American Health Information Community

Chronic Care Workgroup Meeting #10

October 16, 2006

**Disclaimer**

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

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

Let me make a couple of comments, and Craig I\'ll turn it over to you.
This meeting is scheduled to actually achieve a couple of items that
Karen Bell will get into a little later on. But as mentioned last time,
we\'re going to follow up with some testimony from Karen Trudel from CMS
to talk about the synopsis from DMAA and David Whitlinger will speak on
that, and then we\'ll get into the Chronic Care Model. And I guess Karen
you\'re going to lead the vision discussion, which I guess we\'re going
to need to do for the meeting on the 31st, the full AHIC meeting, and
then more of a discussion on the priorities as well. We had wanted to
get a discussion on more background in terms of the demo's criterion.
Karen, I think you said you were going to have that ready shortly. But
you\'re not prepared to discuss that at this meeting. I think that
pretty well covers everything on the agenda, Craig. If you had some
opening remarks you wanted to make.

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

No, just standard opening remarks of I think it\'s important for us to
be as specific as we can with the vision and what we want to try to
accomplish, not let the scope creep come into the game. We\'ll be
successful; we can actually accomplish a few really meaningful targets
to get the foundation, infrastructure put in place. That\'s just the
general commentary.

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

Okay. Colin, did you have anything else you wanted to add?

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

No, you\'re in charge.

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

Matt, do you want to do the review of the procedures and then introduce
the participants.

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

There were a couple of new folks on the phone today just very quickly
I\'ll go over the call‑in procedures. Please keep your phones muted when
you\'re not saying anything so we don\'t get a lot of background noise
during the call. And when you do come in to make a comment, please say
your name first, because we have folks from the public following us on
over the Web and also on the phone, and that helps them know who is
speaking. The only last bit of business to take care of, if you\'re
following along on the Webcast, please don\'t change any of the agenda
slides while we\'re moving along. I\'ll quickly run down a list of the
names I have on the phone and I\'ll turn it over to the folks at ONC to
let us know who is in the room there.

Calling in today we have Paul Redifer from Cisco Systems, he\'s here for
Jeff Rideout today. Mike Crist from LabCorp. Colin Evans and Craig
Barrett from Intel. Kimberly Campbell from CMS. Paul Nichol from the
Department of Veterans Affairs. John Rother from AARP. James Ralston is
here for Eric Larson from Group Health today. And one more, looks like
Ruth Lacey is also on the phone from CMS.

Is there anybody on the phone who I failed to mention? And then I think
we have a couple of folks over at ONC. I\'ll let them introduce
themselves.

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

Jay Sanders from the Global Telemedicine Group.

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

Anand Parekh, from the Office of Public Health and Science.

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

\[Inaudible\]

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

Chandra Branham, with Health Policy Source.

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

Tracey Moorhead, Disease Management Association of America.

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

Karen Bell, ONC.

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

Dave Whitlinger from Intel.

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

Joe Gifford for the Regence Group.

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

Tony Trenkle from CMS.

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

Karen Trudel from CMS.

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

I believe that covers everyone. Is there anything else you would like to
say before we get into the acceptance of the minutes from the September
meeting?

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

No, that\'s it.

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

Okay. Craig, do you want to move for acceptance of the minutes? I
didn\'t get a chance to read them, actually. Karen, do you have any
comments on the minutes?

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

I do not, no.

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

We just got them a few moments ago. Do we want to move acceptance, or do
you want to have people have on a chance to review them?

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

Why don\'t we, if it\'s acceptable, let\'s do it at the end of the
meeting so that way people have a chance to glance over them. I think
most of us have just gotten them.

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

Great. Then we\'ll move right into the testimony. Karen, did you want
to, Karen Bell, do you want to introduce the overall three testimonies
we\'re going to have today?

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

I\'d be honored to, thank you very much, Tony. As you all are aware, we
have spent a lot of time over the past several months really looking at
a lot of the specific concerns related to secure messaging. As that
relates to the chronic care situation. However, it\'s a much broader
agenda that we\'re now moving into at the present time. So in order to
set the tone for that we thought it would be helpful today to bring
together, a number of folks can bring us a broader picture of what is
happening with chronic care across a wider spectrum, so the first of
that is Karen Trudel who has done a lot of work with not only the folks
at CMS but with the Disease Management Association in terms of disease
management structure, Karen, please

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

Thank you. I am here pretty much to set the stage and expand the focus
of the group. Truth in advertising, this is not a synopsis from the
DMAA, I have worked with Tracy over the months to get some preliminary
input from their organization, but this is very much a synopsis of some
studying that I did along with other colleagues in CMS to try to look at
the full range of health IT opportunities as they affected the chronic
care population. So I\'m not here to present options or solutions but
just to expand the focus of the Workgroup beyond the discussions we\'ve
had over the past months about secure messaging.

We now want to expand that focus and have and want to continue to work
with the DMAA and others. We have identified a range of services and
technologies. I\'ll walk through those in a moment. If you look at the
chart, we selected, not the top five, but five very critical chronic
care diagnoses: congestive heart failure, COPD, diabetes, end-stage
renal disease and asthma and let us never forget the last column which
tells us many of these things occur in combinations, particularly from
our perspective within the Medicare population.

Looked at a number of, as I said, technology services and they basically
fall into just a few categories, one is education, another one is remote
monitoring, a third are administrative services, and the fourth is
general communication. And I\'ll just start working my way down the
chart and look at the first five and then we\'ll move on. These are in
no particular order.

General education information for patients and caregivers is essentially
disease‑specific information that isn\'t patient‑specific information.
This may be information that the patient could get from a
practitioner\'s Website or from something as generic as a PHR Website on
the Internet.

\[Inaudible\] on the other hand is triggered by patient data so the
patient could receive dietary tips that were limited to, targeted to
their own laboratory values. And that the optimal way to do that is on a
just‑in‑time basis, monitoring with clear messaging, fall monitoring in
the frail seniors especially is critical. And providing messaging to
someone who can provide help, a call center, whatever, again is going to
help that person remain independent and at least not cause their
condition to become worse.

Weight monitoring and messaging. These are reports that could connect
the scale directly to the healthcare provider, to another family member,
to a disease manager, for assessment, and if you look at the X's going
across this chart, this one is especially relevant to congestive heart
failure, whereas a lot of the others are relevant across the board to
any and all chronic conditions.

\[Inaudible\] monitor and messaging again telemetry that reports test
values to the healthcare provider, disease manager, or a family member
or additional caregiver. Primarily relevant to diabetes. Next slide,
please.

The next two really are what I called administrative services,
prescription refills, online appointment scheduling. These are things
that in and of themselves may not provide improvement to a person with a
chronic condition, but when provided in concert with other services,
these may be the killer aps, so to speak, the patient finds is useful to
themselves. Two‑way communication between the provider and the patient.
We talked about this a lot over the past month. This is the secure
messaging. Two‑way communication between providers, something that we
didn\'t talk about quite as much, but again is very critical in managing
patients with chronic conditions. Especially diagnosed dialogue between
primary care providers, specialists, primary care providers, and disease
managers and certainly is not limited to physicians alone. And the last
is another monitoring item. And it\'s medication compliance. Number of
devices to track whether the patient is actually at least opening the
device, that they need to take a medication and compliance with
medication therapies is a very critical opportunity for monitoring and
managing chronic care patients. And most of these opportunities would be
equal across the board. Some of them are specific to diseases and we\'d
like to work with DMAA and others to make sure that we have everything
on the list to make sure that we have the right diagnoses here and to
make sure that we\'ve got all the X's filled in correctly and actually
I\'d like to ask Tracey if she has anything she\'d like to follow up in
conclusion.

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

Are there any differences?

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

No, I have no idea.

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

That\'s everyone\'s question sounds like.

\[laughter\]

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

Provided a little mystery in the process.

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

Tracey, Karen has pulled this together over the last number of months.
And you and she have talked about this quite a bit. As we move more
towards our broader charge, we are going to be having other presenters
today that will build upon this discussion. Is there anything additional
you want to add before we open it up for any discussion at this point?

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

I would like to applaud the leadership that CMS has shown in the
development of a number of pilot programs to examine benefits of client
care management to beneficiaries. I think it\'s a testament to the
leadership and vision of Preventive Care Model. As DMAA has not been
invited to be here formally, I don\'t have prepared remarks but I\'d
like to reiterate my desire to work closely with this group and provide
input as you go forward.

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

To start the questions off, could I clarify a little bit on the combo
column, Karen. There aren\'t a lot of X's in the combo column. So I
didn\'t know whether these were interventions that you actually saw were
occurring in patients with multiple chronic diseases or these were
opportunities that you could see in people with multiple chronic
diseases

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

I think they definitely are.

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

Okay. So there are opportunities and we still would need to go back and
look to see across the board for this.

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

Right.

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

I guess my question would be why aren\'t there X's in all the columns
under the combination?

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

There probably could be. When we went back and looked at this, I think
some of the people that we spoke to to try to validate where the X's
should be were thinking about it in terms of a specific diagnosis. And I
don\'t think ‑‑ and this is a ‑‑ I\'ll take the blame for not having
been more specific about this, probably should have said specifically if
there\'s an X anywhere along here, it probably would be appropriate for
people with a combination of conditions.

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

All right. I think this is a very important list. And we talked on a
previous call that one of the most important things in patients with
chronic conditions is their engagement in the care process. And so
almost all of these represent ways in which the patient can be involved,
and I think would contribute to improved outcomes in that setting.

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

From a non-medical standpoint, just from an engineering standpoint,
there are only two characteristics that you would monitor. The rest of
this is basically two‑way communication. I mean it\'s glucose and
weight, those are the only options you\'ve listed.

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

The fall monitoring, which is a different kind of monitoring, and
medication compliance. So there are four.

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

There are a number of companies, a number of technologies. This is Jay
Sanders, sorry. That for the COPD and asthma group provide pulmonary
function monitoring in terms of peak respiratory flow rate which is
probably the most critical determinant in terms of their airway
compliance. So those are totally available.

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

I might point out the two‑way communication between a provider and
patient can be either an e‑mail communication, which would involve one
type of application or technology, or it can be completing health status
surveys on a regular basis that are monitored and if they fall out of
line then the patient would be contacted. It\'s either the interactive
communication or monitoring based on survey and a questionnaire
response.

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

I was asking just on the basis that when I go to the hospital or the
doctor\'s office the first thing they do they put me on a scale. The
second thing they do they take my pulse rate. Take my temperature. So is
there some rational reason why all of that happens on a routine basis
but you don\'t want it to happen here?

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

Craig, this is Jay. Fundamentally in the list of technologies available
for home care, all of those vital sign parameters are available.

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

This is Joyce from AARP. Have any of these been vetted in terms of how
effective they are in stimulating patient engagement?

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

I think that\'s on the research agenda.

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

That\'s actually one of the things we need to look at as we begin to
look at potential outcomes is the patient input on that. Tracey I don\'t
know if you have any comments on that.

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

There have been some studies published in you\'re peer reviewed journals
in management that I would be glad to provide to the Workgroup.

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

Would you be able to send those?

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

We\'ll send them out to the whole Workgroup.

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

I would appreciate that. That would be very helpful.

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

There\'s also the study done by Barb Johnston, nurse practitioner at the
time with Kaiser Permanente, it appears in the December 2000 issue, the
Archives of Family Practice, in which she looked at the use of tele-home
care in terms of patient compliance, as well as cost. And there\'s some
very powerful data in that study.

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

Could we get a copy of that one, too?

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

Jay, can we get a copy of that?

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

Sure.

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

Thank you.

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

This is Joe Gifford from Regence. This is in response to the consumer or
the patient, and in that category wonder if we meant to exclude
structured Web visits or make that a subcategory under number eight and
also personal health record is a lot of ink and that\'s a
patient‑oriented device. Then under the category of sort of provider
servicing opportunities in chronic care, you\'d have to put the idea of
online registries as an important bullet point.

That is, those docs that can\'t afford elaborate EHR systems that have
functionality can sign up for lighter Web‑based registries that are very
useful in the treatment of these diseases and those are clearly HIT
opportunities in this space.

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

I thought this was in supplement to the personal health records
discussions we\'ve been having but I would agree that\'s an important
point as it is to communicate vital signs, which is commonly available
and maybe that should be more explicitly listed.

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

This is more a supplement to the PHR area which could include some or
all of these.

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

I have a question, there\'s several different models of PHR, sort of
stand‑alone and I think the term I\'ve heard is PHR that is tethered to
an electronic health record. Do you have a sense of sort of optimizing
the environment, whether one model works better than the other or
whether there\'s experience with that at all?

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

Let me answer momentarily, one of the issues we talked about last
meeting was tying our group closer to the Consumer Empowerment, which
has looked at the PHR models. And Kelly Cronin was supposed to be here
today but unfortunately has a conflict. But Karen is aware of this issue
and I\'m presuming that Kelly is going to get back to us on that, Karen?

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

Yes.

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

This is Colin. We actually had testament on three PHR or patient-doctor
communication models two meetings ago. There was a lot of discussion
there. There was pros and cons all seemed to improve things but they
have different pros and cons, we can go and look at that if you need to.

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

I think that\'s correct. I think we have the three main models. One was
the network that Dr. Fotsch had.

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

One suggestion. In any evaluative process that we often I think overlook
and that is what these technologies do with respect to the sense of
well‑being and the sense of security on the part of the patient and
something I think that would be very important for CMS. And there was a
study done in the \'70s. I remember the authors, I don\'t remember the
specific year in which it appears the *New England Journal of Medicine*,
but the two authors were Dr. Gordon Moore from the Harvard Community
Health Plan and Dr. Wilmine (ph) from MIT. They used the technology of
help I\'m falling pendant and found using an age-matched control
population, that the population that used the pendant spent over the
period of the study one thousand less days in nursing homes than the
group that did not. And it was simply an issue of feeling of security
that the people who wore the help I\'m falling pendant had to be able to
live independently in their own home. And I think that ought to be
looked at as a very potentially powerful outcome of the use of some of
these very simple technologies.

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

This is James Ralston at Group Health Cooperative. I published a study
in *BMJ* in 2004 using an interactive Web‑based electronic medical
record support of diabetes care. One of the key findings from that
qualitative study was this enhanced sense of security that you
mentioned. And so I think that is a very important point. I don\'t know
of anybody who has tested it quantitatively but qualitatively we found
that.

One thing I wanted to mention about the list here which I think is very
good, I wondered if there was a place for a shared care plan between
patients and other providers involved. A lot around communication and
other functionality here, and I think as the other folks have noted,
there\'s this issue that most of these people have multiple conditions.
And one of the key things is trying to figure out how do you develop a
care plan around that that\'s transparent to patients and docs, and I\'m
wondering if that has come up as a functionality that the group has
discussed.

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

This is Karen. It hasn\'t come up in meetings here but I can assure you
it comes up in many other situations where we\'re talking about HIT
opportunities to better support patients who have not only chronic
illnesses but complicated presentations. Where, and perhaps a good
example of that are patients with cancer or patients with disability,
where they have, where there are multiple care providers who are engaged
around the care of a patient and it\'s very difficult to assure that
you\'re getting care across the continuum without that shared care plan.
I\'m delighted you brought the point up here today because it\'s not
been made here earlier but it\'s a critical component in care, critical
opportunity in care for those types of patients.

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

This is Paul Nichol from the VA. I would like to enforce that as well.
We\'re actively trying to figure out how to create a care plan for
communication both among providers as well as sharing that with the
patient in their personal health record so that everybody is working off
the same plan and can contribute to it. I think that\'s a critically
important capability.

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

Any other comments?

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

Glucose monitoring messaging the glucose meter manufacturers have been
collecting data on that and there\'s dozens of doctors who have done
studies on that as well. I can\'t cite anything, but the material is out
there for the effectiveness.

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

Thank you, Karen and we\'ll move on to the next speaker. Karen Bell, did
you want to introduce our next speaker?

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

Yes, David.

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

Maybe someone from Intel. Maybe Craig.

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

I\'ll defer to you Craig, right here on my left. Please do the
introduction.

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

He needs no introduction.

\[laughter\]

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

Let\'s just say that this is an industry-driven effort which is trying
to raise some baseline standards et cetera to allow interconnectivity so
I\'ll let David do the talking.

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

The slides ‑‑

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

It will be up there momentarily.

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

I\'m David Whitlinger. I represent as President and Board Chairman of
the Continua Health Alliance and director at the Intel in the device
standards space. I\'m very thankful for the opportunity here to come
talk to you about the Continua Health Alliance, we\'re excited about it
as we found a lot of industry is. We launched in June. We launched in
June of this last year, June 6, and I\'ll describe the organization now.
So it\'s a nonprofit open industry alliance, and we\'ve collected
together here, I\'ll show it in another couple slides, a large
collection of companies from many different disparate or seeming
disparate parts of the ecosystem. They\'re all coming together here to
work on interoperability between the products and services, and it\'s
really all about this collaboration, and being able to improve the
quality of care. Next slide, please.

So interesting story quickly when we were walking around in the
ecosystem and talking to the dozens and dozens of companies here,
everybody was starting to put together some thoughts with regards to the
impending problems with healthcare and the impending problems with
regards to the age explosion and everybody had what we were starting to
refer to as the sky is falling slides. They had a good solid deck of
five or six slides where they collected together stats on how bad this
problem was getting and how bad it was going to be in the future. We can
then set down into brevity one slide and three bullets and it\'s been
the touchstone with regards to where we need to spend our energy. And
that\'s the three bullets above the line there the overweight adult
population, the chronic disease patient, and the growth in the elderly.
And then of course there\'s an ancillary effect, there\'s of course that
spending that is going into chronic disease and that\'s a good thing to
try to address. And I\'m sure you\'ve already heard from Joe Kvedar
he\'s probably mentioned a couple times how we\'ve already lost the war
with regards to being able to keep up with the number of doctors in beds
to solve some of the problems above. We just have to come up with the
different care model in order to address the volume of issues. Next
slide, please. We have a double slide. Here, I have one more.

We put this organization together as I said before to do a collaborative
industry effort and really there\'s a lot of companies that are part of
this organization. Really want to focus on one aspect of this ecosystem,
but because of the way the nascent stage of the ecosystem today having
to do a full value proposition end‑to‑end and for most of them that\'s a
struggle and a stretch and they don\'t really want to do those things.
What we found is that by bringing these companies together in Continua
they\'re already starting to figure out ways to stop doing some things
and start doing other things in order to benefit from the partners in
this value proposition and they\'re already starting to see new value
propositions that they can produce with their products and services.
Certainly that is valuable to their corporate needs but quite valuable
to the health care model itself. Next slide please.

This is a list of founding promoters. They\'re about 37 companies there.
You can see there\'s a broad mix between medical device companies such
as AMD and Avita and Microlife \[inaudible\], G.E. There\'s also a
couple of drug companies up there Pfizer, Roche. Implant companies.
You\'ll see fitness companies there, Polar, Precore, Technogym. And
consumer electronics companies, every company we\'ve talked to has a
healthcare vertical they\'re building there\'s some element of the
healthcare consumer electronic device they want to bring to market or
add to an existing product. So we\'re very encouraged by that and
that\'s why they\'ve all joined us here in Continua. Next slide, please.

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

And providers.

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

And providers, thank you, Colin. I left that out. Two very strong
healthcare providers. Partners Healthcare has been a very strong
partner, Joe Kvedar and his organization and as well as Kaiser they\'ve
done a good job of providing us with a good balance in what it is we\'re
up to. Contributors, we have another collection of companies here.
You\'ll see some names you probably recognize there. There are also some
very small companies here that are looking to enter the market to do
chronic disease management or they\'re already in the market but don\'t
have a significant market presence yet. And they see a strong benefit in
being able to collaborate with the other companies here. I think we
broke 65 companies this last week. Next slide, please.

The Continuum of Care is what we started with in creating this
organization. And we started with looking at this continuum of life and
all of the different use cases or benefits that would be possible by
adding devices and services to somebody\'s life. That might be anywhere
from doing baby monitoring as in the infancy, doing amateur athletics
being able to provide data and services there all the way over to
elderly independent living and where the chronic diseases might be
there. Connecting all those people to caregivers. And some cases those
caregivers are the individuals themselves. Might be professional
coaches. Certainly when you get to the continuum of life it becomes more
the family, the neighborhood, the community, and professional
caregivers. Next slide, please. Okay.

So the meat and potatoes of what we\'re about, there are three large
themes that we have organized the organization around. The first one is
about enabling health and wellness uses. And this is all about healthy
individuals being able to have devices and services in their home or
mobile context, being able to use those devices and services to address
a weight loss program, a fitness program, or if they\'re, as we\'re
starting to call these individuals, worried well, being able to collect
basic vital sign data on a regular basis into something that might be
considered a PHR or an EHR or something like that in order to capture a
trend.

Many places outside of the U.S. and continuing to be an international
organization we\'ve explored it extensively in Europe, there\'s also the
concept of the extension of the healthcare system into the home. So the
previous discussion about collection of vital signs, that\'s very
interesting in many healthcare systems being able to do triage of
non-emergency medical conditions and being able to do some basic level
of triage of those conditions and treatment from using basic vital sign
devices in the home. So having a weight scale, blood pressure cuff,
glucose meter, thermometer, all those kinds of devices. And certainly
when you start talking about fitness and weight loss, having the devices
such as fitness devices, treadmills, stationary bikes, so forth. So this
set of use cases is enabling those devices to connect to compute
platforms, whether they\'re PCs or cell phones. Perhaps using other
devices in the digital home for user interfaces that then to connect to
the Internet where you would have healthcare providers and professionals
to be able to provide services. Next slide, please.

The second largest theme that Continua is focused on is disease
management or chronic disease management. This use case is probably very
familiar to the audience, and this is all about helping to monitor
somebody either in their own home or in a mobile context, such that you
can monitor their vital signs and maintain a stable condition and avoid
those costly emergency events that are obviously very poor to the
quality of the life as well. So being able to help monitor those vital
signs, and as we\'ve talked to all of the companies in remote patient
monitoring, monitoring of vital signs is intriguing. It helps them to
react quickly and be able to avoid the emergency events. But what
they\'re really after here is behavioral modification. Simply asking
them to collect the vital signs is one aspect. That in itself creates a
behavioral modification, but they\'re building into their systems
different attributes and methods of trying to achieve a behavioral
modification. There\'s all sorts of reasons why that person has a
chronic disease, many are behavioral, being able to effect a change with
those behaviors is a principal element of what they\'re trying to
achieve with these use cases and with these devices. Obviously it\'s
being able to use those devices in the home, being able to have those
devices scattered throughout the home in logical places, being able to
use a home network in order to put those devices in logical places
throughout the home and then connecting that data into back end
services, disease management services, healthcare providers, PHRs, and
so forth.

There\'s a strong concept here as well with the vendors involved on the
family care network. That was discussed in the last presentation as
well, getting this data up on a network where many other individuals
other than the healthcare provider itself is able to provide this
network of care that increases greatly your chances of being able to do
behavioral modification. Having a son or daughter call a parent and say
I saw your blood pressure was high, did you have a healthy meal
yesterday, is very key to being able to achieve a good result. Next
slide, please.

Last large theme is elderly monitoring, ties closely into the other
chronic disease slide or theme. And this is all about adding to that
basic life monitoring. So bed pressure sensors, bathroom sensors, gas,
emergency sensors, so forth. This is all about trying to help that
elderly individual age more gracefully in their own home. As the world
ages and we\'ve seen the statistics on not being able to care for those
individuals in nursing facilities as we move, being able to help those
individuals age gracefully in their own home and providing the family
with devices and services to allow that to occur safely. So being able
to know that that individual is getting up on a regular sleep pattern,
that they\'re going about normal biological functions, that they\'re
able to fix themselves a cup of tea and turn the stove off afterwards.
Take their medication. Of course this overlaps heavily with chronic
disease because you may have at least one chronic disease, being able to
tie all this data together into a care plan that the family caregivers
can look after and help maintain and look after their adult, or their
aging parent. Okay. So we put together these three large themes. And as
you saw before, they\'re largely based off of those three large
statistics that I showed up front. Next slide, please.

What we did with the three large themes we separated out an ecosystem,
if you will, of devices that we wanted to enable with interoperability.
So we have a large collection of sensors on the far left there. We have
a set of compute platforms that are in the middle, and then we have
services on the far right. And what Continua is all about is selecting
the different standards that are necessary to connect these things
together. And so we have collected together a large group of companies
that build these things and that provide these services and we are all
getting together in our collective working groups and selecting the
standards for the individual device types and going off and wrapping
those standards with continued guidelines on specifically how to use
that standard to achieve strict interoperability.

From that then the companies go off and build to those continuum
guidelines, build their data interfaces to the continuum guidelines and
you\'ll see here in a second there\'s a certification and logo program
to improve that interoperability and then we have hopefully achieved a
tight interoperability in the ecosystem. Next slide, please.

So this is the essence of about writing guidelines and the membership of
Continua members are all from the various companies that build these
things. So they\'re very attuned to the data interfaces that put in the
interfaces. We\'re selecting the standards whether it\'s Bluetooth or an
IEEE or wi-fi, we\'re selecting those standards in those workgroups and
then we\'re wrapping those standards with all of the other elements that
are necessary to achieve that strict interoperability. In January we\'ll
kick off the working group that will build certification and logo
program and we expect this to be a consumer-recognizable logo. So all of
the fitness companies, of course, are very keen on this as consumers go
out and buy weight scales and tread mails and heart rate monitors that
they want to be able to specify that that Continua logo shows up that it
will prove it\'s interoperability with a service on the Internet or a
help service on the Internet. Similarly, the healthcare providers that
we talked to and providers that are part of Continua are looking to be
able to specify that Continua logo when they do chronic disease
management or remote patient monitoring solutions. Next slide, please.

These are the ones I set out. First two I described, the last two are
the ones that the organization decided if we\'re going to achieve this
interoperability that would be great that would open up the marketplace
to a large degree, but there were other barriers here that we needed to
try to address as an industry alliance. One of those being regulation
and the regulatory bodies, there are lots of examples of inconsistent
application of regulations to this space. It\'s largely been not
exercised significantly yet. We\'d like to and we have had conversations
with the FDA and the EU regarding how we can help the industry
self‑regulate as well as work on creating best known methods for these
different devices.

One of the aspects that we\'ve spoken with significantly about is by
creating these data interface standards and these points of integration
that we have an availability to compartmentalize the ecosystem into
different device types they can then focus their energy on those device
types that are considered more, shall we say risky, than others. So that
they can put their energy where it\'s most needed. The last one is
reimbursement. And the reimbursement for chronic disease management is
what that\'s specifically speaking to. So we expect that health and
fitness, those are going to be largely retail models. So consumers will
purchase those devices over the counter. We expect elderly monitoring to
be largely reimbursed by consumer dollars and largely retail. Chronic
disease management, as you\'re probably well aware in most people\'s
minds healthcare in general is expected to be reimbursed by the
healthcare provider, whoever it is and whichever (inaudible). So we\'re
looking to enact several programs within our reimbursement working group
to try to move that ball forward legislatively as well as with
demonstration. Next slide, please.

This is our working group structure today. We have use case working
group that is, I think over 60 use cases from the various member
companies from many different healthcare entities within the ecosystem.
We\'ve prioritized those use cases, cataloged them. We\'re now in the
process of voting which cases we\'re going to enable in our Version 1
guidelines.

We have a marketing working group that\'s very heavily focused now on
creating that consumer-recognizable brand, as well as creating market
awareness within the healthcare providers on personal telemedicine in
general. Surprising, perhaps to many of us we\'re used to looking at
these use cases but there are many providers that have not explored this
space at all and they don\'t know the benefits out there. We believe
there\'s a lot of value that can be added to this environment, just by
education.

Technical working group is now broken down into six subcommittees.
They\'re all fairly heavily focused on those different interfaces.
We\'re creating requirements and criteria for selection of the
standards. We expect to have standards selected by the end of the year
and we\'ll start wrapping those with the guidelines and tightly
interoperable.

The reimbursement working group is kicking around different strategies
right now. One of them is in regards to doing a large demonstration
project in order to provide data necessary to achieve a larger
reimbursement and some of the other, the other project is in regards to
a legislative agenda.

We have a government affairs working group right now; we have several of
the large companies that are part of Continua, have folks that are
policy makers here in Washington. They\'re actively working together now
here in Washington and we have another group that just kicked off last
week in Brussels to start working that agenda in the U.K. We expect to
start that same effort in Japan in the spring. Next slide, please.

Timeline is fairly aggressive. We\'re here in September or October, I
should say. And we\'re finishing up our use case vote. We have set the
guideline development to be one year\'s worth of work. We didn\'t want
to create a set of work that would be a five‑year mission and boil the
ocean, if you will. We\'re trying to set the prioritization of the use
cases and contain the scope such we can get something accomplished in
one year on each of the three themes, get that out the door, get if
certification and the products rolling and start the process.
Immediately after that, there is a lot of pent up demand if you will for
us going deeper, we\'ll start immediately into a Version 2 set of use
cases and Version 2 set of guidelines. So we\'ll keep digging into this
deeper and deeper and providing more functionality into those
interoperability guidelines as long as the industry is driven to do so.
Next slide.

Quick set of accomplishments: launched on June 26 with 22 companies, we
now have 65 companies, and we have about 380 people actually now running
around in our various workgroups. It was over 50 use cases submitted for
Version 1. We have an architectural document that\'s a draft internal
that\'s being used to guide our Technical Workgroup. We have two very
significant efforts going on in the Bluetooth standards body and in IEEE
medical equipment device body. They\'re being joined together one is
transport and one data model. There are about 40 companies in both of
those organizations working heavily on trying to get those standards
complete by March of next year.

The reimbursement strategies are in the planning stages. And we have
government affairs people working now. Our summit calendar is now locked
in for next year. We\'ll be in London in January. We\'ll be in Tokyo in
March. Back to San Francisco in June and then Boston in October. Last
slide, please.

And as a proud father, I can\'t go anywhere without a photo. This is the
organization at our last conference. We had about 170 people, with 180
people at Harvard Medical School. Last week achieved quite a bit of
momentum. There are some people on the call Jay was up there as well. We
had quite a good turnout. With that I\'ll stop talking.

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

I\'ll jump in and say thank you so much. I think we\'ve been hearing a
lot of different things about Continua, all good. And it\'s wonderful to
have you come and bring it all together for us. I\'d like to just start
the ball rolling by asking a couple of questions. And first one has to
do with the interoperability piece as you develop the standards for
interoperability how do you intend to work with electronic health
records so the information can be interoperable with the electronic
health records I say that knowing you have committed to the commission
for HIT and been involved with the HCFE work, so I\'m just wondering if
you could articulate that and how you anticipate that will roll out?

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

Sure. Continua, we think of ourselves first and foremost not as a
standards body. There\'s no question there\'s enough standards here to
solve the problems. There are gaps in those standards and so we think of
ourselves as a standards coordination organization and so we\'re going
in and trying to fill those gaps and select the specific standards for
the personal telehealth space. In regards to specific EHRs and PHRs, we
believe that we have an ability of selecting one standard for that space
on how these devices in the home and in the personal space are going to
talk to those systems. And so we have an ability to select one flavor of
HL7, tightly defining it, and allowing that to be the one that is both
approved by Continua and hopefully perhaps harmonized with
\[inaudible\].

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

Okay.

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

What do you need from AHIC or AHIC-type efforts to help you move this
program forward faster?

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

I think we have struggled a bit trying to figure out reimbursement
element. In a large degree we could really use some help from CMS, I
think, in defining what it is that we could do that would really define
the data necessary to move the reimbursement ball forward nationally.

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

Yeah, I think getting back to that, David, I have Justine Handelman is
here as well, I think that\'s one of the issues we\'ll tackle in these
demo criteria that Karen I guess we\'re going to get more feedback on
that shortly, because I think we moved last meeting from just looking at
secure messaging to looking more across the spectrum of HIT and how it
would influence outcomes. So this seems to me to be directly related to
the work you\'re doing and should tie into some reimbursement
information as well.

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

Short answer to your question is of course prove that they saved money.

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

Exactly. It fits into the whole outcomes issue that we\'ve spent too
many meetings discussing. So Jay.

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

Just a few comments. Number one it\'s sort of frighteningly ironic in
your first slide you identified one billion people in the planet that
are obese and millions are dying every year of starvation. The two ends
of the pendulum. Equally terrible. Second, you and I have discussed this
before, one strong suggestion is that in your slides where you talk
about remote monitoring, and you hone in on the home, that we also add
the work site as the other major equal site for this type of monitoring.
And you already have the communication infrastructure in place. So it
may even be that the work site may surface to the top as from the
practical standpoint, the most important place. And in terms of need. In
terms of your expert group, although it wasn\'t probably a complete
list, but given the fact that its familiarity on the part of the
providers is going to be very, very important in terms of the types of
technology that is available, I would recommend that you have a
representative from the AAMC as part of your expert group, the
Association of Academic Medical Colleges. And the fourth, on a lighter
note, I think there is one downside to this in home sensor technology. I
can just see the elderly mother, you know, not taking her medication so
the alarm will go off in her son\'s home and have her call him.

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

As part of the company of Continua that does elderly monitoring, and
they have those categorized. Those individuals categorized. That\'s
exactly right.

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

This is Karen again, could you share with us a little bit about the
direction that some of the use cases are going, and the reason I ask
that is that we\'ve been struggling here in terms of how we might
prioritize the \[inaudible\] American community, work that can be done
by a number of different entities to address some of the barriers around
specific use cases as you described. We came up actually with two
different types of use cases. Some of which are described in the work
that Karen presented a little bit earlier, some of which you described.
But one of them was around the type of monitoring that would be done by
home health agencies, for instance. Clearly and we heard this from not
only Joseph Kvedar, but from the VA, the need of vital signs is
critical. That\'s not just weight. It\'s the blood pressure, the heart
rate, and everything else that goes along with it.

And secondly the area of monitoring of very specific chronic illnesses
we talked about as well. We talked about anticoagulation monitoring, we
talked about weights, which is again a subset of the vital signs. We
talked about the glucose monitoring as well. We have these two different
areas that we know are centrally teaming up as top priorities for all of
the various parties and entities with which we work or with whom we work
to think about. And so I\'m wondering if your priorities match with ours
and whether or not we should find some way to bring these together so we
have everybody working on the top priorities at the same time?

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

The voting is going on now and I can\'t tell you what will be in
Version 1. I can make some, I can make some educated guesses just based
on where the organization is putting energy in some of the first steps
that we have to take. And the basic vital sign devices I expect to be
enabled in Version 1 and that would be weight, temperature, blood
pressure, glucose, pulse ox.

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

Is that in addition to vital signs?

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

In addition to vital signs, yes.

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

\[Inaudible\]

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

Yes, that\'s the sixth one. There are six. I expect those all to be
enabled in Version 1, the coagulation one, there\'s only a few companies
that build a coagulation device. I expect that one could fall into place
if we do something as a dot release perhaps in between because there\'s
a lot of demand for those devices and those companies are just now
getting off the ground. I think on the fitness side that will see the
fitness devices enabled and will fall into the classifications with
regard to endurance devices such as treadmills and so forth and the body
one monitoring devices. Elderly monitoring. I\'m going to expect
there\'s some level of fencing monitoring that will occur there.
Probably basic motion testing and blood pressure testing. Those are
monitors that get enabled.

On the service side there\'s a lot of desire I believe to enable a
fitness device or a fitness service interface, a PHR interface and a
disease management interface. The depth of those I think is a lot to be
determined in our voting process.

Now I have to back up, I\'m saying this just to point out something in
that Continua enabling interfaces and interoperability, we don\'t build
products. All our members of Continua build products and glue these
things together and solutions for the providers. What we have also seen
is that people are starting to have eureka moments, if you will, because
by putting these devices together they\'re thinking of new ways to
correlate data. If I had this data and that data would I be able to find
a new way of determining a way of treating asthma? So they\'re starting
to think about these things and being able to combine the data together
and come up with new things to do with the data.

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

One other follow on question on that, have you thought about looking at
interoperability with respect to images, with respect to looking at
wounds, monitoring wound care or other situations that actually require
a photograph?

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

Yeah, so that\'s certainly, gets presented a lot. I\'m not sure that we
have to work on a lot of standards there, because those are devices that
are already filled with standards. PC cameras have been standardized for
quite some time now. There are quality standards with regards to
protocols on how to use those photos and the ACA is actually focused a
lot of energy on that problem. But as far as device interoperability, I
think that we\'ll probably package that one up pretty quickly.

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

I\'m going to sort of keep pushing here for a few moments if I may. I\'d
like to ask if anyone has any questions or comments before we talk more
about the priorities?

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

Go ahead, I\'m sorry, Craig, go ahead.

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

This is Paul with Cisco. David, quick question for on you the FDA. Do
you anticipate or see any gaps in the existing medical devices or work
that needs to be done by Continua to update?

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

The FDA, you know they see, there are a lot of different ways we can go
with regards to approving of the devices. What we\'re trying to do is
come up with a method that allows rapid innovation here as well as still
provides the quality, safety, and efficacy that the FDA is charged with.
So there\'s a balance here that we\'re trying to strike as we\'re
entering into this consumerism, if you will, of these devices. And so
that I think is going to be an interesting challenge as we work with
that particular regulatory body in order to come up with the guidelines
in order to make this a useful ecosystem.

[**\>\>**\
]{.underline}Do they currently assert jurisdiction?

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

Certainly. On medical devices?

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

Well, on scales.

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

Absolutely. Scales as used in a medical context, yes. All the medical
devices, absolutely.

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

Maybe this is kind of a lead in to Karen\'s next area, I think this
reinforces two areas we\'ve talked about, Karen. One was the
reimbursement and timing of the (inaudible) and overall outcomes but
second it seems it\'s more important that we continue to tie what this
Workgroup is doing to the Consumer Empowerment Workgroup because it
sounds like a lot of the themes you\'re discussing here would be
applicable to that group as well, in terms of the personal health
records and some of the tools that are tied into the personal health
records systems. I\'m assuming that you feel the same way from based on
your charts here.

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

Yes, we have two PHR companies that are part of Continua, that that\'s
why they\'re there, is because they want to be able to get that data
from the home, empower the consumer. They aren\'t healthcare providers,
if you will, they\'re looking to give that data back to the worried well
or somebody who is trying to manage an active chronic disease, not a
homebound chronic disease. So that\'s a great tie in is for us to get
involved in.

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

And work as Jay mentioned, I think. Okay.

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

Any other questions or comments for David? I personally would like to
say thank you very much. I\'ve heard multiple presentations, but I have
to be honest, I think yours is very clear and concise and nicely done.
Thank you, David.

Before we move on to the next speaker I want to prioritize for the next
meeting. Two reasons, it\'s an exercise that needs to be done today and
secondly Brian Austin has been delayed. He can\'t join us until 3:00.
With the Chair\'s permission I\'d like to jump into the priorities
discussion, the visioning exercise, if that\'s all right.

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

Go ahead.

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

As I said earlier, as I said earlier, we do need among those
deliverables for AHIC for October 31st, one is a list of priorities that
will be important for us to consider with all of the entities with which
we partner as we move forward. And again as I mentioned a little bit
earlier, we had talked about two different directions that could go in,
one is through the home health, through the home health agencies and
then secondly through specific monitoring.

What I\'m hearing today from the folks from Continua as well as the work
we have done earlier is that our list probably should be condensed or
can be condensed to one list that includes vital signs, including
weight. The blood pressure and all else that would be part of the vital
signs. Glucose monitoring. \[Inaudible\] monitoring, that the ability to
follow INRs might come a little bit later on down the line but it\'s not
really immediately available a priority right at the moment.

And that the photographic monitoring is already there and we could
choose to add that if we wanted to at this point, because there may be
some other issues around that for a later point in time as well. And
before we move forward with codifying that list and agreeing that
that\'s our list, do we need to have any more discussion about the list
or have we, through today\'s meeting and our previous meeting, agreed
that that is the primary list we\'re going to deal with?

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

What do we have in vital signs again, weight, blood pressure?

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

Weight, blood pressure, temperature, heart rate, pulse oximeter, which
has become a vital sign I guess in the last five or ten years it would
be those plus the results of the spirometer reading and pulse oximeter
reading.

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

The only problem with heart rate ‑‑

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

Rhythm.

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

Somewhere in there especially with the folks from \[inaudible\] you have
to promote rhythm monitoring, it\'s on the list, I don\'t know where it
is. So ‑‑

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

How far is the industry right now in terms of being able to do that,
other than the \[inaudible\] monitoring, which isn\'t a direct feed at
the moment. How far do you think we are on that, Jeff?

There are a number of wireless devices that are being used. One
individual to ask who would probably know the complete world of
literature is Dr. Marvin Sector in Miami. He was the inventor of the,
I\'m sure everything is wireless and is one of the physiologic
parameters that ‑‑ so he would probably know various places.

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

You can be sure that the folks that manufactured the fancy combo
\[inaudible\] ICD so Medtronics and guidance I\'m sure they have a story
around that. Because those devices record and now, all they have to do
is have a Bluetooth or whatever to get it out.

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

Right, you just reminded me, persons who speak to that guidance would be
Bruce KenKnight. And their new Latitude device, Medtronics, has a
similar capability.

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

That\'s very helpful. How does the group feel about doing this in
concordance with the work that Continua is doing?

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

Very important. Why wouldn\'t we just assume we could use them as a
build off of what they can do?

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

That\'s what I\'m thinking.

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

It wasn\'t Brian, it was Craig. I\'m sorry.

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

I\'m sorry, Craig. What I\'m thinking there may be some other issues in
terms of reimbursement, privacy and security. Issues that we are dealing
with across the board for remote monitoring, remote care that we could
focus on these particular, in these particular areas, which I think
could be very powerful since Continua is already doing so much of this
work.

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

Yeah, I would think we would try to leverage off of the organization
that they\'ve created and the progress they have, and then our areas
that we can influence more directly. That\'s why I asked the question
earlier, David, what could AHIC or HSS do to help them drive this
program faster. And all that he mentioned I think was the reimbursement
issue. He didn\'t mention anything technical or stuff aligned with what
they\'re already doing.

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

I think Karen this is, I think it\'s important to hear what Continua is
doing but keeping in mind we are, this is an advisory group that reports
to the AHIC and we have to keep in mind from the FACA standpoint and
other standpoints that we can listen to what they say but in terms of
alignment we have to be careful in terms of how we do that just because
of the, because the way this group is and how it\'s set up. Because
there are other groups that may also be involved in doing work that we
would also need to hear from.

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

Karen, wondered, try and rank the list, in other words, you do get a
laundry list pretty fast. So if we\'re really doing sort of product
management for the good of the cause, you know you keep hearing about
weights and glucose as sort of the hot ones everybody wants so I don\'t
know, I\'m not proposing to do it right now, but if that would be a
valuable document to say, you know, start with these three and then add
these four and these, I don\'t know if that ‑‑

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

That would be very helpful. We\'re thinking just in terms of the first
batch, the ones we discussed a little bit earlier that\'s been refined
by what\'s really available right now. That\'s how I think we get to at
least vital signs and glucose and spirometry as the top ones we would
want to look at.

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

If I could second that suggestion. Even within that small group, it\'s
debatable how some of these, when you talked about chronic care and
trying to get at information which could change a provider\'s decision
making capability, for example, temperature is not necessarily something
that\'s going to be useful to a provider. Pulse oximetry you can debate
with your COPD and asthma population. Pulse with your \[inaudible\] but
some of these are clearly going to be more effective than others. So
even if this is the first, I think it might be an exercise even doing
some kind of hierarchy amongst the first year items.

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

Yeah, I think weight and blood sugar are probably the top two. I agree
with what you said. Those others ‑‑ you start to get the fancy stuff
that has a lot of technical burden or cost burden or equipment burden,
especially blood pressure monitoring that just gets to be much more
arguable. But weights and blood sugars would be really nice.

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

Actually, I would, I\'d have a minority opinion on that particularly in
the patients with asthma. We have an epidemic of asthma. We just don\'t
think about it in the chronic disease patient because it\'s in the
pediatric patient population, and most of the disease occurs at home.
That\'s where they\'re responding to the antigens not in the doctor\'s
office. So doing spirometry on the children would be very important in
that particular space.

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

That\'s probably better than pulse oximetry for that population.

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

Yeah.

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

This is James Ralston from Group Health Cooperative. One thing we\'ve
found in these home‑based monitoring programs is that it also depends on
the amount of data that\'s uploaded for patients who have conchometers
(ph) it\'s much more important for them to up load those automatically
than patients with blood pressure monitors, because there\'s so much
glucose readings, it\'s hard for them to type into a secure message. I
think I agree with the priority discussion, as you guys have framed it.
But I would just add from a usability standpoint when you have a lot of
numbers it\'s more valuable to the patient when they can automatically
up upload them.

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

That was very helpful. What will probably happen next we\'ll take this
back, we\'ll put together a document, circulate it amongst everyone for
sign‑off before it goes to AHIC. And give everyone an opportunity for
one last crack at that, if that\'s okay.

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

What is the drill going to be at the AHIC? Each Workgroup is going to
present opportunities and what\'s the end result of all this?

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

As far as these types, each Workgroup will be presenting a list with
some prioritization to it. Those that are most important to move forward
early on and those that perhaps can wait a little bit. And then there
will be a process whereby what we\'re calling the cross-functionality
work will get done. Because as we\'ve noted before, the Consumer
Empowerment Workgroup will have some priorities that will not look
terribly dissimilar from what we\'re doing.

The EHR Workgroup has been focusing a lot on laboratory information, but
here we are talking about glucose readings as being critical in this
setting so we\'ll be looking at how can we essentially bring all of
these together in a way that the entities that we work with, whether
there\'s contracts around privacy and security or HCVE, how they may
actually move forward in a way that takes into account all of the
recommendations and all the priorities from all the Workgroups in such a
way that we meet all the top ones across the board.

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

Will this take place of some of the broad charge recommendation letter
then, is that going to ‑‑ I\'m trying to see where this all aligns in.

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

No, this is more on the next steps that will be taken around our own use
case development. Now, clearly these use cases are or however we choose
to call them, these priorities, will be looked at in terms of some of
the more broad charge recommendations as well.

So our work is not done in the areas of reimbursement, in the areas of
privacy and security, in the area of organizational change, workflow
change, those big broad areas that we\'re concentrating on right now in
terms of the broad charge. So we\'ll continue to do those
recommendations. They are not due October 31. We have more time to
develop those recommendations, once we get a better handle on what the
overall use case priorities are going to be, and once we again think
through a little bit more of what our own priorities are here and how do
we move forward thinking through the broader recommendations. So that
can be as late as February.

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

So this will inform the next bunch of use case priorities in addition to
other information that comes out like ID prescribing and things of that
sort and this will also help inform the overall broad charge letter
which is going to come out next year. And then what happens with some of
the items we\'ve left hanging for a couple of meetings, the closer tying
into the Chronic Care, I mean with the Consumer Empowerment Workgroup,
and also building on the demos as we\'ve been trying to bring ‑‑ you
know, I\'m getting a little concerned we\'re not bringing either of
those to closure or going to the next step seemed like we\'ve been
talking around them for a number of months now.

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

There\'s no question that there is overlap between the Consumer
Empowerment Workgroup. We hoped Kelly Cronin would be able to come today
to really address some of the issues they\'re talking about so that we
can have a more definitive discussion and how to move that forward. That
will happen at the next Workgroup meeting because at the last meeting
she got pulled away. She was on the agenda but couldn\'t do it.

As far as the work on the pilot is concerned, we have begun some of the
first steps in terms of how we may go about developing a strong man
proposal and the \[inaudible\] enough to agree to work with us on that.
So over the course of time, between now and the next Workgroup, we\'ll
be working on that piece. So the next group will have a presentation of
the beginnings of how we might move forward with the pilot.

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

Because I\'m concerned about it from a timing perspective. We have those
demos that CMS we need to be looking at and sustain us here today, and I
know you\'ve got a number of your execs coming in over the next of, end
of the month, I\'m sure it will be helpful to you to get some feedback
as well.

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

Absolutely. What is your timing, Justine, from when you might need ‑‑
what is the timing that Blue Cross/Blue Shield Association might need in
terms of seeing a first draft of the possible pilot?

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

We\'ve scheduled an in‑person meeting of what we call Health IT Advisory
Group, which is a number of executives across plans, functions, and
internally for the end of this month, October 27, a lot of things are
happening and we want to put things across because, looking from our
areas, of course, we go to them regularly and can continue to do that.
But having everyone in person is always a great way to give input. But
that\'s really our timing on that is the meeting itself is October 27,
and any time before that it\'s helpful to give them something to read
and digest.

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

Are they coming into town any time after that soon?

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

We have nothing planned, in terms of an in‑person meeting. We\'ll
probably have another phone conference of everyone prior to the end of
the year.

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

I\'m just concerned as we go along, even as you and I had talked before
the meeting, Karen, a lot of these items that were laid out in the
specific charge are also so very applicable for the broader charge, the
licensure issues, the reimbursement and some of the other issues we
talked about as well one of which got moved to the Confidentiality,
Privacy, and Security Workgroup, the authentication issue. And I just
want to make sure we\'re tracking these and I guess it gets back to
Craig\'s issue at the beginning, or not issue, but maybe monitor at the
beginning where talk about getting some demonstrated results and focus
and I just want to make sure we can continue to keep moving on these not
just bring them up to the meeting and not get them down the road
further.

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

One of the things I\'d like to call to everyone\'s attention, not for
discussion today, this will also be on discussion for the next Workgroup
meeting, is the first draft summary of public testimony. We\'ve just
started again, just started this work, but we are going through
literally all of the presentations that we\'ve had since the Workgroup
started. And pulling out those points that are referable to the critical
areas that we\'re working on right now. The financial issues, i.e., the
reimbursement, the cultural issues, the technical issues. And this is as
I say it\'s the first crack at it. It\'s work in progress. But what I\'d
like to do is hear back from Workgroup members about whether this
approach will be helpful as we actually sit down and try to look at the
gaps, what other testimony do we still need to address these issues so
we can make sure we get that testimony here at these meetings along with
some recommendations about how who might be a good person to do that or
what would be a good entity to do that. And if any of you have any
strong feelings you might like to help on with this or do that we\'ll
certainly be, we\'ll be more than grateful for any support that we have
working this document through as well. If you think it\'s something
that\'s worthwhile that everyone would find useful. Again, don\'t need
to tell me immediately today whether, how you would like to work through
this document but we\'ll be emailing all of you to get your input on
whether or not we would, you would like to see this flushed out further
and if anyone has any thoughts about that and need for more testimony.
Okay.

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

This is great.

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

I think this is very helpful.

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

I\'m getting positive factor starters but we\'ll let you hear from
everybody through e‑mail. We\'ll send out and get your input that way.

Before we go into the virtual care vision exercise, I understand that
Brian Austin is on the line, is that right?

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

Yes, hi everybody.

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

Perhaps we can go back and hear your testimony at this point in time,
Brian and I\'m just going to introduce Brian as working with the chronic
care improvement Group Improving Chronic Illness Care, that started
quite some time ago with Ed Wagner\'s initial foray into developing
what\'s now known as the Chronic Care Model. And Brian is here today
because we had some discussion last week about predicating our pilot,
our secure messaging pilot, on practices that had adopted the Chronic
Care Model already. So this is an opportunity for everyone to get on the
same page with exactly what we\'re talking about. Brian. It\'s all
yours.

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

Okay. Thanks very much. I\'m told I have about 20 minutes and I\'m
dealing with a head cold. So if I start to talk fast, it\'s either the
medication or I see my time is being used up. So just one quick
question, as far as advancing the slides go, does everybody do that
individual? Do I just say I\'m on slide two or do I advance it here?

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

You can just say "next slide" and we\'ll keep them updated for you.

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

Terrific, thanks very much. All right. As you heard, we are, I\'m
representing both the MacColl Institute and Group Health Center for
Health Studies. I understand there\'s other people on the line as well
and improving chronic illness care which started in 1998 and really has
its roots further back in Group Health\'s own delivery system
innovation.

I don\'t think I need to spend much time on slide 2 from reading your
past materials. We think the Chronic Care Model is necessary in part
because we see deficits in at least three areas of current care, not
only the proper care isn\'t being delivered because of the current care
environment, but also deficits in self‑management support that
evidence‑based new methods of self‑management support are neither
staffed for nor effectively done in current environments and that
there\'s not really provision for good follow-up and care coordination
given the strictures of current care.

Slide 3 is talking just very briefly about our road from 1993 to the
present. We really, the genesis of the Chronic Care Model as I mentioned
was to try to understand the elements of effective interventions both
internally within the system at Group Health Cooperative, as we were
trying to do work in diabetes and other chronic diseases and also try to
understand the literature which was often organized by clinical
condition and to try to really lay out what seemed to be the necessary
set of elements and effective interventions. Starting in 1996, we
received help from the Robert Wood Johnson Foundation in taking our
internal experiment as how we would explain good chronic care and
turning it into a national program.

Slide 4 just lays out what we see as the advantages of a general system
change model. Obviously we were interested readers of "Crossing the
Quality Chasm". We see it as a system problem, not a bad apple problem.
It\'s much easier to organize learnings across chronic conditions if you
have a common model in mind. It\'s also, we thought, would be easier on
systems if they had a grand design in how they might change to organize
care to avoid the silo problem of, okay, here\'s your project in
diabetes. Here\'s your project congestive heart failure. So really we
thought it would be an opportunity to avoid what we call "projectitis."

The next model is the Chronic Care Model itself, slide 5. I should just
mention that not everybody calls it the Chronic Care Model. Internally
at Group Health it\'s called the Plan Care Model. The Bureau for Primary
Health Care calls it the Care Model because they apply it to prevention
as well as other conditions. So even though it\'s got its genesis in
providing chronic care, we, we and our partners aren\'t limiting it to
that at this point.

We usually explain the model from the bottom up that our goal is
improved outcomes, improved cost outcomes, improved health outcomes
improved satisfaction outcomes, and that we work toward improved
outcomes by trying to support productive interactions, really the same
thing as what the chasm report called continuous healing relationships,
we try to support productive interactions between an proactive patient
family and caregiver and a prepared proactive patient team.

That\'s not to say that every interaction has to be one‑to‑one, a lot of
people who are using the Chronic Care Model are utilizing group visits
and other methods of visits. It\'s also not to say that every
interaction has to be in person. Certainly a lot of people who are doing
work on the model are doing e-visits, are doing, you know, secure
messaging, obviously has a place in all of this. But it\'s really, at
its heart it\'s to support that interaction between the practice team
and the patient, and that the four middle layers within the ellipse
without getting too inside baseballish; there\'s a reason for the colors
in the ellipse, that what we were trying to show is that some aspects of
the Chronic Care Model, such as self‑management support, might exist
almost equally within the community and within the health system. There
might be exercise programs at a senior center or that that the elements
to the left are the most visible to the patient and perhaps the most
visible and shared within the community. So usually we talk about it
from left to right. But our feeling is that the elements across the
middle of the Chronic Care Model are really what is needed and they\'re
needed in concert. You can\'t really pick and choose if you look at a
well-rounded intervention, they usually, if you carefully parse it, you
usually get elements of all of these.

Self‑management support, rather than didactic traditional patient
education, emphasizes the patient\'s central role and I saw in your
virtual care vision that you also are believers in person-centric care.
We recognize that it\'s in the community that the patient spends 99
percent of their time. It\'s in the community where they\'re living and
probably have lots of informal modes of support. And so what we\'re
trying to do is meet the patient where they are. Use effective
self‑management support strategies and organize resources, some of which
might be internal to the system and some of which, some of which the
patient\'s going to find in the community to provide that support.
Second over is delivery system design and delivery system design is
really just assuring that the delivery of effective efficient clinical
care and self‑management support can be done. That\'s got elements and
often what teams work on first are defining roles. You have to be very
explicit about who is doing what if you\'re doing planned care with
patients rather than just have patients coming in based on acute
problems. We\'re big believers in planned visits as a whole and outreach
to patients. We find that patients love it and that it gives an
opportunity for the providers to concentrate on what\'s necessary
without the tyranny of the urgent. Case management functions could be
built into here, and again provision for regular followup is a key
element to delivery system design. Working across to decision support,
that\'s more than guidelines. That\'s certainly embedding guidelines,
making the right thing to do the easy thing to do. But it also is
talking about new models for primary care and specialty care to work
together.

So, for instance, in the Group Health environment, the use of a diabetes
expert team that would see patients in concert with the primary care
physician to both deal with problem patients and model what a good plan
visit would look like. Decisions support includes proven provider
methods. What we\'re doing right now, me lecturing at you has, been
shown to be pretty ineffective at changing behavior. It\'s ineffective
when you lecture to patients and it\'s ineffective when you lecture to
providers.

So you really need to find methods to engage and make the learning more
directed. And then also in decision support finally is that guidelines
aren\'t meant for providers only. That the best teams now are sharing
guidelines with patients and really making everyone mutually accountable
for making sure that the care needs are met. Finally, as I said,
there\'s a left to right flow in the middle element of the Chronic Care
Model and we put clinical information systems all the way over to the
right because we thought of that as more of a back office function in
1998. Obviously that\'s no longer the case, that patient portals and
e-visits and there\'s shared medical records so there\'s all sorts of
ways that clinical information systems can be seen to be necessary for
providing state-of-the-art self‑management support and ways they can
augment the delivery system design of the system. At the higher level,
we put the healthcare organization, and that really is noting that what,
if you are in any sort of a system, what you\'re looking for for your
leadership is visible support of the elements that you believe are
critical to ongoing success. Some sort of staying power in some proven
quality improvement methodology. It may not be traditional QI, but you
need to have some way of working with practices and working down the
system to see that change can take place. And we\'d also put in there
provider incentive, other methods of, again, assuring that the right
work is the work that people are incentivized to do. And finally on the
community resources and policy, and this is really an issue where we\'ve
been doing a lot of thinking over the course of the last five years, is
the health system in the community. And I hope, I\'ll leave myself some
time to talk about that just a little bit.

But community resources and policies from the health system perspective
is making sure that a health system knows what effective programs are
out there in the community, that you\'re forming partnerships with
community organizations to support or develop programs, and that as a
citizen of the community that you\'re advocating for policies to improve
care. And what we have been trying to think about over the past few
years is what happens in a small practice that doesn\'t have the
supports of the health system, how can they get some of what we would
see as necessary help in self‑management support or even clinical
information systems via community mechanisms? So that\'s the four-minute
version of the Chronic Care Model.

If it\'s all right with you, and if you want to hear it, what I\'d like
to tell you about is just what we\'ve been doing since 1998 to
disseminate and learn from what other systems are doing with the Chronic
Care Model. Is that the right thing to talk about now?

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

Absolutely.

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

Then on to slide 6. We started in 1998, 1999 with a charge from the
Johnson Foundation to not only develop the Chronic Care Model, but
simultaneously evaluate and disseminate the Chronic Care Model, to
really work with large numbers of practices quickly. The mechanism for
doing that was working with IHI on breakthrough series. At first we used
their national model and kind of what we\'d think of as classic
breakthrough series at this point, which is year‑long, 13‑month long
collaborative improvement methods with the chronic care model guiding
system change, and at this point we\'re well over 1,200 teams that have
gone through versions of collaboratives. Although they haven\'t all been
national, they haven\'t all ‑‑ we\'ve started some virtual
collaboratives, but different flavors of collaboratives.

A large percentage of those have been HRSA health disparities
collaboratives and some of our chief learning has been through what
well-organized but less resourced community health centers have been
able to do utilizing what they call the planned care model and then
finally on that slide a significant chunk of the original improving
chronic illness care budget went to an independent evaluation by RAND
Health of our First National collaborative.

Slide 7 shows it wasn\'t just the chronic care model that was being
tested in the collaboratives. It really took four different elements.
First of all you\'ve got to have a condition or set of conditions where
there\'s some evidence that good care will change outcomes. So you need
evidence‑based clinical change concepts. Secondly, you need a strategy
for changing the system, which is model for improvement. What we used in
collaboratives. You need some way to apply the method in small cycles to
effect practice change third, working clockwise around you need a model
for teams to learn from each other, again because modern education shows
that a lot of learning in both patients parts and provider parts is
learning from each other\'s experience and having an organized way to
step through increasingly complex concepts. And then fourth is you do
need system change concepts. You do need shining city on the hill that
you\'re kind of shooting toward of what a fully organized system of care
would look like.

Slide 8 shows that the RAND evaluation, which was a horrifically
difficult evaluation because it engaged 51 organizations, all of whom
were primarily there for quality improvement purposes, who saw
evaluation as more of a nuisance than anything else, there were lots of
issues around controls, because what we would consider contamination,
they considered good spread. But RAND did a wonderful job and has at
this point I think 10 to 12 papers out about process and outcome
evaluation of the collaborative.

Slide 9 is a one-slide summary of RAND findings. There\'s a lot of
information if you just Google ICICE, improving chronic illness care
evaluation, you can get to a nicely maintained RAND Website with tools
and findings. But basically they found that organizations made a lot of
changes, contrary to popular belief, they made changes in almost every,
almost every team made changes in almost every portion of the model, 5.6
out of chronic areas. As you might expect, IT received the most
attention because it was a target you could see and also because you
needed to get your arms around a population to effect change. Community
linkages received the least because people really at an early stage
didn\'t know what to do with that. And that there were some good process
outcomes, changes in congestive heart failure, pilot patients, in as
that, and diabetes pilot patients. There\'s a new paper that\'s going to
be coming out that compared the UKPDS predictive risk of heart disease
among diabetes patients and showed the intervention group had a
significantly decreased risk for future cardiovascular events. That
paper will be coming out in the future, but there\'s a summary on
RAND\'s Website. We were encouraged a classic collaborative, even though
patients weren\'t followed up for long enough to have extensive outcome
changes, that a classic collaborative applying the four barrels of
system change, strategy learning model, clinical change concepts, and
system change concepts could effect change.

It was also important to us on slide 10 to find out that teams had a
good experience with collaborative. They liked working together. They
liked working with other teams, and a year later, 82 percent of sites
had sustained changes and 80 percent or 79 percent of sites had spread
change to other places or diseases. And that really got us on the road
of thinking about what we\'ve come to call joy in work issues, which is
really the outcome of satisfaction of the care team in thinking that
they finally have a handle on difficult populations and they finally
have some arrows in their quiver and organizational techniques so that
they can help people that they\'ve been trying to help for a long time.
And so we actually have a small project we\'re now doing with some
qualitative researchers to see how we can measure that joy and work.

I won\'t spend much time on slide 11. It\'s just that the Chronic Care
Model has been popular as an organizing principle with a host of other
organizations, including WHO, which has used it in their ICCC model. But
more recently with the American College of Physicians and Academy of
Family Practice and who have different but in some way into models or
advanced home models that combine the Chronic Care Model, medical home
and looking at changes to the payment structure or creativity among the
practice team in how to make the Chronic Care Model work from a business
sense.

We\'ve been interested in a long time, and that\'s slide 12, in does
chronic, do chronic-care-based model changes have an effect outside of
collaboratives? And Barbara Fleming\'s study was a nicely done paper on
looking and this is slide 12, as I may have said. Looking at do
organizations that score highly on an assessment instrument of Chronic
Care Model elements, how are they doing on quality indicators for
diabetes and what they showed was that the top quartile in the quality
measures were more likely to employ Chronic Care Model-based elements
and it listed at the bottom there what were called out in the paper as
elements.

Slide 13 is what we\'ve been doing since about 2001. We found that
working a national collaborative was useful. We certainly learned a lot
from it. But that what we also learned was that some of our star teams
were going back to their own areas and working on collaboratives within
a fixed geographic area. So we actually ended up giving some grants,
collaborative sponsorship grants in helping work in Indiana, Rhode
Island, Vermont, the States you can see listed on slide 13. And we
believe that that\'s where the bang for the buck is at this point. That
there\'s a lot of advantages to teams that are coming out of similar
environments that can work together at lower costs and that are kind of
all swimming in the same pond, working together. Finally we\'re getting
academia involved. Kind of late to the party, but we\'re finishing up
our first collaborative, the ACCC, and that will be finished in Seattle
in November. And we\'ve been really pleased with the progress that\'s
been made in teams from academic medical centers who have picked this up
because they\'re often real opinion leaders in the community.

So what have we learned? Slide 14 shows that what we\'ve learned is that
the people who are going to join collaboratives are always going to be
the vanguard in practices and so we\'re really still just reaching the
early adopters, and we need to have some way to lift all boats better.
We\'re believers as I mentioned in regional or State‑based
collaboratives, and we\'re believers in the system support that practice
design is very difficult in the absence of support and that a lot of
care is still delivered in some small practice settings, in
onesie-twosie practices and we\'ve spent some time thinking about how do
you translate what an integrated delivery system a VA or Kaiser or a
Group Health provides and are there communities now that are trying to
provide some of that same support outside of an integrated delivery
system?

We have thinking about that at the same time, slide 15, as the King's
Fund study came out in *BMJ*. They laid out some organizational factors,
supportive of high quality chronic care, and we agree with them. It
includes a lot of the things that you saw on the top part of the model.
Strategic values in leadership, integration of primary and specialty
care, investment in IT, and use of some explicit improvement model to
kind of organize their thinking.

So slide 16 is where do we go from there. Do we learn from large
systems? Is "systemness" \-- although we hate the term, we haven\'t
thought of a better term \-- can it be a community property? What are
key components? And what can successful systems and innovative community
programs have to teach us? We were fortunate for the last couple of
years to be working with the California HealthCare Foundation. And
they\'ve actually commissioned two papers that will be coming out soon.
For us to actually interview some regional health care coalitions and
look at, at a very early stage, certainly not as far along as the
Chronic Care Model. But look at at least the menu of how they\'re
engaging with each other on a community level, and we\'re helping the
California HealthCare Foundation at the end of next month,
November 30th, we\'re getting around 18 of these regional coalitions
together in a room in San Francisco to talk about how much of systemness
they\'re able to bring to smaller practices in the community.

And that\'s slide 17, is a very preliminary, we\'re not calling it a
model, we\'re calling it a framework for improving care. Not all aspects
of it are equally evidence‑based. We certainly believe in consumer
engagement, but the evidence to date has been limited. We certainly
believe that the middle plank of improving healthcare delivery that you
have to get in there and actually help practices. And obviously a
community can\'t do what can be done on the national level for aligning
finance and insurance, but what can be done should be done to bring
benefits and incentives into line to incentivize the right care. And so
on the bottom of this framework, what we have are three legs instead of
two. We still have the informed, activated consumer, we still have
motivated, prepared practices, and the third is supportive insurance and
payment environment.

And then I know I\'ve been talking for a long time, but my last slide is
there\'s a lot more information, including streaming media, Ed Wagner
giving a very good model talk as well as bibliographies for all of what
I\'ve been talking about on our Website improvingchroniccare.org. And
that\'s very much for asking me to talk and I\'d be happy to respond to
whatever questions I could.

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

That was wonderful. Thank you very much. The floor is open to questions.

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

This is Joe from Regence; could you sketch out the flow of funds for one
of these collaboratives? If it\'s funded by RWJ, is it a million bucks
over a year or two, and does the money go to the providers to help
reengineer, or can you just tell us about that?

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

The earliest national collaboratives, what we found is, was expanded
faculty involvement and a dual instead of single disease focus. So we
actually didn\'t provide any funding to the sites themselves and in fact
they had to pay 12,500 dollars and their own travel expenses and the
time within their delivery system, which seemed to work out at about you
know a total of one FTE over the year.

So we didn\'t fund any internal operations. All we funded was the actual
structure of the collaborative itself. Similarly, on the State‑based or
the regional collaboratives, for the seven that we did support, what we
supported were again kind of the back office functions. But the teams
themselves didn\'t receive funding. We did have a couple of teams in the
early national collaboratives that we did, we gave scholarships to,
because we weren\'t getting certain kinds of teams. We were afraid about
safety net providers not being able to provide it. And we gave
scholarships, and those teams were actually less successful. So the fact
of having to seek out funding was actually a predictor of success for
those teams.

Emmett Keeler and his team at RAND did look at the costs for a team of
completing the 13-month collaborative and cleaning all the set up for
IT, things like that. I don\'t think that paper has been published yet,
but I think it\'s in, I think the total cost of participation in the
collaborative was something like 130,000 dollars over the course of the
13 months, but that included a lot of one time charges and that also
included the travel expenses and things like that. Does that help?

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

Yes, thank you.

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

That was just a superb presentation. I was wondering if you want to take
a breath. I want to cough is what I want to do. Holding it back by sheer
force. The question I have in your collaboratives and regional
framework, have you considered involving the employer?

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

Absolutely.

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

It\'s really the county government and employers that came to the table
first and brought the health plans to some degree to the table and so we
certainly would involve employers and we think you could get Ed started
on this sometime, but we think employers are farther along than some of
the other players give them credit for and often they can be a good
motivating force at the table as well as completely necessary.

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

You mentioned two sources where the Chronic Care Model has really been
massaged in many ways. One of the regional States you described. And
second you mentioned the HRSA\'s primary care sites. Is there a place
one could go to get a listing of all the practices all the entities that
have been involved are engaged in the Chronic Care Model?

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

That\'s a couple of answers to that. I guess one we don\'t hear about
all the places that have been engaged in the Chronic Care Model, because
oftentimes people decide to take it up on their own and have their own
system strategy and just fold the Chronic Care Model into what they\'re
doing. So there\'s some initiatives, and the VA was actually one of
those, where we learned relatively late in the game to what extent the
Chronic Care Model was an organizing force for what they were trying to
do. So we do have a list of teams that we\'ve directly interacted in
collaboratives with.

I think what you\'re really asking, if you want to reach out to some of
what we would consider real Chronic Care Model stars how would you
identify those teams. And the best bet might be to have a conversation
with us and we can tell you about the States like, you know, like Rhode
Island, like Washington State, like Oregon, like Indiana, where there
have been multiyear efforts and lots of time for practices among them,
some stars to get traction in this thing. But what we don\'t have is an
Excel file we can send you of here are four-star Chronic Care Model
environments. But I\'m sure we could work on a list together.

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

I would have to say that we have used the Chronic Care Model extensively
in the VA as a basis of a lot of what we\'re doing in this environment
where we have both electronic health record and personal health record.
If you can look at that model you can see a multitude of ways that
technology can facilitate some of those interactions. They\'re not
dependent on the information technology in most cases but it makes it a
lot easier if you have it.

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

Absolutely. And people, and that started with disease registries really.
The first collaborative we had people who were doing their registry out
of a recipe box with three by five cards and we have some successful
teams doing that. There\'s no question that there\'s a whole array of
electronic resources makes it a lot easier to do this work.

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

Just one other last question, this is Karen Bell, have you done a
meta-analysis on all the reports that have come out on the almost want
to say return on investment but the hardest part of that equation is
describing the investment piece. But on some of the cost outcomes that
have come out of this?

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

No, cost outcomes have been have been kind of late to the party. We
haven\'t found a whole lot of literature out there that we can glean
from. I will say that our newest piece of work that we\'re about three
weeks into is a task order for AHRQ to merge the clinical change
concepts of the Chronic Care Model with the business change concepts to
show some return on investment for the chronic care element. We\'re
actually really excited what we\'re working on now is what we\'re
calling a tool kit that really will bring together we think for the
first time a lot of the business change concepts and clinical change
concepts and make them equally accessible for practices. And that will
be exciting work. But no we haven\'t done the sort of meta-analysis
you\'re talking about.

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

Who is your point of contact at AHRQ, Brian?

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

I want to say Cindy Branch. I can get that information to Karen.

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

Thank you very much.

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

It\'s the cold medication kicking in.

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

Gotcha. We should either let you go back take care of yourself or your
patients, one or the other. So I\'m just going to thank you very much
and wonder if there are any other questions or comments before we let
you go?

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

Before I scare anyone, I\'m not a provider. So my patients are safe from
me.

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

Thanks so much, Brian.

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

Thanks everybody.

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

Do you want to move on to virtual care vision?

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

Yes we may actually finish a little bit early today but I shouldn\'t
predict. In your packet, you have a one‑page, tried to keep it to one
page so the print\'s a little on the small side, document that tried to
capture the comments that were made and some of the work that was
presented on what the future vision could look like for chronic care
patients and actually patients in general. And what we came to, and I\'m
just going to summarize this and try 25 words or less, if we\'re looking
way into the future we\'re really looking at a transformed health
system, because a transformed health system that is truly
person-focused, person-centric has a completely different reimbursement
model than we have right now and really focuses on care from a
patient\'s perspective as a continuum rather than providers. And clearly
we have a provider-focused system right now. And we think about quality,
we think about it from what a physician does, what a hospital does,
rather than across the continuum. We reimburse by units of care rather
than across the continuum. And we think about primary care and specialty
care as if they\'re two completely different things. So we\'re in this
very provider-centric environment right now. And what we can do in this
provider-centric environment is to incrementally change certain aspects
that will ultimately lead us to transformation. And that transformation
really is about use and expectation that everyone will use, completely
interoperable electronic health information. Right now we are just in an
iterative fashion, incremental fashion adding to a small adoption rate,
adding to very small bits of information that are interoperable. And
doing that, in doing this provider-centric model, and we\'ll continue to
do that until we have pretty much widespread adoption of health
information technologies, whether they be electronic health records on
the provider side or monitoring devices and personal health records on
the patient\'s side. But until we actually get much more widespread
adoption in the current environment, we\'re not going to be able to
really move to that transformational environment that we\'ve described.
So what in essence this is is trying to get a sense of if we do move
there what it could look like, but also recognizing that our immediate
work between now and probably 2015 is to really push forward at an
incremental fashion on widespread adoption of HIT. And for virtual care,
it means removing some of those big barriers in the five big areas here
and making sure we have enablers in these big five areas here at the
bottom of the page, the sustainable business model, the interoperable,
user-friendly, secure, inexpensive technologies. We have to really
address all of those in order to get widespread adoption of, in this
particular situation, remote monitoring and the ability to communicate
in a remote fashion.

That in a nutshell is what this vision is about. I\'m going to ask all
of you to read it very carefully and to comment back and there will be a
deadline of when is it, Wednesday of this week? Wednesday of this week.
So you\'ll have 48 hours to get back to us with any changes on this
document. We\'ll recirculate one last version on Wednesday and then it
will be something that will go to the American Health Information
Community.

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

Karen, can I make one comment? I read through this, and I think it\'s an
excellent summary of what we need to do, what we have been doing.
There\'s just one addition I would suggest, and that is we\'re making an
assumption that the information that we are now going to be able to
collect on a continuous more appropriate basis is the same type of
information that would be obtained in the doctor\'s office, and my
feeling is that it is not.

That it is much more valuable physiologic information than is what
presently is obtained in a single point in time by the doctor, from an
engineering standpoint it would be the ludicrous assumption that, okay,
I\'ve taken that blood pressure and therefore that\'s the blood pressure
that this person has 24 hours a day. And that\'s ridiculous. So I think
what we\'re talking about is much more valuable information, more true
physiologic information than what we presently gather.

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

Very good point. I\'ll definitely add that.

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

There\'s a book that \-- I forget his name \-- venture capitalist wrote
recently \-- I want to say Kaufman, that\'s probably not right \-- and
it\'s about, it\'s a futurology deal about health care. It\'s the idea
of dis-intermediating the provider system scanner of the future, put
yourself in, lights up, what\'s wrong, put the information in on the
Internet and you get the pill. It\'s intentionally out there to poke
everybody. But I think this is, you know, this is a milestone, or this
is a lodestone in that road. You\'re going to need a doc, Dr. McCoy on
Star Trek, but still there\'s something there. The future will bring a
variety of applications. It will allow direct consumer health care.

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

That kind of system, by the way, apropos about your contract is being
looked at NASA now in terms of deep space flight.

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

I don\'t doubt it.

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

I think the point you\'re making too is technology is going to continue
to increase geometrically so a lot of the things that we\'re just
talking about today are going to be much further along the way 10 years
from now or as this is 8 years from now.

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

You can predict there\'s going to be a disruptive event or several along
the way.

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

So in a way we may be looking at this too narrowly.

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

Thank you very much. Again we\'re not married to anything on this page,
so red, edit it to your heart\'s content this is just the straw man
proposal so we can get this project moving and off to the AHIC. So thank
you all. And if I might the only other thing I would add is that there
will be on the Web and available to everyone a document by Paul Tang
that was shared by him at the Consumer Empowerment Workgroup we thought
you would find interesting in terms of sharing information between
providers and patients. So that\'s available to you all as well.
Homework.

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

Is that then the end of the formal agenda, then, Karen? Can we spend,
since we have a few minutes left, discuss what will be the potential
agenda for the next meeting and building upon some of the items we
talked about today and also at the last meeting? I think you\'ve
mentioned two items. One I guess the AHIC will be looking at the virtual
care vision and the priorities. I\'m assuming it\'s one of the meetings
next meeting will be any feedback we get back from the AHIC on those
two.

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

Can I ask how that will be presented? Maybe you touched on this earlier
how will that be presented to the AHIC, will the chairs present or will
ONC present?

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

It will be the chairs, Craig.

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

This is Colin.

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

Colin.

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

I think I will be Craig at the next meeting.

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

I don\'t sound at all like Colin, by the way.

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

I can\'t comment at this point.

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

The answer to your question, Colin, is yes.

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

Okay. So there will be presentations and will that go after the
Workgroup ahead of time for people to look at if there\'s any comment
then? So we\'re looking at Wednesday then, we\'ll have to put the
comments in on the virtual care. Priorities document then, go out to the
Workgroup at the same time?

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

Yes.

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

So then the next meeting, just continuing on this, we\'ll have a
discussion of the feedback from the AHIC on those two items. I guess the
second would be or the third, if we want to go that way, would be the
discussion about the tie in into this group and Consumer Empowerment
from Kelly Cronin or someone from that Consumer Empowerment group so we
can start looking at ways that our two groups would be able to at least
complement each other more. And another area that we talked about today
is the demonstrations and the criteria for demonstrations, which I guess
builds upon some of the discussion we had today as well. And then
fourth, if you\'re talking early next year, the broad charge letter
needs to go out, then I think we probably need to discuss the elements
of what will be in that letter. That seems to be to be four or five
agenda items just off the top of my head that based on last meeting and
this meeting we would need to address it at the next meeting, Karen.

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

I think that final document that we will work a little bit more on and
get to you in terms of are there any other gaps in terms of testimony
that we need, we will identify and perhaps we can ‑‑

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

That will help inform some of this other discussion as well, I would
think. Craig, did I miss anything?

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

I think that\'s my list.

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

I think we\'re allowed to end early if we\'ve gotten our work done.

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

We do have to approve the minutes of the previous meeting at some point.

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

That\'s correct.

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

So move.

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

Second.

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

Any dissent? So approved.

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

If we\'re ready to go to public comment I\'ll point out you\'ll see the
call in number and instructions on the screen for making a comment. If
we have members of the public who are already dialed in listening to
this meeting over the phone, you need only press star 1 on your phone
and that will get you in the queue to make a question. We\'ll wait about
one minute for people to work their way through the operators and into
the comment queue.

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

Tracey you\'d like to make a comment?

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

I would. This is Tracey Moorhead, Disease Management Association. I
would like to say I\'m continually impressed by the amount of work being
done by the staff and members of this Workgroup. And I very much
appreciate the job that you have to better inform and to develop
recommendations for expanding the use of health information, technology
and chronic disease care. And I would like to say you look at gaps in
testimony, I would very much appreciate the opportunity for a
representative of the Disease Management Association, particularly one
of our Disease Management Association, to provide testimony on some of
the ways they\'re adopting and implementing HIT in the delivery of these
services. I think that that is one existing gap in your testimony
roster.

Finally, I would like to say as you develop recommendations and criteria
for future demonstration projects I do believe this is another area that
DMAA members can be of great assistance to you. We have members
participating in a number of CMS demonstration projects and also at
Medicaid demonstration projects and current Medicaid chronic care
management programs at the State level. They have experience with
special needs programs and with the medical support program and with
previous demonstration project such as the BIPA demo.

We would be glad to share with you the experience developed through
those programs and hope that we will have the opportunity to do that and
also to provide comment on the criteria as you are developing them. And
as I referenced earlier, I\'ll be glad to pull some of the recent
articles that have appeared in our peer-reviewed journal *Disease
Management* and provide those to the Workgroup for their review.

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

Thank you very much

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

Thank you very much, Tracy. Matt, anyone else want to comment at this
time?

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

No, we have nobody over the phone.

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

Okay. Then Craig I\'d move for adjournment.

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

I second your motion.

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

Okay. Thank you.

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

Thank you all for joining us today. Very much appreciate your input.