American Health Information Community

Chronic Care Workgroup Meeting #8

August 16, 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.*

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

All right, you can go ahead.

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

Okay, Colin. Why don\'t you start and I\'ll add some remarks.

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

This is Colin Evans for Craig Barrett. He\'s out of the country and
unable to attend this meeting, he\'s been a planner of this process and
\-- sorry not to make this one. Tony Trenkle and I are co-chairing the
meeting. We have a packed agenda, as they say, today, and I think one of
the things we\'re going to have to talk about as we get into it is how
we manage the amount of material. We think to go feast to famine and
famine to feast in terms of amount of material. As we get into the
introduction we need to set some ground rules as to how we go through
this material and I think Tony can probably provide continuity from the
last meeting and we can then launch into this. Pretty exciting agenda
today.

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

Yeah, thank you, Colin. Just want to say a few things. We do have a
packed agenda and we want to definitely get to the last few items on the
agenda, which is to discuss the demonstration project for secure
messaging, and the factors for prioritizing next steps.

However, we do have a number of very good speakers today. We will have
to manage the time pretty carefully. But I think it\'s important to get
not only the discussion, but also feedback from the members based on the
testimony that these speakers are giving. So with, that I turn to Karen
to give a review of the call-in procedures.

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

Thank you very much. I want to remind everyone that this is a federal
advisory committee and as such, is open to the public. All comments,
however, during the actual Workgroup itself will only be made by the
members, and public comment will be accepted at the end of the Workgroup
meeting.

We do have a number of presenters today. As they do their presentations,
and they\'ve all been asked to stay within a tight time frame of 20
minutes, there will be an opportunity to query them in terms of
questions. And then we will move on.

So again, the public process, (indiscernible).

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

Matt, are you doing the roll call?

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

We have Mike Crist, Laboratory Corporation of America. Joe Gifford from
the Regence Group for Mohan Nair. Herb Kuhn from CMS. Eric Larson from
Group Health of Puget Sound. Mary Naylor from the University of
Pennsylvania. Paul Nichol from the Department of Veterans Affairs. Jeff
Rideout from Cisco Systems. Is there anyone else on the phone, either as
a Workgroup member or designee that I skipped?

**[\>\> Joseph Erdos (ph):]{.underline}**

Joseph Erdos (ph), Telemedicine for the Department of Veterans Affairs.

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

And are there Workgroup members in the room who would like to introduce
themselves as well?

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

Madhu Agarwal, Department of Veterans Affairs.

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

Adam Darkins, Department of Veterans Affairs.

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

Jay Sanders, Global Telemedicine Group.

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

I believe other than Karen and I, I believe that\'s all in the room from
Workgroup.

**[\>\> Matt McCoy:\
]{.underline}**Okay. And just quickly, the same as we always do. Please
keep your phones and your computer speakers on mute when you\'re not
saying anything. When you have a comment to make, introduce yourself
first so everybody knows who is speaking.

And if you\'re following along on the Webcast, please don\'t touch the
controls to advance or reverse the slides. That\'s it.

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

Let me move into the acceptance of the minutes from the July Workgroup
meeting. And unfortunately, I don\'t have my minutes from the June 28
meeting but it says Action Items 1, 2 and 3 will be deferred to the
August meeting. Richard, do you know what the action items 1, 2 and 3,
are, or Karen, from the June meeting that we were supposed to defer to
this meeting?

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

Yes, I think there are a few of them. One of them was the summary of
secure messaging and that is actually in your packet. We have a short
discussion on that today.

We had also deferred the discussion about Blue Cross Blue Shield
association, and I think we had \-- at the last meeting.

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

And I don\'t know if there\'s anything further we wanted to get \-- I
see Janette is here from AHIC if there\'s any further discussion on
that.

And I don\'t \-- do we have anything on the third item? We can get back
to that later. I just noticed we had that in the minutes.

Two action items from last meeting was prepare template and poll the
Workgroup members, which was done, and we\'ll be talking about that
shortly. And then prepare a briefing on possible technological solutions
for high cost cases.

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

The latter is not a briefing, it\'s a number of presentations to I think
bring to everyone, public included, some of the solution that is we
have.

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

Okay. Any other comments or questions on the minutes from the last
meeting?

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

Move they be accepted.

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

Okay.

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

Then we\'ll move into the public testimony on security messaging models.
Karen, do you want to introduce the speakers?

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

I would be delighted, to thank you very much, Tony. And also to you,
Colin. In our last meeting we discussed (indiscernible) there are
multiple models for secure messaging. This Workgroup has heard
presentation on structured secure messaging that is available and in
fact being used in a number of places.

We also mentioned and talked about the fact that there are three other
models for secure messaging, and Workgroup members essentially
unanimously want to hear a little more about those various models. So
today we are bringing to the Workgroup members presentations on secure
messaging that is actually embedded in EHR. Secure messaging that is
part of a networked model. And secure messaging that is included in a
patient\'s portal to an integrated health system, electronic health
record. And the first of the presenters will be Barbara Klein, and
Malcolm Costello from Kryptiq, and so I guess it\'s you, Malcolm, that
will lead this discussion.

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

If I could have the first slide up. Karen, we\'re having a little bit of
problems with these slides right now. If we could start with Mr. Fotsch,
we should be able to get this presentation up by the time that one
concludes. Otherwise, I\'m not sure we\'ll be able to get the slides on
line for this one.

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

In that case, Ed, are you ready to go?

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

I\'m here and I\'m ready to go.

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

In that case we\'ll do that. Dr. Ed Fotsch is from Medem and here to
present information on what we are calling the network model. Dr.
Fotsch? The floor is yours.

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

Thank you. I must admit I\'m on a dialup connection, about 40 feet from
the north shore of Lake Tahoe, I don\'t expect any sympathy for that but
I\'ll be going through my slides locally. I assume you will be able to
see them and we will just go slide by slide. Does that work?

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

That does work. I will tell you, in the interest of time I\'m going to
play timekeeper. As I say, we\'re giving everyone about 15, 20 minutes,
and \-- once you hit the 13-minute mark I\'ll let you know.

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

Great. On the first slide, \--

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

One other question before Ed begins. Do you want to hold questions until
after each speaker, or how do you want to do that, Karen?

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

I think if we allow the questions immediately after the speaker, that
would be fine, but it does take time to do that. So perhaps after we
have done these three presentations, then we\'ll ask questions of
everyone.

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

Make sure 15 minutes plus 5 minutes of questions.

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

Right.

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

So we\'re going to hold the questions until after all three speakers.

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

Right. Thirteen-minute warning.

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

Okay.

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

Great. Thank you. The first slide has my attempt of humor of drinking
out of the fire hose. Fifteen minutes challenge to go through
everything. Go to the second slide, I think the basic premise here is
that healthcare costs and quality can be improved and IT can do it, and
that chronic illness is the focus, because under current status the
majority of dollars in care used goes to a small number of consumers
most with the most chronic illnesses. That patients are currently
largely disconnected from their care, have episodic treatment, and
aren\'t connecting anything in particular and as a result half of meds
aren\'t taken, half of care not followed up, half of prevention ignored
in very rough terms.

That patients, and this is \-- has to do with my focus, but most
patients are treated in the community provider setting, not in large
institutions, and that most of those community providers don\'t
currently have EMR, and won\'t in the next two years. That\'s my
experience in 10 years of practice and IT, I\'m not suggesting EMRs
aren\'t increasing in number, but they simply aren\'t the rule of the
day today.

And that someone has to engage consumers if this current gridlock is
going to change, and that likely will come not because consumers have
revelation on their own, but because payers or providers engage them. So
I have structured my comments into 10 questions and ten proposed
answers. And a suggestion at the end. And what I\'ll do is just go
through those.

The first is can this work at all? Is there any evidence that healthcare
IT either in secure messaging or automated secure messaging, improves
care quality and outcomes? And if so, how does it do that? And I suspect
you are familiar with studies, and I have some references to them in
here, but show that everything from smoking cessation to weight loss to
diabetes management can in fact be improved using network-based
communication, and the currently the disease management industry
companies like American health and others, are increasingly using online
services to modify consumer behavior.

And I can give specific references if there\'s interest, but I think
that that has been proven the question is how do you engage the
consumers in the first place? Because engaging them in the disease
management program assumes that you somehow have them engaged at all,
which is not the current model. Since they\'re not going to do this
themselves, the question is will it come from the people who pay their
bills or from the people who deliver their care? Who have the access and
the credibility.

If you go to the next slide, the current examples of payer-based and I
include health plans and employers, attempts to engage consumers in
their own care using messaging systems, online programs, PHRs as not had
good update, with the exception of employers who pay their employees to
fill out what are glorified HRAs and call them personal health records.
The best recent example is the New York Blue, the data is there, they
spent a fair amount of time and money and effort to get a 0.7 uptake of
their members. And there are challenges that we don\'t have time to go
into. To engage consumers in their own care when you're a health plan or
employer. That relates to access and trust, other challenges.

The other side of the coin is the provider-based engagement, depending
upon how is implemented, can get in excess of 50 percent uptake of
patients, and specifically in our experience replacing the medical
clipboard with an online registration that puts consumers by default on
a network across 5 years we found to be the most effective way of
engaging consumers. It also has the side benefit of engaging the sickest
consumers first, because those are the people who are going to the
doctor. Healthy people tend to visit the physicians less frequently, and
ill folks more.

The next two slides tie that experience in the marketplace to national
surveys that show that patients prefer to engage in disease management
programs and patient education programs from their doc first and
foremost. From national institutions less, and then of course it
trickles down.

And if you go to the next slide, this is a survey from two years ago
talks about engagement of consumers in an interactive health record. If
you look at the key reasons that consumers would be interested, it again
has to do with communications with and instructions from largely their
doctor. This idea of engaging consumers for chronic care and online
services from the provider, both from experience standpoint and survey
standpoint seems to have the best legs.

The next slide is 7, is a study that we participated in where
ConnectiCare, a Connecticut-based health plan, and the point there,
you\'ll have the slides you can look at the details, most of the
consumers like being engaged by their docs, and felt this was an
effective way of receiving some automated education programs and disease
management programs. I should note that the American Heart Association
is beginning a new study to further document both the uptake and the
benefit of interactive personal health records with automated disease
management and there\'s well position from AHRQ, that the committee may
be interested in.

The next question is what\'s the best method of \-- if you assume
providers are going to engage consumers, what\'s the best method? We
have experience in others with E-consults or secure e-mail as a
standalone service and the fact is that uptake by the consumers is
unfortunately quite low. We spent a fair amount of time looking into why
that is the case. But suffice to say when physicians say I offer e-mail,
the build it and they will come approach to consumers doesn\'t work
particularly well. Which isn\'t to say e-consults aren\'t good. I
actually authored a few \-- approved, I\'m a great believer in them.
It\'s just that they are not the way that anyone is successfully gotten
large percentages of the population engaged on line.

In our experience the PHR is the engagement process. The uptake is five
percent. If it\'s in effect mandated because it replaces the medical
clipboard as the Secretary suggested the engagement is consistently 50
percent and I should mention this is our experience and this is in a
non-Medicaid population.

Part of the time you\'re engaging the consumers, other times you\'re
engaging the care givers and the key point here is the last one, which
is the patients unfortunately will do largely what they have to do and
are told to do, not necessarily what they should do or what we might
want them to do. And I certainly experienced that in my ten years of
running busy emergency department.

So the next point, the next slide reinforces those points. E-consults is
a piece of the bigger puzzle. E-consults as a stand-alone, it doesn\'t
get the uptake that engagement of consumers, has to be largely mandated
if it\'s going to be successful. Mandated in a patient and physician
friendly way. The pacing of the clipboard is the best vehicle to do
that.

Next slide what is the connection between PHRs and improved chronic care
and disease management. I\'m not going to read all those points. It\'s
pretty simple. An interactive PHR, that replace as clipboard creates a
network. That connects a patient to a series of online tools and to
their provider. So that creates a network. Disease management programs
require a network. So they\'re in fact two sides of the same coin from
the implementation standpoint.

The next slide, so providers are the key to engagement of the consumers
and enrollment in disease management programs. How could that occur and
frankly it will occur because some modest incentives to market-based
incentives are put in place that will encourage providers to offer these
service that is will enroll consumers on to a network wherein disease
management type programs can be pushed out to the consumers.

Those services can be integrated into EHRs, but requiring an EHR will
limit the reach of these, obviously the providers who in fact have an
EHR. So ideally there will be simple network-based services with a clear
ROI, and modest incentives, and ideally will be used primarily by the
office staff as opposed to the physicians, because if you get in the
middle of physician office workflow, it will be problematic because you
will impact their ability to make a living and the uptake will again be
low.

Clearly replacing clipboards does not decrease provider productivity, in
fact it increases it.

What incentives are required to motivate provider centers obviously
financially market-based and regulatory, and I cut and pasted some
examples of those that are JCAHO requirements, the new criterion that
are motivating providers to offer these type of services and some of the
health plans are beginning to feature and promote practices that offer
these types of services.

The key here is if you go to the next slide, there are many groups,
including the government and health plans, manufacturers, patient
advocacy groups, obviously the patients themselves that would benefit
from interactive chronic care, and interactive PHRs that enroll patients
by default. They benefit in different ways. The problem is none of them
on their own have the market clout, and I actually would include the
government on its own they will struggle, the market clout to influence
physicians, and the reason for that is from a practical standpoint in a
two to three physician office, you can\'t treat one group of patients
one way because their insurer is Medicare and another group another way.
You have to have a service that will be implemented for effectively all
patients and none of these groups on their own would have the clout to
change that workflow. But clearly together or in groups they will have
that kind of market clout.

How would this work, what financial model would work? In our experience,
motivated providers replace clipboards with interactive personal health
records in integrated disease management. They do that because it helps
them attract patients because they have modest financial incentives.
Patients calling for appointments are directed to register online. This
creates a basic network that has a list of the patients\' meds,
conditions, and allergies, essentially the CCR and based on those
patient-specific criteria the patients are enrolled in disease
management programs. And since it\'s a network model, other groups
participating, third parties, disease management programs, health plans,
others, can participate. Providers offer this without screwing up their
workflow and with a relatively low cost and a clear ROI.

Is this working now? And there\'s not enough time to go into a bunch of
specific details but suffice to say the answer is yes. And increasingly
\--

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

Warning, Ed. Thank you.

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

That\'s five minutes or two?

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

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

All right. So it\'s working now and frankly it\'s working, there are
more and more employers on health plans that are getting behind the
provider-based engagement of patients largely because they\'ve failed
and failure means continued high cost and they can\'t tolerate that.

Can results be measured? Since it\'s a network-based model, the activity
on the network can easily be measured and documented. The scalability is
as scalable as the software that\'s built, and obviously the Internet is
quite scalable. Again note that the Heart Association has a study just
beginning to document this benefit of the patients and the providers. So
there\'s really no problem with measurement or scalability.

So that leads to the last question, what can AHIC do and this committee.
Just a few key points it seems to me. Follow the Secretary\'s lead. I
believe he\'s exactly right on replacing the clipboard to engage
consumers online. And bring support behind regional pilots. I think
that\'s fine. I think getting involved in the Heart Association study
would be great. Understand e-consults as a stand-alone won\'t work but
as department integrated will. Incentives between the private and public
sector. I do note that there is some draft Congressional legislation to
create a public sector/private sector fund to create these kinds of
incentives. And AHIC committee may be interested in learning more about
that. And last is coordinate with the Consumer Empowerment group,
they\'re really the other side of the same coin. Engaging consumers on a
network is required if you\'re going to engage them in specific
programs, pursuant to a network. So I\'m sure my time up is. So I\'ll
stop talking.

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

Ed, that was done to perfection and you\'re right on the second. I\'m
hoping you can stay on the line for the other presentations and then
respond to questions when they\'re over.

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

I\'ll be happy to.

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

Do you want to take questions for Ed right now or save all the questions
for the end?

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

I think we\'ll save them. Now we\'ll go back to where we were before,
and Malcolm Costello, I\'d like you to now address the embedded model.

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

Thank you. Next slide, the \-- next slide. Kryptiq was founded on three
fundamental axioms beginning with lack of data, clinical data, and
really lies at the heart of the cost and quality issues in health care,
thank you very much for taking the (indiscernible) Middleton and others.
We have 3,000 physicians using our technology today for
provider-provider and provider-patient communication. And is a slate of
six case studies. Unique characteristics and I think you\'ll see they
represent the gamut of health care as practiced today from large
delivery systems right through solo providers. Next slide.

So for the first case study I want to share an example prior to
implementation. Next slide.

And this is from Delta (indiscernible) the medical director of family
practice residency program in Memorial Hermann, in Houston, Texas. And
underlying this is both the (indiscernible) saw a 1-day with allergies,
and the transcript in the background details the results and interaction
which occurs hundreds of times every day across America. Seven phone
calls, 27 hours of time, 5 different people involved. And at the end of
it, fail to reach each other, the physician prescribed a new
prescription for the patient. We\'re seeing high costs of care delivery,
and actually an ineffective care system where the solution is to write a
new prescription. Annually for healthcare generally.

Next slide. Following that example and many others like that Memorial
Hermann implements a secure messaging embedded within their electronic
health record to communicate lab results to patients, to handle
medication questions and refill requests. To handle the kinds of
clinical questions that previously came in as phone calls. And to run
off patients request for referral.

And the next slide we\'ll see the results of this implementation. And
based on that you see cost savings both in terms of mail supplies, and
tremendously in terms of staff savings as well. Westchester Medical
Group substantiated these results. Recognizing the result of
implementing messaging, saving over 20 percent of MA time, medical
assistant time, per physician. Moving those staff from mindless
activities like calling patients and not getting responses, to actual
clinical productive activity.

Dr. Barrister made 68 hours per physician failed contact time per year
based on calling patients, getting their voicemail and obviously being
unable to leave a message.

Next slide. Following the implementation, questions from Tom was how a
patient is responding to this and the answer is very, very well.
Memorial Hermann surveyed all their patients who had received
information electronically, and scored between 9 and 10 out of 10 from
each of those patients in comparing them with other practices in terms
of how clear the communication was, how quickly it came, and the overall
assessment and quality of care they were receiving.

So clearly this is changing consumer expectations with patients who are
receiving information in this way. The other thing highlighted is on
average patients opened their results and other communications from
doctors within 15 minutes of receiving them. And on average they
reference them three times. We\'re dealing with informed consumers here
who care about their healthcare, as is typically the case of those
suffering from chronic diseases.

Let\'s skip the next slide, which just gives some quotes from doctors
and patients and go on to slide 10, please. The following slides
describes provider-provider communication between two large medical
groups, Providence Medical Group, delivery network, and the Oregon
Clinic, which is a large independent multi-specialty practice. Together
these two groups occupy 60 locations across the Portland metropolitan
area and have a high degree of referral between them. What\'s
interesting here, both of them are on electronic medical records,
predictably we\'re using paper to transfer mechanisms between the
systems. Began an eight-month study of shifting those from paper to
electronic distribution, and we\'re so impressed with the results they
rolled out the systemwide quickly.

Next slide, the results. They demonstrated cost savings of over 10
dollars per referral. Dealing with between 6,000 and 10,000 referrals a
year, which would amount to 60 to 100 per year for these organizations.
Most of that is in dealing with the pay for work when it returns in to
the practice, if it comes in as paper, needs scanning, integration into
the electronic medical records and needs shredding afterwards. If you
don\'t deal with that mobility issue, you fail to realize the implicit
gains in the system.

As a result of this, they\'ve had many, many doctors within paper-based
practices in the Portland area, call them asking to receive the
information electronically as well. Because they all have PCs in the
offices and we\'re working on them on a deployment called Connect IQ, to
connect the paper-based systems in with the electronic system.

Next slide. Highlight this, telling \-- off the charts, handing them to
the patients and telling them to take them with them so the information
reaches the specialist at the same time as the patient. The project
manager was inundated with phone calls from the physicians doing is get
on to the electronic system to address that. Very successful deployment.

Next slide. This is at the other end of the spectrum. The interest in
smaller medical specialty groups, in a very rural area of Maine. They
are very quality-focused and it was the result of the QI process, they
uncovered low patient satisfaction in regard to receipts of test
results. Next slide.

So they implemented messaging of (indiscernible). This is a build on
this slide, to I have to tell you. They implemented secure messaging to
address the communication lab results for patients. Reduce their error
rate from about three percent, which while it sound a low number, is an
error of one lab result per physician per day. One in 30 patients get
incorrect information in the lab result. They reduce that down to zero
percent. They saved 20,000 dollars per year in costs avoided, which was
about a thousand dollars per physician. And the patient satisfaction
survey afterwards showed the patient savings increased to 97 percent.
The quote shows we\'ve seen a significant change in expectations. The
old adage of I\'ll contact you with test results no longer acceptable in
today\'s consumer.

Our fourth case study I\'m going to move to Michigan State University.
Academic medical practice.

Next slide. Look at some interesting data. Following slide, please. This
MSU health team, their patients, they have regular communications with,
regarding shifting those communications from phone to e-mail. And so
this has only been deployed to a small group of patients, 256, of whom
94 have used \-- as reported in the (inaudible) date. Use of secure
messaging tends to be slow but sustainable growth. Not a big bang
approach. It gradually gains adoption, but that adoption is sustainable
over time. Just as we\'ve seen for ourselves in so many areas of our
lives, in communication with banks, arranging travel, and so on.

Next slide. A key concern of physicians, adopting secure message
something will they be inundated with the frequent flyer patient? And
the evidence is no, the majority of patients in one, two, three messages
a year. Which really equates to the phone calls that are previously done
to the office. And the graph you can\'t see behind, there\'s evidence of
one patient in this practice who thinks 24 messages over the course of
the year. And when they went in and investigated, the doctors concluded
every single one of those communications was clinically relevant.
Meaning previously, either been a phone call, more inefficient, or the
communication would not have occurred to the detriment of the patient\'s
health.

Following slide. I think the other interesting news a comment on Ed\'s
point that this isn\'t about e-visits or e-consults, the data bore that
out. A quarter of the messages that came in from patients were about
clinical \-- about half of those may have qualified as a \-- the rest
were basic \-- replace the basic phone call. Significantly, ten percent
were chronically sick patients delivering information. Blood glucose
reading or blood pressure. Allowing the physicians to stay managing the
data on a real-time basis instead of just in the office. Bulk of the
rest were regarding test results or questions regarding medication of
patient. Necessary care.

Next slide we\'ll skip. This is a build and you\'re not seeing the
build. But this is a Greenfield house. Probably most significant point
I\'d like to bear out here is these communications, as you can kind of
see in the graph in the background, 3 a.m. insomniacs communicate, it\'s
everyday consumers communicating when they would otherwise be calling
the office. In fact, the highest workload in communication is between 8
and 10 in the morning. When the phone would need to be staffed and
everyone is trying to get through and not getting through. The advantage
of this is patients are communicating when they want to communicate. The
response is asynchronous. No one needs to answer the phone exactly at
that time.

Okay. Final example is from Providence health system. Four years ago,
published the report, I think in (indiscernible) which highlighted that
while the implementation is electronic medical record, clearly improved
operational efficiency. And quality of care for acute episodic care, it
had not fundamentally shifted chronic care management. So they rolled
out a new system that allowed them to do a population management for all
of those patients, and to communicate with them on a regular basis. So
they attributed their implementation prior to that, so it continued to
be episodic care model, the reliance on patients seeking care. They
wanted to shift to a model where physicians could engage patients where
necessary on their care.

If we go to the next slide we\'ll see the impact of this, if you can
scroll to the right. So deployed this across stroke prevention,
diabetes, CHD, and now rolling it out to tobacco cessation and cervical
cancer screening. We\'re looking here at the results of 18 months study
over 9,000 patients, all of the patients in the medical group, with
diabetes. Okay? This is a nonprofit health system, so it sees its fair
share, or more, of uninsured and underinsured patients. Many patients
clearly are Medicare coverage. And yet within the 18 months, they
achieved significant improvements in clinical outcomes. Not just in
terms of the process compliance. We see in the patients the
(indiscernible) eye exams and foot. But also in terms of goal
attainment. Within that 18 months, the number of patients who had their
blood pressure under control, their blood glucose and HDLs under
control, went from 1 in 4, which is a shocking statistic we\'re faced
with in American healthcare, to better than 1 in 2. A long way to go but
an incredible improvement in an 18-month period. I think when you look
\-- when you look at this in terms of the long-term costs to both the
quality of care and the patient outcomes, and the predicted overall cost
savings across health care, you know the results are tremendous.

Next slide. The system is available commercially nationwide. It\'s now
being tied in to the secure e-mail system so the communication with the
patient, which originally was done by a printed mail to patients now
goes out electronically to those who can receive by e-mail or \-- this
allows a whole change in the way those physicians are thinking about
caring for these patients. Patients can now go to the Website and see
how they\'re managing their diabetes or CHD on a regular basis. As Tom,
a solo practitioner, reports, having that information available in front
of the patients when they\'re in the office and also when they\'re not
in the office, really changes their perception of their role in the
management of the disease.

Final slide. Middleton has looked at the results of the findings that we
did \-- or the work we did with Providence Medical Group in their
communication with Oregon Clinic and clearly concludes what we\'re doing
there really does substantiate the points being made in the original
report published by CIPL. The majority of the cost \-- the 78 million
\-- billion dollars in cost savings can be made in American health care
to do not with the application but within the practice. The ability to
achieve system interoperability. We believe that our customers a\-- are
proving time and time again the secure messaging gives them an
operational efficiency within their practice that pays for itself both
in terms of saving money from phone and mail costs and in releasing
staff time for more productive activities. It does so for the very
reason that most of us use e-mail today. We embed data in the context of
a human discussion occurring. The MGMA report from a year ago
highlighted the majority of, 17 percent of referrals today do not
include the reason for referral when they go on paper. The specialist
does not know the identity of the primary care physician who has sent
the patient to see them. Secure e-mail enables that information to be
embedded within the context of an ongoing dialogue between the provider
and the specialist, and, where necessary, including the patient. We
believe that the fundamental way to make this work in American
healthcare is to integrate it into the daily workflows in practice.
Because not 100 percent of patients will be using it, or 100 percent of
providers, it needs to work alongside existing systems. That\'s why
every other American industry has found as it tries to shift consumer
behaviors to doing things online, that those online \-- those online
workflows have to coexist with paper-based. We fundamentally believe
that the PC revolution in America was driven not by a compelling
application in the PC, but by the existence of e-mail and the Internet.
And that same driving catalyst behind adoption in our homes and in every
other American business is a fundamental driver of IT adoption amongst
physicians. And as I said earlier, while most of our work to date has
been based on extending those who have the EHR to realize their benefits
beyond the practice, a majority of our work on an ongoing basis is in
tying those systems in with the paper-based offices as well.

Karen, thank you very much for your time.

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

Thank you very much and you were right on target also. We\'re looking
forward to questions and answers for you as well.

The third of our presentations today on this particular area will be
from Dr. James Ralston from the Group Health Collaborative who will talk
a little about secure messaging, included in the patient portal to their
EHR. Are you with us, Jim?

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

I am.

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

Thank you. You also get the same two-minute warning.

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

I\'m going to share with you today our experiences with two different
systems that connect patients and providers over the Internet. Both of
these systems are based on patients accessing and interacting with their
provider's EHR, or clinical information system. Our results from the two
projects, I hope will help inform the Workgroups\' deliberations on
secure messaging. And specifically in the areas of adoption, patient
satisfaction, and quality of care. Don\'t \-- we won\'t yet be able to
help you with the impacts of cost.

Next slide. So we\'re going to cover the experiences of two different
institutions, with secure patient Websites. One of these is Group Health
Cooperative, and their MyGroupHealth Website. And that site is an
integrated part of care with over 100,000 patient users. The other site
is University of Washington MyUW and part of the medical center\'s
system and that\'s a research-only system where we have about 200
patient users involved in clinical trials.

Next slide. Both of these sites had a common goal of trying to redesign
care to better meet the needs of patients. They weren\'t just an add-on
to existing care processes but really were part of a much larger attempt
to redesign healthcare to better meet patients\' needs. And to
specifically shift that sole focus of care away from office-based visits
to include patients\' lives at home, at work, and on the road. Where we
particularly know chronic care patients may benefit. So it really
attempts to address the kind of experiences that the gentleman in the
next slide experiences when he comes into the physician\'s office and
the receptionist says your appointment with the doctor is at 11:15 but
his appointment with you is at 12:15. But tries to shift away from the
physician-centric experiences that our patients too often experience.

Next slide. To understand the Group Health shared record, you really
need to understand the goals and culture of the healthcare organization.
Group Health is a member-governed, not-for-profit integrated financial
and delivery care system. Has over a half million patients, 860 medical
staff, 25 medical offices, two hospitals, throughout Washington, Idaho,
and in addition to an integrated delivery system, we contract with over
600 physicians in Washington State.

Next slide. Six years ago, Group Health thought to transform itself to
better meet the needs of patients for access to care, and their portal
was a cornerstone of that larger transformation strategy. And it tried
to provide and attemptrd to provide, help provide care wherever and
whenever patients need it. The portal provides a shared and interactive
medical record between patients and docs, patients can refill
prescriptions online which are mailed free to their home. Can engage in
secure electronic mail with physicians and those messages go right into
the electronic record along with office encounters, hospital discharge
summaries, and tele-encounters. The docs and patients are writing the
records together. Patients can also review their summaries of all their
outpatient visits which include their vital signs as well as any drugs
or laboratory studies that have been ordered or referrals that are
ordered. And also includes patient education and care plan. It can also
view most of the medical record, including results of medical tests,
medical tests. Most of those medical tests including abnormals, reach
patients in real-time. It can also schedule office appointments online.

Next slide. I want to show you one example of the services within this
shared record. This \-- these are how our test results with charting are
reported. Patients receive their actual test results with the normal
values displayed. Each of those results has a hyper link to Healthwise
Knowledgebase to help explain what those results mean. Physicians can
attach notes to those test results as well. And then we\'ve added these
photographical functions to help patients watch trends for results that
benefit from seeing those trends.

Next slide. Registration for the MyGroupHealth portal has continued to
grow at a fairly remarkable rate. This graph shows the uptake of
enrollee registration for access to the shared record. The x-asis is
from September \'02 to December \'05, and the y-axis is the percent of
Group Health adult enrollees. Now has over 35 percent of its enrollees
registered for the portal in the integrated delivery system. And by this
metric we\'d be, Group Health would be moving out of that early adoption
phase.

Next slide. The use of the individual portal service is also continuing
to climb. And particularly for those services that are most actively
involved in the ongoing care and communication of patients with
physician. These are eight different portions of this, of the shared
record with patients, that they\'re using over the Web. The top four are
medical test results, medication refill requests, they\'re after-visit
summaries, and then the secure electronic mail encounters. There\'s a
little bit of semantic difference between this slide and how your group
is defining secure messaging. These are secure e-mail encounters.
They\'re not clinical consults. Those, they occur in the context of an
existing physician relationship. And they may be about a new issue, but
they are often about ongoing chronic care issues.

The bottom four portions of the shared record on this slide are those
that are having less adoption, their list of medical conditions,
appointment request, immunization list, and allergy list, and again all
those are pulled straight out of the clinical information system. So
they\'re the same data that the docs have in the office when they see
patients.

The y-axis on this slide is unique monthly users per thousand enrollees.
So as December 2005 you can see we had about 54 users out of every
thousand enrollees every month, accessing medical test results online.
So we\'re beginning to understand who uses the portals. You might think
they\'re used for shared record through port always, used most by folks
like this guy who is at home and evening with his partner and she points
a gun at him and says, okay, step away from the laptop and hold up your
end of the conversation. There\'s a lot of folks think about who uses
computers and may actually use online health services. But in fact it\'s
not the man who is the most common user in the Group Health system.
It\'s the woman. In this cartoon.

Next slide. So our typical online patient in 2004 was a 51-year-old
woman who was managing multiple chronic conditions. And had a primary
care provider who had over 20 percent of all patient \-- all their
patient encounters through electronic messaging. And I think that last
item is key. It echoes what Ed Fotsch was talking about earlier, that
physicians are really key to engaging patients online, and it\'s really
the patients and docs are using the shared record together in the
context of the ongoing care and in their personal relationship.

Fifty-one years old is also the mean age of all of our enrollees whether
they\'re using the shared record or not. We\'re really seeing the shared
record being largely used by the same people who are using other
portions of our delivery system. We have seen some drop-off in relative
use over the age of 65. And in our Medicare population \-- or Medicaid
population.

This slide shows a \-- the results of a satisfaction survey of users
from 2004. Not surprisingly, patients like those services that they use
the most. The top two bars represent those enrollees who are satisfied
and very satisfied with the services. You can see the satisfaction was
high overall, but particularly high on the left-hand side for messaging
refills and lab results, which as you might recall, were the most used
and also the most highly adopted, or most quickly adopted services
through the shared record.

Next slide. I\'d like to shift to results that we have from the UW,
University of Washington patient Website. Again, this is different than
the Website I just presented to you. This is a research-only site. And
it is part of several kind of larger multifaceted interventional studies
to improve care of parents with diabetes and other chronic conditions.
Harold Goldberg is the principal investigator and I\'m co-investigator.
All of the studies are based on Ed Wagner\'s chronic care model and use
a case management approach that is integrated with the primary care team
at the clinic. We\'ve completed one trial and have three others in
progress.

Next slide. This site provides patients access with many of the same
components as the Group Health site. This site provides complete access
to the electronic medical record and in this case it\'s the exact same
record that the providers use, including the same interface and no
delays in uploading of any medical test results or transcriptions.
Patients can also upload their blood glucoses into a graphical viewable
simultaneously by the patient and their provider. So in this case we
look at this more as self-management support function, than remote
monitoring. We\'re really using our physicians and case managers over
the Web to help patients understand the patterns of their blood glucoses
and how they relate to diet and exercise so they can better manage
themselves at home.

There\'s also other integrated disease management tools including some
weight management tools, patients also have secure electronic mail
between patients and providers, and then some Web links for general
diabetes information.

Next slide. Last fall we completed the first trial, it was a year-long
trial on patients with Type II diabetes. A1c's dropped by 1.1 percent in
the intervention versus the controlled group and that was significant.
And then subsequently, the program was stopped in the clinic we rolled
it out in, despite the best efforts of that clinic director. It was
stopped because of reduced healthcare utilization overall in the clinic
by these patients. And it was not viable in that fee-for-service
environment.

Next slide. Take-home points. Use and satisfaction for the shared record
over the Web are greatest for those services that support ongoing care
and patient provider communication. The top of those I think I mentioned
before were test results, medication refills, after-visit summaries, and
secure electronic e-mail. And it looks like the constellation of those
functions that really represent the breadth of what patients and doctors
do really are driving adoptions and satisfaction with the shared record.

Largely the same patients use secure electronic patient provider e-mail
as used other healthcare services with some drop-off in the Medicare and
Medicaid populations. And then lastly, in the UW study we\'ve shown that
management of diabetes can be improved among patients who have access to
a shared interactive electronic medical record when it\'s part of a
larger healthcare redesign.

Thank you.

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

Thank you very much. That was certainly a nice cap to the three
presentations that we\'ve just heard. And Jim, I\'m hoping you can stay
on the line a little bit, because with so much \-- I just have to
comment a moment, if I may, Tony. I don\'t think this Workgroup has had
this much substantive solid information presented to it in one hour
before in the history of the Workgroup. So I really would like to thank
and commend our three presenters, and I also believe that the ones that
will be presenting shortly will essentially step you want to plate and
keep up this new tradition.

But again, thank you all very much, very informative and now the floor
is open for comment and question among the Workgroup members.

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

Jay Sanders. More of a comment to echo what Karen said. I think the
presentations, both the data and the comments, very compelling. I think
once again, the issue of compliance raises its ugly head in terms of one
of the greatest weaknesses in our healthcare delivery system. But not to
point a finger, this is not premeditated, noncompliance. It is just lack
of information, lack of understanding. On both sides. I was very
impressed with the data that Malcolm presented with respect to the
changes in compliance with respect to foot care and retinal care on that
18-month trial. The LDL reductions, very significant in what a lot of
people forget is the blood pressure reduction being a very critical
component. That was just dramatic. I\'ll probably get kicked here by
Tony, but we actually have probably have more data with respect to
secure messaging than we had at the time that Medicare approved
reimbursement for pulmonary artery catherization flying \-- so I think
this is very, very compelling.

I also think that one of the fundamental underpinnings of all of this is
to demonstrate that information acquisition is very important on the
part of the patient and provider. But information acquisition shouldn\'t
only be defined as occurring within the doctor\'s office. In fact, the
exam room is more appropriately where that patient is. Not where the
doctor is. So I just want to thank the presenters. I think it\'s a great
presentation.

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

Jay, I\'m not going to kick you, but I did want to ask a question on
this chart. I guess I\'m not clear as to how that ties back to secure
messaging. You\'re saying these results, I mean obviously they look
great. But I mean, can you tell me what the relationship is between
secure messaging and how this results in these change in baseline?

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

Absolutely. I think it goes to Jay\'s key point, which is in terms of
chronic care management, the most important interactions are
interactions that occur outside the doctor\'s office. Even in terms of
regular therapy, Memorial Hermann, there\'s typically two interactions
between the patient and the physician or the physician\'s representative
for every office visit.

So what we have done with care manager is enable physicians to manage
patients outside of the time when the patient calls for a visit. So for
instance, to go to Jay\'s point, doing the LDL test is one thing.
Writing the prescription for the patient for the Lipitor is another
thing. Ensuring the patient takes their Lipitor, stays compliant over
time, and is in communication if there\'s any trouble taking their
Lipitor, is the hardest piece of healthcare and I\'m required \-- the
system enables physicians to regularly monitor those patients when
they\'re outside the office. So the time with secure messaging was
really on the next slide. Providence\'s work today has been based on
using printed mail to communicate with the patients, or having
(indiscernible) with the patient. They partnered with us to embed the
secure messaging into that. So as they\'re dealing with their 9,000
patients with diabetes, and the 6,000 who they\'re managing for stroke
prevention, more importantly, the 100,000 for whom they\'re doing
cervical cancer screening, they have fast and efficient way of
delivering personalized individualized information to all of those
patients who can receive it electronically.

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

You didn\'t answer my question. I mean, how does it relate back to
actually secure messaging? I mean \-- it was taken advantage of that
among these people and how has it resulted in a decrease.

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

I would say those results are based primarily on driving intervention
that is occur by phone and mail. Not based on secure messaging.

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

Okay.

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

But adoption of that is other customers to adopt that. They mandate that
they need to tie in to their secure messaging and patient portal.

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

Okay.

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

This is Joe Gifford at the Regence Group. Can I ask how long you\'ve
allotted for these questions so I can modulate myself.

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

We\'ve allotted 15 minutes. We have about other 12, 13.

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

Great. My first question to Dr. Ralston is, the biggest hit for me was
that the clinic dropped out of the MUW trial because of decreased
business which to our point of view of course was a huge success.

\[laughter\]

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

I echo that sentiment entirely.

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

Do you have any quantification of that? I understand a pilot with only
100 patients, but did they give you any indication of how much business
dropped off?

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

We don\'t have that yet. There\'s a formal cost-effective analysis being
done on that study now. So that will be out. It will be published. I can
tell you anecdotally that we had some patients who were receiving eight
or more adjustments of their hypoglycemics virtually over the Web
through this connection, without ever coming in, and as you know that\'s
not a billable service.

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

Overall it\'s just stunning if you\'re able to get the hemoglobin to
decrease by one and a half percent and actually reduce business so much
that the clinic says it\'s nonviable. You knock the ball out of the park
on that one.

And I just sort of just to change topics briefly. I have a question for
Medie. You say engagement via PHR, into a provider network. You make it
fairly bold statement this will never happen without a mandate. And
I\'ll just say that our thinking, anyway, at Regence is, nobody had to
mandate eBay and mandate Amazon.com. When they provided value they
became viral and sort of lit a prairie fire and it happened. What do you
mean by that? Or maybe I asked more directly. What mandate, if you had
\-- if you were King, what\'s the mandate you would make that you think
would work?

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

Yeah, Ed Fotsch here. I guess I would say fundamentally the premise that
consumers want to engage in their healthcare the way they want services
from online banking or eBay, practical experience is consumers
unfortunately are largely disengaged from their care and prone to remain
disengaged. Unless a good reason, a really good reason is given. Which
is typically go to the doctor because I\'m awfully sick. But not engaged
in an ongoing basis. And the mandate that I would suggest, the only one
we\'ve seen that works is a provider-based mandate that says I offer a
service and I want you, my patient, to participate in that, that\'s how
I do business. I don\'t use clipboards anymore, I don\'t \-- I try to
get my communications online, and I auto-enroll all my patients in
disease management programs specific to the conditions indicated in
their network. So it\'s a literally the replacement of the clipboard.
It\'s a great metaphor because it sort of says this is the new way we do
business.

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

So I\'m sorry, you weren\'t really making a public policy statement
about a federal \-- a regulatory man day. You were making a statement
about sort of a business practice mandate on the behalf of the
physician? Am I correct?

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

We haven\'t seen \-- and I think the other presentations bear this out,
the market, we haven\'t seen any group save the providers who are able
to motivate the patient and so the mandate really has to come from the
provider community. I don\'t think this is a \-- you know, we\'re going
to jail people if they don\'t use these service. So the mandate is not
public policy. The mandate is a here\'s how we want providers to do
business, because as this data shows, the aged consumers online take
better care of themselves reminded that they need to take care of
themselves. And the only caveat is that most consumers are cared for by
physicians in small group practices that don\'t have EHRs, and so that
makes it more of a value.

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

All right, thank you. Those are my questions.

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

Ed, this is Colin. I have questions that follow on. I listened to all of
these presentations and I\'m asking my questions the activities that
AHIC is thinking about in terms of standards, in terms of the pilots
that are going on right now in terms of looking at ways in which data
can be exchanged and aggregated between providers, I look at all these
three of these and wonder what you would be asking AHIC to be doing,
emphasizing, whether it be asking HITSP to be focused on certain
standards or accelerating the integration of data. Because I look at
things like an EHR solution and that sort of assumes the EHR portal to
which the patient is going, in fact has all the information about that
patient. Which sort of assumes that it is the point where it\'s
aggregating lab results and referred (indiscernible) so forth. It seems
there\'s a dependence in terms of being able to scale any one of these
things on many of the things that AHIC is advocating. And I\'d welcome
comments from all three presenters on what they expect AHIC to focus on
around these efforts to bring about scalability in broader success in
any these models.

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

This is Edward again, I\'ll be happy to start. My focus, and I would
suggest a key focus, would be providers in community settings, physician
practices, one to ten, who see the majority of parents in the U.S, and
who largely don\'t have EHR. And I think that the standards for
interoperability and data sharing that you reference are important. As
the slides indicated on the HL7, very committee compliant. And I\'m
certainly pushing for that. But frankly, if the systems aren\'t used in
the first place, all the standards in the world won\'t mandate their
use. And the challenge right now, frankly, is not in interoperability
challenge. It\'s a relevance challenge. Unfortunately, most of the
physicians in smaller group practices are sort of marching along
grabbing a chart. And seeing the next patient and wishing phone calls
would be reduced and efficiency would be better. But it just simply
isn\'t. So I think tying any \-- if AHIC at the end recommends some kind
of financial incentives, market-based, cash, whatever. For physicians to
adopt systems, that\'s the point to tie in to standards. Meaning you
don\'t qualify for the incentive, unless the system that you are
adopting fulfills some basic requirements. As it relates to PHRs and
online systems, I think HL7 is probably doing some of the best work. But
standards without market drivers are kind of a light under a bushel
basket.

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

This is Jeff Rideout, I agree what the speakers say. Cisco has a
relationship. I guess the only thing I would suggest is that distinction
may be fairly artificial. As Ed pointed out, and others, a lot of the
services in quote, the network model, go certainly well beyond Web
visits or e-visits, and it\'s really the connectivity that most people
are looking for, whether it\'s with or without embedding it into an EMR.
And a lot of the more standalone applications, in addition to having a
full range of services, can be integrated into EMRs if people want to do
that. So I think the network model, I think we\'re saying more about the
delivery system and the size of the clinic rather than the \-- rather
than necessarily the application solution, if I\'m thinking about this
right. But I\'d like others\' opinion on that.

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

This is Malcolm. To address Colin\'s point. From our point of view.
(indiscernible) the Workgroup not to let satisfaction get in the way. I
think we\'ve seen many standards in healthcare die on the kind of vine
of everyone arguing about how to represent all 16 elements of the chem
screen. I think we\'re seeing if we can bring focus and clarity and
visibility to some key workflows that affect every physician and every
patient, in the management of common chronic diseases like diabetes and
asthma, and keep attention on how we improve that mobility, we can see
the gains. Thanks.

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

James Ralston. I\'ll also comment. I\'m a bit more hopeful today after
hearing Ed Fotsch\'s talk about the network model as being viable. But
I\'m \-- but so far my experience that \-- with chronic care, we\'ve
really only seen two big things really push adoption. And one is that
the secure messaging be part of the broad scope of what patients and
providers need to do. And that for us has included not just chronic
mail, but lab tests. And refills. And care plans. So those constellation
of features have driven adoption. Any one of those features we\'re not
sure is really enough to drive any kind of significant adoption. And the
second point is that so far the effectiveness that we\'ve seen is really
tied to understanding how larger redesigns around chronic, integrating
these systems into larger redesigns around chronic care, and I think
that speaks to Malcolm\'s point about understanding workflow but also
understanding about how you can leverage these systems to redesign care
to really meet the needs with patients with chronic illness care. I
guess I would think AHIC should look, the Workgroup should look closely
at incentives that would push in that direction. I\'m not sure I can say
there\'s any one system out there, though that I could say you\'d want
to drive incentives towards. Especially given, as Ed Fotsch spoke, most
patients receive care in small practices. So \--

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

So the state of the art is not sufficiently \-- there\'s not sufficient
consensus that you\'d want to go and get behind models to appear,
encouraging experimentation, and innovation in the space before deciding
to get behind one or two \--

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

Well, my own opinion is the U.S. healthcare system is too fragmented to
really support the coordinated needs that chronic care patients really
require. And so you\'re trying to patch technologies on to that that
don\'t allow it. That\'s why you end up with a network model as opposed
to a model that really integrated with an EHR. And if you use a shared
record that really does integrate the breadth of patients and doctors do
that provides an online service that\'s valuable to patients. But once
you move into the community, where care is fragmented and docs are on
different electronic health records, and all their workflows are
different, then I think the value equation there for patients is really
hard. I know Ed Fotsch has worked in hard on trying to do that. But I\'m
not yet convinced that \-- that that will be a viable model. I\'m
hopeful, but that\'s not been our experience.

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

Colin, we got time for probably one or two more comments and then we\'re
going to have to move on.

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

Could I jump in? This is Eric Larson. While we have these very
experienced people here, I had a question that I think picked up on a
comment earlier on about standards. And maybe each of you, if you\'re
interested, any of you, can tell us, are there aspects of standard
setting that you think would have impaired the ability of what you\'re
doing, early on we talked about in-person verification of identity, and
we were able to throw that out as part of a standard. What kind of other
standards would harm your ability to go forward with these efforts if
they were set in place? Or can you imagine any?

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

This is Ed Fotsch. I\'ll jump in. Having participated in some of these
standard setting bodies, I don\'t think there\'s a huge threat there. I
think there are reasonable people there and most of the standards have
some basic level of reason. I think that the real challenge and the real
concern for the standard setting groups is that unless there is actual
uptake and market drivers to get average docs and patients engaged,
it\'s kind of useless. A lot of \-- standards without a market are
largely irrelevant. And there\'s certainly plenty of those out there. So
I don\'t think there\'s a big threat from the standards group. I think
the threat is that all of the service discussed today, whether it was
e-consults or automated disease management programs, or providing labs,
or any of these online services, have a fundamental requirement that the
consumer is engaged online. And any effort from AHIC that doesn\'t
address, okay, how are we going to get the average consumer engaged
online, if they\'re engaged online, it\'s a network model and assuming
\-- if someone is engaged online, there\'s an unlimited service you can
provide to them. You can tune them up over time. You can add new ones.
The problem right now is the consumers aren\'t engaged, the only people
who are going to engage them are community-based providers if you\'re
looking at the majority of the proposition and there\'s little incentive
for them to do so.

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

Yeah, I\'d follow on from that. I think one of the questions that if
Craig was on the phone he would be asking the question about what role
\-- you talk about \-- I can\'t remember the name who commented defining
mandate, I think it was you. But rather than government mandate, I think
the role of employers as a driving force for deciding and defining what
engagement with employees and tools is an important potential driver in
this particular space and I\'d welcome your comments or anybody on
comments about what role employers ought to play particularly as the
Secretary\'s goal to enroll players to play a more vocal role in this
area. Sort of welcome comments as to what role employers might play and
how important they would be in driving adoption.

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

This is Edward again. I don\'t want to monopolize this. I think
employers are essential because they\'re the one group that the health
plans and the providers listen to. Because they are clients of both
providers and health plans. So they can be a powerful force.
Unfortunately, if the goal here is to motivate providers to offer
services and get patients on a network, which I think is the fundamental
goal, there will be almost no self-insured employers who by themselves
can change provider behavior, because they don\'t represent a large
enough portion of any physician\'s book of business to change their
work, or the workflow, or the systems they implement. So if the
Secretary could identify simple incentives that would modify provider
behavior, in mandate or cajole them into getting their consumers engaged
online, and employers were to match or participate in that exact same
incentive program, so providers wouldn\'t have to learn 35 different
programs, which they would ignore, each of which having no adequate
portion of their book of business, if the employer\'s line behind
incentives and standards that are created by the Secretary, their force
will be magnified because they carry such weight with providers and with
payers.

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

This is Joe Gifford at Regence, and I would take what Ed says and I
would \-- I would say that we have found that while true, that the
providers have the greatest credibility in this sphere, they also have
the least political sort of coherence. And that it is, in our view, has
been more practically successful to try to try to lead parade of
employers. While true, you still don\'t get big percentage of book of
business. As aggregated. For example, in Seattle we have Starbucks,
Boeing, Microsoft, Weyerhaeuser, a bunch of big companies all of whom
want to play. When they get together and say we want to start a sort of
PHR-type solution, for employees, and tie it to the sort of HRA
bandwagon, it does see quite a little crystallization I would add that
flavor that I think there is great value in engaging the employer simply
because they\'re more \-- I guess the word is just more organized.
They\'re just able to get things done in a and in our experience the
provider community is notable for its inability to come together and get
things done.

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

This is Malcolm Costello. Absolutely, I think you should be driving this
towards the employers. As you know, Craig has been very passionate in
the impact on U.S. employers of \-- in terms of global competitiveness
due to the extremely high and ever increasing cost of care, and I think
every attention should be brought by employers to environments where
practices particularly across, across the communities are endeavoring to
lower the cost of care and increase the quality of care. So I certainly
applaud work of Leapfrog Group in trying to do that select collectively
on behalf of employers, but I think anything that can be done to make
employees more aware of the options that exist, how to demand quality
and how to demand less impact on their lives in terms of seeking care of
services will be positive.

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

Okay. We\'ve had a very good discussion. Karen, do you want to move on
to the next speaker, then? Since we are getting tight on time.

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

We are getting tight on time. I think it\'s been a robust and helpful
discussion and again we would like to thank all three speakers, those in
the room and those absent at the moment.

We are going to move on to Item 6 on the agenda. And this is Eileen
Elias from the Office on Disability here at HHS. As many of you recall,
we had a discussion at the last meeting about the various populations
for whom secure messaging of some form or remote care of some form would
be of great value. And we recognize that the chronically ill include not
just the usual diabetes and CHS, asthma that most people think about
chronic illness, but includes people with cancer and the disabled. Since
we really didn\'t understand very much what this means for the disabled,
Eileen agreed to give us some information about not only that population
but some of the costs and utilization. So Eileen, would you take the
floor from here, and I will also give you a 13-minute warning.

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

I\'m going to start off with a challenge to the group. And that is to be
very careful on how you\'re including persons with disabilities under
the chronic care rubric. Many times when people address people with
disabilities, they see it perhaps through an illness perspective which
is totally incorrect. And that\'s what I want to emphasize in addressing
the type of topic areas that Karen had recommended that I cover. I
thought that I would start off first with just understanding that within
the Department of HHS, this is the next slide. There is there is an
Office on Disability that Karen alluded to, and that office was created,
and about now almost four years old, so it\'s a very young entity but in
the immediate Office of the Secretary. And I would say to you of all the
various bullets that you have in the PowerPoint, the most important
aspect here is that we work wit,h interagencies, within HHS with all the
other federal departments, and most importantly as well, with all of the
national constituent-based disability-based organizations representing
providers as well as advocacy and constituents themselves. And we bring
them together at quarterly, during the year, to address key subject
matters. And this is one of the areas that we intend to present to them
at an upcoming meeting. When we talk about disability, it\'s also
important how we proceed, which is the next slide on understanding what
is meant or the definition of disability.

And so you can refer to disability through both understanding it,
through the Americans with Disabilities Act. Definition. Which we \--
and we to be frank with you, we walk in very muddy territory when you
try to define disability. There are over a hundred different definitions
on disability just in this nation. Let alone many, many more when you
look at it on an international basis. And for the ADA definition, is the
one that we have been emphasizing, it\'s the one that we use when we
help write the 2005 Surgeon General\'s call to action on accessing
health and wellness services for persons with disabilities. And so
therefore it clearly states as a physical or mental impairment, that
substantially limits one or more life activities. And by physical,
physical includes sensory. Both blindness, and visual, and by mental,
that really also gets at cognitive. And when you get into the definition
of itself within the ADA, it also includes substance abuse. And then has
a record of such impairment or is regarded as having such an impairment.
This is very succinct. The definition is actually much more
comprehensive, but these are the general points.

What we also have been emphasizing is the international classification
ever functioning definition, or ICF. And in fact I\'ll be talking about
ICF as I proceed, because of the importance of understanding functioning
as a way of addressing people with disabilities. And that where the ADA
interfaces with all of this is the importance of understanding
accommodation.

What\'s accommodation? That the person is able to function in daily life
activities outside of an institution. And what, as I go on in my
presentation, that we found in looking at various (indiscernible) we\'ve
seen come out of reports, et cetera, for example, out of this committee,
has to do with perhaps seeing the person with disability from a more
institutional perspective. Recognizing very clearly, and Medicaid does
this as well, as well as Medicare, that CMS has and owns an
institutional bias. And that happens to be a challenge when we\'re
trying to figure out costs, cost-effectiveness and cost benefit.

There are over 54 million Americans, persons with disabilities, who have
at least one disability. And that\'s from a McNeil report, as I
footnoted. And that 52 million of them reside in the community pursuant
to the Census Bureau, recognizing that even the 2002 Census data is not
always the best data, because it doesn\'t pick up as well as we would
want people living in rural areas, people living in institutions, and et
cetera. But at least this gives you some kind of a statistic to work
from.

Most individuals will experience a disability at some point in their
lives. That\'s a fact. Prevalence of disability increases with age;
i.e., 7.8 percent for those 15 years and younger, 73.6 percent 80 years
or older.

The follow slide, in fact, and this is taken from the U.S. Census Bureau
of 2000, and in fact we included it in the call to action for persons
with disabilities, it shows a breakdown per disability per the age
groups that I identified, how you can begin to look at disabilities
around the various categories, and aging.

When we talk about health and disabilities, and this is getting at the
point I started with, disability is not an illness. Good health is
necessary for persons with disabilities to engage in all aspects of
life. People with disabilities face unique challenges, though, in trying
to access healthcare. That\'s when we get to the problem. And when in
fact people who are unnecessarily institutionalized, when individuals
with disabilities in fact do not get the healthcare that they require,
that\'s when you see the healthcare costs occur. When in fact the person
attains the necessary accommodations, be that a power wheelchair, other
type of wheelchair that they may need, or a lack of a \-- a hearing
disorder when they could benefit from a hearing aid, to a cochlear
implant, to someone who requires a personal care attendant, et cetera,
when those are provided, even if the person is diagnosed with
quadriplegia, they can well manage in life if in fact they have the
appropriate accommodations and do not need to be institutionalized. And
the cost to healthcare grossly decline, as long as that healthcare
access is maintained.

What are the challenges? What we have found in numerous number of input
meetings that we have had with provider organizations, and other groups,
is that when in fact the physician\'s office does not accommodate the
person with disability, when in fact the diagnostic tools are not
necessary, when in fact you don\'t have an examination table that can
accommodate the individual, when in fact the physician does not have an
interpreter or does not have some other mechanism to address people with
visual or hearing disorder, and other kinds of accommodations for people
with visual disorders, that\'s when you have your health mistakes,
that\'s when we see various errors occur, et cetera.

When we talk about barriers to healthcare access, I summarize, we can
also look at the fact of what is or is not covered by public and private
healthcare insurance. Where the emphasis, as I\'ve said before, tends to
be historically more on the institution. The challenge of poor
communication and accessibility. The focus more on acute short-term
treatments. And the provider education is a key factor. When we in fact
have been able to work with providers and their respective trade
organizations, and ask, you know, how have the physicians, how have the
social workers, the nurses, OT, PT, et cetera, really been trained to
work with people with disabilities? How much time have they spent in the
residencies and in their internships? It\'s truly minimal. And so what
\-- it\'s not a simple statistic. It\'s not just about electronic
record. It\'s about what we are challenged to address in the Office on
Disability of improving this access problem. And then we have provided
to you under population characteristics, just some general information
about the employability of people. It\'s not that persons with
disabilities can\'t be employed. It\'s the fact that we have the
discrimination challenge, et cetera, which ensures that the public
health insurance continues to have to be the baseline. When we get to
telecommunication, we\'re talking about opportunities here. It\'s
obviously access to healthcare information. Enhance and streamline
delivery. Remove communication barriers. It\'s been already found to be
a fabulous accommodation. But what are the barriers? Many times persons
with disabilities cannot afford the computers, the adaptive equipment.
The difficulty in using the Internet at public facilities much the
limited exposure. Age is a factor here. And just difficulty in
monitoring secondary conditions.

When we talk about cost analysis, we found from reviewing Medicare data,
from 2001, that there was 242.4 billion dollars expended on
beneficiaries with disabilities, from CMS data. Persons with
disabilities are more than likely than not to have to rely on public
health insurance, and that the challenge here is what we\'re paying and
the support for personal care attendants. When you look at the
institutional versus community-based care, and you see the graph, it
speaks for itself. The reality is 52.8 percent is spent on institutional
care, that\'s the institutional. Many of those individuals do not need
to be in that institution. It especially in a nursing home, or other
long-term care facility. What we do know is that with the accommodations
as I said earlier, majority of those people can be placed in the
community. We are working very closely with Medicaid on a number of
different waivers to help move individuals through the community through
a process called Money Follow the Person. But there are political
factors in this that one needs to consider because it\'s talking about
nursing homes and it\'s talking about the challenge of nursing homes not
\-- either having to change their venue of how they operate, which is
difficult.

Cost-effectiveness also can be identified. CMS has done various research
to develop risk adjustment methodology all of which we have not been
able to obtain any firm data on. Further research is absolutely needed
on cost-effectiveness, comparing institutional community-based care, we
expect to find that more from the recent waivers that are about to be
implemented as grants on what\'s called Money Follow the Person. And if
in fact I was to tell you anything, it\'s a secondary disorder from the
lack of access to health care that becomes the problem; i.e., the
(indiscernible) that could have been prevented, the kidney problems,
diabetes that can often result from in fact the poor monitoring.

The ICF that I spoke of earlier is in fact a functioning process that
Medicaid or Medicare has begun to use. And we\'re looking through our
process to see ICF become more a programmatic clinical tool as it\'s
being used elsewhere in the world. As a way of monitoring how the person
functions so that it pushes us from just a simple diagnosis into how the
person is functioning, and with the ability, and I keep saying this
again, the accessible tools for the person, that in fact you find the
person functioning increases and the cost begun decrease at least
elsewhere in the world.

And I\'ve mentioned already the secondary conditions, the \-- try and
identify some additional examples. I\'ve talked about the LOF, and its
important on in light of Medicare. And in summary, what we are
emphasizing when you talk about electronic communication, et cetera,
that in and of itself it\'s not enough. That we need to look at
universal design that applies to all examination tables, tools,
diagnostic equipment, medical facilities, and IT software and hardware.
And this is really the factor we talk about with electronic
communication. When you have a visual or hearing disorder or physical
disorder, you may require a certain kind of software. Now, if you work
for the Federal Government, that\'s not a challenge, because it\'s
available. When you work for a nongovernmental entity, it may become a
factor. When in fact not employable or employed and you require that
software, attaining it can be very expensive. These are all factors that
need to be considered, as well as accessible hardware.

The self-management and collaborative care increased emphasis on health
literacy and prevention and wellness services. All of which goes in line
with electronic communication. The challenges going back to the first
bullet about universal design.

Improving consumer clinician access, we totally emphasize the importance
of the electronic communication in light of perhaps also services that
cannot be provided electronically for people with disabilities who are
residing in the community. And therefore the need, especially in rural,
frontier, and sometimes urban areas, of mobile service teams so. The
service team may not need to have the physician there. And the physician
can be available and through telecommunication or electronic
interaction. But clearly the occupational therapist, the physical
therapist, et cetera. On the mobile, as mobile outreach in light with
the other. All has to be considered. So? Summarize summarizing,
increased emphasis in looking at disability from functional perspective.
To enhance what has been emphasized here around client-centered services
in order to avoid institutionalization, and provides data to support
what in fact everyone here is seeking.

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

Thank you very much. Are there any questions or comments?

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

The only comment that I have is what I started with also about chronic
care. I\'m going to strongly emphasize, and Karen and I have discussed
this already. The importance of having a subcommittee or however the
nomenclature will work, of individuals who are knowledgeable or expert
in disability. And to be able to bring them aboard into this process, I
strongly recommend not calling them chronic care. That will back
immediate barrier.

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

Thank you very much, Eileen. Any comments or questions from the
Workgroup members? Okay, thank you very much. I think what you presented
to us is a very robust concept which clearly indicates that having the
ability to communicate electronically with the disabled population is
critical and important to their care. But there are many, many other
factors as well. And we\'ll certainly consider that in the
consideration.

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

And not to rule it out.

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

Thank you very much.

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

Shall we move along, Tony?

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

Yes.

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

The next part of our presentation is to really focus a little bit more
on the entire scope of what patient communication with \--
patient/clinician communication can be about. And to that effect, we
have with us today here in the room as well as on the line,
representatives from two big delivery systems. One private, one public.
And I\'d like to introduce first Joseph Ternullo, and Dr. Joseph Kvedar,
who are with the Partner Telehealth, Partners HealthCare telemedicine
program in Boston. Joe, would you like to make a few comments here,
first, or are we going to the doctor?

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

I\'ll go.

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

Dr. Kvedar, you\'re on.

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

Can everyone hear me all right?

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

Yes.

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

Very well.

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

Good. I applaud the group, I\'m actually very pleased to be able to talk
to all of you. I applaud the group for putting up with all these
presentations over the phone and the Web. It\'s hard to do and it\'s
hard to, I think, give a presentation in this medium. But I\'ll try to
make it interesting for you. I also applaud people who put together the
agenda and the order of the agenda. Because I think it\'s quite
interesting that we\'ve gone from applications that make the provider
more efficient and engage the consumer, through the work, the important
work, on disability, and now myself and then Adam will talk about
extending the technology and interactions, I will say into an orbit
slightly farther out, which is care online. How can we provide care when
the patient isn\'t in the office and add value? And that\'s really what
I\'m going to focus on. Can I have the next slide, please.

Just a bit about Partners HealthCare and why that\'s important. It\'s
important because we have \-- we\'re delighted to work in a system in
Boston and our CEO has mandated we believe like a system. Partners is an
integrated delivery network anchored by two academic medical centers.
The Brigham and Women\'s Hospital and the Massachusetts General Hospital
in Boston we have care \-- we care for approximately 40 percent of the
citizens of eastern Massachusetts on a given day, and we do so in a
cradle to grave manner from pediatrics to acute care to primary care, to
non-acute rehab, home care, and the whole gamut. And for those of us
interested in looking at the use of technology to move care to the
appropriate setting to improve quality and increase efficiency, a good
place to work. And as I said, we have mandate, but support from the top
down to do interesting and innovative things to make that happen.

The group I work for is called Partners Telemedicine. And we have a
ten-year history of playing in this space. One of our two \-- our
mission is bipartite. One of our missions is indeed to put together
programs that thoughtfully move care out of the institution, out of the
office, out of the hospital, and to wherever the patient is. Really to
quote something that Jay Sanders said earlier, the point of care is
where the patient is, and that\'s really our model. We use consumer
technology largely on the Internet to achieve that. Next, please.

This is really why we\'re here. I suppose it\'s a bit like bringing coal
to Newcastle to remind this group of this challenge. There really are
two challenges that are pushing Partners in this direction. One is
illustrated here, which is the capacity challenge. We aren\'t training
enough providers to take care of the demand that\'s coming our way. And
we probably won\'t be able to do that even if we changed dramatically
our, the way we train people. Starting today, we couldn\'t keep up with
demand as evidenced by the two graphs on this page. So we seem to have
lost the capacity ballots. The only real way to fix that is to start
giving patients more opportunities to care for themselves and to make
better use of our brick and mortar, and perhaps a third way, which again
speaks to our work: to think very, very carefully about whether every
single healthcare interaction has to be one-on-one, provider and patient
in an office setting or a hospital setting, can we move some of that
care into an online environment and realize efficiencies doing so, that
showed the premise on which our work is based. The other imperative
again, of course, not news to this group, is the cost imperative. I was
very interested in the discussion earlier about employers. In a moment
I\'ll share with you program that we\'re undertaking in collaboration
with a large local self-insured employer. To get employer involvement in
this arena. Next, please.

So again, we\'re talking about a world that\'s patient-centric, where
the care is delivered where and when it\'s needed. A big component of
success is giving patients access to their own data. Giving them tools
for self-management. And indeed we can demonstrate that this is a less
capital intensive environment and makes more effective use of providers.
This is one of our patients in a heart failure monitoring trial pictured
on the slide. Next, please.

How would we achieve this vision of moving care into an online
environment, into an environment where patient and provider are
connected only by the connectivity of a network? We really view it as
having two large components, and we talk about platforms, and in a
moment I\'ll share with you a few of our projects and I mentioned this
platform discussion because it puts them in context. It\'s really
important, as I said earlier, to give patients the opportunity as much
as possible to care for themselves. And that\'s really what the
adherence platform is about. It\'s a combination of giving patients
access to data about themselves, we\'re particularly interested in
physiologic data and imaging data, but of course access to records and
medications and so forth equally important. Motivation and support is
huge. Someone earlier mentioned how important adherence is. Adherence is
a really important part of our thinking, and we\'re of the mind that
simply giving people annoying reminders isn\'t particularly interesting,
that we have to do it in a way that engages them much more than that and
motivates them. And of course patient education is important as well.

The other side, you might think of the top, is self-care. The bottom we
think when a provider needs to become involved in care, then we have to
create a remote care platform, which includes monitoring for sure,
that\'s very hot right now in the industry. And there\'s a lot of
activity going on in that area. Of course, we don\'t really want our
patients just to feel monitored. They need to feel cared for. Which is
why we need to include these other types of activities in the platform,
remote diagnostics, which we\'ll see more and more of as the era of
genetics and genomics fills in our life. And then of course remote care
delivery, which really is about, again, caring for the patient and \--
and in today\'s models, most of that means sending a nurse out to the
patient\'s home or having a nurse phone the patient. But we\'re quite
(inaudible) in developing systems where that can happen in a virtual
environment. And that\'s part of our research platform.

Now I\'ll take you three or four of our projects. The goal is to
illustrate some of the principles that I have alluded to. One is can we
move patients to a lower cost environment, improve their quality and
improve their care experience and win for everyone. That\'s one
principle. Another is can we take advantage of information as a
flattener and be able to extend care decision-making to lower-cost
providers, so that\'s a theme as well. And again self-care is a big
theme and keeping patients cared for but remote is a fourth. Those are
the kinds ever things we\'ll talk about in the next few slides. Can I
have the next slide, please.

These are the three projects. Again, given the time constraint, I
decided to just highlight three, heart failure monitoring has two parts.
There\'s a really interesting study we\'re doing with e-visits and I\'m
happy to report on that given all the talk earlier about e-visits
having, being not such a hot idea and so forth. I want to tell you our
experience. And then hypertension self-management is the other one I
chose to illustrate. So let\'s go on and talk about heart failure,
please. This is really, how do I want to say? This is the poster child
of success for the type of initiative we\'re talking about. These are
patients, a patient and one of our nurses, these are not pictures of
actors. They\'re our folks. We started this journey many years ago, but
became \-- it accelerated a couple of years ago because of the advent of
prospective payment in the home care sector. And of course if we have
capacity challenges in general, there\'s nowhere where it\'s felt more
dearly than in the nursing sphere, and home care nurses are a
particularly inefficient group of providers, so the home care agencies
became very interested in using this kind of technology, particularly
for their Medicare population. So we started that journey a few years
ago by doing a formal test of whether adding scale, blood pressure cuffs
and pulse oximeter and some structured questions on a handheld device in
the home, whether that package could change care in a positive way. And
I know Adam\'s going to share similar data in larger scale. What we
found was we were able to reduce the need for skilled nursing visits to
the home by 40 percent, which solved home care\'s problem. And we were
able to reduce admissions to the hospital by 25 percent. And indeed the
patient\'s quality of life improved uniformly as measured by standard
scale SF-36. So the home care people took that data and they have been
scaling this now, this is an offering that they give to a number of
patients in their Medicare population, moving beyond congestive heart
failure to COPD, renal failure, anyone that they feel they can manage
more effectively with this tool set that gets monitored now. And again
the idea is the visiting nurse is more efficient and the patients are
kept out of the hospital. So everyone wins. So it seems. Next slide,
please.

So we\'re formally now evaluating an interesting concept which is should
the acute care hospital reimburse the home care agency for monitoring of
these patients that are not Medicare patients, not homebound? Those of
you who know the details of Medicare reimbursement knows that for
patients to qualify for a prospective payment, they must be home bound
and Medicare eligible. And we see the value of the services and wanted
to ask the question, could we extend them to other patients with chronic
illness, particularly heart failure? It turns out that in our delivery
system, the hospitals are quite full, there are very important and large
challenges around getting patients in the hospital that need to be in.
So the idea of maybe keeping heart failure patients out of the hospital
is quite compelling at a system level. Again, as long as we\'re
providing high quality care as we do so. And so our current initiative
is indeed that, that we\'re enrolling patients and we\'ve made the
commitment to the Mass General who is participating in the trial, that
we can keep a patient, on average avoid one admission in six months. If
we do that, our math tells us we\'ll actually make the hospital some
money and provide better care to the patient, keep them out of the acute
care setting. So we think there\'s an opportunity there, and again all
the while the hospital is reimbursing the home care agency on a per
patient, per month basis for the monitoring. And that\'s taken into
account in the costing. This seems to be an economically viable way to
tie monitoring in the whole system for chronic illness, our next targets
are going to be COPD, diabetes, and we\'re looking carefully at mental
health. Next \--

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

You\'ve got about 2 more minutes.

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

Okay. That\'s good. Next.

This is electronic visits for acne, and the e-visit is allowing acne
patients to submit three images and fill out a structured form. You can
see the RelayHealth Website, a partner, in there, the other important
point is BlueCross BlueShield of Massachusetts is a partner in this.
Reimbursing physicians for these visits at a slight discount over office
visit rate. And the goal is to do better management again of office
workflow, we think this is a model, we think there are a lot of probably
repetitive, mechanical visits in our system that we could put op to this
kind of platform. So far patients are finding it very attractive because
it\'s convenient for them. Providers are adopting as well, we\'re midway
through our clinical trial on this so I don\'t have definitive data but
so far things look promising. Next, please.

The last one is hypertension, the theme here was where are we adding
value, so we\'re partnered with EMC on this particular project, EMC
being a large self-insured employer. The idea, we\'re working this one
through, it\'s not started yet, patients will get access to a blood
pressure cuff and a series of rich educational materials online,
including tracking of their own blood pressure reading. Our hypothesis
is that will lower their utilization and improve their quality of care.
But I want to make one important note, that this is being \-- it\'s
patient-driven and therefore when they choose to involve their doctor
with this data, it\'s going to be up to them. That\'s sort of an
innovative aspect of this trial. That\'s scheduled to start in first
quarter of \'07. Next, please.

Just want to finish up by pointing out there are ways to \-- we\'d love
to have more people visit the Connected Health care Website. I don\'t
know how your version looks but it\'s cut off here. It would be, we
would be delighted to have visitors to that site join the discussion,
help us figure this out. We just published a book in this arena and we
do have a conference September 18 and 19. And we\'ll have a number of
talented speakers at that conference. Joe Turnello who is with you, is
the chair of that conference. And at this time I\'ll \-- later, perhaps
offline, he can tell you more about it \-- I do appreciate the time and
when it\'s question time I\'m happy to take questions.

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

Thank you so much, Joe. We will hold the questions for Partners
HealthCare until after we\'ve had our final presentation from Dr. Adam
Darkins, chief consultant. Thank you.

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

Thank you very much.

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

Maybe I should \-- can come up.

**[\>\>\
]{.underline}**Probably you should begin, given the time constraints.

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

Let me begin. Perhaps we should start by staying there\'s no evidence
that the routine outpatient clinic works in terms of the most chronic
disease. In fact, anecdotally you can say so often patients turn up two
weeks or four weeks after the clinic with a problem. So I start with
that. There\'s some evidence that home telehealth works and Joe has
given the background to it.

\[break\]

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

Basic model of how you provide this kind of care at home. Which is very
much based upon defining models implementing the evaluating the
critically reviewing them.

The devil as I said is in the detail. The models require the clinical,
technical, and the business processes to be in place. In terms of doing,
this we worked on the presumption, this should be standardized, helps
back to standards being important. The idea is a veteran who is a
snowbird who might live in Seattle and go down to Tucson in the winter,
moving the technology but also the care down there. And be essentially
plug and play, with the technology with the care is very much behind
what we\'re doing.

An important thing we\'ve done is actually concentrate also on training.
I think one of the things that happens in some of these programs is
they\'re dependent on the initial enthusiasm. When they leave often the
programs diminish and disintegrate. We established a training center in
January 2004 that links into Florida, has a certification program, the
three and a half thousand staff have been trained, takes under three
weeks to train a staff member to become a care coordinator. It means
there are the staff to be able to expand this out.

The reason we\'re growing at the 800 or so patients a week at the moment
is because essentially the effort has gone into refining model. I\'ve
put the case to you to develop large networks. You\'ve got to get the
model right. Rather than allow things to sort of expand up. Next slide.

I\'ve put the iceberg in here to really show that a lot of it is \-- the
devil as I said is in the detail. The care coordination goes very much
with patient education, and the patient-held record. The idea
self-management Joe has talked about is very much behind what we\'re
doing is well. This very much links into the MyHealtheVet initiative
within the VA, and we certainly would see a large proportion of what
we\'re doing on MyHealtheVet not too distant future. But in terms of
defining the patient, clinical (indiscernible) standardized way of
providing clinical services, we have a quality assurance program that
has been the forerunner of one of the programs, is subject to this on
yearly review. We have got quality assurance in terms of outcome
measures which I can talk in detail about.

The implementation in terms of covering the security, privacy making
sure this is a robust technology that\'s up there. The fact 18,000
people might be non-institutional care means this has to be technically
robust in ways that there are backup and redundancy and it can\'t go
down. Just issues, how do you distribute equipment to 18,000 homes,
refurbish it, not inconsequential. Management and support coding and
workload credit. We use what are the current state of the art for codes
in addition the VA has the ability to do codes internally using some
decision support system. And interesting thing I think that comes up in
terms of discussion that talked about episodes of care or fee for
service for this, this really in terms of how we\'re doing it comes
under looking at programs of care. Which are very different ways of how
you look at care than episodes of care. So just like to sort of feed in.
If you\'re going to fund these, it looks like the funding mechanism
looking at programs of care than episodes of care is probably that\'s
going to be required.

I hope I\'ve given you a sort of rush through in terms of the flavor, a
very large program. Been instituted over three years. And the next jump
in the program is 2009 when we intend to reach 50,000 patients. And as I
said, the vision is relatively easy about how you do this in the home.
The devil is in the details. And often when you start off with programs
and projects, it\'s how you change what essentially were
relationship-based ways of doing business into process, so I would very
much advocate the need to do things in a standards-based environment.
We\'ve contracted for our technologies nationally and locally which has
allowed to us put standards out to what is essentially an emerging
technology industry for which there is no standardization, which we\'ve
had quite major problems in terms of dealing with.

Thank you.

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

I think it\'s fair to say \-- this is Karen again \-- we weren't
disappointed. Clearly did provide huge amount of information going to
take a while to digest. But we have some time for questions and comments
from the Workgroup members at this point. And before we move on I just
would like to add my personal thanks to particularly those who came here
to Washington to do those presentations today, as well as those on the
phone. So thank you to both Partners HealthCare and the VA for your very
robust presentations.

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

Thank you very much.

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

Thank you.

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

I had just a quick question for you, Adam. You mentioned the focus on
reimbursement on programs of care versus episodes of care. Could you
just give us a little more feedback on your thoughts on that?

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

Well, it\'s interesting in terms of constructing a coding system. The
coding system largely in the VA is based on episodes of care outside.
That doesn\'t require you to have a start and stop date when it takes
place. We look at how you enroll somebody for a period of time in terms
of test outcomes. And it works towards what you\'re trying to
incentivize is not how often they\'re seen but what the outcomes are. So
in terms having that program of care, you have a start date and stop
date and really the outcomes associated what you\'re interested in,
which is very different way of looking at it how you deliver care. We
kind of work towards what that might look like and working internally to
discuss that. And I raise that as what I think is certainly a serious
proposition for us in the future and would imagine it might be outside
as well.

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

Absolutely. So you don\'t have any information at this point that you
can share with the group, you\'re still looking into that?

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

All I can say, the other thing we\'ve done is try to develop data
systems. One advantage of having electronic systems which manage the
patients, electronic systems can equally register patients on databases.
And can make sure you get very robust data sources. So in terms of
looking at what those programs of care may be, we have ways in which we
can look systematically of October from this year, thanks to internal
resources in VA which we\'re lucky to tap into. That we can look at
outcomes related to those kinds of programs. So I can\'t give you
detailed data but I can happy what will be forthcoming is to give data
exactly on what might be the outcomes from kind of programs of care
we\'re talking about.

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

All right.

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

Looking quickly, and not just how you enroll people but what might be
some of the issues around dis-enrollment but the continuum of patients
we\'ve got may well be moving into long-term institutional care. So
it\'s almost like a glide path. One could see these like an air traffic
control system. Monitoring some of these people in community and
determining flows of where they go.

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

Okay.

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

This is Jay Sanders. Once again, I think two great presentations. I\'ve
got a little bit of a conflict of interest in saying, that because both
Joe and Adam are good friends. But great examples both in the private
and public sector and I think the results are seminal in terms of giving
us the kind of data that we need to assess the quality of care within
the home. With that stated, just a little caveat, and a mild warning
perceptually, and that is in the same way we got caught up in the
traditional healthcare system of thinking about the office as the
location for care, I don\'t want us to now begin to think, well, now we
have to shift to only the home. Because we talked about the employer and
the employer being a major component of change here, and I think the
same sort of technology and systems and programs, can be easily adapted
at the worksite. And in fact, in any demonstration of valuation, we
ought to make sure that from a cost standpoint, we try and capture a
cost which is never caught today, and that is the cost of loss of
productivity of that worker while they\'re going to see their care
provider. The so-called windshield time as well as their time at the
office being lost by going at provider.

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

Thank you, Jay. Other comments?

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

This is Colin. Just a question I asked the previous presenters. You
know, Dr. Darkins finished on the mention of standards at the end of it,
and I\'d like to comment again on what AHIC and the other initiatives
that AHIC is sponsoring should be thinking about in those areas in order
to make the kind of systems being experimented \-- being scaled out
here, you know, more easily, more easily connected.

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

Well, I\'ll offer my thought on that, which is brief. It is indeed \--
for us, the not unlike what Adam said, the way we\'re moving is through
\-- once we prove these things out, we\'re moving them through our
patient portal, and linking them in to our electronic record, and I
think that\'s the wave of where this activity going. And indeed the
larger context that your committee deals with, which is the
interoperability across electronic records and the country, and is
incredibly important in seeing it. One of the things in our system is a
quick example, is we mentioned earlier that we\'re \-- energetically
moving patients from our acute care service to the home care service and
creating a model and so forth. Of course, it wouldn\'t surprise you to
know that the physicians at the Mass General can choose to send a
patient to the Boston VA if they want. They don\'t have to use Partners
home care organization. So that\'s \-- off that patient goes whether
home care organization offers monitoring or not is one question. Turns
out every home care organization of greater Boston area does offer it
but there\'s no way to quickly link into the data unless you\'re in our
system. So that\'s just an example of why interoperability and standards
will become important to really scaling this.

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

I just have a quick comment, if I may. This may sound \-- I apologize.
But the electronic patient record which is really revolutionized by what
the VA does, provides solid information, information coming into clinic
or hospital. Talking about, to pick up on Jay\'s point as well is a
continual health record for people with chronic disease. Not just in the
home but also when they travel, at work, and the rest of it. So setting
the standards what that might look like, I think are extremely
important. And it provides a very different way of delivering care. So I
think one could see this really an extension of the electronic patient
record. Not as something separate or distinct.

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

Absolutely.

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

And this is certainly not the policy but there\'s no reason why we might
not think we\'ve instituted this in a group of patients,
non-institutional care patients keeping the home. Which very much makes
sense economically, as well, for the VA to do it. As the cost of
technology and the robustness of these systems grow, there\'s no reason
why patients with a PDA at home or at work might not be able to monitor
their diabetes and might help people remain active and at work rather
than did you but that\'s again something we may explore in the future.

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

This is Karen Bell. I\'d like to pick up on that standards question for
just a moment. As we think about the work that is being affected through
the Office of the National Coordinator, clearly harmonizing data
standards is one of the cornerstones of this work. We have our program
and we are looking at standardizing lab data and medication histories,
et cetera. As you, and I\'m looking at both Adam and Joe Kvedar, think
about the programs that you have in place right now are there particular
elements you believe would be important to make a higher priority for
vital signs, weight, as opposed to perhaps some of the less prevalently
used clinical indices?

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

This is \-- and Paul, are you still on the call?

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

Hello?

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

Yes, I am.

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

Okay, very good. Jump in. We have auto health data story which I\'m not
sure we have discussed here at previous meeting or not. But HDR is the
first step for us to sort of begin Mr. Standardization and we have
prioritized as you mentioned, Karen, vital signs as being one of the
very first ones to go forward with. The second happens to be I think
it\'s either labs and pharmacy, because we have to have some things to
start off and there\'s a list that we can share with the group, if
you\'re interested. And what are our priorities and standardizing as we
move forward into the HDR.

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

And this is specifically for remote monitoring, as opposed to \--

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

It\'s going to be used across \-- this is because we are still
interconnected and I think that\'s one of the biggest advantages that we
have of being an organization that started off as an electronic health
record, having \-- and a repository, going on. And moving on to
telehealth and bringing it back now to the HDR. So it\'s very much
linked and interconnected and I think it will be useful for the group to
perhaps (indiscernible) the entire story on that as well at some future
point.

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

I think that\'s an important point. The vital signs currently go into
CPRS, our laboratory service had some issues with patient-obtained lab
values such as glucose monitoring go into the lab files and so that\'s
something that is being worked on.

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

You could perhaps comment, too, Joe because we set some standards in
terms of being able to make sure. We are interoperability in terms of
different vendors we use.

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

Actually, that was what I was going to say, is for us vital signs just
to get to Karen\'s question, I don\'t think there\'s any point in doing
just weight first or something, because they\'re all a package of HL7
messages that are fairly easily, I think, implementable. And that\'s
certainly what we\'ve done as well. Having said, that, we\'re just
getting our vital signs into the electronic record. It wouldn\'t
surprise you to learn that our home care organization as has its own
electronic record and we\'re just beginning the discussions of merging
that and interoperating that with our own medical center-based
electronic record, but in that process vital signs will be woven into
both.

**[\>\>\
]{.underline}**So if we were to move forward and prioritize vital signs
including weight, a high priority for HITSP, our standardization panel,
that would be helpful to everyone who is in the remote monitoring space
right now.

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

Right.

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

Yes.

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

I think it\'s critical. I don\'t think you could really do it without
that. I mean, there are other things, as I said, monitoring is only one
slice of the pie. But it\'s a critical first step.

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

Could I muddy the waters by mentioning the fact that one other area
it\'s going to be really important for us to think about to standardize
something going to be disease management. Because the way in which one
ends up linking the patient around specifically asking questions makes
disease management what they are and how those questions and the answers
get prioritized and dealt with is going to require standardization in
the future. I won\'t elaborate.

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

The VA is a terrific model. Terrific laboratory for a way to do
proactive care. It has the unique feature, though, that the funding
source, obviously is \--

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

Joe, we\'re losing you.

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

I don\'t know if that\'s me or somebody else. Anyway, so the funding
source is different, obviously because it\'s not the typical CPT-based
fee for service sort of deal. Do you have \-- so my question to VA, do
you have \-- are you able to do the analysis or the research that
actually shows cost savings or utilization savings based on typical fee
for service metrics in a way that would make it sort of a useful
laboratory for the rest of the healthcare world which is driven by
employer-based healthcare and folks that are actually employed. So do
you capture CBT encounters and are able to say if you do this process,
you know, you have 30 percent less of them and like the UW found, nobody
wants to do it because you don\'t get paid. Are you able to report on
that kind of thing? That would be so useful for us.

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

Yes, and all these patients have CPT codes as well, as best they can
related to these service itself. But just again, flag up, I would just
put to you that maybe this requires a different way to look at how it
may be reimbursed and funded in the future. Therefore, the VA may well
be a ideal laboratory to actually think about some of those things,
because if some of the things \-- again my personal opinion, if things
would be a couple of percentage points out it wouldn\'t be the end of
the world in terms of a capitated system. But if you put it out to the
world at large that could translate into something very different.

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

I just would emphasize \-- this is Joe, that the \-- we can really only
do this if we change the way we reimburse for care. I love the picture
you painted, Adam, with the care as units of time as opposed to episodes
of care. I\'m not sure what the right model is. We\'re trying different
models here as well. That\'s why I highlighted the experiment with EMC,
because their component of that is reimbursing for that hypertension
management system in a different way that\'s completely unrelated to CPT
codes. So the codes of course bring us back into the environment where
the patient comes to see the provider and the cash register rings and
it\'s hard to make these things work if that\'s your basis for running
your economic engine.

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

But I would say, again, from Regence, I would say the data point we all
need is just an estimate of what the deltas are in short-term costs.
That is, we\'re doing a pilot and in which we actually have to write a
check on a PNP basis for the care coordination piece to become proactive
and that\'s a short-term cost but I would be interested in the VA could
tell us, we studied this and in fact doing it this way, is in the
short-term, is five percent cheaper, you know, or ten percent more
expensive, or whatever. Just so we \-- so you can make budgets \-- you
know what I\'m saying.

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

Yeah \--

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

The one \--

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

Sorry, just one more comment. The one thing that we will have to comment
on, not right away, cancer, are the CMS trials, Mass General is
participating in the trial and I know others are as well, and that\'s
the kind of arrangement that we have with CMS. For those trials. So we
should be able to comment on that as those roll out.

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

Karen, I guess we should probably move on to additional topics. I\'d
like to thank both speakers again, I think it was an excellent
discussion. We have a little more than a half hour to go. Colin, I
suggest we probably focus on Items 8 \-- not Item 8 -- 9 and 10, with
the time we have remaining.

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

Alan?

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

Yeah, I think that\'s a good idea, Tony. Sorry, I was talking through a
mute button.

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

That\'s okay. I don\'t know, is there anything on 8 you wanted to
mention, Karen, before we move on?

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

No, I think I would like to reiterate what I said a little bit earlier.
We will pull together some information on what is available in the
peer-reviewed literature. Richard, I think did an excellent job and
doing that. You might want to comment on it a little bit, Jay. I know
you certainly are very cognizant of what is in the literature as well.

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

No, I think as you said, Richard did an excellent job of surveying a
number of the projects that are out there. I think the only
disappointment I had is that we\'re not further along in some of the
studies that are ongoing, so we have more results. And once again, I
think the toughest problem is going to be the issue of sorting out what
specific intervention led to what specific conclusion. So many different
things are occurring in these specific \-- excuse me, specific trials
that it may be a little difficult to identify what the specific value of
one of those interventions might be in the conclusion that the trial
came to.

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

I know last time we had Justine Handelman and Jeanette Thornton give
some very high level survey information, Jeanette is there anything
further you want to add at this point?

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

Do you want to talk about the demonstrations or ideas we had?

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

Before you get to, that any further information you want to add about
the trials involving secure messaging?

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

I think that the interesting point to consider is the link between
personal health records, not only electronic health records in providing
a service to consumers, and I think that should be looked at by a
Workgroup as well. In addition to the link between electronic health
records as a way to engage consumers. And I think the point that was
made earlier about using the electronic clipboard as an incentive, or a
driver to other secure messaging is something you should look at in
terms of a link between the Consumer Empowerment Workgroup and your
Workgroup as well.

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

Thank you.

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

Moving on to number 9, demonstration on secure messaging, that ties back
to one of the recommendations that recommended a number of
demonstrations, some private and some government, including the CMS. And
I guess there\'s two areas I was looking at here. One, I know Karen you
wanted to sit up, wanted to have a separate discussion with part of CMS,
RTI, or AHIC, BlueCross BlueShield Association to discuss some, and AHRQ
to discuss some of this further.

But for today\'s purposes, did you want to review some of the Workgroup
responses in terms of some of the criteria they would like to see in
these demonstrations? And I think keeping in mind as we discussed last
meeting, these would be existing demonstrations that we would be looking
at both from CMS\'s standpoint and from the private payers.

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

Or it may be \--

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

Right, because some of them are to include the direct messaging between
patients and \--

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

Yeah, that\'s what I meant. They could be (indiscernible) modified.

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

Thank you very much. I think you\'re absolutely right, we do need to
come up with a consistent set of core outcome measures or value
measures. And that work will be on going now that we have been able to
define all the appropriate members of that group and we should be moving
on that very quickly in the next week or two. But the bigger question
that we \-- questions that we are were still dealing with at the end of
the last Workgroup meeting is everyone will remember had to do about
which populations, which clinicians, what type of remote data monitoring
do we want to look at, and are there other processes. So we agreed to
essentially survey everybody on a little bit of a matrix here to
determine whether or not there was a significant concordance on
particular factors so we could actually begin to flesh out the first
framework for how we might be able to advise any modification that
perhaps would be helpful. And a demonstration project. So I\'m looking
briefly, just go over how all of this turned out. Because there is still
going to be a couple of places where we may need to do a little bit of
discussion in remaining few moments. I think that in terms of
population, it came up fairly clearly that it\'s the patients with
multiple chronic conditions that we really need to be focusing on, not
those with a single problem and again this very specific to the Medicare
population where so many of them do have multiple diseases.

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

Karen, before we finish on that. You\'re talking as much about the
broader charge as a specific secure message, is that correct? You\'re
really looking at both areas \--

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

This is about the demonstration related to secure messaging.

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

I wanted to make it clear.

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

That\'s right.

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

We\'re specifically talking about secure messaging.

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

In this particular situation, the demonstration project should, if
possible, focus on patients with multiple chronic conditions, not just
on diabetics or patients with a single disease process. The second area
has to do with clinicians and (indiscernible). This is an area where we
probably will need a little bit more discussion. I think there was a
fairly strong concordance we didn\'t want to (indiscernible)
oncologists, cardiologists, or endocrinologists. That came out to be
fairly low and most people felt that was a low priority. There was not a
lot of agreement in terms of limiting it to particular areas, or
limiting it to particular delivery systems. So again, this is an area
where we had quite a bit of comment. That in addition to these
particular areas focusing on clinicians, we probably need to think about
other areas as well, and that\'s where we got into care processes and
workflows. So I\'m just wondering, for those of you who responded and
for those of you who didn\'t, are there any direction that you can share
with the rest of the Workgroup on clinicians or (inaudible) at this
point?

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

Can I?

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

Please.

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

About 30 percent of patients we\'ve got have multiple (indiscernible) so
it comes up exactly the same way. The other thing that comes up is who
you would want to manage these patients when you have (indiscernible)
and one of the things we wrestling with the generic versus the specific
of who it is who provides the care. So if you\'re thinking it\'s
physicians are going to provide the care then it\'s fairly expensive
resource to provide that management. If it's not a physician who is
going to provide the care, you\'re really into skills mix changes and
who that staffing mold might be. If you do the demonstration it\'s not
just demonstration of working, there\'s a bigger HR issue, it seems to
me in reels to who might (indiscernible).

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

That's a very good point and I think one of the takeaways that does come
to the fore here is that it will be important, that if no matter how we
think about the reimbursement, how we think about the staffing, that we
really are looking for areas where we can have multiple payers coming
together, multiple stakeholders come together. To do this more on a
community-based level as opposed to a situation where we take a
particular type of physician or particular type of problem and rule it
out nationwide. So I think I would just put on the table that my
take-away from what we are hearing or what we receive today is that we
will be looking for \-- we should be hooking for specific areas where we
can get multi-stakeholder involvement and this type of demonstration on
the payers and delivery system. Is that something that everyone would
agree with?

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

Yeah, Karen, I don\'t want to complicate this. This is Jeff Rideout. But
I\'m sure most of the people are aware of what Secretary Leavitt and
David Brailer were out doing the last couple of weeks in terms of a
forthcoming executive order from the President. That includes a
commitment to price and quality transparency, but also as a condition of
contracting for the Federal Government, standardization, adoption of
information technology standards that have come out of AHIC and
specifically the secure messaging mentioned, along with prescriptions
and lab results. So can you tell me, or could somebody explain how they
see that sort of initiative that Secretary Leavitt is personally driving
fitting with the extension of existing demonstration projects for this,
for this Workgroup?

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

I think it\'s \-- I think it\'s going to be, again, an issue of overlap.
We certainly have demonstration projects for certain areas and multiple
different types of arenas. We have the AQA pilots as they\'re called,
the pilots that are in six cities now, moving to 20, where we\'re
testing the measurement of the AQA measure, the quality measures. I
think most people are aware that in addition to that, as we move out
into these various arenas, clearly we are looking for multi-stakeholder
involvement to support the adoption of health information standards. And
that\'s a lot of what the Secretary has been talking about as well. So I
think the best answer to your question is we\'re looking at places in
the country where there is a congruence of activity and
multi-stakeholder involvement that will help move the agenda forward for
not only standardization but for standardized measurements and
standardized ways of looking at the delivery system and that\'s part of
the transparency model.

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

I guess part of my question, though, is also you know, how many trips
can you launch in this area. And we\'re being asked as an employer to
raise our hand, which we\'ve done several times to be on public record
as supporting this forthcoming executive order. So \-- and it is built
off the AQA pilots in the State of California along with the five other
pilots. I\'m just wondering if there\'s a coordination opportunity here
where we would push demonstrations of secure messaging to align where
people are being asked to sign up for something much broader.

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

I think that is the real issue here, is definitely we have to do the
coordination. And take advantage of leveraging as well. So it\'s \--
we\'ve not \-- I think what we\'re deciding here today is that we will
be looking at individual regions and try to coordinate some of the other
activities with what\'s going on in the region. A State or city or
perhaps a regional area that crosses the boundary in some size, shape,
or form. But this is not something that has widespread across the nation
effort.

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

This may be a naive question but can they be fit under the umbrella?

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

They certainly could be.

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

I was wondering whether or not there could be some opportunity to link
this with Medicare health support projects that are ongoing or you
already have focus. You have multiple stakeholders and CMS randomized
clinical trials. And it may be the capacity to test the added value.

**[\>\> Tony Trenkle:\
]{.underline}**This is Tony. We\'ve looked into that actually. There\'s
some other areas that we think are probably more appropriate because
they really, those don\'t tie as much to providers and patients as the
physician group practice demos do. But we\'re going to get together with
Karen, as I said, in the near future to talk more about this. Jeanette,
I believe you and Justine had gotten together from the plan perspective
and come up with thoughts as well.

**[\>\>\
]{.underline}**I guess our recommendation would be before we start
picking regions and states that we look at three general categories of
where a demonstration project could add a lot of value. We kinds of
divide that into three different buckets. One is looking at how do you
measure the value of secure messaging and that was along the lines of
what they said regarding ROI. The second bucket, some of our members are
having difficulty in defining the criteria for use, how do you prevent
overuse, under-use and how do you find that balance especially when
co-pays are involved and you\'re having to get co-pays for the secure
messaging, so that was another area we thought some research and other
work could be done. And finally, as mentioned by several of the speakers
today, the provider considerations, and looking at marketing and how do
you utilize the providers to increase usage, because one of our plans,
self-insured plans, 80 companies say they would love if their providers
would reimburse. But out of those 80, you know, only two providers
reimburse and they got like four claims in one year actually reimbursed,
so there was some disconnect. Employers were saying yes, we want this.
And the providers weren\'t able to provide that service. And when they
did, they weren\'t actually using it. So it was, there's a lot of other
work that we think needs to be done with providers, and looking at some
of the pilots that are already going on, what worked and what didn\'t
work in terms of increasing provider utilization. So those are those
three general buckets that we thought would be helpful in terms of
demonstration projects. There\'s different roles that we can play in
each one of those depending upon how you all want to go.

**[\>\>\
]{.underline}**Thank you very much. I do think some of those have
actually been addressed in some of our previous meetings and we can
bring you up to speed on those. For example, unless there\'s a 30
percent penetration rate in any given physician office, it\'s unlikely
they will change your workflows to accommodate secure messaging. So I
think some of that we already know. But I think you put your finger very
appropriately on other areas that we will need to explore as we go
through the demonstration.

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

Thank you.

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

Any other comments on this item?

Okay.

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

Karen, I guess the next item we would turn to would be to discuss
factors for prioritizing \-- Colin, did you want to mention anything in
that regard?

**[\>\> Colin Evans:\
]{.underline}**No, I think just press straight on.

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

Okay.

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

Thank you. Maybe I\'ll just jump in here in the last five minutes.

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

Because one of the things you had said earlier, Karen, is you had shown
us a timeline where we had to move towards getting a recommendation
letter to the AHIC by December, I believe. So I guess it would be good
for you to talk about where we are in terms of meeting that timeline and
what are the steps we need to do in the next several meetings to move
further along here.

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

Thank you very much, Tony. I think there are a couple of things that we
can highlight right here. And I think that we are beginning to really
get the kind of information we need to make those steps. One of the
deliverables that we will need to make through the AHIC to the Secretary
will be recommendations on where our various technology and policy
contractors need to be looking with respect to other types of remote
care. Clearly secure messaging is one. We\'ve had a lot of presentation
and discussion today about remote care in other venues. And one of the
interesting pieces of information that came from the last group meeting
is that there are pretty much right now a fairly limited number offers
that are being looked at. And so whether we prioritize vital signs as
being something that we would like the Standardization Panel to not take
up next or whether it should be gluclose readings or INRs from
monitoring anticoagulation in the home settings or the resource of
things we need to look at and we need to really develop a set of
priorities to essentially create the road map for the types of
interoperability activities we would like to press forward with. And so
that being number one, there are a number of factors that could be
considered. One factor could be penetrance. How likely are some of the
information pieces to be used. Another can be effect on changing
outcomes, either clinical outcomes or utilization outcomes. The third
may be the degree to which there\'s already technology devoted to these
types of clinical indices. So I\'m just throwing those out as
possibilities, and again we\'ll reiterate the fact this particular
deliberatable basically is focusing on what clinical elements should we
be teeing up that are important for remote care so that the
interoperability standards can be developed.

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

Yeah, I\'m going back to something Jay said the last meeting, he said
focus on what is the condition and what is the need and what is the
technology to help support that. Which I thought was pretty appropriate.
Jay, I don\'t know if you have anything more you want to add to your
previous remarks.

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

No, I just think we sometimes get so excited by the functionality of the
toy that we forget what the need really is and we really have to start
at the starting point. The starting point is what is the condition,
what\'s the disease process, what are the parameters that the clinician
here being either the physician or the nurse, needs, to assess the
patient. And then find the technology that provides that functionality.

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

I think talk about accessibility just from our experience some things
that are happening. Tele-based technology is very easy to use because
essentially you have to plug something into a jack and it doesn\'t
require a lot of fiddling and changing. Once you start going to things
which are on broadband or IP, it gets more complicated. These things in
the home whether it\'s the patient or staff. And also you got the
question about just upkeep and maintenance. I think we can all say
there\'s going to be some kind of information technology appliance in
the home which sometime in the future into which all this is going to
fit. I guess the other thing you have a way in which you\'re shaping
what things might look like. So it\'s worthwhile thinking more broadly
of what you\'re shaping as well as just sort of passively saying it\'s
just \--

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

Right.

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

And that did come up in previous meetings, particularly looking at rural
areas and the issue of broadband penetration.

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

Also, for us, a nurse can take a device in the home, and train the
patient, they can plug it into a phone jack and it\'s relatively easy.
Once you start getting into having designate IP addresses and the rest,
it gets a little more \--

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

Good point.

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

Although I would add to that the fact that we need to perhaps be looking
at the entertainment industry and the telecommunications industry that
are expanding the infrastructure into the home for things other than
healthcare and try and bring them into the discussion to make all of
this technology compatible and easy to use. And the same way that some
of the companies are saying look for the elderly population the best way
to activate the telehome care system is give them a remote control that
only, you know, works for the TV, with ultimately work for their
telehealth care system.

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

I think it\'s going back information appliance in the home that\'s what
it\'s going to look like. The question is how do you get there and I
think your point about e-mail and that it\'s \-- whatever the
application, it\'s going to drive that is what\'s \--

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

Right.

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

In the interest time, we may have to continue this discussion later.

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

I want to turn to what we want to discuss at the next meeting based on
your timeline. Where do you want to go? I think it was good that we got
a lot of speakers at this meeting. I would suggest that we may need some
additional speakers, but we probably should devote more time in the next
meeting to more discussion so we can get towards the recommendations. I
don\'t know what the other members are \-- or Colin feel \--

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

Tony, I agree with that. As you and I talked before, your point about
the sort \-- I also think that meetings of this sort are better
structured and better able to drive themselves when there is a more
specific deliverable. I think your comment about working back \-- I
think when we talked before we thought about working backwards a little
bit from the December expectations and sort of staging the meetings
between now and then to show that we\'re actually on track of meeting
some deliverable. Maybe naming earlier than to complete some things. I
think we should definitely block out the next meeting to be mapping out.

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

Yeah, and I think clearly the important piece of work that does need to
be completed at the next meeting is essentially creating that road map
for clinical indices for which we feel are most important for
interoperability in the remote care setting. So that will be that \--
will be the deliverable for the next meeting. We will probably also by
that time, Tony, have a little subgroup that, the little group that is
come together to look at outcomes, should have met and so we can have a
report on that as well.

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

Exactly.

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

Which actually prompts another thought that, Karen, in some of the areas
we, as we look to recommendation that is were made to AHIC, we
aggregated a number of recommendations that fell across multiple groups
into separate Workgroups, I\'m thinking particularly as a security and
privacy area here. I wonder if there\'s some need or requirement that we
sort of have some interim synchronization of what\'s going on with that
area so we can plot that relative to what we\'re doing. Is there a time
when connecting with these other splinter groups would be a good idea,
or is that expected to happen only in AHIC?

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

No, no, no. It does need to happen here in the Workgroups as well, and
they'll have a meeting of the Privacy and Security Workgroup between now
and then. So I\'m looking at Tony because he\'s sitting on that one
also. We would hope that either Tony or someone else in that group would
come and give a report to this Workgroup after that meeting.

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

Yeah, I think that\'s important. I also think the point that Jeanette
made and others have made about the consumer empowerment because one of
the recommendations about consumer empowerment, as you know, Karen, is
the electronic clipboard and the medication history. Related to persons
with chronic illnesses.

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

Right.

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

So we need to also look at how we tie what we\'re doing with the effort
that group is doing to implement that recommendation.

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

As well as the longer term objectives.

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

So brief presentation from the CE Workgroup would be appropriate?

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

Particularly where it ties to our efforts. But \--

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

It assumes listening, I was thinking of that group, listening to Ed and
James and Malcolm, there\'s a huge overlap there.

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

Right, I think several of the speakers made that point pretty clear as
well. So we need to think about how we can begin to tie that closer with
us.

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

Okay, any other comments from the members at this point?

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

We probably should move to \-- we have very little time left for public
comment. We should at least open the floor up there, I would imagine
before we close today. Would move the public comment. When is the next
Workgroup meeting?

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

September 20. Wednesday. Before we open to public comment I would like
to acknowledge that Richard has been supporting this Workgroup since its
inception. Is moving object to greener pastures. So \--

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

Shame.

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

Not allowed.

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

I would like to thank him for all the support. Thank you, Richard.

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

Thank you, Richard.

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

Great job.

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

Okay. Colin, shall we move to public comment? Matt?

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

I think we should.

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

Yeah, anyone following along, there's a call-in number on the Web to
phone in and make a comment or ask a question of the Workgroup. If
there\'s members of the public who are already called in, you simply
need to press star 1 on your phone, we will wait a minute and if no one
has called in, I will let the Co-chairs know and they can adjourn the
meeting.

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

Matt, do we have any comments?

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

It doesn\'t look like it.

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

Okay. Then Colin, would you like to move to adjourn?

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

Move to adjourn.

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

Second.

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

Okay, thank you all very much.

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

Thanks, Tony.