inside baseball kind of language. Scaleable approaches to quality
measurement and reporting is something we talk about from time to time
amongst ourselves, but I\'m not sure that it will resonate with the
broader community. So just wonder if a strong editorial hand might be
taken to this, to make sure that the language communicates as broadly as
we would like.

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

I think that\'s a fine idea, and would certainly be open to that
suggestion. I don\'t necessarily think it\'s a good use of our time here
to debate specific phrasing, but we\'d certainly be willing to follow up
with you, and then send something out for folks to take a look at.

The point is that you\'re not disagreeing with the concept, but just
thinking that \-- I mean, even to be candid, this may be a little bit
foreign even to some members of the community.

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

Yes, that\'s exactly what I was saying, and I\'m happy to follow up, and
agreed, not on this call.

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

Any other comments?

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

This is Pam. I think this does a nice job of capturing both the broad
overview of what we\'re trying to do, integration concepts, and a little
bit more specifics, so it\'s pretty clear what is \-- really what we\'re
focused on.

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

This is Margaret and I\'m sorry for my voice because I\'m sick today,
but I thought it was very well put together myself. I was just going to
add one suggestion, and I can send language in later, but on the
paragraph About the success of the work group, on the first page, it
talks about how it would be measured. And I just thought in addition to
an example on consumers and clinicians that it would be worth putting an
example for hospitals just so that the hospitals see themselves in this
document as well.

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

Thanks, that makes a lot of sense. Any other comments, just on the
preamble? And I recognize that you\'ve had a chance to see this before.

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

I think it looks very good.

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

Good. Okay, why don\'t we move on, then, recognizing that we have a few
weeks, so if you were to take a look at it later this week and suddenly
say wait, I don\'t like that sentence, there\'s time. And why don\'t we
move to the specific recommendations. Which I believe start on page
three.

So on the top of page three there is a general discussion of automating
data capture and reporting from electronic health records to support a
core set of AQA, clinician-focused and HQA inpatient quality measures.
Which then goes on to describe a little bit about the AQA and the HQA.

One specific point I probably should have brought up earlier, and it
went out of my brain, the reason for the word clinician focus there is
that it is likely that some measures for other clinicians who are not
medical doctors will also be coming out of AQA. This is something of a
work in progress. The CMS \-- legislation directing CMS to implement
this new pay for reporting scheme, it turns out is also relevant to some
other clinicians, including, very importantly, nurse practitioners and
physician assistants as well as in some instances social workers, and
occupational and physical therapists.

I believe that\'s the whole list, but if I\'ve inadvertently left
someone out it was not intentional.

Some of these groups have developed measures, and in fact as I
understand it, the AMA consortium has worked closely for awhile with
nurse practitioners, and physician assistants, where they are providing
care that\'s very similar, and so I don\'t think that\'s going to be
such a stretch.

I don\'t quite yet know how it\'s going to work for the other
clinicians, but that\'s why the word clinician is there instead of
physician.

Turning to the very first specific recommendation, which is 1.1. This
says that the quality alliance steering committee \-- now, this is a
group comprised of leadership from the HQA and the AQA, with support
from HHS and other relevant federal agencies, should convene an expert
panel that would accelerate the current efforts to analyze the data
elements and workflow changes needed to enable automation of a
prioritized set of AQA and HQA measures through electronic health
records and health information exchange. And that the first group of
recommendations from the expert panel should be shared with the
community by June 5th, 2007.

So just to highlight a couple of points, there. You may recall from our
prior discussions that we had talked a bit about the work that\'s
ongoing with an initiative that was launched by the National Committee
for Quality Assurance or NCQA and the AMA physicians consortium, with
some support from CMS as well, where they have begun to do this for a
couple of measures. Literally creating a map of data elements for a
group of measures is a non-trivial sort of task.

However, we also believe that it would be very important to precede that
detailed work with a very clear sense of which are the most important
measures to be doing this work for. In other words, when I had mentioned
before that some measures might be transitional, in the runup to July
1st for physicians, for example, there are some measures I think that
would not necessarily be a priority to be on this \-- on a set of more
prioritized lists right now.

So our thought was that because Janet Corrigan had done a really
superlative job leading a group of measurement experts and others to
identify the challenges involved in harmonization of measures that are
specified slightly different in different clinical care settings, for
example the use of beta blockers for someone who has had a heart attack.
The concepts are the same, but the specifications are different
inpatient and outpatient. And they put together a really terrific
report. Our thought was that that group would be a very logical nucleus
to take on this next set of work.

I think it would be \-- and one could begin to imagine some other
priorities as well, and I think that their initial group would need to
be enriched by \-- or supplemented might be the better word, by some
folks from CMS and other parts of HHS, as well as folks whose first home
is in the community of health IT, to move forward.

I don\'t believe that we will have all of this work done by June 5th,
but it is our hope and expectation and what we\'re going to propose is
we will have enough for a very well reasoned report by that time. So let
me ask if there are any questions about this.

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

I think it was \-- Charlene. I think it would make sense to \-- the
folks on that team are trying to just develop, if you will, the use case
for how to work together between measures and, you know, to come up with
a process.

That has to do \-- as you look at the measures, was focusing on the data
elements necessary to capture, or to be able to report the measure. So
it turns out that as you start to look at the data elements you still
need that framework of what is it we\'re trying to measure, but in some
cases they\'re focusing on the data elements which could feed into more
than one measure.

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

Yes, thank you. You said that much, much better than I could.

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

Yeah, so I think it needs to be collaborative in whatever way, because a
lot of work has been \-- you know, I think moved forward by CMS and
NCQA, Jacob is also at the table, so the process they\'re defining is I
think pretty solid. And again, which \-- you know, they\'re trying to
review it by all the parties. But in addition, I think, you know,
they\'re finding that it\'s really the analysis of the data to be
captured could drive a set of measures as opposed to one or two. So we
just need to get our language right there, I think.

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

I think that\'s right, so let me just try this to make sure that I\'m
understanding you correctly. How I would envision this working, and we
may need to make the wording more precise to bring this out \-- and I
think I\'m going to be calling you the night before this presentation,
so that I have it right, or rehearsing in the morning. But in essence
what you would be doing is coming up with some criteria for selecting
what might be considered the most important measures. I see this as less
of a problem on the hospital side, A, because it\'s a shorter list with
the HQA right now than on the physician side. But once those criteria
were established and agreed upon, then you need to construct sort of a
map of the data elements needed for each measure. And then of course
what you \-- the map has to be big enough, so I always envision a chart
that sort of fills a good sized room by the time you\'re done.

That you begin to look at which data elements, for example lab results,
cut across multiple measures.

And in some way, I haven\'t figured out the right narrative description
of this, the visual for me is sort of flashing graphics or something,
you know, clarifying for the health IT standards folks what are the data
elements where there are standards that they \-- where we\'ve got
standards and where we might need to think about either developing or
bringing folks together to come to consensus on a standard that\'s
needed.

Do I have that right?

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

Yes. I think it\'s a set of common data elements needed for
prioritized \-- you know, change that language a little bit.

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

Okay.

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

In addition I think this could be very applicable to the work that CMS
is pursuing right now, because I know there were some issues with some
measurements \-- the measurements that were selected for this first
phase. Now, we might not be able to impact them because of deadlines,
but there were some \-- you know, proprietary data elements in there for
this first set of measures that CMS \-- the hospitals, the physicians
have to report on. There were issues there too. I don\'t know if we
should go back and crosswalk that. I think they did some work on that.

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

Well, first of all I would very much see this as being done in
collaboration with CMS.

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

Yes.

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

I don\'t know the nuts and bolts of the specific that you just brought
up and how they\'re thinking about it. It seems pretty clear to me that
most people are expecting that sort of version 2.0 of what they have to
implement this July is likely to be refined and improved.

And I sure wouldn\'t want to speak for how much flexibility they have
between now and July 1.

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

Right.

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

Carolyn, this is Janet.

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

Janet, yes.

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

I think it\'s a great idea, and I think it makes a whole lot of sense.
The measures that are out of AQA, as you indicated, an awful lot of them
are in the NQF process being considered for endorsement. They have
really been put to scrutiny as they move through that process, so I
think we will have a very good idea very soon which measures are likely
to be the transitional and which are likely to sort of stand the test of
time. We\'ll also have a very good idea out of those measures which ones
we think pose particular types of data challenges. And to be able to
also look at the measures and identify the types of data that they draw
on, because I think that we would really want a mix of measures that
draw on all different kinds of data building blocks in that sample, or
group that we choose to put through this process. And I think that could
work very well.

This does flow nicely on the measure of harmonization work, where we did
identify sort of common building blocks of many different types of
measures that if we could construct them and standardize them within the
EHR world it would make the measure development and implementation just
a whole lot easier.

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

Yeah, and the one message that I remember that you articulated on behalf
of the work group before, Janet, very, very clearly is \-- and I think
it\'s consistent with the vision that we presented to the community, and
will be sort of reemphasizing, is that, you know, in the better world
that we have been projecting, you would like to be doing a lot of this
on the front end. Rather than looking at this sort of pile of measures
that don\'t quite line up in a way that anyone would have wanted on the
back end.

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

Well, and we are, at NQF, we meet now on a monthly basis, pretty much
have a call with many of the major measure developers to talk through
how to standardize and have more common approaches or guidelines to how
measures are developed, because that\'s a key part of it. And I think
what now we\'re saying is the next step really there is to bring the EHR
folks in to make sure that both pieces fit together really nicely.

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

Carolyn, this is Jonathan.

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

Jonathan, I think I cut you off before, I\'m sorry.

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

That\'s okay. I\'m sort of taking off on something that Janet said as
well. We spend most of our time talking about the data elements, which
is the number one line. In the recommendation it says work flow changes,
health information exchange, and that brings up the various other issues
of data reconciliation, and data stewardship, which as you know has been
considered by AQA as well. And it\'s sort of ambiguous as to whether
that\'s in the scope of this particular panel. I think we should
probably be very clear as to whether we want to get into that area or
not in this particular proceeding.

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

Well, do I think it is in scope. The issues I think are certainly in
scope, because if you think back to our vision, and where we were
struggling with time lines, what is near \-- what is medium term and
what is longer term and so forth \-- I think we all recognize that in
the near term, which I\'m going to define arbitrarily as five years, we
will not see a majority of physicians with certified interoperable
electronic health records. Maybe I will be wrong, and I would be
thrilled to be wrong, but there will be large parts of the industry, and
I think the hospitals are going to be even further behind just because
they\'re sort of on the next tier of the certification commission\'s
work.

What that means is for the foreseeable future we\'re going to be needing
to rely on some kind of hybrid strategy. But it is my aspiration that
this group would be focused as well on figuring out how does that hybrid
strategy take advantage of breakthroughs that are coming through the
AHIC.

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

I think that\'s fine, in a sense I\'m okay either way. I think it makes
sense to at least have the panel take knowledge of what\'s going on in
those other areas and make that part of the list of recommendations that
comes out of it. So it may be as clearly said as it needs to be here or
not, I think I\'m happy either way.

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

Well, I think what you\'re also clarifying for me, Jonathan \-- some
days I feel like my whole life distills to Powerpoint slides, but when
presenting this to the community, that\'s probably a point that needs to
be made way up front.

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

Great.

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

This is Margaret. There is one thing I would like to see this panel do,
and I think, Carolyn, you had it as part of what you were saying, but I
just wanted to clarify.

I think it\'s an opportunity, when this panel begins to put together the
list of building block elements, and look at where they need to be
harmonized, to also make very concrete recommendations as to where
standardization of certain data elements will lead to much better data
quality. And I\'m concerned, because I know we have many different ways
that organizations input, for example, date of birth, or the date of
service, and so forth, and many other data elements that are prone to
differential formatting.

And it\'s an opportunity, therefore, to really get better data quality
in, and some ways not put in problems that end up with maybe even
medical errors or other problems of patient safety that can occur when
data is not standardized.

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

I think that\'s a very important point, and I think that I just want to
test that I\'m actually hearing two components of this.

Some of this is about where are additional IT standards needed, and some
of it is about \-- I guess I would define it as a set of issues even
more basic than that. So I wanted to ask Kelly for clarification on
that. One of the points that I got \-- I wasn\'t sure that I clearly
understood at a recent community meeting, was whether the HIT standards
panel actually develops new standards, or whether they are trying to
reconcile existing standards.

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

Yeah, it\'s actually a process to reconcile our named standards along
with interoperability specifications. So that could be both
terminologies, so it\'s sort of focusing on the data itself and how to
standardize that, or it could be how to make sure the data gets from
point A to point B, in a certain format. Or using a certain type of
messaging standard.

So it\'s sort of all different types of standards. And I think if we
could add something in that Margaret suggested, that it would really be
helpful to \-- as their recommendations get transferred from the quality
alliance steering group either from this work or directly to HITSP, I
think that would really help focus their effort.

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

Uh-huh. Well, I think that\'s a very important point, so Margaret, thank
you for that. And I\'m start \-- the visual I have right now is this
very huge report going to the HIT standards panel, but that\'s good and
very much what we need. And certainly what I hear from lots of people
who live in this world every day about what\'s particularly challenging.

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

This is Helen. I\'d like to add something that builds on comments that
were made by Janet and others a minute ago, and that is that to the
extent that we don\'t move quickly on some of these things, it isn\'t
just that information is being reported in inconsistent ways and may \--
and if it\'s not done properly it may enhance or increase the likelihood
of medical errors, but it\'s the waste of the resources that\'s so
compelling, especially these days when resources are increasingly become
more constrained. So I think somehow working that end, so it isn\'t just
it\'s not good to have consistency, it\'s not good to have
standardization, it\'s not good to have harmonization, but we\'re
wasting millions, perhaps even more, until we act.

And second is a related point. I was so pleased to see the dates still
in there, and hope that at no point that they would come out, that there
will be counter pressures because the dates are tight and the timelines
are tight, that we really have to stay firm in the importance of keeping
dates \-- dates certain, that things have to be done. To keep that sense
of urgency.

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

I would like to echo that point. The other issue \-- This is Josie \--
thinking about those resources, as I sit and look at these 65 hospitals
we\'ve got in a database right now, just standardizing the sets has
improved the quality significantly. And yet, if we think what we\'ve
done in the last two years we have to change it again and again and
again to meet different standards, not only do you have the dollar
resource but you have enormous capital resource in your human capital,
as well.

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

Great. And Helen, I like your emphasis and sense of keeping us on
timeline, so we\'ll take that very seriously. Any other comments on 1.1?

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

This is Susan Postal. I did want to acknowledge the importance of the
timeline and leveraging work that\'s already being done, and did want to
acknowledge that the American Health Information Management Association,
AHIMA, is also working on this data element analysis by measure and
doing a GAAP analysis, so I challenge us to look at that work, as well.

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

Thank you. And I think if there\'s one sentiment that we\'ve repeated
here and prior meetings it\'s that any lick of work that\'s been done
already we\'re not going to repeat. So we\'ll definitely follow up with
them.

Turning to 1.2 and 1.3, this part of the first recommendation actually
just specifies very clearly sort of where the outputs of the first tasks
are going, to the health IT standards panel, and also to the
certification commission. Any comments on either of these?

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

Carolyn, what\'s not happening is you\'re certifying untested standards.
So when you go from step 1 \-- unless it\'s implicit in there if you go
from 1.2 where they\'re adopting potentially \-- I mean, if there are
tried and true tests of standards, which I\'m not sure how many we have
out there to do this yet, in the quality domain specifically, we\'re
going to have to do standards development there. So there needs to be a
recognition, at least from the implementation community, the
implementation guides have to be written, that (inaudible) there be
testing on the standards before you\'re giving them the certification
criteria. Because the vendor community will push back pretty hard to
say, you know, if it\'s a brand new standard it has to be on that
roadmap for 18 months. And I think you\'re going to want to demonstrate
use of these in a pilot or something before that to make sure that they
work.

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

I couldn\'t object to that. Any comments?

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

Carolyn, this is Kelly. Karen Bell is also here who has been very
engaged with CCHIT, and I think that\'s really consistent with how CCHIT
is operating now. And I think it also speaks to the sense of urgency.
Because the quicker we can get this harmonization work done and all the
common data elements specified we\'ll be \-- and HITSP then has the
information they need to get their work done, we\'re then going to have
the opportunity to do any necessary additional testing. So you know, the
faster we do our work, the rest of this will fall into place. But I
think there\'s definitely recognition that there \-- that the standards
that are going to be incorporated and, you know, interoperability
specifications, have to be implemented once they are thought to be
mature.

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

Right, but I guess \-- thank you. I guess what I\'m also hearing,
though, in that comment is that it would be very helpful, again, I guess
clarifying expectations for members of the community to be real clear
about a timeline. So I\'ll be coming back to you too about that, just to
remind folks who don\'t follow the day-to-day activities of the
certification commission, what that\'s going to look like. It\'s not
just like here\'s a standard. Go.

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

Yeah, we\'ll have hopefully a good graphic by that time.

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

Good. Any other comments on these recommendations?

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

Carolyn, it\'s Nancy, I was just going to loop back in terms of
something Janet said a few minutes ago, it seems to me that the work
coming out of this ought to also then loop back to her efforts to work
with the measure developers around standardization, and wondered if we
need to include a recommendation to that effect. Or just simply
acknowledge that it will happen, because Janet has charge of this.

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

I think certainly as a matter of communication and presentation at this
upcoming meeting, I actually think it\'s a very important sort of
educational point to make to reinforce that the importance of the
quality forum is precisely in that kind of feedback. Whether it needs to
be a specific recommendation, I\'d ask Janet.

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

I think it\'s a great idea to mention it perhaps in the text, the
critical importance of this work being so closely coordinated with the
measure developers, and that\'s the importance. How we do this work, and
need to be involved in it each step of the way. I don\'t know if it
needs to be right in the recommendation, but it certainly could be in
the text.

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

On my way to a talk today I was looking for a slide of yours that I
borrow a lot. Which is, you know, sort of the supply chain of quality
measures, if you will. Which sadly is not on my new little laptop. But
something along those lines that people can understand I think would be
very helpful.

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

And I think what\'s really critical there is people realize this is just
the first step. Although there\'s clearly got to be the time frame here,
and deliverable at point certain. I support that 100 percent.

This will be an effort that is ongoing, though, because we\'re only at
the beginning of really moving these measures forward, there are going
to be many others in the pipeline that pose very different challenges as
we move to episode of care measures and composites. So in some ways I
think it\'s also important to recognize that we\'re building a certain
foundation, which we hope will be a structure that carries this kind of
coordinated effort forward over many years.

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

Wearing my other hat, this is Josie, I think it would be very helpful to
have it in the text at a minimum. And I think we would welcome that back
to some of the major developers.

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

One other slight correction but important, Carolyn, and it goes back to
1, not to 1 point two or three, there it notes that HQA is working on
inpatient quality measures, but the new wrinkle of course is that we
also have outpatient quality measures, so perhaps just deletion of the
inpatient, and hospital related, would be a substitute there.

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

That\'s fine, that\'s very good. God knows every time I talk to someone
from hospitals sooner or later you can just set your watch until the
topic of medication reconciliation comes up. Which is obviously not a
pure inpatient measure, but amazingly important. Any other comments on
these first three?

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

Going back I think \-- oh. This is Charlene again. I\'m not sure who
made this comment, but \-- maybe this is you, Janet, talking about how
what we\'re doing here is the beginning of a process. When we worked the
vision, we kind of had organized the vision into some like categories,
and we talked about how key processes were going to transform. Well, it
felt like as I listened to this, I thought first it would be almost good
to position like your recommendations in terms of, you know, we\'re
transforming key processes, one of the first things we have to do is set
to infrastructure for quality. So \-- and I think we actually put that
in the vision document. You know, the infrastructure for quality, I
forget what we exactly called it.

But you know, it almost sets the pace where you look at these
recommendations, if you could even put in the short term okay, the first
steps to put our infrastructure into quality are these things, and maybe
in the second one providing assistance to feed back \-- you know, first
steps to impacting the delivering care, or whatever.

It sets you a framework up of the steps in the context of the visioning
framework of what you\'re doing in the near term, and it also would
parallel us to the next steps in the longer term. It\'s just a
mechanism \-- it\'s more of a presentation approach to link back to the
visioning process as opposed to necessarily a comment in terms of
what\'s written here.

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

Great. Are we ready to move to the other side of quality reporting?
Christine, did I hear you jump in a moment ago? I thought I heard her
voice, she may not even be on the phone.

The second set of recommendations relates to \-- you know, and gets
right back to our vision, that simply reporting and making retrospective
views of quality assessments more efficient, isn\'t enough. Ultimately
where we\'d like to get to is a place where clinicians and others can
get this information in something close to realtime. Which many people
would refer to as clinical decision support. So rather than figuring out
how to create a very efficient enterprise that can ding you faster than
the one that currently exists \-- by you, I mean clinicians or others
providing care \-- we\'re actually trying to envision how this can
actually be built in that people can get the information that they need
to do the right thing in realtime.

So any comments on the first two paragraphs?

Okay, so moving to recommendation 2.1, which says HHS through the AQA
pilot sites should identify and evaluate mechanisms to identify patients
who are eligible for inclusion in the AQA and HQA measure populations
that would align clinical decision support with quality reporting by
October 31st. And measure inclusion mechanisms must protect privacy and
confidentiality. Comments or questions on this one.

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

Carolyn, this is Jonathan. I think it\'s great as written. My question
only is whether the entities listed here can do all the things that are
named. If HHS through the AQA pilot sites, are there above what we call
for an expert group, to sort of help grease the skids, do we need anyone
else involved to make sure these kind of mechanisms can actually be
developed?

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

Well, I guess in some ways \-- and this may be a little bit simplistic,
so I\'m going to look to Janet to tell me \-- it does seem that there is
a sort of logical alignment of the first group of work that you and your
team have agreed, with others, have agreed to sort of take on.

So what I\'m not clear is whether it would make sense to be keeping that
off in the distance as they start the first phase of work, and then ask
some of the same people to look at the second piece.

Kelly or Karen, do you have a comment on this?

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

I think this is getting around, you know, sort of unique identification
and ways to make sure that you\'re able to sort of match records. I
think in some ways, I mean, honestly, the logical AQI site \--

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

Is Indiana, yeah.

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

\-- is Indiana, and they already have mechanisms to do this, and I think
we need to make sure that they can be done in other kinds of
environments, too.

So in many ways, it could be both a function of the next round of NHIN
contracts, and I think it\'s probably somewhat relevant to the health IT
standards panel\'s work, as well. So we could try to maybe work on \--
you know, Charlene was just saying to me here, that this is a bit
confusing the way it\'s written, or a little complicated.

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

Complicated.

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

So I was wondering if there\'s way for us to sort of specify, you know,
what we\'re really trying to do, here.

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

As I see it, the real process here is to take these same measures that
have been developed which have had their data elements nicely aligned up
above in number one, and be able to turn that around and push that into
the EHR, so that when Mr. Smith is in your office we can say hey,
you\'re one of these. Or when you\'re reviewing your panel you can say
hey, these 50 patients are among these. So there\'s a sort of a
push-back process that\'s involved. I think you\'re right, that they\'ve
done that some in Indiana, but I\'m not sure how extensive that\'s been.

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

Yeah I think the EHR part of that has not necessarily probably been all
that \-- there\'s just not that much EHR adoption, at least in the area
where I think that pilot is going on. So there might be other
opportunities to look at that, and perhaps that\'s one aspect of this we
need to specify. Or feedback, I mean just an electronic report, but it
actually should be incorporated into whatever systems already in the
office.

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

This is Janet. I think it\'s a very important point, and it really is a
logical next step.  As Jonathan says, after you\'ve really taken a close
look at the various measures and the data elements that support them, to
then really see whether or not you can identify the denominator
populations effectively.

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

Doesn\'t it also get to the direct link, at least where it\'s available,
to health information exchange in some fashion? I keep thinking of the
great example from the work that was done for HQA, where one of the
issues that comes up all the time is \-- isn\'t that you couldn\'t find
someone to write an algorithm for percentage of patients with an MI who
got a beta blocker, but it\'s the exclusions that are so difficult,
because the information often resides elsewhere.

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

Sure.

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

So it seems to me that one potential rewording is to say \-- is to
change \-- or change or expand AQA pilot sites, because right now that
first six \-- that\'s Indiana, as far as I know. I\'ll find out if
there\'s anything breathtakingly new happening in Minneapolis and I\'ll
get right back to you, but \-- my guess is that there may be some other
communities who have begun to take on some of these issues, as well. And
so we could certainly broaden that.

Other comments on this one?

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

Carolyn, this is Jerry Asheroff. I think the first two paragraph lay out
a very exciting vision, where they talk about helping providers know
precisely what they need to do and for whom. When you get into the text
of the recommendation itself, the wording that says measure population
that would align clinical decision support with quality reporting, I
think that leaves a lot to the imagination, and I\'m wondering if it
wouldn\'t be useful to be a little bit more explicit about how \-- what
exactly that alignment means and how it\'s going to enable providers to
know precisely what they need to do.

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

This is Karen Bell. I would add just one other issue that I think
probably needs to be addressed here, and that is the ability of a
physician or clinician, to access information that he or she has not
ordered. This has come up in the EHR work group a number of times,
particularly around lab data, a number of these measures do include
laboratory information. And in order to allow that kind of a
transmission, there are a number of \-- particularly around labs, a
number of issues that have to be addressed very carefully. So I would
just suggest that before you go too specific in this area, we think
through some of those other issues related to privacy, security, and
particularly around labs, CLIA.

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

So I guess \-- I would agree with what you just said. I\'m not quite
sure how to take your comment and Jerry\'s, in terms of how to apply it
to this recommendation. I think what you\'re both saying is it\'s really
important, but also potentially a little harder than we\'ve laid out
here?

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

That is exactly what we\'re saying, and I would suggest that we still
have a recommendation, but that part of it would be that we explore all
of the very significant issues that attend the ability of nonordering
physicians to access information from other sources.

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

We\'ve identified three or four different things that are part of this,
I certainly wouldn\'t leave out the recommendation by any stretch of the
imagination. It may be that what we\'re saying is that we need to have a
consistent reported out list of the issues and the likely solutions that
best leverage the data that\'s being acquired now, to make it work
better. It may be that the recommendation is pretty much as it stands,
but we\'re really sort of taking a strategic as well as tactical look at
identifying these mechanisms.

So that\'s kind of the addition, perhaps.

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

I think one of the ways of looking at what Karen was talking about and
what I was talking about, if I understand what each of us were saying,
is that if you look at the recommendations under 1, that\'s sort of a
big topic and it\'s broken down into several different components. This
is also a critically important topic, I think everybody is excited about
having this in here, but there\'s a lot that\'s going on. I think I
heard Karen talking about the data components of what\'s being
transmitted around. I was actually referring more to the knowledge piece
of what\'s being sent around.

So if a quality measure says that a patient should be getting a certain
kind of treatment drugs or tests or whatever, what the preamble seems to
be saying is, well, like you were saying, Carolyn, instead of dinging
them later when they didn\'t do that, let\'s put the knowledge in their
hand as they\'re making the decision, so they can do that properly. So
maybe the way to go, since it\'s so critically important and there\'s a
lot left to the imagination by packing this all together in one
recommendation, maybe the thing to do here is to break this down into a
couple of subcomponents so that each of these critically important
aspects of what\'s \-- you know, what we\'re trying to accomplish here
can be made, you know, clear and specific, and actionable.

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

So I think what we need to go I think is come back to the group before
the March 13th meeting with some more finely detailed
subrecommendations, if you will, as we did for recommendation 1.

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

Yeah, maybe we could send in a couple of line items.

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

And we will get it around to members of the work group.

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

Carolyn, it\'s Nancy. I just wanted to lend some support to your idea of
expanding that AQA pilot site, as part of this recommendation, and I
think perhaps one of the substeps to be thought about is whether one
could simply convene people who have tried to embed the HQA measures
into a decision support system, and learn from that. Since those
measures have been out there a little bit longer in broad base use, the
learnings from that ought to form some foundation for moving things
forward.

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

I think that would be terrific.

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

It will be much more complicated whether you get to physician offices
and trying to link all those different databases, but you\'ve got to at
least learn something relatively simple.

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

To say nothing of physician offices without databases, but that\'s
another subject. Okay, so we will come back to with you some more finely
specified or more nuanced, I guess, this recommendation broken out and
amplified to address the issues that you\'ve brought up and to make sure
that we\'ve actually gotten it right.

Moving on to recommendation 3. This speaks to enabling data aggregation
as needed to allow public reporting of quality measures based on
comprehensive clinical data that are pooled across providers and merged
as appropriate with other clinical sources. With other data sources,
rather. And again, this is the recommendation that gets into the issues
of the fact that we\'re going to be likely to requiring data from
multiple sources, particularly in a hybrid world where the majority of
providers are likely to be reciting for the near term future, anyway.

Let me ask if there are any comments on the paragraph before getting
into the specific recommendations.

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

Carolyn, just one comment, which is I think it would be appropriate in
here to reference the need to protect patient privacy while we\'re
aggregating the data.

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

Yeah, a really important point. Anyone else? Okay, so then moving to
recommendation 3.1, this says that HHS, working with relevant public and
private sector leaders, should identify and articulate the key
challenges associated with linking claims data from multiple sources.

What I understand, and Pam, you may want to jump in here, that even
doing this on the private sector side is not for the feint of heart
because of a lot of differences in internal coding policies, and the
benefits and challenges of linking clinical data to other data sources,
including claims, by June 30th.

I mean, what this gets to is that in a hybrid world I think our work
group has an opportunity to make recommendations that very clearly
delineate how the use of claims data, which can be a very efficient way
to aggregate information for quality reporting, could be substantially
refined and improved by adding selected clinical data elements for which
we do have good standards right now. Notwithstanding the subtleties of
what Karen Bell and others were bringing up earlier. Lab results can
make a huge difference, because no financial claim is ever going to tell
you lab results. It can tell you if you ordered it, obviously.

Similarly, pharmacy data, as the final standards for electronic
prescribing, are finalized and reported to the Congress I think very
soon, will be another source of data.

So let me ask if there are any questions or comments on how this is
worded.

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

This is Pam, and I think you captured it pretty well, Carolyn. This is a
huge issue to resolve, and I\'m \-- you know, when I see that we\'re
going to articulate the key challenges, you know, I think that\'s an
important element. I\'d love us to see us be able to go further than
that, because I think in general, there\'s a lot of groups who
understand the key challenges. What we don\'t have is based on those key
challenges, what are the kind of the top three things that if we were
able to address, would much better facilitate the ability to get
integrated information.

But I think, as I said this is probably wishing for world peace or
something, but it really is, if you think about \-- again, I think we
all have a good sense of what some of the challenges are. But I think
for this issue to really get worked we\'ve got to kind of come up with
what the priorities are, and get some alignment on those amongst groups
to work those. Because I think it\'s, you know, beyond any one
individual \-- one segment\'s issue to work.

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

Carolyn, this is Reed Tuckson. I was just also wondering why this was
identified as HHS ought to do it and why is this not an AHIC.

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

Well, I will say, speaking for myself only, in the event that I
inadvertently insult my colleagues from the Office of the National
Coordinator.

The boundaries between what HHS does through a whole variety of
investments that are related to and take advantage of the capabilities
of health IT, what the community does, and what the Office of the
National Coordinator does are sometimes a little bit fuzzy or blurred.
Oftentimes that\'s good because it inspires a lot of collaboration. But
Kelly and Karen, do you have a comment on that?

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

Yeah, I mean, I think this is largely a question of do we want to do
this as a work group, and take this on over the next three months and,
you know, do a lot of work in between our meetings so we can all sort of
flesh it out and agree on not only what the challenges are, but maybe
some ways to resolve them. Based on I guess, you know, a really good
environmental scan of what\'s going on out there. Or is this something
that should be done through a contract, or some other mechanism, because
it might be more efficient.

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

I think if you could \-- however you decide to answer that, I mean, I
think that the point of it is, though, is this \-- whether it\'s a
matter of a tactical issue of solving a major problem that has \-- that
requires the voices of multiple stakeholders, and trying to find a way
to do that efficiently and effectively, if that is what\'s being stated
here, then let\'s try to add that, so it becomes clear this is not just
a conversation that government is going to have within its own self.

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

That\'s actually a very good point, thank you, Reed. Pam?

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

I think there is an important link back to HHS on this, because in some
ways, if there were certain things required, for example, for Medicare
reporting and all that, that would probably change the system pretty
quickly. You know, throw some requirements on that. But I do kind of see
the link back. I agree there are certainly other stakeholders that would
want to be part of the process, but I also see the link back to HHS as a
way to \-- you know, I think that\'s a powerful group that can help to
start to require some things that might accelerate the ability to
collect this data in a more integrated fashion.

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

This is Helen, I\'d like to add on this last couple points, it seems to
me that this, by leaving it with what are the challenges, and not
actually specifically saying and in our best \-- you know, collective
judgments, here are the top \-- whether it\'s two or three things that
should be done right away, or could be done right away, that we leave an
important opportunity to communicate something very important to
progress. So adding that is key.

But to focus those things just as the secretary did with the
transparency initiative, that the government actually has some ability
to make happen, to actually have some leverage \-- and I agree with both
Reed and Pam that we certainly don\'t want to leave key stakeholders out
of the decision making process. But by ensuring that there\'s both
accountability and the responsibility is given to an entity that has
power to make things happen, as opposed in some instances to a group
that may be powerful from consensus, but can\'t act as fast. And I think
if you see what the secretary did with transparency, and how quickly he
was able to move on the President\'s executive order, and to really leap
over 30 years of inaction on requiring, by the government, of their
suppliers to do certain things, that in fact enormously significant
changes can be affected.

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

Helen, let me just say before I have to go, I\'m definitely going to
quote you on that. Let me just say that leap is like a big part of my
working day now. But I think you\'re right. So I\'ll certainly accept
the points that you made.

And Nancy, I\'m going to pass the baton to you, and thank you. I\'m
going to try to come back, although I\'m kind of hoping that all of you
will be done by then, at about 3 o\'clock your time.

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

Great.

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

And I\'ll follow up with you later, Kelly. Thank you.

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

Nancy, I have a suggestion that I think might be sensitive to Reed\'s
comments and some of the other comments we just heard.

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

Please, go right ahead.

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

Is we want to sort of give a home to this work, and at least initially
doing a lot of the detailed evaluation, and, you know, the hard work
looking at disparate codes and even sort of the complications of trying
to take data that may not be perfectly standardized, but electronic
clinical data and mixing that in with various claims data sets. Since we
know there\'s a huge amount of complexity and a lot of detailed work
there we could leave it as HHS working with relevant private and public
sector leaders, but then require whatever initial analysis is done to be
reported back to the quality work group, so that we could then make
recommendations on the specific ways to resolve the really big problems.

And I think there\'s going to be a report available from the first 6
BQI, or what you refer to as AQA pilot sites, in May, and that will be
really good input into this process.

So I think there may be some kinds of activity underway already that
will help us get to some of the answers.

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

This is Margaret. Kelly, I think that\'s a great idea. I think if we
could get some more information brought back to here, we should vet some
of the issues. Because there are VERY big issues here, so I like your
suggestion.

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

Reed, do you want to react to Kelly\'s suggestion?

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

Yeah, I think it\'s fine. What I think it does, Helen I think got really
right to a lovely nuanced way to approach it, and I think that advances
it. So I think you\'re on the right track.

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

Great. Others want to augment this or provide other suggestions around
this particular recommendation? Okay, hearing none, Kelly, sounds like
you\'ve captured the main notion, here, of the comments, and not only
will we expect to see a revised recommendation here, slightly revised
recommendation, but also look forward to the additional work coming back
to this quality work group.

How about recommendation 3.2. Where we are enabling, through NHIN
contracting process, efforts to combine administrative and clinical
electronic data for quality measurement and timely reporting of results.
Comments, questions?

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

This is Helen, and I would add that\'s excellent, and I think that does
a nice job of making the points we were making on the other one, it sort
of reinforces that. And that\'s important now.

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

Certainly is. It has much more relevancy to me now, given the amendments
that were made to the 3.1.

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

Yeah, I would just add from a timeline perspective if we can actually
get at least some of the big issues articulated and some, you know,
perhaps some early ways to resolve some of them, by the summer, I think
that that will be around the time that the next round of contracting is
really going to be kicking in. So if we have some regional sites across
the country that are going to be actually trying to do this, they\'re
going to have some of those answers.

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

Comments? Additional comments on that particular recommendation?

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

This is Charlene. This is really kind of a point of clarification. I
guess most of this, in recommendation 3.1, is coming from claims as
opposed to clinical \-- well, it\'s really talking about clinical data
from other sources, right?

Just a challenge \-- I hope this comes under a challenge, a challenge
that we would find is as we eventually think about sending this in from
EHRs, it\'s a bit unclear whether it\'s going to an aggregator or, you
know, where the smarts is in terms of creating the numerators and
dominators, and that type of thing. So I think those are the kinds of
issues that are going to need to surface coming out of this process,
because that will also impact what the standards look like in the longer
term.

So now, the kinds of questions coming out of the people working on the
measures, is, well, do I ship one of these off monthly, do I ship it off
after every encounter, do I ship it off \-- and then you\'ll hear CMS
say, well, I can\'t take it every day, that kind of stuff. But there are
some process issues, and I think this is the one \-- this is the area
that\'s got to also look at those issues.

So I don\'t know how to quite fit this in there. But like \-- because
then we will say like if it\'s after every encounter you use one kind of
transaction, and if it\'s at the \-- you know, end of the month you\'ll
use another kind of standard. So it\'s really important kind of back
to \-- I think the previous \-- recommendation 1, where we say we want
to give it to HITSP to be selected, well, we kind of have to know the
operational apparatus on the other end, so they know what kind of
standards. So it\'s a little bit cyclic here.

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

I think I understand what you were saying, and it has to do with the
complexity that comes out because these different data streams that
we\'re now trying to bring together for a unified purpose, were in fact
created for disparate purposes, and may have very different ways of
identifying and counting things because of their different purposes, and
that will create some complexities as we\'re moving forward. Am I
capturing that correctly?

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

That\'s one, the other one is like there\'s just different people that
we have to deliver these data streams to. If one is an aggregator or
CMS, they can only accept \-- they can\'t accept all the data, they
don\'t know \-- so like where is that processing done that aggregates
it. Is it \-- you know, does the EHR have to be smart enough to be able
to do that, is it going to be the aggregator that does it, do both of
them have to do it? At some level the EHR is going to have to be able to
do that so they can provide online feedback of the reporting to their
providers, but then the numerator and denominators get confused. So I
think it\'s all in identifying the issues, I just don\'t want to miss
the fact that it will also impact, as you look at generating these
directly from EHRs, how that data gets communicated, which will impact
the standards.

And that needs to be included in that scope of those issues you\'re
looking at. That\'s all I\'m trying to say.

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

Absolutely.

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

Yeah I think one of the other complexities and one of the things we\'ll
probably be getting into I think as we talk about this more as a work
group over the next few months, are what are the appropriate roles for
different kinds of organizations to be taking on, and if there\'s a real
or regional effort to establish a health information exchange. And
that\'s going to be part of this, the next round of the NHIN. And
they\'re going to be trying to do this aggregation of administrative and
clinical, electronic clinical data, then they may not be the ones who
are actually trying to make sense of the numerator and denominator, or
doing the analysis. They may be relying on another organization with
that analytic expertise to do that.

So I think the process Charlene was just articulating, in addition to
where is the home for this data, and who is responsible for doing what,
in actually getting to the point that you have a reliable measure that
you feel comfortable publicly reporting. I think we\'ll probably have to
work to articulate that better.

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

Absolutely. We\'ve talked a lot about the data, producers, and trying to
harmonize measures, harmonize the way in which the information is
produced and transmitted. But equally important to harmonize the capture
on the other end of the data to the extent possible, or at least
recognize the disparate uses, and needs of the folks that are capturing
and aggregating the data. And to the extent those other uses are tied to
functions that are performed on a timely basis, disrupting those
sequences, for instance, disrupting the flow of dollars from a billing
process, would cause enormous consternation if we\'re not careful. So a
lot of complexity there.

Other questions, points, to be made on these particular recommendations?

Hearing none at this point, let\'s move on to recommendation number 4,
around aligning quality measurement with the capabilities and
limitations of the health information technology.

Does anyone have comment on the opening paragraph under this particular
recommendation? Sorry, under this particular item number.

Not yet? Okay. Well, let\'s move on to the recommendations, then, 4.1.
HHS through CMS and AHRQ along with major measure development
organizations, should identify opportunities to enhance the measure
development enterprise by consideration of data needs when measures
targeted for public reporting are developed.

Questions, comments?

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

This is Pam. I just had a question on who are the major measures
development organizations do you think would be included with this?

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

I can answer that, Nancy, this is Janet. We at NQS, we convene major
measure developers on a regular basis. And we haven\'t done that in a
way that really excludes anyone except that we do recognize there are a
handful of measure developers who develop the majority of measures, and
also who tend to develop measures that really need to be harmonized with
each other. And those are I think the ones that are clearly most active,
are the AMA, PCPI, the physicians consortium. NCQA, JCHO and CMS. AHRQ
is a major measure developer, too, but they tend to be the survey
measures, so theirs don\'t quite \-- enrollee survey measurement tools,
to a great extent. And to some extent also to the hospital level
indicators and measures. So AHRQ would probably be in there too.

There are a whole lot of smaller niche players in the measure
development world, and there are many that probably would need to join
that group. But clearly, there is a central core whose measures relate
to each other, and they account for the majority.

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

So would NQS\'s role be to try to harmonize those or \--

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

That\'s what we have been doing, that\'s what the harmonization work
group, the steering committee asked to us do, we convened that group, as
well as some others, and moved to harmonization, and we\'re continuing
with that, to work with them really on an ongoing basis. They\'re the
ones that tend to be most interested. But as I said, we don\'t mean to
exclude others, there are other important measure developers, too, but
there is that core that I think drives the overall system.

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

I think that\'s good because it keeps it still targeted, it allows those
others to weigh in through other organizations. I think if we want to
keep it moving forward, it has to be somewhat targeted to do that.

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

This is Helen. My only point about this one is that I think a comment
was made very early about maybe having an editor who doesn\'t touch the
substance, it\'s such a kind of indirect way of saying something very
important. If there is a good editor that would just put it in more
direct language, without changing the substance, which is fine, I think
it might help the reader, especially someone who is not \-- who is not,
you know, heavily, heavily engaged in these activities.

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

Helen, thank you, I think you\'re correct on that. In fact, I have to
admit I\'m a little bit confused by the language of the recommendation
itself. So I would find it hard to personally clearly articulate exactly
what it is we\'re trying to convey, here. Kelly, could you \-- do you
want to take a crack at that?

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

Yeah, I can definitely try to make it a little more mainstream. We
sometimes balance the need for specificity with having this reach a
broad audience, just because we need to \-- usually work with a lot of
folks internally to get this done, and so there needs to be some kind of
common understanding on what exactly that is. So I think we could
definitely make this a little more sensible and keep it in spirit with
the overall section 4. And trying to, you know, make sure that we have
very difference levers, or mechanisms. And really, it\'s the people who
are funding a lot of this work that can encourage better alignment up
front as measures get developed, so that we really understand what the
data needs are, so that the electronic health records and network
services can be designed \-- or developed and certified in such a way
that this data will become more readily available over time.

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

That sounds perfect, maybe we just take that off the tape.

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

Yeah, that did sound much clearer, very clear.

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

Nancy, this is Janet.

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

Yes, Janet.

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

I think we\'re sort of missing an opportunity here with this
recommendation, I think it could go further. And in part I think it
needs to recognize that NQF has the potential, through the endorsement
process, to develop criteria for measure development, and indeed we
already do, that reinforces those basic principles that measure
developers need to adhere to, so that measures can be incorporated in
the EHR.

So for example, let\'s say that a part of the work of the little work
group that we talked about earlier that we\'re going to play a role in,
that working with those measure developers in the EHR vendors, that we
make some real progress on how to develop a more standardized approach
to specifying exclusions from the denominators that could be used across
many or most measures.

Then the next step I think is once that\'s out there, and the measure
developers are accustomed to that process, what we\'re expecting is that
every measure developer will then adhere to those standardized building
blocks of measures, which are also standardized building blocks of the
EHR.

This recommendation I think it could have a second part, recommendation
4.2, that says that NQF should then develop appropriate criteria, or
incorporate into the measure endorsement criteria, those standardized
requirements that are needed so that these measures can move into the
EHR.

So much the same way that CCHIT under recommendation 1.3, we\'re looking
to them to, once the initial work has been done, to sort of provide some
clout to the EHR role that says, you know, you will construct EHRs in
ways that they\'re capable of producing these data for the measurement
calculations, I think there could be a directive to NQF that we will
then move to develop our endorsement, further expand our endorsement
criteria, to make it a requirement that over time the measure developers
begin to move towards the development of measures with detailed micro
specifications that adhere to those standardized approaches to doing
things. Whether it\'s exclusion criteria or age ranges.

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

I think that\'s an important point, and I\'m glad you made it, Janet. I
wonder if indeed there\'s even a 4.3 that would follow, emphasizing the
need for organizations that are picking up these measures and then using
them for public reporting, whether it\'s the HQA or AQA or other
organizations, to really get behind this notion of using measures that
conform to the NQF endorsed criteria. I mean, maybe it\'s inflected in
the fact that at least AQA and HQA have said we want NQF endorsed
measures for our work, but even being more explicit about that,
everything \-- or calling upon other organizations that might use these
measures for public reporting, to really be attuned to that as well.

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

That would be great.

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

Because I mean at NQF we want to move in that direction, we want to do
everything we can to encourage that all the measure developers, and that
\-- the major measure developers that we talked about earlier, I mean,
they\'re already on board and all really trying to move in this
direction. But I don\'t want to minimize the fact that there are dozens
and dozens of other measure developers out there who aren\'t nearly as
engaged in this process, and they too need to adhere to these more
standardized approaches and clear guidelines for how they develop
measures.

Otherwise, for the foreseeable future we\'re going to continue to have
an awful lot of measures that really don\'t fit in well and can\'t be
incorporated into the EHRs.

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

Hey, Jan this is John White from AHRQ. This brings up for me the issue
of certifying bodies. And you know, we\'ve \-- right now, there is a
contract with CCHIT, but the discussion has always been for the future,
that there might be other certifying bodies or certifying entities
related to health IT.

Are you taking this to its logical conclusion, are you suggesting that
maybe NQF might want to seek certification as \-- or, you know,
recognition as a certifying body, for quality measurement relating to
health IT?

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

well, we are \-- I view us as being \-- we\'re the national endorsers of
the performance measures. And we want those performance measures to be
ones that can fit into HIT. I\'m not sure at what point that crosses
over into certification. We\'re not a certifying body for the EHR, what
we are is the endorsement or certifying body for the performance
measures themselves. But I\'m not sure I fully answered your question, I
realize we\'re in a world now where we\'re trying to bring those two
pieces together.

And the AQF endorsement process for performance measures, we go through
a fairly elaborate process. We put out calls for measures, we look for
the best measure of a particular aspect of performance, then we look to
see whether the measures that have come in that are being competed head
to head, whether they\'re science based, whether or not they have been
field tested and can be implemented. So we have a whole set of criteria
that go way beyond whether they could be incorporated into EHRs.

And increasingly, in the future we\'re going to be looking at whether
performance measures really respond to national priorities for the most
high leverage important areas that we should be focusing our attention
on in terms of quality improvement.

So it\'s a bit of a different ilk. But it does strike me there is an
element of it, we want a part of our endorsement process to be clearer
and provide clear guidance to measure developers, as to what their
responsibilities are, to make sure that their measures can fit into the
EHR. So there is a coordinating effort needed here.

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

As my boss is so fond of saying, a script yet to be written.

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

Yes. Yes.

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

Janet, this is Charlene Underwood, I think that makes a lot of sense to
include that recommendation there, that process evolved out of the
collaborative work. Because it will just get clearer, we\'ll get this
down to a process.

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

Other comments? I think Janet\'s suggestion has a lot of support, Kelly,
and I hope you have enough information to capture that. Do you feel like
you do?

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

Yeah, I think between Michelle and Christine and I we\'ll be set. Really
helpful comments.

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

As I was listening to Janet talk I was envisioning a picture, a diagram,
if you will, that might help folks sort of capture the flow of
information, here. I don\'t know if that\'s possible, but \--

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

Actually Sharlene and I are looking at one now.

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

There you go. Because it is such a complicated area, it may be very
useful. So that brings us to the to the end of our articulated
recommendations. I assume no one has comments on the last paragraph, or
if they do, please speak now.

Okay, good. Are there \-- are there things that you expected to see in
this letter of recommendation that are in fact missing? Things you want
to raise to Kelly for incorporation in the next iteration?

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

Nancy, this is Jerry Asheroff. Can I throw some ideas out in response to
that?

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

Please.

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

These recommendations that are talked about in this letter are designed
to bring about a world where clinical performance measurement and
improvement happen much more efficiently and effectively than they do
right now. So they\'re like pieces of a puzzle, and I think the vision
statement that\'s been developed kind of articulates at a very high
level what we hope these pieces of the puzzle will add together.

But when you get down to, when you look at the AQA and HQA measures,
we\'re talking about very specific clinical conditions and very specific
things that need to happen, and these puzzle pieces will hopefully come
together in ways that make sure that specific conditions that are
covered by those measures will be managed much more effectively.

So what I would put out as a question is would it be useful to sort of
take the next step and have as an additional recommendation be that this
work group take responsibility for basically creating that picture that
goes on the puzzle top box, that sort of gives an illustrative example
for how a patient with a particular clinical condition covered by one of
these quality measures, as they transition through their journey with
the health care system, what things will look like once all these
recommendations are in place.

And by putting together something like that, enable all the different
people who are responsible for the different parts of these puzzle, the
CCHIT, and HITSP and measure developers and all these other folks, will
sort of have this common sense of how all these individual pieces fit
together to make, you know, clinical care that\'s \-- you know, more
effective and efficient and all that stuff, and where the performance
measurement and improvement happens better.

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

I think that\'s a wonderful notion. Is that in fact what\'s intended to
be captured in the quality use case, Kelly, or is it \-- is it a
different notion?

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

I think this would be \-- I think it\'s a wonderful idea, and it might
be an opportunity for us to actually put something together over the
next month, and vet it with the work group members. Building off of
maybe some scenarios that have already been drafted for other reasons.
And if it does sort of tell the clinical picture, but also sort of bring
the message home to the consumer as to what they could anticipate down
the road, I think \-- I think it would be really helpful to put our
recommendations in context.

But also, get the point across that even though we\'re starting small
because that was our specific charge, and a lot of work around AQA and
HQA has helped us focus, that we are really talking about more
system-level change.

So if folks are amenable to having at least \-- you know, internally us
trying to draft something up, we can vet it with you, and if, you know,
a month is enough time to pull this together, we can try to do it in
advance of the next AHIC meeting.

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

Kelly, this is Jerry. Can I build on top of what you were saying? I
think this picture could potentially be, you know, something that\'s
dynamic and actually a tool for engaging all the different stakeholders
that are going to have to really work closely together, and in harmony
to make this stuff happen. So there might be a sort of a first crack at
this that could be created and vetted by the work group. But then there
could be a larger group of constituents that are pulled together to
perhaps refine it, and expand it, or maybe even specifically sign on to
it as a way of saying yes, this is the world that we\'re trying to
build.

So rather than it just sort of being something that\'s done once, at one
level of granularity, maybe there could be a crack at this that would be
developed before the presentation is made, and then, you know, a group
along the lines that are recommended in the other recommendations that
get convened, to sort of further vet it and further get more
stakeholders engaged in fleshing out the vision, you know, so that it
could happen not just as a one-time thing, but sort of iteratively, and
continue to expand and be refined. And like Nancy was saying, being a
use case of sorts, but sort of a mega use case for where this whole
enterprise is going.

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

Yeah, that makes an awful lot of sense. I think just like we thought our
vision would probably be something that would be realtime, and we\'d
need to revisit it and update it as our deliberations became more
advanced, I think this could really help us through that process. And
make it more real and more tangible for a broader audience.

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

Sounds very good. Others want to get engaged in this, the particular
ideas? Any additional comments or tweaks to this? You\'d like to add?

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

This is Pam, and I would just kind of echo what was talked about, and
particularly with the focus on consumer-user friendly information. Right
now we\'re really focused on getting information, and working with
providers and, you know, setting up the structure for it all to happen.
And I think a really critical element downstream, and hopefully shorter
term of downstream, is just making that information be useful in a way
for the average consumer.

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

Absolutely.

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

Nancy?

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

Yes

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

This is Jerry Shay. I would second the last comment. I was thinking
earlier about raising that, in terms of the paperwork. I\'m not sure
that it\'s appropriate to put in here, but if we\'re talking about, you
know, a vision of where we expect this to be, it probably would be worth
putting in something that acknowledges what a knowledge gap we have
between even the ideal state of easily available information and the
useability of that information for people. Never mind its capacity or
likelihood to impact behavior or translate into any of the \-- you know,
visions that we have about more efficient, more cost effective, et
cetera, et cetera. I mean, there\'s \-- on the other hand maybe you
don\'t want to do that because it\'s a whole other dimension, but in
that case it seems to me that at least we should say this is essentially
a technological vision we have here not you know sort of a new health
paradigm.

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

This is Helen. We actually talked, Jerry, talked about this at one of
the early meetings, and I think a number of us felt that this was really
an important point, and if we weren\'t really making a difference with
consumers then, you know, we were missing a golden opportunity.

But we were reminded that there is a whole separate group on this topic,
so we were kind of encouraged to \-- you know, sort of acknowledge that,
and not do as much in this group, because the other group was doing much
more. And maybe Kelly has something to add about that, because that
was \-- I sort of yearned for moving in that direction, too, but I think
we were encouraged to \--

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

That\'s fine, thank you.

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

I think in terms of our vision we really tried to focus on the consumer
perspective and needs. And I think if we try to put this picture
together and update it overtime to engage all stakeholders needs and
perspective, that this is really an important part of that. And, you
know, we certainly can take on issues around availability and useability
of data and try to more specifically address the gaps that we know of
today as we move forward.

I think the consumer empowerment work group is very focused on a lot of
issues relevant to personal health records, and data that might be \-- I
mean, there are some overlaps, but I think if we\'re really focused on
consumers having access to public supposedly reported measures, that\'s
a discrete part of what they\'re working on. And I don\'t think there\'s
really a lot of overlap there.

So I think we definitely can include it in this picture, and probably
talk about it a lot more moving forward.

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

I think that we should. I think we should make that distinction clear,
and acknowledge that the other group\'s working on this, but to the
extent where we \-- when we are working on what should be coming
forward, either from the beginning of the data collection process, to
the end users who ought to definitely include consumers, then we should
emphasize how important it is not only that we build in what we expect
at the end, but we build in the expectation that it will be useful to
consumers. And if we have to decide and prioritize that maybe putting
more emphasis on that at the front end, a point that several people have
made, I know Janet particular, would be very valuable.

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

Anyone disagree with that point? Good, sounds like it\'s something that
we fully support incorporating into this particular set of
recommendations.

Other comments about this discussion?

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

I don\'t know, I was just going to suggest for maybe other people on the
call, but I know we might at least have, in terms of helping Kelly and
our team do this, might have some samples of this stuff that we could,
you know, donate of pictures that each of us I\'m sure have done to give
them a starting point. Because I know personally, you know, doing these
story board kind of things, if you\'ve got something to start from,
something might resonate. So I don\'t think I\'ve got anything perfect
that would get her going but I know there are probably others of you on
the team who have done something along this line.

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

Actually, RWJ has done this. It took on probably a scope that\'s broader
than quality measurement and reporting, but I think it really did touch
on almost everything we\'re interested in. And they were willing to
share it once they sort of fully vetted it and granted it. But they did
share it with AHIC probably five months or so ago, so we could leave it
at that.

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

That would be helpful.

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

Yeah, if there\'s a consistency in starting point that would be helpful.

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

That would be good. Jerry, you also clearly, as you brought this issue
up, had very definitive ideas about how this might be captured. And
perhaps if you could articulate those in bullet points or something it
would be helpful to Kelly and her crew in getting this started.

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

Okay, can do.

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

Other comments on this? Great. Well, a related issue of sort of related
in terms of how does our work relate to that of other subcommittees and
work groups that are working, as Kelly knows, when I talked with the
formerly \-- the work group formerly known as the biosurveillance work
group of the AHIC, and I\'d be hard pressed to tell you their new name,
but she could, I talked about the need for the data they\'re looking at,
which is a really \-- they were talking about adverse event data
collection, like infection information, medication errors, and so forth,
to be linked to the work that\'s going on in this work group. And I
would like to propose to the group that the letter \-- maybe it doesn\'t
rise to the level of a recommendation, but at least include a reference
to the fact that the work that\'s going on in that biosurveillance work
group does need to be linked to our work group\'s work, because \-- in
many senses it will be the same data elements, or similar data elements,
similar kinds of measures, that are of interest.

At least from my perspective that\'s true.

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

This is Margaret. I\'d agree with that, Nancy.

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

Yeah, Nancy, luckily we\'ll have both John Lumpkin and Carolyn Clancy
and Chip Kahn, who I think are all in agreement that there\'s some clear
common needs, and really, the lines become so quickly blurred between
different kinds of public health surveillance or quality improvement
initiatives. When you\'re talking about sort of an EHR system, or what
kind of process changes you might need.

So I think we could definitely add it to the letter, and I think
they\'ll probably mention something when they\'re presenting, as well.

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

Good, I think it just has some harmony to have our hat tipped to that
work group as they tip to ours.

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

There is one other part of \-- one other comment that\'s been made in
recent work group meetings, that we haven\'t addressed in this work
group, and I just wanted to see if anyone else felt that we need to
address it. And this goes back to Helen Darling\'s initial comments on
how important a business case for quality reporting is. We have
discussed this over a few meetings, but we don\'t have any specific
recommendation around it. And I\'m just wondering if anyone would like
to discuss it now, or think about what we might add.

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

Anyone have opinions or suggestions on that issue?

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

This is Margaret. I like the idea of at least referencing that
somewhere. Because I think the business case is often lost on people,
and so the burden of the performance measurement is easily seen, and the
intellectual value in terms of being able to have data to improve your
processes is certainly brought into. But the actual business case often
eludes people in their thinking. So I think it would be good to have
something to that effect.

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

I\'m not sure it\'s whether the business case eludes them in their
thinking or whether the business case is in fact elusive.

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

Maybe both.

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

But I agree having reference to the complexities of financing here and
the need to pay attention to how the payment system supports the effort
to move information technology forward would be appropriate, I think, to
reference here. Without getting into \-- my personal preference is that
we not get into any particular specifics, because there we might find
some discord.

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

Nancy, this is Janet. By the business case for quality, I assume what we
essentially mean there is a big piece of making quality better we hope
will also slow the rate of increase in health care expenditures. And it
seems to me we can make that point in a couple of ways. It may be that
we do want to be a little more explicit that when we\'re talking here
about quality measures, we\'re also talking about resource use measures,
and overall measures of value eventually that really do incorporate
both, you know, medical care, effectiveness measures, outcome measures
on the part of patients, as well as measures of resource use, used in
conjunction with the quality measures along with it. I think that could
be made explicit.

The other thing would be, the business case to me becomes very clear
when you do start to go to looking at a specific chronic condition, I
mean for example if you take MI, and we do start to think more in terms
of quality, quality measures in the general sense of measures that move
upstream, why did that patient have an MI, and were they receiving all
the appropriate care prior to that that could have prevented the MI.

Then there\'s the basic measures around the MI, and then there\'s the
subsequent hospital care, and the health behavioral change, and the
management of their treatment program. And then underlying that you\'ve
got metrics of resource use to see whether or not you provided all those
services, the patient got the best outcome, and did you do it in the
cheapest way possible to get those good outcomes in the most efficient
way possible.

So I think there are ways that we can weave into this document and
future documents a bit more that keeps making that business case for
quality, pointing out that, you know, so much of resource use is
probably unnecessary, and if we look longitudinally and we get good
measure sets that look longitudinally, and that encompass that resource
use, it will really begin us to move us into good indicators of value.

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

Thank you very much, Janet. I was actually thinking smaller than that, I
was thinking more of the business case for the information technology
itself. I like the idea of going to the business case for quality, and
making reference to that broader issue.

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

And that\'s the issue was thinking of, as well, it was not the HIT issue
specifically.

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

I need to think bigger. Others want to comment on the inclusion of that
particular point?

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

Just that point I would add safety, and I realize Janet I\'m sure
implies that quality improves \-- includes safety, but there was \-- I
don\'t have it off the top of my head, but I used it in a speech
recently, some information that showed that the cost of infections,
which \-- you know, it\'s always argued that well, if you do something
about that, then payers save money but hospitals don\'t.

But in fact it\'s demonstrated that hospitals, in a sense, waste money
on infections themselves. So they \-- that, to me, if you can use
technology to improve quality and reduce \-- and safety, and reduce
infections and other avoidable medical mistakes, then that\'s the
business case for improved systems.

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

Helen is absolutely right, you can really \-- both the infections and I
think medication errors, we\'ve got pretty darn strong immediate
business case data. Over the long term, really doing that, looking
longitudinally over the chronic conditions probably has even more
dollars in it, but they\'re harder to get your arms around. So go after
those infections and medication errors first.

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

Right.

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

Absolutely, and I think maybe one of the studies you referenced, Helen,
is the recent study by John White\'s colleague, Ken Luzon in AHRQ, that
looked at some of the these errors in care, costly errors in care, and
the cost both to payers and to the health care organizations in which
they occurred.

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

Yeah, it\'s one of the callings that AHRQ should be congratulated,
because that has silenced, at least in my judgment, some of the constant
complaints that I have heard about that if they have better quality and
safety, then we will lose money. So they will in this sense not lose
money, they will gain back the money that\'s wasted.

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

Thank you. I\'ll take a cake to work for them.

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

Terrific.

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

And I would pay for it if somebody would let me, but it would be more
than 850 or whatever the top is.

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

Kelly, have we given you enough to try to capture this notion?

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

Yeah, that was really great. And we\'ll try to circle some things \--
we\'ll try and make these edits, and additions, and get something back
out to you within the week.

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

Terrific. Are there any other points people wanted to make that might be
included in this letter that are not currently there? It will become
quite a tome if we do too many more but \--

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

Just congratulations to those who did the drafting. I know that\'s
always hard, and I think it\'s a very nice job.

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

Thank you.

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

Agreed. And the reason you can get some constructive feedback here is it
was a terrific job. Of course, a lot of thoughts I think among people, a
lot of good thoughts.

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

Yeah, Christine Solano a big thank to her, too. She\'s done a lot of
this.

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

Great. I think that concludes our comments on the letter and the
recommendations. Are there any comments that we\'ve missed that people
want to make?

One last opportunity to take a crack at the letter, at this juncture.

If not, then I believe the agenda, Kelly called for us to go on and have
a discussion of future meeting topics.

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

Yeah, that\'s right. I also just wanted to make note of the fact that we
would like to better disseminate the vision that we developed as a work
group, and then present it to AHIC. And the one way we could do that is
to make sure there\'s a link on AHRQ\'s website. But I\'m wondering if
work group members would want to have a hard copy sent to their
organizations. I think a lot of our work group members head up their
organizations, but I\'m just wondering if anyone has any ideas on how we
could better disseminate the vision that we have created so far.

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

Thoughts or ideas for Kelly?

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

Kelly, this is Janet. We would love to disseminate it to the NQF
membership.

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

That would be great.

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

Kelly, I think it\'s something that we would like to disseminate
particularly to some of the more forward thinking folks who are actively
involved in big picture thinking about quality measurement in the
hospitals.

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

And Kelly the joint commission has lots of advisory groups that we\'re
using, and we\'d love to disseminate it through there as well, to all
the folks who come in.

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

Kelly, the group called integrating the health care enterprise, as you
probably know, has started up a quality domain and this takes in folks
from HIMMS and RSNA and American College of Cardiology, and there\'s
likely to be a lot of activity there. I think they\'d be very interested
in hearing what\'s going on with this group.

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

Great, I\'ll put it out.

And the vendor association, too. That sounds great, thank you all for
your willingness to do that. And I\'ll follow up, Jonathan, with you to
figure out how best to get through to IHE and others.

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

Kelly, how can we access that document in its final form, to send out to
our groups?

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

You know. It\'s actually right now packaged in with a lot of other AHIC
materials from the last meeting, the Jan 23rd meeting, so I think we\'re
going to have another posting on the website, and we\'ll certainly send
out everyone that link, but we can also send out hard copies to \-- and
hard copies and electronic copies to those of you who want to
disseminate to your members.

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

That would \--

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

That would be very nice, thank you.

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

Great. We\'ll look for that in the near future.

Kelly, do you want to say anything else about the kinds of information
you were looking for in terms of future meeting topics?

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

Yeah, I think this is something that Carolyn and folks here were talking
about, in terms of planning out the next few months as we go to our
broad charge. And since we\'ve been through our vision exercise already,
I think we\'ve already sort of brought out a lot of the issues that we
need to address, more in depth. One of them being, you know, a lot more
complexity around clinical decision support and what needs to be done to
advance that. And then also, the other idea that we haven\'t more fully
explored is how to enable \-- how HIT could enable the development in
more patient-centric measures. So there\'s a lot to address with the
broad charge, and I think we just were looking to get some input on what
folks wanted to take on next.

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

Well, certainly along the lines of my last comment, this is Jonathan,
I\'ve certainly been mentioning enough times trying to get to the
clinical decision support thing, which in fact we did quite a bit of in
the last exercise, but there\'s certainly a lot that we can discuss in
terms of how we are going to try and help move forward solutions to the
problem of why clinical decision support can\'t be better, easier, and
more out there for more folks.

So there\'s certainly a number of different areas that we can explore,
and there\'s obviously a number of efforts that we can rein in for that.

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

Excellent. Other ideas?

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

This is Jerry. Following up on the comment that Jonathan just made,
clearly there\'s a lot of work that needs to be done in the area of
clinical decision support, and one thing that I think might create a
nice bridge between that and all the, you know, sort of specific quality
measure stuff related to AQA and HQA is to sort of ask the question, you
know, as a group, what is the most high leverage things that this work
group can do, to make it so that performance is improving in those
specific areas. And how to leverage, as Jonathan was saying, all the
different things that are already happening, and kind of rein that in,
and make it so it\'s focused more efficiently and effectively on
improving performance in those specific targeted areas.

So the idea of cataloging who the stakeholders are in this business, and
figuring out how to get them together and do other infrastructure things
to move the ball forward to leverage clinical decision support to
achieve these outcomes better, I think figuring how to get the group\'s
arms around that would be very helpful.

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

Very interesting. Other ideas?

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

Nancy, this is John White. Back in November we had a meeting in Chicago
that actually some of the folks on the phone attended, around health
care data collection from providers. And we are finishing up the report
from that conference in the very near future, and would probably like to
share it with the work group as it pertains to a lot of the
recommendations that have been made here, I think complements them well,
and can inform the group.

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

That would be an interesting report. I\'m looking forward to seeing that
myself.

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

Good.

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

This is Margaret. To follow up on the issue of decision support, and
really the issue of getting more improvements, I\'m wondering if people
on the group would be interested in any demonstrations from
organizations out there that are providing performance measurements back
to clinicians in realtime. I don\'t think we\'ve had a demonstration in
that area, but I know there are some groups that are doing that. And I
don\'t know if that would be informative and help us really flesh out
some of where we want to go with our recommendation two area. So I just
throw that out because I know there will be some people interested in
coming in.

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

Reaction to Margaret\'s suggestion?

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

Actually, Montefiore has a nice program called Clinical Looking Glass
where they do just that. I\'m sure they would love to talk about it.

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

I\'ll be happy to try to organize some of this if people want it, but
I\'d like to know if people think it\'s a good use of time.

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

Tom, Reed, Jerry, anybody want to comment?

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

It sounds promising. It\'s a little hard to say in the abstract, but it
sounds promising.

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

Let me explore that and get back to the group.

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

They say the future is here, just unevenly distributed. So getting some
examples of what the future looks like could be potentially very useful.

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

The other thing that might be interesting, again one of the things, you
mentioned Robert Wood Johnson is doing some work. I know they presented
at that (indiscernible) progressive learning announcement last week, and
they talked about doing grants in 16 regions in terms of helping advance
quality at the local level. I think that would be very \-- the work
they\'ve done, I think would be very beneficial in informing us. Because
on one hand we\'re kind of saying how it should be, but I think that
will bring forward kind of a domain of issues that to get really this
happen on the ground, they\'re trying to address it, but I think that
would actually help inform the group.

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

I think there might be also some ability to do some monitoring of some
of these regional activities, and have them report on their status and
their challenges, which again could help us figure out all the problems
and challenges with the integration of claims and clinical data.
Probably a handful of communities that are really advanced at this point
with that.

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

Another one that\'s worth getting in here is the New York City
Department of Health, which has done, in the middle of doing a great
deal of collecting data for all their underserved health clinics, and
trying to apply many of these quality measures into direct decision
support for these people. They really have done a great deal of work on
trying to figure out how they can turn their measures into data and how
they\'re actually going to express them to their clinicians.

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

Excellent. A lot of ideas about people who can provide us with a reality
check on our work. I think that will be extremely helpful.

Other suggestions?

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

I just have a suggestion in terms of what we might consider in future
months. In several of our work groups, Nancy, like you experienced last
Friday, we have all-day in person meetings where we get a series of
panels with testimony. So to the extent we feel like we need a lot more
information we could arrange for that. The downside is there\'s a lot of
very busy people on this work group who have a whole lot of
responsibility, and if it\'s not feasible for folks to be in Washington
for a whole day at a meeting like that, we don\'t need to set it up. But
to the extent there is a need for a fair amount of testimony and more
factfinding, we can do that.

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

This is Charlene. I think that\'s a great idea, because if we could
actually get \-- we\'ve talked about some of the key stakeholders. And
especially if you\'re going to come up with that that story board, it
would be really good to, as we\'re starting to flesh that vision out, to
validate okay, let\'s hear the consumer perspective, because we\'ve kind
of written our vision from everyone \-- this group of people will
(Inaudible) but what\'s that consumer perspective, what\'s the provider
perspective, what\'s the hospital perspective. And maybe what\'s the
nursing home perspective. Because we tend to leave that one out, but
it\'s such a crucial part of that continuum of care.

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

Yes.

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

The consumer and/or the consumer\'s caregiver\'s perspective.

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

Great. I personally wonder if it\'s \-- which would be more valuable of
having a bunch of folks coming to Washington to present something to us
in a \-- you know, fairly quick presentation, or us identifying a system
where they really have advanced pretty far down the line in terms of
clinical decision support, and go to them.

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

Yeah I guess I would really support the looking to places which
represent the future. I\'d be surprised if everybody \-- not only on the
call but the people who couldn\'t make the call or couldn\'t make the
meeting, I\'m actually not only pretty aware of the problems, but get
told them almost daily by the people who are \-- you know, working in
these systems. And if anything, our problem is not getting slowed down
by what\'s going on on the ground, but keeping focused on what the
opportunities are for success, and the places where it is working.
Because seems that we\'ve had a lot more of the latter or the former, I
think, if I\'ve got my reference right, that is, we hear, if you sit on
any of these committees with the NQF, NCQA or joint commission or any
place, you hear over and over what can\'t be done, and why it can\'t be
done.

And so for at least for this group, which has a limited purpose, and has
limited time, and limited resources, to stay focused on the successful
examples, in order to kind of \-- it\'s more like a pull factor. Sort of
if we keep our eye on what\'s aspirational, and what\'s possible, but
still aspirational, like what\'s going on in Indiana, it\'s likely
we\'ll make much more of a difference than if we just do what\'s really
done all over this country every day.

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

Others want to react to that?

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

I think there are some real opportunities to get folks from the
Intermountain Health Care system and Cleveland Clinic and other academic
medical centers who already have really good examples of clinical
decision support or systems that connect clinicians and consumers.

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

I would add Partners in Boston, too. A lot that\'s going on in
Massachusetts. Because there was a new survey, and somebody correct me
if I\'ve got the details wrong, but said something like 50 percent of
the physicians are either already using some amount of computerized
tools and/or plan to very quickly. And there are people like Tom Lee,
and I think he\'s naturally an optimist, but he feels that we really
are, at least in Massachusetts, at a tipping point.

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

I think there are some very forward-moving places around the country.

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

This is Jerry. We could use \-- I mean sort of tying back some of the
other things we were talking about, we could use, you know, not just
look at what these organizations are doing, but we could \-- they could
actually become part of painting the picture of what the future looks
like, the picture that\'s on the top of the puzzle box. Maybe even as a
part of that distilling some best practices or whatever for
accomplishing some of the specific things that this work group is trying
to make happen. So maybe that group like, you know, the Davies award
winners is sort of an analog of this sort of thing, what the equivalent
of that in the quality improvement and quality measurement domain would
look like. That\'s another kind of thing that this work group could
contemplate and potentially do in collaboration with some of these
cutting edge organizations.

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

Sounds right. Other ideas? Kelly, does that give you enough feedback?

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

Yeah, that\'s so helpful. Thank you, everyone.

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

Very exciting ideas there, I\'m looking forward to these discussions
over the next few months. Well, I think that brings us to the point
where Carolyn was supposed to do a recap. I am no Carolyn Clancy, but we
had a series of wonderful ideas for amending a set of recommendations,
which I know Kelly has captured, and we will be seeing soon.

We have also talked about ideas for future meetings, which Kelly will
be \-- Kelly and her colleagues will be working into a plan for us. Are
there other things you wanted to say, Kelly, about the action items
coming from today\'s meeting?

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

No, I think that\'s it. The one thing we didn\'t touch on, but we
touched on last time, is the development of the quality use case. And I
think by the time we meet again, and maybe even before then, we\'ll be
able to get more of your input on that. And that again will shape the
work in this next round of the health IT standards panel, the
certification commission and NHIN work. So we\'ll be articulating the
hybrid approach, and a lot of the processes we\'ve already talked about,
but we\'ll give opportunity for everyone to weigh in on that.

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

Great. I just want to remind members of the work group that to the
extent we have anything or can craft something that would help Kelly and
her colleagues capture the picture that Jerry has described for us, that
we\'re going to try and incorporate into this letter, please send those
to Kelly.

I guess at this point we come to the time for public comments. So Kelly,
would you talk with the operator about making that happen.

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

Yeah, they\'ll go head and open up the line, just will probably take a
couple minutes. Might have a little bit of down time here.

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

This is Jennifer, I\'ll just remind everybody that if you\'ve already
dialed in, you just need to press star 1 to alert the operator to the
fact you\'d like to make a comment. And there\'s also an e-mail address,
you can make comments that way, too.

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

Thank you, Jennifer. While we\'re waiting for folks to indicate their
desire to comment, we should remind everyone that the next quality work
group meeting is March 27 from 1:00 to 4:00. That\'s eastern time, make
sure that\'s booked on your calendar if at all possible. Operator, do we
have any public comments?

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

I think there is one person in queue.

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

We do have one, Jane, could you open that line?

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

Line is open, go ahead.

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

Yes, is that for me?

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

Yes, sir.

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

Hi, Nancy, this is Lou Diamond here.

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

Hey, Lou.

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

How are you doing. I just wanted to make a few brief comments, I
apologize if one of them is repetitious, I had to leave a short while.
In reference to our recommendation 4.1, I would hope that you could
capture the issue that the considerations are more than just the data
needs, obviously, that need to be coordinated across the implementers,
and the measure developers. There are all sorts of work flow issues and
related issues that you\'ve already discussed, and that\'s the first
point.

The second point is in that recommendation I would hope that you would
also be able to say something about the coordination of an integration
of efforts at the measurement development level. With the upstream
development of the clinical practice guidelines and evidence. We
frankly, as you all know, have a kind of silo set of activities going on
with clinical practice guideline developers handing off to measure
developers, handing off to implementers. And I think that would not be
in our best interest going forward. So that was my first comment.

My second comment, I think you might have captured well and was
discussed in the previous call, and I didn\'t have an opportunity to say
anything about it, was it\'s in regard again to the letter, the
secretary\'s paragraph 2, and it\'s the preamble, and it\'s the second
sentence. And if Jonathan is still on the phone, I think Jonathan Teich
made some comments about this in the previous discussion. That sentence,
and some of the discussion by some people, appears to imply that
measurement and feedback of information is kind of a separate set of
activities from clinical decision support.

It\'s not totally clear from that sentence whether we are believing
that\'s an integrated approach, and it seems to me that at the point of
care, the clinical decision support is not only integrated with the
performance measure for individual patients, but also for populations.

Relating to the construct of action lists and related activities in near
time, and sometime as realtime.

And I would hope that the group would be able to capture that integrated
approach between individual patient and population management, which is
now accruing the responsibility to individual physicians and groups and
other providers, as well as this notion of performance measurement
integrated with point of care decision support.

So I appreciate the opportunity to make those comments. Thanks.

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

Thank you, interesting points. Interesting points, they do I think,
marry well with things Jonathan said both on this call and earlier.

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

Thank you.

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

This is Jonathan. I agree with that, and I think maybe that\'s one of
those pieces of editorial clarification that we haven\'t quite gotten
to, and need. Because in both section 2 and section 4 we talk a lot
about both something that could be defined as either those lines,
individual CDS or population based. But we probably should say somewhere
explicitly that we\'re talking about either or both.

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

Yeah, and I wasn\'t in on the discussion, because I did say I had to
drop off for a period of time, it might be that Jerry\'s diagram will be
able to capture that as well going forward.

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

I think when \-- as we were saying before, when that detailed
recommendation gets broken down and fleshed out, in the nuances, as
Carolyn was saying, hopefully we\'ll be able to make it that much more
explicit.

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

Thank you.

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

Operator, are there any other additional public comments?

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

There aren\'t.

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

I\'m sorry, there are not?

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

No.

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

And did we have any e-mail inquiries or comments?

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

No.

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

Okay. Kelly, anything you want to say in closing?

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

No, this is a really a good, productive meeting, and we\'ll be sure to
get a revised letter out to everyone, and iterate with you all on the
emerging picture. And thanks to everybody for all your contributions.

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

And I want to on behalf of Carolyn thank everybody as well. Efficient
work. I yield back the rest of the hour that you had set aside, to you,
and to the work you have to do at home. Thanks so much.

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

Thank you.