American Health Information Community

Electronic Health Records Workgroup #1

Tuesday, January 31, 2006

**Disclaimer**

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

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

As we get started, I hope people have had a chance to go through some of
the material. We in fact have both a narrow charge and a broad charge
for the workgroup. As I said, our task is formidable, and starting with
the broad charge, our task is to make recommendations to the Community
on ways to achieve widespread adoption of certified electronic health
records, minimizing gaps in adoption among providers.

The specific charge that is offered to us is to make recommendations
similarly to the Community, that in 1 year, provide standardized, widely
available, and secure solution for accessing current and historical
laboratory results and interpretations, deployed for clinical care by
authorized parties.

Today we\'ll go through some introductory material, we\'ll have the
benefit of having a business use case presented to us by members of the
AHIC and ONC staff, and we will set for ourselves some goals and
milestones in making measurable progress towards our 1-year deliverable.
I should note that when flipping through the preliminary material that
we have do-outs quarterly, so we are really bound to a very tight
timetable in the aspirations or ambitions. But I think we have
tremendous talent in the group and will have the ability to work with
colleagues as well, and we'll get more into the technical aspects of
that.

I\'m going to stop at this moment and ask my Co-chair if she has any
comments and recommend that we take a quick spin around the group just
to perhaps provide a little bit of introduction to each other as we
form, emulating what we hope will be one of the products of our group,
advanced technology to provide improved health care, but in this sense,
to make communication possible across the distances that separate us. So
let me turn to Lillee Gelinas.

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

Hi. And Jonathan, thank you so much. It is really a pleasure and a
privilege to be a part of this enormously important work. I work for
VHA. I know Jon is smiling, the other VHA, and he and I have been
talking offline about how to make best use of our time on this very
urgent task that we have at hand. And I want to underscore what Jon just
said, and that is the notion of urgency.

As we review our charge, as we look at who is comprising this particular
workgroup, you can see that the members of the workgroup represent a
very broad segment of the various interests which have to be brought
together in order for our task to be successful. And I really do want to
commend the staff for the work that they did in pulling together the
workgroup in such a short period of time, with such a spectacular group
of workgroup members, who I have every confidence in the world will be
able to achieve the very aggressive timeline that we have in front of
us.

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

Lillee, if I could just let -- just jump in for a second, I\'d like to
let the group know Secretary Leavitt has joined us. And Mr. Secretary,
you have an open line, and you can go ahead with comments whenever
you\'d like to.

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

Go ahead, Mr. Secretary.

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

Hello?

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

Hello.

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

Is this Dana?

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

This is Lillee Gelinas.

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

Hi, I\'m calling for the workgroup.

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

Good afternoon, Mr. Secretary. This is Jon Perlin, and we have the
members of the electronic health record workgroup all assembled.

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

Thank you, Dr. PERLIN. I know that you have a great deal of work to do,
and I don\'t want to take a lot of time. I did want to just tell you how
appreciative I am of the level of effort and to ratchet up the urgency
that I\'m feeling to see progress on these, and I know you\'re feeling
the same way. And I just wanted to let you know I\'m conscious of your
work and appreciative of it and anxious not to get in your way. But
wanted you to know how much I appreciate the effort that\'s being made.

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

Thank you.

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

Lillee, thank you so much for your effort on this -- you\'ve been a
champion -- and Dr. Perlin, for your effort as well, and for all the
members of the workgroup. I very much appreciate the progress that\'s
being made, and in this particular area especially.

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

Mr. Secretary, I think we speak in unison: we appreciate your support
and leadership and feel that you\'ve given us an extremely important and
urgent charge to speed the adoption of electronic health record, and we
hope to bring you our very best advice as soon as possible.

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

Thank you. I\'m looking forward to a report on your deliverables in
March, and I\'m optimistic that you\'ll have an exciting agenda to lay
out.

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

Thank you very, very much sir.

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

Goodbye.

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

Thank you. You know, Jon, it strikes me, something you said: no issue
can be addressed without successful leadership, no matter what that is,
whether it\'s taking care of the patient of the bedside or implementing
a task such as we have in front of us. So we are very grateful and very
fortunate to have the Secretary\'s tremendous support across all of our
work.

And I want everyone on the phone to understand one key word that the
Secretary just said: deliverable. As we\'ve all said, we\'ve got the
talking part done. We now need to move to what it is that we\'re going
to be able to achieve.

So as I look at the agenda, Jon, I want to make sure, before we go into
our in-depth review and charge into defining scope, and Matt, maybe you
can help with this as well, but do we have all the call-in procedures
completed, and do we now need to do a roll call so all the participants
know who is here?

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

Yeah, we can do both of those right now. Let me start with the call-in
procedures, then I\'ll ask the operator to open the members' lines, and
then we\'ll take a roll call.

First, for the call-in procedures for those of you who didn\'t hear it
when we went through it the first time, members of the workgroup, you
all have your lines set to "Listen Only" during the conference. Which
means that if you\'d like to ask a question or make a comment, you need
to press star 1 on your phone. That will put your name in a queue from
which we can recognize you and open your lines for comment.

If while you\'re waiting in the queue you feel somebody has asked your
question or it\'s no longer relevant, you can press star 2 to take your
name out of the queue.

The only other piece of important technical information is, I would ask
all workgroup members who are logged into the Web interface not to
change the slides on the display. We\'re all looking at the same
interface, so if you change the slides on your side, everybody is going
to see them change, as well.

Operator, would you please open everybody\'s lines? We\'re going to take
a roll call now. And I would just ask the workgroup members -- and
operator, only open those lines which are members of the workgroup, not
public lines. And I would ask the workgroup members to mute the phones
on your end just so we can cut down on background chatter as we take
roll.

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

If you don\'t mind, what I\'ll do is open each person\'s line manually
when you call on their name, and then I\'ll close it.

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

We can do that. Carolyn Clancy, please?

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

Just a moment. Carolyn, your line is open.

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

Yes, I\'m here. Can you hear me?

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

Yes, we can.

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

Okay, thanks.

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

John Houston, please.

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

I am here.

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

Okay. Dr. Blackford Middleton?

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

Good afternoon.

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

John Tooker, please.

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

The line is open. John, your line is open.

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

Yes, here.

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

Pam Pure.

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

Pam, your line is open.

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

I\'m here as well.

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

And Dana, I believe we have some members of the workgroup live in
Humphrey Building with you.

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

Howard Isenstein for Federation of American Hospitals.

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

Jason Dubois with the American Clinical Laboratory Association.

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

Bart Harmon with the Department of Defense.

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

And those are the members that we have from here.

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

And that\'s it for workgroup members that we have on the call right now.

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

And then from my side, just some things: all the workgroup members have
been -- should have been sent and received an agenda, a contact list, a
milestones document, and a briefing document. And those will be
discussed throughout this meeting. I\'d also like to acknowledge Karen
Bell, who is the Office of the National Coordinator representative, who
will be a primary point of contact for this workgroup and will be the
link into the agency as well as the coordinator for the deliverables,
working closely with the Co-chairs to make that happen.

We will have, at the conclusion of the meeting, a time for public input,
so please note that, and the last thing that we\'d like to do is --
comments are only reserved for workgroup -- designated workgroup
members. If you are a workgroup member and you find yourself having to
leave in the middle of the call, please indicate that to us and who your
designated representative is. That way, we can go ahead and then let
that person speak.

With that, I\'d like to defer to the Co-chairs, and welcome each of to
you today\'s call.

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

Thank you. And Matt, just for a clarification, we only have two
workgroup members that are not present today. If I heard the roll call
correct, that would be George Lynn from AHA and Barry Strobe from CMS?

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

That\'s correct.

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

Okay. Okay, Jon, it looks like we\'re into the meat of this, huh?

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

I think we are. Many of us know each other professionally, many of us
know each other through -- in and around the community, but we have a
formidable task ahead of us, and we\'re going to have to work very
closely despite the distances that separate us. I wonder if, at the risk
of the exercise that we just said, it wouldn\'t pay for all of us to
offer perhaps 30 seconds on sort of their interest and association, both
electronic health record, this task, the community, and perhaps the
first business use case on laboratory systems

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

I agree. If we could ask the operator to open the line again, and
starting at the top with Carolyn Clancy.

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

Carolyn\'s line is open.

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

Oh, great. Good afternoon. I\'m Carolyn Clancy, I\'m an internist, and I
direct the Agency for Health Care Research and Quality. And our focus,
not surprisingly, is on improving quality and safety in health care. We
have a fairly robust portfolio of projects that examine how various
applications of health information technology, including health
information exchange, can effectively help us all get smarter about
improving quality and safety and doing so in an efficient manner. So
we\'ve learned that there is a whole lot to learn about effective
adoption, and there\'s many ways to do it badly. So I\'m really very
excited about being a part of this.

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

Operator, will you please open John Houston\'s line?

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

Hello, this is John Houston.

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

Go ahead.

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

I sort of wear two hats here, first being I\'m a member of the National
Committee on Vital Health Statistics, and probably the role I play on
that committee, and probably here, too, is I work with privacy and
security. And hopefully, I can provide a lot of help in that regard. But
I\'m also -- I work for the University of Pittsburgh Medical Center, and
as such, we\'re a very large integrated delivery system that is very
progressive in its use of clinical information systems and is deploying
EHR solutions across our enterprise and has made an enormous commitment
in that regard. So I think I can also provide a lot of practical
experience with regards to the deployment of EHRs and how that might,
you know, impact -- how that deployment might be used as a -- you know,
a catalyst to understand how to deploy them in other areas.

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

Operator, would you please open Blackford Middleton\'s line?

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

Good afternoon. Can you hear me?

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

Yes, we can.

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

Hi. It\'s a pleasure to be a part of this esteemed group and have an
opportunity to contribute to something. I\'ve been banging my head
against the wall for almost 20 years at Partners HealthCare, the
Corporate Director for Clinical Informatics R&D, and responsible for
clinical systems development and implementation here.

We have an EHR now in use by about 4,000 docs and a patient portal now
in use by about 25,000 docs. Prior to coming to Partners, I was the
Senior VP and Chief Medical Officer at Medicologic, which is now owned
by GE Medical Systems, and built the EHR system there, logician. And
this year, I currently serve as Chairman of HIMSS, and I\'m Chair here
at Partners HealthCare at the Center for IT Leadership. Very happy to be
part of the group.

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

John Tooker, please.

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

Can you hear me all right?

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

Yes, we can.

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

I\'m the CEO of the American College of Physicians. I\'m also an
internist, and the leading agenda items for ACP are quality improvement
and how that might happen, including the adoption of health information
technology.

I am a commissioner on CCHIT and, along with Carolyn and others, are
engaged in the Ambulatory Care Quality Alliance, which recently added to
health care technology subcommittee to its charge. So I think there are
some solid opportunities here, and I also look forward to participating.
And thank you.

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

Pam Pure, please?

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

Hi, this is Pam, and I\'m also really thrilled to be part of this group.
My current responsibilities at McKesson: I\'m responsible for the
information technology business and the automation business. My
background is, I\'ve been in health care about 23 years, and I actually
spent the first 15 years implementing systems, and in addition to my
operational responsibilities, I have a personal passion around health
care adoption. And I probably spend 20 to 25 percent of my time right
now working with organizations that are in the process of implementing
electronic health records, and work very hard to keep a diverse group,
so I cover some academic medical centers, some large public
organizations like Triad and Iasis and a number of community hospitals
spread across the United States. So I\'m really thrilled to be part of
this group.

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

Dana, why don\'t you go to the workgroup members that you have in the
room with you?

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

I\'m Howard Isenstein. I\'m here on behalf of Chip Kahn and American
Federation Hospitals. We\'re thrilled to be on this EHR group, as well
as the community, and two of our key interests are using EHR for quality
reporting, for our member hospitals, as well as helping the voluntary
physicians adopt electronic health records.

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

Hi, I\'m Jason Dubois. I\'m the Vice President of Government Relations
for the American Clinical Laboratory Association. We represent
independent clinical laboratories throughout the country, such as Quest
and Labcor, and we\'re delighted to be taking part in this effort.
Importantly, lab information is some 60 percent of electronic -- or any
medical record, for that matter, and so it\'s kind of -- it\'s obvious
that this is the first step for the workgroup to be looking in terms of
functionality for the EHR, and actually it\'s been in -- surveys is the
most sought-after functionality amongst many practicing clinicians.

And looking at the briefing document, I think the work we\'ve done --
and Dr. Tooker didn\'t mention, but he\'s also a member of the steering
committee much like myself of the E-Links project, so I think that
particular endeavor is going to help provide a bulk of the basis for the
work that the EHR workgroup does.

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

Hello. Colonel Bart Harmon here with the U.S. Department of Defense.
I\'m a physician, a pathologist, trained in medical informatics, and
I\'ve been with the Department of Defense working as part of the
electronic health record project for the department for about the last 8
½ years. I currently also Co-chair a NATO expert panel, the medical
communication and information systems panel for NATO. So just as time
goes by, a number of groups are very interested in this same topic of
sharing health information nationally and internationally. It\'s very
exciting to be part of this group, and the department looks forward to
what can come out of this, because we definitely need electronic health
information back in the community when we purchase health care on the
economy, which we do quite a lot of. It\'s a pleasure to be here.

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

Okay, Lillee and Jon, that\'s the group.

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

All right. Jon, you know, one thing that strikes me as we do that round
robin there is the notion of alignment, and it\'s not just alignment of
purpose, but it also seems to be that the members of this workgroup are
aligned around exemplars, because each member of the workgroup brings to
the workgroup excellence and activity in their particular field. So I\'m
very encouraged by the talent that we have assembled here. The last
thing we need is duplication; that\'s for sure.

Jon, should we move on now to the use case substitution?

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

I think that would be good, unless you want to say a couple words, a few
words about yourself for the group as well.

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

Oh --

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

But you\'re going to skip that.

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

I knew you were going to do that. Hello, everyone. My name is Lillee
Gelinas; I am a nurse; I\'m a master's-prepared nurse; I am Vice
President for clinical performance here at VHA at our corporate
headquarters in Dallas, TX; and I am also the Nurse Executive for VHA,
responsible for a lot of our nursing activity across our system. We
represent 2,200 health care organizations with 1,493 acute care
hospitals. One-fourth of all the registered nurses in the United States
practice in our organizations, so the amount of accountability that I
feel on my shoulders is great.

I have a personal interest in the success of this particular task. Jon
and Dana and those close to me know that I am a native New Orleanian,
and I saw the havoc that hurricane Katrina wreaked. And Jon, I think we
heard it was 1,600 physician practices and dental practices that went
under water. And I know the urgency that we felt personally around the
need for medical care with no medical records; it really upped the ante
around being asked to serve in this capacity.

So I do consider it an enormous privilege. Hope to bring that front-line
nursing perspective to the table, but also have just some tremendous
personal interest in making sure we\'re successful, so we don\'t
duplicate what happened in the aftermath of hurricane Katrina as it
relates to the electronic health records.

And Jon, what about you?

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

Turnabout is fair play. I\'m Jon Perlin. I\'m going to refer to myself
as being from the Department of Veterans Affairs, lest there be complete
confusion around VHA. But as most people in the group know, is that we
are a virtually entirely electronic environment. We consider our
practice across 1,400 sites and 200,000 direct employees and other
quarter million trainees, volunteers, affiliate faculty, etc. 98 ½
percent paperless. So I, like many of you, I hope, represent a point of
hope, of optimism, that this task is not only achievable but achievable
in the near term.

I think one of the important aspects of our presence is that we in
Department of Defense are building toward greater interoperability, and
that of course is part of our task, and one of the prerequisites for the
President\'s vision to be ultimately fulfilled of making electronic
health records available to most Americans within 10 years based on
executive order actually of this past year.

And we have -- segue, here -- we have before us a very formidable task.
There are use cases -- it\'s not an accident, that we have -- and very
appreciative of additional representation in the field of laboratory,
specifically. As we go through the cases that will be presented by the
OMC staff, let me just add my thanks to the ONC staff, to Dana and to
Kelly and Dr. Karen Bell for all the assistance with this workgroup.

I think we want to take a look at labs in particular in terms of it
being one of the areas that in fact does exist, at least in its primary
form in, as electronic data, and then in the contemporary environment
finds its use among practitioners in certain environments, also in
electronic form. But in 2006, still finds its way to the use of
providers and patients in paper-based forms transmitted by any number of
fairly antiquated, noninteroperable means. Ranging from fax to snail
mail, etc.

And so as we go through the use cases and we come back to these
questions -- what are some of the lessons we might learn, both from the
specific use case; what might we learn specifically from laboratory; and
a bit of an early-adopter effect in terms of this particular domain of
health care; and as we move over the course of the year toward our
broader task, what might have been done differently; what serves as a
facilitator to overcoming barriers that might have been identified to
broader uptake.

So a large charge ahead of us, a focal area immediately ahead, in the
business use cases. And I\'ll turn back to Lillee, not only for the
introduction -- additional introduction of the cases, but rather than
bouncing back and forth today, for the rest of the discussion.

And at 1:45, I\'ll just let you know that I\'m proud to say I\'m here
with Linda Fischetti, a Nurse Informaticist, who is really a right hand
and copilot and leader in informatics but will be stepping in as we
begin our budget hearing season and, unfortunately, our first event this
afternoon. So I\'ll be on until about 1:45. Lillee?

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

Thank you. And Jon, we do need you in the budget hearings; thank you
very much. We need you to be successful with that. So Linda, many thanks
for stepping in as well. And I was enormously impressed with the report
that you gave at our first AHIC meeting around how the Veterans
Administration has been able to do what has been done in this area, and
I just want to underscore one segment that Jon said, and that was that
this task is achievable.

If we want to move, now, to the review of the use cases. And I believe
some of the ONC staff are going to tee this up for us.

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

Thank you very much, Lillee. This is Karen Bell. And again, I will add
my gratitude to everyone else\'s and express how excited I am to
actually be able to be involved with such a group of people to really
move the agenda forward, and we will really accomplish something by the
end of the year.

In order to do that, however, we are going to have to move very quickly
into a very focused modus operandi, and the intent of this particular
briefing document is to essentially help you all get there.

Now, you\'re very familiar with the broad charge of the workgroup. David
Brailer has just joined us. Hello, Dave.

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

Hi.

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

You\'re also familiar with the broad charge for the workgroup as well as
the specific charge. But as they said many times, the devil is in the
details, if one looks at the specific charge. What exactly is meant by
"historical"? What is meant by "interpretation?" Who are authorized
parties? What is meant by "widely available"?

The really crux of your deliverable for March 7th will be to be able to
characterize exactly what this looks like, what is this charge at that
level of detail. And in order to do that, we\'ve put together this
document to essentially be a conversation starter. We worked with a
number of our contracting partners and offered them to essentially do a
use case around this particular project. And while this is not the full
assessment of that work, what they did provide us with are a couple of
things. Number one is a list of all of the entities that we need to take
into account as we move forward with this project. And that\'s involved
in the listing of who is involved in making this happen, which you all
have.

The second was that we got quite a bit of information in terms of what
is already being done, and I\'m not going to talk very much about the
E-Links project, because we have an expert in the room with Justin, who
I\'m sure can help us in that area very shortly.

But what I would like to concentrate a little bit on are what are the
questions that we have at the end. These were designed, again, and with
the help of the participants in the use case process, to help us focus
on exactly what it is that will be recommended to the Secretary on March
7th. What will this project look like, and who will be involved in it?
How will it be scoped out for a particular population or particular
group of providers?

The other begins the discussion of the kinds of questions that you will
be asking yourself about how -- about what can be done to eliminate some
of the big barriers to move forward. So the other -- and those big
barriers can be addressed at a later point in time if you can at least
outline what those issues can be for the March 7th, then you will have
met that deliverable.

So again, this discussion and these questions are really geared towards
beginning that approach and beginning the discussion on the
recommendations on what will this project look like, who it will
involve, where will it be involved. And lastly, what are the big issues,
and what are the big barriers? So that is the thumbnail capsule summary.
And with that, I\'ll turn this back over to you, Jonathan and Lillee.

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

So probably some of the best use of our time right now as we\'re jumping
into this is to talk about modeling the project. Would you agree that
that\'s the best place for us to start now, with some discussion around
that?

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

I think I absolutely agree that would be a good beginning place.

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

Because it really strikes me, this first question, "What is the most
efficient and effective model for electronically transmitting lab
information?", and understanding that we should really address the model
policy aspect of this, and it\'s my understanding we\'re not to be
getting into the technical infrastructure or standards conversation; is
that correct? This is more about the model?

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

Yes.

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

Okay. And I don\'t know the best way to be engaging the members of the
workgroup, here, given the phone lines' peace. Forgive me; as we have
these meetings, I\'m sure this will become much more seamless, but it
strikes me we need to be having workgroup conversations here, and I
understand their lines are muted.

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

Lillee, whenever you\'re ready to open something up to the workgroup
members, just announce that to all of us on the call, and workgroup
members can start buzzing in by pressing star 1 on their phone, and
I\'ll let you know as soon as they begin to queue up.

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

That would be great, because I\'d like to begin this conversation around
the most efficient and effective model for electronically transmitting
lab information. And let me just wait a minute for those of you to chime
in. Dana, are those of you there -- I\'m sure Jason might be able to
start us off, as well.

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

Obviously, in the briefing document, you heard what\'s been done
already. Well, you can see some of what\'s been done already, with the
E-Links project, which was all started at the behest of Dr. Brailer a
little more than a year ago. And as you can see, it\'s developing a
national standard for the delivery of real-time lab results.

I can say that the first version of that, version 1.0, has been
accomplished. It encompasses 80 percent of the 100 most commonly
performed tests under the clinical laboratory fee schedule. And that
particular standard specification was included into the certification
commission for health information technologies, ambulatory EHR
certification.

The second stage of that process is version 2.0, which will encompass 95
percent of the 100 most commonly performed tests. And the technical
workgroup -- and I should say that that\'s been a very consensus-driven
process that included folks from Department of Veterans Affairs, from
CMS, from HIMSS, from AHIMA. It\'s really been a cattle call, for lack
of a better expression, for wide participation. And they\'ve just
finished going over public comments on the latest specification, so we
hope to be finished with that shortly.

I also can report February 6th, the California Health Care Foundation is
helping to shepherd this effort, is actually going to be awarding five
grants, and they will be named February 6th. And it\'s basically going
to pilot-tech the E-Links specification. And again, they\'ll be
announcing the recipient for those grants on February 6th.

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

Jason, what do you think, given the E-Links project and how important
that is? And that group is really dealing with the technical aspects,
correct?

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

That\'s right.

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

What do you think is the most important charge for us as a workgroup,
given that the technical aspects are being handled by those who are most
appropriate to handle them?

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

I think one of the things I have to come to grips with is that
laboratory information is provided in not just independent clinical
laboratories, but there are other sources of that information including
hospital laboratories, and what we in the industry like to call "small
mom and pop shop"-type laboratories that are more regionally located and
also physician office laboratories. And so there has to be some means to
help incorporate all of that information, because the way that all those
different sources contribute a pretty significant amount, there\'s no
single sector of the population that\'s contributing, you know, the
overwhelming majority of the laboratory data. But I don\'t know that
that\'s the model, but maybe that\'s more a concern that has to be
addressed.

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

So coming to grips with that. So maybe John Tooker from the American
College of Physicians could help us with that. That\'s very true; there
are a number of physician practices who have their own labs.

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

Operator, please open John Tooker\'s line.

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

One moment. John, your line is now open.

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

I think Jason said it well, with version 1 already going through the
first round of the pilots for certification of electronic health records
and version two just having, I think, Jason, completed its period of
comment. And when you actually look at the comments, it really is quite
technical.

But then when you look at the landscape of what we\'re trying to do, to
get every physician practice engaged in a two-way exchange of
information to both receive laboratory information from laboratories
outside of their practice, but also being a provider, and a set of
information to inform others is a substantial challenge. And current
demographics are that 50 percent or more of internal medicine practices
are five or less, and 20 percent of those practices are still solo
practice.

So you have to find a way to get to the majority in the beginning, but
ultimately to everybody, if we\'re going to achieve our goal. And it\'s
not only the ability to exchange this information but to do all the work
that everybody has already talked about for quite a while, of getting
electronic health records into these practices, and the very large
cultural changes to allow physicians to begin to use this information.

But I\'m impressed with the California Health Care Foundation, with the
pace at which they\'ve been moving and the discipline that the technical
workgroup has been moving to get this work done, and I think the pilots
will be very helpful to us and more in the practice field to begin to
demonstrate how it can be done.

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

Dana, I wonder if just in a future workgroup session we can have someone
from the California Health Care Foundation talk to us and give us a
sense of how they\'ve been able to move rapidly, do what they\'ve been
able to do, what cultural attributes they\'ve been able to address.
Because clearly, they\'re leading the pack.

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

Okay, we\'ll be happy -- we\'ve noted that, and we\'ll make sure that
happens.

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

That would be great. And John, if we were going to make a recommendation
to the Secretary around strategies for adoption, in this area of the
current demographics as you described so well, I know that ACP has
certainly had discussions around this. Are there some things that we
could be discussing here now, around this notion of physician practice
adoption?

And Dr. Brailer, I heard that you had joined us and I\'m so glad you did
chime in, as well.

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

Thanks, Lillee. And in fact, I\'ll just take that as bait. But I have a
factual question for Jason before I comment. What\'s the end date for
the grant? When do those projects have to deliver results?

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

Actually, I\'m not positive about that. I know that they actually have
to start, and they\'ll be up and running long before the end of the
year, so I think it may actually only be a year-long contract.

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

To me, I think, Lillee, the question here, in a way, is if this group
decides, after it does its due diligence, that building on and
supporting the E-Links efforts, which we in my office have had cause to
take a look at and are pretty happy with both the process in terms of
all the different stakeholders and level of public dialogue and
transparency, and the results in terms of coming up with some obvious
things as well as some things that are really somewhat elusive task --
the question here is, should we try to just take that and expand it
under the name of this project or to build a whole separate layer of
adoption on top of it, regarding some of these physician workplace
issues? And I think that\'s a strategic question this group needs to
deal with.

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

Uh-huh.

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

But I certainly hope, if you go back and try to decide you have to
reinvent the wheel or bypass E-Links, that there\'s a very good reason
for it, in the sense that there\'s really been a lot of investments in
it already.

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

Did you say "bypass E-Links"?

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

If you decide -- the group decides that there\'s just cause to not use
it or take advantage of it, that it does so in a way that makes people
understand what that means. I\'m not suggesting we do that; I\'m just
suggesting that to the extent we do, we stick with this and build on it,
but I don\'t want to presuppose that. I think the group has to validate
that and decide for itself. But hopefully, we view this as we figure out
what we can do to build on top of that, to really take it to the next
step in a way that -- that the current effort can\'t do because of its
relatively narrow focus on getting the technical decisions made.

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

That\'s a great idea.

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

David, this is Jon Perlin, I might jump in. I heard you say "doing due
diligence on this," and given the format of this group, the desire to
come to consensus, would hope to hear any comments from the workgroup
members, particularly individuals from the vendor community as well. We
haven\'t heard from Pam, for instance, yet. But also, others who we
believe are joining us either by audio or Web links. And Dana, we might
ask for comments on ways which individuals might provide comments to the
workgroup, so we can ultimately present the Secretary with consensus
recommendations.

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

Dana, would you like to speak to the public comment issue?

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

Jonathan, the way we have the call set up right now, members of the
workgroup can buzz in with star 1 whenever they want to make a comment.
When we\'re done going through the agenda today, the last item we have
on there is public comment. And at that time members of the public can
call in with a similar procedure and engage in a dialogue with the
Co-chairs and the workgroup members who are on the call.

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

I\'d like to call on Blackford Middleton, if I could. When we were
introducing ourselves and you noted the scope of your work in the
Partners HealthCare system, and the electronic health record being
adopted by 4,000 physicians, if I got that right, perhaps you can give
us some perspective, here, on what we should be considering and
recommending to the Secretary around adoption.

And I get a sense we\'re all struggling. You know, the technical stuff
is fairly easy to -- you know, easy in a broad sense, but this seems
like we\'re talking about the much bigger and broader challenge of the
cultural changes that have to take place for physician without EHRs to
be able to adopt on a grand scale. So can you enlighten our discussions
here based on your experience?

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

Sure. Am I online now?

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

Yeah, we can hear you.

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

Thank you for the question. You know, the good thing about Partners
HealthCare is the commitment to IT and the infrastructure has been very
solid for a long time from the top. And I think that actually, in a
setting, you know, prior to just recent years, in fact, prior to there
being any kind of economic reward for such investment on a financial
basis, clearly some of the work here has shown reward on a clinical
basis in terms of improved reduction in medical errors, and serious
adverse drug events, and things like that.

But it\'s only recently that I think we\'ve seen perhaps the table
turned in the sense that there now is an economic reward on the table
for EHR adoption in Massachusetts. Our payers here, you know, are very
interested of course in value-based purchasing or pay-for-performance,
call it as you like, but they are significantly incentivizing the
physicians to adopt EHR. And in that window, there\'s only a window of
opportunity for that incentive. And then they are being rewarded --
physicians are being rewarded for their implementation and use of EHR to
achieve quality benchmarks.

So this incentive has been perhaps the most powerful force locally,
beyond the sort of the legacy and historical intent here, to drive IT
adoption, and to cause us to drive IT adoption to every end and every
corner of Partners HealthCare.

I think that is one of the major issues that we\'re going to have to
confront as a workgroup, along the lines of the cultural issues, are the
professional and workforce issues. And frankly, I think there are
technical issues which I would not sweep under the covers. I\'d love to
hear much more detail about the projects under way in the E-Links and
the like. But I think the financial issues, you know, first and
foremost, are going to have to be addressed at some level with very
considerable national leadership and or policy moves that help make this
make sense for the average doc. I mean, if you know about the work from
the Center for IT Leadership, where we\'ve done some pretty deep and
thorough analyses of the value of different kinds of IT and the return
on investment associated with adopting IT in sort of different sets.

One of the earliest projects we did was on the value of ambulatory CPOE.
And just looking at CPOE in the ambulatory context, i.e., looking at
CPOE in EHR, in ambulatory care settings including the small office
environment, the mid-size office, and large office context, we find
there\'s a huge misalignment of incentives. That is, according to our
model, and it is a model, but according to our model, that the
physicians who are largely being asked to foot the bill for EHR adoption
are not the ones experiencing the majority of the benefit.

To put a number on it, we found that when -- when you look at the
benefits distribution, physicians under an assumption of 11.6 percent
national capitation across the land, which is a realistic assumption for
the 2003 time frame, under that assumption physicians were experiencing
approximately 11 percent of the benefit of IT adoption, and the other
stakeholders, payers principally among them, were experiencing 89
percent of the benefit.

The many physicians in my own environment here, even in Massachusetts
where there\'s sort of a groundswell for adoption, are really looking
for there to be, you know, a material or financial incentive of some
kind. I think that\'s something where we as a workgroup can say
something has to be done either in a direct mechanism or indirect
mechanism to help stimulate IT adoption.

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

So if payers are getting 89 percent of the benefit, clearly there is
misalignment.

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

Correct.

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

So to tease out the obvious, here, what is the policy change that needs
to be made?

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

Well, you know, I\'ve written a couple of things on this. I\'d be happy
to share with the workgroup, and have you all dissect them and critique
and please help refine. But, you know, some of the policy suggestions
have been on the order of providing both access to low cost capital to
get over the adoption hurdle. One of the things I think we need to tease
out is what exactly is being adopted. Is it a full-blown EHR, or is it
simply a browser mechanism to view labs off a lab system in some
convenient way? Both do have value, but obviously the hurdles are very,
very different.

So one idea is this low-cost access to capital to get over the IT
adoption, whatever form it is, but then there\'s a serious issue of how
to maintain the adoption, if you will, how to reward ongoing use or to
incentivize use. And I think those are what we\'re experimenting with
here, are programs that of course pay for performance or reward
attainment of benchmarks and the like.

But those are very early, and they\'re not widespread, but something
like that I think we need to consider.

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

What\'s the incentive, the Massachusetts incentivizing component? And
you said that that\'s been your most powerful force?

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

Yeah. Right now, some of the major payers here are offering a one-time
capital payment to the physicians who are adopting EHRs, to the groups.
And as I said, this is a window which will close after some predefined
period of time. I think we have about a year to go, in fact. I don\'t
have the details on the numbers or the time frame or which payers are
doing what exactly on my fingertips, but that is the first part of it.
The second part of it is payment for performance for attaining
predefined quality benchmarks in the routine kinds of things, asthma
care and the like.

Interestingly, though, the payers were ultimately interested in
assessing or paying for, you know, demonstrated use of EHR -- that\'s
another wrinkle, I think, on this. You might suggest we can enable
laboratory access and the like, or perhaps even adopt EHR, but the
question the Certification Commission is going to address is, "What is
EHR at a level?" But then a second question arises: "How do you know
when you\'re using EHR to a sufficient degree? Does it have an order
entry system, a medication prescribing system? Does it have decision
support on both those features that actually warrant a differential
payment?" That kind of level of analysis is something else that needs to
be considered as you consider putting money on the table, frankly, I
think, to incent docs to do it.

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

As an idea, I wonder if it might be useful very quickly, at least as
much as we could, really tease out this use case that\'s happening in
Massachusetts around incentivizing physicians. And it strikes me, if
payers are getting 90 percent of the benefit, based on your research,
but at the same time payers also giving a one time payment to physicians
to adopt IT, would seem like a reasonable compromise to reaching the
tipping point to where we had a very large group of physicians that
finally were adopting.

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

Lillee, this is Howard Isenstein. Is it okay if I make some comments?

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

Please.

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

I agree with you, and with Blackford Middleton, on the -- you know, it
is about the money. What concerns me is that a lot of the payers on the
private side have done these pay-for-performance and
pay-for-technologies experiments the last few years, and they keep a
warning light that, "Hey, you know, we\'ve got to sort of stop with the
experiments and actually see the money. What\'s in it for me?" So I\'m
wondering if they might start getting fatigued about this without seeing
the payoff. That concerns me.

The second thing is -- so it would be great to have a private sector
payer give their perspective, say the Massachusetts Blues or someone
like that, what\'s in it for them when we do the use case for
Massachusetts.

The second item I want to talk about is, I\'m not all that familiar with
E-Links. I\'d love to learn more about it, but I definitely think we
should also have in there some alternatives. The things that come -- at
least some presentations, the idea that comes to mind, to me, is Office
Vista, and Vista as an ASP. That was sort of what Blackford Middleton
was talking about; this is sort of a Web-based application of Vista. And
you know, maybe it\'s the greatest thing since sliced bread, maybe it\'s
really not very relevant and it\'s not going to work, but I would like
to at least look at that. Because from what the -- what is being -- what
the touts say, it\'s a very low-cost way to get into it without a lot of
financial investment. So I\'d like to at least learn about it more.

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

I agree; that\'s a great idea.

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

Lillee, this is Linda. Dr. Brailer has charged us with doing due
diligence, so we can go ahead and put that on our to-do and report on it
on March 7th or at least the progress we\'ve done towards examining
due-diligence-related E-Links, so if there are any other topics which
need to be considered while we\'re going through the due-diligence
process, I suggest people bring those forward either now or at the end,
when we\'re in the end in the public comment period.

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

I have one to add to the list. It\'s Blackford Middleton. I guess if
we\'re looking for topics where research might be potentially helpful,
one of the things that strikes me is the current model of IT
implementation may not actually be the right model for broad-scale
adoption. I think a question arises as to, do we organize clinical
information management at kind of the local individual physician\'s
office or hospital setting, or even integrated delivery network, or is
it time to consider actually an implementation of a framework which
allows access across a region to relevant clinical information, in sort
of the RHIO context, if you will. If that were the case, then a
different model might actually be applied and we might actually be
considering sort of, you know, a different framework rather than
physicians' offices having to interoperate with a diverse number of
laboratory, regional lab systems, and the like. A physician\'s office
EHR might just have to interoperate with a RHIO. So I would suggest
there might be investigations we can do there.

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

Right. Any other comments on this one? Just refresh where we are on the
agenda, we\'re on EHR adoption barriers and facilitators. I think we\'ve
had some great discussion around especially the financial issues, and
some of the professional issues.

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

Lillee, it\'s David. Before you finish or wrap up, at some point, I\'d
like to make one side comment.

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

Sure.

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

But go ahead, though.

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

I was just trying to get us centered on where we are on the agenda.

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

Okay. One comment I have on the discussion that\'s transpired, which I
think is a very healthy way to begin kind of putting boundaries on this,
is just to go back to the nature of the breakthroughs. I think the
discussion that\'s been held is very much emblematic of the problem of
the whole uncut cloth of the EHR, and the significant wind resistance it
has with respect to misaligned incentives and a lot of other significant
long-term challenges in the health care industry.

The goal that we had, and you might deliver it back to us as not
feasible or not sufficiently clever, was to package something that\'s
much more narrow, much more aerodynamic, if you would. And by focusing
in on the lab result component, our thinking is that we can buy much
less resistance and be able to link a very specific change to a very
specific value and essentially decompose the EHR adoption into some
pieces to begin creating momentum.

Now, that\'s something this group needs to discuss and decide if it\'s
right. Hopefully it is, because this is the charge that AHIC has given
you. But you\'re your own, people, and you need to make your own
decisions. But the thing that I think follows from that is a very
obvious question, which is kind of the first question on this modeling
issue, which is, if the goal is to get laboratory information to
doctors, which is ostensibly what this is about, there\'s two ways to do
it. We can get the information to doctors in a way that promotes EHR
adoption by linking it to the EHR, where it could only benefit those
that have them in a place in the short term, or it could be a more broad
benefit such as a portal or some other way to deliver information.

It could be more challenging and work but much broader an adoption. Not
necessarily delivering a linear pathway for EHR adoption, even though it
certainly increases dependency on broader data and electronic
information.

This is really the core of the strategic question that was posed that at
some point we\'d like to hear some dialogue about, because I think many
of the other decisions you make over time will flow from that.

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

So David, this is really addressing at our very first AHIC meeting when
the Secretary used an analogy of a jigsaw puzzle; there\'s a lot of
pieces to the big puzzle. And it just strikes me that this narrow focus
is a piece of the larger puzzle.

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

I think that\'s right. In fact, you know, that discussion the Secretary
had was very much emblematic of our efforts then, as you recall, to go
back and begin identifying some very specific endpoints that we called
breakthroughs, and there were more than 30 of them that were explored.
And you know, clearly here, we don\'t have all the puzzle pieces on the
table; we\'re only biting off four, but each of the four breakthroughs
that we have put on the table touches a very different kind of
information and a very different kind of constituency or relationship.
So begin having leverage points for all of these. So I think that narrow
focus hopefully will empower you to really take bigger steps than we
could had we just said, "Let\'s go get EHRs in place; good luck."

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

Lillee, just to jump in here, we have some people from the workgroup
queuing up.

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

Great.

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

And just for all the other workgroup members, let me remind you one more
time, if you do want to make a comment, press star 1 on your phone to
get into the queue. Please open Pam Pure\'s line.

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

Great. Hey, this is Pam, and I agree 100 percent with what David was
saying and think we need to get some clarity around scope. Because if
our goal is just to return a lab result to a physician\'s office who
ordered that test, we may come up with a very different solution than if
the goal is when I show up in my physician\'s office, they have access
to lab data about me that may not have been initiated in that particular
office or not done as part of that particular encounter, especially when
you start talking about chronic disease and really being able to have
aggregated data on a patient.

I saw on the notes we\'re also talking about what happens when the
patient shows up in the emergency room. So it\'s not as much a
point-to-point, EHR-related, office-specific EHR related charter as it
could have been. So I think we need clarity around what the goal is --
that when results are obtained, they\'re always obtained online, or
there actually is an aggregate view of a patient that we provide as part
of this process.

And I agree that this can become very big, if you start looking at an
aggregate. I think the good news from the technology perspective is if
we get started, whether it\'s at a regional level or at an integrated
delivery system level, once the information is online and exchangeable,
I think we can add additional patient information or even change the
structure of the data movement relatively easily with the technologies
that are available today.

So I think, you know, if we take a practical look at this and keep the
scope small, we would probably be able to do things very quickly,
because so much of this data is really standardized today.

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

So Pam -- and thank you for that -- given your comment, and looking at
the specific charge for the workgroup, are there recommendations that
you would make to change that?

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

Well, I guess I was just recommending that we get clarity on this.
Because if you put it under the umbrella of the patients looking \-- at
the present, looking for every patient to have an electronic health
record, then what we\'re really designing is something that\'s more
patient centric, versus if you look at it in terms of going to an office
and having access to data, it\'s really episodic or really tied back to
an order. And -- I think Blackford said this -- the reality is today
most electronic health records are designed to take care of the patient
in that particular office, unless they\'re sponsored by a larger
delivery system.

So I think we just have to scope this in terms of what we\'re trying to
do, and it may be a multiphased approach. First get all lab results
electronic, then exchange them with the health care system, then build
them regionally. Or it may be the opposite. Let\'s just go to a regional
network and take a patient-focused view of this, out of the chute. And I
think the issues and the challenges will be very different based on how
that end result is defined.

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

And David, wouldn\'t you say this is also crossing a little bit over
into the consumer empowerment workgroup? Just based on what she just
said?

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

Hold on one moment. Karen Bell is going to respond on behalf of David.

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

Yes, unfortunately, David had to leave. Absolutely. I think yesterday,
when we were working through similar issues around the consumer
empowerment, the message came forth that ultimately this is a very
patient-centric, consumer-centric model that will ultimately incorporate
not just the deliverables to the consumer empowerment workgroup but
other data as it comes through. So we do see a natural alignment
subsequently down the line between this particular laboratory projects
and ultimately providing information to a patient.

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

Lillee, we have a few more comments queued up.

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

Please.

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

Please open Carolyn Clancy\'s line.

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

Good afternoon. I had actually a very tactical request. I can
distinguish Lillee from Jonathan pretty much, and I do know David\'s
voice, though he\'s gone now. I\'m actually sitting next to
construction, so until we all get very familiar with the various voice
tones, if you could identify yourselves, maybe for the next hour, when
people speak? It would be helpful.

I wanted to actually support the broader adoption boundary that David
Brailer spoke with. I think for us to make recommendations to the
Community to enhance what\'s happening for doctors who have already made
investments in electronic health records would be way too narrow. Having
said that, I think it might make sense to think about adoption as part
of a diffusion curve. We think of it that way in terms of people who are
likely to have made investments very early, and people who are still
kind of pondering and maybe people who haven\'t heard about electronic
health records yet.

But I think you can also think as a component approach. And some of our
surveys of physicians and physician practices would suggest that, in
fact, browsing results is very often a sort of first step into
transforming your practice into interacting with an electronic world. So
I just want to support that. And just as a footnote, in response to
Howard Isenstein\'s comments, there\'s at least -- I know CMS has some
work going on right now, to refine what\'s happening with the ASP model
of Vista.

We also have a project ongoing right now in Dr. Brailer\'s home State of
West Virginia, and I can certainly give Karen and Kelly and others more
information about that.

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

That would be great.

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

Please open Blackford Middleton\'s line.

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

Hi, it\'s Blackford here. I want to make two thoughts; two factors come
to mind. One, on David\'s comments, I actually agree with Carolyn. I
think the broader target has appeal for the transformation angle and
whatnot. I think, though, what\'s not clear is what is the value
proposition defined in chunks that can take the community along toward
adoption or perhaps, as Carolyn was saying, along a diffuse curve. I
think the evidence would suggest that, you know, the access to labs is
perhaps a first step towards transformation, but laboratory access by
itself, absent decision support or some organizing capabilities, is not
a huge leap, by any stretch of the imagination. That was kind of thought
number one.

How we make sure that whatever we recommend is part of an ongoing
chunked value proposition -- because what I\'ve seen too often is that
folks -- perhaps the vendor folks will have thoughts on this -- all too
often, you know, sort of EHR Lite is implemented, or even less than EHR
Lite, and then nothing else happens. And thus we actually do not achieve
perhaps the, you know, more important goals and objectives of more
decision support and organizing of the information, not to mention
information interoperability.

The second point is just about that issue of how do we organize the
access to information in a way that drives, again, adoption, in a
reasonable way, but now looking at it from a technology dimension, I
think the intersection here with the consumer empowerment group is going
to be extraordinarily interesting, and I wonder if we want to actually
have a touch point organized at some point along our respective paths.

It strikes me the way we organize information, as I said earlier, in
health care is sort of anathema to sharing. You know, perhaps we need to
look at the personal health record concepts, the health -- my health
data bank, or my personal health data bank sort of ideas are emerging in
different places around the country, and see if there\'s a way to
leverage perhaps RHIO concepts as they\'re emerging to once again
facilitate the access to laboratory data.

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

Jason Dubois, you can go ahead with your comments.

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

Okay, I want to touch on just a couple of things. First of all,
Blackford talked about the pay-for-performance issue, and I think in a
couple of these examples, we can tie it back to why a lab
standardization is important. And first of all, in pay-for-performance,
laboratory data is often used as a means to help quantify physician
performance. So in a lot of these examples, whether you\'re using a
hemoglobin A1C to help identify proper lifestyle for diabetic patients,
that\'s just one example. So to the extent you can standardize some of
this laboratory data to create pay-for-performance programs, that\'s
going to drive presumably physicians\' adoption.

And on the physician adoption piece -- and I\'m strictly coming from the
laboratory perspective -- the e-Health Initiative did a study that they
recently finished on laboratory connectivity, and they looked at
actually the resources cost to laboratories. A lot of physicians in the
country and hospitals and the like have relationships, and their first
run-in with any type of information technology is through laboratories
who have helped set up existing relationships with them.

And the e-Health Initiative study actually looked at the cost to
laboratories to provide this data, and this relationship runs in the
area of \$30,000 to \$50,000, and the idea here being that the cost
comes in, or a significant portion of the cost comes in, when
laboratories have to burden the cost of marrying the data streams,
essentially, the existing data stream from physicians and that of their
own data that they\'re trying to transmit to the hospital or physicians.
So to the extent that some standardization can occur, it\'s going to
help facilitate laboratories reaching out to more physicians, and that
includes rural areas.

The last piece I wanted to talk about -- and this is kind of a lot, but
just recently I was talking about some folks with the AHIC, and you
talked about connecting in with the consumer empowerment group. They
actually have an effort that\'s under way, as I understand it, to
develop a portable and universal personal health record. And they
actually came to us with interest on what laboratory results reporting
standards were out there, and we put them onto the E-Links project, and
presumably that may very well be the way they go with this.

But in essence, as I understand it, it was explained to me it would be
essentially whether you have Blue Cross -- if you\'re a patient with
Blue Cross Blue Shield, and you\'re moving to Aetna of Tennessee, I
don\'t know, essentially you would have a personal health record that
you could take with you -- and you could take with you then to the Aetna
in Tennessee. So I\'ll leave it at that.

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

So Jason, you said that\'s done, or it\'s --

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

Oh, no, they\'re just starting the effort, in fact.

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

They\'re just starting.

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

They came to us with an interest in trying to leverage existing
specifications, and he had asked obviously what was there in the area of
laboratory standardization.

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

It seems in a broader sense, though, that the consumer empowerment
workgroup might very much want to hear a representative from AHIC to
talk about where they are.

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

Please open John Houston\'s line.

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

Hi, this is John Houston. One general administrative comment, first.
I\'ve been trying to break through for about 25 minutes and make some
comments, so I fear that some of this conversation is going to be
somewhat disjointed and I\'m afraid participation is going to be
difficult, based upon the fact that it\'s hard to break in.

My other comment that I wanted to make was related to the fact here in
Pittsburgh, currently one of our payers is actually also incenting
physicians to do e-prescribing by providing a one time payment, which I
think is also one way to, if you think about it on a per -- what\'s the
word -- per discipline basis, you could probably look at ways of
stratifying payment to physicians as they continue to try to adopt EHRs
through, you know, pay based on function achieved.

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

Open Barry Straube\'s line, please.

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

Yes, good afternoon. Barry Straube from CMS. Just wanted to add a couple
of points. One, I wholeheartedly endorse David\'s suggestion of a
broader approach and the other folks who seconded that.

There was mention made earlier of the Vista EHR office products, and
just to give you a brief update, actually David and myself and Karen
Bell were online with our staff this morning. It had been our hope to
get Vista EHR out this summer, but I think I, being new to the central
office role at CMS, plus some other folks in the Office of the Secretary
and David and Karen, felt that that particular product, before it could
be released widely, still needed some additional analysis and beta
testing. So we\'re in the process, actually, of developing a further
beta test site process in order to be sure that it\'s a feasible,
workable product before we get it throughout broadly.

It would not be a good thing for us to release that if it weren\'t very,
very clear that it could be adopted broadly. So we\'ll have more on
that.

There are several other things. Again, it\'s sounding like maybe some
people are suggesting we either, by paper or in person, perhaps need to
get each other up to date on what the respective agencies and
organizations are doing. But two other areas I wanted to mention. At
CMS, first of all, the QIO 8th scope of work, which began in the
mid-late summer 2005, does have a significant component where QIOs go
out and meet with 5 percent of physician offices and do readiness
assessments, etc., for their ability to accept EHRs and then to counsel
them about vendors who offer their products, etc.

This is going to be a very major focus at CMS, working with David and
his staff and making sure we\'re in alignment. And I feel, being a CMS
representative, that we\'d like to, as much as possible, keep aligned
with this workgroup\'s efforts, also. So this workgroup will be very
important to give us some guidance on what we do in that arena.

Similarly, in a pay-for-performance, in a recently announced physician
voluntary reporting program, we are initially using, with some degree of
luck -- reluctance, G codes appended to traditional claims submissions.
But it\'s our definite long-term goal, of course, to have quality data
submission and use for quality improvement and/or pay-for-performance to
be done electronically.

So we\'re struggling with how we can make that transition jump, and
again, I think that\'s an effort that will be very pertinent with the
work being done by this workgroup.

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

Barry, this is the EHR project?

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

Yes.

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

Are you at least far enough along to update this workgroup, and what\'s
going on there that can inform our work? I wouldn\'t want us to get so
far down the line and then the beta testing comes out. Is there a chance
we\'d be taking a fork in the road here, or what can we learn?

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

Well, I think, to some extent, we could potentially give a high-level
view of where that\'s at. But I think, you know, again, in terms of a
need for beta testing, don\'t want to get too far out ahead of the game
here. I think expectations were raised prior to this summer, and people
have been disappointed in that regard.

So I think probably internally we need to put our heads together a
little bit about what the appropriate message is, and there are some
different viewpoints, you know, about how we should be approaching this
internally, and then I think it\'s appropriate for us to brief this
group.

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

Okay.

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

Please open Pam Pure\'s line.

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

This is Pam. I was just going to say that one of the balances I think we
have to pay attention to as we do this work is the fact that all across
the country, many hospitals like Partners and physician offices are
already in the process of spending millions of dollars implementing
technology independently to solve many of these issues.

And it would be great if we could factor that practical market activity
in terms of our solution, and so folks that were, quote, ahead of the
curve or aggressive adopters could be brought into our solution very,
very quickly, because it would drive critical mass quickly versus coming
up with a totally new solution that kind of bypassed the technology
that\'s already pretty widely implemented in, you know, organizations
across the country.

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

Lillee, the queue is empty now, and whenever you want to start hearing
from workgroup members again, just let them know you\'d like their
comments and they can start buzzing in with star 1 again.

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

Great. And I\'m also going to ask Kelly, Karen, and Dana to keep us on
track here as well, in terms of the agenda, to make sure we\'re meeting
key milestones during this call.

But it seems I heard there was consensus, if I could declare a
consensus, in endorsing David\'s broader approach. Did I hear that
correctly? It\'s hard when you\'re on the phone; you\'re not looking at
body language or faces or -- that it seems like I heard Carolyn, Pam,
Barry -- John, I don\'t know if you commented on the broader approach.

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

Lillee, it\'s going to be difficult for the members just to jump in and
respond to you since they\'re all on listen only right now, but I would
suggest you go ahead and declare that consensus. If the workgroup
members have comment or issues with that, they can certainly ring in
with star one and we can respond to them that way.

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

Lillee?

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

Yes.

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

This is Jason Dubois again. I would agree with the exception, as the way
Dr. Clancy put it as, an adoption of a diffusion curve. I don\'t know
that \-- I think it has to be a stepped approach, but I certainly think
the overall goal is to get there. I don\'t know how \-- it would depend
on what the model is again for adopting. But I think that\'s ultimately
what we\'d all like to see. But whether or not you take steps to get
there or not.

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

Go ahead.

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

Lillee, this is Rob Kolodner, I\'ve been able to join now.

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

Hi.

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

Hi. I think the key is we want to get that information out there because
it\'s important. We also want to make sure that all the incentives are
aligned, that the adoption of the electronic health records is where we
go, although I don\'t think this is going to be the only incentive and
won\'t be enough of incentive to go. But we don\'t want to preclude
those individuals who haven\'t yet made the leap, because at least
they\'ll be able to give better patient care because of that continuity.

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

And I believe Bart Harmon was waiting to make a comment as well.

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

Yes, this is Bart Harmon again from the Department of Defense. I would
suggest that we actually have to do both, or we could end up a little
bit off track or derailed. In our experience, we\'ve had to maintain a
broad high level of vision of where we think we\'re going over 5 to 10
years and then take any small tactical steps with the broad vision in
mind. Because otherwise, you can end up derailing the longer-term vision
with short-term steps that move away from the long-term vision rather
than toward it.

And we actually found that we had to have a certain amount of critical
mass in our short-term steps or we took energy away from the long-term
initiatives. So I think you probably have to do both: paint the
broad-term picture, and plan for short-term success in view of that
long-term picture.

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

So Bart, given that and given the broad charge for the workgroup as well
as the specific charge for the workgroup, are you advocating for what we
already have in front of us?

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

I\'m advocating --

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

Or what would you change?

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

What I\'m hearing, I think, in the middle of the discussion is that the
two can\'t just be done as if they\'re somehow independent of each
other, but the short-term strategies always have to be looking back
toward the longer-term strategies. And in fact, I get a little bit
nervous when I start hearing of people proposing specific solutions when
we don\'t have the vision, the broad vision, and a moderate amount of
detail in front of us, because any particular solution could actually be
taking you away from the long-term vision rather than toward it. That\'s
not to criticize any particular solution, but you could have actually a
solution that is a little bit inferior in the short term but far
superior in the long term, and it\'s more of a strategic decision to
take the long-term view.

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

Yes, and as the Secretary says, we don\'t want perfection to trump
progress.

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

This is Karen Bell, and what I will do is, I will just summarize what I
think I\'ve heard from the conference, the next steps that we can take
here, with support from some of our staff that might be able to move you
a little bit further along with the decisions on how to model this. And
that\'s that clearly, we would like a model that would allow linkage to
consumer information, consumer prior information, or PHR information and
one that will allow information to flow from multiple labs or lab
sources to multiple other providers. And that can take the form of -- in
several different ways, but one of them could certainly be a RHIO type
structure, as Blackford mentioned a little bit earlier. Another might be
a trust-type structure such as exists with RxHub, something of that
nature, and there may be others as well.

So what I would suggest is that we do a little bit more research on
these various models, what they will entail, and provide a document to
you within 2 weeks that will outline these in detail, along with some of
the pros and cons of each, and that will then, I think, allow you to
make a better decision -- more informed decision about the type of model
that you would like to support. Is that acceptable to the group?

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

Lillee, we have a few more comments in the queue, and I\'d just like to
make a quick note to people who are listening who are representing the
members' organizations. We\'re only taking comments from actual
workgroup members right now. So if anybody else pings in, you will not
be recognized. Please open Blackford Middleton\'s line.

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

Thank you; it\'s Blackford here. Karen, I think that\'s right on target.
I\'m not sure that necessarily is the exhaustive list of potential
scenarios, though, you might consider. So perhaps some dialogue or
e-mail or correspondence might occur on that still.

I did want to return to just one thought. I think Pam might have said,
you know, and I appreciate the thought that, you know, a lot of
institutions have made huge investments in EHR or IT and are barreling
down the path at varying degrees and whatnot. And we have to accommodate
them, wherever they are.

I think that\'s good and actually very, you know, in a way, reassuring
to hear. But I would suggest that the biggest upside opportunity is in
fact in the doctors' offices and/or hospitals where nothing has happened
or very little has happened. You know, the EHR adoption statistics, what
David Brailer talks about is the adoption gap, and John Tooker mentioned
the small office environment. In 75 percent of small office physicians\'
practices, it\'s five or six or less physicians, and only in, you know,
5 to 8 or 9 percent have adopted any form of EHR whatsoever. So we just
try to make sure we remember the market segments, if you will, and be
sure we target the biggest opportunity with the greatest upside
potential in that small office environment.

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

Well-said.

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

Please open John Houston\'s line.

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

Hi, just a couple comments. To Blackford Middleton\'s point, though, I
think, you know, probably the place where the EHR is going to, in my
mind, have the most impact, though, is still in the hospital setting.
And I think there\'s a lot of small hospitals out there that are equally
in the same position: they haven\'t adopted EHRs, and frankly they
don\'t have the money to do it themselves, either. And they may very
well be in a lot of rural areas the way the RHIOs come together with
physician offices. So I think there\'s a point where, I think, we need
to be careful about also not just looking at physician\'s offices.

To a second point, though, I also would hate to see us tell people to
sort of slow down or stop EHR efforts that currently exist. I think the
clear message still has to be that there are organizations that are
really pushing for EHR, you know, their EHR solutions and are currently
in the process of implementing them. I think they need to be able to go
forward aggressively, because I think you still make more progress
overall, even if it turns out that they need to make slight shifts in
the direction down the road.

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

Please open Pam Pure\'s line.

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

Hi, this is Pam. And Blackford, I agree with you. I just wanted to make
sure my comment wasn\'t misinterpreted. I think some of the
organizations, whether they\'re physician groups or hospital systems,
that have already invested in these technologies could be hubs, in terms
of helping accelerate the rollout to organizations that don\'t have the
technology.

There are groups, you know, like the one you represent, that have a
wealth of IT experience, have a secure network, have the applications
running, and I don\'t think we\'ve fully explored taking the existing
networks and making them more readily available to small community
hospitals and physician groups in the surrounding areas.

So my suggestion was we look at building on the strengths of the early
adopters and the technology leaders, because I think we\'ll get to
critical mass faster.

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

Please open John Tooker\'s line.

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

I just want to follow up on what Blackford and also John said. I think
it may be -- I think Blackford is right on about where the very large
implementation gaps are in the ambulatory setting, but thinking about
this from a patient\'s point of view, it\'s not as useful for me, at
least, to think about how a patient gets to the system. And it may not
serve the patient well if we have, for example, uptake in the ambulatory
physician\'s office but the other sites of care in that community don\'t
have that same capability. So the more we can provide the linkages and
networks from a patient\'s point of view, the closer I think we\'re
going to be to our goal.

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

Please open Blackford Middleton\'s line.

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

I just wanted to respond. I\'m keeping -- having trouble keeping track,
but I\'m making notes. Pam, I agree with your sentiment exactly. I think
when we consider those ideas, though, of how to use the existing
infrastructure in the larger environments that have big installed IT, in
many ways I like to call Partners HealthCare an NHIN in situ. You know,
we have just a huge number of devices and huge number of hospitals and
clinics, and all the rest of it -- it really is an NHIN in situ.

But where we think about extending the technology envelope, if you will,
across the community and the region, it\'s no longer a technical issue,
of course; it rapidly becomes a business issue. And the business issues
are historic related, policy related, financially related, and the like.
So I think it\'s incumbent on us as a workgroup as we consider these
scenarios not only to consider the technical dimensions, of course, but
then, as you\'ve already outlined, the policy and financial issues as
well.

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

Lillee, the queue is empty.

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

Thank you so much. Karen, back to you. I heard that you\'re going to
summarize and provide a document to us within 2 weeks around this
modeling piece. Is that correct?

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

That\'s correct, and if it\'s acceptable to the members of the
workgroup, I\'ll be in contact with all of you for refining of that and
for newer ideas as well.

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

Of course. And related to that, Karen, given the questions we\'re
discussing here around modeling the project and the use case, have we,
in the staff opinion, addressed these questions to the degree we could,
given that we need some more clarity and research?

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

Well, I think that I absolutely agree -- and thank you, Lillee -- that
the workgroup has really laid on the table all of the issues, or most of
the issues. I think there may be some more that come up, and you can
certainly let us know -- that will at least allow us to work -- create
that first working document or the first draft of a working document for
you. And then you can then make modifications as necessary.

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

Thank you for that. And I did hear there is a thread through this fabric
of EHR, as David would say it, but it does seem like this issue of the
patient, and how the patient is identified and how the patient is part
of this equation, that this needs to be addressed across all the
workgroups. I heard it really specifically with consumer empowerment,
but understanding the charge of some of the workgroups, I just want to
make sure that the obvious is said here.

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

Yes, this is Karen Bell, and I\'d like to turn this over to David for
just a moment, to respond to that.

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

Well -- and I just mentioned it to Karen here in the room -- I think
that talk about big hurdles that need to be overcome in order to
accomplish this, and we talk about -- Karen talked about this RHIO type
structure, a trust-type structure, the 800-pound gorilla in the room
here is really to accomplish that. Amongst other providers feeding into
the network is the unique patient identifier, or a national algorithm
that would help, you know, protect privacy.

And I know that\'s a huge hurdle for -- you know, that Karen has said
the consumer empowerment workgroup is looking at it, but I think that\'s
a big keystone to the effort moving forward. And so I\'m reminded of
what Bart said in terms of the long-term goal.

And another thing that we have to also keep in mind -- and again, I
don\'t know whether it\'s been raised, but at least with respect to
laboratory information, CLIA comes into play. And Bart can correct me if
I\'m wrong, but I think under statute under CLIA, and I think even in
State laws traditionally, you can\'t share lab result information with
anyone other than the ordering clinician in most examples throughout the
States.

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

Okay, thank you. And Karen, just also as you\'re summarizing and we\'re
talking about these models, we\'ve jumped around a bit, but we\'ve
tackled what we needed to tackle in terms of EHR adoption barriers and
strategies. There were a couple, though, that I didn\'t hear that I just
want to make sure are on the table, and that is when we\'re talking
about the workforce issues, we\'ve talked about cultural, financial --
we haven\'t touched a whole lot on workforce and physical plant issues,
although I think those will tease out over the course of what we\'re
trying to do here.

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

Please open Carolyn Clancy\'s line.

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

Hi, this is Carolyn again. One issue I didn\'t want us to lose sight of
-- and I think this from the perspective of "Ongoing managing of this
process might be a little tricky," but I think Pam Pure had it right
when she talked about -- we\'re talking about two different models in
terms of what works for an individual physician or small group of
physicians or large group or hospital, for that matter. What works from
the provider side versus what works from a patient centered model.
They\'re quite different.

And so I didn\'t want to lose sight of Blackford\'s footnote that we
might want to think about some intersection. And that may end up being a
bit down the road with the consumer empowerment group.

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

That\'s great; thank you for bringing that to the forefront.

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

Lillee, the queue is empty.

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

Great. Okay, Karen, I think you have your charge, right?

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

I certainly do, and thanks very much.

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

Let me just ask the group, are we ready to move on?

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

I think unless anyone rings in, Lillee, we\'ll assume that they are.

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

So I think we have, for at least this portion of the agenda, talked
about our charge and defining scope, and David certainly got us really
thinking about scope. So if we could move on now to the next part of the
agenda, which is developing the work plan.

And if we look at some of the hard deliverables here in terms of
developing our work plan, developing our timeline, and understanding
that by our March 7th AHIC meeting we do have some hard deliverables to
deliver to the Secretary, what I had asked -- and you may look at the
length of this agenda and go, "Gee whiz," but I had asked the staff to
embed into the agenda the timeline milestones that we as the committee
are going to have to adhere to. And that\'s why the agenda may look long
to you, but it was for clarity of purpose and clarity of task at hand.

But -- and this notion of developing the work plan next, we need to
identify what we\'re going to need in terms of human resources, leaders
for the main topic areas in the work plan, and then communication
process and document exchange, which are no small issues. And when we
talk about -- just to try to get your thinking going here -- when we
talk about needed human resources, we\'re talking about administrative
support, the things that we\'re going to need to really get the work
going.

When we talk about the leaders for the main topic areas, you know, what
does that mean? Do we make sure that we\'ve got who we need on the task
at hand?

And then the communication process and document exchange, because, my
goodness, you know, we can have great ideas, but it is the broad
dissemination of ideas, the building of consensus, and then trying to
really define how we\'re going to have the most impact. Without broad
communication and document exchange, it\'s just not going to go very
far.

So let\'s, under this large topic of developing a work plan, in
identifying the human resources that we may need, perhaps Karen or Kelly
or Dana, there\'s someone in the room that can start to tease this up,
and then I\'d call on the workgroup members to chime in.

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

Lillee, could you just clarify a little bit in terms of resources? I
think that I can certainly respond from the perspective that both myself
and Kelly and the rest of the staff here at ONC are available to meet
the needs, to ensure that the information is gathered and presented in a
clear format.

We will also be dependent on working with other staff throughout the
Federal Government, as well as, we hope, from the private sector as
well. And so if there are folks in the private sector that you know of
that may be able to help inform this discussion, then we\'d very much
like to engage them as well.

So I believe that the team of Federal, both the public and the private
supporters, as well as our staff here, can meet your needs. But if you
have any other ideas about how to approach this, please give us some
guidance.

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

No, I don\'t. I think in just seeing how the staff has worked so far,
certainly you are -- and to tease out the obvious here, you\'re
certainly organizing and scheduling the meetings. That\'s not something
we as the workgroup will be doing. You\'ll be doing that. You\'re
tracking our tasks. You\'re tracking our deliverables. You\'re helping
us craft the final document that we will put in front of the Secretary
on March 7th.

But I just want to make sure we\'re not missing something here, because
we have a very talented workgroup here who have participated in many,
many large-scale projects in the past, and we could perhaps learn in
this particular area, because underresourcing can really hinder
progress.

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

That\'s correct, and I also would like to underline the fact that our
role is that of coordinator. Clearly, you and Dr. PERLIN will set the
direction working with the workgroup members, and we will follow your
leads. On the other side of the coin, if we feel that there are
questions that need to be answered, or specific areas that need to be
addressed, then we will bring those to you.

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

I already see a good example here of how the staff is staffing this in a
robust way, and that\'s Karen, of course, summarizing our last group of
discussions and providing a document that will help us reach some
consensus and some conclusions.

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

Okay.

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

All right. So, leaders for the main topic areas, I\'m not sure how we
want to approach this one.

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

Hi, Lillee; this is Linda Fischetti. Within the timeline section, we can
go through the outcomes and activities and ask for volunteers to put
their name to some of these items.

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

I think that\'s a great task, and that\'s very much one of the reasons I
wanted us to have the timeline embedded in the agenda: so we weren\'t
shuffling papers and going to multiple forms. But there needs to be some
accountability and responsibility tied to the tasks.

So with that, can we -- am I hearing consensus to move to developing the
timeline piece and as a result the workflow would flow from that?

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

That would work for me, Lillee.

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

Okay, great. There we go. Let\'s talk about the first quarter \'06,
which the month of January is over already, and the first outcome here
is identifying existing tools and solutions that could be rapidly
deployed and present recommendations to the Community. And here we\'re
looking for a lead on who is actually doing this inventory of existing
tools and solutions and who might be able to help. Because again, we
really want to present at the March community meeting what we found.

And you know, is the E-Link piece an example?

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

Please open Pam Pure\'s line.

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

I was just going to volunteer to help out with this. I apologize; I
thought you were at the point where you were asking for volunteers.

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

I am.

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

Okay. So I\'m your first.

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

The quicker you volunteer, the sooner this meeting will be over. But you
know, it strikes me, whenever we cast the broad net and try to get an
inventory of what\'s already out there, this could be a really critical
piece to our being effective.

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

Right. And what I was going to suggest is, I\'m pretty well-connected
with the vendor community. I could go out and assess my peers and
colleagues in the vendor community and get examples of what they believe
exists today that we could build on, if someone else could handle the
public sector, with some of the projects that we discussed earlier, in
terms of pilot projects that were out.

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

I know I could call on -- maybe John Tooker could perhaps help in terms
of the existing tools in physician practices. And perhaps the Veterans
Administration staff as well as Bart Harmon, talking about the VA and
the Department of Defense tools that are already in place. John, could
we get you to chime in?

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

Can you hear me?

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

Yes, thank you.

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

Yes, ma\'am.

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

So you can do the physician practice component of this, trying to
identify existing tools and solutions?

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

I\'ll sure try.

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

So Pam, you will take the -- I\'ll ask you to be the lead of this task
and survey the vendor community for existing tools.

John will tackle the physician practice component. And Rob or Linda,
Bart, what about the VA and the DOD component?

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

Yeah, we can certainly work with our staff to join with DOD,
particularly in the area of moving information out; we\'ve been working
together on that.

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

Okay, great.

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

I think -- this is Bart -- some of the most valuable recommendations or
offerings might be the ones we\'ve built together.

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

Very true.

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

Please open Blackford Middleton\'s line.

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

I just wanted to suggest -- you know, I think the couple of dimensions
makes sense for ways to explore the phase; that is, the private-sector
side and small-office kind of environment side. I don\'t want to lose
sight, though, of perhaps exploring the technologies being considered in
the real work, and there are obviously demonstration projects in a few
-- and the technology -- not the usual suspects, if you will, from the
HIS base, but somehow I think that might be useful to do, too.

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

Well-said.

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

The queue is empty. Lillee?

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

So Pam, if we\'re to look at this task, and knowing how aggressive our
timeline is, how soon could we pull together a report that showed the --
I don\'t want to say "fancy reports" -- just the inventory, the existing
tools and solutions? How long will that take?

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

The sector side? Are you asking me to coordinate the overall effort?

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

Yes.

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

Okay, so I guess that would depend on how quickly my colleagues on the
line could get their piece done, I think, you know, maybe if we did a
30-day assessment. Give me an idea of how much time we have to do this,
and I guess we'll determine the level of depth we go into.

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

This is Karen Bell. Just to remind everyone that the next series of
meetings is the week of February 21st. You will probably want to get
written information long before that, or at least the week beforehand.
So I suspect that your timeline is going to be a little bit tighter than
anyone would like.

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

All right. Well, that\'s helpful, Karen. So as I understand, it\'s going
to be John and Bart working on this with me? Did I miss anyone?

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

In the Veterans Administration, you have Linda Fischetti and Rob
Kolodner also helping you, but I think the February 21st meetings would
be a great point to update on where we are with this particular goal.

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

Okay, so -- and I will also get with the folks that are putting together
the current status of the E-Link project as well. Is that a separate
initiative, or is that part of our report out?

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

The E-Link? I think --

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

I\'m happy to provide a report on what\'s been done up until now, more
than -- I don\'t know what else I could say other than what I\'ve shared
today.

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

I think it would be helpful. You know, part of achieving consensus is
broad understanding. And we need broad understanding. I don\'t know that
you -- I don\'t throw my hat in the ring around consensus until I
understand it, so that would be great if you could do that.

And then, Pam, if you -- the workgroup here, we have our existing tools
and solutions workgroup to the workgroup created. And it is being led by
Pam Pure and John Tooker, Bart Harmon, Jonathan Perlin, and Dr.
Perlin\'s staff will help compile that piece. And again, I just want to
keep saying, don\'t let perfection trump progress, Pam. I mean --

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

Okay.

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

If you get us a list now, it\'s more than we have now.

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

Okay, and I will get that group together on a separate call and maybe
outline some thoughts on how we can get this work done quickly.

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

Let me -- Karen, Kelly, or Dana, let me just get some staff clarity
around how to -- I think I\'ve put the urgency for this group to get the
task done. Given that these meetings are open, what\'s the protocol for
work that needs to be done between now and just a couple of weeks?

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

This is Dana Haza, and because these are FACA run meetings we can only
do these one-on-one, we cannot do any subgroup meetings, and
transparency is the order of the day.

So please be sensitive to that, and we will continue to provide more
information on the specific guidelines as to what you can or cannot do.
But we cannot get small groups, because all workgroup meetings must have
advance notification, and the public must be able to participate in any
group\'s contributions.

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

So do we just need to take a few minutes here in this public forum and
help Pam\'s subgroup get their arms around the task at hand?

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

I think that\'s really what Dana is saying at this point.

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

Okay, so it sounds like what we\'re trying to do is identify the
existing tools and solutions that could be rapidly deployed. We\'ll have
three sections of that document, if I understand correctly. The first
would be if we built on what\'s already available in the private sector,
what is out there, and actually how could we build on it.

The second, which John will take a look at, is if we -- we looked at the
existing tools out there that physicians are using in their community,
what could we build based on that. And Jonathan would also give us the
look at what\'s out there in the public sector that might be used to
accelerate the progress. Is that kind of a high-level summary?

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

Sounds good to me.

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

And maybe for each of those sub-subsegments, we could identify the
projects that are in progress, maybe do an overview of what\'s happening
at each, and the opportunity to extend those projects, and what the
barriers would be. Does that sound like a good starting place?

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

That sounds like a great starting place, and the first report will be --
Dana, I think our next meeting is February 22nd, is that correct?

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

That\'s correct.

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

Okay, so --

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

So just to be clear, can I exchange documents with this group to put
together a consolidated document? I just want to make sure I understand
my obligations.

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

I believe that we can do fact finding so that individuals can do fact
finding. That can be reported essentially into our office, and we can
then provide that back to you. But the interchange between you or among
you is what is not acceptable in the fact-finding assignment.

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

Additionally -- this is Dana again -- we\'re going to begin to post
documents so everyone can see them, understanding that some of them will
be documents in development. But again, it\'s -- transparency is the way
we need to do it.

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

Help me just a little bit -- and I apologize; I just want to make sure
we get this clear. We just asked John and Jonathan to help out in this
process of overviewing what\'s out there, talking about the opportunity
to extend and talking about barriers. If we each took a first draft,
where would we send that?

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

That would be to Karen Bell.

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

Okay, so we send it to Karen, and Karen, you can post it somewhere that
would make the documents available to all of us?

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

They will be posted; that\'s correct. And we can do some internal work
bringing them together, and we\'ll post that as well.

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

Okay.

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

That\'s great, and I just want to support you in your task here, because
this will be -- what a terrific report to put in front of the Secretary
on March 7.

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

Right, and I guess I\'m just a little bit confused about my role as
coordinating this when I can\'t talk to the other people on the group.
So I just talk to Karen; so Karen is really the coordinator here.

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

Right. I have the privilege of essentially being you for a little bit of
time, so thank you very much.

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

Okay. Well, Karen, I\'ll get in touch with you and just make sure we\'re
clear on this and how I can help.

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

That would be great; thank you very much. There is one thing I would
like to present to the workgroup, though, and that\'s that we spent
quite a bit of time talking about the various models for how we could
construct making data available.

What we didn\'t do was really have any discussion about what data would
be available. And as I\'m sure everyone is aware of, that there are
multiple issues around various types of laboratory data.

I think you heard from Jason that there are about 100 frequently used
labs. Some of those have one particular set of standards in terms of how
they are presented, (inaudible) standards; there are others that use
SNOMED. And if we\'re going to be very simple, we might be going down
one particular path or we might not. Should we just be looking at
hematology and chemistry, for instance? Do we want hematology chemistry
and some pathology? Do we want to be presenting just the normal lab
values as interpretive data, or do we want to be providing some test
information as interpretive data? And how historical should this data
be? Shall we go back 2 months, 3 months, 6 months, a year? Those are the
kinds of questions that we do need to answer for the 7th and may be
helpful as we begin to pull this model together.

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

Do we want to have some discussion on that? Is that what I heard?

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

If that\'s possible, yes.

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

Operator, please open Blackford Middleton\'s line.

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

I just wanted to -- before we change gears, just to make sure that -- I
don\'t mean to be perseverating on this RHIO dimension, but among the
four categories I guess Pam is leading the charge on with Karen\'s help,
I wonder if it would be useful to, you know, try to harvest some of the
data from AHRQ perhaps about the current RHIO demonstration projects, or
perhaps from EHI or Markle.

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

Great idea.

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

Karen, I wonder if you might have a thought on that.

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

Certainly can harvest that information; there\'s a lot out there, and I
know the consumer empowerment workgroup is looking in that direction,
too. So we can do that research as a fact finding for you.

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

Okay.

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

Good idea.

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

Okay, the queue is empty, Lillee.

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

This is Rob Kolodner from Department of Veterans Affairs. Regarding the
use of RHIO, I think it would be useful to get that information, but I
want to be very cautious because of the time frames for the various
demonstration projects to deliver their product and then to be culled
through in order to have the standard that will be the national standard
that we\'ll be aiming at.

I don\'t think that\'s going to be on their 1-year time frame. So I
think what we may want to do, looking at what we need to deliver from
this group, is to be tracking that but make sure that we start
delivering something in the shorter-term time frame, which probably
won\'t have to do with that.

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

Please open John Houston\'s line.

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

Yeah, just to discuss the privacy implications related to making
historical (Inaudible), I think we do need to be cognizant of the fact
that there are going to be concerns from -- reasonable concerns from
individuals who say, "Okay, I can understand historical lab values
related to the type of care I\'m receiving from a specific provider, but
that doesn\'t necessarily equate to me being provided -- my lab values,
my lab information, being en masse provided to whomever requests it." So
I think we\'re going to have to have some discussion about, you know,
what is the context when lab values are being made available and how do
we get the consumer buy into making those types of lab values available.

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

Just a quick note to workgroup members who are on the phone. If you\'re
following along on the computer as well, please turn off your computer
speakers, because we pick up a little bit of echo that comes across on
the phone.

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

This is Howard Isenstein. This goes back to what -- the time series and
what should be on the lab results. And again, looking at the specific
charge, I think it kind of suggests it should be smaller rather than
larger. I mean, it says within 1 year. And I was wondering if someone
had just some benchmarks -- perhaps Jason does -- on the small group
practice, the one-to-six doc, since that -- you know, we really want to
get them involved. What is the subset of that 100 or 150 that they use
the most? What\'s most important to them, looking at it from a user
perspective?

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

Sure. With the E-Links effort, the idea was to try and essentially --
they look at something similar to what the specific charge here is, and
that is, you know, what can we use right away. And that is, these 100
most commonly used tests are simple things like hematologies and
chemistries, where it\'s a number. It\'s not a big thing that they\'ve
tried to steer away from, for the time being, and that\'s why when we
talk about 95 percent of the top 100 commonly order tests, a lot of
those don\'t include narrative description type tests, where, like,
you\'re going to have your -- any kind of gynecological cytology,
you\'re going to have a narrative value for the outcome for a pap smear.

So a lot of that is chemistries and CBCs and the like. So that was what
we determined, because actually E-Links had -- we talked about this with
the steering committee -- was having a much broader charge; they wanted
to do a much bigger proportion of tests, and they also wanted to do test
requisition or test ordering. But we wanted to work within a small
subset of what we could get accomplished in the shortest amount of time,
and that\'s why we chose the 100 most commonly ordered tests, and by
extension of that, most likely to be utilized by the largest proportion
of the population of physicians and other clinicians across the country.

On the -- we talked -- I think it was Blackford, I think, who had just
talked about this, or maybe it was Dr. Kolodner, about the sharing of
laboratory data value. And I brought this up earlier, and I did make a
note of it in my notes before today, a use or disclosure permissible in
one State for one type of provider may be impermissible in another State
for other types of providers. In the laboratory context, the Federal
clinical laboratory improvement amendments permitted a clinical
laboratory to disclose test results only to, quote, authorized persons
and, if applicable, the individual responsible for using the test
results.

So individual States are responsible for defining authorized persons
under their laws and regulations governing clinical laboratories. So in
most instances, laboratories are prohibited from disclosing test result
information except to a limited number of persons, usually only the
physician that ordered the test. So just to answer that other question.

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

Please open John Houston\'s line.

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

Towards that end, though, I think that you hit the nail on the head,
though. You used the word "authorized," and I think that, you know,
"authorized" also means that the patient may authorize individuals to
receive tests. And again, back to the whole privacy issue, you know, one
way that -- one thing that has to be considered in all of this is
patient rights, as well as how do you get maybe the patient -- how do
you develop an authorization scheme that the patient buys into, that the
patient maybe, you know, authorizes their information to be made
available globally or certain types of information to be made available
globally. Maybe it\'s a certain set of tests, or maybe the patient
authorizes that, you know, physicians who are delivering a type of care
are permitted to see lab tests of a certain type. I think you have to
couple all this discussion with some idea that we\'re going to have to
develop an authorization scheme that the patients would sign off on.

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

The queue is empty, Lillee.

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

Okay, great. Well, thank you all. I think that was a robust and
important discussion around this first milestone that we have to
achieve. Have we sufficiently dived into the data piece?

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

This is Howard again. I mean, I guess I think a good default would be to
accept the 100, you know, labs.

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

Right.

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

I mean, just as a default, I think that\'s a good starting place. And
you know, except that it sounds like they did a lot of work to figure
that out, and maybe we could do a little more due diligence there, but I
would say let\'s use that as the starting place.

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

And as well, with John Tooker taking a look through the American College
of Physicians, I\'m sure that there may be some broad datasets that
might be useful to our deliberations on our next meeting.

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

This is Rob Kolodner. We\'ve been talking the 100 tests. It might be
useful to send those out or post those so we know what tests we\'re
talking about. I would imagine that among those tests are some like HIV
and alcohol levels.

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

Right. That\'s right.

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

If they are, those are the ones that may run into the legal issues
first. And if they\'re going to slow us down, we may end up needing to
say, "Let\'s set those aside for a second so we can get all the rest
out."

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

Please open Blackford Middleton\'s line. Operator, do we have Blackford
Middleton open?

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

I\'m sorry; that was my fault. Speaking with the mute button on.

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

Okay.

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

Anyway, I just wanted to follow up the thought on security and release
of laboratory data with patient consent. One of the things we\'re doing
here and others are done is, of course, release laboratory data to
patients directly through a patient portal, and the way we are setting
that up here, and have implemented, is to develop an embargo algorithm
so that physicians get to determine what information might be released
to the patients, you know, based upon a specified schedule and whatnot.

Obviously, things that are less concerning are released without
physician review, if they\'re normal, potentially. Things that are more
concerning are released only after review, and some things are embargoed
forever and only discussed in person.

The same type of schema might apply to this issue of getting around the
policy constraints of releasing laboratory data to nonordering
physicians. I just wanted to throw that out as something to be
considered.

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

You know, it strikes me: if as Blackford has indicated, there is an
exemplar there around security and release of lab data and algorithms
and embargo algorithms that have already been developed, as we consider
our implementation adoption conversations, right now it strikes me our
most important task right now is fact finding, broad net. But some of
these exemplars that already exist may really help inform our
deliberations going forward as well.

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

Lillee, this is Jason. I was just going to follow up on that. I think
that\'s a good idea at least to the patient, but in terms of the greater
context here, I think they\'re talking about this being information
sharing with other clinicians. And that\'s an issue with State laws that
have chosen to enforce regulations that are stricter than CLEA, which
serves as kind of the floor for regulation amongst all States, and
States can in fact then make a decision to provide stricter standards.
And that\'s where I think the difficulty would arise.

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

Well-said. Thank you. Thank you for the clarity. You\'re exactly right.

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

This is Rob Kolodner again from VA. Just to piggyback on what Blackford
is talking about, we\'ve heard about some of the complexity of the State
laws and how that could end up being a barrier. I think what Blackford
pointed out is that one way to address it is to have it to get between
commissions by having the patient act as a conduit or be able to throw
the switch.

In that case, it becomes an opt-in strategy, and we would be meeting the
charge of the committee to make a solution available, but not have it be
something where somebody could get a hold of my lab data when I didn\'t
want them to. So maybe an opt-in type of strategy, either through a
personal health record or, if I don\'t want to have a personal health
record, through a surrogate, and I authorize an entity to act as that
conduit. May be a way that we could deliver this within the year without
running afoul of all the legal barriers that would ensue if we tried to
do a straight provider-to-provider exchange.

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

Thank you. Rob and Linda, before I move on to the second outcome under
the first quarter, is there anything else that you\'d like to see framed
in this first part representing Jonathan there, or have we tackled that
sufficiently?

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

I\'m not sure that we finished on some of the detail about how much
historical data there was -- you know, one or two comments, but I don\'t
know that we reached a consensus yet. If we need to move on and deal
with that another time, we can, unless there are further comments.

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

No, I think we ought to tackle it if there are any other comments.

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

We have nothing in the queue right now, Lillee.

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

I -- this is Jason Dubois -- I can speak for some of our members, and I
will share with you, some clinical laboratories do not store patient
test result information longer than is necessary to transmit it to the
ordering physician and comply with any State or Federal regulations. So
obviously, this would be onerous. Any requirement to store information
for long periods of time in order for it to be accessible to a, you
know, to a national health information network or RHIO, you know, could
incur costs for the laboratories that are going to be asked to store
this data.

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

Jason, I think on any of this, it isn\'t so much a requirement that you
have to store, but it\'s whether, if you have it, whether you can
provide it, should provide it, or are allowed to provide it. Because I
don\'t think, in the context of this, we have the leverage to tell
entities what their archiving or storage policy must be.

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

Okay.

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

Jason, is that easy to come up, when we talk about historical data, to
inform our deliberations? Is that easy to ascertain, if these are the
top 20 labs in the United States, these are their store data policies?
Or is that something really difficult to get?

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

I don\'t know whether it\'s proprietary, but it\'s certainly something I
could -- if it\'s deemed not proprietary, then it\'s something I can
probably go and ask at least ACLA\'s member companies to provide
information on. And I could give you a ballpark estimate, I guess, or
something to that end.

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

That would be helpful. Any other historical data we should ask the staff
to help us with?

And John Houston, is there anything from -- from your long-term work
with the National Committee on Vital and Health Statistics that we
should be considering here, or have we tackled it?

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

Can you hear me?

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

Yes.

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

Hello? Okay, sorry, I wasn\'t sure I was on or not. I\'m just going to
go back to my earlier comment which -- I think a patient can send
authorization as it relates to releasing. This is going to be absolutely
vital here. And I think we have to think about a scheme in which we can,
in some type of efficient fashion, get patients to opt in. And I don\'t
know if patients in the middle of this is going to -- as I think
somebody had suggested -- is necessarily going to work. But I know
we\'ve really been focused in the privacy work, about how patients
either opt in or opt out of participating in any of these types of
things.

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

Good question; thank you. Not anyone else in the queue?

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

No.

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

Rob and Linda, can we move on?

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

Yes, Lillee.

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

Okay. Under "January to March 2006 Outcomes," our second task was to
identify local, State, and Federal agencies; NGOs; and private entities
that are needed to support the tools and solutions. And just as we had
the very robust discussion around the first task, there look to be some
obvious workgroup members here who could greatly, greatly populate this
piece. But I will defer from some of what my recommendations here, to
see those of you that would like to work on this particular component.

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

Lillee, I\'m wondering -- this is Rob Kolodner again from VA --

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

Yes.

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

The need to identify what entities are needed I see as being bundled
with knowing what the tools and solutions are. I don\'t know how you
would do that in parallel. And it would either have to be in sequence or
bundled into the -- you know, the suggestions that here\'s a tool, and
here\'s the kind of infrastructure or entities that are needed at
different levels.

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

You\'re exactly right. It\'s almost as if there were a matrix where the
existing tools and solutions are down the left-hand side of the page and
the local, State, and Federal agencies and private entities across the
top. That could speed adoption, support the tools and solutions.

But one of the things that strikes me is, you know, the CMS support with
strategies, in the private sector, certainly what Blackford is
representing, and what the Federation of American Hospitals are
representing, certainly the Veterans Administration and Department of
Defense, but I don\'t want to pull on you too much, because I think some
of the things you\'ll be able to help us here are very broad in the
first task. But again, this looks like the inventory of Federal, State,
local agencies, the whole 9 yards, to make sure we\'ve got them all
captured.

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

We\'re just waiting for some people to queue up, Lillee. Right now
there\'s nobody in the queue.

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

Come on, guys, get those fingers going on the star button.

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

Carolyn, let me ask you, does AHRQ have any lists somewhere? Given your
broad research base, do you -- is there any work that AHRQ has already
done around a master list of those who could be supporting the
implementation of this work or something that we could adapt?

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

Please open Carolyn Clancy\'s line.

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

I need a moment, please.

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

-- the RHIOs, because we\'ve got six demonstrations going on right now.
In terms of other master lists, we could certainly check that out and
get back to you. I actually interpreted this task as something of a
policy question, which we had started to get into in the sort of most
recent discussion.

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

Uh-huh.

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

And I almost feel like we sort of need a map of what policies are
relevant here or not. What I\'m a little less clear about is how much of
that territory has been covered by E-Links, and where we could step in
and supplement.

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

That\'s really good, that to me this is what is, and what needs to be.

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

Yeah.

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

I have a feeling that the "what needs to be" may be a pretty big bucket
here.

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

Well, I think that\'s correct, but I also think there are folks who work
on this stuff, and clearly, you know, at Blackford\'s institution,
they\'ve given this a great deal of thought vis-à-vis the patient
portal.

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

Yes.

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

And to be quite honest, I think there could be a huge contribution if
the -- you know, this would be quite an undeliverable, but if the
Community could make some of this clear for a broader audience, not as a
specific action, but just a clarification point, because my experience
is that institutions tend to address this one at a time: who has access
to what data under what circumstances, so forth. It\'s not clear to me
there are a broad set of policies that are relevant here. I mean,
there\'s sort of a State and Federal law that relate to laboratories,
but then there\'s issues that relate to the workflow piece and so forth.

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

Right. Right. Excellent comment. Anyone else?

Rob and Linda, how should we frame this? I agree that I think the
experience that Blackford has articulated at Partners, but also -- and
Blackford, maybe we need to open your line; has HIMSS -- put your HIMSS
cap on here -- has HIMSS done any research, white paper, process about
what\'s going to be needed to advance the tools and the solutions?

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

Am I on now?

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

Yes, you are.

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

Carolyn, thank you for the endorsement, I guess, but just sort of
returning to the basic question here, this task -- I\'m not sure it\'s
clear to me what the task is yet. Is it the policy framework at local,
State, Federal, or other agency levels, public or private, that are
relevant to this information sharing, or is it something else?

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

I think it\'s both. I think it\'s policy and practice. I\'ll ask --
I\'ll ask the staff for clarity. And then we\'ll come back to Blackford
to see if HIMSS has tackled this.

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

And I would agree; I think it is both. I mean, clearly there are policy
issues across the -- across the board here, but it also would help think
through the best way to operationalize something. If there clearly are
very -- stricter rules, privacy rules in one State, you might choose to
go to a different State, or we might choose to work within some of the
communities where we have HIMSS contracts. There are multiple ways we
can operationalize this based on the findings from the matrix.

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

Right.

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

I guess the knuckleheaded thought I would have is if one broke it down
to the practice versus the policy and tried to analyze both, I think I
certainly could describe, you know, our practice here in Partners
HealthCare, with both the patient portal and the EMR, frankly. Because
I\'m sure I broke a wide variety of laws when I was accessing both the
patient portal and my EMR from overseas recently. But you know, we are
accessing data essentially now wherever the Web will go. And the
practice, then, underneath that is, you know -- I can define to you sort
of basic policy and procedure in that regard.

The policy issues, though, I think, have been alluded to several times
already. If we were to imagine a world where either regionally or
nationally there were more salient information exchange, there are a
wide variety of policy questions that come immediately to mind as to
ownership and access rights and distribution rights, and even
aggregation rights and privileges or monitorization rights and
privileges with those data, secondary use for either marketing or
research, etc.

So, you know, I guess the -- what I\'m volunteering to do is to help on
the practice side. I think the policy side, now, putting on a HIMSS hat,
I would just to have inquire. I think the HIMSS has established a RHIO
coalition, folks interested, basically a workgroup interested in RHIO
formation and whatnot.

I think EHI, the e-Health Initiative, Janet Marchibroda\'s organization,
has also been doing pioneer leadership work in this area. We might tap
on them. I don\'t recall if Markle has done any survey in this area as
well. Does anyone know?

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

I don\'t know.

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

No.

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

The only reason I\'m not volunteering to lead this one is because
between now and the end of HIMSS, I have to chair the HIMSS meeting in
about 2 weeks, in the school is on vacation. I don\'t think I can comply
with the timeline.

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

I think your experience, though, is tremendous and helps us, so --

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

A coleader or something?

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

Coleader.

Barry, what about CMS? Certainly CMS looks to adoption strategies,
especially as you talked about the Vista project.

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

Can we open Barry Straub\'s line, please?

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

One moment, please. I\'m sorry; his line is actually disconnected.

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

Oh, okay.

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

This is Karen Bell. I\'ve just been notified Barry had a three-o\'clock
meeting that he had to jump off for. So he apologizes.

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

Well, I think everyone knows the rules of Robert\'s order that if you
leave a meeting, you get assigned a task, right? I just think that the
CMS staff would be enormously helpful to us in this one.

Howard, what about the Federation? Have you looked at this in any way in
terms of what\'s needed to support adoption?

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

I\'m embarrassed to say I just came. I was just out to get some water,
so I didn\'t hear the whole discussion. The one -- I wanted to go way
back, and we talked about all the high-tech stuff, in terms of
permission and authorized use.

Did anyone bring up just sort of the 12th-century -- probably the, you
know, minus 3000 B.C. method of paper, where, you know, in addition to
the clipboard, where you\'re writing in everything, your name and
insurance, there\'s some kind of, you know, some use form that we create
language through the use of some outside law firm, and we allow the
physician to adopt it, and they can use it and integrate it into their
clipboard? I mean, I really hate to go back to that; I would love for
something much more slick. But then that would get transmitted to the
lab, or, you know, something like that. Have we talked about that as
being one mechanism? I\'m just curious what people think of that.

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

Anyone?

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

To get to your question, we -- in terms of -- we mostly looked at the
financial incentives in terms of getting physician adoption, and we\'re
much more -- and this is not in the -- I don\'t think this is in our
purview of our subgroup here, our working group, but, you know, we
looked much more into Stark and antikickback and that kind of stuff
versus things we\'re talking about now.

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

Howard, did you hear that (inaudible) is working to what we need to do
from a policy standpoint versus what we need to do in from a practice
standpoint?

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

I did not.

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

And I think some of what you were just talking about was in that policy
area that we were talking about in terms of ownership, access rights,
secondary use, that type of thing that Blackford was just talking about.
But in terms of the practice components, has the Federation looked in
any way at tools and solutions that enable adoption, that you know of?

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

We really -- I\'m sorry; we really haven\'t. And again, even though I
represent hospitals, I\'m really thinking today my whole thought is, you
know, the one-to-six person physician office. We haven\'t -- and we
haven\'t gotten down to that level. We mostly talked about, again,
allowing our -- finding ways to allow our hospitals to push adoption via
Stark and antikickback and not actual practical tools.

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

Well, I think you could be extremely helpful, then, to the policy
component of this, if you could help this task.

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

That\'s fine.

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

And Karen, can we get Barry and CMS to help as well? Because I think
that their experience would help us a great deal.

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

Yes, I think that there are a number of people there that I can work
with.

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

Just based on this conversation, it seems like Howard, Barry, Blackford
-- let me see, here -- certainly John, especially as it terms -- John
Houston, as we talk about policy, confidentiality.

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

Please open Carolyn Clancy\'s line.

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

Please.

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

Hi, it\'s Carolyn again. I was just going to volunteer to help, because
it strikes me again that some of the State demos we\'re supporting would
be very helpful, here. For example, in Indiana, to move laboratory data
around, they\'ve already had to address some of these issues.

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

Great.

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

Obviously, they\'re only going to be focusing on their State, but I
could certainly work with my staff and get back to other folks.

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

That would be a great use case for us to look at though. Perfect.

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

Yeah.

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

This is Jason Dubois, just to interject here on a couple different
issues. One is, I think that what e-Health issue does have on this -- I
think somebody mentioned it already -- they recently did a report on lab
connectivity, and it does kind of address practical and policy adoption
strategies or barriers here.

Dr. Clancy mentioned the Regent Street Institute and their ongoing
project. And I remember Clem McDonald gave a presentation before MedPAC
-- maybe it was a year, year and a half ago -- and talked about the
transition of laboratory results, and I think the acme he used was
something akin to one hand clapping. You need to incentivize the
laboratories to help share this information, and there\'s no incentive
like money. And I think what they did was help provide a small -- some
type of pay-for-performance system where they did provide some
remuneration to laboratories to help transmit this information
throughout their network.

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

Jason, that\'s great.

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

And on the practical applications for laboratories, at least, I can only
give an example that a big incentive for us to get into helping create
standardization for laboratory results is, as I mentioned earlier,
helping to facilitate new relationships with the physician community,
given that so much of the resources today -- I mean, exactly the case
that EHI has talked about, this \$30,000 to \$50,000 that you have to
invest in order to establish connectivity with a physician or a
hospital, and by helping to eliminate that cost vis-à-vis standards for
result reporting and eventually lab test requisition, that that\'s going
to help facilitate more diffusion of laboratories into physician and
hospital practices, even into rural areas.

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

Okay.

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

Actually, Karen -- this is Howard -- I understand that I\'m working on
the policy with the other folks, but confidentiality, authorization,
privacy, what was -- that\'s one -- is there anything else I\'m -- you
wanted me to work on?

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

No, that\'s certainly what I heard. And remember, this task is around
what is and what needs to be.

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

Uh-huh.

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

Okay, it\'s like a two-column slide: what is, and what needs to be to
support the tools and the solutions.

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

Please open John Houston\'s line.

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

This is John Houston. From a privacy and security authorization
perspective, I obviously can help out on that regard.

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

Thank you. Okay, Linda and Rob, where are we? I think we have this
second task at hand.

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

I think we do. And Lillee, I think that we\'ve gone through the two
hardest tasks that we have as outcomes for the January-to-March
timeline. For the third one, which is to present a detailed timeline for
the realization of the specific charge to the Community, I would suggest
that maybe we work that on staff in the background after we see the
outcomes of the first two products.

Once we have both Karen Bell\'s documents as well as the outcomes of
these products, then we\'ll have a better idea of what we need to put on
that timeline and what that content will be. So at this point in time,
Lillee, if it\'s acceptable to you, possibly we move this item C just
into our own domain, and we can work on this alone.

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

That\'s great, that\'s fine.

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

Okay.

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

I think the group here has done a terrific job with these first two
tasks.

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

And as you said before, the outcome of the first two tasks is going to
be of great value, and it will be wonderful to report that out.

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

That\'s right.

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

And then the good news is that the January activities really roll into
the higher-level outcomes. So we\'ve already dealt with the outcomes,
and if you look at the wording on the activities, it\'s really just the
items that need to be done to create the outcomes.

So I think we\'re actually further along here than we thought we were.

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

So as you look -- I\'m looking at my computer screen here with our
developing timelines pieces. January activities look like they\'ve been
accomplished, except for this detailed environmental scan of existing
solutions. Is that something staff has under way or something we need to
do?

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

Karen, let me defer that to you.

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

I\'m right over here. I think it\'s a combination of things. Clearly, we
are looking at the possibilities of the models that can be set forth and
providing you with a lot of information around that. You, however, are
also going to be doing some work on your own that will help us scope
this out, and that was defined earlier when we had a discussion about
what we could do under FACA, and what we could do under FACA. So I think
we\'ve met the needs under this particular piece, and that will all come
together.

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

Okay. I want to make sure we didn\'t miss something there. I\'ll be real
excited to get the input back from the task set, and I want to thank you
all for your tremendous patience, but I really believe that we have a
pretty powerful matrix developing here to put in front of the full group
on March 7th.

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

And just a quick note, Lillee: the timeline that everybody has that was
handed out on the meeting agenda is divided into three slides. So if you
want to look at later dates, April to June and July and onward, let me
know, and we could advance the slides to show those.

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

Okay.

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

Would you like to go April to June?

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

Rob and Linda, is that okay with you? Are we missing something?

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

Lillee, I think we\'re still on page 4 of 7 of the agenda, the February
activities. I think most of these we\'ve already handled on our
(indiscernible). So "Receive input from the scans," that will take place
the last week of February, when we meet back here. "Develop detailed
operations work plan for the group," that will be an output once we have
a better idea of what our work will be.

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

Right.

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

For the March activities, the detailed recommendations, we\'ll have to
have a discussion on how we want to get this workgroup\'s concurrence on
that presentation before it is presented to the community on the 7th.
But maybe that will come together more in the week of -- the meeting at
the end of February?

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

And there\'s not a lot of time between February 22nd and March 7th.

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

That\'s right.

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

I do think this probably should be the Co-chairs, in terms of the "who."

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

Okay.

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

And then the "what" may very well be the deliverables that may come out
of our February 22nd session. So we need to let the work occur behind
the scenes before we can make other recommendations. Rob and Linda, what
do you think?

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

I agree, Lillee.

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

Can\'t do much more without some detail, here.

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

Right. Anybody who objects? Hit your star button. Star button?

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

And then the second March activity. Identify the policy and privacy
issues, I think we\'ve already done that with the inclusion of John
Houston and others on the second large outcome workgroup, or -- excuse
me -- work product.

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

Okay.

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

And that takes us to April and June. So at this point, yes, we would
advance the slide to the April and June outcomes.

And just looking at this, is there anything that we see that could be
picked up and started at this point in time? And I open this to the
group.

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

The notion of identifying public and business policies, that again may
be part of some of the work that will be reported out on February 22nd.
John is really bringing to the table -- John Houston is helping so much
around these privacy issues, and John, I would just ask that you keep
that front and center, keep us honest, here.

One we have not talked at all about is reviewing standards,
architecture, and certification criteria relevant to the realization of
the goal and make recommendations to the Community.

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

Lillee, I wonder if we\'ll go ahead and start that as we go through the
due diligence that Dr. Brailer requested on the evaluation of the E-Link
proposal. And I open that up to the group for comment.

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

Please open Blackford Middleton\'s line.

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

I just wanted -- two thoughts, actually; this is the part of the
conversation I\'m very interested in, and I think there might be a
couple of thoughts on both evaluating the E-Links architecture and
standards used not only as already alluded to but also de novo
considering, you know, what might be a, you know, a breakthrough
architecture or reference architecture, if you will, to achieve the
goal. So I wanted to throw that out as a possible task for us to
consider. But more importantly, I have a fax I have to get out the door
in 10 minutes, so I\'m going to drop off just for 10 minutes.

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

Breakthrough architecture; I like that.

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

Yeah. I will be right back.

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

I was going to ask his permission to pencil his name in next to this
item, but without him in the room, I think I\'ll go ahead and do so.

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

Pencil him in. Tell him we achieved consensus on that. Anyone else,
around this notion of standards architecture and certification criteria?
Pam, how about you?

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

Operator, please open Pam Pure\'s line.

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

No, I\'m in agreement. Again, I think a lot of this work is going to
come together when we decide what platform we want to build this out on.

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

Okay. All right.

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

This is Howard Isenstein. I mean, one thing, I keep looking at this
timetable, and I always -- looking at it -- this is great -- then I go
back to the specific charge for the workgroup and, you know, within 1
year. And you know, that really circumscribes our work here. Because,
for example, on the policy -- let\'s say barriers, for example -- if we
determined, hey, we need a new regulation or congressional legislation
or whatever, I mean, all that is completely out of the question, as far
as I\'m concerned.

Is that wrong? I mean, or -- we\'re purely talking about getting
something quick and dirty so that we can have a demo in 11 months?

And so all of the stuff that we\'re coming back with, we might want to
talk about here, are long-term barriers. But in terms of what our charge
is for the next 11 months, I don\'t think that can be part of it. Is
that right?

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

This is Lillee. I\'ll give you my sense and then ask the staff to chime
in, but I certainly didn\'t get a sense from Secretary Leavitt that we
were to delay any recommendations that we needed to make. Granted, the
implementation of those recommendations may be a little bit longer, but
I\'ve also seen that when we have to do something, we move mountains.

And I just keep referring back to -- I know what Dr. Brailer did with
creating KatrinaHealth.org within 1 week of Hurricane Katrina, and it
still amazes me how we could pull off something like that in 1 week, and
yet it takes us years to implement other things. So Karen, do you want
to comment?

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

This is actually Dana. One thing I was going to say is that we\'re
hoping that the workgroup make a series of recommendations, one
beginning on -- for the meeting of the 7th, and then the June meeting,
and then the October. So it\'s not just one time where there\'s an open
platform, but -- and hopefully, we can get the hardest things in front
of the Community first, because it\'s going to take more time to move
the bigger issues than waiting for the big stuff at the very end.

So, you know, should you make recommendations now? Certainly, just
identify, and then there will be several more times for you to be able
to put things in front of the Community, most certainly. Karen, anything
to add?

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

That\'s absolutely correct. And I think, just to sort of go back again,
from March 7th, the recommendations really are about what is this going
to look like, where is it going to be ruled out, who is going to be
involved, and some listing of the big issues. Because at the April 25th
meeting is, you will have the opportunity to go back to the Community
with some of the major levers that you think the Federal Government
might be able to exert in order to address those big issues. And then
the rest of the work can follow, subsequent to the AHIC meeting.

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

Okay, good.

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

Nobody in the queue right now, Lillee.

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

No one in the queue, all right.

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

Shall we move through the calendar with the July--September outcomes?

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

That would be great.

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

Thank you for the context now. That makes sense that this can be work
that we build and develop off of what we discover as we go forward.

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

And again, you want us to just look at this segment of work to see if
there\'s anything that can be jump started now?

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

Yes, exactly.

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

This looks more like pilot and rollout, though, and --

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

It does.

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

We need a little bit more time here.

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

I agree.

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

But it\'s important for the public and others who are viewing this to
understand what the workgroup agenda is and what the time frames are.

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

I\'d like to make a quick note here. It looks as though the
July-through-September portion of the timeline did not make it online.
So we have the October-through-December piece, but we don\'t have the
July-through-September slide to look at right now.

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

Dana, will these be posted on the HHS Web site for the public to see?

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

Yes, they will.

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

Okay, good.

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

And this is the same content that\'s in the agenda as well; the agenda
has already been posted, correct?

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

Yes.

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

Okay, great.

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

That\'s really why I wanted as much of the time frames embedded into the
agenda, so that everyone can see not only how aggressive it is but how
comprehensive it is. Okay. We\'ll advance the slide.

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

Would you like to go beyond the October--December or do you want to stay
and work with the October--December piece of the timeline?

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

I think we were saying that the October--December piece of the timeline,
we are under resourced in terms of our knowledge to be able to comment,
here. And this also alludes to the final report.

Rob or Linda, am I missing something there, or --

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

I agree.

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

I just don\'t know how we can do more. I want to make sure we have
plenty of time for public input; that is such a vital part of our
considerations here.

Let\'s move to next steps. I think that the next steps have really
fallen out with clarity around the tasks at hand in order for us to
advance our knowledge and make good, purposeful decisions on our
February 22nd conference call or meeting. And I know that the staff is
also going to get to us -- pawing through my notes, I know everyone
there has the same situation. Karen Bell is going to summarize and
provide a document to us within 2 weeks around some of this modeling
aspects. And we have two workgroups within the workgroup that are going
to help us identify existing tools and solutions, as well as the
enablers to support those tools and solutions.

What am I missing, here? In terms of next steps, everyone please chime
in.

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

The one part that I captured, Lillee, when Dr. Brailer was talking, is
the specific charge for the workgroup at the March 7th presentation.
They expect us to really be able to drill down on each of the words. So
for example, "standardized," what does that mean? "Widely available,"
what does that mean? "Secure solutions," what does that mean?
"Historical." And I think we\'ve already touched on much of this, and
will be in a much better position to be able to come up with the
drill-down on these words within a specific charge, which will be our
high-level principles and scope that will guide us for the rest of the
year as we work through this.

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

Right. And you know, something that we know now that we didn\'t know at
the beginning of the call, for instance -- maybe others did; I know I
certainly didn\'t -- was the notion that Jason brought up, and that is
the amount of institutional memory around how long lab results may be
archived. So just by having a little bit more of that information is
going to help us a great deal.

Anything else around next steps?

Okay, Matt, I\'d ask you to help us on how we will engage public
comment.

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

Sure. What\'s going to happen now, I\'m going to put a slide up on the
Webcast for any of the members of the public to look at, and that has
call-in information and the password for connecting to the conference
and instructions on how to indicate that you have a question or a
comment to make.

In the meantime, while I put that up and we wait for members of the
public to queue up over the phone, I will ask Dana if there\'s any
members in the live audience who wish to make a comment.

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

No comments from here, thank you.

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

Okay, Lillee, it\'s probably going to take a few minutes for people to
call in and to get through to the conference. Feel free to talk, and
I\'ll just jump in and let you know when we have some people ready to
make comments.

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

Okay. Well, Rob and Linda, maybe one thing we can do is review our
break-through workgroup activities and Community milestones which is one
of the documents sent out in preparation for this call, just do a check,
I\'ll make sure that we\'ve accomplished what we needed to get
accomplished. But between January 30th and February 2nd, I think we\'ve
been able to press forward -- make forward progress on most of these.

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

Lillee, as you notice, the schedule that is in the agenda is pretty much
a cut-and-paste directly from there.

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

Yeah, that\'s great.

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

Lillee, we have our first public comment. Would you please open Steven
Keeler\'s line?

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

Hello, Steven, we\'d like to hear from you.

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

Operator, do we have that line open?

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

Give me just a moment.

Mr. Keeler, your line is open.

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

Hi, Lillee. Thank you very, very much; it\'s been very helpful. I\'m a
vendor in this space with a fairly unique personal health record
application live in the marketplace. I wanted to know -- I don\'t know
Pam -- how we would be able to share with her our experiences in working
with providers and payers and patients, with our application, and, you
know, get on the inventory list.

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

Thank you. We appreciate you calling in. Matt, is there anyone else in
the queue?

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

Not presently, but we should probably hold on a few more minutes and
wait as people call in and get through. The process takes a few minutes.

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

Thank you. Please let us know.

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

Okay. We have an additional comment now. Operator, please open Neville
Coward\'s line.

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

Neville, your line is open.

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

Good afternoon. I\'d like to thank you all for the privilege of allowing
us --

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

Mr. Coward, would you please speak a little closer to your phone?
You\'re a little hard to hear on this end.

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

Okay, I\'m sorry about that. My name is Neville Coward, and I\'ve been
listening to your conference. I think it\'s very informative, and I
really appreciate the fact that your conference is open to members of
the general public like myself. So I\'d like to start at the beginning,
because I know this is at the end, where you guys start at the beginning
-- have done an eloquent job. I really appreciate all speakers and the
conclusion that you guys have met in terms of advancing this whole
process.

But I\'d like to start back -- I\'d like to start with Congress and go
to the White House and down to the Secretary and bring us back to these
meetings. The reason I say that is, as a taxpayer, I don\'t plan on
paying any new taxes for anything. So I think, basically, what my basic
suggestion is that the American health care system really isn\'t broken,
that what happened in the health care is just at the turn of the
century, most companies were spending about \$8,000; health care was
spending about \$1,000 on technology. So nowadays, you have an
initiative everyone wants to fund.

But I want to start by saying that health care is a business, and a
business itself, to me, is that each and every person\'s medical record
is currently within health care compliance; it\'s a licensed body by the
Federal law and State authority. So whether or not we start talking
about bringing this into the electronic era or using the old
horse-and-buggy-whip pen and paper, it makes no difference. It\'s still
a person\'s medical history. My point is saying it\'s proprietary
information to whoever holds it.

Therefore, I think that HHS should be focused on bringing -- making sure
this information becomes accessible and interchangeable and not trying
to reinvent the wheel, because I heard throughout this whole process
that millions of dollars have already been invested in health care. So
we don\'t need to reinvent the wheel. What HHS needs to be focused on is
what would it cost for this entity that\'s holding this patient\'s
medical history, whether it\'s the hospital, a clinic, because in
hospitals, we have hospital cards; in clinics, we have clinical cards;
Medicaid, we have Medicaid cards. Totally.

We\'re talking about one point -- I don\'t remember the exact number,
but about a couple trillion dollars we\'re talking here the other day
about what we spent a couple years ago in health care, \$660 million for
people who got job benefits, about \$600 billion for people who have
Medicaid benefits. The bottom line on this is that there\'s money
already being spent. The objective here is to find policies that\'s
going to allow the system to cut overall health care costs. And instead
of us sitting here talking about "Let\'s do this" and introduce these
policies, these are great in the sense that they are overall policies
that need to be examined by HHS. But I think the strategic objective
here is to try to get electronic health care measures, and we should
confine ourselves to bring in policies in place as you go over the
course of the year only to strictly advance health care.

Now, that\'s my basic opinion, that, you know, concerning what I think
that, you know, that we should be focused on. One of the things I want
to change --

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

Mr. Coward, I\'m going to have to jump in here. We ask that we keep the
public comments brief just so everybody can get through. If you want to
take about 10 more seconds and just wrap it up.

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

Okay, I will. I just want to say that in yesterday\'s conference -- I
just want to say that there was a comment about the delivery of service
that patients want 58 percent; the doctors, 50 percent of the payers;
and 12 percent to something else. And I just want to say to you guys
that throughout all the conversation today, I heard two Web sites that
you \--

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

Okay, Mr. Coward, I\'m sorry. We\'re going to have to go to the next
public comment. Operator, would you please open Peter Winklestein\'s
line?

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

Yes, hello, is my line open?

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

Yes, it is.

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

Yes, this is Peter Winklestein from Roswell Park Cancer Institute.
Somewhat difficult to follow the previous comments, I\'m sorry to say.
I\'d like to pick up on some of the comments that were made earlier at
the very beginning of the conference, regarding the scope of the
committee\'s work.

If, as David Brailer suggested, the goal is to improve EHR adoption
rates, then I think that you have to be very clear about whether or not
you are approaching your task with the laboratory data from the
patient-centric point of view or from the physician-centric point of
view, and I know there was some discussion on that, and I would like to
put my -- I\'d like to suggest that the patient-centric point of view is
a -- I think, has a greater chance of encourage EHR adoption on a wide
basis. Blackford Middleton\'s experience at Partners and Partners\'
wonderful patient portal, I think, would support that.

And so I just wanted to add my comment that I think the patient-centric
view and close cooperation with the consumer empowerment group, I would
encourage that for this group. Thank you very much.

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

Lillee, the queue is empty. I will defer to you in terms of how long you
want to wait for additional call-ins. I\'m sorry; we just had one person
jump in as I was saying that. Operator, please open Janice Zalen\'s
line.

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

Hi, is it open?

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

Yes, it is.

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

Thank you very much. I\'m with the American Health Care Association, and
I\'m concerned that long-term care facilities, such as nursing
facilities, seem to be completely left out of the equation here. Lillee
Gelinas opened the meeting pretty much by pointing out that being from
New Orleans, she\'s very -- that really shows how important the need for
electronic health records was during Katrina, and everybody pretty much
also knows how particularly important it would have been for nursing
homes.

We have patients with Alzheimer\'s who ended up in other States, and
they didn\'t know their names and didn\'t know where they were, and they
didn\'t even know their medications, and their families couldn\'t find
them. And to be talking about Q/Care and physicians and talking about
labs and hospitals, but leaving out nursing facilities, where, you know,
just having the electronic health records stop at the door at long-term
care facility, doesn\'t make a whole lot of sense to me.

I think you\'ll be needing to look at the barriers for nursing
facilities, as well as the barriers that physicians have and hospitals
and labs have, and think about ways to incentivize the nursing homes. So
if there\'s anything we at the American Health Care Association can help
with that, we\'d be happy to do it, but we surely don\'t want to see
that whole segment of the health care infrastructure left out.

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

Thank you. Please open Adrian Groper\'s line.

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

Hi, my name is Adrian Groper with MedCommons, and I\'ve heard two
different approaches during the conference, one of them I would
characterize as portals into RHIOs and large enterprise systems, and the
other one I would characterize as patient-centric and primary care
practice, six physicians or less focus.

And one suggestion, or one -- yeah, one suggestion I have is that the
portals and the large enterprise systems could adopt a
primary-care-friendly architecture by opening up or standardizing the
way that the primary care physicians within an enterprise or RHIO
communicate with the RHIO itself, instead of simply making the portals
look into a proprietary or an otherwise closed system. This would help
pay for performance, and it would also make the whole system much more
open in general.

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

Lillee, the comment queue is empty right now, and I\'ve been signaled
from the operator that nobody else is calling in at this point.

I just want to let members of the public know, if you do want to make a
comment, I will put up a slide very shortly that has an e-mail address
which you can send your comments to, and we will forward them on to the
Co-chairs of this workgroup.

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

Yes, I think up on the screen right now is the public input piece.

Rob or Linda, and to the staff there at the Humphrey Building, is there
anything more to accomplish today?

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

Yes. What I\'d like to do is just remind everyone that our next meeting
is on February 22nd. We\'ve got a lot to get done before then. If you
have any comments or questions, please don\'t hesitate to forward them
to Karen Bell at karen.bell@hhs.gov or to myself, Dana Haza, dana.haza,
spelled h-a-z-a, @ hhs.gov. The minutes for this meeting will be
available 5 days from now, and we will get those up as fast as we can.
And we also encourage those of you that are in Washington. We\'ve had
three members present here today. I think that there is a quality to
being present, and please feel free to join us in person at the HHS
building for the 22nd.

Thank you all, and thank you for the wonderful leadership, both from Dr.
Perlin and his team and from Lillee. And Co-chairs, I\'ll let you all
close it out. Karen, do you have any comments?

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

My closing comments are just to thank you all very much. It\'s been a
very robust discussion. We\'ve pulled out a lot of good information and
a lot of direction from all of you in terms of what we can do in terms
of next steps to support you. So I have no doubt that you will have a
very succinct and focused set of recommendations on March 7th. And thank
you all again. And I\'ll be available to all.

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

Rob and Linda, any last comments?

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

Just to thank everybody for a very productive meeting and appreciate
those who stayed to the end. Look forward to the next meeting.

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

Well, to everyone there, wherever you are, I really want to thank you
for open, honest, robust dialogue. I want to encourage more of that;
that\'s how we get the task at hand accomplished. Many, many thanks to
the staff; you\'ve done a terrific job in your coordination and in the
materials compilation here.

Dana, do I assume the time of the meeting on the 22nd is the same as the
time for this one? I didn\'t hear a time.

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

That is correct. We\'re keeping the times all the same so that we\'re
considerate of our West Coast community members.

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

So that would be 1 p.m. Eastern Standard Time on February 22nd?

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

Yes, ma\'am.

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

With that, everyone have a wonderful afternoon. We will talk to you on
the 22nd. Bye, now.

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

That will conclude today\'s conference call. We\'d like to thank you all
again for our participation and wish you a great day.