American Health Information Community

Biosurveillance Data Steering Group #2

July 27, 2006

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

Welcome. This is Marty LaVenture, and welcome to all of our guests in
the Streaming Community Group. Art and I will be here again as Co-chairs
for the Biosurveillance Data Steering Group for this two-hour call.
We\'ve got a full agenda, so we want to jump right into it, and I
believe that we\'ll begin with Scott doing a roll call. Art, do you have
any other opening comments?

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

No, that sounds fine I think we\'ll just get into the meat of the
discussion here.

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

Sounds great.

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

Actually, before we begin, Matt, do you want to go through the initial
call-in procedures, and then we\'ll have Scott do the roll call.

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

Sure, just very quickly, I think this is the second call, so it\'s the
same procedure that it was last time. But for the group members that are
on the phone, please keep your line muted when you\'re not saying
anything, so we can cut down on the chatter getting into the conference.
And when you do speak up to make a comment, please say your name first
so we know who\'s speaking. And if there\'s some of you that are
following along on the Webcast, looking at the slide we\'ll be
presenting today, please don\'t touch any of the controls to advance or
change the slides. Lastly, if there are members of the public who are
listening along, you\'ll have an opportunity at the end of the meeting
to ask a question or make a comment.

Gloria, I think we can go ahead with the roll call.

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

Okay, I\'m going to have Scott do the roll call today.

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

Hello, everybody, welcome. Who we have on the line today, I believe
Dr. LaVenture, Dr. Davidson, Dr. Barthell, Lynn Steele,
Dr. Stevenson \-- or Stephens, excuse me. Here in the room we have Lynn
Steele, Kelly Cronin, Scott Holter, Gloria Cohen and Judy Sparrow. And
Angela Fix is also on the phone.

Did I miss anybody?

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

Laura Conn is also on the phone.

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

Thank you, Laura.

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

And Perry Smith just joined on the phone.

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

Welcome, Perry.

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

Hi, this is Eileen Koski I just joined, too.

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

Well, welcome, everybody.

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

Thank you, Scott. This is Marty. We have really four key objectives that
we want to try to achieve here, beginning with a review of work that\'s
been done since our last meeting. Starting with the functional area
results, we hope to understand the recommendations that folks have
inputted into their sort of voting on the spreadsheet and identify where
we can \-- areas where we can agree, but most of all, make sure we
understand some of the thinking where there are variances.

The second is the results from the ad hoc data group that has met, and
have Ed Barthell update us on that make sure we understand the thinking.

The third area is really look at our next steps, particularly related to
what we want to consider for feasibility, if you will, the ability for
us to move ahead in the next year with \-- in what we make as
recommendations. And then fourthly, some critical updates related to
HITSP and other ONC updates, including the work from the last meeting on
the scope of work and the glossary.

So that\'s the major focus for this meeting, and are we ready to go
ahead, Art?

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

I think so, I think we\'re ready. Was Scott going to start out this
function of the results discussion?

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

What I can do is I can go through the spreadsheet and kind of let you in
on how we tallied this, and what the bold \-- the bold indicates an area
on number 2 and 3 on the first early event detection, a consensus of
short term, identified that functional area moving forward. If you
notice numbers 1, 4, and 5 in that area, there\'s not a clear consensus
on moving forward either in the short term, long term, or not in scope.
So I think further discussion is needed from the group on those areas,
in particular.

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

You\'re saying that there\'s a bolded section for those that have passed
into the short term results?

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

Yes.

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

Maybe I\'m looking at an older version of this document, I don\'t see
that \--

Pardon?

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

The numbers should be larger and in bold.

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

Art, this is Marty. Art, that was sent out just about 20 minutes ago, I
believe. You may not have it. But it\'s the same information, and for
those that may not have it, it\'s \-- where there\'s five in Item
numbers 2 and 3, is that correct, Scott?

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

Yes, it is.

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

Thank you, Marty, I now have it open, thanks. It\'s the only one from
yesterday.

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

But Scott, there\'s no difference other than the bolding, is that
correct? This is Marty.

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

That\'s correct, just the shading is a little bit different, that\'s
all.

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

So I guess if we take the first one, early event detection, it\'s clear
that we have the four and five lines of interest to the group as
short-term goals. What we have is some variation for Lines 3, 6, and 7.
How do you feel about how we would deal with the ones that are in the
middle, here? Any comments?

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

Certainly I think not everyone voted. How many members of the committee
are there? How many people were given the opportunity to vote?

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

11\. And we received seven. With some extensions.

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

I\'d just like to comment on whether or not number 2 is truly automated
or reporting or would really represent simultaneous data flow from
clinical care to public health. Perhaps it would, but when you say via
the Web, it would imply that perhaps there\'s some manual data entry on
a Website, and that\'s really not the intent of what the charge is to
us. I think we\'re really supposed to be focusing on what we can get in
an automated fashion from clinical care into public health.

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

It also seems like a call reporting system would not be an automated
transfer of data, either.

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

Right.

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

But Kelly, there may be some areas of the country that are using those
things successfully, and I don\'t think you want to rule out being able
to use their existing processes, if they are being used successfully,
even if you\'re planning on longer term changes to more passive
automated systems.

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

So you\'re thinking that there is some kind of automated process?
Not \-- and it wouldn\'t be manual data entry on the Web?

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

Well, and I\'m just saying rather than rule out the Web-based forms for
submitting case reports, it may be that \-- I don\'t know this for a
fact, but it may be that some entities are using that successfully and
I\'d hate to say their data is no good until they get some kind of
passive automated data feed in place.

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

Or is this really because this was voted on as part of this
biosurveillance initiative, it\'s the reportable disease case
recognition from existing clinical data? Through a Web page?

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

I know ours \--

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

I think it depends on how people read this, and in the context of what
we\'ve been talking about, you know, this is repurposing of clinical
data. For biosurveillance purposes. So the ability to use that data for
reportable disease identification might be what people voted on, here.

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

This is Ed Barthell. I can tell you for sure that\'s the way we were
reading this at ACEP, is reportable disease case reporting we think
clearly is something that we should be encouraging.

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

Right.

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

By whatever mechanism.

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

I think it\'s important to really have that distinction, because for
example the other Biosurveillance Workgroup is now trying to prioritize,
you know, out of sort of real-time time public health monitoring what\'s
most important, and one of the things they\'re going to be prioritizing
is case reporting. So there\'s going to be whole another set of
activities around that over the next year. Most likely.

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

So you\'re saying that our current approach with this wording is
confusing?

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

Yeah. Yeah, I think so.

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

Okay, but we are \-- maybe we can work on the wording, but we do have
basically a consensus among those who voted to move forward with this
idea. So is this really an issue for us to deal with right now, do we
have to deal with the wording? Or have we enough consensus that we may
adjust the words, but this is a short-term goal for the other
biosurveillance group, and it seems to be a short-term goal from the
voting of the members of this committee.

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

Right.

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

Is that okay? I hear what you\'re saying, we need to get back to the
term and make sure that everybody understands what we\'re saying, here.
I think that\'s a good point.

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

The other one that is didn\'t rise to the top in this first area of
early event detection, clearly everyone thinks those should either be a
short or longer term goal. So wouldn\'t they just really move to
consensus at least in the longer term?

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

Well, I think that\'s where we need to \-- this is Art again \-- I think
this is what we\'re trying to decide, here, is it\'s \-- at this point,
we just need a way to move forward. And with the number of items that
are on this list, and, you know, there must be something on the order of
about 30, we attack all of them at once, and what Marty and I were
trying to do is just figure out how might we prioritize for the short
term, and then likely most of the rest of them would fall into the long
term, except there may be some things that we identify in this group
that are really not germane to our discussion here. Or we need some way
to explain why it should be part of our discussion.

So I think, if that was Lynn asking that question, I think the likely
thing is if something is in the short-term and we can\'t come to
agreement, something is split between the two, and we can\'t come to an
agreement about that, that we likely will postpone that to a longer-term
item.

Is that a sufficient answer for you, Lynn, or \--

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

Yeah, but just going back to the very first one, I mean, that\'s the
whole premise of what \-- you know, and I said it without really reading
that. The premise of what we\'re doing, and what I think the charges
were, was to reuse clinical data. So to say that that should be put off
as longer term makes the rest of it not flow. So some of these I think
it wouldn\'t make sense.

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

Well, but maybe we\'re trying to achieve \-- I think the fact that there
was a difference in opinion about the way this plays out, maybe it does
have to do with the wording, which I think Ed was suggesting there may
be a Web-based system that we shouldn\'t discard. That may be valuable,
there are some examples of that around the country. Or maybe it\'s that
the way that it was focused on disease reporting more than it was on
just secondary use of clinical data. And maybe there\'s a question
whether we can achieve early identification of a public health event.
Maybe we don\'t know that yet, and this group is feeling like we should
just focus on a disease case.

I think what we\'re trying to do here is identify a clear next step. It
may not be everything that we all want to do, but it will (inaudible)
the work so we can define the data elements to achieve that next step.

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

Right, yeah, I just wanted to reinforce that if in fact folks were
thinking about case reporting of notifiable diseases that that really
that\'s something that we\'re going to be taking on through a separate
process, and that really was not in scope of this specific charge that
should be guiding our work. Which is really the \-- you know, just
getting data that\'s available from clinical care, and having that
simultaneously flow to all levels of public health.

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

This is Perry Smith in New York, I think that was Lynn speaking?

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

That was Kelly.

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

Okay. I thought that the charge to our group was that we had three
purposes for defining the minimal dataset, and the third one \-- we
actually collapsed it into two, as I recall. But one of the purposes was
to be able to follow back for chart review and for case investigation,
that we had all talked about that and agreed upon that. So I answered
the reportable disease part of early detection as short term, because
that\'s what I had understood from our first call.

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

So that there would be a way to identify the actual additional cases.

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

Right.

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

You know, I just looked at the directions that we sent out with this
voting, and I don\'t think we were clear enough about the charge. We
didn\'t remind people what the charge was, just about the minimum
dataset. There\'s nothing in it that talks about the charge of the
biosurveillance activity, here. So I\'m not sure what people voted on I
think it depends on how you interpreted \-- it was clearly in every
other document that we disseminated, but it depends on how much people
were paying attention to it.

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

This is Marty. I guess I have a similar interpretation to what Perry has
been saying from our first phone call, where we clearly identified that
a type of reporting, if you will, that number 2 in this early event
detection becomes a secondary use of clinical data. The mechanism of how
that may be received could vary a bit, but it\'s clearly use of clinical
data to support public health action.

I guess I saw it as definitely in scope, and how \-- sort of looked at
that number 2 very consistent with the charge, I guess is the way that I
looked at it.

And in terms of what we can do, it becomes, as Art was mentioning, a
really logical next step as we move this forward.

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

Ed, this is Bill Stephens. I had one other concern on number 4. Although
I realize now better in terms of the overall charge of the group, you
know, the primary goal there in terms of finding that minimum dataset.
But I guess I feel like, you know, maybe along with the comments there,
or the notes there, I think not only that it\'s important that we
consider this HL7 infrastructure \-- and again, not to say that
everybody is going to be involved in this automated data reporting, but
I think for those that are, and I think there are a lot, that we will
miss a significant opportunity, here, for a steering \-- a data steering
committee to help define and drive things towards a standardization
here, that right now is not in the bag. And a lot \-- necessarily in the
bag, and a lot of people are looking at a lot of different ways of going
about this that\'s going to make essentially a big mess of integrating
this on any kind of a data exchange type of strategy. If we miss the
opportunity to put that in there.

And maybe it\'s already a done deal, maybe it\'s not, so maybe it\'s a
moot point, but I think that in my mind, and from our perspective here
on a regional basis, that HL7 sort of implementation infrastructure is
almost an overarching issue that we should maybe talk about a little
further, as to whether it should be a short-term \-- should be addressed
short term as well.

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

I think that the \-- this is Art \-- I think the process by which the
data are transmitted is not in our purview as a group. Is that correct,
Kelly?

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

That which charge is not in the direct purview?

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

For us to say \-- to start talking about HL7 \--

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

Yes, that\'s very clearly not within \-- yeah, that\'s right. I mean,
we\'re more focused not so much on how the data is going to be
transmitted and in what format, but that we need to identify the data
itself that is needed to serve public health.

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

Right, so while Bill, I agree with you, it\'s needed, it\'s not in our
scope.

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

And how was that \-- just, you know, wondering how that was not
included.

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

Well, that\'s the \--

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

It\'s really \-- the Health IT Standards Panel has been spending a
considerable amount of time trying to identify the standards, the
technical standards that are needed to \-- you know, enable simultaneous
data flow across public health. And Ed Barthell can speak to their work
in more detail, because he\'s a member of that technical committee. But
that\'s really the role, and they\'re being funded to take that work on,
and have been doing that kind of work for over six months now.

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

Okay, so it is being addressed in parallel, you\'re saying.

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

It is \-- one of the challenges, and Ed can explain this later, is that
HITSP is really dependent on what comes out of this group to refine what
they come up with. So they\'re sort of patiently waiting for \-- you
know, the results that are reported out of this group.

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

Okay.

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

That would be able to identify \-- not only settle on the main
standards, but also implementation guidance.

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

This is Ed. I don\'t know that they\'re really being that patient about
it, but they\'re certainly waiting. I guess \-- can I just comment,
maybe what we should do is try to interpret this ranking on a little bit
higher level? I mean, you do have kind of five main types of functions
that public health folks are going to be performing and are going to be
informed by the surveillance systems that provide the data, and I guess
my takeaway on this is that the emphasis or things people see as most
important is having those surveillance systems help our public health
officials with the early detection, and kind of early assessment of an
outbreak, as opposed to these other functions. Although the connection
with the lab systems certainly seems to \-- and the adverse events are
also up there, but as line items. But if you look at the major category,
it seems to me the first category is the one that\'s getting the most
interest.

Maybe that\'s what the takeaway should be from this.

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

Well, it\'s the early event \-- and I guess I\'m having trouble a little
bit with that term now that we\'ve talked about this, because, you know,
I think about early detection, or detection at all, is sort of a
pre-event type of thing, and then followed by situational awareness and
assessment, I guess event assessment, followed by outbreak management
and response management.

But \-- and I think you\'re going \-- Ed, what you were saying, you\'re
going back to defining it more the way \-- you know, we sort of think of
it here in terms of the phases of the event there. Detection is very
important and situational awareness is very important from a public
health standpoint.

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

Well, one of the other assumptions I think we need to work off of as you
all settle on which \-- either high level or more detailed levels of
functions we should agree on, is that this data is going to be shared at
the same time with local, State, and Federal health departments. So I
think you just want to be comfortable with how that data is going to be
used. You know, from each perspective. And the previous discussions we
had around this, folks were pretty uncomfortable with some of the
aspects of what the Federal Government could potentially do with this.

So just keep that in mind as you sort through what each \-- what all
three levels of public health would be \-- what function would they
perform with this data.

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

In regard to event detection, you know, you seem to be drawing really
distinct lines, and I don\'t know that those lines are so distinct. I
mean, there is initial event detection that people believe we can or
cannot really do with automated data. But this concept of early event
detection is that idea of confirmation, and finding additional cases. So
it\'s not necessarily pre-event, very early in an event.

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

Okay.

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

This is Laura, just a comment. I wonder if I can try to summarize where
we went with reportable diseases, just to make sure that we all ended up
at the same place, if we can get there. In that we said that getting
data from existing clinical care would certainly provide data on
reportable disease cases, and having the ability to go back and follow
up with those would be needed, and beneficial by public health. But
we\'re not talking about advancing the HIT side of reportable disease
cases \-- case reporting in the scope of this group. Is that correct?
Are we comfortable with that?

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

I think we\'re not advancing the HIT \--

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

We\'re not working on how disease cases get reported, aside from getting
cases out of existing clinical care. But we\'re not necessarily talking
about changing the business and data flow of case reporting in this
context.

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

Well, right now some cases may be reported on paper. So aren\'t we
trying to get them to be reported electronically?

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

I don\'t think this group is trying to get them to be electronically
reported. I think there are other activities going on in public health
that are working on that, but this group is working on getting existing
clinical care data out of clinical care sources.

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

\-- identify additional reportable disease cases. And so that\'s why
it\'s so closely linked, to me, to event detection. Because you\'re
identifying additional cases that may not have been reported. Obviously,
having all of these clinical data builds that foundation for the future
for, making this a reportable disease case reporting system potentially.
But I agree with what Laura is saying, that\'s not where we\'re going
initially in our discussions of biosurveillance.

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

I think that\'s a fundamental we we\'re trying to answer here, is in the
short term, should we be trying to ask the NHIN projects to be doing
early event identification, or can we use reportable diseases as a
demonstration of progress?

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

Yeah, I think we need to go back to what the Secretary charged the
groups to do, both from a short-term and then a longer-term, broader
perspective. And in the short term, the specific charge that we talked
about during our last call is really how do we get data from clinical
care to all levels of public health within 24 hours. So really whatever
can be fully electronically enabled, you know, going from one
information system to another without any kind of manual data entry,
it\'s really just true automation of data from clinical care into public
health without \-- you know, any interruption.

So that\'s what the premise is going in for this group. Now, that\'s not
to say that we won\'t have a use case next year for the NHIN, the Health
IT Standards Panel and the Certification Commission that will be focused
on case reporting. It\'s very likely that will happen, because the other
biosurveillance group seems to be making that a priority.

But that\'s really separate from our specific charge, which is really
how do we get data that\'s available from an electronically enabled
health care delivery systems into public health.

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

This is Marty, and I guess I\'m having a hard time separating the two as
being inconsistent. I can make a case for them being separate, but I
think we \-- as Art was articulating, I think we can make a case of
saying on getting an electronic feed from a laboratory information
system that involves reportable diseases, that\'s a demonstrable piece
that we need today, and we can potentially put in place today. And that
seems very consistent with the functionality you described in the early
event detection. That we\'re drawing to some degree an artificial line
between the two. And when in fact I think they\'re quite consistent, if
we choose to define it that way.

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

This is Perry Smith. So the \-- I guess I\'m struggling, too. Let me
just talk for a second and explain where I\'m coming from, and see if
this resonates.

First of all, I think Laura Conn made a comment about surveillance, and
my understanding is that we are not trying to decide our short-term
priorities with the idea \-- for instance, with the example of
reportable disease case reporting, that we would be trying to think of
all the minimal dataset that would be needed to replace the current
reportable disease case reporting. My understanding was that we would be
looking for the minimal \-- defining the minimal dataset that would
foster the ability, or allow the ability to \-- when a case is
recognized in the clinical dataset that is reportable, that would allow
the public health, local public health in this instance probably, to go
back to the reporter and identify the case.

But there would be many other aspects of reportable disease case
reporting that would not be part of early event detection or would not
be in the initial minimal dataset that gets submitted.

I mean, all of these applications are kind of like octopuses, they have
ramifications in all directions in different formats. And so I
approached it with the idea that the only thing we need to do with this
minimal dataset definition is be able to trace back so that everything
that happens with reportable case reporting can happen outside of the
dataset that we\'re trying to define. But we have to be able to identify
cases.

So when it goes to electronic lab reporting, many States are developing
fairly sophisticated electronic lab reporting for identifying reportable
diseases. And again, I was approaching this task not with the idea that
we would immediately try to define a minimal dataset that would obviate
the need for all these other electronic lab reporting systems. Someday
they will, probably, but at this point I wasn\'t thinking with the
assumption that we\'re trying to make electronic lab reporting available
through this mechanism, through this minimal dataset.

Is that kind of consistent with other people\'s thinking, or am I off
base?

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

This is Kelly and Lynn, and we\'re both shaking our heads, I think
that\'s exactly right. When you start talking about reportable diseases,
and a minimum dataset, immediately, you know, we know reportable
diseases come with names. And I think you hit it right on the head,
there\'s really a difference between a micro lab report for enhancing
situational awareness for public health, where a person is looking at a
report, versus where there\'s a micro lab report that has a discrete lab
result, which is \-- must be positive to be a reportable disease.

So having the capability to have continuous information about a lab
order and preliminary results would be part of potentially a
biosurveillance system. And that may not end be being a reportable
condition.

So I think what you\'ve described is exactly right, the difference
between a minimum dataset for biosurveillance purposes, which eventually
could evolve to.

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

This is Marty. Comments from other members?

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

This is Ed. I think if we get into the detail data elements, some of
this may to sort out a little better.

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

Okay. This is Marty. I guess I would agree with what you\'re saying,
Perry, in concept, particularly the fact that the minimum dataset Ed is
mentioning we\'ll be getting to does deal with a potential for linking
back as necessary.

So Art, with the time that we have here, on this group, I\'ve heard some
suggestions that if we look at this sort of three groupings here, the
main functions that folks have generally agreed to that are in, those
that are not in the scope of the group, and those that perhaps need some
further discussion. As an example, numbers 2 and 3, early event
detection, being in. I\'ve heard the others as either longer term or not
in scope. For example, the issues related to HL7 and some issues related
to the algorithms.

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

I hear you, Marty, I just want to make sure. Lynn was \-- I was not sure
if I fully understood your plea for including some items here.

What will happen if our group proposed a dozen of these in yellow,
let\'s say, as Marty is kind of leading to now. That we have 12, let\'s
say, that are in a category we\'ll all agree to. What will happen, Kelly
and Lynn, if we exclude some? How will that be perceived by the
biosurveillance group? Or the Secretary?

Is that acceptable? Maybe we started down the wrong path, here. I don\'t
know, I think what we were trying to do is get a little more clarity
about functions of biosurveillance, and I think I heard concern on both
Kelly and Lynn\'s part.

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

Well, certainly, I feel as though the first one is the premise of what
it is we\'re doing. And so how that would become a secondary or longer
term goal \-- the rest of what \-- really, the rest of everything here
doesn\'t make sense. I mean, that secondary use of clinical care data
isn\'t just for early event detection, but it\'s for all of the
activities associated with what we\'re discussing as biosurveillance.

So again, it just makes me question how \-- what the charge was, or how
people interpreted this charge for voting on these specific items.
Because if you don\'t believe that that\'s the premise, and so
immediately a short-term goal, then how do you get to the rest of this.
How do you get to all of these capabilities.

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

Well, part of the problem is that there were no definitions provided in
the statement. The word \"early event detection\" I don\'t believe is in
the statement of work, is it? So we\'re trying to define it here, with
some functional components, and we went through this voting process. But
do you think that, you know, if we go back with this list and the first
comment, well, where is secondary use of clinical care data for early
event detection, if we don\'t have that in there, well, I\'m not
interested in having the committee just turn around and say to us, go
back and do more work. We want to be useful to the committee.

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

Kelly and Lynn, let me explain what our thinking was as ACEP, and the
reason we had checked longer term for number 1 and number 4, the reason
being that we expected that those were good things, and we wanted to see
them, but it would take longer than a year to get a substantial number
of the hospitals across the country on those kind of HL7 data feeds. And
we checked numbers 2 and 3 for short-term thinking, well, that\'s
something that we can accomplish right away, the first year. There\'s a
lot of reportable disease case reporting stuff in place already, in
getting the situational awareness stuff in place right Away, and could
be done very quickly.

So that was our thinking. It wasn\'t that we shouldn\'t do number 1,
it\'s we\'re just saying that you can accomplish two and three without
doing numbers 1 or 4.

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

Where do the data come to accomplish number 3? If it\'s not secondary
use of clinical data?

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

Well, and it all depends what you call secondary use of clinical data.
You have to define what that means, too. But I\'m thinking, too, that
one and four were more the HL7 data feeds from \-- from legacy systems,
as opposed to Web-based systems that you could get right away.

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

Yeah, I mean, I do think that it makes a lot of sense to think what is
practical and what can be used, you know, in the short term. I think
that quite honestly, you know, the Department has heard about an awful
lot of controversy around both \-- you know, initial event detection
and, you know, things that would be comparable to what people would call
syndromic surveillance. Because the methodologies are still being
formed, there\'s a lot of problems with false signals. I think from a
practical perspective, what folks are looking for is something that is
going to be viable in the short-term, that we really could implement,
and that would really deliver some value to public health. That involved
sharing of data, you know, real time, with all levels of public health.

So what we can all agree to as being reasonable that will really, you
know, be \-- a public health function that\'s achievable in the
short-term, would really be a step forward.

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

This idea of looking at function, and temporizing what can be done early
and what can be done late is of value. Was that Kelly who was speaking?

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

Yes.

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

So then back to Marty, Marty was suggesting that we have some items that
we think could \-- in the short-term, and then others that may be
longer-term. And if we proceed down that path can we then kind of link
it to elements required for the shorter term for our projected report
back to the committee? Is that what you were headed toward, Marty?

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

This is Marty, Art. Yes, I think so. I was just trying to \-- I think
I\'m hearing some kind of consensus out of this first section that
numbers 2 and 3, if I interpret Kelly\'s comments correctly, is
consistent with what we could try to be achievable in public health to
move this ahead. That we have some definitional issues with number 1, in
the sense that this whole thing is related to secondary use, which seems
to be confusing us. And that\'s \-- as a particular issue.

But those two we could agree on; the others seem to fall into the second
categories.

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

That\'s right.

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

That\'s what I\'m hearing, and I guess I would suggest that we consider
moving ahead in terms of we take numbers 2 and 3, and say let\'s work up
both the definitions for that, and for number 1 here, as the group\'s
recommendations for moving forward, at least on these two. The others
moving into continuing evaluation, but they\'re sort of the next step.
What we\'re listing as longer-term at this point. Simply as a way of
prioritizing.

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

So Marty, you said these two. Did you mean 1, 2, and 3 as being
short-term, and 4 and 5 being longer-term? Or did I misunderstand?

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

Well, I\'ve \-- 2 and 3, which is reportable disease case reporting and
situational, clearly were voted that, I heard in the discussion, the
general nature of secondary use. If I\'m hearing a redefinition of that,
which in my mind then would become \-- would fall into moving that
forward, as well. Being on how we want to define it. So 1, 2, and 3
becomes the priority, the 4 and 5 become longer-term.

Yes, I think that\'s what you said. Right, Perry?

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

Yes, that\'s what I understood, right.

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

Is 4 not \-- did we not think that 4 was really not within scope of this
group, and that was the work that HITSP was doing?

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

Right.

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

Do we have agreement on that, members?

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

Yes.

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

So 4 is not in scope, how about 5? There\'s \-- is that in scope or not?
I heard the data yes, the algorithms probably no, from the comment. This
is Marty.

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

Yes, this seems to be out of scope.

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

I\'m sorry could you repeat that?

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

Sorry, this is Eileen. It does seem to be out of scope for what our
charge was. Unless we were just to have to consider what algorithms were
proposed for use to see if they required any data elements that we
didn\'t have in the minimum dataset. And see, that\'s \-- you know, I
was a little bit confused, also, about how we were voting on these,
because I wasn\'t sure what implications we were supposed to be
deciding. But that would be where I would ask the question about this,
is what is the implication of including this.

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

Other comments from members? This is Marty.

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

Well, we\'re wrestling with that very thing right now. In fact \-- and
developed a considerably expanded dataset, because of some of the other
algorithms, as proposed by some of our stakeholders across the region,
here, that are doing exactly that. I would say the algorithm \-- not
only the algorithms, but the protocols, you know, because we\'re not
looking at \-- you know, someone mentioned a minute ago, you know, the
questionable utility of syndromic surveillance. I think that partly
depends on the level at which you\'re trying to conduct that
surveillance, and make \-- you know, sort of independent or stand-alone
decisions. Because at a low enough level, protocols definitely enter
into the syndromic surveillance sort of total decision-making process
that utilizes some data that the system processes automatically, and
some data the system collects but doesn\'t really process in an
automated way but is used in the decision-making process. As to whether
there is an event happening or needs investigation, or that an alert is
true, or false alarm versus \-- you know, versus true alarm.

So the algorithm and protocol I think definitely will influence the
dataset decisions that we come up with.

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

This is Perry Smith, and that\'s kind of the way I interpreted it, too.
That you have to know the algorithm in order to define what data you\'re
going to need to receive. So deciding whether or not we want to put ZIP
code into the minimal dataset is totally dependent on what algorithm
you\'re going to use, at what geographic level you\'re going to analyze
the data. So I interpreted this to mean that the algorithms were
important in determining the data, not that the charge to the group was
to make up all the algorithms or recommend \-- you know, how the
algorithm would actually get carried out. That\'s the way I interpreted
it.

But I could go either way. I can see the ambiguity, here.

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

This is Marty. So it sounds like with this, we have to determine in the
scenarios perhaps, as we follow up to the next section with Ed\'s
conversation, that what algorithms may be associated with the scenarios.
And once we identify the algorithms, we could then look at potentially
what data is necessary. So this seems to be contingent upon the
algorithms that we actually could get identified in this, in some
scenarios. What may or may not be in. Is that a correct interpretation
of the comment?

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

I\'m sorry, are you asking me?

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

Any of the members.

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

Are the algorithms available for us \-- I mean, I\'m not sure that
they\'re canned algorithms out there that we can just refer to.

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

Again \-- this is Bill Stephens again. Part of the thing I bring back,
too, is some of the things we\'re looking at collecting also are not
processed by algorithms, but are more related to protocols that we\'re
developing here involving things like travel history, you know, food
history, and some other sort of patient background information, some of
which is collected, some of which is not collected today by \-- you
know, in routine hospital ED \-- you know, visit information, or
clinical care information.

So, I don\'t quite know how to incorporate those things, too, but those
are very important things, again, in early event detection and
situational awareness.

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

This is Eileen again, I guess this takes me back to something Kelly said
earlier and I keep trying to think back to what our charter is. If our
charter was to think in terms of what data is currently today in
electronic form in health care systems that can readily, easily be made
available to public health, as you start to add on items like that, that
don\'t actually exist in most systems, is that really something that you
would put in a minimum dataset? When you know that it\'s not in any of
the target systems from which you expect to get data?

Or from virtually any. I mean, if we\'re talking about ultimately all of
the data elements we would like to have, that\'s one thing. But if our
charge is really to create a minimum dataset of what you absolutely need
to have, and also what you can reasonably to get, there\'s a conflict
with looking out into that kind of data.

So I think that we have to think about what it is that we\'re really
trying to create in this minimum dataset, what is it supposed to
represent.

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

I\'m a bit unclear. Certainly I don\'t think we\'re saying that
algorithms are part of the minimum dataset. It\'s the data that would be
coming in as part of the minimum dataset that would \-- if there\'s
discussion of whether the biosurveillance functional area should include
the application of algorithms or analytic algorithms to those data.

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

No, no, I was referring to the comment that was just made about some of
the algorithms that are using things like travel history. I\'m perfectly
on board with the idea that okay, if we have standard algorithms that
people are using, what are the data elements they deploy. But once you
start to talk about collecting data \-- which again, I completely
understand the value for public health of knowing a person\'s travel
history, I\'m not arguing the value of the data, but in terms of what
our charter is, if we\'re trying to compile a minimum dataset, and we
start out with the premise that we\'re trying to get data that is
currently enabled in electronic form, is that likely to be anything that
you\'re going to get from anywhere? Where are you going to look for that
data now?

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

This is Ed. I think we probably should try to keep in mind that these
surveillance systems aren\'t intended to do all the work of case
investigation reporting. And what they\'re really intended to do is give
you a continuous stream of data that helps indicate something is going
on, which may then trigger some investigation work that needs to be
done. And hopefully isn\'t giving you too many false signals so you\'re
spending all your time investigating false signals. But let\'s keep
those two things separate.

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

Right. This is Kelly. I think that\'s really helpful, Ed, and I just
want to also clarify that if we\'re considering number 5 under early
event detection, and this discussion around algorithms is with respect
to that, that particular function, I think this really is, then,
implying syndromic surveillance, and I just would caution that there\'s
an awful lot of discomfort around the sophistication of these
algorithms, and the readiness to sort of widely deploy them in a \-- you
know, a biosurveillance effort that really is intended to share data
across public health, so that everyone would be performing these
functions.

You know, my sense from what I\'ve been hearing is that people are not
ready to go there.

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

This is Marty. So am I hearing the issue, then, Kelly, more longer-term,
or not in scope?

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

It could be longer-term, it\'s \-- you know, if folks feel that these
methodologies are going to be more sophisticated and we\'ll have a lot
more reliability and confidence around how to do this. But that I think
there\'s a certainly level of discomfort at this point, in the short
term.

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

Right now the group has \-- if you simply use the numbers, as I\'m
hearing either longer-term and maybe out of scope, but certainly
longer-term, are people comfortable with the recommendation that this be
considered longer-term, with the comment also that we may need to
obviously look at this in greater detail, depending on the scenarios?

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

That sounds fine.

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

Marty, this is Perry Smith. Being somebody who voted actually to put it
in the short-term, I feel entitled to change my vote, if that helps.

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

Okay.

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

And put it actually out of scope, because I think there\'s a lot of
confusion. I certainly don\'t think we should be talking about
algorithms in scope. so if that helps, I don\'t know. And I think if it
does become a problem it will rear its ugly head very quickly when we
start talking about the data elements.

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

This is Marty. So I\'m hearing already a vote change. A negotiation here
for an out of scope. So we have a 3 to 2. Do I hear any other out of
scope direction? And move this to out of scope at this point?

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

Well, this is Eileen. I hadn\'t voted initially, and my initial response
to this was that it should be out of scope, so I think I\'ll stick with
that as my vote.

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

I\'m hearing a shift. And if \-- I can\'t see everyone nod, but if we
get okays, are we okay with moving it to out of scope for this phase of
the steering committee work?

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

Yes. Bill Stephens, I\'m okay with that.

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

Just for summary, Marty and Art, I have 1, 2, and 3 are in short term, 4
and 5 are not in scope.

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

No, no. 4 is \--

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

Yeah, I thought we had previously agreed that the ANSI and HITSP was
going to deal with number 4.

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

The comment should reflect that it\'s being dealt with through the ANSI
group. Sounds good.

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

We\'ve used up nearly an hour of our call.

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

The most important one here \-- this is Marty \-- is the one that had
the most in-scope, short-term.

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

Right. I agree. I don\'t know whether we should try to review all the
others during this call, or kind of move to the next section of the
call, or maybe review the ones that are bolded and see if \-- can we get
a consensus on where they sit, and come back to the gray ones at another
call? I just don\'t want us to spend the entire call without having a
chance to hear Ed\'s report.

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

We\'ve got an agenda item to kind of come back to this and cross-match
it back to the data element list, maybe we can do it that way.

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

Another suggestion, just having clarified with the discussion over early
event detection areas, is to potentially have people revote from here
down so that we\'re now all voting with the same concepts in mind. And
then see if we come to more consensus.

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

Beforehand. Before the next call.

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

Before the next call.

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

Okay. How do you feel about that, Mary? And other members of the group?

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

Yeah, I don\'t know if people would feel like they would change what
they did now, but I think we did have a conversation about how to
think \-- the context in which to think these through.

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

This is Marty. I\'m not quite sure how I would change my vote at this
point in the other areas, but it\'s \-- perhaps after we take a look at
the field we could come back to that.

I\'m also okay with, you know, taking five minutes, there\'s only two
more that have stood out as \-- that at least are highlighted as
something to move forward on. And I guess the question is, this is
always a \-- always a challenge, you put your toe in the water, and it
may pull you in here if we start one of these. But clearly, connecting
for labs and adverse events are the two others that I have that are
short term, where we would consider focus.

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

Right, and I think that we\'ve gotten a little clarity from earlier
discussion that Line 17, or connecting laboratory systems, number 1,
probably is not in our scope.

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

Right.

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

So even though that was voted as short-term, that\'s \-- that\'s not in
our purview.

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

That\'s a good point, Art.

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

And I can tell you that HITSP is all over that one.

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

I think we \-- the recognition that this is important is correct, and
certainly accepting laboratory results is in the short-term charge of
this group, so it snaps to the importance and the voting here, but I
think the formats and the standards are within scope of what HITSP is
doing.

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

Right. I mean, I think we can recognize its importance, and then defer
to HITSP.

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

That\'s another one taken care of, this is Marty, that\'s great. Anyone
not agree with that approach? Sounds good.

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

So how about the other one that you pointed out, Marty, the adverse
event reporting, in the countermeasure and response?

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

Had no comments with it. This is Marty. Either.

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

You know, it\'s so interesting to me that this was ranked as a priority.
Just really my bias, I think it\'s important from my previous work, but
I think it\'s curious that the Biosurveillance Workgroup, as a rank \--
they ranked what they thought was going to be the most critical aspects
of public health event monitoring moving forward that we should
prioritize with these cases next year, and they ranked this low. So
just \-- it\'s just a very different response.

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

This is Marty. So do you think it\'s a definitional issue, here?

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

Yeah, maybe I think it is worthwhile to talk about what people were
imagining, how this secondary use of clinical data was going to enable
adverse event monitoring, and how that relates to countermeasure and
response administration.

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

Well, I voted for this in the long term, so I can\'t answer that.

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

This is Perry, and I apparently voted for it in the short-term, and I\'m
wracking my brain to figure out why. I think I was thinking that if we
were doing a population-based endeavor, I can\'t think of a good
example, maybe pandemic flu vaccinations or something, I think I may
have been thinking that we would use clinical databases, maybe, to
quickly assess whether there was an increase in something crudely,
and/or to follow back with institutions with the patient link, to
investigate suspect cases of adverse events.

That\'s what I was thinking when I checked this. But I\'m not sure that
anything that I can think of right now would affect the minimal dataset
that wouldn\'t already be probably taken care of by our priorities with
early event detection. So I\'m not sure my vote \-- I think we could
remove this, if folks wanted to move it, and it wouldn\'t affect any of
the decisions in the data elements.

But that\'s why \-- maybe it\'s a stretch, but that\'s why I put it in
the short term.

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

This is Ed. I\'d second that suggestion, because I don\'t know why we
had it, unless it was just something we thought feasible to do in the
short term, and that\'s why we had it ranked short term. But I\'m
confused myself in how I ended up in that cow town.

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

Well, Art, this is Marty, and I\'m wondering, back to sort of Ed\'s \--
was it Kelly\'s suggestion, that at this point maybe we do need to,
having some discussion, come back and rank the other items or re-rank
them again. And move \-- and use what we learn in the next section with
Ed to help sort of inform our thinking in this context, and make sure we
hear about the work that was done there, since it\'s directly related to
this.

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

Right, so what are the \-- I think as far as who said \-- what are the
guiding principles about how to complete this, what \-- there was a
couple of points that were mentioned earlier that I didn\'t write down,
about some ways that we should organize our thoughts.

Do we have that? Should we just send it out again without a little more
direction \-- I\'m ready to end the discussion here, Marty, I just want
to be sure we\'ve captured what are the guidelines for completing it a
second time.

Was it Laura or was it Lynn? I\'m sorry, I can\'t remember. Or anybody.

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

It doesn\'t matter. We agree.

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

I think Lynn was describing them earlier, and then I seconded that we
agreed that those were the right contexts to think about them in.

Scott, do you feel comfortable that you have that captured, so that we
can resend it back out, or do we need to talk through it one more time?

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

It\'s going to have to come from the summation of the meeting notes,
but \--

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

This is Perry again. I actually, in order to answer this questionnaire,
had to \-- I went through the meeting minutes myself, and some of the
materials, and wrote out for myself what I understood the assumptions to
be, and I\'ve got them in front of me. I\'m willing to either read them
now, or if you want me to I can send them to Marty or whomever, because
I think it is really helpful to bullet the assumption \-- at least it
was for me, to bullet them, again, and be very explicit as to how I was
making decisions. They may be wrong, but at least I think we all need to
be in agreement about what the assumptions are. But I can read them down
if you want me to, or if you want to save time I can send them to
somebody.

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

Maybe we could send those out and Marty and I can review those. If it
was Lynn who made those initial comments, maybe Lynn, Marty, and I can
just come to quick agreement as bullets for how to complete the next
go-around.

I really do want us to get to Ed\'s discussion today. I\'m worried it\'s
just going to take too long.

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

That sounds good to me, Art.

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

I\'d be happy to be part of that discussion.

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

Thank you, Lynn.

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

Thank you, Perry. This is Marty. So you want to send that to Scott,
Perry?

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

Sure. It\'s not very long.

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

If you want to copy Art and myself, that\'s great.

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

Thank you, Perry.

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

All right, are we ready to move on to the next section?

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

I think so.

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

Deep sigh.

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

Good comments, good discussion here, very important issues. All right.
Moving to our next important item, results from the ad hoc data group.
And Ed, if you\'ll lead us through that, that would be wonderful.

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

Sure. And hopefully everyone has got the spreadsheet and is able to see
what was sent out now. Understand this is generally my notes from the
meetings, so please, Laura or others that were involved with the calls,
interrupt me if I\'ve got my biases and many missing anything. I\'ve
tried to add a few things, even, since this spreadsheet was sent out to
you, that I\'ll just talk to.

What our group did, and this was a group of public health
representatives from across the country, we went through the five
different planning scenarios: pandemic flu, major hurricane, food
contamination, chemical attack, and radiological attack. And for each of
those scenarios, we started with this base dataset that was defined back
last spring or late winter, as perhaps being the set of data we would
want to see involved with surveillance data systems.

Then we tried to go through those data elements and say are they needed
or not needed or are they missing anything, for each of these specific
scenarios. We tried to consider whether we really needed to know that
information versus it would just be kind of nice to know. And we
specifically said let\'s think about what pieces of information you need
to be able to manage a disaster or an event like this in your region as
a public health officer as opposed to worried about what system is going
to collect it or what system is going to be used to transmit it. So when
we got off track and started talking about the specific systems or
standards we tried to redirect back to what is the information you need
to know to perform your role as a public health official.

And we had significant debate that we\'ll probably get into here
somewhat, in terms of the work that it takes to get fairly comprehensive
information flowing to public health on a routine basis, as opposed to
having more specific and limited data flowing to public health on a
routine basis, and then maybe triggering an increase in flow of
information for specific circumstances.

Now, it\'s kind of two different philosophies on how surveillance
systems need to work.

So I\'m going to just start going through the chunks of data that are on
the spreadsheet here, and I\'m going to start with the first set of six
elements that\'s listed, which is institution data. And most of these
are really base data elements that don\'t necessarily change rapidly.
The hospital system name and et cetera, really what you need is just
some kind of identifier for where the data is coming from. So if you
have hospital Medicare number, you probably don\'t even need the system
ID, name, location address, et cetera.

We talked about it being important to know, for gauging the size of the
institution as part of that base data, some measure of the number of
facility beds. But that if you just have the licensed beds, it\'s
probably insufficient, because most hospitals don\'t utilize the entire
number of licensed beds even on their best days. And then when you get
to type of bed, there was pretty good consensus that you need more than
just number of beds, type of bed, like this. We really want to know some
specific things about the bed availability.

And that\'s what\'s listed especially in the pandemic flu. If you think
about pandemic flu, you want to know not only what type of bed \--
that\'s there\'s beds available, you want to know if they\'re medical,
surgical, regular or general beds, if they\'re ICU beds, whether
they\'re for adults or for pediatric. You want to have some assessment
does the ER still have capacity to care to more patients. You may want
to know about negative pressure rooms in an influenza situation, or
other significant infectious disease situation.

Importantly, the number one thing is you need know not only are there
physical beds available, you need to know if they\'re staffed. If you
broke that into six or seven additional data elements on each of those
different bed categories and said beds available, but with a definition
that not only physically available but available and staffed, meaning
they can take care of an extra patient in that slot.

That was the breakdown. And that theme got \-- was recurrent in some of
the other scenarios, as well.

When you get to a major hurricane or some kind of huge natural disaster,
beyond knowing about specific bed types you have to know, first of all,
is just the facility open or closed, and are there some significant
infrastructure issues with either power or communications or supply or
staffing shortages. So even on a higher level knowing about the status
of the facility.

And those things didn\'t change a whole lot with either the food
contamination, chemical attack, or radiologic attack except for the
importance of knowing about decontamination availability.

We talked about, moving to the next section, the daily facility summary,
which most folks felt would be valuable for just trending baseline on a
regular basis kind of what kind of volume of illness is flowing through
the community. And that\'s these three main data elements, the number of
admissions, number of discharges, and number of deaths. We thought that
would be relatively straightforward to collect that data from most
places by one means or another, and would give you a nice trend line for
the burden of illness in the community.

So that\'s \-- I think that\'s a natural place to break, which is kind
of the resource stuff before we get into the patient data. Is there any
questions or comments on that?

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

Well, this is Lynn Steele. We\'re working to validate what we\'re
getting for the BioSense's data in regards to beds. What we found is
that these data exist in all of the hospital systems, where we\'ve gone
to implement BioSense. That is, there\'s a way to calculate census data
because there\'s a census system and it\'s existing data. And by being
able to see the beds on a daily basis by unit helps to understand just
exactly what you said about the types of beds. Not probably isolation
beds, or decontamination facilities, but again, you know, the way we\'re
thinking about it for the BioSense implementation is if we\'re
collecting data that exists in IT systems, we certainly should try to
validate whether we can calculate some census that won\'t require any
type of reporting other than what is \-- you know, reported through an
existing IT data setup.

So especially during emergency, this may be the only source of data.

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

This is Perry, I just had a quick question on the layout of the table.
It sounded to me like you said under daily facility summary, 8, 9, and
10 was voted a yes. The data sheets I have only have the Row 8 checked
with yes.

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

Yeah, that\'s my shorthand for indicating the whole section is a yes.

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

Okay, thanks.

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

Ed, this is Marty. In the categories do we need to change the 1 through
10 in some way, or just really clarify that when we get to the detail of
the data we need to make sure the counts for the examples you provided,
the staffing, beds, then later \--

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

Yeah, I would anticipate \-- I wanted to get input from this group, but
I would anticipate some of those that are in Columns D and E actually
would become numbers 7, 8, 9, 10, and 11, and there may be 20 elements
we try to get with regard to the institutional data.

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

Which items are you thinking, if you add some \--

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

Ventilators, ICU, med surg, adult ICU, adult general medical, adult
peds, adult ICU, negative pressure rooms, and ED capacity.

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

Yeah, I think the column E \-- the column E we sort of decided that if
availability of beds goes to zero or if the data stops flowing we\'re
going to realize the facility is closed or not functional. But \-- the
elements in Column D were important across the board, that multiple
scenarios. We just didn\'t put them across each one, if it was a
repetitive thing.

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

But you were expecting \-- this is Art \-- at some level there would be
the ability to track staffing?

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

Well you want to know that not only is an ICU bed open, but there\'s
staff there to take care of the patient if they\'re placed in that ICU
bed.

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

I totally agree with you, we need to know that. But there would be a way
out of the information system to acquire that information?

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

We purposefully didn\'t ask that as part of our charge. We said don\'t
worry about the systems, just say what do you need to know to optimally
manage one of these situations in your role as a Public Health Officer.

And I don\'t know, does anybody think of anything else they would want
to know about the health facility scenario? As you imagine these
different scenarios occurring?

Okay, I\'m ready to go down to the next section, unless there\'s any
other comments in the resource stuff.

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

I think so, we can always come back. This is Marty, Ed.

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

Because the next few sections are all about data on individual patients.
That are flowing through the care system. And there\'s the top section,
which currently are numbered 11 through 18, which is really demographic
and identifier type information.

We had significant discussion about what level of detail you need in
defining something like date of birth, in that we\'re trying to minimize
the patient identifier type information if it\'s not really needed for
the purposes. And we went back and forth on that, then frankly came back
to date of birth as defined by just month and year of birth, that
that\'s probably the right choice for describing that data element.

We talked about ZIP codes and the fact when you have five-digit ZIP code
and gender and date of birth you can usually figure out who somebody is.
And we said that\'s all right, it\'s important enough for us to have
that in a stream of information, surveillance information, that we still
think that even though you can potentially identify those patients,
it\'s important enough to have it to justify it.

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

Well, we\'re also looking at several different classifications of ZIP
codes. You know, home ZIP code, residence ZIP code, specifically in
cases like hurricanes, where you\'re dealing with evacuees, potentially
home ZIP code, residence ZIP code, which may be different, or work or
even school ZIP code. So there may be several different classifications
of ZIP codes there that need to be \--

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

And we started with just home ZIP code figuring if you really wanted to
investigate something you could go back and find out who this
patient \-- I made note also there\'s a randomized data link where the
idea that you stripped off quite a bit of data, but if you want to go
back to trace a case to investigate it further you do it through that
randomized data linker.

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

Do you do that in an automated fashion or \--

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

We didn\'t define the system.

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

Yeah, that gets back again to the not necessarily algorithms, but at
least the system, and the protocols that you may follow.

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

Go ahead, educate me, tell me, do you think \-- what, on a general
routine stream of information, which \-- you\'d like to have more than
home ZIP code, you would like to have work ZIP code and school ZIP code,
is that right?

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

Again, it gets back to the kind of protocols or spatial \-- if you\'ve
got spatial algorithms that you\'re running in the background that look
at other relationships other than just home ZIP code, that again can
help you quickly, or help investigators quickly \-- public health
quickly run through different scenarios there. Apply different spatial
algorithms based on other ZIP codes.

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

Are there other people that have comments on that? We can certainly add
work and school ZIP codes if available.

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

I have a slightly different comment about the ZIP code, not about that
suggestion.

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

Go ahead.

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

Which is that while it may seem redundant to take both state and ZIP,
historically looking at very large datasets, I found a much greater
percentage of ZIP code data that was incorrect and unusable, and at
least if you also had the state you\'ve got a better chance of resolving
that and having at least minimal geolocation information.

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

Yeah I would agree with that, and that\'s another one that again, when
we say ZIP code, I was going to suggest the same thing for state. Making
sure that you can validate the data, if there are data entry errors,
because we see that all the time.

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

Yeah.

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

There are data entry errors in hospital IT systems. We\'re not finding
that in the BioSense data, this is Lynn, because probably some of the
most reliable information are patient addresses because of billing and
insurance purposes.

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

That\'s true.

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

So in response to Bill\'s question, is there anybody else who believes
that we should be adding additional ZIP codes for any of these five
scenarios? I mean, I know one thing is that it\'s not readily available
generally in these hospital systems, they\'re going to store mostly, as
Lynn points out, the residence. But let\'s forget about where the system
stores it. Is there an indication for us to ask that as part of a
minimal dataset. Or school or occupation ZIP code.

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

In some ways I think it goes back to where we think we\'re getting this
data from. And again one of the premises, and again maybe I\'m being
short-sighted, but we said we\'re not really changing clinical care.

Now, should we change clinical care or clinical requirements for data
entry.

One of the things that we found is that all hospital ABT systems
somewhere have occupation as a field for the patient, but it\'s almost
routinely blank. So you can see that at some point if there was an
occupationally related illness, that hospitals and health care providers
may start to use that field. So you could say the same thing about ZIP
code of that occupation or school, that may or may not be existing
fields in the hospital IT systems. But \--

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

I think if we stay true to what the purpose of this exercise was, it\'s
saying what would you want to have to optimally manage these emergency
events, and it sounds like work and school ZIP code in an optimal world
would be available. And we can say that and decide if we can or can\'t
get it down the road, right?

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

We are getting it from the large percentage of the 36-odd hospitals that
we\'re collecting across the north central Texas region right now.
Again, they don\'t all have it filled in, but a lot do.

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

Puts occupation back on the table, and say if in fact \-- we wouldn\'t
be able to turn this on as an element if we had an occupational related
event, but if we could get it, we would want it.

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

Definitely, that\'s \-- yeah. I would agree with that.

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

I really think we should put these elements in, and if HITSP can come up
with standards and people can build systems that collect them, that\'s
great.

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

As long as it\'s understood that providing the data is optional, because
we know providers might not have that. I think having it in as target
data elements is very good.

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

So will we have a column called minimal \--

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

We did have the minimum.

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

We had a minimum target before, but so \--

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

So we\'re still aiming for that sort of representation of our output.

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

We have not split this into some kind of minimum and desirable.

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

Now we\'re just \--

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

We\'re saying all these are desirable if you can possibly provide them.

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

So this is Marty. For this section we\'ve heard occupation, ZIP code of
work, school. Was there something else? Or are those the additional
items we\'ve proposed, here?

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

The only other one that I indicated, potentially for \-- and we used it
a lot, here, in the north central Texas, because we had a lot of
hurricane, you know, victims, is residency that may be different than
where \-- or rather home as opposed to their residency. You know, for
tracking or identifying, you know, specific disease problems. And, you
know, again, in a hurricane type disaster, in a sheltering operation.
Both Tarrant and Dallas county used that information pretty extensively,
we actually had to derive it after the fact, but \--

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

You mean like the difference between an address and a permanent or legal
address?

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

Yeah, their home versus their \-- you know, their residence, where they
were staying, in other words. An apartment or \--

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

Is that contact information?

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

Well, you could create another field, and that\'s something else we
proposed or some of our stakeholders proposed, too, is creating another
event flag that\'s nonstandard. But rather than doing that, you know, we
wanted to see if there was some way we could use existing define fields
within \-- by the way, all these have \-- as you probably know, all
these have HL7 message and, you know, segment definitions there, so \--
and again as I say, a majority of the hospitals that were reporting in
our area were capturing that information, actually. But we just
weren\'t \-- and our system was collecting it, but not processing it. So
we had to go back and rescan the databases to actually extract that
information. So it was an important piece of information that we
discovered we had, and utilized in the course of the hurricane, you
know, shelter management that we were doing.

So it\'s residence versus home. In other words, where they\'re living
temporarily versus where their home ZIP code was.

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

But I think \-- you know, I\'m not sure if we\'re getting down to a
level of detail about where the person lives \--

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

Right, that\'s what I\'m saying. We don\'t even have their home address,
much less their local address.

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

Right. So I mean, I guess \--

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

I\'m not talking about their address, I\'m talking about their ZIP
codes.

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

I understand, but wouldn\'t you presume that ZIP code location of the
place where they\'re getting care is pretty close to where they\'re
staying at that point? Unless they\'re en route somewhere, in which case
it probably doesn\'t matter anyway.

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

Actually, I can tell you we did a small study with our data with the CDC
a few years ago looking at the relationship of home address to
caregiver's address, because of the fact we only get home address on
about 65 percent of our records, and we found that the average distance
between the caregiver and the patient was about two miles. 

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

If they live in the area I would agree, but in the case again of some of
these disaster scenarios, specifically hurricane people, they were going
all over the place. I mean, between the two cities they were \-- you
know \-- and there\'s no way you can control that. You know, they would
go into one shelter, they\'d show up in another shelter across town. We
had 27 shelters in our county alone. And then, you know, they had fewer
shelters over in Dallas County but, you know, there was a lot of moving
around in that particular scenario.

So again, maybe like Art said, this is a level of detail we don\'t want
to go into, here, but it definitely involves one of the five scenarios
that we\'re dealing with here, so \-- something to think about.

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

So maybe we should qualify the Line 26 \-- or number 16, to say home
ZIP, and then if we\'re in a hurricane, you feel it\'s necessary to have
current residence ZIP?

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

Yep.

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

So this is desirable. Anybody else have an opinion on whether it\'s
desirable?

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

Well, I think it\'s desirable, I just don\'t know the likelihood of
finding it in any of the systems. Because even having like the
occupational ZIP or the school ZIP is a reach, I would suspect, for most
systems to have that available.

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

Right, and I\'m not trying to make little of how difficult it will be to
make this happen, but I think we backed off from what is easy to do to
what is desirable. And that \-- I think Bill is pointing out that if a
major hurricane, that would be a desirable deal. And whether we\'re able
to achieve that is something we\'ll come back to later.

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

Yep, feasibility is the next thing on our agenda.

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

Good.

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

So you\'re using the word desirable the way we talked about target,
before. Not necessarily minimal.

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

Yeah, but I\'m trying to qualify it by getting people to say, you know,
not what\'s nice to know from your surveillance system, but what do you
need to know to optimally manage these circumstances. And really try to
be critical about that.

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

What good will it do to know that someone lives in New Orleans, when
they\'re being cared for in, let\'s say, Tarrant County, and there\'s
something going on in that county regarding food or water or \-- and a
whole bunch of people who are ill, and it says that they live in New
Orleans.

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

Well, the question is one of tracking the likely \-- whatever you want
to call it \-- the likely progress of the disease in \-- you know, under
consideration, Art, is whether it started there, whether it\'s something
that \-- you know, it started or, you know, originated in a shelter or
particular group of shelters. Again, if everything is in one shelter
everything is simple. But you know, we had \-- in this area we had two
different strategies or theories of shelter management. One which was
highly centralized, which makes it easy from the standpoint of
residence, but hard from the standpoint of outbreak management and
control if something does break out.

And then if something does break out in a multiple shelter type of
situation, you want to know which shelter or shelters it\'s coming from.
And so some of these surveillance systems, with the items that are
already there, can very quickly process it and help you pinpoint those
kinds of things, or slice and dice the data to help you find the answer
to that quickly, if the information is captured. And number two \-- in
other words, if the system captures it, which again most of our systems
do have fields in there, and the hospitals are reporting it, but not all
the hospitals actually fill in the data. Some of those fields are left
blank on the systems that are supposed to capture it, so \--

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

I agree with you, Bill. I was trying to state what you said very well,
so I think we should add that variable as a target or desired variable,
and deal with feasibility later.

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

Yep, got it down. Are we done with demographics, can I move to clinical
data?

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

Before you move on \-- this is Perry \-- I actually was in the process
of typing up my criteria, my assumptions for you, and I \-- as I
listened in on the call, and then I came to the \-- one of our
assumptions, which has a bearing on institutional data, the first \--
actually, the first \-- the daily facility summary and institutional
data.

The specific charge to us \-- and I\'m reading from the scope of work,
here \-- will be to identify the requirements for data from ambulatory
care emergency departments and laboratories. So I\'ve been assuming that
we are not talking about inpatient care or hospital inpatient care and
beds, and ICUs and isolation rooms, and pediatric beds, but obviously in
the discussions it\'s the assumption that we are today.

So can we clarify, are we to include inpatient care with our minimum
dataset discussions?

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

Kelly, can you help us?

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

That\'s a very good question. You know, I think that it hasn\'t been
clearly considered so far. I think to the extent that there are data
points or data elements that are readily mobilized from the inpatient
setting, that are really needed, then there\'s nothing that should hold
us back. I mean, if there\'s a lot of people, you know, in the ICU
because they\'re so severely compromised \-- their respiratory function
is so severely compromised, it would be a relevant pandemic outbreak.

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

Flu-related hospitalizations are going to be critical. We know that.

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

There\'s no doubt about that, obviously that in a way is the low hanging
fruit. I wondered why the scope of work was worded this way, it was kind
of conspicuous, inpatients were kind of conspicuous by their absence.
But that\'s fine, I think we should change the scope of work, then, so
everybody is working from the same assumptions.

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

Should we change it to include, in that Point number 1 that Perry is
referring to, inpatient?

Pardon? Hello?

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

I\'m sorry, I was just trying to figure out what he was referring to in
terms of scope of work. I didn\'t mean to chime in there.

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

I think it\'s important enough that we should just leave it in for now
and keep going.

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

This is Marty, I agree. What I\'m hearing is that it should be added to
the scope of work, given the functions and the data that we\'re talking
about. Perry, are you okay with that?

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

Yeah, I think we just \-- when we report out our recommendations, we
just say that we assume that \-- we included inpatients in our
considerations, because I think it\'s important.

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

It was clear from the public health folks that were giving their
comments about these five scenarios and what they wanted to know to be
able to manage their regions during these five scenarios, it was very
clear they wanted more information about the inpatients, not less.

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

Well, our charge, Bill, does not mention that. I\'m happy to include it,
but are we leaving out the ambulatory side, and is there something that
needs to be referenced regarding ambulatory in the institution data, or
is this something different that we would be collecting from the
ambulatory and/or emergency? Because those are the two areas that are
called out in point one of the scope of work.

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

Yeah I mean to be honest I think the reason they were pointed out was
\-- heart we thought was opportunistic, because it is readily available,
to a certain extent. But the conversation, at least at the community
level, the physicians represented in the community felt there was data
to be readily mobilized from certain ambulatory care environments that
have electronic health records that could export data. Now, we know
that\'s really a relatively small universe of physicians at this point,
and we don\'t know exactly how that data on a practical level would be
available.

But there are regions of the country, like we have folks in Boston who
keep on wanting to try to collaborate, and do a pilot, we\'re trying to
get some data from a growing number of physician practices in the Boston
area that want to participate in a biosurveillance program. So there\'s
a possibility we can sort of inch our way there, it\'s just that this is
not going to be something that we could expand into 33 MSAs over the
next, you know, year or two.

But I do think the spirit of trying to figure out what data elements
would be needed from ambulatory care, is the right way to think. But I
think the feasibility assessment is going to quickly bring us to
reality, that it may be very difficult to get that data other than lab
workup.

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

Speaking of inching our way to ambulatory care again, the model for
BioSense is if you\'re getting emergency department data that\'s linked
to a hospital, it\'s the ambulatory care centers that are also linked to
the hospital IT systems that are those that are most feasible to get,
and that will be moving more quickly to standardization. So if you\'re
working through a hospital or health system IT to get ED, emergency
department patient data, and the associated ambulatory care data, this
idea that hospital inpatients, at least to have that window on community
health status in real time with a minimum dataset, seems like it\'s very
low hanging fruit at that point.

So you\'re right, the specific charge did not mention hospital
inpatients, but it also doesn\'t exclude laboratory data from that
patient population, so we\'ve always interpreted it as being inclusive.

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

I think we all agree that the hospital remains in this scope. I\'m just
wanting to be sure that \-- (inaudible) we\'ll be able to (inaudible) a
series of ambulatory practices that are, you know, early adopters of HIT
and ready to contribute data, whether it be in Boston or the Kaiser
system, you know, they have plenty of ambulatory data. So maybe we
don\'t need to do this today, but we can say that we\'ll come back to
this at a later point and kind of elaborate for the non-hospital
situation

And Lynn, you\'re right, for the majority of the EDs, it\'s no
different. It\'s the same systems for inpatient and EDs, I assume. Is
that what you\'re saying?

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

Yes.

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

So Scott would be able to take a note on that, that we\'ll try to come
back to this and revisit it at another point? I think we want to make it
through this sheet at least today. So Perry, you were the one who had
stopped us to clarify based on writing out your assumptions what\'s our
focus. Is it okay now to move on from patient data to clinical?

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

Sure. I\'m sorry, yes, that\'s fine.

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

Thank you for the diversion.

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

The clinical data section you\'ll see is focused on the chief complaint
or reason for visit, and various points around the diagnosis. So both
the diagnosis type and the code for the diagnosis, if it\'s available,
we\'re trying to capture. And by diagnosis type, we talked through about
how it would be nice to know not only admission diagnosis but sometimes
discharge diagnosis, presumptive diagnosis, or different types of
diagnoses. So that\'s where diagnosis type gives you that opportunity to
reclassify, and not just be stuck with waiting for the end of a
three-week admission before you give them a final diagnosis.

There was some discussion about filtering for certain diagnosis groups.
This again goes back to the concerns about confidentiality of patients,
and are we providing more information to public health than they really
need to know. So should we be filtering out particularly the psychiatric
or HIV-type diagnoses. Because those are obviously the ones that are
most sensitive.

I don\'t know that we had a specific answer for that, and we thought
we\'d kick that up to this level for discussion.

The other point of question was if \-- well, first of all, let me say
chief complaint, we talked about the fact that\'s not always as helpful
as the nurse and/or triage note, if you can get it. So one thing that I
didn\'t have on my initial list that needs to be added, because we all
felt it was useful, was nurse and/or slash triage note.

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

I would add that, too.

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

And the other thing that we talked about, and I didn\'t have a definite
feeling, but I\'d say fever, dash, no there, in the first call we said
we probably don\'t need to track fever, it\'s more information than we
needed to know during a pandemic flu. But the decision also went around
the fact that when a flu syndrome is beginning to break out are we going
to get a lot of worried well that are all going to present with chief
complaint of flu systems symptoms, but they really don\'t have the flu,
they\'re just the worried well, and then how do you sort that out. And
fever or an indicator like pulse ox gives you an objective measure of
someone who is sick or very sick that you otherwise wouldn\'t have. So
that\'s what some of that discussion was around.

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

What about BP?

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

BP blood pressure

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

Yes.

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

Just not felt to be specific enough to be particularly useful in a
surveillance system. At least that\'s my opinion, we didn\'t really
discuss that in our Workgroup in detail.

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

We agree that all of those \-- this is Lynn again, just giving you the
rationale for BioSense, that all of those, fevers and other vitals, can
be very noisy, but may be very important for specific patient
populations. And so we are limiting the collection of that to emergency
department patients.

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

Right.

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

You can say the same thing that during a flu it may be really useful to
have an initial fever or some vitals from ambulatory care. But we wanted
to first evaluate the usefulness, so we picked just the ED population.

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

So Ed, would you say that fever is now a yes?

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

Well, we wanted to get the opinion of this group.

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

I think it\'s a good idea if it\'s available, for the reason that was
mentioned before.

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

Okay, I think I would make it a yes, too.

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

It also helps differentiate GI exposures of different kinds.

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

Okay, let\'s put it in. My bias is to also include pulse ox, if it\'s
available, because in our experience that was the one that was much more
specific for truly sick patients. Fever you\'re going to get about five
percent of the patients, in a typical ER, that will have a significant
fever. But if you ask for fever plus hypoxemia, you\'re probably down to
about point five percent. So it\'s a much more narrow window in terms of
identifying the truly sick patients from upper respiratory illness.

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

This is Lynn Steele. I guess this whole concept of what clinical data we
have as part of biosurveillance, I mean, I\'ll just struck by we\'ve
spent, you know, a few minutes talking about nice to know, ZIP code and
schools and occupations, et cetera. Fever and other vital signs may be
part of a clinical case definition that would help determine \-- or help
identify cases, and you go back to SARS where we were looking for, you
know, fever and other clinical symptoms associated or clinical signals
associated with chest X-rays. So is this biosurveillance data to help us
do that case identification or that \-- you know, as I call it, event
detection when you know something is going on to identify additional
cases.

So it\'s interesting that we\'re ruling out or we\'re limiting the
dataset for things that we know could be clinically relevant. We\'ll
have a lot of information about where people came from, but not enough
to identify who needs further followup.

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

Well, I thought we just agreed to put fever back in and pulse ox is now
being discussed. Were you talking about other more complete vitals, is
that your suggestion?

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

I think we need to think of the implications for excluding some of them.

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

Meaning the blood pressure in particular? Because I\'m not sure which
ones we\'ve excluded in this recent discussion. I just want to
understand which ones you\'re referring to.

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

It wasn\'t clear to me that we were leaving even fever in.

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

No, I think Ed just agreed \-- he just asked the group, and I think so
far from the group we only heard yes include it.

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

Okay.

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

Who said no?

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

This is Perry. I don\'t think anybody said no. However, I think I\'m
about to. At risk. Let me check with myself and see what comes out. I
guess my thinking is \-- and I\'m certainly open to being converted \--
is that in terms of identifying cases, I\'m not sure that we at the
State health department level, or even more so at a local health
department, would use large clinical databases such as we\'re talking
about here, a BioSense, to identify cases or even to trigger
investigations. So if we were in the middle of a SARS outbreak or, you
know, an early flu epidemic and we really wanted to identify febrile
patients with low oxygenation or something, we wouldn\'t use this kind
of data to do it. We would \-- in fact we already do, our local health
departments, many of them do it every day, call the emergency room and
ask specific questions of the clinician, and other health departments
implement this during emergencies or when we\'re really \-- when we know
what we\'re looking for and we ask specific questions.

New York City, when they get into an emergency mode they actually send a
public health person into the emergency room to do data collection and
case reviews.

So there\'s an existing \-- I guess my thinking is that there\'s an
existing infrastructure out there now for emergencies, for identifying
cases in clinical settings, and for reporting. And our experience has
been that a clinician\'s sense of something \-- you know, that \--
something wrong, or something \-- a patient who presents and is suspect
for SARS or has a febrile illness and has recently traveled from China,
or whatever the scenario is, that that\'s much more sensitive and much
more specific and much better use of our public health investigators\'
time than thinking that a database of the type we\'re describing here is
going to be used for identifying cases or following up on cases.

We just \-- we wouldn\'t use it that way. At least we haven\'t in the
past.

I would \-- just one last point. I think I would use \-- to the extent
that we would use it, we would use the diagnosis of the clinician rather
than a pulse ox or a fever, a temperature measure, I think.

So I\'m arguing I think not to collect the vital signs. Because I\'m not
sure, for the things I\'ve just described, that we\'d use it.

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

Okay now, think about it the other way, though, and that is you\'re
getting a call from a reporter who is saying the city in the next State
has had a big breakout of severe pneumonia, they\'re trying to figure
out what it is, are we seeing that here in your city, too. And you can
look right on the screen and say well gee, we haven\'t seen any increase
in fever or pulse ox or hypoxemia or any of those kinds of signs at all.
And I\'ve not had any individual cases reported.

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

We can already do that, and we don\'t get the vital signs. We already
have a system, that\'s what I\'m saying, we already have a system \--
our health departments are very much in synch with what \-- maybe New
York is different from the rest of the country, but we have a fairly
good finger on the pulse, to use an analogy, of what\'s going on.

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

Based on individual case reports?

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

I beg your pardon?

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

Based on individual case reports?

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

Based on local health departments knowing their clinicians. Marcy knows
her doctors in New York City, Marcy Layton. Many of our county health
departments are talking to every one of their emergency rooms every day.
And that\'s \-- and they find that \-- and we also have syndromic
surveillance systems where we have chief complaint data, we have ED
visits, so maybe we\'re not typical, but I \-- I would question whether
we need vital signs. Whether we would use vital sign data.

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

But Perry, if you were getting individual patient level data with this
level of detail every day, would you still have people calling the
emergency rooms? I mean, it seems like \--

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

We already do.

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

Yeah, but you might change your business process, because this might
potentially give you some efficiencies. Of not having people have to
call every emergency department every day. You have the data, you can
just scan it very quickly and then know \-- still know the same answers
you know today.

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

Or alternatively, let\'s say it is pandemic and we\'re overwhelmed and
your staff and all the staff of Marcy Layton and all the others are just
burnt out on calling all the EDs. Would this be valuable at that point?

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

Or sick themselves.

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

Yeah, so I think it was Laura who said \-- I think you do have a process
to solving this given the current situation. It could be that you could
revise that process, that business process redesign, or it could be that
this process you have has not been tested at a high scale.

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

Yeah, we do have a number of counties with fairly complete syndromic
surveillance data from their hospitals, and what I don\'t know, I\'d
have to check, is whether some of those counties have stopped calling
the EDs because they think the syndromic surveillance data is good
enough. My sense is that many counties do not think so, but I need to
check on that.

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

But I think there\'s the question about the whole long-term direction of
this. I think it would be quite some time to come before people would
have had enough experience with any of these systems to feel confident
that they could rely on them, given what people\'s responsibilities are.

So I don\'t think that we ought to necessarily constrain our thinking
entirely based on how we do things today, based on our confidence in the
way systems exist today. And really, think a little more about, you
know, if we thought these systems were reliable and complete, how might
we use them, how might we incorporate them into our processes.

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

This is Paula, if I could just make a comment, I know I don\'t get a
vote, but it seems as if vital signs have been a topic of much debate
both in this group as well as with the Biosurveillance Workgroup, and I
would just suggest that one of the other charges of this group is to
develop evaluation \-- work on evaluation once this piece is done, and
it might be valuable to really look at vital signs in the evaluation
component to really once and for all determine if the data is
worthwhile, is useful in the field, rather than keeping \-- you know,
continuing to have discussions where we really don\'t know.

So I really would argue that there\'s value in maybe it won\'t tell us
anything, maybe it will, but at least through this process we might be
able to find out.

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

I like that. Yeah, that\'s obviously right on target. I think everybody
agrees we need to evaluate these systems, and my understanding is
there\'s money going to be made available to do that, so hopefully in
the next few years we\'ll have better data to make these decisions on.

I guess \-- I don\'t mean to push this any further, that\'s fine if we
want to put this on the list, I\'m not going to \-- you know, stop it. I
guess my experience has been, though, that there\'s almost no
replacement for clinical judgment and talking to \-- having local public
health talk to the clinician. And I\'m dubious, quite dubious, as you
can tell, from being able to tell what\'s going on or even recognize
that something is going on, from data that just has vital sign data. I
just doubt that it\'s going to be able to replace it.

But we do need very good evaluation of all of this, so we have data to
base these decisions on.

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

You know, I think this concept of situation awareness and looking into
data to do hypothesis sort of generating, it\'s not to replace
traditional epidemiology, it\'s to arm traditional epidemiologists with
more information than they would have. And we\'ve heard the other side
from hospitals that frankly, they don\'t want to interact with public
health by them calling all the time on all of these things. So it\'s an
advancement in exchange of existing information, if we could think of it
that way. I know New York has very good systems, but I don\'t think
that\'s the way hospitals and public health need to interact necessarily
into the future. It can be done in a more informed way.

And as we go through these other clinical data elements, it\'s what
clinical data have been useful to public health. To prompt \-- begin the
traditional investigation, not to replace it.

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

Art, this is Marty. We just need to do a time check, here, on our
schedule. This is great discussion and very important one, and I think
we should get sort of a time plan for our next steps. Clearly, we\'ve
got some issues on this to continue, and the feasibility piece as well,
and have a call scheduled in which we can potentially do that.

So in the \-- do we have, Kelly, any options for continuing for a few
minutes beyond our scheduled time?

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

We do, actually, I think Gloria asked the operator to keep the lines
open. So we should keep going if people can spare a few minutes.

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

Art, thoughts?

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

Yeah, I think we probably need to move to our next steps. This has been
very helpful, Ed, thank you for your work. But I do think we need to at
least define what are our next steps, and where we need to go. I don\'t
think we can indulge on everybody to kind of spend their time here going
through the rest of this, we have so many other things to cover.

So I agree with you, Marty, we need to do a time check here, find out
whether we could summarize our next steps with the group, and then plan
for our next call.

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

And excuse me, this is Gloria. I think we could probably go another 10
minutes, and I think it would be fine to do just the things you were
talking about. Keep in mind that because of our FACA guidelines we do
need to allow a few minutes at the end for public input, if there are
any folks who would be getting on the line at that time.

So we have about four minutes after 6:00, I think that we could probably
talk until about 6:11, and then open it up for public comment, and be
finished by 6:15. Is that acceptable?

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

I think that\'s acceptable to the members of the committee.

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

That\'s fine with me.

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

Sounds good to me.

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

Okay.

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

So we had some items on the agenda here for next steps. We certainly
have been focusing on the short term and I think we came to
a (inaudible) the rest of the items just to rescale them, based on the
assumptions that Perry is going to provide, and Lynn is going to assist
us with.

We would then move from that to some assessment of the availability, and
then (inaudible).

I think we\'re going to have to figure out yet another bit of surveying
the group to get an idea about what they think is available or not, so
that as we report back we are able to comment on what is feasible and
what is not in the next year, as we start targeting just the short term.

Marty, do you think that\'s a way we could proceed? We\'ll need to spend
some time defining what feasibility really means, too. I don\'t think we
have enough time here to discuss this today.

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

Sounds like good agenda items for our next meeting, with an update of
the scope of work based on our discussion today, a re-categorizing list
with Perry and others criteria that we talked about, and then I think we
need a little bit further discussion on Ed\'s work here, if that would
be possible as well. As agenda items for our next meeting.

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

Yeah, last discussion is just about laboratory orders and trending
those, and laboratory results and trending those.

The big question being whether all tests should be trended or just some
subset of the tests.

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

I think it would be good to have some discussion on that. This is Marty.
As an agenda item on followup on our next call.

Art, I think what you outlines makes sense to me, how about the other
members, for next steps for our next meeting?

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

Sounds all right.

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

Sounds good.

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

Sounds good to me.

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

Terrific. Do we want to do \-- how are we doing on our clock, here?
Gloria?

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

I think this would be a good time to go to the public comments unless
there\'s anything else that\'s really urgent you want to talk about.

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

Can we have a reminder of when the next call is scheduled?

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

The next call is scheduled for August 8th, that\'s a Tuesday, and the
time is from 2 to 4 p.m.

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

Thank you.

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

Matt, do you want to go ahead and post the public call-in information,
and while we\'re waiting for a couple of minutes to see if anybody is
calling in \-- thank you \-- then we can continue talking as a group. If
there are any other details like that that you want to discuss. Any
other logistics, or whatever.

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

I would like to hear a little bit if we have a moment from Ed and Eileen
about the update, if possible.

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

Sure. Eileen, I don\'t know if you want to comment, but I\'m just
impressed there\'s like a tornado going on in HITSP because of all the
work that\'s trying to be done simultaneously. It\'s very difficult to
keep up with it all.

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

And the EHR group actually seem to be making quite a lot of progress on
moving through these cases and selecting standards and identifying
issues to be addressed. There\'s also a subgroup right now, because they
were considering perhaps using the e-Links specifications, but there was
a lot of push to go to HL7 2.5, and e-Links is written to support 2.4,
so there\'s a subgroup that\'s also been formed to see what would be the
difficulty level of migrating e-Links from 2.4 to 2.5, how much that
would take.

So there are quite a few little subgroups that ended up getting formed
to address very specific issues, to come back with a response.

And on an extraordinarily tight timetable, that group has to have their
response back in by this Friday. And they only got the charge on Monday.
So there\'s a lot going on very quickly.

And I forget who made the comment before, that they\'re not waiting as
patiently for an answer from this group, but they\'re very, very eager
to hear from us. And I think frankly they\'ll be relieved that we\'re
not planning to tackle standards selection as well, and that we\'re
going to try to coordinate our activities rather than try to do the same
things over and over again.

So I think in the time we have, that\'s about probably the best I can
share.

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

This group should be thankful for the time that they have, we gave you
more than a week.

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

Thank you.

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

Yes.

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

Thank you, Eileen.

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

You\'re welcome.

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

So are we open now to the public?

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

Yes, I just checked and there are no \-- no one from the public has
called in to make comments. So if you want, you could \-- this would be
an appropriate time to adjourn the meeting.

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

This is Scott. I just want to make sure that everybody knows that August
18th so far has been kind of the front runner for the in-person meeting.
I\'ve received three people giving me a positive response on that day,
rather than the 17th.

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

Ed, can you make this \-- I can\'t remember which date was going to work
for you.

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

That coincides with the next ANSI HITSP meeting.

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

Coincides or overlaps?

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

Overlaps, I\'m just opening up the schedule.

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

Yeah, that HITSP meeting goes that whole week.

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

Yeah.

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

You said the 18th, Scott?

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

Is that for the technical committees or the panel?

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

Technical committees.

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

This is Ed. I could do either day, I just said if it\'s Friday I need to
be able to cut out about 1:30 to hit the right flight back. So morning
is better for me than afternoon on Friday.

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

So does it conflict with the HITSP technical committee? Is someone
checking that?

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

Yeah, according to the schedule, yeah. But as Ed said the HITSP
technical committee meeting is from Tuesday to Friday. Now, to be
honest, this time on the last day so many people had to leave early the
third day that they ended up adjourning at 11 a.m. that day. But again,
you know, since other folks have already indicated that they would have
to leave early \-- I guess there\'s only so much we can do about
schedules clobbering each other.

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

Ed is the only one who is on both committees, is that correct, or are
some of the \--

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

I\'m on both.

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

So would you need to be at the other meeting that day?

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

Well, we could conceivably leave the HITSP TC meeting early and then fly
to D.C. I think the HITSP meetings are in Chicago for that week.

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

Yes, unfortunately you can get a flight from Chicago to D.C. every hour,
pretty much.

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

Okay. So are we pretty firm on the 18th, is that sounding like the best
day, still?

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

Yes.

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

I\'ve been trying \-- this is Gloria, I\'ve been trying to sort of make
little notations as you were all talking. But I have a couple questions.
Ed, did you say, Ed Barthell, did you say you would have to leave by 1
o\'clock on Friday, or was that somebody else?

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

That was me. Ed Barthell. Like 1:30 or so, I think it\'s a 3 o\'clock
flight.

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

Shall we start at 5:30 in the morning? Just kidding.

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

No, we\'re just going to be real efficient in getting all the work done.

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

I\'m thinking we need a two-day meeting.

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

Right.

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

As slowly as things kind of went today.

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

As long as we can do it at the beach.

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

And you said we\'d miss too many people if we had it on the 17th,
correct?

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

Well, everybody responded back it\'s better for them on the 18th rather
than the 17th. At least the three people that \--

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

I am a little worried that adjourning by 1:30 may not be enough time.

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

Can we start on the 17th, you know, do a half day each day, or is it
that people want to try to do a day trip? Start on the afternoon in the
17th and complete in the morning in the 18th.

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

That means Ed and I will have to miss two whole days of the HITSP
meeting.

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

I can still stay on by phone, I just have to get over to the airport and
checked in. I think it\'s a three o\'clock flight I\'d be catching on
Friday afternoon, so \--

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

Well, we can all continue the meeting on a little longer after Ed left.

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

You don\'t have to stop on my account.

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

If we can potentially date it like 8:00 to 3:00, would that work?

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

Do we have agreement, this is Marty, 8:00 to 3:00 on Friday the 18th?

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

Okay.

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

Okay, can add others by phone if necessary?

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

Works for me.

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

Okay, and there will be information related to travel time and so forth
from Scott?

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

Yes.

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

Okay. Good. Art, are we ready to close? Any other business at this point
from anyone?

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

I had one other question. Did we reach any closure on the last part of
that clinical \-- clinical data discussion, there, on adding fever,
leaving it as is, including vital signs, whatever?

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

I think my assessment was that Perry was suggesting to leave it out, but
I heard enough of a plea from others to say consider that it might be
valuable, and if I heard Perry correctly, he said well, we might
consider it.

Is that correct?

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

Yeah, I \-- I heard overwhelming support for including them, so I think
that was \-- I\'m willing to yield on that.

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

So that we could continue with evaluation on the next phase.

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

Right.

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

Yep.

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

Okay, that works for us.

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

Okay. Well, thank you all, sorry that we went over and that Marty and I
did such a wonderful job of managing the \-- but we did cover a lot of
ground here, and this is not an easy topic for us to just come to
closure on so quickly, so I really appreciate everybody contributing
here today.

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

We appreciate your efforts, as well.

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

Absolutely, it was time well spent.

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

Same here, thanks. This is Marty. It wasn\'t four hours, so we have to
remember that.

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

That\'s right.

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

It felt like it \-- no, no. Thanks, you guys.

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

Thank you.

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

Thanks a lot. Bye.