American Health Information Community

Biosurveillance Workgroup Meeting #12

December 8, 2006

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

Okay, Judy, you can go ahead.

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

Great. Thank you. And good afternoon everybody and welcome to the 12th
meeting of the Biosurveillance Workgroup. Just a reminder that these
meetings are designed to represent the Federal Advisory Committee Act,
which means they have been published in the Federal Register and they
are held publicly. They are being broadcast over the Internet and
recorded and transcribed so please speak clearly and distinctly, and
please identify yourselves for the recorder before you make any comment.

Also the public will be invited to make a comment at the end of the
meeting.

Just one change on the agenda for today. Unfortunately Dave Ross is sick
so Item 5 on your agenda we will not be having. With that I will turn it
over to you Matt to go through the introductions and then we will open
the meeting.

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

Okay. Calling in for the meeting today, several people. Leah Devlin from
North Carolina. James Hadler from Connecticut State Department of Public
Health; Rick Heffernan in for Dr. Frieden from the New York City Health
Department; Chip Kahn, Federation of American Hospitals; Brian Keaton,
\[American\] College of Emergency Physicians; John Lumpkin, Robert Wood
Johnson Foundation; Robert Martin, CDC. Shu McGarvey and Laura Conn are
also on from CDC. Dave Parramore from the Department of Defense. Abid
Rahman from the Department of Veterans Affairs, and Mary Shaffron is in
for Scott Becker representing the Association of Public Health
Laboratories.

Any members or designees who I have missed?

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

Go ahead.

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

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

Tom Savel, CDC for Ed Sondik.

**[\>\>\
]{.underline}**And in the room we have Lisa Rovin\-- Food and Drug
Administration.

**[\>\>]{.underline}** **[Matt McCoy:\
]{.underline}**I think Judy that you already covered all the call-in
procedures so I\'ll turn it back to you.

**[\>\>\
]{.underline}**Mark Paladini (ph) is also listening in, in New York
City.

**[\>\>]{.underline}** **[Judy Sparrow:\
]{.underline}**Okay. I think what I\'ll do is turn it over to the
Co-chairs, Chip Kahn and John Lumpkin for opening remarks.

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

Yes. This is John Lumpkin. Thank you all for joining this call.

Just to follow up, one of the things that, while I think I heard this is
our 12th meeting as the Biosurveillance Workgroup, we will have some
discussion later today about the expanded scope and, as such, we may be
changing, if the AHIC so directs us, to reflect that expanded scope.

But I think we are meeting at a very auspicious time, because of all the
progress that is ongoing in the development of electronic health records
and personal health records, making sure that these issues of the
interface between public health and the clinical care environment are
considered in the development of the standards and the implementational
system, will assure that the goals of both systems can be met in a way
that is effective and efficient.

So I think we have an agenda we will work through. We will have our
first, our letter of recommendation as the last item. And then an
opportunity to begin to think a little bit about how we are going to
achieve our goals as we have a discussion in our next meeting about our
expanded scope in a little bit more detail. Chip.

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

Yes, thank you, John. And I think that what was seen sort of in a draft
letter outlined some of the work that sort of lays ahead of us in terms
of the agenda that we had prior to sort of the name change and the
notion of population health being included in our scope.

And so I look forward to getting our meeting recommendations sort of
done by the group and sent on to the Secretary for consideration of
AHIC, I guess in the 21st or whatever it is of January, the next AHIC
meeting. And I think the name change and the expansion of our scope is
very exciting and one of, and really helped along, I think, by the work
that John did to expand our minds, helped us to expand our minds and to
be thinking more broadly about where we wanted to go over time.

That\'s what I had to offer.

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

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

Is Kelly going to be late \--

**[\>\>\
]{.underline}**I got a note she\'ll be 1:15 to 1:30. She has a budget
assignment she has to complete.

**[\>\>]{.underline}** **[Judy Sparrow:\
]{.underline}**One other thing we can do before we get into the meeting
is, has everybody looked at the minutes from the November 9 meeting?
Perhaps we could accept those minutes if there are no changes or
additions?

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

Do we need a motion for that?

**[\>\>]{.underline}** **[Judy Sparrow:\
]{.underline}**Yes. Somebody from the group needs to do that.

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

Are there any \-- I guess the first question, does anyone have any
changes?

Hearing none I move \-- since we're informal here, I move to accept the
minutes.

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

Okay. Since Chip moved it I will say, all those in favor.

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

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

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

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

**[\>\>\
]{.underline}**Any opposed? Or abstentions? Okay. We have done it.

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

May I ask a technical question first? I apologize, but just when I guess
it was Judy was going through the change in the agenda my, I pulled my
earplug out and didn\'t get it back in. So Dave Ross is not going to be
here, is that right?

**[\>\>]{.underline}** **[Judy Sparrow:\
]{.underline}**That\'s correct.

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

So we are going to skip over that portion. Is that correct?

**[\>\>]{.underline}** **[Judy Sparrow:\
]{.underline}**That\'s correct.

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

Okay. I just wanted to clarify that.

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

And my guess, looking at this, we will not take up the entire time
that\'s allotted.

Depending upon how verbose we are in our discussion, but just to give an
estimate for those in the public who may want to make comments, that
will occur perhaps a little bit earlier in the agenda.

The Item number 4, if we are ready to move to that.

And this is, as we begin to move in the new environment, there was a
presentation at the last AHIC meeting that I was at in relationship to
population health. And the charge to our committee and actually from the
AHIC is that this is an area that they are interested in exploring. And
obviously as we begin to scope out our work as a committee, what that
means, what are those, the domains of population health we want to
engage in and how some of those aspects may overlap with some of the
other workgroups and, therefore, how we will divide up some of the
workload of making progress in that area.

However, it is pretty clear that the first task that we will accomplish
will be within the areas that we have already addressed. And we have
already, as part of the visioning session, identified some areas that we
want to continue to do some work. So I think that we will have a clear
agenda reflective of that. It is our hope that we will be given, we will
have a chance to review with the leadership of AHIC a draft scope that
we can then present at the meeting in January. Are there any questions
or comments about that, the expanded scope?

Okay. I think that takes us to Item number 6.

**[\>\> Abid Rahman\
]{.underline}**This is Abid Rahman, for VA. If it is okay for the
benefit of those who are not at the inception, if you can just summarize
it for a brief sentence or two how it has deviated from the initial
intent, how the scope has expanded?

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

Sure. One of the attachments to the call for the meeting is a broad
charge for the expanded scope.

**[\>\> Abid Rahman:\
]{.underline}**Right.

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

If you will look at that, below that, there are two paragraphs which are
the change, the charge I believe for the Biosurveillance Workgroup.

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

John, this is Laura. Sorry to interrupt, but I think the document they
have is the construct document that has the five \--

**[\>\> John Lumpkin:\
]{.underline}**Oh, I didn\'t realize they had that document.

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

**[\>\> John Lumpkin:\
]{.underline}**That makes it easier.

**[\>\> Laura Conn:\
]{.underline}**Yes, they don\'t have the document you were talking
about. That was just a draft.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So I\'m talking from the wrong document. Let me
read the current scope of the committee.

The broad charge is to make recommendations to the Community to
implement the informational tools and business operation, to support
real-time, nationwide public health event monitoring and rapid response
management across public health and care delivery communities and other
authorized government agencies.

So the focus at that time was on the real-time reporting of health event
monitoring and rapid response management. Now, if you will look at the
document that starts off with the pretty pictures \--

**[\>\> Abid Rahman:\
]{.underline}**I see that.

**[\>\> John Lumpkin:\
]{.underline}**\-- and that says "Population Health and HIT Constructs".

**[\>\> Abid Rahman:\
]{.underline}**Yes. Okay.

**[\>\> John Lumpkin:\
]{.underline}**And look at the following pages. As you can see, once you
begin to go into population health, we describe that roughly within five
domains. Those five domains being public health surveillance, health
status and disease monitoring \-- and just a word, we tried to
differentiate these two items because, while those of us who may have
worked in public health agencies would understand much of this disease
monitoring as being surveillance, we wanted to differentiate that there
are some things that are done to provide assessments of community and
patient health, level of health status, with more of a focus on chronic
disease, which has been an increased charge to the public health
environment.

As \-- I won\'t say other challenges environmental, infectious, have
been conquered, but more so that theye have been controlled to the
extent that they have been in the last three or four decades. And the
rise of the importance of chronic disease management and risk factor
control.

The third domain \-- so the first domain is public health surveillance,
the second one is health status and disease monitoring. The third is
population-based clinical care.

And in this area it is, how can the population health system, the
broader public health system, within the context of bidirectional and
others, aid in the provision of care to \-- particularly built around
the determinants of health.

The fourth area is population-based research, which is how can we now,
with the potential of having access to data in a much more close to
real-time fashion and also in a higher degree of granularity, get new
insights and innovative solutions to help problems on a population
level.

And then finally, the last domain is health education and health
communications. To what extent can we think about the interaction
between what is known and what is possible in, as perceived within the
public health arena so that those who are providing direct individual
clinical care can have access to health education, health promotion, and
also provide that same information to consumers directly.

So those are roughly the five domains that we sort of started to think
through.

Any questions or comments about those rough areas?

Now, obviously some of these will have overlap with some of the
workgroups, the Chronic Care, Chronic Disease Workgroup as an example
and we will have to think about how we can synergize the work of this
new expanded charge versus our work, the work of that particular
workgroup.

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

This is Bob Martin from CDC. This is my first call so please excuse the
question or comment if it is inappropriate. But from what you just
described and what was provided in the materials, this was a vastly
different scope of work than was originally envisioned from what I can
read. And am I correct in that assumption?

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

Yes, you are.

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

Thank you.

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

Bob, do you have any comments about that?

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

No real comments. I mean, from a, my perspective as being in public
health for a long time, I mean, I think this approach, the broader
approach is certainly more desirable. The concern of course will be
resources required to accomplish that.

And I realize that\'s much further down the line to get to that
discussion, but it is an important part of the discussion.

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

Yes.

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

John, this is Brian Keaton from ACEP. One thing I would add in the
population-based research. I would \-- second from the last bullet.
Strategies to evaluate the effectiveness of health services and health
systems. I think one of the things that comes out of this is, as we
start to break down the silos, we have the opportunity to look at the
actual system rather than the individual components; and I would make
sure that\'s an included item so that people are aware of that.

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

This is Chip. I think it is important to note that, where we started,
those of you who have not been involved before, we really started from
the Secretary wanting to have each of these workgroups find low-hanging
fruit in terms of \-- (inaudible) rapidly, but also things that fit into
his overarching agenda. And really we were called biosurveillance
because of his need to know more so he could do his job in terms of
being the national public health officer.

And this really moves us, I think now, although we were creeping this
way anyway, way beyond the notion of just thinking about HIT from the
standpoint of collecting better data for some of the most classic public
health, in a better way, the most classic public health functions, to
obviously getting involved in population health and impacting individual
health in a way that goes way beyond what the Secretary originally
designated us for. I don\'t know if that helps.

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

This is Mary Shaffron. I just want to say thank you, and this is a much
more compelling approach.

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

I concur. This is Abid Rahman from VA \-- I commend the committee for
the expansion. It is more comprehensive from the initial intent.

**[\>\> John Lumpkin:\
]{.underline}**And Brian we did take note of that addition. Thank you.

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

This is John Loonsk. I have one question about, one of the things we
have been talking about in the context of biosurveillance. And it is
touched on though, I think perhaps not expressed to the same degree, and
it was actually in our biosurveillance discussions rated pretty highly
in terms of priorities, was response management.

And what I see here is information dissemination that can support
decisions, but I don\'t quite see all of the issues around response
management systems which are, at times, very integrally involved with
surveillance systems in terms of affecting the ideal outcomes. And I
just think it would be a shame if we lost that.

**[\>\> John Lumpkin:\
]{.underline}**Would you see that under the first broad heading then,
John? Near public health surveillance.

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

Yes, I mean, I think classically when people think surveillance, they
are not necessarily thinking about those systems. They are thinking
about informing them but not necessarily the systems that help implement
outcomes in that regard. So \-- and I could try to look for the best
place to put it. I\'m not sure that would be exactly where.

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

Because I think we don\'t want to lose that within the context.

Although, you know, at least from my perspective when I was at the State
of Illinois, when I talked about a surveillance system, intervention and
mediation was always considered to be part of what I would consider
surveillance systems.

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

Yes, and I think \-- I understand that. And I \--

**[\>\> John Lumpkin:\
]{.underline}**Need to be explicit about that.

**[\>\>\
]{.underline}**The surveillance system providing information that can
inform decisionmakers about how to act. And what I\'m trying to take it
to is the step of the fact that, in an electronic world, the systems
that actually implement those countermeasures and those response
activities are electronic, too. And unless we explicitly state them in
the area, I think we will lose them.

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

**[\>\> John Lumpkin:\
]{.underline}**I think looking at that same document bidirectional is
not as well covered either.

**[\>\> John Loonsk:\
]{.underline}**So the whole area of countermeasure and response
administration which we talked about incorporates apportionment of
vaccine, apportionment of prophylaxis, systems to know where the
inventory is that, et cetera, et cetera, is what I would \-- maybe it is
another heading. I don\'t know. But I think it is important to keep in
the mix.

**[\>\> John Lumpkin:\
]{.underline}**Okay. If you could play around with that and maybe give
us some language.

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

This is Laura Conn. Let me just clarify too. I think it is important
that we find where it goes in here as we move forward, but we\'re not
replacing the four priority areas that we talked about. We\'ll talk
about the recommendations in the first two priority areas, in the draft
letter coming up. But we do have on our schedule for this Workgroup to
address response management and adverse events starting probably at the
next meeting with getting more testimony and leading to recommendations.
But I do agree we probably need to add language to this broader document
so that, as we move forward, we don\'t lose it as well.

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

This is Leah Devlin, and I certainly agree with that. And I could see
response management going into a number of these different headings. I
mean, going under the different groupings in a number of different
places. Certainly under surveillance, situational awareness and response
management could be added there. And it is a part of a lot of these
different things, in my view.

Because I think if we start globbing on other categories it is going to
get cumbersome.

I did see adverse event handling under population-based clinical care on
another point.

**[\>\> John Lumpkin:\
]{.underline}**I think rather than trying to wordsmith this, let\'s note
that we need to have something that addresses some of the four \-- and
make sure that all the four current areas are addressed within the
context of this broader construct.

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

Yeah, I don\'t think that will be a problem.

**[\>\>\
]{.underline}**Does anybody feel like it might be its own category? It
is pretty compelling, strong thing that needs to be added.

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

I\'m sorry. Meaning its own category in what sense?

**[\>\>\
]{.underline}**I mean actually adding a category to the five that you
have here for response.

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

This is John. From what I heard Laura saying these are intended to be
sort of the new articulation. And to get the total articulation we need
to take some of the old. And so that might, in bringing that text in, we
might actually bring in the material from previous articulations and
that would be maybe at the category level.

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

Yes. John Lumpkin here again. I think what we need to think about is, if
you go to the diagram, the pretty diagram in the beginning, there are
certain things that sort of cover multiple domains. And from Leah\'s
comments, I think that these issues may cover more domains than just
being a separate domain. So I think we will need to play around with
this in order to develop a model that will give the appropriate
attention to those, particularly the bidirectional and the response
management piece.

**[\>\> Abid Rahman:\
]{.underline}**I think if we get into the process area, we probably need
some technical expertise, which may be a subsequent step.

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

Okay. So within this context, and looking at the four priority areas,
the bulk of our work, given the two areas that we have talked about that
are not adequately covered; but in the initial phase, so over the next
four or five months or so, or the next couple of meetings, we are going
to continue to focus in the public health surveillance domain. And that
domain, and the four areas that we have already selected, as we begin to
further develop the remaining four domains.

That sit okay with people?

Okay.

Anything else on the concept for the expanded scope?

Okay. Then we are going to move on to recommendations. And I think we
have a slide deck for that. Do people have that or \--

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

Yes.

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

Okay. Let\'s go then to the, for those of you who have the letter, we
are going to use the slide deck to kind of walk through the letter. The
letter begins with a discussion of the \-- I\'m sorry, I\'m shuffling
paper there.

Begins with a letter to the Secretary Leavitt, the head of the, from
AHIC, because this letter will be then going to AHIC to be sent to the
Secretary. Talks about the broad and specific charge. Highlights some of
the experiences from the workgroup's deliberation and then moves on to
the four areas that we have highlighted as being priority areas.

It then goes into a set of recommendations. The first recommendation,
which is in Slide #3, will be the overarching ones. The first
recommendation is that the State Alliance for eHealth, in collaboration
with State and local governmental public health agencies and clinical
care partners, and in consultation with HHS, should develop a business
case for data and information exchange between public health and
clinical areas, as well as develop a communication plan, improve the
understanding of the need for this exchange.

Any comments on that recommendation?

Okay. What I\'m going to do is I'm going to walk through all these
recommendations, and then I\'m going to ask for some general comments on
the letter as a whole. Is that okay?

Good.

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

Yes.

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

Recommendation 1.1, which is by April 30, 2007, HHS, in collaboration
with Federal, State, and local government, public health agencies,
should consult with HITSP to establish a plan for harmonizing public
health standards.

Any comments on that? Okay.

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

Yes, this is John. There are a lot of, there are a lot of demands on
HITSP and coming in from different angles. And so I, one of the things
we have been trying to do is to use the AHIC as the priority setting
group for HITSP. And so they could, you know \-- just the concern I have
with this is that, if we really want to get public health, population
health priorities, that we really di sort of have to work them through
the prioritization process of the AHIC. And it is possible that down the
road HITSP could develop additional capacity, particularly sort of, you
know, perhaps on a pay as you go basis. I\'m not sure that that could
happen in this context. And so I just would, you know, think about this
in the recommendation, in the context of the fact that it may be better
to focus it on trying to advocate for those population health priorities
at the AHIC level, instead of sending groups off to talk to HITSP
specifically because it is a little disjointed in that regard.

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

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

I\'m sorry. Is that what this really says, though? Because this is a
recommendation to the Secretary.

So that if we are making this recommendation to the Secretary then
presumably wouldn\'t the ONC \-- I mean wouldn\'t this have sort of fall
into the normal process of discussion at the ONC about what\'s going to
be sort of presented to HITSP? Am I confusing something? This is Chip.

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

The point I\'m making is ONC is not describing the priorities for HITSP.
The AHIC through its processes is describing the priorities for what
gets run through these different activities, and so that\'s what I\'m
trying to just rationalize with this. Because it, to send off to HITSP
directly and try to talk about public health. Unless it, you know, if it
is advocating the consideration of additional capacity for HITSP, and to
do it parallel with the priorities it gets from the AHIC, that would be
a consistent message. But \--

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

This is a recommendation to the AHIC though.

**[\>\> John Lumpkin:\
]{.underline}**Yes. And let me take it further, John, because I think
that there was a lot of discussion as we were preparing this, these
recommendations. There is a recognition that there is a difference
between saying that HITSP should develop a plan versus saying that we,
that the department should develop a plan and, if possible, consult with
HITSP.

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

I think this, as it stands now, could engender some confusion. And I
think if we want to be clearer, we could perhaps craft some language to
complement the language that\'s here to indicate that a plan through
HITSP would have to be in addition to work done to meet the AHIC
priorities. And there would have to be some discussion of how that could
be supported. So it just \-- otherwise, I think we are going to confuse
others like we are, as we talk about these issues.

**[\>\> John Lumpkin;\
]{.underline}**Well, help me, John, because I\'m looking at the
language. And it doesn\'t say the plan should go through HITSP.

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

And I think if you look at the letter rather than this language, it is
in the context of steps to articulate standards of use cases to be
prioritized by AHIC and promoted for harmonization by HITSP and then you
have the recommendations. So unless I\'m missing something, I think you
are taking this slide out of context of how it would be expressed in the
letter. Am I missing something?

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

Maybe you are not. I think \--

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

It is on page 2 of the draft letter that I have.

But my \-- so it seems to me that it places all of the concerns you have
in context of AHIC\'s role, HHS\'s role and HITSP\'s role.

**[\>\> John Loonsk:\
]{.underline}**In the letter per se you are saying.

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

Yeah. Yeah. Unless I\'m misreading this.

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

Okay. I was just \--

**[\>\>\
]{.underline}**The language and the slides and the language in the
letter should be exactly the same.

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

I understand that. But there is a preamble paragraph prior to the
recommendations in the letter which sets a context that answers John\'s
question, I think. You see my point?

**[\>\> John Lumpkin:\
]{.underline}**Yes. It says specifically the recommendations are
interrelated and targeted at establishing the basis on which specific
public health use cases, can be defined by HHS, prioritized by AHIC and
applicable standards can be harmonized by HITSP.

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

All these recommendations are under, in a sense subordinate to that
preamble so I don\'t think we have a problem.

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

Okay. I mean, I guess I\'m a little confused then by what the
recommendation is asking. If you are expressing the same sort of process
that we are using right now, what is the recommendation saying? And I
don\'t mean to belabor this. I just \--

**[\>\> John Lumpkin:\
]{.underline}**Here is what I see this recommendation saying. It says to
HHS that, as we found, that there are different standards that are being
used in public health systems, national, State, and local level. That
those standards need to be harmonized. And it is important for those
standards to be harmonized with other health information technology
standards that HITSP is addressing.

So as we begin to look at that process, we want to give a lead role to
HHS to look at the public health standards and provide leadership and
coordination at the Federal, State, and local agencies and to put this
on the list of things that HITSP needs to think about. So it is a plan.

And I think it is important to mention that \-- HITSP in that, because
we have to recognize that at some point and at some time all of the
standards related to health information technology, both clinical and
population health, need to be harmonized.

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

Yes. And beyond that, I think we need to say this, because right now my
assumption is that the kind of questions that we are posing, HITSP is
not thinking about. That\'s the whole reason for this. And when AHIC is
looking at its priorities, to suggest to HITSP, it is not thinking about
this, so putting it on the agenda, it seems to me.

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

This is Lisa Rovin in FDA. And I apologize if you all completely
understand this and my newness is what\'s speaking here. But are the
boundaries around the phrase "public health standards" clear and well
understood so that HITSP and ONC will understand what we are asking them
to do? I think if we are going to give an assignment, we should probably
be clear on the boundaries of it.

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

Well, let's see, I think you need to look at a whole \-- well that gets
back into the use cases. Right? I mean, in a sense it\'s the use cases
that will, that will -- that we come up with, that they will be
developed, that will then feed back into HITSP. Isn\'t that right, John?

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

Yes. And that\'s actually what\'s in the introductory paragraph. Next
step is to articulate the need for public health standards in terms of
use cases to be prioritized by AHIC and promoted for harmonization by
HITSP. And then those harmonized standards for public health should then
inform certification of public health systems used at the State, local,
and national level.

Did you want more clarification than that, or does \-- I mean, does that
address the issue?

**[\>\> Lisa Rovin:\
]{.underline}**I don\'t think the question is whether it clarifies it
for me. I think the question is whether it clarifies it for the people
to whom we are giving the assignment.

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

No. I mean \-- see, this is for a letter that\'s going to AHIC. When we
work through \-- and that\'s why I brought up the ONC a minute ago. When
it sort of worked through to HITSP it is going to be worked through in
the context of use cases that would make it through the prioritization
and get to HITSP. It is not going to be in terms of this generalized
recommendation.

This is simply \-- if I read this right, this is saying to AHIC when you
are putting together your sort of book of business for HITSP, this needs
to be part of it and then the use cases that actually go to HITSP so
what HITSP gets would be something very tangible. I mean, that would be
my understanding.

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

Again, and I\'ll stop after this, this is Lisa at FDA again. If this is
all in the context of the use cases, what exactly are we asking ONC and
HITSP to do?

If somebody gave me this assignment, I don\'t think I would understand
what I was being asked to do. If everyone else understands it, we can
definitely move on, and somebody can explain it to me later.

**[\>\> John Lumpkin:\
]{.underline}**I think that the context of that is there needs to be a
plan on exactly how those issues that you are raising are being, will be
identified and what those use cases need to be in order to pass this on
to HITSP. So it really is not saying, you need to develop or harmonize
these standards, but that we need to look at the steps that need to be
taken that will ultimately yield the product that can be harmonized.

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

John, this is Leah. Do you think we should put an example in here or is
that going to make it too long?

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

I think in terms of what I\'ve seen going to AHIC before, everybody
understands that. As an AHIC member, I don\'t have a problem with the
level of specificity here. But if the group does we can do more. But I
think \-- I think this is really sufficient for the AHIC level sort of
recommendation.

**[\>\>\
]{.underline}**Okay. I\'m fine with that.

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

This is Paula from NACCHO. It might help if we actually put some
language in here that this is relating back to the use cases because by
just putting a plan for harmonizing public health standards, it really
is not clear that we are relating it back to the use cases. And to look
at this, it looks like we are trying to tackle all public health
standards, which I don\'t understand that to be the case.

**[\>\> John Lumpkin:\
]{.underline}**So if I take it from that then, should consult with HITSP
to establish a plan for harmonizing public health standards based on the
use cases?

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

**[\>\> John Lumpkin:\
]{.underline}**Okay. And just as a methodology, we are going to \-- I
think the finalized version of this will go to our January meeting and
then on to AHIC. Is that correct?

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

Yes.

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

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

So \-- this is Laura. I just want to clarify because I think I\'m
confused now. Because the HITSP, HITSP is already harmonizing standards
relative to the three use cases. And this was an attempt to get broader
public health standards on their plate, which is related to John\'s
comment of getting population health priorities to the AHIC. And I\'m
not sure how it all comes together. But if we are just pointing to the
use cases, that\'s already an established process so then I\'m not sure
that it makes this a new recommendation.

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

Laura, this is Paula. I just don\'t know how \-- I mean that is
absolutely a monstrous task, and I don\'t see how you make a
recommendation like that without putting some kind of parameters around
it.

**[\>\> John Lumpkin:\
]{.underline}**I think that \-- refer you to again the introductory
paragraph that says, the next step is to articulate the need for public
health standards in terms of use cases, to be prioritized by AHIC. So we
would be talking about additional use cases, and that the plan would
identify which use cases we want to develop and then subsequently go
into the prioritization process.

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

I almost think you have to think about these recommendations in the
context of the letter, not in the context of this sort of, of the free
standing recommendations.

**[\>\>\
]{.underline}**Yes I \--

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

I really think it is taken care of in the letter.

**[\>\>\
]{.underline}**I mean, I am reading the letter, and I agree with what
was just said. It just didn\'t seem to synch with what Laura had said.

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

Okay. Where are we?

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

I guess we are, we were still on 1 through 1.2. I guess we \-- are we
all the way through 1.4?

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

No. We are still on 1.1, and I was just trying to get a sense of \-- it
seems to me, from where we are, is that we want to look at these
recommendations in context of a direct tie-in to the preceding, that we
were going to change 1.1 to refer back to the use cases that would be
developed on public health in the last, second to last paragraph, last
sentence of the preceding paragraph to the recommendations.

Is that acceptable?

**[\>\>\
]{.underline}**Mm-hmm.

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

Okay.

**[\>\> John Loonsk:\
]{.underline}**I don\'t \-- I think this recommendation needs to be
reworked offline, and I don\'t think we\'re going to edit it right now.
I think there is adequate confusion about it, that it is not ready to go
forward. So I would like a clearer articulation of what it is saying,
how it relates to the existing capacity of what use cases is being
talked about. Because I think these are all critical issues and I just
don\'t understand it. So \--

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

Okay. Then, John, I would like to ask you to help us with that.

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

I would be happy to.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So we will rework that for our next meeting.

On to 1.2, which is process. The process again is the use cases
harmonization, and then use of those harmonized standards to develop a
certification process for public health information systems.
Consultation with CCHIT would occur. To the extent they would be
interested in doing this, it may occur through CCHIT, otherwise it would
be through a process developed by the department.

So that\'s Recommendation 1.2. My interpretation of that language. Are
there any comments on that one?

**[\>\> Art Davidson:\
]{.underline}**This is Art. I just wondered how does this relate to the
efforts of CCHIT for provider systems. In Recommendation 1.0 you talk
about the relationship between the public health and clinical care. And
I think there will be something in this, that we should talk about
certification of clinical care systems to talk to public health.

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

Yes, Art, this is John. I think in some respects that\'s already on the
agenda. For example the biosurveillance interoperability specification
from HITSP has been put forward to CCHIT for, to be put on the roadmap
for certification potentially EH, ambulatory, in patient, and network,
you know, over time. So I think that the issue here, and I think this is
a good recommendation, is that CCHIT has not had it in their purview to
think about public health systems, the public health side of that. So in
the context of this, and maybe I\'m overinterpreting it, but the reason
to consult is to make sure that these processes are linked. But there
has been no commitment by CCHIT to bite off this other piece as well. I
think as John described, it\'s a possibility. But minimally, a new
process could learn a lot from what they have been doing.

**[\>\> Art Davidson:\
]{.underline}**So the use case that we are \-- (inaudible) \-- is that a
new use case that would be referenced in 1.1 or one that currently
exists?

The old BT \-- the biosurveillance, you know, activity that they are,
the data steering committee worked on or something different?

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

I think that this would, you know, there is two processes here.
Obviously this one is not addressing the one of the standards within
CCHIT. Although if you go down to Recommendation 2.3 --

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

Okay, and I\'m just looking on the web. I\'m in a cab, so \--

**[\>\> John Lumpkin:\
]{.underline}**I'm sorry. Let me read you Recommendation 2.3 which we
have not gotten to. CCHIT should include certification criteria for
automatic case reporting of nationally notifiable conditions in
electronic health records, by date not \-- we will have to set, put in
there.

I think that addresses \--

**[\>\> Art Davidson:\
]{.underline}**Okay. Now I see. I just didn\'t see those. Thank you.

**[\>\> John Lumpkin:\
]{.underline}**Okay. Yes. So this addresses the issue of doing
certification of public health systems so that they can receive that
data as well as exchange data between different jurisdictions.

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

Good. Okay.

**[\>\>\
]{.underline}**Are there other questions? Comments? Then let\'s move on
to 1.4. \-- I\'m sorry, 1.3. HHS in collaboration with ASTHO, NACCHO and
other appropriate organizations should, through cooperative agreement,
encourage and support the establishment of a proof of concept
demonstrating that data can be shared from clinical care to public
health through a RHIO. Okay?

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

This is Paula. Could we actually go back to 1.2? I\'m sorry. I don\'t
like to impede progress, but we are having a little offline discussion
here. And we were just wondering, the certification, would that be in
addition to, in replacement of what CDC is thinking about? And I know
that they are talking about certifying health departments, and they are
having some discussion of certifying public health information systems.
But I guess, where does this recommendation lie in CDC\'s plans.

**[\>\> John Lumpkin:\
]{.underline}**Well, I can\'t speak for CDC, but it may be that HHS who
we were directing to do this, may decide that the process for
certification, in consultation with the State and local government
agencies, will actually be the process that CDC has been talking about.
We are just saying there should be a process that is developed.

**[\>\>\
]{.underline}**Okay. Thank you. Now we will get to the part where we
find out if we are getting money.

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

Back on 1.3. Any other comments on that? Let\'s move to 1.4. The plan
for State funded public health surveillance programs to be integrated
with RHIO, and emerging health information network services for clinical
care. The plan should be developed within a date certain.

So first on the concept and then, or any comments about who and when.

Would this be HHS in collaboration with ASTHO and NACCHO?

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

This is Angela Fix from ASTHO. That would be my first guess. Of course I
just want more work to do and more money to do it with, but who
doesn\'t.

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

This is Paula from NACCHO. I would agree that it should be with ASTHO
and NACCHO. But some of our members are on the call so they can chime in
as well.

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

This is Brian. Just a comment. This implies that there is a two way
discussion. We have got groups that represent public health. Are we
going to have individual RHIOs represent the continuum or are we going
to look towards somebody to represent RHIOs as a whole, or how do we
plan to have that other side of the discussion?

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

**[\>\>\
]{.underline}**Yes, those were the \-- I had, too, who was going to be
on that side.

**[\>\>\
]{.underline}**So, that would be HHS in collaboration with ASTHO, NACCHO
and \--

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

**[\>\>\
]{.underline}**IHIE is probably the most recognized, connecting
communities program.

**[\>\>\
]{.underline}**So IHIE and other appropriate organizations.

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

**[\>\> Brian Keaton:\
]{.underline}**That would probably cover it.

What I don\'t want to do is make this a one on one discussion from RHIO
from this State and RHIO from that State, that doesn\'t necessarily
represent the continuum.

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

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

**[\>\>\
]{.underline}**That looks like a good \--

**[\>\>\
]{.underline}**A question. Should CSTE be listed there? The question is
whether we come under \-- or want to be sure that the technical
epidemiologists are there as well as ASTHO. ASTHO often includes CSTE
when appropriate, but it's not always a guarantee.

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

This is Mary Shaffron from APHL. We are actually doing some very
interesting work that could inform this.

**[\>\> John Lumpkin:\
]{.underline}**Okay. I think I\'m hearing the list of ASTHO, NACCHO,
CSTE, ASP.

**[\>\> Mary Shaffron:\
]{.underline}**Well, I\'m feeling like an appropriate organization so
\--

**[\>\>\
]{.underline}**Okay, good. How about CSTE, would you feel like an
appropriate organization?

**[\>\>\
]{.underline}**Yes, I think so.

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

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

This is Rick Heffernan from New York City. It says "to be integrated
with RHIOs". Obviously for this document no details on what that means.
But a lot of that will depend on what is learned in proof of concepts
and how RHIOs develop. It struck me as a little premature,
Recommendation 1.4, that we would develop a plan for integration when it
is not clear, you know, how that, how that should be carried out.

**[\>\> John Lumpkin:\
]{.underline}**That is probably why the date is left certain. Unclear.
Is this something that you think, once we better understand RHIOs, it is
easier to develop that plan, in which case would you have a candidate
date? Or do you think that this is just something that shouldn\'t be
done at this point?

**[\>\> Chip Kahn:\
]{.underline}**If we struck \--

**[\>\> Richard Heffernan:\
]{.underline}**I would not include it as a recommendation. It seems
premature. And we already have 1.3, which indicates that we are going to
look very carefully at RHIOs and how we can integrate with them, but
doesn\'t say we are ready to make a plan for integration.

**[\>\> Chip Kahn:\
]{.underline}**Is the term emerging health information network services
encompassing of RHIOs?

**[\>\>\
]{.underline}**I\'m sorry, could you repeat that?

**[\>\> Chip Kahn:\
]{.underline}**Yes. I just wondered \-- you know, I hear what Rick is
saying, and maybe if we just left it with emerging health information
network services rather than specify RHIOs.

So that could be what \-- not in New York if it is not a RHIO.

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

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

**[\>\> John Lumpkin:\
]{.underline}**Yes. And, you know, I\'m hearing this discussion about
whether or not this is ready for prime time. But, you know, there is a
program that the Robert Wood Johnson Foundation is funding to get State
and local health departments at the table at the RHIO. So I would think
this is something that, taking that experience and moving it in a
broader spectrum, rather than it being public health negotiating within
the RHIOs, or negotiating with the RHIOs.

**[\>\>\
]{.underline}**Yes. I think the distinguishing point here is that RHIOs
are more the, at an organizational level. They are taking care of
government and priority setting and making decisions on policy and
ensuring privacy and security. So I think if public health wants to be
represented at a decisionmaking level, which they do, that they should
be actually participating in the organization as opposed to perhaps
being involved more on a technology level. I think that, you know, when,
we are talking about emerging network services, we are talking more
about the network service providers that will likely be contracting with
regional or State-level organizations, and will have more of an
oversight responsibility. So I think from a planning and governance
perspective, similar to what RWJ started a couple of years ago, I think
public health interests would be better represented if they were
involved perhaps at those levels.

**[\>\>\
]{.underline}**Is it possible to put on a qualifier that might be
helpful like "be integrated to the extent possible" so that doesn\'t
sound like \-- it doesn\'t sort of imply it is maybe fully integrated
and that it may or may not be as functional for some things as we would
like?

Would that help, Rick?

**[\>\> Richard Heffernan:\
]{.underline}**Yes. I definitely think public health needs to be at the
table. This seems to be suggesting that we are ready to integrate in a,
yes, in a way that didn\'t seem to me that we are ready to specify that
yet.

So maybe softening the language would help.

**[\>\> John Lumpkin:\
]{.underline}**The question is, is it the fact that this is, "develop a
plan", not to implement. Does that soften it enough without putting "to
the extent possible", which is, makes it pretty soft.

**[\>\>\
]{.underline}**Yes, I think \--

**[\>\>\
]{.underline}**That\'s okay.

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

This is Brian. I think that, combined with the softness of the word
"integrated". I mean, we can integrate it with a sneakernet or we can
integrate it at the data level. But it implies there is going to be a
way they work together, and the proof will be in what we are actually
able to do on the ground.

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

So if I can take that then, we have got a little bit of discomfort but I
think \-- sorry, the noise \-- sounds like we can get our arms around
this one with the expanded group. Is there a recommendation for a date?
All the other ones are April and June of \'07. Because we think this is
a little bit less cooked would we want to look for a date more like
October?

**[\>\>\
]{.underline}**Yes, I think there is actually a fair amount of
complexity with this one, and I think the department \-- (inaudible) \--
which, probably have a lot to sort through in terms of the scope of the
public health surveillance programs they want to consider. And perhaps
maybe sort of a phased in plan because it is going to require an awful
lot of change over time.

I would think we want to allow for at least a year for people to get
this done.

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

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

But it \-- this is Brian. It seems that 1.4 is going to be very
dependent on what is learned in 1.3, which is going to be dependent on
creating pilot projects and learning from those.

So that it is difficult to plan for the integration until you have done
some pilots. And now you are looking years down the road.

**[\>\>\
]{.underline}**That was my thinking.

**[\>\>\
]{.underline}**Well, we could take \-- based on initial experience, in
2007, that a plan be developed in 2008. I mean the only experience
really that we have, I think to date, is in Indiana which \-- is Shawn
on the phone today?

**[\>\> Chip Kahn:\
]{.underline}**I don\'t think so.

**[\>\>\
]{.underline}**No. No.

**[\>\>\
]{.underline}**So there is a little bit to learn from, but not much.

**[\>\> John Lumpkin:\
]{.underline}**I\'m hearing June 30th of 2008, for the development of
the plan?

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

**[\>\> John Lumpkin:\
]{.underline}**Is that okay?

Okay.

**[\>\>\
]{.underline}**I just also wanted to point out that one of the tasks
that is in the State Alliance for eHealth scope of work, is to do
something similar to this. So it could be that the State Alliance is the
convener. So they are going to have a third task force that we will be
focused on sort of integration of State government programs. And since
this would be sort of consistent with that, they could be convening all
of the public health groups that are appropriate, and they would also
probably have some staff support to get this done.

So if we feel this needs a definitive home in terms of who would be the
convener and who would really, sort of get a good cross section of
States, we could consider specifying that.

Quite honestly, otherwise it will be up to either CDC or, you know, ONC
probably will be the convener \-- (inaudible) and I think \--
(inaudible) \-- there is more uncertainty in terms of \-- (inaudible)
\-- right at that time.

**[\>\> John Lumpkin:\
]{.underline}**Are we \-- so my reading on this one is, if we are
comfortable with that sort of scenario, by June of 2008?

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

There was \-- this is Brian. I had the talk cut out there for just a
little bit. Did we decide the who?

**[\>\>\
]{.underline}**Yes, the who was HHS, in collaboration with ASTHO, NACCHO
and IHIE and other appropriate organizations.

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

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

This is Kelly Cronin. Could I ask one more time, would folks consider
the State Alliance for eHealth because they have the third task force.
And it is focused on looking at public health programs and programs like
Medicaid. They are funded on a State level. To try to figure out how
they might be integrated with what we are doing for health information
exchange and health IT. So that is a potential home for this in terms of
convening and providing some staff support.

**[\>\> John Lumpkin:\
]{.underline}**Are you \-- I\'m sorry. Were you suggesting as opposed to
HHS, or as a, an additional organization in collaboration with?

**[\>\> Kelly Cronin:\
]{.underline}**It could be HHS through the State Alliance for eHealth
\--

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

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

\-- in collaboration with ASTHO, NACCHO.

**[\>\> John Lumpkin:\
]{.underline}**Do we need to tell HHS who to collaborate with or who to
grant an RFP to, to do the work?

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

It is helpful \-- if this is a widely read document people know where
the home will be.

**[\>\> John Lumpkin:\
]{.underline}**I think that, I would be more comfortable with adding a
note at the end saying that the State collaboration might be a suitable
location rather than directing HHS to do that through them.

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

Okay. Yes, we just had a Consumer Empowerment Workgroup meeting earlier
in the week. And, you know, we talked about this there. And I think we
were, you know, it \-- from an ONC perspective it is not, it is not a
problem to specify what the State Alliance should do. They are getting
formed and they are quite open to direction. At least they want to know
what\'s most important and what they should be focusing on. And that in
part will be of course informed by their steering group and their
advisory board, which is made up of both elected and appointed State
officials.

But if there is, you know, something important to public health it is an
opportunity to express this to them.

**[\>\> John Lumpkin:\
]{.underline}**Okay. Do we \-- I think we have enough on this particular
one that we can perhaps move on because we will be bringing it back.
Unless there are any other comments on it.

Okay. We are going to move on to case reporting. And this is the first
area of our four focus areas. And \--

**[\>\>\
]{.underline}**Sorry, John, I don\'t mean to interrupt. And I do
apologize. I stepped out, but did you discuss 1.3?

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

Yes, we did.

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

**[\>\>\
]{.underline}**I think we missed it here in the room.

**[\>\> John Lumpkin:\
]{.underline}**Really? I don\'t think there was much discussion.

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

We went through it pretty fast.

**[\>\>\
]{.underline}**I think it's because ASTHO and NACCHO were involved in
another discussion, we didn\'t really hear.

**[\>\>\
]{.underline}**The one thing I wondered about was whether \-- I\'m not
sure that it's the proof of concept that it can, or the proof of concept
that would demonstrate the added value of a RHIO potentially, or a
regional health exchange, in doing public health sharing data. And I
think, you know, I think there was a lot of value in the second, which
is to demonstrate, you know, because there have been discussions about
ways in which regional health exchanges could potentially help
facilitate public health surveillance particularly for ambulatory care
settings that don\'t have a lot of technical infrastructure, et cetera,
et cetera. And so I think putting a fine point on that, that it is not
just that it can do it. It is to, because we know, I mean Regenstrief
and others do this already. The value would be in showing what the added
value is of a regional health exchange in accomplishing that.

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

This is Angela. I would also add in too that not only the value of
clinical care to public health, but public health back to clinical care.

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

**[\>\>\
]{.underline}**Which is discussions we recently just had with IHIE
themselves in their developing a value proposition so \--

**[\>\> John Lumpkin:\
]{.underline}**Okay. Anybody uncomfortable with that change?

Hearing none, let\'s move on to case reporting. Recommendation 2.0. By
April 30, 2007 CSTE, in collaboration with CDC, should determine a
process for standardizing national case definitions and defining the
standard list of nationally notifiable conditions for all States.

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

This is Jim. I wanted to say, before that in some of the description, I
think, I would like a crack at sort of making some modifiers at some of
the description. We don\'t have to go over them in detail right now. But
I think it a little bit mischaracterizes the reporting system. It
certainly points out flaws, but it doesn\'t \-- but it kind of does it
with omissions about what it does do. And I think as this goes to
Secretary Leavitt, it gives unnecessary emphasis, or it doesn\'t give a
balanced picture of case reporting as it is, and doesn\'t even mention
telephone reporting. So I think it is important to change that a little
bit.

Then getting to Recommendation 2.0, I would say, actually, there already
is a process for standardizing national case definitions, and there is a
process for defining a standard list of nationally notifiable conditions
for all States. Doesn\'t mean that all States necessarily modify their
lists to include all those conditions. But there is a process, and there
is a nationally notifiable disease list that has a countable number of
conditions on it. And again, and there is a process for standardizing
case definitions which is at the annual CSTE meeting through resolutions
that get passed by the majority of States represented there.

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

This is John. And I agree with Jim. And there is a process, but I think
there is another point here that \-- and maybe we could advance the
recommendation in regard to, but \-- and that is if, you know, as the
electronic infrastructure advances and we have different EHR vendors
providing services to a variety of different jurisdictions, is it really
going to be tenable for each, for there to be an expectation of a high
degree of variance in what is reported for all those different
commercial products.

And I think that there is a \-- the important point there around the
fact that, you know, it is something that we have seen in many, in
circumstances before, where there is a national group that needs to
report in many jurisdictions that it can be an obstacle to reporting.
And the analogy here is that if we are trying to build an electronic
infrastructure that can do case reporting, for example, it is adding
that much more of a challenge if it has to be customized to every
jurisdiction relative to what is reported.

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

Yes, I mean \-- this is Jim. I think that there is that there, a couple
of sort of challenges to that. One is, I mean from my perspective if I
got case reports of something that I didn\'t ask for, that probably
wouldn\'t be a problem, although some of the people on whom the
reporting was done, you know, might not like it if they were aware of
that.

That\'s one side of it. Because I think most of our confidential laws
are such if we get information that we didn\'t ask for, it is still
required to be kept confidential per our State confidentiality laws
because there is still data on morbidity or mortality that is kind of
covered by the confidentiality.

The other side of it is, there are conditions, and I think we in
Connecticut have plenty of them, that are not reportable nationally but
for which we require reporting in Connecticut because they are diseases
that may be geographically unique or we may have special funding to do
something that the rest of the States are not ready to do yet. And we
use the disease reporting system as a way of dealing with it because it
is one that is appropriate for those particular conditions.

So that there are always \-- I think there are always going to be
differences even if, you know, everybody, even if there is a
standardized kind of minimal list. And that\'s going to be a challenge
for sort of the eHealth-type reporting.

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

Jim \-- this is John. Recognizing all of that, the way I saw
Recommendation number 2 is to sort of codify the process that\'s in
place as a HHS-wide process now under recommendation from AHIC.

And one of my concerns has always been that this is a system that has
worked, worked pretty well. But every time this issue comes up, somebody
wants to try to reinvent it.

And so I thought this was a way to really concretize what currently is
in place.

**[\>\> James Hadler:\
]{.underline}**Right. And in that sense, and that\'s obviously something
that by April 30th is doable, even without a national CSTE meeting
because all it takes is somebody explaining the current \-- is
describing the process and saying it does exist \--

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

**[\>\> James Hadler:\
]{.underline}**\-- and there is a process.

I guess, mainly I wanted to point that out. And if that was your
intention then I would say this sounds fine to me. If my response would
be, would be an acceptable response, which is actually there is, there
is a system and here is what it is.

The other side of it that John Loonsk brought up, the question of sort
of having sort of a fully, all States kind of going along with the same
standards in a sense. At least for purposes of electronic reporting it
would be easiest if there didn\'t have to be any variations between
places.

And on one hand I would \-- I mean, I fully, you know, appreciate that
to get all States to come up with exactly the same list I think won\'t
happen again. Because some of them have processes that may, and maybe
individuals, either processes built into their State laws or individuals
who don\'t necessarily want to make everything that's nationally
reportable, reportable in their State. And then I think perhaps more
importantly, the other side of it there are conditions under
surveillance in some States because there are local or regional
conditions or they are ones they have the resources to deal with.

And of course we each have our own state laws that enable us to make
conditions reportable. And I think you are never going to get 100
percent match across States. That\'s just a practical, that\'s a reality
and it is probably desirable. Because we want public health to be
flexible and responsive. And if one State is capable and interested in
doing something that another State may not be, either lacking interest
because they don\'t have it or don\'t have the capability and don\'t
want to, you know, get data, that they cannot really use, to me, that\'s
kind of healthy.

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

This is \-- this is Art. I wonder if we are talking about two things
here. Is it the method of reporting or is it actually the content, the
actual list of things that are reported?

**[\>\> John Lumpkin:\
]{.underline}**I think there are at least three things here. And I was
not by any means suggesting that in the immediate future all the States
were suddenly going to report exactly the same things. But there are
several pieces to that, and I think it would be to the betterment of
adoption of notifiable disease reporting in EHRs if a, there were
efforts made to make, for example, the terminologies the same, where
they could be the same, to modularize some of the reporting so that, you
know, not saying that this State has to report the same disease as this
other State; but maybe, as they do, that they strive to have similar
case reports so that, you know, the specifics of it are not so
complicated for a vendor to implement. So I think there are a number of
things that could be described along these lines that are short of
suggesting a monolithic, consistent reporting structure, but that would
still be helpful in advancing adoption of notifiable disease reporting
through electronic health records.

**[\>\>\
]{.underline}**And let me just sort of say what John Loonsk just said
another way. If Connecticut wanted to, they don\'t have to collect
reports of hantavirus; but if they do they are going to report it in
this form.

**[\>\> James Hadler:\
]{.underline}**Right. And I think from \-- all of that sounds fine to
me. And again, just to point out something that I think many of you
know, and it is sort of a limitation of the electronic reporting but it
is a necessary one. It is a limitation of regular reporting. And that is
that for many diseases we do have forms that collect additional
information. And an electronic report may not have all that on it.

From my perspective, just getting a core report \-- that\'s actually
what we do in Connecticut. We get a core report. And if it doesn\'t have
all the information we want on some of the diseases, and anything we
want more information on, obviously we go after, after we get our
initial report. And I think that probably won\'t change with the
electronic health record entirely. We may be able to get more of it. So
that from the standardization perspective there is a core set of data on
any reportable disease that could be reported. And then if people want
to get additional information, that could be standardized across all
States and all systems that are capable of doing that.

And I think that would be highly acceptable, and then it would be up to
each State to decide whether it wanted to go after more information or
not. Recognizing that that may be happening no matter what. Because
there are diseases for which we need more information, especially those
we are involved in intervention and case management, like TB.

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

This is Rick Heffernan from New York City. We discussed this internally
and had really the same thoughts that Jim has already expressed. I agree
that there is useful standardization around data elements and
terminology, et cetera, and would support that. I think the
recommendations as currently written imply that you are going to have
standard lists of notifiable diseases. And we had this \-- we had the
same reaction as he. So I think this needs to be revised to reflect more
along the lines of what John Loonsk was just describing.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So when we bring it back we will do those
revisions. Any other concerns with this one?

**[\>\>\
]{.underline}**Only to go back to my, actually my first comment and sort
of say, how do you want to handle that in terms of kind of the
descriptive paragraphs preceding the recommendations? Would you accept
some efforts to kind of modify them somewhat?

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

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

**[\>\> John Lumpkin:\
]{.underline}**Okay. Any objections to moving to 2.1?

HHS should ensure the harmonization of standards through web based case
reporting. Standards adopted by NEDSS should be considered.

Hearing nothing, 2.2. By December 30, \'07, CDC shall ensure funding
provided for case reporting to State and local public health
jurisdictions, as well as internal CDC programs, requires use of
harmonized standards.

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

Right. This is Jim. I\'m generally in favor of that but just want to be
sure I understand what it means.

And that is that, just to kind of paraphrase it, is that funding that we
get, that\'s surveillance, or especially I guess electronic surveillance
oriented or surveillance oriented in general would require that we use
these harmonized standards. And I think that is \-- I mean, that\'s in
the process of happening already with requirements that are coming out
that are sort of various PHIN based requirements coming along with
public health preparedness funding. Is that correct? Although they
don\'t specify case reporting.

**[\>\>\
]{.underline}**That would be my reading of it.

**[\>\> James Hadler:\
]{.underline}**And so obviously, you know, whenever we go beyond those
standards for whatever other information we want to get or have other
conditions reportable, that\'s all of our own \-- and I imagine that\'s
all of our own business. And the reality is, I mean \-- and that\'s of
course governed by our own State laws anyway so I imagine that could not
be entirely \-- so that wouldn\'t be subject to this.

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

This is John. Relative to the first point, I think that \-- one question
would be do we want to say HITSP-harmonized standards explicitly, and
the second point would be, I believe that the CDC has made a commitment
that the standards they consider in the context of PHIN and cooperative
agreements will be consistent with the HITSP-harmonized standards so
that that would alleviate the anxiety there was some sort of conflict
here.

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

This is Rick. I agree. I think that\'s important because the concern
would be that standards that are not mature enough would be somehow
required, and I think the HITSP process or some process like that
ensures that they are well thought out and ready for prime time.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So with that modification are there other concerns
about that?

Then 2.3. CCHIT should include certification criteria for automated case
reporting of nationally notifiable conditions and electronic health
records by 2007? Eight?

Anybody have a candidate number? 2010.

**[\>\>\
]{.underline}**It might be too late for \'07 unless a lot of work is
done in the next several months.

**[\>\>\
]{.underline}**I think we had a number \-- didn\'t we have a number of
2010?

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

**[\>\>\
]{.underline}**Oh, yeah. That\'s right.

**[\>\>\
]{.underline}**Yes, we originally did.

**[\>\>\
]{.underline}**\-- on the road, weren\'t we.

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

**[\>\>\
]{.underline}**That\'s \-- that\'s a bit of a slow track, don\'t you
think?

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

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

**[\>\>\
]{.underline}**Okay. Do I hear any votes for 2008?

**[\>\>\
]{.underline}**Three years?

**[\>\>\
]{.underline}**Anybody opposed to 2008?

**[\>\>\
]{.underline}**Reality is whatever we set it, it will either slip or it
will stick, but 2008 sounds as good as any to me.

**[\>\>\
]{.underline}**Yes, I\'m good with that.

**[\>\>\
]{.underline}**Okay. Anything else on the wording of that one?

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

No. This is John. And I happen to have some experience with this because
of efforts to get the biosurveillance interoperability specification
considered for ambulatory care, EHR and inpatient.

And, you know, I think what we need to think about here is the value of
assigning a date if we don\'t have a reason for them to find it
compelling. And in that regard what I\'m really talking about is part of
the business case here. Because that \-- there are several different
factors when it gets down to certification that are considered. It is
heavily weighed towards the existing infrastructure versus the "to be"
state, and it is weighed toward, you know, where there is a clear
business case for inclusion.

So I\'m not \-- you know, please understand I\'m very supportive of the
general concept. But I think in terms of the value of the
recommendation, it may be improved or increased if we can articulate why
or how that should be considered. And the date is not a surrogate for
that. You know, I guarantee if you put in 2008 it is not going to be
there.

**[\>\>\
]{.underline}**Let me ask this question of Jim. How many States are \--
exist for which there is no legal requirement for reporting notifiable
diseases of some sort?

**[\>\> James Hadler:\
]{.underline}**I don\'t think there are any States that don\'t have a,
you know, a State-based list of reportable diseases and laboratory
findings and statutory language relating to it.

**[\>\>\
]{.underline}**So when we talk about existing function, this is a
function that exists for every provider, just about every provider in
every State currently.

**[\>\> John Loonsk:\
]{.underline}**And that is part of the value proposition. But right now,
the obligation is on the provider. It\'s not on the EHR vendor or on
other aspects of the infrastructure or the provider community to do
that. And so I\'m just challenging a little bit, I think here, to say
that I think if we put our minds to it, we might be able to come up with
an equation that could, to be advocated that could help break this log
jam. Because the legal reporting is oriented to the provider, not to
their, to these other pieces.

**[\>\>\
]{.underline}**Well, one could say the same thing for most of the
functions in an EHR.

**[\>\>\
]{.underline}**But I think the difference is that the providers are
demanding the capability in the EHR. And by and large most providers
aren't consistently doing disease reporting at the moment. So this
wouldn\'t necessarily be something they would be demanding.

**[\>\>\
]{.underline}**Well, yes. It is hard to demand something that you cannot
imagine.

**[\>\>\
]{.underline}**Or that you don\'t regularly do.

**[\>\>\
]{.underline}**Or that you refuse to do.

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

**[\>\>\
]{.underline}**As far as public health we need to develop the value
proposition for why providers want to do this.

**[\>\>\
]{.underline}**Right. Well, I think my only \--

**[\>\>\
]{.underline}**2.5.

**[\>\> John Lumpkin:\
]{.underline}**My only point on this one is, we don\'t have a date, then
we won\'t feel any pressure to develop the use case and the business
case. And we will end up two or three down the road or four years down
the road having the same conversation.

I just think we need to have some date that becomes a goal for us, for
HHS to do the groundwork that needs to be done in order to enable this
to happen.

And I\'m not wedded to a particular date. I just think we need to have
one.

**[\>\> John Loonsk:\
]{.underline}**I know \-- you know, John, I don\'t object to having a
date. I think 2008 is not realistic. And then \-- I\'m not sure about
the groundwork because, you know, CCHIT had been set up to an
independent public/private process. So what I\'m trying to articulate is
what I would perceive should be the groundwork, which is not necessarily
that HHS do it, but that we have a broader challenge to express why this
should be something that that community asks for.

So, I mean, I think we are on the same page in that regard. I\'m just
not sure HHS is the party that can deliver on that exclusively.
Obviously we would like to try to help.

**[\>\> John Lumpkin:\
]{.underline}**Right. But I think HHS is the leader in this particular
area. And I am not looking necessarily that they do all the groundwork,
but certainly can, at a convening process and leadership process, make
sure this issue is discussed and the parties, the States and so forth
who have perhaps a better position in doing this have a coordinated
approach to it.

So we \-- how about \'09 or \'10?

**[\>\> John Loonsk:\
]{.underline}**It is sort of \-- you know, it is sort of general. It
just says some certification criteria. So I mean, I think putting
something out there that, in \'09, might be able to get something in.

**[\>\> John Lumpkin:\
]{.underline}**Okay. Anybody opposed to \'09?

Okay.

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

Hey, John, this is Angela Fix. You know, I think it is, actually we are
taking a turn around the table here to see how far back we can go and
impede progress.

So back in Recommendation 2.2. Is it saying, just so I\'m not
misunderstanding it. Is it saying by December 30, 2007, funding that
comes from CDC is only going to happen to the grantees if they are using
harmonized standards.

**[\>\> John Lumpkin:\
]{.underline}**I think we talked about harmonized HITSP standards.

**[\>\> Angela Fix:\
]{.underline}**Right. I mean, it doesn\'t matter to me if it is HITSP or
whatever. But I\'m just thinking to the \-- maybe I\'m misinterpreting
CDC's PHIN requirements and certification process. Kind of out there,
the States and locals are at that point where, by 2010 you have to be
PHIN-certified. And it kind of, they feel that they won\'t get their
funding if they are not certified by 2010. And does this kind of bump up
their deadline to 2007 instead? Maybe I\'m misinterpreting this. And
John is smiling at me right now.

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

No, I was not.

**[\>\> John Lumpkin:\
]{.underline}**But what I heard, I heard \-- I didn\'t hear any
objection from the State folks who are on the call.

**[\>\> Angela Fix:\
]{.underline}**Right. I know. I\'m just wondering \-- I want to make
sure I\'m not misinterpreting it. I mean, just \-- because I just
realized it when I look back at it. So I just wanted to point that out
real quick. I\'m sorry to make us go back again.

**[\>\> John Lumpkin:\
]{.underline}**But there is also, you know a \-- will be pressure upon
CDC and other Federal agencies to make sure that when they include data
requirements, that they are reflective of those harmonized standards,
too \--

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

**[\>\> John Lumpkin:\
]{.underline}**\-- in grant proposals.

**[\>\> Paul Soper:\
]{.underline}**This is \--

**[\>\>\
]{.underline}**I\'m sorry.

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

This is Paula. Just to clarify it a little bit more. I think what Angela
is trying to get at though is the recommendation intended to essentially
withhold funding unless the State or the grantee is compliant with the
HITSP harmonized standards; or is it just saying that this needs to be
added into the cooperative agreement language? Because right now the
grantees are currently planning their informatic strategic plans and
everything they are doing around a 2010 deadline. Did I articulate that
correctly Angela?

**[\>\> Angela Fix:\
]{.underline}**Yes.

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

**[\>\> John Lumpkin:\
]{.underline}**Jim, what do you say.

**[\>\> James Hadler:\
]{.underline}**Yes. I\'ve been kind of relooking at this, and I share
the concerns.

I also wonder which funding of course this relates to. Obviously it
relates in part to public health preparedness funding, but I know that
we get TB funding that assures surveillance, STD funding that assures
surveillance, immunization funding that is tied to surveillance,
emerging infections program funding at some States tied to doing
surveillance. In all those cases there is actually \-- in many of those
cases, there are stand alone systems that may not meet that, at the
moment may not meet some of the future standards.

And that States, most small States like Connecticut just borrow whatever
technology the CDC has created for us to use, because we don\'t have the
IT capacity to develop it ourselves. Bigger States like New York where
they have great IT capacity, say, tell us the standards. We are going to
use our own system. And that usually works out. I think following
standards is not necessarily a problem, as long as they are readily
accessible to everybody. If we each have to develop our own, that\'s a
problem because some States just don\'t have the capacity to do it.

And so one question, how broadly across all the funding streams might
this apply? And secondly, you know, will the technology be available for
people to either adapt to use directly or mimic, in the case of again
New York or California with big systems that have great IT capacity that
can develop their own systems and just have to produce output that\'s
consistent with what CDC wants.

**[\>\>\
]{.underline}**Let me suggest a way to get around this.

Let\'s leave this right now. Ask the NACCHO, ASTHO, the labs and the CDC
to have some internal discussions about this date and come back when we
discuss it in January with what they believe is a realistic date.

Because what Jim, a point that Jim made, which I think is a very crucial
one, is that there are a number of States that use systems that are
directly provided by Federal agencies, both CDC, HRSA, and others. So in
order to implement this particular item may require that those Federal
agencies make system changes that are then provided to the State. And so
I think it will be important for them, you know, especially CDC in its
lead role to have that discussion about whether or not that\'s a
reasonable date.

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

Yes. This is John. And I think that this date is maybe problematic, but
that there is another factor that may overweigh some of that process you
just described, which is that it is conceivable that the executive order
that was recently signed actually trumps all of that.

And so the alignment of that is probably more, less aggressive than the
State here, but probably trumps the process that was described in terms
of how those dates would be defined.

And that \-- it will be important that we don\'t send mixed messages
here. But essentially, for example, the expectation would be that the
HITSP interoperability specification would probably be recognized \--
and this is just, this is not committed but this is where it seems to be
headed \-- recognized by the Secretary in December of 2007. And then at
that point in time there would be an expectation that Federal systems
and contracts and cooperative agreements would incorporate that standard
by virtue of the executive order.

So I think we just want to make sure that this is reconciled with that,
with those timeframes and the specific language that\'s used in that
context.

**[\>\> John Lumpkin:\
]{.underline}**Okay. And is that something that ONC can look into?

**[\>\> John Loonsk:\
]{.underline}**Yes. We can help with that, yes.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So I think there is a little bit of reconciliation
with the executive order as well as, I think it would be useful for the
organizations represented on the call who would have to be faced with
this implementation to have those kind of discussions that will enable
us to have a clear date when we come back in January.

Okay. If that\'s okay, then can we go on to 2.4? Okay. 2.4. HHS should
convene a meeting to determine a process for defining requirements and
implementation criteria for supporting an automated case reporting from
electronic health records or other clinical care information systems.
The meeting should include industry vendors as well as State and local
public health officials, with the requirements and criteria being used
to inform Recommendation 2.3 above.

In other words, it would need to occur before the dates of 2, of 2.3
above, which is the CCHIT should include certification criteria.

So HHS should convene a meeting of the involved parties. Any problem
with that one?

**[\
]{.underline}**Okay. Moving on to 2.5 \--

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

Sorry. It\'s John.

**[\>\>\
]{.underline}**You got to get quicker on the draw here.

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

Yeah.

**[\>\>\
]{.underline}**There are some problems with the microphone.

**[\>\> John Loonsk:\
]{.underline}**I would not do well on Jeopardy.

\[LAUGHTER\].

**[\>\> John Loonsk:\
]{.underline}**I just want to make it clear \--

**[\>\> John Lumpkin:\
]{.underline}**We just don\'t want you doing Final Jeopardy.

**[\>\> John Loonsk:\
]{.underline}**I\'ll take requirements for 2.4 right now.

\[LAUGHTER\].

**[\>\> John Loonsk:\
]{.underline}**And the \-- I want to make it, just want to make sure
that people don\'t think that, if these criteria are developed, they
would innatively be the sort of criteria that were used. And it may be a
subtle point, but I don\'t want people to misinterpret that, again, that
the certification process is an independent process. It has validity on
its own. And so if these are tended toward that certification process, I
assume that the public health process was developed as well. There is no
one-to-one assurance that, you know \-- it is fine to build something
and say, these, you know, these seem to make sense; but there is no,
there is still other process steps before those would be considered or
as, you know, worked in definitively. And I just wanted to make that
clear.

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

Okay?

Given that, and I think though that, you know, certainly my view on this
is that having the vendors meet with those of us in, people engaged in
public health, I think would be an incredibly important meeting.

So any other comments on 2.4? Going once\...

2.5. HHS, in collaboration with State and local governmental public
health agencies should develop a business case for automated electronic
case reporting. The business case should articulate the burden
associated with manual reporting and the benefits of automated
reporting.

I think we have actually talked about that one a fair bit.

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

John, this is Angela Fix again. Do we need to add some other players
into the collaboration at all? I mean, obviously CSTE because they are
the gurus in case reporting. But maybe the Public Health Informatics
Institute because they have done a lot of stuff around business case
development for information exchange in general. So really, this is in
no way a plug for Dave Ross, but I am the president of his fan club so
\--

**[\>\>\
]{.underline}**I would \--

**[\>\>\
]{.underline}**\-- (inaudible).

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

I would clarify \-- this is Art. I would clarify that a little bit. I
think, not that Dave and PHII have done work around business case which
to me is around value proposition, but they have done more about
business process analysis. And I\'m not sure that, you know, you promise
that you are going to get value proposition out of this by just saying
we are going to have a business case.

That\'s something to be determined by all the players that sit and
review it and see where the value lies.

I don\'t know if Dave is on the call, but he may comment \--

**[\>\>\
]{.underline}**No. Actually Dave is ill, which is why his item was
skipped on the agenda.

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

**[\>\> Art Davidson:\
]{.underline}**So I\'m wondering whether when we say "develop the
business case", do we mean the business process analysis or actually say
that there is value and we have to then prove that the value exists?

**[\>\> John Lumpkin:\
]{.underline}**I think that my understanding of business cases is really
talking about looking at the costs versus the benefits, as well as the
value that\'s achieved through that.

**[\>\> Art Davidson:\
]{.underline}**Okay, so you are talking about that real business case
here rather than as Angela, I think, was referring more to the
experience of PHII around business process analysis.

**[\>\>\
]{.underline}**No.

**[\>\> John Lumpkin:\
]{.underline}**Well, but it is \--

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

I mean, that could help drive a business case.

**[\>\> John Lumpkin:\
]{.underline}**Right. Right. Because if you don\'t know, if you don\'t
understand the processes that you are trying to justify \--

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

**[\>\> John Lumpkin:\
]{.underline}**\-- then it is hard to say what the expected costs would
be, as well as the expected benefits.

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

This is Paula from NACCHO. It might be wise to include someone from the
provider community and/or perhaps IHIE so that we know that we are
really articulating \-- we have our idea of what the business case
probably should be, but providers may have different ideas about what
they would like to get out of the business proposition.

**[\>\>\
]{.underline}**That may be a position for somebody like PHERC, the
Physicians' EHR Coalition or a group like that.

**[\>\> John Lumpkin:\
]{.underline}**Maybe so we don\'t have a list, would it be okay if we
put in there "collaboration with State and local and governmental public
health agencies and other appropriate organizations"?

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

**[\>\>\
]{.underline}**Well, there is also other, non-provider organizations.

**[\>\>\
]{.underline}**Yes. I think it is wise to put providers in there.

**[\>\>\
]{.underline}**It\'s certainly of benefit to them. I mean, every time we
add something to our reportable disease list or laboratory finding list,
the burden on the reporters also has to be considered.

**[\>\> John Lumpkin:\
]{.underline}**How about this, "in collaboration with State and local
government, public health agencies, provider organizations, vendor
organizations and other appropriate organizations"?

**[\>\>\
]{.underline}**That sounds good.

**[\>\>\
]{.underline}**You got it covered.

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

**[\>\>\
]{.underline}**Is \-- the other question is, do you want to leave it
generic, State, and local government public health agencies, or do you
want to say CSTE and NACCHO or whatever other organizations, and have
the organizations be the ones or do you want to leave it more generic?

**[\>\>\
]{.underline}**For consistency we have named the ASTHO, NACCHO, CSTE
previously.

**[\>\> John Lumpkin:\
]{.underline}**Yes, I think we used \-- the format we used previously
was ASTHO, NACCHO and other appropriate organizations.

**[\>\>\
]{.underline}**Yes. Just whichever works for consistency.

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

**[\>\>\
]{.underline}**It is implied we know what it means.

**[\>\> John Lumpkin:\
]{.underline}**Okay. We will work out that language when we bring it
back.

**[\>\>\
]{.underline}**Okay. As long as there is other organizations like AT \--
(inaudible) \-- CE are not left out. Just want to make sure. If you feel
like you need to write it in there so we don\'t get left out, that would
be helpful.

**[\>\>\
]{.underline}**Exactly. I agree totally.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So we will come up with something to reflect that.
Any other comments on that section, on 2.5?

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

Actually \-- this is Jim. I want to make one slight modification
proposal to Recommendation 2.0. Go back even further than everyone else.
I want to change the words \"should determine a process\" to \"describe
the process.\" Since there already is a process \--

**[\>\> John Lumpkin:\
]{.underline}**How about if we have a wiggle word and say \"define the
process\"?

**[\>\> James Hadler:\
]{.underline}**Sure. That sounds reasonable. I would say, "define the
process", implying that it is already there.

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

**[\>\> James Hadler:\
]{.underline}**Because, I mean, the only \-- I mean, your intent sounded
good to me initially but as I realized that if you kind of just read it
stand alone, it implies that there is not a process when there is one,
and so I think the implication should be that there is a process, but
people may not know it.

**[\>\> Paula Soper:\
]{.underline}**Jim, this is Paula. I concur with that.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So it\'s "define the process"?

**[\>\> James Hadler:\
]{.underline}**Sure. Define or describe, whichever you prefer. I think
either is okay with me.

**[\>\>\
]{.underline}**Okay. We will bring that back. Anything else on, under 2
at all? Et al?

We can move on to bidirectional communication.

Recommendation 3.

HHS should identify a standards development organization to define
requirements, implement and manage a centralized website for the sharing
of standards, including standards that are being tested but may not yet
be fully accepted by SDO.

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

John, this is Brian. Back up in the description of what we are trying to
accomplish, I think we have limited this a little bit more than we
originally talked about

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

**[\>\> Brian Keaton:\
]{.underline}**\-- in that bidirectional communication implies a couple
of relationships. One is public health to the clinical care entities and
back.

But it also implies the clinical care entity to the clinical care
entity, public health to public health. And eventually to an incident
command structure as we start talking about the continuity of that
communication. I think that was the discussion that we had had early on,
that there was, needed to be a conversation that \-- the example we used
is an emergency physician sees a patient with purple spots. He may
communicate to an adjoining emergency response, are you seeing purple
spots orto , public health, are you seeing purple spots or are you
hearing about it? And that escalates up and down the chain. And I\'m not
sure that, as we develop standards, we shouldn\'t be developing a
communication standard that would go across that continuum from the
initial detection, to the assessment, to the management, to the final
question of, is it over.

**[\>\> John Lumpkin:\
]{.underline}**Brian, can I ask you for, to work on that?

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

I\'ll be glad to work on that, yeah.

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

Any other comments on that section?

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

Well, this is Leah. And I would just say that I think that that would be
the next generation. I thought the bidirectional part was, as stated
here. And if we can ever get that accomplished, that would be completely
unbelievable. And then clinician to clinician would make sense. I can
see some chaos in the whole way we run down diseases and develop a
picture of what\'s emerging in that whole situational thing, and
everybody is talking to everybody at the same time. It seems a little
bit like we need to mature a bit before we get to that part.

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

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

This is Art. I concur with Leah. This is a big thing to all of what was
described. And the first step would be just the limited exchange between
public health and the clinical provider.

**[\>\>\
]{.underline}**My point was that the standards that would apply through
that communication doesn\'t mean you implement that. But if you are
going to define a clinical communication and public health communication
standard, it should be implicit in the charge that we intend that we
will start with the use case that we described, but that this is part of
a bigger communication network rather than having somebody else running
off, doing another part of it differently.

**[\>\>\
]{.underline}**I think I agree with that, just in terms of standards,
but that \-- (inaudible) might be included there. But we do need to take
a first step hopefully achieving that first bidirectional. And then if
it is to be scoped out and just in terms of design, and then to work on
actual implementation for the larger picture or for the \-- it should be
scoped in design for the large picture and for implementation on the
small one. Is that what you are saying?

**[\>\>\
]{.underline}**There is a couple of things going on. There is already an
effort that\'s under way linking emergency departments. We use it for
ambulance diversion and hospital closure and other information like
that, but that exists. And I think it is important to take those types
of things into consideration if we build standards and make sure that
those efforts stay consistent so they can be rolled in at some point in
time.

**[\>\> John Lumpkin:\
]{.underline}**I think, if I can sort of take an EMS model in here and
apply it, that we are talking about both, that the standards should have
the capacity to facilitate horizontal, which means from ER to ER
communication, bidirectional communication, as well as vertical, which
would be to the State or local health department and so forth in both
directions.

But that the focus of the activity would be on the vertical in the first
phase.

**[\>\>\
]{.underline}**I think that\'s reasonable.

**[\>\>\
]{.underline}**Yes. I agree.

**[\>\>\
]{.underline}**And I, too.

**[\>\> John Lumpkin:\
]{.underline}**Okay. So we will \-- Brian, if you can take a cut at that
and send it to me, and I\'ll take a whack at it. And hopefully by
January we will have something that sort of says that.

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

**[\>\> John Lumpkin:\
]{.underline}**Okay. 3.0. Basically saying that HHS should identify an
SDO to do this. And you know, there may be an existing SDO. There may be
one that would be encouraged to take this on. Any comments on that?

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

This is John. I\'m not entirely clear what this is asking, particularly
in the context of if it's asking an SDO to maybe contain the directory
of other SDOs' work or not, which may be somewhat problematic. And also
it is not clear to me that any SDO is going to do this unless they are
resourced to do it. So I\'m just not sure that \-- you know, I think
those are issues with the recommendation as it stands.

**[\>\> John Lumpkin:\
]{.underline}**So are you suggesting either that we eliminate it or are
you suggesting a modification?

**[\>\> John Loonsk:\
]{.underline}**Oh, I have to come up with something?

\[LAUGHTER\].

**[\>\> John Loonsk:\
]{.underline}**\-- well, I mean, one issue is is an SDO a proper place
to house it or should it be somewhere else. And I think that would
depend on whether you are really, you know, I think in all likelihood
the standards represented would represent several SDOs\' work. So I\'m
not sure that an SDO is the right place to house that, and then the
other question would be, how it would be supported and \-- so that, I
don\'t immediately have a solution to the latter but, you know, a number
of agencies have different agreements with SDOs as they currently exist
in terms of other activities, that I don\'t think any of them have this
per se in their sight.

**[\>\> John Lumpkin:\
]{.underline}**How about this: "By June 2007 HHS should develop a plan
to identify a process for standards development, and adoption, for
bidirectional reporting"?

**[\>\> John Loonsk:\
]{.underline}**You see, I thought this was saying something quite
different, which was it was trying to identify a place where the, where
all this material would be stored so people could see what it is.

and \--

**[\>\> John Lumpkin:\
]{.underline}**Right. What I\'m just trying to do is say that, you know
\-- right now what we are saying is that it is important for this to get
done. Whether it gets done by an SDO or some other entity, someone needs
to take responsibility for putting together the thought process of how
this would get done.

And it would seem to me that HHS would have the greatest stake in \-- to
at least try to do the initial thought of developing a plan.
Specifically CDC.

Am I off base there?

**[\>\> John Loonsk:\
]{.underline}**Well, I just wasn\'t sure \-- I mean, I think, you know,
I agreed to help work on one of the previous recommendations which was
about the existing process for getting some of the standards through. I
thought this recommendation was focused more on how they may be
maintained and communicated, but, you know, maybe I\'m misreading it.

**[\>\>\
]{.underline}**Yes, John. That\'s correct.

Also to include standards in, so that they are available in one place
and then to include standards that haven\'t gone through the process,
the HITSP harmonization process, yet but that still need to be made
available for people to access. That was the intent.

**[\>\> John Loonsk:\
]{.underline}**I would be happy to try to work on some suggested
language for that, to advance for January, if you would like, or \--

**[\>\> John Lumpkin:\
]{.underline}**Well, that would be a Christmas present for me, that you
would volunteer. Or Hanukkah gift. Okay. John is going to help us refine
3.0 so it is clear and doable. Any other comments before we move on to
3.1?

Okay. HHS should ensure the harmonization of standards for formatting
health alerts and exchanging directory information.

**[\>\>\
]{.underline}**Is this \-- this is provider directory information?

**[\>\> John Lumpkin:\
]{.underline}**Yes. That would be, you know, okay, we have an alert. Who
are we going to send it to.

**[\>\>\
]{.underline}**But I suppose it could be public health or clinical care
provider?

**[\>\>\
]{.underline}**That was the intent. Public health or clinical care
provider.

**[\>\> John Lumpkin:\
]{.underline}**Okay. Any questions on that one?

**[\>\>\
]{.underline}**A question about formatting health alerts. Health alerts
are things like ones that CDC has set out recently on polonium and on
Taco Bell and E. coli. Is that what you mean by health alerts, or are
these health alerts of a different nature?

**[\>\> John Lumpkin:\
]{.underline}**I think \-- well, let me take a stab at that. Those would
be the kind of things that would be alerted, it would be what we talked
about with bidirectional.

But they may also include case definitions. You know, the usual exchange
that happens when an outbreak is being managed. Treatment
recommendations.

**[\>\>\
]{.underline}**Okay. Yes. In terms of the standards for formatting, this
is basically to assure that the formats come out and don\'t, and don\'t
get lost, and don\'t somehow get lost in message, confused or garbled or
unable to be received. Is that right?

**[\>\> John Lumpkin:\
]{.underline}**I \-- my read on this initially, that would be the case.

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

This is John. I think there are a number of reasons, and we had looked
at this some time ago. There are a number of reasons \-- there actually
are some standard alerting formats that are being used by other
agencies, other Federal and regional activities around emergency
preparedness. There is an attractiveness to using those standards where
possible because it will eventually get to the, to facilitating
automated management of some of those so that you can, you know, have,
actually set rules up that look at what the alert is, who it should go
to, who it was from, potentially what the content is and manage it that
way and so some of this is about whether the data around the alert and
using a common standard for that so that they could be, some of the
activity could be immediately initiated and facilitate their better
processing.

**[\>\>\
]{.underline}**Okay. That\'s helpful. I was not sure how much discussion
might have happened in the previous conference call of which I was not
part. So I didn\'t want to prolong it, but I just wanted to get a sense
of what you meant.

**[\>\> John Lumpkin:\
]{.underline}**Okay. Anything else on 3.1? I think that\'s the end.

**[\>\> Art Davidson:\
]{.underline}**Do we have any idea about how this directory information
will be shared across provider institutions with public health?

**[\>\> John Loonsk:\
]{.underline}**I think, it is one of the concepts and discussion points
that the Nationwide Health Information Network is working on around
federated directories and how there may be \-- some of the standards
here are about the ability to appropriately exchange provider
information. And obviously there is a lot of complexity there because
not all providers want their information shared for a variety of
different purposes. So it is complicated, like most of this. But sharing
provider information is one of the \-- sharing directory information is
one of the things one would consider in terms of thinking about
standards.

**[\>\> Art Davidson:\
]{.underline}**Yes, I look at it as pretty complex, too, John. I\'m not
sure \-- I\'m sure the harmonization of standards. And each locality may
have a way to identify the providers in that locality. If there is
clinical messaging going on, it may be through there; but I doubt that
each public health department is going to be creating a directory of the
providers in its community that it would share.

**[\>\> John Loonsk:\
]{.underline}**Yes, I don\'t know that that\'s what this is
articulating. But these two things sort of come together. If you have,
if providers are stored somewhere, whether that be in clinical care, in
a network service provider or somewhere where \-- what type of specialty
they are involved in, what their, you know, attributes of their
jurisdictional involvement and other things like that, then alerting can
be much more targeted to the right person that should receive an alert.
And so that\'s one of the reasons one wants to consider both the
standards for directory and the standards for alerting.

**[\>\> Art Davidson:\
]{.underline}**I agree with you. We purchased that from a vendor who,
you know, does marketing on who are all the docs in our community and
then use that as a method to contact them. But I don\'t know whether
that\'s the substrate upon which we are going to create this directory
exchange. I agree it is complex, and we can go on. I don\'t mean to
belabor this. I just see it as very complex.

**[\>\> John Loonsk:\
]{.underline}**It is complex. One of the things in previous thinking
about this was that there are different ways that these things might be
deployed but that eventually one wants to have the standards for how
they are \-- the attributes of a directory listing are accumulated. And
there are a number of different standards that are already done in this
regard. So it is not just new work. But as one gets that, then one is on
their way to having, to sort of reach a division of matching alerts and
other activities up to those providers, and that those would \-- so I
mean, I think it is in keeping with what you are saying, Art. I don\'t
know that that particular vendor implements a light weight directory,
LDAP standard or some other standard for how directory information is
accumulated, but that would be something to be moving the industry
toward.

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

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

This is Lisa at FDA. I have a boundary question about this. Is this just
intended to be applicable to state public health agencies? Are you
talking about our "Dear Doctor" letters, for example?

**[\>\> John Loonsk:\
]{.underline}**I think the idea was that providers and \-- health care
providers and public health providers are suitable for having the data
standardized. The rule then, considerations for how those data would be
shared, where they would be stored, those are highly complex and still
are not determined. But you can still see the value in moving all these
different directories toward a common goal, a standardization goal to
accomplish some of this, even as those other aspects are being worked
out. But it was inclusive of providers in clinical care and in public
health.

**[\>\> John Lumpkin:\
]{.underline}**Okay? The next steps for this letter is we will bring
back what we hope to be the final draft at our next meeting on, I think
January 5th is our next meeting. Is that correct?

**[\>\>\
]{.underline}**Yes, that\'s correct.

**[\>\> John Lumpkin\
]{.underline}**Thank you.

And at that time we will hopefully have a draft of the new charge, or a
new charge to finally, to have some final discussions on.

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

John, this is Leah. Is that an afternoon meeting on January 5?

**[\>\>\
]{.underline}**I think the time is 12 to 3.

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

**[\>\>\
]{.underline}**Had to accommodate somebody in \-- I forget who it was.

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

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

Okay. I think we have concluded the initial portion of our agenda. And
at this point, unless we have other comments \--

**[\>\>\
]{.underline}**We need to bring in the public. So let\'s see if there is
any comments \--

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

Yes. What I was going to say is, it is time to have public comments.

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

For folks following along on the webcast, there is a slide up right now
with information to call in and make a comment. And if we have one or
two people who already called into the meeting while it was going on,
you can just press star one on your phone and that will buzz you
through. We usually give it about 30 or 40 seconds for people to get
through on the operator. And if not, there is also an e-mail address at
the bottom of the slide, and people can submit comments that way.

**[\>\> John Lumpkin:\
]{.underline}**And while we are waiting for that to occur, I did want to
just note that this has been, I think, a very productive year by this
Workgroup. I\'m pleased to have the opportunity to have joined you, and
hope everyone will have a wonderful holiday season.

**[\>\>\
]{.underline}**The same to you.

**[\>\>\
]{.underline}**Yes. Thank you.

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

**[\>\>\
]{.underline}**Same to you, John.

**[\>\>\
]{.underline}**Yes, thanks John.

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

Doesn\'t look like we have anybody calling in with comments today.

**[\>\> John Lumpkin:\
]{.underline}**Okay. And with that, I think we have completed our
agenda. And for those of you traveling, travel safely. See you next
year.

**[\>\>\
]{.underline}**Okay. Thanks. One quick question. Should we get comments
to you or to Judy?

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

I think probably they should go to \--

**[\>\>\
]{.underline}**Laura. I think to Laura.

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

To Laura.

**[\>\>\
]{.underline}**To Laura? Okay.

**[\>\> John Lumpkin:\
]{.underline}**And she\'ll distribute them.

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

**[\>\>\
]{.underline}**We will send our e mail addresses to the group.

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

**[\>\>\
]{.underline}**Thank you, all.

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

**[\>\>\
]{.underline}**Thank you. Bye bye.

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