American Health Information Community

Biosurveillance Workgroup #10

October 20, 2006

**Disclaimer**

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

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

Welcome again to the tenth meeting of the Biosurveillance Workgroup here
in Washington, DC. We have members on the phone and as well as members
from the Biosurveillance Data Steering Group, which is making a
presentation today.

As Director of the AHIC, I want to remind you that all of the
deliberations here are public and publicly available to the public as
well as the documents which we put up on the Website following the
meeting. We have an archived section on the Website you can go back
through all ten of these meetings.

One other caveat is this committee is advisory to the AHIC. And a final
note, if you cannot make it, if you\'re a member of the Workgroup,
can\'t make it in person, we encourage you to nominate one person as an
alternate so we have a sense of continuity and awareness of what the
Workgroup is doing.

So with that, I think I\'ll turn it over to you, Matt, to review the
call‑in procedures and introduce who is on the phone. But maybe before I
say that to you, I\'ll just say who is in the room with me.

I have John Lumpkin from the Robert Wood Johnson Foundation. Captain
Rich Haberberger, representing David Parramore from the Department of
Defense, and Ed Barthell, and Scott Holter. So go ahead.

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

The procedures are the same as we always do them. It\'s important we
stick to them as much as possible. We have a couple extra folks joining
us on the phone so it\'s actually a rather full call compared to our
usual group.

Very quickly for all the Workgroup members and the folks we have calling
in to participate in this session, you all have an open line during the
call so you can speak whenever you need to but when you\'re not speaking
please keep your phone on mute so we don\'t get any chatter coming into
the call. And when you do speak up, to say something say your name first
we have folks from the public listening over the Web and listening on
the phone to this and it\'s hard for them to understand who is talking
if they don\'t hear people say their names. And as much as possible that
goes for the people over at ONC, too, even though you\'re looking at
each other. Those who are listening remotely don\'t know necessarily who
is talking. With regard to the Webcast we\'ll show some slides for the
presentation today. If any of the members are logged in we just ask you
don\'t touch or change or advance any of the slides while we\'re going
along. Any changes you make on your desk top are streamed out and made
on everyone else\'s desk top too we can get confused that way. For the
call-in procedures, we\'ve got a lot of people on the phone today.

So I\'ll go down the names of those I know who are members of the
Biosurveillance Workgroup and if we have other people to participate in
this call today only, I\'ll let them introduce themselves as well.
Members of the Workgroup today on the phone, we have Edward Sondik from
the CDC. Laura Conn from the CDC as well. Leah Devlin from the North
Carolina Division of Public Health. Maureen Allen is here on behalf of
Michael Barr from the American College of Physicians and Larry Biggio
from the State of Wyoming and any Workgroup members who I didn\'t
mention or designees?

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

This is Michelle Meigs from the Association of Public Health Labs and
I\'m standing in for Scott Becker today.

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

Judy, did you want to give everybody else who called in today an
opportunity to introduce themselves or do you want to just wait until
later to do that?

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

Why don\'t we have them say who they are, yes.

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

We\'ve got some additional folks on the phone today. Megan Treber, is
that correct, from Pennsylvania Department of Health.

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

That\'s correct.

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

Kevin Carr from BearingPoint.

**\>\>** Art Davidson, the co-chair of Biosurveillance Steering Group.
It sounds like somebody has an echo in the background, if anybody has
called in on the phone and listening to this over the Web, please mute
your computer speakers so we don\'t get any echo.

We\'ve got Vonna Henry from Sherburne Public County Health. And Michelle
Meigs we went over that. Lisa Rovin from Food and Drug Administration.
Lynn Steele from CDC. Roland Gamache from Indiana State Department of
Public Health and just a couple more. Robert Tuch from the Department of
Defense. And Sally Johnson from Rhode Island Health Department. And
Marion Kainer from the Tennessee Department of Health. If anybody has
their computer speakers on please mute them. We get that echo when
people have their phone and speakers on at the same time and Brian
Carnes from Indiana just joined us.

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

This is Brian. I\'m trying to find the place but I\'ll listen in until I
find it.

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

Anybody else who called in to participate in today\'s discussion who did
not get mentioned? I think that\'s that it, Judy.

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

I believe I\'ve heard, although I didn't personally hear, that Chip Kahn
is sick today. And I don\'t know if Jeff Cohen or Howard Isenstein is on
the call for him.

If not, I guess Laura, do you want to say a few opening remarks as
Co‑chair alternate?

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

Thank you. John Lumpkin is sitting in for \[audio difficulties\]. I
appreciate the effort that you have made to \[inaudible\] in person as
we bring the work that we\'ve been doing over the last several months
together to think about some of our short‑term priorities but also to
John Lumpkin is helping us with and John we certainly appreciate your
willingness to help in making yourself \[inaudible\] we do have a fairly
full agenda today and we\'ll go ahead and get started. I think our first
call in our recommendations from May was to have a Data Steering Group
to determine some of the minimum dataset issues feasibility and
filtering of data and that group has been working very hard and was
co‑chaired by Art Davidson from the Denver Department of Public Health
and Marty LaVenture from the Minnesota Department of Health. Appreciate
the work they\'ve done to pull that group together and do a lot of hard
thinking and contemplation over how to move this forward in the next
year. We\'re going to hear from the recommendations that are coming out
of that group first item.

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

This is Art and I\'m not sure if everybody is having the same difficulty
hearing as I did Laura. It was fading in and out. So I don\'t know if we
need to make sure that the audio is working well here or not. Matt.

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

I just got a message from the operator. Looks like that\'s a local
issue. So maybe Laura, I don\'t know if you\'re calling in from a cell
phone if you could call back in from a land line.

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

It\'s a land line with a speaker I\'ll just pick up the phone when I
speak.

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

It\'s still bad.

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

Are you speaking into the receiver now because we\'re still getting you
fading in and out.

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

Does this help?

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

I think so; it was a five-second fading in and out. I can\'t tell but
that sounded better.

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

Thank you Laura.

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

We probably caught two‑thirds of everything you said.

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

I\'ll just go ahead and introduce Art Davidson, one of the co-chairs
with Marty LaVenture for the Biosurveillance Data Steering Group and as
you recall the formation of this group was one of the formations of this
group we presented in May. This group has done a lot of work over the
last several months to think about minimum dataset issues and Art will
talk about the process that the group has gone through to come to the
recommendations that they\'re presenting for our consideration today.

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

Thank you, Laura. On behalf of the entire Biosurveillance Data Steering
Group, and my co‑chair Marty LaVenture who is off to better adventures,
I want to thank the Biosurveillance Workgroup for the opportunity to
support your efforts and develop a system that builds a strong
biosurveillance system for the nation.

The work would not have been possible without the concerted effort of
our entire membership and the committee. Numerous experts and the Office
of the National Coordinator. I want to thank you for permitting us to
make this presentation today from the work of our Workgroup. I\'ll move
to the next slide. In response to our charge the group has made the
following recommendations. I don\'t think I need to go through the
entire slide set today. If there\'s any need please ask me questions as
we move along the group should have the right to stop me as we run
through these recommendations and I\'ll touch on a few slides toward the
end here. I want to point out that the labeling of these slides may not
entirely coincide with some of the labeling of the appendices in the
letter to the AHIC and I\'ll refer to the documents specifically by
their name title.

1.0: the Secretary should adopt the minimum dataset to guide data
collection and biosurveillance programs that involve the simultaneous
sharing of clinical data from health care providers to authorized local,
State, and Federal public health agencies. We have as an attachment the
minimum dataset document that you should have in front of you. The work
of the committee was very intense. We used a couple of elements that
were provided to us in our direction to look at feasibility and
filtering of the data elements that have been provided in an earlier
version of minimum dataset for elements that would accomplishable in the
near term. That near term would be a one‑year period.

Next, to the next one, 1.1: by 2007, the U.S. Department of Health and
Human Services in collaboration with State and local governmental health
agencies should work with clinical caregivers to implement the
short‑term minimum dataset and enable simultaneous data access to local,
State, and Federal public health entities for biosurveillance purposes.
So here we\'ve outlined a short‑term, meaning less than one year, and
we\'ve defined that in our feasibility as what might be accomplished
within one year\'s time. And specifically look at the minimum dataset
document, the footnote on each page we have defined feasibility as could
a data element be transmitted electronically by 25 percent of reporting
facilities with currently available resources in the short‑term, less
than one year; longer term, one to two years; or not feasible, greater
than two years.

We\'ve tried to stick to the same short‑term and say within one year we
believe 25 percent of reporting facilities would be able to provide
these data elements.

Our focus has been throughout all of our work, whether it be here as I
present in the recommendations or if you look through the other document
called the functional matrixes, the prepared functional area matrix we
define things as well as one year to three year or not in our scope.
We\'re looking at things that might be accomplishable within a one‑year
timeframe. Part of the work we did was spend a fair amount of time
deliberating on what it would take to make these data elements flow to
set preconditions that will define feasibility and what should be our
scope of work as we set to come to conclusion about what the MDS would
be. I refer you to a document titled preconditions for deciding minimum
dataset elements, which has 18 different preconditions or guidelines or
assumptions that the committee had decided needed to be included in our
presentation to you, the Biosurveillance Workgroup and to the AHIC as we
move forward to make this presentation in the next two weeks.

I\'ll move forward, unless there\'s questions, I\'ll move forward to the
next recommendation, Recommendation 1.2. That is by March 2007, the U.S.
Department of Health and Human Services in collaboration with State and
local governmental public health agencies and clinical care partners
should evaluate implementation models, costs and determine availability
of resources and establish a plan to effect a short‑term minimum dataset
implementation. We believe there\'s still much work to be done. We have
defined the MDS but we have also uncovered that there are multiple
implementation issues. Costs are addressed at the end of the MDS
document. If you flip to the end of that document you have a brief
description of some preliminary estimates which need to be more fully
explored. Our task was not to define the burden of implementation but we
know that that still needs to be defined and more fully understood and
to best define cost‑effective strategies to maximize the output and
minimize its impact on healthcare providers and clinical care partners.

While many facilities around the country may be able to quickly adapt to
these MDS reporting needs, others are in their infancy in terms of HIT
adoption. The challenge for some providers may be enormous. Finding
resources and creating a comprehensive plan that may involve some
incremental progress should be a priority if the MDS and the
biosurveillance system is to become a reality. So I just think that
it\'s important that we share our collective knowledge. We were
concerned while we were trying to do the minimum we still saw that this
was quite costly and heard that from our expert testimony as well when
we asked for advice about feasibility and filtering.

Let me move on to the next recommendation. The Recommendation 2.0:
public health agencies and partners who implement the short‑term minimum
dataset should filter out some components of the following data elements
as appropriate. That\'s date of birth, age, ZIP code, diagnosis or
injury code, and laboratory and test procedure codes and all of the
details of this filtering are included in the MDS document. We feel it
necessary to do some of this filtering for privacy and to maintain a
clear purpose why it were collected and not expand it beyond the purpose
what was our charge for purposes of biosurveillance. And I\'ll just give
you some examples here. In terms of date of birth, in terms of
confidentiality, we figured it would be important to limit potential
exposure and remove the day and date of birth so month and year would
remain. For age, in certain age groups in certain areas of the country
in ZIP codes where there are a limited number of elderly individuals you
might be able to determine who that person was. We might say instead of
giving exact age above a certain age, for instance above 85, that might
be the point where we say above 85 rather than saying this is a person
who is 92, where there might be only one person who is 92 who lives in
that ZIP code. It may that people live in very sparsely populated areas
rather than use the five digit ZIP code, which might be fine in urban
areas, it may be important to limit to smaller bits of information,
restricting it to only three ZIP code characters for some geographic
regions.

I think I\'ll skip over the other two. You can read them. Just to give
you a flavor of why we think the filtering may be important in
proceeding with a minimum dataset. Lastly, our last recommendation is
that CDC no less than annually involve local, State public health
agencies and clinical partners in a for biosurveillance usefulness and
to make appropriate modifications as evidence develops to support such
modifications.

We figure that due to the potential expense and the potential need to
expand this effort over the long‑term, if we\'re doing this
incrementally, there\'s a need to reflect on what has been learned.
There\'s a need also to synergize with the broader Nationwide Health
Information Network efforts going on around the country. And a
structured evaluation should be undertaken by a Federal agency and the
committee suggested that CDC be the one who leads this as qualified
entity but that they should involve all of the stakeholders, including
other Federal agencies and other partners across the healthcare
spectrum. There may be modifications that need to be made. We should
take advantages of the lessons that are learned rather than proceeding
and continuing to make investments or putting undue burden on healthcare
partners who have yet to invest in it in the early stages of this.

So rather than running through all the slides, you have much information
in this slide deck. I think I\'ll just move on to just one visual which
is the 12th slide in the deck if you could proceed to that one, and just
point out the process that we used as the committee did its
deliberations. As I mentioned earlier we received a minimum dataset from
a variety of resources, potential sources around the country. We sought
expert testimony. We used, with Ed Barthell and Eileen Koski, the work
of the HITSP and had a direct line into the work the technical committee
has been doing the last several months. They helped to facilitate an ad
hoc group who provided us with a gap analysis. We used in our planning
five of the national planning scenarios of 15 as examples rather than
trying to burden everybody with trying to manage 15, but took five
examples, all of that is pointed to in the appendix, and then looked at
a document that John Loonsk and Laura Conn published that are required
in the Public Health Information Network and just general preparedness.
We scaled it all down through the work of our committee members and
through multiple meetings, to the minimum dataset that you have in front
of you which was refined looking at the minimum data elements, a
classification as to their feasibility and filtering and defined
although this slide says 17 as I mentioned there are 18 preconditions
that were defined by the committee and we have two ancillary documents,
one that you do not have in front of you, a functional crosswalk and
then the other document that really took the 33 functional areas and
boiled them down to seven that we thought that were in our purview or
the immediate scope for our committee. So I think I\'ll stop there and
see if there are any questions and allow the committee to proceed with
the rest of the meeting.

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

Are there any comments or questions for Art for the presentation or the
work the group has been undertaking in order to get to this point?
Hearing none the plan is to have this work presented at the AHIC meeting
on the 31st with the endorsement of this Workgroup.

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

Laura, I actually don\'t have a disagreement here but it\'s a matter of
context. And I\'m little bit concerned because I don\'t think that most
of the members of AHIC have the context that we do. And so I was looking
at the draft letter and what I think is missing there is it\'s implied
but not stated that the biosurveillance is in a sense emerged overlaps
with the current system of disease reporting. And what we don\'t want to
have happen is someone to think we submitted this stuff to
biosurveillance so now I don\'t have to issue a report on this person
with syphilis. And while I think I see everybody here in the room
nodding their heads, I don\'t see that being more clearly described in
what we communicate to AHIC. And I just think it needs to be embellished
a little bit.

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

Thank you. I think those are great comments and you\'re right we all
have a context where this came from and how it might fit in, although
we\'ve had those conversations in the Workgroup and are, please speak up
but I think we can add some context to the background part of the letter
to the Secretary.

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

Maybe what I\'ll do is make that point even in the oral presentation. We
have it all built into these preconditions, and I did not want to take
your time to review some of these, but thank you. If there are other
points you think in particular that need to be included please point
them out and I will prepare my testimony accordingly.

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

I think the corollary this system is not meant to be a comprehensive
system that replaces all the work that public health folks do in
investigating a potential outbreak. It\'s an adjunct to that.

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

Correct. Thank you, Ed.

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

This is a task we\'ve wrestled with, and you\'ve done a masterful job in
putting it into something we can work with.

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

I had a comment here and a question about logistics on how the data, how
you perceive the data flowing. Part of this goes to what John said
earlier. Are we going to ‑‑ is the laboratory reporting, was this going
to go through the NEDSS system or is this going to be a separate
reporting to BioSense and to NEDSS.

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

I don\'t think we presume we knew how things were going to happen and
that\'s why we have the recommendation that we look at implementation
models. I mean there are a variety of models it can go to NEDSS, some
source, it could run through BioSense. I don\'t think we have, I don\'t
think that was our charge. So we don\'t have an answer to that. We think
that needs to be addressed next. And that\'s why we put that as more
immediate concern to be achieved by March is to define precisely how
this is going to work. The national laboratories want to do it. One
source, or to 50 States. I think there\'s much that needs to be defined.

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

Okay. My second one is kind of a clarification, because I see two, I
always get confused with the wording here, because this is
biosurveillance. A lot of what we\'re collecting is for outbreak
management afterwards. In fact the ones that are more expensive are at
the outbreak management end. I didn\'t know if presenting this it would
be good to highlight those differences a little bit.

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

That\'s a good point in the preconditions I\'m hearing I need to
summarize the preconditions to provide a context, because that is one of
the elements here listed as number four in the preconditions document.
So I\'ll prepare my statement to include that as well, thank you,
Roland.

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

Comments from other Workgroup members? Thank you, Art, for the hard work
your group did in order to get to this.

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

I want to thank the group again and the experts, in particular ONC for
putting forth the effort. We would not have gotten this far without a
lot of hard work by many people. So thank you for your trust in the
group and we look forward to an opportunity to present this to the
larger committee and community. Thanks Laura.

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

Proceeding with our agenda, if there are no more comments on the work of
the Biosurveillance Data Steering Group work ‑‑

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

I\'m sorry, I do have a comment mostly on the preconditions. On the
second page where it\'s talking about local health departments will be
involved with the biosurveillance and working with local health
departments, I want to be sure that the leadership role of the States
are captured somewhere in this document. Maybe I\'m missing it. But I
don\'t see it quite there, except you\'re using the ASTHO definition,
it\'s clearly a major role for States here.

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

Well, maybe we need to refine this. That was in reference to the NACCHO
document. But I will review this. It does say the multi-jurisdictional
approach, number ten.

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

I do see Federal, State, and local in there. But this doesn\'t roll up
the State awareness then forget about it. Of course I\'m a State
officer, so there you go.

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

Marty was definitely representing the State as was Steve Hinrichs in
Nebraska, representing a State perspective and ASTHO was at the table.
We can review this and see whether there\'s a need.

This point number 13 that you\'re referring to was because there is a
document as well from the local health department that we wanted to make
reference to as foot noted at the bottom of this document.

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

I think we can probably simply do that by saying at the end widespread
capture should leverage complex existing relationships between local
health department, local hospitals, and providers within the context of
a State.

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

Okay.

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

Okay. That\'s great. Thank you.

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

Okay. Thank you very much.

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

Great. Thanks. We\'re going to move on to item number six on our agenda
review and discuss the matrix for priority areas. I\'m told that Kelly
Cronin has now joined the group in the room. And I think if I can ask
you, Kelly, to walk through this and I\'ll chime in since I\'m not there
in person, that might be easier.

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

I think what might be the best use of our time today is to ask if
there\'s any points of clarification on what we\'ve added from
everyone\'s comments and then sort of touch on our ranking sort of what
that ranking means and then we can proceed on to the visioning, because
I think that\'s where we want a lot of discussion to be focused to. So
does anyone have any questions or points of clarification with how the
priority matrix is being presented now?

I think from where we started a few months ago, it now has some really
good information that I think is going to help us when we get to
recommendations over the next few months. Okay. What we heard with this
last round of ranking is that case reporting is most important to the
Workgroup. And then we had a very close ranking between bidirectional
communication and emergency response. And with some clarification from
an outstanding vote it looked like bidirectional communication was
coming out just above emergency response. As the number two priority.
And then number four was adverse event reporting. One thing I think we
need to keep in mind is while we\'re trying to present on the 31st some
priority areas to the AHIC so they can consider not just with actually
public health but across all the Workgroups they\'re working on, a few
of which involve secondary use of clinical data, how we might be more
fully understanding what all these individual priorities are but how do
they actually compare across Workgroups. So I think when it comes to
infrastructure development and making recommendations to the AHIC,
we\'ll be able to have more of a cross‑cutting perspective and see where
there might be some synergies, particularly for us as it applies to
secondary use of the data. So I wanted to just give you a little bit
more background on how this information will be used to inform the
discussion on the 31st. And actually at the end of today we\'ll be
sending out a summary, a narrative of what we\'ve already worked on with
this matrix, and be explaining that we have these four priority areas
that will not only allow us to focus some of our activities over the
next year in getting additional testimony and deliberations and
recommendations, but this can be considered in the context of all the
other Workgroups' priority areas and developing some use cases and the
infrastructure development.

So does anyone have any questions about our process or how we came out
on that? Then I think we\'re in great shape to start on our visioning.

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

Kelly, this is Lisa at FDA can I put in a plea whoever knows what the
phrase "automated drug recall" means if they can call me offline, we\'d
like to know what that refers to.

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

I think in previous public meetings Lisa we talked about the example
when Vioxx was pulled from the market and there\'s CPO systems and some
provider information systems that have the ability to automatically
handle their inventory and when an order is placed electronically, they
can have the right alerts and ability to let clinicians and pharmacists
know that the product is no longer available it\'s recalled.

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

This is like the system that Hopkins is implementing. That\'s what the
one we thought. Thank you very much. No we want you to participate. I\'m
glad you\'re on.

So I\'ll turn it over to John to lead the visioning.

**\>\> John Lumpkin:** This is a followup to our session at the last
meeting. And you will have, you\'ll notice in your packet a document
that is entitled "Draft," which probably doesn\'t help you much but
after the word "Draft," it says "Description of Current Intermediary and
End States for Biosurveillance."

As we look into this, I want to put it into context the kinds of things
we\'re going to want to do over the next period of time and then talk
about that in a little bit more detail when we look at the workplans for
the rest of \'06 and \'07. Ultimately if this environment is going to
work data is going to have to flow in ways that it currently does
generally in paper, if it does at all. And in order for that to be
developed the issue is various items, data standards and other kinds of
pieces of work, have to be done. There\'s a very complex relationship of
how data flows between public health and with the vision of
bidirectional flowing from public health to the clinical setting, people
building current electronic documents in the health environment are not
thinking of aspects of case reporting, disease reporting, emergency
response, and bidirectional will make decisions that will have
significant implications making what we\'re trying to do much harder.
Ultimately we\'ll end up with not only the vision of what it\'s going to
look like, how it will be accomplished, but also what the barriers and
enablers will be. As we develop this list we want to get as much
feedback certainly from key organizations that will be playing a role in
this new environment.

Having said that, what this document that you have before you has done
is take the four areas. Case reporting, bidirectional, and emergency
response, and adverse reporting. And put them into the context of what
could we expect to do within the short period of time, 2010, and what we
can do in the end state. I think we\'ll start off by ‑‑ we have listed
here that we\'re going to start off by talking about the current, the
end state. But maybe we should just run down the current state so we\'re
all in agreement that that\'s the way it is and there hasn\'t been
anything missing, and what I\'d like to do is as we go through to walk
through case reporting through the current state, the end state, and
then work our way to the mid-state. Then if you\'ll notice the document
will go through all four areas, and at the end we try to pull together
some of the enablers that sort of cut across all four domains of areas
and then the barriers. As you can see, we have a lot of work to do on
the barriers, because I think we can all agree there are more than three
dot points.

So unless there\'s any disagreement, let\'s pay attention now to the
issue of case reporting, which identifies notifiable diseases national
notification system and we have a system where what would be reported
under infectious diseases is developed in a collaborative fashion. Those
that don\'t have involvement the state and territorial epidemiologists
in coordination with CDC sort of reach an agreement of what are those
nationally reportable diseases in a context that\'s not necessarily what
we would call as standards of development organizations, but it is the
current environment.

Do we have any comments or questions or concerns about the current
environment of case reporting?

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

I would make a comment as a practicing emergency room physician. Talking
about clinicians there still exists a lot of confusion certainly
there\'s diseases that are obviously, smallpox shows up or something
like that, but I suspect the actual percentage that get reported are a
small fraction of what really exists.

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

That was Brian Keaton from the College of Emergency Physicians?

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

Any other comments and by the way where there have been studies where
people have looked at that exactly what the data indicates. Any other
enhancements there? Okay. Let\'s go to case reporting, and as I\'m
looking on this, we\'re going to go to mid-state next and we build upon
to end state.

Under that we\'re talking about requirements and strategy for e-case
reporting. And this is a push kind of environment. So this is and I\'m
going to contrast where end state where it happens as part of decisional
support as an electronic health record so this is one step down from
that. A second reality in the mid-state would be that disease reporting
would be standardized so it wouldn\'t be something that you have to
learn State by State. The message formats and so forth for disease
reporting would be standardized. Post net, I think that what we would
want to say not only is it integrated into the network, but I think it
would be universal throughout all 50 States. Unless I\'m wrong, Laura,
that\'s still only a few, limited number of States.

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

17\.

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

That\'s the number we think.

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

Referenceable, I don\'t know what that is I\'ll find out what it is.

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

Does anyone not know what HealthNET is? Okay. We\'ll have ‑‑ obviously
we\'ll have to de-jargonize the whole document. For outbreak
investigation during a case, one item that\'s listed is to enable remote
secure electronic query between the public health systems for authorized
individuals and obviously we need to very clearly identify how these
authorized individuals would be not only authorized but enabled by
legislation so we\'re actually talking about a legal authorization as
most State and local public health jurisdictions already have. And
enable electronic requests for additional information. Just as I reread
this the second time I think the first bullet point ought to move over
to 2014.

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

Yes.

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

Depends on how you want to do it, it could be a Web‑based query that
would go to a select group of emergency departments and something like
that could be supported we do that with SARS reporting fairly quickly
with a very simple, it\'s not complex.

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

That was Brian Keaton again and I think his recommendation was perhaps
to bifurcate that so there would be an ability for there to be messaging
type query as opposed to an automated type query so maybe we would talk
about an electronic query system for mid-state and for the end state it
would be a automated system of query.

Any other comments under mid-state.

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

I\'m wondering for standardized disease reporting and harmonizing
definitions is that something that would require State legislation then
or are we talking more on the technical end? I\'m just wondering, this
is a little bit getting into enablers and barriers, but I think we need
to be thinking about what\'s realistic and how we might get there.

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

Maybe Leah would know this. In the States I\'m familiar with, it\'s in
regulation, which is not easy in itself to change, but I don\'t know
that there are States for which it\'s also in legislation. But, however,
just going back to my example in Illinois legislation refers to
communicable diseases. So if you have things you want to monitor that
wouldn\'t be in the rubric of communicable diseases that would be in
legislative changes. That would be in the area of a barrier.

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

In North Carolina ours is by rule we have a lot of flexibility about
that, with a commission that handles what\'s added and taken away from
the list but wouldn\'t this be a Federal legislative initiative that
covers all States? You wouldn\'t go State by State, would you?

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

That would be something that we should think about more as we get to
solutions, because I mean it could solve a problem but it also might be
very sensitive, you know. Unless there was real agreement among the
States that that\'s the solution.

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

This is Ed Barthell. I think ASTHO has a point to try to do that with
all the State diseases in one big spreadsheet with 50 columns. Leverage.
I don\'t know how far along they are.

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

I\'m sure they\'ll speed it up for us, won\'t they?

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

I\'m sure.

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

I think we have some other members of ASTHO from the Informatics
Committee. Anybody familiar with the status of that?

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

Anna Orlova (ph) to find the status.

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

I haven\'t heard from them. I wonder if ASTHO is the epidemiologists
that are doing that?

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

That may be I may have the wrong organization.

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

Sounds like a good idea, though.

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

We\'ll look at that. Larry, if you\'re still on the call, what\'s
Wyoming do? Is it reg or legislation?

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

I don\'t really know for sure. I\'d have to check on that one for you,
though.

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

Shall we move on to the end state? Now, Leah, I wanted you to know
because I\'m seeing "state" like 25 times now.

[\>\> Leah Devlin:]{.underline}

Thank you.

\[laughter\]

I\'ve done my job, then. Can I go home now?

\[laughter\]

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

Not yet. Okay, for the end state, it\'s everything in the mid-state plus
instead of being a generated report, this would be now built into the
decisional support. So the system would remind the clinician, as Brian
pointed out, a lot of times reporting is because people just don\'t
remember. I mean something rare and unusual, you say, hey, I need to
report and we found that out with anthrax, that that\'s more than likely
to happen. But with something that\'s of lesser rarity and perhaps more
common and what the data shows, they tend to be less commonly reported.
And there would be decisional support and direct reporting that would
then go to the local health department, the state where there is no
local health department and then the abstract would be shared with the
appropriate jurisdictions to allow ongoing surveillance. For
investigation of outbreaks, there would be integration with electronic
health records where case definitions would then be transmitted to the
electronic health records to be incorporated into the decisional support
algorithms. And then an interface with contact tracing and the
investigative process that would be engaged by the local and State
health departments as they try to nail down an outbreak by bringing
together disparate reports from multiple jurisdictions. So that would be
the end state.

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

I\'d like to make a comment that as we get into this we\'re going to
have to talk about the business case for public health and how all of
this might get realized by the health IT industry buying into the fact
that there\'s real public health needs and there\'s actually a market
for them to serve. Because as long as certification is a function of
more or less self‑policing it\'s really a private sector activity that
represents all stakeholders, but that it\'s really a function of the
market to drive adoption over time, then we really need to think
realistically about the place for public health and how we can make sure
that clinicians and healthcare providers more broadly understand how
important these particular aspects of software is or are.

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

And I think tying that in, the context of the business case may not, we
may look on building off for more than just disease reporting, because
there are other things that people in clinical settings are required to
do reporting. Adverse events is one that we have as one of our four
focus areas. But there are other kinds of reports that are required to
be submitted. So if we think about what are the context of an electronic
health record is the ability of that health record to enable the
commission to meet their legislative and legal obligations, then we
begin to make a business case.

I mean if you got to submit your bills, that sort of ties in. So I think
that we can look at it within that context and perhaps sweet talk
somebody at CCHIT to explore that for one of the later renditions of the
certification criteria.

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

So the legal requirements end up driving workflow and business
considerations, because you would want to have an efficient way of
meeting your requirements, in addition to meeting your public health
obligations.

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

Right.

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

I think the other extreme is something we need to touch on as well.
There\'s literature that exists about if cost of outbreaks. Certainly we
could bring the cost of the recent *E. coli* or some of the other things
that have happened and following along with the discussion that we had
at our last meeting, be able to give some prediction of how that cost
would be reduced with a system that was able to capture this and catch
it quicker, so we could show both ends of the day‑to‑day type activity
and some projection of major events and how we could you know give
significant advantage. We know those events will occur, we just don\'t
know how often or how severe.

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

In those types of analysis, it would be particularly helpful to
understand both the \[inaudible\] perspective and perhaps the employer
or payer perspective so they know the people who are paying a good
portion of the bill of healthcare can understand how this is adversely
impacting them as well.

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

It would be easy to discuss for years and years the economic impact of a
hurricane hitting New Orleans, but until it hits, you really don\'t
appreciate how much benefit there would be to avoid it. If we can focus
there\'s a big end event to this bioterrorism and terrorist attacks like
that, there\'s a day‑to‑day case that can be made as well and we can
address those ends.

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

I\'m going to put a plug in here for the RWJ. We just pretty much
completed a grant looking at health information exchanges in Indiana
trying to get public health development, when you talk about those
issues that way it doesn\'t seem to be an issue to get public health and
AHE together and discuss what their needs are and probably the biggest
group that everyone wrapped around right away was the indigent care
population. It\'s a big expense for the community. It\'s something that
everyone wants to address public health, the health information
exchange, and all the community partners. And that to me was the big
thing we found out. We had six local health departments in their
communities and in a State meeting and that was the one common
denominator in every of these communications and organizations sharing
information and brought everyone to the table and everybody saw the
business case for it right away. And it was like everyone bought into
it.

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

And one more example. When I was in Illinois, we were exploring some
electronic reporting. We had a meeting with one of the large
laboratories, and we found out that they employed two full‑time
equivalents to take their, who took their report at the end of the day
printed up hard copies and wrote them down on the forms that they mailed
into the health departments. So you know the business case for an
electronic kind of system becomes real clear for someone like that.

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

I had a question about the end state case reporting, when we talk about
providers getting their little algorithm that notifies the provider,
does that also, and the clinician it says here, is the lab, does that
need to be part of that or is that just so electronically already dumped
down into the EHR, that you really just mean clinician or do you mean
clinicians and labs? Because we get a lot of reports from the labs.

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

I think you\'re right we need to add laboratories in there. And both
outbreak and case reporting.

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

I want to say this is a nice segue now to bidirectional communication
because we talked about the sticks we can put in place and educating
people, the clinicians, not necessarily the big thinkers like Brian,
that don\'t appreciate the big picture societal view. They may want
something that helps them in their day‑to‑day life. If we can
communicate, alert better help those folks in their everyday life, they
may be more likely to help us with submitting that data.

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

With that segue to bidirectional, let\'s move on. These are technologies
to support bidirectional communication to try to get away from an
environment where everything seems to go to the State or local health
department and nothing ever comes back, and except when they really,
really want something. In the current environment we have the alert
health network where many States are trying to get clinicians on e‑mail.
E‑mail to professional organizations by specialty, where there are sub
sets of the entire list of physicians that may be part of a notification
system. The system of incorporating drug recalls into CPOEs and other
systems within that, which we\'re shorthanding for automatic drug
recalls. The structure ‑‑

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

That\'s not the letters we get in the mail that say stop \[inaudible\]
they come from the manufacturers.

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

Efforts in both those respects to communicate with the \[inaudible\]
automated way and a communication \[inaudible\].

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

Right.

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

If you didn\'t hear that that was John Loonsk who is here but sort of
\--

The FDA structured product labeling, Web‑based communication,
collaborative forms. And e‑mail, Web‑based electronic message to send
alerts. That\'s sort of the current state.

The mid-state is that we will have completed the process of establishing
contact information and having those coordinated at the State level. And
within larger jurisdictions those directory exchanges will be
standardized. And I think within that context is it\'s reasonable to
think about a concept that we don\'t always have in public health but
certainly between, teaches us a lesson about it which is mutual aid,
which if you have a system of, that\'s set up, and it\'s running out of
Baton Rouge and New Orleans and all the power is out for a week, who is
going to notify the docs in the rest of the State. That\'s sort of
thinking about the network in more than just the State context. Linking
the regional and State-based systems into integrated standards space,
national network. This kind of thing would include, you know, when we
look at the biosurveillance committee report and it looks like
generating standards for how a hospital reports their status and the
patient that creates the basis for States initiated data in a structured
way as well as a Federal level to roll them up where as how you code for
hospitals can be done in a standardized fashion, and across the
pre-hospital environment into the public health domain.

Development of a Web repository creating links between clinicians and
public health to learn lessons learned and following up from the
experience, for example, SARS, where all that was linked to a national
basis. Look at pandemic flu, experiences as we\'re doing the planning,
the prototype for doing that in the context of national communication.
And creating a central area, repository for standards and messaging
formats and so forth. And that\'s the mid-state. Are there things that
we think, are we comfortable that everything can be done within the
context of 2010? I\'m seeing nodding on this end.

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

I was wondering at what point you want to talk about the how.

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

I think that\'s when we talk about workplan.

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

All right. Because I know in terms of enablers and barriers there\'s
probably a lot of things we really would need to address to make sure
we\'re reality based.

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

Do you want to say something about if work that we\'re doing now in
terms of better availability that I think has diversion and ambulance
diversion, this closure-type monitoring that goes on in about 40 percent
of the Nation\'s emergency departments now. I think there\'s leverage
coming off those existing facilities. Ed knows more about that than I
do.

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

Yes that\'s where the whole half standard comes through linking multiple
systems together for common integrated view that you can look at Federal
level, State level, local level.

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

I think the how and the what would be done in the mid-state region is to
recognize that this is a national issue and really to begin to convene
people who are working on this across the country and reach some
agreement. Maybe one of the hows is to look at into what extent the role
CDC has played in helping develop standards in the non-clinical setting
of trying to get common agreement upon standards and using those
standards as a way to generate compatible reports across jurisdictional
lines.

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

I think that\'s a good point because I think that HHS and across the
Executive Branch, the emphasis will be more on the Health IT Standards
Panel and to be recognizing standards not just for clinical care but for
public health as well. I think one of the enablers can be having
harmonization across political care and public health in order to have
some of this happen.

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

They can\'t hear you on the phone.

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

Improved operability standards that HITSP has just advanced there\'s
reference to have standards and there is a need to map them into HL7
messages so they can bridge between some of the different communities,
but I think it\'s very much under consideration and has a track forward.

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

Immunization records were perhaps the earliest models for that one of
the earliest HL7 messages for communication was developed.

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

I don\'t want to get off course, but the emergency responders use case
that\'s being created, how is that going to feed into the process here?
Clearly there\'s overlap between what we\'re trying to do here and the
activities that are going to be probably be driven by the active use
case, do you know how that will play out yet?

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

There\'s every intent that that use case would feed into the overall
agenda, could, would be then mapped against for example at HITSP but in
terms of architecture considerations to make sure that it\'s indeed
compatible with the previous activities that have gone on. And feed the
whole system. So it is bringing in some new areas beyond that of
biosurveillance obviously in terms of emergency responder needs but
there\'s definitely some overlap as you\'ve pointed to as well.

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

The other thing I would suggest is that as we look at communities we can
learn from, I suspect if we engage our friends in the fire, police
communities in terms of the way they respond to local events and are
able to maintain communication, mutual agreements, things that we talked
about, that there may be things we can learn as we start to look at
scalability and expanding the focus of what we\'re doing here. It\'s
another one of those hows and not reinventing wheels.

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

The title of the document implies that we\'re thinking broader than
preparedness and communicable disease. Is that the case or is it really
communicable disease surveillance?

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

Well, the broad charge is really real-time public health surveillance.
So we can define public health surveillance as we think is appropriate.

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

Maybe a larger discussion, but certainly even some of the registries,
the surveillance seem to be missing obvious one would be injury
surveillance.

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

I think that ties more into the last area under case reporting.

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

Yes, potentially.

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

I think that\'s a good comment for case reporting, because if we\'re
going to build a business case it ought to be wherever case reporting is
required. And we talked about that last meeting about including there
are extensive case reports required for cancer register. To the extent
that\'s automated it decreases the cost of, you know, to individual
providers who are required in most cases by law to submit those reports.

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

Just to follow up on that. I think there\'s on the back of the document
a footnote that talks about registries.

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

That\'s what I was referring to. There were a few that were missing.

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

It starts the list and there are others. But one of the comments I was
going to make when you actually got to another part of the document, I
think when we talk about registries throughout here, we need to,
sometimes we footnote it. Put number two beside it so you\'re talking
more broadly than immunization registrations and sometimes we don\'t. I
want to make sure we\'re always looking at all the registries, maybe
more appropriate than others. But I guess that\'s a call that would be
made at the situation at hand.

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

Feeding off your comment, I\'m just wondering if we maybe need to change
the nomenclature of registries and put a modifier on there. The reason I
suggest that is there are disease registries for asthma and diabetes,
which are really therapeutic registries and these are more public health
registries, if we put the public health before that on the document it
would become more clear to people who are more in the clinical treatment
world than not in our world. Does that make sense to ‑‑

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

Or population registries, that\'s fine.

[**\>\>**\
]{.underline}There are some asthma, lead, other things more critical but
they\'re in public registries also.

\[multiple conversations\]

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

Population health, public health. It\'s very, there\'s a lot of
overlapping.

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

In terms of these registry discussions, I think here we\'re trying to
look at registries in a very broad sense. It gets back to I think one of
the comments about the business case. You know, there will be registries
developed for therapeutics, there will be registries developed for pay
for performance and for public health needs, and if we segregate them we
may be losing an opportunity to find a way to leverage the business case
support of public health registries.

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

We had the same discussion yesterday in New York at the Connecting for
Health meeting, as we started to sort these things out. And the
conclusion we came up to is they\'re all the same data, it\'s a question
of where you direct it. So that our feeling was not to focus on which
registry but focus on a population and the data and figure out how we
can get that data to where it needs to be. And this would be one more of
those applications.

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

So we\'re going to continue to make sure that we, when we talk about
registries, we really refer to this, it does state that it\'s not, it
uses these as examples, not as a complete list of registries. I think we
could say registries serve many functions, for example, immunization or
something that may help us.

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

If I could beat that up one more minute. It seems to me that we should
be, for example, I could save this comment from the response discussion,
but like all the end state response, we talk about integrating EHRs with
immunization registries. If we\'re talking more broadly than
communicable diseases could be we could be looking at environmental
impact on disease down the road, I do think it needs to be generic
throughout the document, to be appropriate. Immunization and appropriate
registries, there may be others we don\'t have them created yet. We want
to make sure that the EHR is linked to all the registries out there.
That\'s what I think.

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

Uh‑huh.

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

I think maybe we missed the point of the previous speaker that it\'s not
about the registries at all, it\'s about the information based in the
registries. So it\'s probably more about standards as opposed to
registries.

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

That\'s okay but I know some policymaker is going to read this and say
EHR is to be linked to the immunization registry. We don\'t want them to
miss the point that there\'s other reg industries out there available
uses maybe yet to be determined we don\'t want them to miss that. It\'s
just data. But I was thinking ‑‑

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

I think it\'s about linking the data with the EHR.

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

I agree. But it\'s all the registries.

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

Getting back to a question John posed and we had sent out to you all,
this is Kelly Cronin, I think in the end state, when we describe our
ultimate vision, we would ultimately like to have standards-based
exchange and certainly having data moving from clinical care enabled by
an interoperable EHR going to all different, whether it\'s a registry,
whether it\'s various levels of public health, it ends up in the right
hands, the right public health people. But that we probably also need to
think about in terms of making steps to get no that end vision, what are
some important opportunities that we think would really meet the needs
of public health, also deliver some value to clinical care.

And getting back to John\'s question, what would be the top ten case
reports that we\'d like to see let\'s say in the next few years, be
automated through electronic health records. Certainly ultimately we
want all data to go to registries that are relevant. We probably need to
think about what\'s the incremental plan.

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

So should we think about then, since we\'re kind of drifting back up to
the first one on case outbreak, investigation or case reporting, would
we want as a mid-state, that the top ten reports would be automated as
sort of a mid-state and then by 2014 that we would have them all
automated.

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

I\'m not sure that\'s an optimal number given nationally reportable
diseases and how many are there, versus ‑‑ certainly one has to be
progressive in terms of incremental in terms of thinking about it,
whether that\'s the exact number or not.

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

Depends on how we define them because I was thinking of nationally
reportable notifiable diseases would be one.

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

I was thinking the same thing really not case, not top 10 case reports
but top 10 public health reports.

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

That clarifies.

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

Immunizations would be too, we don\'t know what the number is but some
number. So back to bidirectional. For the end state, this would be 2014.

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

Just to drop in, couple of the other Workgroups felt 2014 is not going
to be the be-all-end-all state because we won\'t have realized the
transformation that we all want to see happen. So I don\'t think we
ought to be bound by numbers with that state. We probably should be more
concerned about where we want to end up ultimately in describing it.

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

Okay. So we\'re going to use 2014 as the mythical date by which
everything \--

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

I think we agreed to 2014 because that\'s the date that the President
set when he said every American would have a electronic health record
that they controlled. And it was easy to pick that date because it was
already decided that would be the future.

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

That\'s exactly right. I think that\'s why we started off that way and
it just so happened that two of the groups thought well we\'ll be
probably be passed the mid-point or right at the mid-point where we have
most Americans having access to a personal health record but we\'re not
going to be at the 99.9 percent with having complete interoperability
and appropriate exchange of data across every setting of care for almost
every patient.

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

Maybe the compromise on that is let\'s stay with the 2014 date, because
my guess would be by 2014 there would be enough people who have
electronic health records and personal health records that we will be
able to understand what\'s going on with the population. We don\'t need
everybody to report.

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

Medicare in 2019, so let\'s aim for that.

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

So I think for this Workgroup it may actually work better because I\'m
not sure what that number is. But it\'s certainly not 100 percent. My
guess anything over 50 percent is going to better than what we have now,
it\'s going to be hard to fathom what we\'ll do with all that good
stuff.

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

So unlike those other Workgroups, we\'re not going to get hung up ‑‑

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

And we really shouldn\'t. I didn\'t mean to suggest that.

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

Bidirectional communication, outbreaks outlines or warnings are
disseminated to EHRs. Outbreak investigations, laboratories are notified
to expedite suspect cases. This sort of bleeds over to response
management but updates the decision of support algorithms based upon
public health case definitions. So that what that means is that you know
most physicians don\'t know how to treat anthrax. And their EHR may not
have that in there because the data is going to be old. But as we learn
experience in an outbreak how best to treat anthrax, that can be
disseminated out into electronic health record. It can be part of that
decisional support.

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

I would say in near-real-time. It\'s not something that\'s sent to the
manufacturer, circulates ‑‑

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

Okay in near-real-time. Finally make reports available to commissions
based on information reported in real-time. And let me give an example
this is one I\'ve always wanted to do but couldn\'t do when I was in
public health, but every laboratory does culture and sensitivities. And
you could envision a real-time aggregation of that data. So that a
clinician can click on not only where in their treatment ZIP code as
well as the patient\'s ZIP code, what the natural flora would have of
culture and sensitivity, enable them to make better guesses on treatment
management. That\'s an example of this kind of report that could be
developed by aggregating data that would be clinically significant.

\[audio difficulties\]

Okay other things for the end state. Are we ready to go on to response?
Okay. This area talks about, encompasses application support. The
management of either a major mass casualty event or illness or attack as
well as response to an outbreak, includes management allocation
distribution of medical supplies and drug products and long‑term
followup as part of that. So vaccine supply and distribution system
pharmaceutical stockpile management, automated immunization registries
which would, for instance, right now we don\'t track most adults are not
part of an immunization registry. If you\'ve got a vaccine that\'s going
to go across if age spectrum, we\'re out of luck. In trying to track
what we\'re doing in case we decide to vaccinate large segments of the
population for things like bird flu. As part of this, protecting first
responders so the system of distribution would recognize that they\'re
people who may be at greater risk, long‑term followup of those who may
be receiving drugs that would not commonly be used in clinical practice
but may have side effects that would need to be studied. And then
monitoring availability and utilization of facilities along the lines of
what Brian talked about earlier as being done for diversion of
ambulances. That\'s the current issues and state. So the mid-state on
response is that by 2010.

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

Let me jump in on that on the current state. Do we need to have some ‑‑
this is Brian ‑‑ some kind of acknowledgment or statement that we\'re
part of the bigger incident command structure in a feedback loop when
you start talking about DHS and the HHS and the different reporting
mechanisms that come in, is this some acknowledgment we need in this
part that we\'re partners of a bigger system of responding and at the
same time assessing the severity of the thread, the significance, and
finally deciding when it\'s over? There\'s things in place now to start
that command structure.

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

And there\'s gaps in those links.

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

Right.

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

I think that\'s a very important point. Looking at it from the sphere of
public health the assumption is that of course people in medicine can
only relate to the public health system and we know that\'s not the
case. Emergency management, most of EMS is outside of the clinical
system.

They frequently report to the fire department channels or other kinds of
emergency response systems so they cross the borders. So I think the
fact we need to think about this in a little bit more integrated fashion
not only integrated across public health clinical emergency management
but also thinking about the role of DOD both at the State level through
National Guards and reserve units as well as at the Federal level
through those as well as homeland security emergency response. I think
that\'s the piece that needs to be added here.

Mid-state. Standards to integrate medical supply with medical demand.
Something along the lines of the 835s, not the 835s, what am I thinking
about? The determination of eligibility, you know might be a good
example where there\'s a messaging standard to request eligibility or in
other words request supplies and ways to do bidirectional communication
on supply and demand both across the community and up and down between
the State and Federal and local hierarchies.

Track standards of responders and volunteers so essentially we\'re
talking about a registry for those ones and to the extent we may want to
incorporate those States that have already begun to develop, like in New
Jersey, a medical service corps which involves licensed practitioners
and interested volunteers who have already signed up and other States
are creating similar registries.

Interoperability infrastructure for prophylaxis and treatment and
implementation on NHIN.

Standard data exchange for tracking product distribution for
manufacturer and distribution to clinician. This is obviously something
that\'s of significance in the other sector. So we can build upon that.

Enable access to national systems by local, State, and Federal partners.
For use in surveillance and outbreak and response.

And I actually would word that differently you can see it\'s an
integrated system, where the data and the \[inaudible\] are shared. And
then expand immunization registry for results for management of
vaccinations ‑‑

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

The registry do you have the legal authority and capability to accept
vaccines they just haven\'t recruited the providers. The survey would be
\[inaudible\] and it was a small portion that didn\'t have the
feasibility of the legal authority.

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

I agree. They just don\'t do it. So it\'s doable.

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

It\'s doable.

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

By 2010. But in the sense it\'s not in the current state as opposed to
mid-state because there\'s things that have been to done to make that a
reality.

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

And unless you currently have the supply vaccine capability as well.

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

Most States it\'s interesting because I think they have the capability
but I don\'t think that the VFC program, which is where they managed
that, has been very well integrated into the emergency response system.
Kind of like parallel systems.

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

Lots of changes going on in the way it\'s orchestrated.

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

And then (indiscernible) and implement the earliest versions of systems
addressing the emergency response. So that\'s the mid-state.

Anything in that list that we think ought to get moved to the end state?
Anything missing from that list? Remember you\'ll have another swipe
feel free to e‑mail, send cards and letters, as we try to flush this
grid out.

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

Just to let everyone know, this is Kelly we\'ll present as much as we
can to the Secretary on the 31st. So it would be best if we do most of
our creative thinking at this go around then we can flush out specifics
as we go more to the recommendation phase, obviously. But today we\'re
hoping to get as many good ideas on the table as possible.

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

I\'m not sure how to fit this in but I think I need to say it maybe you
guys can do that for me. If we look at the use case of pandemic flu and
take it to an extreme where we have to go to some kind of social
isolation type activity, that may create new treatment areas or
isolation of gathering areas different than what we traditionally have
here. Do these necessarily address being able to get vaccination and
being able to get drugs, get the other things that we need through those
areas to that population? I\'m not sure if it fits here but there\'s
something in the back of my head saying at least raise the question.

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

I think there are a lot of really naughty issues under the covers of
what you alluded to that have been traditionally avoided in the context
of modeling for mass events. And those are practical issues that are
always, that you think in reality of the time, there\'s a large enough,
quarantine, isolation \[inaudible\].

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

Is there a need for us to acknowledge that, just allow that to stay with
that \[inaudible\]?

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

It seems to me it would be helpful in the early days of an event like
that if you could have some surveillance that said what States or
localities were undertaking certain community measures. What we have to
do is decide on what those measures were to fit into a dataset we ought
to be able to do that by 2010. I like that idea.

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

This would be monitoring system performance?

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

It would be monitoring social distancing strategies who is implementing
what. Like if I would be interested in knowing if New York was locking
down, then Virginia.

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

Closing schools, canceling events.

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

That kind of thing.

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

I get it now. One of these days I\'ll tell you a story about Missouri
and contaminated well water. But, yeah, I think you\'re talking about a
clearinghouse of strategies. And the truth of the matter is I don\'t
think it fits in here. It\'s something that needs to be done. It needs
to be coordinated. I\'m not sure that fits within the kind of
interactions between the clinical setting and the in the public health
environment as opposed to what needs to happen as part of management of
an event.

[\>\> Sherri McDonald:]{.underline}

And it occurs to me that while social distancing and large population
matters like that may not fit in here, what might fit in here is issues
of being able to track isolation and quarantine orders. From a local
level that would be really important.

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

I\'m sorry I haven\'t tracked the whole isolation quarantine thing
through here. But starting perhaps with the local isolation management,
which is showing itself to be critical in so many, in so many public
health events, whether, and you know, whether it be in the context of
keeping people in their home or larger-scale activities, you know that
at least it should be a place holder for that continuum and some of
those activities given the fact that it\'s one of the more powerful
public health tools.

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

For instance, from a local level wouldn\'t it be great as part of the
electronic health record that the primary care health provider knows we
ordered a particular individual to refrain from working in a particular
food establishment to avoid a particular diagnosis?

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

I think what we\'re talking about, and I don\'t know the words for it
because not only is it the issue of ‑‑ and I think it was Leah who just
commented a person who has a disease that should not be working in a
food establishment. There\'s one component to that. There\'s orders for
a quarantine. But let\'s suppose we were to think about a pandemic flu
environment and there was a lockdown order or something along those
lines. Who is taking care of the patient with diabetes who now doesn\'t
have any insulin supply but they\'re in lockdown order? There has to be
an interface between a public health system that\'s engaged in taking
extraordinary measures and extraordinary system and personal health
records that are looking at managing individual people and their needs.
That\'s kind of what we\'re talking about.

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

I think that\'s one part of it. I think it\'s just one facet.

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

To bring this forward it was eating at me saying we needed to talk about
it.

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

Let\'s put a place holder there. I think we ‑‑ systems design these
issues are being piloted on a local basis.

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

I\'m sorry, I can\'t hear this person.

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

I just want to say these types of systems are being piloted locally as
mid-state and integrated nationally as an end state for quarantine
alternative care site management and what were the other ‑‑ isolation
quarantine, maintenance, management.

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

So we have quarantine, alternative site, and what was the third one,
I\'m sorry.

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

Isolation, quarantaine, alternative care site management.

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

Management system and the mid-state is being ‑‑

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

Systems because it may be ‑‑

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

Systems.

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

I don\'t think any of these things exist right now.

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

Local and regional piloting and end state is fully integrated at the
national level. That gives us the place holder we need.

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

Anything else that we\'re missing on the end state? Actually go through
the end state?

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

I don\'t think so.

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

Okay. So in the end state, response integration of electronic health
records with immunization registries, interoperability between the
commercial sector supply chain and the national stockpile, implement
hospital bed capacity and resource monitoring.

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

Implement automated ‑‑

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

Okay. Right. Automated hospital bed and other resource monitoring at a
regional, national level. Integrate response activities with ongoing
monitoring. And ensure availability of granular data for each
jurisdiction and analytic at that time for entire outbreak.

Anything else we want to add into the end state for response.

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

This is where I was hoping that we could say integrate EHRs with
immunization and other appropriate registries.

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

Okay. So we would ‑‑ yes, integrate EHRs with appropriate registries,
for example, immunization and adding a couple more?

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

I was just saying immunization and other appropriate registries. I
didn\'t want you to have to list them all.

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

I was just thinking that if you really are worried about the person with
diabetes in the midst of a pandemic outbreak, then you need to make sure
that you\'re talking about chronic registries as well.

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

I would agree with Leah. It needs to say \"appropriate registries.\"

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

We have integrate EHRs, immunization registries and other appropriate
registries.

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

That\'s fine.

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

This is \[inaudible\] in Tennessee. With regards to the outbreak
management, things that are important on a local level on occasion is
the contact tracing, contact management, and the case management and
also the followup. And that\'s not reflected at all in the current
language. Yeah, I think that would go there last bullet ensure
availability of granular data for each jurisdiction. Granular data to
facilitate case management and contact tracing and analytic data to for
the entire outbreak.

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

That sounds great.

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

I want to be sure to putting things in end state make sure they\'re not
ongoing because in fact there\'s ongoing efforts in contact management,
contact tracing that are extant and that relative to airlines and
relative to just outbreak management, critical function, counter measure
administration to their ongoing efforts that are there and to look at
the commercial supply chain in the context so much of a significant
amount of it exists, and I do think that I mean I know that there are a
number of efforts ongoing around isolation management in the context of
you know it was actually proven in SARS to be very effective to have
bans on ‑‑ may not be fun to talk about but where people are put in home
isolation because of those needs and there\'s a need to track that
activity at some level because they\'re a threat to society. I just
wanted to make those points because I think we\'re teasing out all the
points. We may need to map some of those into the earlier stages as
well.

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

If it\'s agreeable as part of what we\'re trying to do in the next
couple of days to the extent that those of us here and on the phone
identify those items that need that are in the end state that ought to
be tracked into the mid-state and I think we did that on a couple ones
so far, but where we want to talk about some intermediary stage to
reflect the work that\'s currently ongoing.

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

I have another issue to raise. Is this the appropriate time? Well, the
notion of tracking patients, triaging, tracking, transporting patients
from different providers and different hospitals depending on what the
situation might be and then the other issue is dead bodies, linking to
the medical examiners and the mortuary system, is that out of scope of
this? We haven\'t addressed mass casualties and how we track people that
become a body.

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

That\'s really an interesting one, because there\'s a piece here for ‑‑
one is, maybe this is a bit radical, but under first, under outbreak we
would say there would be a nationwide electronic death certificate
system by 2010.

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

There\'s already been discussions. That\'s not at all unreasonable.

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

And I think by 2014 that system would be driven by the electronic health
records.

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

Okay.

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

Because most of at least the systems I\'ve been familiar with it just
means that there\'s a way for the State to collect it electronically,
the State and local jurisdictions, but that doesn\'t mean that the
information that\'s in the death record has any relationship to what was
clinically involved in this person\'s death and those of us who filled
out death records know exactly what I mean.

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

It\'s also a surveillance opportunity.

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

Right. So that\'s the reason I put it up at the top. But under response
the issue that I just heard mentioned is some sort of system to manage,
you know, to monitor and manage the availability of mortuary locations
by coordinating the dead bodies is something that\'s reality and needs
to be addressed.

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

Does that already exist in other disaster management activities that
don\'t fall under public health?

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

The DMORT systems in larger scale events do exist in this context. And
it\'s another area in exchange that need to be ‑‑ and integration that
would need to be considered.

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

So would this be a mid ‑‑ mid-state would be integration in the response
system the integration of the public health and clinical response system
with the DMORT.

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

Capacity at the State and local level.

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

Right.

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

That was the DMORT piece, we helped with Mississippi\'s situation. And
what happened was patients got triaged on occasion more than six times.
We couldn\'t ever find where someone was to inform the family or even
keep the record with them and that kind of thing.

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

That\'s the emergency response?

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

Yes.

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

Case management and emergency response and put in RFID and everybody as
they come by.

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

Tracking triage.

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

We reserve that for certain people.

\[laughter\]

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

Bar coding.

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

I mean this is an area that the emergency responder EHR is targeting.

Do we want to mention that as part of the mid-state, emergency response
to EHR or EHR like? I think we mentioned it on there.

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

It\'s on there. One of the statements that came from \[inaudible\].

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

I do like the integration of the DMORT.

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

Part of the use case.

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

I think we have them covered. It\'s a whole page just dealing with the
dead people. Anything else on the end state for response?

Adverse events. Supported through a variety of avenues that include
stuff that the FDA is doing with MedWatch, nosocomial infection
surveillance system. Medication errors through the U.S. medication error
reporting program. Medical errors for patient safety organizations and
some places in State government. That would be the current environment.

Mid-state, automated reporting of events from EHRs. Develop standards
for adverse events reporting. Consolidate existing adverse event systems
for standardized reporting process, and enabling EHRs to query FDA\'s
FPL structured property labeling database.

Any other things for adverse event reporting that we want to add in
there?

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

I think one of the things we used to talk, when we\'re talking more
about the list of six priorities was around data aggregation and data
mining. So the concept of doing analysis to look for safety signals in a
large database. It could be repositories or it could be registries.
There could be a variety of sources of that data, but it would be
perhaps just a large representative sample from clinical care where you
would be able to look at these signals over time. And I think a couple
of considerations are you would have to obviously have better
statistical methods, fine tunes, and agreed upon so you minimize the
noise of the false positives, but I think there\'s been a lot of work on
that in recent years. And if this clinical data does become available
over time to do that type of analysis you wouldn\'t necessarily have to
be or as dependent on just having individual reports, but to be looking
more over a population and looking for trends and you know signals
across or in a larger population.

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

This is why registries are not just a data issue. Because where data
persisted, how they\'re accumulated from a longitudinal record
standpoint, who has access and how, how they\'re defied, how they\'re
anonymized and how they\'re accessed are all critical to the public
health outcomes. And so there\'s some important concepts there that need
to be tracked through.

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

We need to capture that as a mid-state.

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

I think it has to be more of the ability to do signal detection and data
mining. At least on a regional not if a national basis and again build
the evidence base and know that it\'s something that does prove value to
public health. Because I think it\'s really, it\'s very much in the
proof of principle stage at this point.

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

Would the mid-stage be we have the ability to do it and the end stage be
that we automate it?

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

Yeah.

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

The question, though, is to my mind that that cuts across at least three
of the functional areas that we\'ve talked about. So one way to handle
that would be to pop it in each of the three and the other would be to
raise it up as part of a general intro and discussion about
across‑the‑board functionality that we would see in the mid-state. And
we\'ll do either one or the other. But we don\'t need to decide in a
group how we do that.

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

I would give my two cents for doing the latter in terms of making it
relatively prominent because it\'s one of the differences the way some
people think about patient-centric data versus the population-centric
data. If not this group, then who?

[**\>\>**\
]{.underline}So we will raise that to another level.

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

This is Lisa at the FDA. We completely agree with what Kelly and John
said. From our perspective the ability to do the kind of broad
population view of safety issues is much more likely to result in public
health improvements than adverse reporting from clinicians, although we
are working to improve that and that is important to us. The information
that we get from that tends to be \[inaudible\] it\'s voluntary
reporting and people describes things differently and we feel the
capacity to actually ask questions to aggregated data would, is a much
bigger win for the public than improving AE reporting.

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

I actually have been sort of on and off so somebody may have said this.
I think related to these comments, I think there\'s an important point
that should be made in this that there\'s a relationship in this and
healthcare quality. And you know I would hope that by whatever point it
is in the future, let\'s say 2014, that we can get a number of the
measures in the AHRQ quality report for example from these records. And
I think that overlap is important to state in this because I think it\'s
going to be one of the great benefits that\'s going to come from this is
that kind of quality, that kind of quality assessment. And I think these
comments all fit that. And I think the way the document is currently,
it\'s sort of the more traditional public health function, and if it
does, if as the capability improves to get this kind of information, who
else is it going to fall to other than public health to aggregate and
address these issues?

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

Here I\'m going to pause for a second for a point of information. One of
the other Workgroups of AHIC.

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

We just started a Quality Workgroup that\'s taking on automated
reporting of quality measures and they are wrestling with the concepts
around data aggregation. In fact, we\'ll probably be taking, having some
testimony around that very issue on November 1st. And I think that the
common theme which I think we talked about a little bit earlier of
secondary use of clinical data, is common across a few Workgroups. And I
think part of what we\'ll be discussing on this October 31 meeting is
what are those cross-cutting themes and how do we address them across
the board. Not only now in sort of our planning phase and some of the
early infrastructure development, but how do we over time make sure the
right set of policies are there to enable the right kind of secondary
use, appropriate secondary use and that you know we protect privacy. We
are doing this in a way that, you know, is acceptable to the public but
that we\'re meeting population health needs more broadly so not just for
quality or not just for what\'s considered to be more traditional public
health responsibilities but really population health as it relates more
broadly to the clinical care and how we view it for a variety of
perspectives.

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

Let me suggest that there are two areas of overlap, and that this again
may be brought up rather than under this particular area. And that is
that the approaches and the way that you want to look at data to
identify adverse events that may not be identified by the people engaged
in that clinical setting as an adverse event. You know, the experience
that was shown with Vioxx and all those drugs that were all of a sudden,
took large datasets to be able to identify that there was a trend here.
So that\'s one where there\'s overlap between what\'s done in quality.
The second overlap is a fair number of health agencies have I believe
responsibility for monitoring healthcare quality. And so I think we
should note those two overlaps in that the harmonizing the approach and
the architecture between the public health surveillance piece and the
quality piece is going to be an important task as the work of the
various Workgroups are then brought together.

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

I can understand this may be brought together but I think it\'s
important that we make the point of this ‑‑ it really is ‑‑ it\'s sort
of almost necessary overlap. And I say that because I just am concerned
that the public health functions may be viewed as more limited than at
least I think they are with the capability the \[inaudible\] are going
to expand.

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

What I thought the statement would say is that in many cases actually,
you know, I started out my career in public health regulating healthcare
facilities and monitoring care in nursing homes and hospitals. And
probably when I was State Health Officer at least about a third of my
staff were engaged in an activity. And it really talked about
integrating the two sides of the public health house that frequently
people don\'t think about that as a role of public health.

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

I don\'t want to cut off this topic, this is Ed, the general concept I
see I see people coming outside the \[inaudible\] that there\'s a lot of
stuff already going on. And I don\'t know that you\'ve identified in
this grid where there\'s problems with the current state. So either when
you present this or talk \[inaudible\] there\'s problems. You can add or
\[inaudible\] but there\'s already a lot of \[inaudible\].

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

I think we need to be really clear about our barriers.

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

That\'s exactly where I was going next.

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

So we\'ll have some discussion about the importance and role in quality.
Any other things on end state or adverse event reporting? Automated
prompting and filling of reports.

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

I don\'t know if this belongs in this discussion would belong under
adverse events or under the response management. But we don\'t have too
much in here that links us to mental health. And one of the systems that
is present in over half the States is the controlled substance
monitoring program, registry where you\'re trying to look at people that
get in trouble with their medications of course with I guess suicides
and those kinds of things or sometimes an outcome that you have to
measure after a major disaster. And I didn\'t know if that, if you would
want anything to be noted in that or in mental health issues, if
there\'s something else. But that is a technology system that\'s out
there.

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

I think that\'s a good point and I\'m thinking a footnote to clarify
that we\'re not just talking about, that we\'re talking about health
reports in the broad sense. And obviously where they make sense, it\'s
engaged in response, it needs to be part of the response when we talk
about health response it\'s got to be more than just drugs and bandages.
And I think it\'s probably best handled as a footnote in a number of
places. And it would be helpful if you could as we\'re preparing this
document to get to the AHIC make sure we\'ve got it in the right places.

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

Thank you.

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

We\'ll jump down if we don\'t have anything further for end state into
the barriers. I think that\'s the area where we need to do the most
development. And I\'m just going to talk about two of the barriers that
I wanted to add to this group. The first is both in the mid-state and
end state and that\'s privacy. If we don\'t address it as a barrier, it
will be a real big barrier. Although I don\'t know if barrier is the
right term for that. It\'s a disenabler.

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

Deal breaker.

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

The second one is the point that Kelly raised earlier which was the lack
of a clear business case. And maybe, let me rephrase that. Lack of a
clearly described business case. Not that we don\'t think there\'s a
business case having been described. Others that we\'ve thought about?

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

This is Sherri. And the two that I think or maybe three that I think
would be barriers are financial issues. That would be one.

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

Cost.

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

Cost, yes. And another piece is we have a number of legacy systems, how
do we incorporate those into how we\'re trying to do this? And the third
one is this is around workforce development, training and educational
background and that sort of thing.

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

Okay. Others.

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

Is it envisioned you\'ll be able to capture like the undocumented
aliens?

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

The question is raised. I\'m not sure they heard you so I\'m going to
say it a little bit louder, the issue of undocumented people living in
this country.

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

That\'s a barrier?

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

Well, it is if they, you know right now they tend to be invisible to the
system because they don\'t want to be noticed by the system. And if you
have an outbreak, that potentially could be just within that community
initially. That could be a fairly large barrier.

But it\'s good that you didn\'t raise something that was controversial.
\[Laughter\]

[\>\>]{.underline}

Relates to the confidentiality axis and things.

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

Another barrier is the episodic nature of public health emergencies and
the fact that information technology is not well oriented to episodic
activities. In other words, to have a usable public health
infrastructure, would you need to have it in place and being used all
the time, attention to public health needs is episodic based on the
emergency du jour or can tend to be that way so these things are in
conflict. So it\'s an effort to try to ensure that the adequate
infrastructure exists to sustain emergencies that are, that may not
present themselves that frequently.

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

Just to comment on, along that line, we spent a long time on the ER1
process looking at how you design facilities and processes within the
emergency medicine community. To deal with the need to rapidly scale up
by 10 or 100. One of the things that continued to come out was the
doctrine of daily routine. That is if you don\'t do something on a daily
basis you certainly are not going to do it as something new during an
acute episode. New routine in hospitals is you bring anyone to come work
in the emergency department to respond to disaster. The answer is don\'t
do that. You create environments where people who do that every day just
do more of it better and faster. And I think the crosswalk to here is we
need to build systems that are gathering this data and doing these
processes, even if it\'s not quite at the level of what we need at an
emergency that it\'s done as part of the routine and build in a
scalability. Instead of gathering data every 12, 24 hours we may make it
every 2 hours but it\'s the same process that people are used to doing
and the same people are used to do go it. I don\'t know how that fits
into this but it\'s a valid point.

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

I\'m going to try to put words to it and tell me if I\'m getting close.
What we need is a system that is in place and scalable. Rather than a
system that\'s turned off and on.

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

In place, in use, and scalable. And has to anticipate to some extent the
dynamics of a larger event whereby information flows and needs differ at
times as well. And that\'s partly where it gets complicated. In a
smaller event, the local infrastructure may be totally able to sustain
it and support it. In a larger event you\'re bringing in resources from
a variety of different areas, you\'re bringing in additional
capabilities and it just, and the information sometimes flows in
different ways than it did before or needs to flow in different ways.

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

What we need to think about in the implementation is what currently
exists that would be able to manage the system if it had the capability
to be more robust. So, for instance, when we were doing a lot of our
disaster planning when I was back at the State, we overlaid our disaster
response network on the emergency medical services system. Because
that\'s the way people were used to referring and who they were used to
work with in place. So we were every day using the emergency medical
servicing system, and in a disaster we would just make it more robust.
We can start to conceptualize this system as being very similar, that we
would use it, build it upon the currently existing systems of disease
reporting but with the conceptual design that it would have the ability
to be robust enough to handle the kinds of information that we think
potentially could clarify.

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

Other part that\'s corollary to that from the clinic standpoint this
can\'t add steps to the clinical process. Because those are the first
things that quit being done. This needs to be, when we look at the
overall electronic health record and future state of automating a lot of
the care processes or at least documentation in the care processes, that
this be a byproduct of care and allows the clinicians to go through
steps wherever possible.

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

Wonder as a standing eligible sort of step or enabler to address that
issue do we need to be educating CIOs as hospitals and hospital
executives more broadly about what are the requirements over time for
public health. It\'s going to ease your burden, make your workflow not
be disrupted, and through the procurement process and through the
implementation process, have them really look carefully about what
exactly are the reporting burdens. What do they want to be doing. I mean
there\'s reporting burdens from a quality perspective and from a public
health perspective. They need to be more fully aware of that across the
board. We\'re hearing certainly from the quality side that those who are
investing in the HRs don\'t have common requirements. They don\'t think
about it. So therefore there\'s no common back end to these systems.

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

I think it was Brian who made the last comment about getting it into the
workflow or maybe it was Ed. I can\'t tell. But I think.

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

We all look alike.

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

Got it wrong on both? I think one of the barriers is CCHIT hasn\'t
really incorporated some of the things into their requirements or the
way they\'re defining what an EHR might be, and following on what Kelly
was saying. To get it into the workflow, the EHRs need to be flexible
and adaptive. It\'s not only about scalability but it\'s about having
that bidirectional flow that allows for adaptation and change. So when a
SARS occurs, we can collect the right information rather than just say
we need to know about travel but we haven\'t got a way to do that or to
alert the person they should be doing something about travel.

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

It comes full circle to business case and business value-add. That what
CCHIT has focused on particularly in the first year with ambulatory care
record mostly a substantiation of what is and not what needs to be.
That\'s what they\'ve started with. But then really in the
biosurveillance and public health realm it\'s the hardest case to make
that it should be included because there\'s a heavy titration of vendor
and provider priorities there and not saying you\'re art in terms of
having the desirability there but when you get to the end of the agenda
there\'s a big issue about it. I think it\'s fair to say that public
health has not been very clear in terms of what their needs are and not
been coherent in terms of articulating them consistently or in a unified
way, and that\'s been part of the problem. So those things factor in.
But the big thing is if what you\'re comparing is not reporting now to
something else, which is the cynically the status quo, it\'s harder to
make the business case. If the case of reporting oh we can do this in an
automated way and it saves effort but you\'re contrasting it not with
the burden of reporting because people aren\'t reporting, then you\'ve
got a problem. And that\'s a barrier, that\'s an issue. It\'s a real
issue if you look at the amount of reports that actually done that\'s
part that will have to be thought through in the business case because
frankly the status quo for the amount of reports that have been done is
so dismal, that the pain of reporting is not perceived by everyone.

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

I think we touched on two important aspects of the business case that
might be things we can really advance if we think more about it. We\'ve
already pointed out that there\'s already this burden, much of it due to
legal requirements for public health and maybe it\'s not fully
understood by CIOs of hospitals and they know it exists but not tangible
to them. And we\'ve already touched on the fact there\'s not even an
understanding what the requirements are or not articulated correctly or
communicated. Those are opportunities for us, we can figure out how to
articulate the requirements for public health recording, make sure that
not only CCHIT understands that, but more importantly that more broadly
that major hospitals in the community hospitals and small rural
hospitals all understand moving forward what those requirements are, so
as they make their decisions they know from quality and public health
perspective what they can do and how it could be easier for them.

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

It was an effort to speak to each of the working groups of the CCHIT
around the use cases, and that putting the biosurveillance use case on
the road map at least for action. And that has been somewhat successful.
So that biosurveillance is getting on the road map hardest place is in
the ambulatory sphere where there\'s not the infrastructure to support
it I think this is where we to think about strategically looking at
network systems and how networks can play a role in facilitating that
because I\'m not sure ambulatory scare and individual docs
\[inaudible\].

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

As you carry that forward it also comes back to the value proposition.

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

Public health never gives anything back to those docs in response to
what they do send. So that bidirectional communication again it starts a
feedback loop and gives value to the clinician. We\'re into a circular
argument here. But I think the key from hearing this, this is a
visioning exercise. This isn\'t to say we know today isn\'t where we
want it to be. This is an opportunity to define where we would like it
to be in 5 years, 10 years, 15 years, something we certainly want to see
changed.

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

One of the enablers for this ‑‑

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

We can make all the barriers into enablers.

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

That\'s right. Is having a good business case.

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

For building on requirements and I don\'t think there\'s much public
awareness about the requirements of facilities and I suspect people
wouldn\'t be happy if they knew how poor reporting was. And I don\'t
think people say anything about how poor reporting is because of the
\[inaudible\].

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

The cost, if I\'m a State Health Officer, I\'m not going to, you know
harangue all the people who aren\'t reporting. I\'m going to thank the
ones who are through encouragement. But electronic health records get
established, the cost, the incremental cost to send the report drops so
dramatically that it now becomes a different environment. And I think
that\'s the kind of way that we need to craft it.

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

I agree with what you said and maybe this is implied in having a good
business case, but it seems to me that the business case needs to be
made not only for public health but with inclusion from our end stage
reporters. So one of the things in the e‑mail from Kelly Cronin in the
question, the top 10 list for public health reports so that we don\'t
have to bother clinicians, it seems to me that if we don\'t bother
clinicians we become even less visible than we need to be. So we need to
as part of the business case create some buy-in of clinicians so they
understand the value of reporting and that we do a much better job of
that bidirectional communication as you said.

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

This may be, as we are thinking about our next steps and taking those,
you know, let\'s build a list of top ten reports that you don\'t want to
be bothered doing and reaching out to all the professional associations
that are working within this process, is to ask the flip side of that,
what were the top ten things that you would like to see provided, where
you get information from the public health system. And then we can use
those to help build the business case.

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

This may be crazy ‑‑

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

We\'re visioning.

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

That\'s fair game.

\[multiple speakers\]

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

\-- is that we\'re trying to establish the business case for health
information network service providers. And these would not be national.
This is not a national backbone. This is networking activities that
occur at a State and local, State and regional level that interconnect
different healthcare providers in different parts of the system. But it
seems to me we should be thinking about ways that the business where
population health needs and public health needs can support their
business model because they\'re so well positioned to help with public
health needs. And so it\'s not just a one‑to‑one clinician to public
health issue here. We have to think about others that are going to be
intermediaries in this game and whether there\'s a way to realign the
incentives so that we can support those health information network
service providers even though so that there isn\'t a burden on
clinicians even though it\'s \-- the law states that the clinician has
to report.

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

But it\'s about supporting the clinician practice. It\'s not about not
bothering them. That frankly is \[inaudible\] if we\'re not bothering
them we\'re not involving them and we\'re not helping them at all.

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

The company is going to have to pay for the health information exchange
is what it comes down to. Either it\'s transactional-based model or you
have a monthly fee. These business models are going to be evolving over
the next couple of years and what will that mean for the local or State
or Federal public health agency? Do they pay? To that health information
exchange and what if most of them are on a regional basis?

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

General concept public health has a long history of not paying.

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

That\'s what I\'m saying we need to talk realistically about it.

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

Sustained funding to do that. So thinking about a triangulation ways in
which at least three different priorities and needs can be met through
that process. And I know that\'s what you\'re referring to, Kelly.

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

Let\'s go into the categories here. Current state is, the barrier
there\'s no intermediary to help the physicians with the burden of
reporting, and maybe the information health networks with direct results
delivery systems help take some of that burden off the individual
clinician to improve the percentage of reporting, is that what you\'re
getting at?

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

I think actually part of encouraging the intermediaries to create the
services necessary, I think we\'ll have to create some momentum from the
reporters, the CIOs and the end users to ask for that.

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

Another way of saying that can if I\'m a healthcare provider can I buy
into someone else doing my reporting for me?

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

I think what\'s going to happen is if pay for performance really comes
up to be successful or is in place in many communities these health
information network providers will be doing work for them. And what we
need to do is be on the coat tails for the reporting they\'ll do for
chronic diseases for outbreak management and case reporting, because
it\'s the same method.

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

Exactly, once you build the pipe you use the pipe for a multitude of
things.

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

This is another issue entirely, maybe we mentioned it and I missed it.
We do have the possibility we\'re increasingly litigious society
there\'s a thing such as reporting for your own protection. I can see
the scenario I don\'t know if it\'s ever happened someone went after a
physician someone got sick due to failure to report.

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

It happens in real life in the exact opposite way. At the local level we
get when there are particular outbreaks especially around *E. coli*, we
get subpoenas for records for people now that have reported. So it
happens in exactly the opposite manner.

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

That\'s very concrete before we lose this thought, just that that is a
major barrier, because it\'s data access and access to public health
data and it\'s on the confidentiality spectrum but it\'s about several
different groups who potentially seek data to use it for different
purposes, law enforcement is one, but there have been congressional
subpoenas. There have been obviously other aspects.

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

I know in Maryland once that data is reported to public health they can
deploy it. I mean it\'s no longer under privacy protection.

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

There are various protections around clinical data and private data.

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

In Maryland we have a legal case where it was actually determined in
court that it could be \[inaudible\].

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

Well, I think we\'re getting into the weeds here a little bit. And
we\'re working on a product that we will need to develop, I think, and
help flush out, which is thinking about the business case, thinking
about the privacy and the confidentiality barriers and how we\'re going
to propose ways to overcome them, but I don\'t think we need to flush
them out today on a Friday afternoon.

So can we think of other areas for barriers that we want to address
before we get into the enablers?

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

Clearly the data is more prominent in population in health activities
than it is in some areas. If you\'re standing multiple organizations
inconsistent data, this is just another reinforcer, inconsistent data,
data that are inconsistently accumulated or stored is a barrier.

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

I think another barrier is the low adoption of technology tools by
practitioners as well as public health.

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

Let\'s make those two sets of barriers. Since we\'re doing mid-state and
end state, and the mid-state it would be relatively low rates of
adoption. In the end state, because everybody will have had it by 2014,
that won\'t be a barrier.

Well that presumes that because there\'s adoption of EHRs that the local
public health has adopted it as well. The President did not state every
public health department will have a comprehensive HIT system in place
to mesh with the EHR adoptive rate.

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

We\'ll disaggregate that and put public health into both mid- and end
state, 2014.

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

Yes.

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

Here\'s another barrier, which is that whether it\'s a legal issue or
otherwise, that if any public health officials had viewed, had concerns
about knowing too much about what\'s going on because of the needs to
followup on all those things. This has been prominent in the
biosurveillance community because there\'s a fear that if they get data
that are of low, you know, of low specificity, so in other words you get
a high number of errors but you\'re getting a lot of data because you
get a lot of data are moving, a lot of possible events are moving and
they all need to be followed up on but the burden on public health to
having those signals, if you will, is very concerning.

So the specificity, however you want to phrase that the concern of
public health of being able to process all those possible events when
there are more data elements coming in and they\'re of potentially lower
specificity, they\'re not as sure that they\'re actually true
\[inaudible\].

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

Is that kind of who is learning to fly commercial aircraft in Florida?

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

I think it goes back to issues of workforce from the local level.

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

Well, I think there\'s three components here. First is the workforce
issue: does the public workforce know how to deal with the data that
they get? The second is, are data systems smart enough to be specific
enough to give public health the task that needs to be done
appropriately? So they\'re not doing non-value‑added work based on this
new data. And the third is, let\'s suppose that now we\'ve got a new set
point, because we\'re getting more data and we\'re better in discerning
what actually needs to be responded to. But the task demand exceeds the
capacity of the system to respond.

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

I believe it\'s incrementally, at least.

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

So I think you\'re talking about three components, one would be the
barriers, one we\'ve already talked about, and the other being as
specific as possible, and the third may be we may identify a weakness in
the public health system.

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

Ready for more barriers?

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

Yes.

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

Another barrier that I believe is a problem is the issue that in many
systems, whether it be hospitals or governmental entities or whatever,
that IT systems are actually not under the purview of the particular
organization.

So, for instance, counties have IT direction, that is, located outside
of public health departments.

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

I hear that and I\'m trying to think about how we want to say that
without getting too much into describing organizational structures at
the State and county level.

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

Is it too detailed for this report?

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

No, I think it is ‑‑

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

The reason I bring it up is not only at a local public health entity,
but, for instance, what if a hospital lab wanted to figure out how to
send us data and they\'re not in charge of their IT, for instance. Then
it becomes a barrier for them to be able to make it happen.

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

I think the barrier is given the general information technology
priorities, will the implementation of the system have a high enough
priority so we have the capability. We have the resources, but something
else is going to the resources.

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

Sometimes there\'s conflicting standards issues too, where you\'ll have
a health IT organization or State, for example, or a local or whatever
and they adopt a standard on a statewide basis then you\'re trying to go
through a vertical in public health and how the local and States need to
communicate and that may be a different, if you\'re not careful they can
be in conflict. It\'s been an issue.

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

Huge issue at the local level. Because you may be looking at a system
that is interoperable with someone else but it may conflict with your
recorders system.

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

So we\'re talking about two different issues here. One is the one that
John just mentioned, which is the conflict between horizontal and
vertical standardization. The second is the inability of public health
to prioritize their work within the environment in which they\'re
working.

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

\[Inaudible\].

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

Right.

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

So one is a technical standards issue and one an overlapping of
regulatory responsibility.

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

They\'re wedded because as it turns out that\'s why public health
infrastructure is supported somewhere else partly as add on and doesn\'t
have its own resources.

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

Maybe stating that in another one is public health, public health
information systems not having enough priority within their local or
State organizations.

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

It isn\'t just priority, though. It\'s authority as well. It\'s
authority. And sometimes money makes a big difference.

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

Okay. I think ‑‑ I\'m not hearing disagreement. I think it\'s just a
matter of trying to wordsmith this. So how about if we say we all agree
and then we\'ll try to capture that.

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

Okay.

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

Other barriers?

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

One of the ones I\'ve seen, this is Minnesota, is the lack of definition
of roles between State, local, and Federal in these things. Often it
feels mushy.

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

Lack of clarification of roles at different levels of ‑‑

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

Of government.

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

Which becomes a barrier because providers, well first of all it\'s a
barrier for those of us in the system because we get frustrated as all
heck, but for providers outside the system they just don\'t know who to
follow.

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

They don\'t know who to call, who to follow.

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

Okay.

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

I\'m getting discouraged with the barriers. We\'re heaping on here. I
want to put as much energy into enabling things as barriers. And I
don\'t want to put all our dirty laundry out there. Public health is
really putting it on the table and I\'m not sure that\'s smart.

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

Then we need to come up with the answers.

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

If you send me the list I might shorten it up a little bit.

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

Maybe a slightly more positive way of putting the last one was, would be
that health issues don\'t necessarily follow jurisdictional boundaries.

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

That would be a good way of putting it.

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

Well, I don\'t know I just don\'t want us to put I could say the last
four five things we talked about were sort of like big system issues
that really don\'t have that much, I don\'t know, it just seems like
we\'re really ‑‑ everything that\'s ever been wrong with the public
health system.

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

If this will ease your concern, I think that our discussion here on
barriers and the one on enablers will probably be more granular than we
will want to report out.

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

That\'s good then I don\'t have any problem. I agree with everything I
just don\'t want to put it out there.

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

It seems to me in discussing the words so to speak we get into the
principle of the fact if we take a system that\'s already flawed on
paper and in the verbal process, and automate that system, we really
have a barrier because we\'re not going to get a chance to do this
again.

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

We can give words about the emergency department. I mean we just don\'t
need to go there.

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

We need to keep bad things happening faster with automation rather than
getting the benefit that we really can.

The EHR work for the emergency room.

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

As long as they\'re there.

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

Let\'s go to enablers. In the current environment, certification of
public health information systems. Is that happening.

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

CDC has a program for certifying in association with the cooperative
agreement for the bioterrorism fund that there\'s not a broad, by
analogy CCHIT is a multi-organization participatory effort and I think
there\'s no equivalent to that. CCHIT does not believe its role in
certifying public health systems the CDC program does not include the
breadth of participation.

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

So I think what we want to talk about there for that enabler we probably
just need to expand it a little bit to say the current environment and
certification of some public health information systems \[inaudible\]
that\'s an enabler because of the way ‑‑ because we do have an enabler
for mid-state that would be that we recommend that CCHIT incorporate the
requirement for mandatory EHRs.

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

I think long‑term EHR, it will not two separate things it will be two
views and roles for users looking at the same thing.

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

I think that\'s true in many respects but I really think it\'s important
that we have a certification process for public health systems be
developed at least in the interim.

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

\[Inaudible\] you know I think that an enabler to this would be a
certification process for public health systems. If we can figure out
where to put it, I think the working team would be the right spot for
that, because it will take a while to get to that point.

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

I would not put it on of that far. I think it\'s a pressing and
immediate need.

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

I thought it was being done.

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

Small scale it\'s being done.

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

We\'ll put it at 10.

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

That\'s where it\'s at.

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

PHIN is an example of an enabler. Mid-state ‑‑

[**\>\>**\
]{.underline}But is it working beyond much beyond the State level right
now? So by 2010, as John just suggested, PHIN has to have a greater
presence at the local level.

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

PHIN is under the current state as an enabler.

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

Yes, I\'m sorry. Okay.

[**\>\>**\
]{.underline}We\'ll move to the mid-state which is 2010.

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

Thank you for correcting me.

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

Next generation.

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

I want to add something to the data sharing agreement, I think it\'s
important to note that data sharing agreement, this sort of implies this
is about governmental data sharing agreements and there are data sharing
agreements that enable this between public and private organizations.

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

Does that make sense?

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

Or am I reading this wrong.

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

I don\'t think I\'ve gotten there yet.

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

Under enablers.

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

Right. I think that that is data sharing agreements between. I don\'t
think \"data\" is the right word in a structured sense of language.
Because I think data flows one way and information flows the other way.
So there needs to be agreement about sharing both data and information
between the public and private sectors.

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

I\'m saying that\'s a state that\'s happening today. So there\'s data
sharing and information flow amongst governmental agencies as well as
between the public and private entities.

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

You\'re saying that\'s a current state?

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

Yes.

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

Enabler.

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

Okay. And would continue to be an enabler throughout would get more
sophisticated.

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

I would hope so and more efficient.

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

Okay.

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

In fact, in many ways that\'s an enabler to the barrier of having a lack
of clarity with who is doing what. Either in \[inaudible\] data sharing
agreement to specify the various roles of public health is.

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

And the intermediaries that are assisting in the information health
exchanges.

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

Exactly.

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

Okay. Are we ready to go on to mid-state?

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

Did you want more that are occurring currently that we think that are
enabling?

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

I\'m sorry, say that again.

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

One that I think is occurring right now is public health is, at least at
the local level, is starting to identify their business processes and I
think that\'s an enabler.

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

And would you also add in there certification? I mean accreditation as
an enabler? Because it\'s going to lead to a little bit more
standardization of ‑‑

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

I think that\'s a very good enabler.

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

So we\'ll put that as a mid-state one?

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

Yeah.

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

And how about accreditation of intermediaries that would include
criteria for public health, they have to serve public health in order to
get accredited.

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

So an enabler, does that tie into, well, it\'s actually are they
accredited now?

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

I don\'t know how many really exist or serve public health.

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

Certainly no formal accreditation.

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

That would be a mid-state.

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

I mean you could say Indiana, Indiana Health Information Network right
now is serving public health but it\'s not accredited.

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

Okay. So I think I\'m thinking clearinghouses and you\'re talking ‑‑

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

There could be multiple intermediaries.

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

I was interpreting the first comment to be about accrediting local
public health departments.

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

We got that.

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

I moved on closer to something else.

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

Accrediting in that context, maybe certification in a different context.

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

So certification of exchanges.

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

I think certification ‑‑

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

Exchanging entities.

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

Where groups are consistently using for technology or applications, but
I\'m actually thinking about the entities or the organizations that
might have responsibility for the data sharing. So rather than doing
that how about if we say standardization of the roles of data exchange
in organizations? Certification or accreditation are some other ‑‑

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

I think there\'s another enabler happening formation of RHIOs of public
health at the table.

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

Okay.

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

What about enabler of improved partnerships with hospitals that can have
other \[inaudible\] and services.

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

Improved partnerships with hospitals?

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

We have them in our State, the fact that we\'re sharing data and doing
reporting, we\'re all in it together. We\'re sharing resources. It has
some real positive things for us. And I meant with all partners that
you\'re sharing data with. You become more of a system.

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

This is Brian, maybe this is overarching, given what\'s happened over
the years, the increasing public awareness and wide group of
stakeholders in the need to do the stuff that we\'re doing. I mean this
wasn\'t even on the radar screen before 9/11. The biggest enabler is
it\'s on the radar screen and it\'s attracting the attention and funding
to make it go forward.

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

Okay. Increasing public awareness of need. Any other enablers?

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

Is it increasing, is it meeting the increased expectation of the public
that we\'re going to do all we can to protect their health, the
responsibility we have to rise to the occasion in the new age.

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

The other one that\'s a parallel to that is the improving technology and
lowering price point of allowing these activities.

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

As the market matures for healthcare, it\'s going to benefit public
health.

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

Let me summarize where I think we\'re at. Then we can move on to next
steps. I don\'t think we\'re quite ready for a workplan. Skip that step.
We\'ll take this document and massage it so it\'s ready to be presented
the week after next at the full AHIC. And then based upon the assumption
that they think we\'re moving in a good direction, our job is to really
take this and talk about how this will happen. And we will spend the
remainder of this year and next year doing that. Fair statement?

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

John you\'ll be the one who is going to be presenting so I have some
depictions of what we might be presenting on the 31st which we\'ll work
on over the weekend, because we need to be drafting this up actually
early next week. I think the more substantive recommendations will be
our next big phase, which we can develop our workplan around to make
sure that we have a well thought out process and we have additional
testimony as we need it and I think since now we\'re settling on our
priorities and when we initially put this Workgroup together, we
didn\'t, weren\'t really fully conceptualizing our broad charge and now
I think we understand what the cross-section of expertise and skills and
knowledge base we need to really develop good recommendations. So I
think we\'re going to need to revisit who else we need to add to the
Workgroup to make sure we have the right cross section from local,
State, and Federal public health but also from clinical care and from
labs and make sure across the board we have the right people that we can
all work together on this in an effective way.

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

It will be very important \[inaudible\].

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

That\'s a gap.

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

There\'s a group that represents a large cross-section of physicians
PHR.

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

That\'s right.

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

Probably be a good group to go to to get input from those groups and
hone it down to one or two representatives that could participate in
this process.

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

PERC. That sounds great. That\'s what we\'ve called them informally.

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

If anyone has any recommendations on who should be included on the
group, please let me know or let Judy Sparrow know. We\'d appreciate
that.

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

That\'s the next step. I think the last item on the agenda is public
comments.

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

Now, can you open up the lines for public comment?

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

There\'s instructions on the screen now for anybody who has been
following along on their computer to call in make a comment. If somebody
is already dialed in, you need to press star 1 and it will put you
through the queue to make a comment. We\'ll wait for one moment if
anybody would like to do so.

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

Hello?

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

Yes, we\'re just waiting for public comment now. We have to just sit
tight for just a moment.

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

Thank you.

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

If you have closing comments on the vision let us know.

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

I fell off the call for a second there and I just called back in.

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

Thank you. Laura and Sheila are you still on the phone?

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

We are.

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

Okay. Sorry we were getting off mute.

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

I was hoping we might be able to debrief right after the call because
we\'ll have some things to take care of in the next three days.

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

Okay. That would be great.

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

You want to just call me?

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

I\'ll do that. Thanks.

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

Looks like we\'ve got one person. Can you let Sally Johnson speak,
please.

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

I\'m fairly new to public health so I\'ve been listening but I feel very
overwhelmed by all the stuff I\'m learning without understanding all of
it. But Amy Zimmerman who knows an awful lot than I do the had comment
that she wanted to make sure when you\'re talking about electronic
health records that you included the concept of health information
exchanges and I didn\'t notice in the comments I heard today or in the
revisions to the draft that that was incorporated and I would be remiss
if I didn\'t carry that forward. She wanted to make sure that we, in
looking at the way we do surveillance, we\'re thinking of the concept of
health information exchanges in so far as we\'re not doing point to
point for all electronic health records, but going towards one central
repository and then be able to feed out. And that\'s about as much as I
can say on it because she knows it a lot better than I. Does that make
any sense to anyone here?

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

Makes a lot of sense. And I think while we probably didn\'t use the
words \"health information exchange\" I think much our conversation,
particularly in the last half hour, we did touch on someone mentioned
RHIOs when we were talking about intermediaries, many of the
intermediaries we\'re envisioning would include Nationwide Health
Information Network service providers that could operate on a national
or local or regional level. So I think that we definitely have that in
our conceptual thinking and we need to communicate it clearly both in
the vision matrix we put together and on the presentation on the 31st.

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

The only place I saw for it was where you talk about integration of EHR,
when she and I were going over this yes. You might say integration of
the EHR using health information exchanges or, you know in consideration
of the model of, but that was one thought that she had had.

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

It\'s very helpful. If you look at the mid-state and under the enablers,
the first bullet point is ensure the Nationwide Health Information
Network can be used by all entities mandated to report adverse events.
So the concept is to actually have health information exchange or
network services to be able to do that connecting. So I think we\'ll
just need to make sure that\'s sort of prominent up front.

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

Thank you. And I learned an awful lot. I was telling people I had to
take breaks every once in a while because this is all, I\'m in charge of
the meds project here but there\'s an awful lot of other related
projects I\'m not familiar with and to hear things like national death
registry it\'s like oh never thought about that. There\'s been a lot of
concepts new to me and I appreciate being able to listen in. So thank
you.

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

Thank you. It\'s great that you called in.

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

That\'s all the comments for today.

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

Thank you.

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

Thanks, we\'ll be in touch and we\'ll send materials over the weekend.
Bye‑bye all.