American Health Information Community

Quality Workgroup Meeting

September 22, 2006

**Disclaimer**

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

**[\>\> Carolyn Clancy:\
]{.underline}**We'll hear from Dr. Rob Kolodner who is the new interim
National Coordinator, an announcement we\'re quite excited about. We\'d
like to do a quick roll call.

**[\>\> Matt McCoy:\
]{.underline}**Okay. And this roll call, we\'re going to have full
introductions \-- or let the participants introduce themselves later in
the meeting so I\'ll \-- I\'m sorry? I\'ll quickly run down the names of
those members who are calling in on the phone and we\'ll have somebody
at the ONC building do the same for members live in the room, and as I
said we\'ll get full affiliations and introductions later in the
meeting. So calling in for today\'s meeting, we have Mark Leavitt, Janet
Corrigan, Susan Postal, Margaret O\'Kane, George Isham, Jonathan Teich,
Abby Block.

**[\>\> Abby Block:\
]{.underline}**Here.

**[\>\> Matt McCoy:\
]{.underline}**Nancy Foster. Charlene Underwood.

**[\>\> Charlene Underwood:\
]{.underline}**Here.

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

**[\>\> Helen Darling:\
]{.underline}**Here.

**[\>\> Matt McCoy:\
]{.underline}**Our Co-chair Clancy. Reed Tuckson, and Theresa Cullen.

Is there any additional Workgroup members who are called in whose name I
did not read off? And Kelly, I think you have a few people there in the
room, you can introduce them and then I\'ll do a quick rundown for the
call-in procedures for everybody on the phone.

**[\>\> Kelly Cronin:\
]{.underline}**Margaret van Amringe, Barry Straube from CMS, and Rob
Kolodner.

**[\>\> Matt McCoy:\
]{.underline}**Quickly, since this is a different platform for a meeting
and the first time this group is coming together I\'ll go over a couple
of key points for how we make this whole thing work. All the members of
the Workgroup have an open line, so you can chime in whenever you need
to during the meeting. We just ask that when you\'re not speaking, you
keep your phone on mute so we cut down on the amount of background
chatter that gets into the meeting.

Then when you do come in to make a comment, please say your name first
because we\'ve got members of the public listening over the phone and
over the Web and it\'s hard for them to identify who is speaking if you
don\'t introduce yourself.

With regard to the Webcast, I believe most of you are logged in. If
you\'re looking at the slides and following along, please don\'t press
any of the buttons that are on the left hand panel. Those change and
advance the slides not just on your screen but everybody\'s screen who
is following along with the Webcast, so it can get fairly confusing.

And one last piece of business, the log-in information we originally
sent out for the Webcast contained one wrong item. The room number you
should be logged into is 828-5155. I think originally what we sent out
was 5166. So again, the room number is 828-5155.

**[\>\> Matt McCoy:\
]{.underline}**Carolyn, I think that does it for our opening
housekeeping.

**[\>\> Carolyn Clancy:]{.underline}**\
Terrific. So can I turn to Dr. Kolodner now at this point?

**[\>\> Rob Kolodner:\
]{.underline}**Thank you, Carolyn. Well, I want to just give you
greetings. I am now five days into my role as the interim National
Coordinator. I\'m on detail from VA, and that\'s the reason for the term
interim. So I\'ll be here for the next few months. And look forward to
working with all of you, looking forward to working with the ONC staff
as well, to help move the agenda forward and increase the trajectory and
speed to make sure we are able to deliver a number of the items that we
have promised to.

In the short time that I\'ve been here, it\'s clear, when I get with the
Secretary, that he very clearly frames that while some of us like IT,
and toys, the purpose of them is to improve quality and to cut cost for
care, and that\'s something that I think in looking at the list of
participants here in the Workgroup, all of you are very well aware of
the opportunities there. So that this group, which is critical in
helping us to identify the targets that we can (indiscernible) and
deliver, is one that is very much in line with the way the Secretary
talks about the entire initiative. Look forward to meeting with you
periodically and seeing the progress you make. Thank you very much.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much, Rob, and since this launch occurs
during your first week as the National Coordinator, I know that means
we\'re going to have a special place in your heart and on your agenda.

\[laughter\]

**[\>\> Rob Kolodner:\
]{.underline}**And as you know, Carolyn, with the background that I
have, certainly in VA we were able to tie these together and serve that
as kind of a laboratory of what happens when the alignments are right
and the things go forward. That\'s what we really need to do for the
Nation. And for those of us who aren\'t veterans, that\'s how we\'re
going to benefit. So I look forward to a great success in this area.

**[\>\> Carolyn Clancy:\
]{.underline}**Terrific. Thank you. Let me welcome everyone and thank
you for making the time today, and thank you in advance to members of
the Workgroup and others who have joined us for the contributions
you\'ll be making in the future.

Those of you who were actually able to attend the meeting of the
American Health Information Community on August 1 will recall that I
believe we went about an hour over time, which was a very clear
reflection to me of the excitement among members of the Community for
this topic. And we will be shortly going through the specific and broad
charges, but what I simply wanted to say was our charge, as I see it, is
to make sure that the dots are connected between IT and all the power
and potential it brings to transform health care, and the quality
enterprise.

Right now, that is not as connected or as aligned as the \-- as some of
us would like to see happen, and we\'ve got a lot of work in front of us
to make sure that indeed health IT and all the power it brings can
actually serve the overarching goal of improving quality and value in
health care. To say this is high on Secretary Leavitt\'s mind I think
would be a profound understatement, and I know for many of you on the
call this pretty much defines a great deal of your working day as well.

So we certainly have a lot to do to improve health care with the group
of folks convened on this call. I know that we\'re going to make
enormous progress.

Let me also just say that I had a chance to speak with Rick Stephens
last week, who shares my excitement about all this. He may even \-- he
speaks quite a bit more rapidly, so he is pretty excited and passionate
about the topic as well. I think he\'s going to be joining us at noon
today. Is that correct, Kelly?

**[\>\> Kelly Cronin:\
]{.underline}**Yep, that\'s right.

**[\>\> Carolyn Clancy:\
]{.underline}**Great. So with that, I\'d like to turn now to
introduction of the participants. So I\'m Carolyn Clancy, the Director
of the Agency for Healthcare Research and Quality, have had great
opportunity to work with both colleagues within the department,
particularly Barry Straube and his team at CMS, but also (audio
interruption) from the Indian Health Service, many other projects in the
department and many folks in the private sector and I can tell you we
have a really terrific team here assembled. By way of background I\'m an
internist, I\'ve been with the agency for 15 years, and \-- as one
person I\'ve been dreaming about this day. So I think I\'ll just \--
I\'m going to go in alphabetical order. Abby, you just introduce
yourself briefly.

**[\>\> Abby Block:\
]{.underline}**Hello. I\'m Abby Block. I\'m the director of the Center
for Beneficiary Choices at CMS. The center administers both the Medicare
Advantage Health Plan and the Medicare Prescription Drug Plan. And
obviously we have a very great interest in the area of quality and
quality measurement.

I know, I think, almost all of you from my previous life where I
administered the Federal employees health benefits program at OPM. And
have been involved in quality initiatives for probably close to 20
years.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks, Abby. Is Janet Corrigan on in the line?

**[\>\> Janet Corrigan:\
]{.underline}**Yes, I am.

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

**[\>\> Janet Corrigan:\
]{.underline}**I\'m the President and CEO of the National Quality Forum.
We are a public/private organization that is charged with endorsing
national performance measures for public reporting and pay for
performance purposes.

I wear another hat. I also chair the Harmonization \-- Measurement
Harmonization Workgroup of the Quality Alliance Steering Committee. So
I\'m spending a lot of time actually trying to figure out how to
encourage more consistency in how performance measures are specified and
developed.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks very much. Helen Darling?

**[\>\> Helen Darling:\
]{.underline}**Yes, I\'m President of the National Business Group on
Health, formerly the Washington Business Group on Health, a membership
organization of mostly large employers, and our members will be major
consumers of and users of the information that this process generates.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you. Anne Easton?

**[\>\> Matt McCoy:\
]{.underline}**Yeah, I don\'t think she\'s joined us yet, Carolyn.

**[\>\> Carolyn Clancy:\
]{.underline}**Okay, Nancy Foster.

**[\>\> Nancy Foster:\
]{.underline}**Good morning, to all of you. I\'m Nancy Foster, I\'m the
Vice President for Quality and Patient Safety Policy at the American
Hospital Association. I also have the pleasure of serving as the
principal staff person for the Hospital Quality Alliance because the AHA
is \-- there\'s a convener for that group. So in that role I\'ll be
talking to you later today, but I wanted to just offer a particular
congratulations to Rob. A few years ago I worked with many of you who
were in Federal service on the Quality (indiscernible) Coordination Task
Force and Rob, we came in touch over that and I\'m really glad to be
able to work with you again.

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

**[\>\> George Isham:\
]{.underline}**Hello. I\'m George Isham, I\'m the Medical Director and
Chief Health Officer at Health Partners here in Minneapolis, MN. I\'m in
that role responsible for our quality programs, and involved quite
heavily in the Community in promoting quality measurement and quality
improvement for a number of organizations.

And then in terms of involvement in national activities, very active
these days in the AQA, as Co-chair of the Data Aggregation Workgroup of
that alliance. Also involved in a number of other things and very happy
to be part of this conversation, which I think is very important to
bringing quality measurement together with the requirements of
automating electronic data.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks, George. Is Jane Metzger on the line?

**[\>\> Kelly Cronin:\
]{.underline}**Carolyn, I don\'t think she is. But I did want to point
out we have a typo on the slide on the Webcast. She\'s from the First
Consulting Group but I think important to point out is that she\'s also
a board member of the Certification for Health IT, and has been really
an active board member and very in touch with where the vendor community
is right now with respect to both clinical decisions support and quality
measurements. I think she\'ll be a great contributor.

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

Jane should be on the call very shortly. There actually are two Jane
Metzger and I think some of the materials went to the wrong one so I
sent her some of the information.

**[\>\> Kelly Cronin:\
]{.underline}**Our apologies, we rectified that earlier in the week.

**[\>\> Carolyn Clancy:\
]{.underline}**Peggy O\'Kane.

**[\>\> Peggy O'Kane:\
]{.underline}**Hi. I\'m the President of the National Committee for
Quality Assurance, we\'re a 501(c)3, probably best known for being
developers and implementers of HEDIS, the health plan data and
information set, which is, I think, the first nationally implemented set
of performance measures that\'s been widely used for over 10 years.

We accredit health plans, we have recognition programs for physicians
and we\'re involved in a gaggle of quality projects including helping
with the measures development for AQA, working with the physician
consortium for practice improvement of the AMA on measures development.
We\'re the measure developers and aggregators for the integrated health
pay for performance project in California, just among others. Glad to be
here.

**[\>\> Carolyn Clancy:\
]{.underline}**And knowing about the work events of AQA, that is a very
succinct synopsis. Thank you. Susan Postal?

**[\>\> Susan Postal:\
]{.underline}**Good morning, this is Susan Postal and I\'m the Vice
President of Health Information Management for AQA. I work out of our
corporate office in Nashville, supporting our hospitals and other health
care treatment entities in the operational management of health
information to support quality health care. Looking at how we have to
have effective processes in place to support the collection and the
dissemination of that data for quality health care advancement.

Prior to joining AQA, I worked with Quorum Health Resources and have
also held roles as the health information management director in
hospitals in Chicago, Phoenix, and Iowa, and I\'m pleased to be part of
this work. Thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much. Is Jerry Shea with us today? Okay.

**[\>\> Kelly Cronin:\
]{.underline}**I think he\'s joining us later.

**[\>\> Carolyn Clancy:\
]{.underline}**Okay. Let\'s turn to Barry Straube, then.

**[\>\> Barry Straube:\
]{.underline}**Thanks, Carolyn, I\'m Barry Straube, a nephrologist and
transplant physician by training, having served at primary, secondary,
tertiary and quaternary care, and including on the hospital board and
being involved with medical staff issues. Then at a large national
health plan as Vice President of Quality Improvement, and most recently
I have two titles at CMS. One is Director of the Office of Clinical
Standards and Quality, where we oversee coverage and evidence-based
decisionmaking in the agency; regulation writing for conditions of
participation and other quality standards; quality measurement and
health assessment development; quality improvement group work which is
primarily involved with oversight of the quality improvement
organization program; and we also have an information services group
which is involved with collection, aggregating and reporting of data.
I\'m also Chief Medical Officer for the agency, which gets me involved
with looping in all the other components of the agency into the quality
program, but also getting involved with other activities in the agency.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks very much. Is Jonathan on the phone yet?

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

Yes, I am.

**[\>\> Carolyn Clancy:\
]{.underline}**Great, can you introduce yourself.

**[\>\> Jonathan Teich:\
]{.underline}**Thanks. I\'m Jonathan, I\'m a physician and professor at
Brigham & Women\'s Hospital in Boston, founded the Clinical Information
Systems Department there, and I\'ve been involved from academics, from
industry and government sides on a variety of quality improvement and
quality reporting efforts. I\'m Co-chair of the AMIA and just rolled off
as director of the HIMSS, and have been particularly involved in the ONC
and AHRQ roadmap for national action on clinical decision support, which
was presented to AHIC in June. And I\'m hoping to chip in not only to
the quality reporting discussion where I have involvement but also the
other part of the group\'s broad charge which is to accelerate the use
of clinical decision support and other strategies to improve the
performance and execution of quality.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks very much, Jonathan, and we will come back to the
critical importance of thinking about how Health IT can not only
accelerate and scale our capacity to assess quality, but also transform
our capacity to feed that information back to those delivering care to
be able to make improvements.

Reed Tuckson?

**[\>\> Reed Tuckson:\
]{.underline}**Thank you. I am the Physician Senior Vice President of
United Health Group, a large health and well-being company that is
involved in these issues from the point of view of being a very large
insurer that has to be active in this area. And also we have a company
called Engenics that is also very much involved in data acquisition,
analytics and reporting. I just finished a tenure on the initial board
of the CCHIT, and I\'m active ongoing in a variety of ways with AQA,
among other related initiatives. Thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you. Margaret van Amringe?

**[\>\> Margaret van Amringe:]{.underline}**

Hello I\'m Margaret, I\'m Vice President for Public Policy and
Government Relations at the Joint Commission on Accreditation of
Healthcare Organizations and fortunately we may be shortening our name
soon. I'll make my introduction shorter. I\'ve been working with quality
of health care for over 20 years, now both inside the government and
outside the government. Inside the government, at what is now CMS, and
AHRQ, a number of years there. But at the Joint Commission, I\'ve been
working in quality for \-- and patient safety really \-- for over 10
years now and the Joint Commission has a 60-year history of collecting
information on quality. We have accredited over 15,000 health care
organizations, both acute care and post acute and ambulatory care. Our
interest in collecting information in the new digital electronic age is
quite acute. We have performance measurement requirements on all our
accredited organizations and that\'s about been about 10 years now for
hospitals and shorter time for some of the others but are very
interested of course in how we can have more efficient data collection
and better use of information technology to assess quality of care.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks very much. Is Josie Williams on the phone? Okay.
Well, thank you all for introducing yourselves.

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

**[\>\> Josie Williams:\
]{.underline}**Can you hear me now?

**[\>\> Carolyn Clancy:\
]{.underline}**Oh, yes, great.

**[\>\> Josie Williams:\
]{.underline}**Oh, great. I\'m sorry, I\'ve been trying \-- having a
little technical challenge.

I\'m Josie Williams, Texas A&M Science Center, and the Rural Institute.
And I started to say I\'m a physician by training but then I realized
that my interest in quality care and patient safety probably came
because I was an R.N. long before that. Began to measure quality in my
office in \'83, found I couldn\'t do it very well, subsequently have
been involved in both the Physician Consortium for Performance
Improvement and am a Commissioner on the Joint Commission, and in my
real life, I have a large small \-- large network of small and rural
hospitals doing a number of safety programs.

**[\>\> Carolyn Clancy:\
]{.underline}**Great, well, thanks very much, Josie. And thanks to all
of you again for making the time.

I think we\'re going to turn now to the specific and broad charges from
the American Health Information Community.

**[\>\> Kelly Cronin:\
]{.underline}**Carolyn, this is Kelly, I wanted to mention Charlene
Underwood has joined the call as well as Rick Stephens.

**[\>\> Carolyn Clancy:\
]{.underline}**Terrific. Welcome, Rick. We have a fabulous group of
folks.

Charlene, would you like to introduce yourself?

**[\>\> Charlene Underwood:\
]{.underline}**Yeah. I\'m Charlene Underwood, and my \-- my job is I\'m
the Director of Industry and Government Affairs at Siemens Medical
Systems. The other hat I wear is I\'m Chair of the HIMSS EHR Vendor
Association, a trade group of over 40 ambulatory and acute care vendors
who provide EHRs to the majority of the health care providers in our
market States. And it\'s a real pleasure to be part of this Workgroup,
and clearly a role and I think Carolyn reinforced that when she said
having HIT at the table so we can talk about the intersection of
bringing quality, will be crucial in the involvement of the vendors of
knowing what these requirements are, not only to report them but more
importantly to help them in their capabilities support the processes
that lead to improving the outcomes we\'re all striving for. Thank you
again, appreciate it.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you, Charlene.

**[\>\> Matt McCoy:\
]{.underline}**Just, I\'m sorry to butt in, it sounds like somebody\'s
got their computer speakers on and we\'re getting pretty strong echo. So
quick reminder, if you\'re on the phone, mute your computer speakers so
we don\'t get that delay on the audio. Thanks.

**[\>\> Carolyn Clancy:\
]{.underline}**Rick Stephens, now that you\'ve joined us, do you want to
introduce yourself to the group?

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

Carolyn, he\'s dialed in, but I think he might have temporarily stepped
away.

**[\>\> Carolyn Clancy:\
]{.underline}**I got it, okay. Well, why don\'t we just move on, then,
to the specific and broad charges from the Community.

And I\'m just looking for my piece of paper. Forgive me. Here it is. It
did pop up on the Web site. Because I think there\'s potentially so much
work to do, I actually do think it\'s worth a few minutes to focus our
attention on the broad charge for the Workgroup from the Community, and
then the specific charge. The specific charge defining what will be the
near-term agenda for our work.

So the broad charge is that we are to make recommendations to the
American Health Information Community so that health IT can provide the
data needed for the development of quality measures that are useful to
patients and others in the health care industry, automate the
measurement and reporting of a comprehensive current and future set of
quality measures, and accelerate the use of clinical decision support
that can improve performance on those quality measures.

Also, to make recommendations for how performance measures should align
with the capabilities and limitations of health IT.

The specific charge \-- again, this is the sort of very near term charge
for our work \-- is to make recommendations to the Community that
specify how certified health IT should capture, aggregate and report
data for a core set of ambulatory measures. Let me just pause here and
ask if there are any questions or clarifications from Kelly or anyone
else at ONC.

**[\>\> Kelly Cronin:\
]{.underline}**No, Carolyn, I would just add that these charges were
informed by the panel that presented to the Community over the summer, I
think there was a fair amount of back and forth that you were involved
with, in trying to determine the appropriate scope for the Community,
given its charter and all the other activities that are going on outside
of the Community. So I think there was a fair amount of thought that
went into crafting both the broad and specific charge, but it\'s
probably important for everyone in the Workgroup to understand what the
scope is and how to interpret this in a consistent way.

**[\>\> Carolyn Clancy:\
]{.underline}**And let me just comment while you\'re gathering your
thoughts, or questions, if you have them, that from my experience on
another Workgroup for the Community, this is accelerating the adoption
of electronic health records. I\'ve noted how important it is to keep
focused on the charge. Because given where we are today in Health IT,
and given frankly where we are in quality measurements, there is a vast
amount of work to be done.

However, if we attempt to boil the ocean, or make the current scope of
work before us too broad, we\'re not likely to make the same amount of
progress. And I think it\'s been a tribute to the Office of the National
Coordinator and to the Community over the past year that they have
managed to keep the broad vision in mind, the vision that we all share
about improving quality and value in health care, while at the same time
trying to figure out how it is, you know, trying to figure out how do we
make progress right now.

So this will continue to be, I think, something of a challenge for us,
again, when I think back to the excitement for members of the Community
and so forth. But that is our specific charge before us.

Questions or comments?

**[\>\> Nancy Foster:\
]{.underline}**Carolyn, it\'s Nancy Foster. I want to ask a clarifying
question. The terms that are used here can mean different things to
different people, of course. So in particular I\'m focused on the
reporting term, specific charge for our Workgroup. Are we talking about
the act of submitting the data to (indiscernible) \--

**[\>\> Carolyn Clancy:\
]{.underline}**Nancy, you\'re breaking up. Is it possible for you to get
on the phone-phone, supposed to the speaker?

**[\>\> Nancy Foster:\
]{.underline}**I\'m actually on the phone.

**[\>\> Carolyn Clancy:\
]{.underline}**Oh, okay, sorry.

**[\>\> Nancy Foster:\
]{.underline}**Sorry. Is this any better?

**[\>\> Carolyn Clancy:\
]{.underline}**It\'s still a little static-y, but keep going.

**[\>\> Nancy Foster:\
]{.underline}**Okay, I\'m just asking about a clarification of what we
mean by report in this statement. Is it simply the act of submitting the
data to an organization that might be making it public? Is that the
limit, or are we talking about IT that would enable \-- that would
actually take it through to fruition of public reporting?

**[\>\> Carolyn Clancy:\
]{.underline}**I think that that is clearly the first agenda, although
you\'re right that it could mean different things to different people. I
think how I\'ve heard the Secretary say this a lot, and again this was
based on a comment made by a Community member, is that in too many
places in the American health care system today, quality assessment and
reporting can be \-- the picture that comes to mind is a nurse or other
health care professional sitting in front of a pile of charts on off
hours. And you know, put it succinctly, that\'s not a scalable model. So
yes, the first step in reporting is actually trying to automate the
collection of the requisite data required by a select set of measures.
Does that help?

**[\>\> Nancy Foster:\
]{.underline}**It helps me a lot. Thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Other comments or questions?

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

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

**[\>\> Barry Straube:\
]{.underline}**Barry Straube here. Just a \-- maybe a comment,
clarification. One, I think that the verbiage of the broad charge and
the specific charge are very good. Although, Nancy\'s comments about
sometimes words can be interpreted by different folks in different ways,
is absolutely correct. A lot of us have been invested over the last two
and a half years or so a tremendous amount of effort getting AQA and HQA
up and running. Now with you and Mark convening the Joint Steering
Committee, I think most people\'s expectations are that that effort is
first of all starting off with data collection, aggregation and
reporting, and some of the challenges in that process, but particularly
focused on the development \-- identification and development of
measures. I think the end game to that effort, though, is also to
implement those measures for quality improvement purposes for pay for
performance and transparency and public knowledge of what is going on in
the health care system.

And overall I think that effort is also going to loop in to the setting
of national goals and objectives for quality. How I think I interpret
the charge, and maybe this is where we really need to be clear, because
when AHIC first started, the Secretary was possibly headed in a slightly
different direction, and some people may assume it was the same one. And
that was almost the suggestion that AHIC become possibly the setter of
national goals and objectives. Some people interpreted it that way. And
I think my interpretation and we\'ve had so many rough bumpy spots, is
that\'s not the purpose of this Workgroup. The purpose of this
Workgroup, from these charges, is to loop in the IT piece, get advice
and counsel from the Office of National Coordinator on issues that those
setting national goals and objectives, implementing things, developing
quality initiatives, how we need to be sensitive to and actually assist
in the implementation of HIT standards. What this Workgroup is not here
to be is yet another group that would set national goals and objectives
for quality per se.

**[\>\> Carolyn Clancy:\
]{.underline}**Think we have enough groups who think they\'re setting
the national goals and objectives?

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

**[\>\> Carolyn Clancy:\
]{.underline}**I\'m being facetious. I think you said it very well,
Barry. I will say there has been considerable discussion by members of
the \-- several members who are part of this group right now, and the
folks who participated in the presentation to the Community on August 1.

And I think the issue was not in any way to suggest that the AHIC would
be setting national goals, although obviously many people sitting around
the Community table would be vital participants in that process in other
venues. But the area where things got \-- where we struggled a little
bit, was the fact that our current set of quality measures writ large is
very much constrained by the availability of data.

Any process for developing performance measures, the question of the
feasibility of collecting the requisite information inevitably comes up
and in some cases actually ends up driving a pretty large chunk of the
conversation, including whether that performance measure needs to simply
be discarded as an area that\'s important but we can\'t get the data
that we need.

Once we get closer to the President\'s goal, when this is a critical
mass of \-- there is a critical mass of practitioners and large
organizations that have made investments in electronic health records
and in some fashion connected interoperably to other components in the
system, that begins to change the landscape of what\'s possible in terms
of developing performance measures. But I think it was our clear sense
and contributing to these charges that that day is a little bit off. So
I think that your synthesis of where we stand, that is to say that
we\'re trying to figure out here is a way to accelerate use of health IT
effectively on reporting and improving quality of care, this is not
about another venue for setting national goals, you\'re exactly correct.

Other comments or questions?

**[\>\> Reed Tuckson:\
]{.underline}**This is Reed. I just, I think this is an important sort
of thing. So that one of the things at least the assumption will be, I
wonder about the assumption, is that if there are \-- as there are
multiple competing initiatives for performance assessment, that the
sense of our understanding of how those are and hopefully are
coalescing, so that while we may not be the people who are setting the
national standards, the sense that there is, I hope, some recognition of
the need to have those, and a sense that our work is informed by an
assumption about whether or not those are coalescing together or are
not, because of course depending upon your assumption, makes the IT
component of this either more complex or more streamlined.

**[\>\> Carolyn Clancy:\
]{.underline}**I think you\'ve got that right, Reed, so I would say
building on what you just had to say, we\'re not about developing
quality measures, and we need to be highly informed by activity in that
arena which has informed the presentations we\'re going to be hearing a
little later during this call. So that those who don\'t live every day
in the world of quality, or aren\'t necessarily intimately familiar with
various points on this landscape, will have some sort of grounding on at
least the leading initiatives.

Any other comments here?

**[\>\> Jonathan Teich:\
]{.underline}**Carolyn, this is Jonathan. I agree with what\'s been said
about not being another measure organization and also I\'d like to say
even as we are being informed by many of these organizations we may also
have the capability of informing some of them since a lot of our charge
is to talk about the interface between health IT and the ability to do
these measures, that there\'s a lot to be said about the things that are
necessary to make these things feasible and practical for health IT. So
this is going to involve as we go along, standards and dealing with
people with different levels of electronic capabilities and so on. So
hopefully we\'ll be able to have some general output that may guide some
of the work of these bodies as they try and revise their standards.

**[\>\> Carolyn Clancy:\
]{.underline}**No, I think that\'s absolutely correct. And just speaking
from my own personal knowledge, I know that a number of people on this
phone and NCQA comes to mind almost instantly as well as the work of
Janet Corrigan both at the Quality Forum and her prior life at the
Institute of Medicine. You can\'t read anything about quality
measurements that doesn\'t immediately point out that with advances in
health IT and greater penetration of health IT in the health care
landscape, we\'d be having a different conversation. I think your point
is well taken.

Anyone else on this point? Great. Let me just say that this is not your
last and final time to ever comment on this. I would expect that in our
future conversations and as our work proceeds, we will end up coming
back to this. And so I\'ll just leave it at that.

Kelly and Judy, do you want to talk to us about the Workgroup process
and guidelines in \--

**[\>\> Kelly Cronin:\
]{.underline}**Sure. I think Judy \-- I\'ll let Judy start. She wanted
to give a brief overview of some considerations that we need to be
mindful of when it comes to FACA.

**[\>\> Judy Sparrow:\
]{.underline}**First of all, let me thank everyone for participating on
this important Workgroup, and remind you that we do operate under the
Federal Advisory Committee Act, and I\'ll just touch briefly on some of
the highlights. I did send you out a report, a short summary of the FACA
guidelines so I\'m encouraging you all to read that. Basically, in a
nutshell, we really need to remember that we\'re operating in public
view, we make sure all our meetings are reported in the *Federal
Register* so the public has advance knowledge of this and we encourage
the public to follow along with us.

Second of all, everything that we say here is made public, we keep
detailed minutes, and make transcripts of all the meetings, which are on
our Web site. And available to anyone.

And third, we\'re acting in an advisory capacity. We just talked about
the broad specific charges, and it says make recommendations. So again,
we are funneling our thoughts and advice up to the AHIC.

And finally, given the high profile and complexity of this issue, I
think it\'s very important that you as members participate as often as
you can. And having said that, I realize you\'re very busy people and
that\'s not always possible. So I would request that you nominate one
alternate, so at least if you cannot make a meeting, you have one point
person that can be up to speed and get you up to speed on any meetings
you might miss.

And if you have any questions after you\'ve read over that short
three-page summary, please give me a call. Thank you.

**[\>\> Kelly Cronin:\
]{.underline}**Thank you. I\'ll just add to that by saying that we\'ve
had about nine months of experience now in trying to organize these
workgroups, and while it\'s always been a consistent challenge given
that the Secretary has a growing list of interests, most recently
personalized medicine, we are now in a place I think within ONC that we
are staffing up and we are able to provide, I think, the level of
support that\'s needed now to move these workgroups forward. Which I
think in this case is going to be relatively intense. We\'re lucky to
have so much work already done though AQA and HQA, the Joint Commission,
National Quality Forum, NCQA, and all the other organizations
represented on this phone, and those that are not. So we can build off
all that work, luckily. But it\'s still going to be intense to pull it
all together. And in particular we\'re going to be asked to make
recommendations to the Secretary and AHIC on October 31 with respect to
our specific charge. Which only gives us roughly five weeks to really
dig in to this. So hence the need to leverage other people\'s work
that\'s already completed.

I think it\'s also important to note that we\'re going to have not only
a good team internally here in ONC, that includes Michelle Murray who is
in the Office of Programs and Coordination, Judy Sparrow who you just
heard from but also some support from people in the Agency for
Healthcare Research and Quality who have been very much engaged with the
data aggregation work, Dr. John White in particular, and to the extent
that Nancy Wilson has time, she\'ll also be engaged.

We\'ll also have some support through some senior advisors and
clinicians from the Indian Health Service, the Department of Defense,
and the Veterans Administration, since they have an awful lot of
experience to draw from when it comes to implementing electronic health
records, and in particular I think the VA has demonstrated some
significant performance improvement through automating much of what can
be done in the way of quality measurement reporting and clinical
decision support.

So we have a pretty rich group to draw from to support this work. And
with respect to the October 31 recommendations, I think we\'ll, you
know, be able to shape what we think we can get to over the next 5
weeks, but ultimately I think you\'ll note that it refers to certified
health information technology and how that can enable the automated
reporting of measurement, or automated measurement and reporting.

And certainly we have the Health IT Standards Panel and the
Certification Commission for Health IT, and the Nationwide Health
Information Network activities that will be going on over the next year.
It is expected that the recommendations that will be presented to the
Community on October 31 will then go into use case development that will
guide all of those activities over the next year. So we need to be
keeping that in mind as we get to the point where we think we can craft
some recommendations.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you, Kelly. Can you be a little more specific about
the expectations for the October 31 meeting?

**[\>\> Kelly Cronin:\
]{.underline}**Yeah, I think that you know, you could interpret the
specific charge to say, well, I think we just need a use case and to
make sure this work gets done, the core HQA, and AQA measures are
specified to sufficient level of detail in a use case. So that will put
the standard harmonization process into motion, as well as development
of criteria for the Certification Commission for Ambulatory and
Inpatient EHRs. But I think given the complexity of where we are today,
and the fact that EHR adoption is relatively low in some portions of the
market, we also need to be thinking through how to get from our current
situation to an end goal of having streamlined and automated reporting.

So while we won\'t have enough time in the next five weeks to figure out
exactly what that path looks like, I think we should start considering
some of the issues around where we are today with respect to having to
merge data from a variety of sources, so while we may be heavily
dependent upon claims data in some areas, there are other areas of the
country where there are data available through PBMs or pharmacy,
electronic data, as well as lab data. So I think that we need to be
starting to pull together what that data flow looks like in the current
environment, and how through certified technologies \-- and the data
sources that are available today, we can start to piece this together.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you. Questions or comments on anything that\'s just
been said? Any questions from people who are not members of the
Workgroup?

**[\>\> Peggy O'Kane:\
]{.underline}**This is Peggy. I\'m a member of the Workgroup, obviously.
But I\'m wondering, is there \-- has there been much thinking about who
is held accountable and who they\'re held accountable by?

**[\>\> Carolyn Clancy:\
]{.underline}**I guess I would say personally in general there\'s been a
lot of thinking about that, and as we\'ve discussed in many \-- and many
others have, the concept of accountable units does tend to be a
challenge here in the quality enterprise. But I think there\'s no
question that that is going to at least be at the periphery of the work
we\'re trying to get done here. But I don\'t have much more to say about
it other than that.

**[\>\> Peggy O'Kane:\
]{.underline}**I mean, is the thinking that individual providers and
hospitals would be held accountable by payers?

**[\>\> Carolyn Clancy:\
]{.underline}**Yes, and I think the spirit of the recently issued
executive order sets the stage for public and private payers using a
core set of measures to which that accountability would ensue. I think
there\'s also a fair amount of speculation about the Federal policy
direction that most policymakers are interested in taking publicly
supported payers toward the greater use of incentives to reward high
quality of care, which isn\'t exactly saying that there\'s a necessarily
a very clear accountability map for every participant in the health care
system.

**[\>\> Peggy O'Kane:\
]{.underline}**Yeah, I\'m wondering about the accountability of health
plans, for example. You know, obviously it\'s an area of interest to us,
and you know, you\'ve seen the kind of result that the plans have
achieved over the the years they\'ve been publicly reporting. A lot of
that is done by the plans directly through disease management, either by
the plans or by their vendors. So I mean, I think that there seems to be
a kind of \-- you know, the payer is more passive in the vision that I
understand to be the prevailing vision at the moment. But I think it
would be a shame if we kind of disregarded some of the important
progress that\'s been made by some of these other players that come in
as kind of \-- that fill gaps between providers and so forth, you know.

**[\>\> Carolyn Clancy:\
]{.underline}**No, I would \-- I couldn\'t agree with you more. And I
guess I wanted to make one clarification. You\'re talking about
accountability for performance.

**[\>\> Peggy O'Kane:\
]{.underline}**Yeah.

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

**[\>\> Peggy O'Kane:\
]{.underline}**I mean, I\'m talking about accountability for value. Let
me put it that way. Because I think we should keep cost and quality
probably pretty much aligned in our minds they\'re hard to separate. I
couldn\'t agree with you more, and that\'s obviously been the subject of
intense debate that \-- and I think you\'re completely right and we
would be very foolhardy to focus just on accountability, but should also
focus on the levers and experience of multiple parties in using that
information to improve care.

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

**[\>\> Peggy O'Kane:\
]{.underline}**It\'s a very easy the accountability in public reporting
can take a life of its own and overshadow those activities and if we
don\'t lead to improvements in care, one may \-- you know, it raises a
question about trees falling in the forest and that kind of thing.

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

**[\>\> Josie Williams:\
]{.underline}**This is Josie and it\'s very important, I think
specifically but in the areas where we have seen care and we can
evaluate that with information technology. The group that I work with,
as you know is very challenged not only with information technology but
also with knowing what those gaps and the barriers to improvement are.
So I think it\'s a very important concept to at least if we \-- to the
extent we can, to identify the things that are going to make it
important to be able to utilize the technology and then also what things
are going to have to be utilized to make an impact on that.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you, Josie. I agree. Other comments?

**[\>\> Barry Straube:\
]{.underline}**This is Barry again, and I think this discussion starts
to get off in what I and Reed and several others were bringing up about
the charge. Because if we go back to the executive order, you know,
there were three components in that charge with the Federal agencies. It
was to collect, aggregate, and report on quality information. The second
piece was to promote the adoption of health information technology. And
the third area was to incent providers and consumers to use that
information in a way that could affect the marketplace. Those are my
words of resummarizing that.

In terms of the accountability, the Federal agencies are \--
(indiscernible) audio interruption).

**[\>\> Carolyn Clancy:\
]{.underline}**Did somebody \-- could somebody mute their phones there?

**[\>\> Barry Straube:\
]{.underline}**We\'re going to be coming up with ways in which we\'re
going to be accountable to the Secretary and the President in all of
those areas. I think again in terms of this Workgroup, there are
sections of that executive order that are more relevant. I think in
particular doing things to promote the adoption of HIT falls in my mind
to this Workgroup, and then again getting back to our charge, giving
advice to the various efforts that are going on, so how the quality
measurement development and how the implementation of the use of those
quality measures make sure that it ties in and promotes HIT adoption,
and the use of \-- and facilitation of electronic health records, et
cetera.

So some of the accountability we almost got started talking about has to
do with end use of all the data again, and that gets back to quality
goals and objectives. And I think it\'s potentially beyond the charge of
this Workgroup.

**[\>\> Carolyn Clancy:\
]{.underline}**Yeah, and I did promise you all a few moments ago that
when we were first discussing the charges, you\'d have other
opportunities to weigh in. And I think this had come up again and again.

I do think, though, if you look at the executive order, as you described
it, Barry, on one hand providers across the health care system are being
encouraged to adopt health IT. They\'re also going to be encouraged to
report on \-- report and use information from selected quality measures.
And yet our job, I think, might be summed up sort of colloquially as
we\'re trying to connect those dots because right now in the health care
system today, adopting health IT does not necessarily put you ahead of
the curve in the quality improvement domain. So that\'s really where we
need to focus a lot of our attention.

Any other comments before we turn to the presentations?

**[\>\> Charlene Underwood:\
]{.underline}**Carolyn, this is Charlene. Just to kind of continue on
that same thought and it relates to, I think the charge, but also the
adoption. One of the other things that the quality group, I think the
selection of the use cases that are defined by the other workgroups,
because as a result of those use cases, the outcome of those are
standards, and potentially data content standards and kind of as you
started, a lot of the success of this ultimately depends upon being able
to capture the right data in a standards form so the data is comparable.
So the other touch point, if you will, would be influencing the
selection of the use cases in those other workgroups such that the data
necessary to address, if you will, the quality standards that
(indiscernible) goals and objectives can be accomplished. I don\'t know
if that\'s clear, but it really, this Workgroup will really transcend a
lot of the other areas.

**[\>\> Carolyn Clancy:\
]{.underline}**I agree. I think that's a very good point, Charlene. I
would also say that this Workgroup will inevitably interface with some
other workgroups, including the one that\'s focused on the adoption of
electronic health records. I think that synergy is likely to be very
productive, if providers are being asked \-- or suggested or given a new
opportunity \-- to report on quality of care, and electronic health
records actually make that easier for them. I think that\'s going to be
a profoundly important incentive for adoption. And at the same time I
think we can learn from some of the work that the EHR Adoption Workgroup
has already commenced with in terms of trying to identify areas where we
could make selected standardized data available to practitioners right
now.

**[\>\> Kelly Cronin:\
]{.underline}**Carolyn, I would just add that I think part of what will
likely come out of the October 31 priority setting process the Community
will undertake will be final recommendations to the Secretary that will
then inform the set of use cases for 2007. And when ONC makes sense of
all that and actually passes them on to the Certification Commission and
HITSP, and will be doing that crosswalk, we\'ll be thinking about how
can we draw from the output from all the workgroups to make sure the
data content is there for the core set of measures. So I think behind
the scenes we\'ll be trying to piece that together and I think as we go
along even in the next five weeks, we\'ll try to see how that might
overlap and inform each other, or the work can all fit together.

**[\>\> Carolyn Clancy:\
]{.underline}**That\'s terrific. And I really appreciate that.

Should we turn, then, to George Isham for the first presentation?

**[\>\> George Isham:\
]{.underline}**I\'m ready if you guys are. Can you hear me okay?

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

**[\>\> Rick Stephens:\
]{.underline}**This is Rick Stephens, I\'m on now.

**[\>\> Carolyn Clancy:\
]{.underline}**Rick, if you want to introduce yourself to the group.

**[\>\> Rick Stephens:\
]{.underline}**Sure. Rick Stephens, I\'m the Senior Vice President for
Human Resources and Administration for the Boeing Corporation.

**[\>\> Carolyn Clancy:\
]{.underline}**And very, very involved in health care, in certainly in
the Seattle market, and nationally as well.

**[\>\> Rick Stephens:\
]{.underline}**Yes, and in fact one of the things we\'ve been off
working on is trying to make sure we\'re aligning all of us in the
aerospace industry to really support the initiatives that are under way
about transparency of information and including records \-- my computer
is going nuts on me soundwise, sorry about that. So anyway, I\'m excited
to be part of this and really want to do all I can to help make sure we
got industry lined up to support this.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much. Okay. George.

**[\>\> George Isham:\
]{.underline}**Thank you, Carolyn. Tell me how much time you want me to
take here.

**[\>\> Carolyn Clancy:\
]{.underline}**Hold on one second and I\'ll give you an answer to that
question. I was told 15 minutes or so. Is that wrong?

**[\>\> Kelly Cronin:\
]{.underline}**That sounds good. Shorter would even be okay.

**[\>\> George Isham:\
]{.underline}**I appreciate the opportunity, Carolyn, to talk to this
group about the important work of the AQA. And our use of health
information to improve quality of health care delivery. And
particularly, its relationship to the work of this Workgroup. I\'m
impressed with the effort of Secretary Leavitt, the AHIC, to promote the
goal of providing Americans with the access to electronic health records
and to promote consumers and care givers to make better health care
decisions and improve quality, value and efficiency throughout the
health care system.

So I\'m going to focus on a couple of parts in these comments. One, I\'m
going to talk about an overview about the AQA, very briefly. Do a little
bit of conversation about the starter sets that we have been \-- that
have been recommended by the AQA. Talk a little about data aggregation
and sharing. Make a few suggestions about what we need to do to enable
quality recording, and finish with some opportunities for comments.

I don\'t have any slides for this, but I\'m going to refer to documents
that I know the Workgroup has in its packet for this meeting and that
are available on the Web at the AQAalliance.org site. That site is a
pretty complete and transparent site for all the documents that I\'ll
actually be referring to. So again that\'s AQAalliance.org.

So getting into that, the AQA itself was established in the fall of 2004
to determine how to most effectively and efficiently improve physician
level performance measurement reporting. Measurement systems currently
in the market unfortunately divert limited resources and focus away from
clear priorities to improve care, because there\'s so many of them. And
multiple measurements systems also create unnecessary burden for
physicians and create confusion among consumers.

Therefore, the AQA came together with the mission of improving health
care quality and patient safety through a collaborative process, in
which key stakeholders agree on a strategy for measuring performance at
the physician or group level.

Collecting and aggregating data in the least burdensome way, and
reporting meaningful information to consumers and other physicians and
other stake holders to inform choice and improve outcomes.

There\'s four big goals the AQA has to reach consensus as soon as
possible on. One, a set of measures for physician performance that
stakeholders can use in the private health insurance plan contracts and
with government purchasers. Secondly, a multiyear strategy to roll out
additional measurement sets and implement measures into the market set.
Thirdly, a model including a framework and governing structure for
aggregating, gathering and stewarding data, and fourth, critical steps
needed for reporting useful information to providers, consumers and
purchasers.

Turning to now the performance measures itself, we have an active
Workgroup that\'s chaired by \-- well, let me say one thing further
about the AQA overall. Over 135 organizations are now participating in
AQA, representing various stakeholder communities, consumers, employers,
physicians and other providers, including health insurance plans and
other key health care groups. They include all of the main professional
societies, so it\'s as a very broad group of coalition with the purpose
of accomplishing these ambitious goals. In I might say a very short
period of time under Carolyn\'s guidance as well as other leadership.

So, let me now turn to the physician. Our work on the initial set of
physician performance measures. And this is a Workgroup of the AQA under
Kevin Wise has been working hard on this agenda, and they include the
work so far has included determining some parameters for selective
performance measures, and those are included in the packet, and
available on the Web at AQAalliance.org. They include a starter set of
26 measures for primary care, and that is also included in your packet
as well as available on the Web at AQAalliance.org.

And AQA has adopted a starter set for cardiac care, surgery care, and
principles for efficiency measures and is currently actively working on
a number of other items.

Turning to that starter \-- recommended starter set, this was a process
\-- a process was used that included a recommendation \--
recommendations that were developed by the Workgroup after a lot of
discussion. The Workgroup started with a list of measures, all of which
were CMS, AMA physician consortium NCQA ambulatory performance measures
that currently we\'re going through the NQF expedited review process.

Using a modified Delphi method, and applying that method against
criteria such as clinical importance, scientific validity, feasibility,
relative to physician performance and consumer relevance and purchaser
relevance, the Workgroup developed a \-- what is in your packet as a
list of recommended starter set of measures.

And as you can see by looking at that attachment in your packet, this
starter list includes preventive measures, coronary artery disease
measures, measures that relate to heart failure, diabetes, asthma,
depression, prenatal care, and quality measures addressing overuse or
misuse of care.

So we think this is a very good starting point. And it\'s only a
starting point for this process. It certainly isn\'t a final product, it
doesn\'t represent all the measures that should be used in either
ambulatory or inpatient settings. And it doesn\'t necessarily represent,
you know, a \-- advanced measures in the sense that they\'re as good as
we want them to be. But it is just that, a very useful anchoring point
to start with in this process.

Turning now briefly to data aggregation. A workgroup that I\'ve
co-chaired with David Kibbe up to this point, the Data Aggregation
Workgroup, has turned its attention to the need for a uniform approach
to collect, aggregate and share data. And also has developed guidelines
and questions for data aggregation and for data sharing projects. We had
input into the proposal for awarding data aggregation pilots, which are
now accomplished, and they are pilots in California, Indiana,
Massachusetts, Minnesota, Phoenix, and Wisconsin.

And these pilots are critical to testing the approach toward aggregating
and collecting information against this pilot set of data in real
communities.

The pilots also are obviously leading examples of communities organizing
around this general task and purpose. And so we hope to learn a lot from
these pilots in terms of how a national system of this type might
operate, and what some of the major problems and challenges are and how
to improve going forward.

So you have some documents also in your packet that relate to data
aggregation. You have, I believe, the principles in your document as
well as some parameters \-- some \-- you have at least the principles in
your document, and you may \-- and you also have the principles for the
HIT subgroup of the Data Aggregation Workgroup.

So the second thing we\'ve done besides the work on the pilots, and \--
is the HIT subgroup. And we recognize the need for beginning the
dialogue across what I call performance measurement and the HIT work.
And so we\'re very concerned about beginning that dialogue. And I think
that interest has produced the principles for HIT which I believe are
also in your materials.

Those documents again for everybody else on the call, are also at
AQAalliance.org.

The last bit of work we\'ve done is recommend some principles and some
aspects of a proposal we call a national health data steward, which I
won\'t talk about during this call but that\'s also available on the Web
should you wish to look at it.

In terms of enabling quality reporting, we think it\'s very important
that there\'s a need for a uniform approach to measure, collect,
aggregate and share data. And that approach needs to be uniform and
specified in detail down to actually the level of automated information
systems.

And with the advancement in increasing use of HIT systems uniformity is
increasing important to reduce limited resources are optimized. At a
minimum there are a couple of things that are important to promote that
uniformity, which lead to effective and efficient quality reporting.

First, principles that guide and components that support quality
reporting, and again we have, AQA has endorsed principles in area.
Secondly, a standard approach to electronic health records to routinely
produce quality data based on measures, such as AQA- and HQA-approved
measures. And then thirdly, uniform operating rules and standards for
sharing and aggregating data, implementing guidance and establishing a
framework for collecting and analyzing data. And so again, the national
health data stewardship activity that we\'ve talked to, we think perhaps
might address that.

Some of the short-term opportunities to advance aggregation and then
I\'ll conclude. Looking to the future, there are opportunities. We
believe our pilots are very much a tremendous opportunity to test these
concepts and advance the state of the art. We believe they leverage the
experience of existing efforts to effect the most effective processes
for measuring and aggregating and reporting the information. All the
sites chosen have an existing infrastructure key leaders and commitment
of local stakeholders. We believe each of these sites will combine
public and private information on clinical quality, cost of care,
patient experience to measure and report on a physician practice. So we
think that\'s very important in providing a comprehensive view of
physician practices.

We \-- as I\'ve intimated so far, believe they\'ll serve as learning
laboratories various sources, and will test different uses of different
IT systems and different technologies and consider the impact of IT
systems on quality outcomes and costs as well as value.

So we expect that this will be key in developing a national framework
for doing this more effectively in the future. And I think that\'s just
about 15 minutes, Carolyn. I\'m sorry, I didn\'t go shorter. But I tried
to jam a lot of stuff in there. I hope that\'s a useful overview of AQA
activities and in particular some of the activities we\'ve done around
data measure and aggregation. Thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much, George. I think you\'ve done a
terrific job presenting a really very big volume of work, and a great
deal of activity that has preceded over the past two years.

Let me ask if there are questions of clarification of what George
presented. I\'d like to hold more general questions till the end.

**[\>\> Kelly Cronin:\
]{.underline}**Carolyn, this is Kelly. I think at some point we should
probably talk about at what point we might expect some preliminary
results or just more of a discussion around some of the early findings
from the AQA pilot since I think they\'ll be particularly useful to us.

**[\>\> Carolyn Clancy:\
]{.underline}**Yes, let me just say that first results will be posted
publicly in \-- somewhere in relatively early 2007 but we can get you
more specifics on that. And I think we\'ll end up coming back to the
pilots particularly when we hear from Marc Overhage\'s presentation
because he\'s leading one of the initial six pilots.

**[\>\> Jane Metzger:\
]{.underline}**Carolyn, this is Jane Metzger. I\'d just like to report
that I am here.

**[\>\> Carolyn Clancy:\
]{.underline}**Terrific, welcome. Delighted to have you.

**[\>\> Anne Easton:\
]{.underline}**Hi, this is Anne Easton, I\'m also here.

**[\>\> Carolyn Clancy:\
]{.underline}**Oh, that\'s great. Thank you very much for both of you
\-- do you want to say a word or two introducing yourselves?

**[\>\> Jane Metzger:\
]{.underline}**I\'m a research director at first consulting group,
that\'s the applied research arm of the company. I\'ve been in the field
of research and consult on clinical systems for 30 years. One of my
personal areas of research and interest is clinical decision support.
And folks at CCHIT, are probably tired of hearing about it. I\'ve done a
recent project with the Leapfrog Group that gives a lot of insight into
where the vendor marketplace is in terms of being able to support
medication checking to avoid adverse drug interactions.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you, Jane. That\'s a project, as you know, I\'m
very familiar with. And it might be something that we bring to the
attention of the Workgroup at a subsequent meeting. It\'s a really,
really important work. Anne?

**[\>\> Anne Easton:\
]{.underline}**I\'m Anne Easton, the Chief of Insurance Policy for the
Federal Employees Health Benefits Program here at OPM, and we\'re glad
to be part of this Workgroup. Very important Workgroup. So thank you
very much.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you. I think we\'ll turn then to Nancy Foster.

**[\>\> Nancy Foster:\
]{.underline}**Thank you very much, Carolyn. Can you hear me all right?

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

**[\>\> Nancy Foster:\
]{.underline}**Good. And I just need a point of clarification, which is
will you all advance the slides or do I need to advance them?

**[\>\> Matt McCoy:\
]{.underline}**We will advance the slides and just a note to Nancy and
you, this interface we use for online slides doesn\'t support animation.
So if you have animation in your slide, you might notice things look a
little jumbled on the Web but people can down load the actual versions
on the Web page.

**[\>\> Nancy Foster:\
]{.underline}**Thank you so much and I appreciate your advancing them.
Let me talk a little about the Hospital Quality Alliance work that is up
and running and the first thing I should note is in just another day, in
fact on the 21^st^, an update of the information on hospitals quality
was made to our Web site so you can go there to
www.hospitalcompare.hhh.gov, check out the quality data on nearly 4,300
hospitals from across the country on a variety of measures. This work,
which we are delighted to be bringing to folks and are passionate about
expanding, is really the result of an activity that began 3 years ago.
If we could go to the next slide.

Right after I came to the American Hospital Association, our board and
the board of the Federation of American Hospitals, and the Association
of American Medical Colleges, were clamoring for their national
organizations to help hospitals, because what hospitals were feeling was
that they were being asked by a multitude of organizations for good
quality data. And the intent of all of those organizations was to make
that information available to the public so they could make wiser
choices, and to purchasers, so they could, on behalf of their insured,
make wiser purchase choices.

All of that made sense, but for hospitals it simply felt like a deluge
of requests and no real information being pulled out of it. They asked
us to try and bring together the other leading national organizations to
talk about whether they could do something collaboratively that would be
better, and make more sense and get more momentum than each of us
working independently.

Out of that was born this effort which has come to be known as Hospital
Quality Alliance after it went through several iterations of names. So
it is now the HQA. Can we go to the next slide.

And the work that we are doing is incredibly important because it brings
together a variety of stakeholders to really share information on
hospital quality. You can see the partners in HQA listed on the slide.
We don\'t have nearly the number that are involved in the AQA, but this
is a diverse group of people. We really came together over the last 3
years in a true collaboration, true consensus kind of organization where
each and every one of these organizations as we get together around the
table gets to speak their mind, make sure their interests are heard, and
be involved in the decision-making. We work by consensus. So it\'s been
a very rewarding set of activities.

We have also over the course of the last three years learned how to draw
the expertise out of each of these organizations to make the large
national publication of data happen. It would not happen without the
work of the Joint Commission, CMS, the Agency for Healthcare Research
and Quality. But equally all the other organizations have been committed
and have made important inroads to creating the product that you see on
our Web site.

Next slide, please. The participation rates that you see here are as of
June. I don\'t have the most recent data for yesterday\'s update, but I
know that we\'ve added more hospitals in total reporting. What I would
like to point out to you, because many of you know that for the acute
care hospitals paid under the Medicare payment system, there is now a
financial incentive, and a fairly significant financial incentive
pass-through for the reporting of these data. But for critical access
hospitals, the smallest of our hospitals, there is no similar financial
incentive. And yet, we have \-- we had in June over 600 of just over a
thousand critical access hospitals doing all of the work necessary to
collect the data that was relevant to them, submit it and get it
publicly reported. I understand in September that number has gone up.
And that, I think, reflects the fact that even without the financial
incentive, hospitals are committed to sharing this kind of information
with the public that they serve. As long as they can do so in a sensible
way. And the work that we\'re talking about as part of this committee.
The work of making it easier to collect and report these data through
the use of electronic mechanisms is essential to enabling this work to
move forward.

Next slide, please. We started off with a simple set of 10 measures. Not
because there was any magic of these ten measures of heart attack, heart
failure and pneumonia that you see on the 10th slide of these slides but
because they were measures already in use and our real question was
could we get this data voluntarily, because this was at a point when
there was no financial incentive tied to it. Could we get this data
voluntarily from a broad array of hospitals who \-- could we put it
together in a way that we could display it and it would make sense to
the public? And could we then see people pick it up and use it for
improvement, for choice, for payment?

That set of data has been up for 3 years now. We started with \-- when
the first time we went live with the Web site, we had almost 500
hospitals reporting. We knew that was far too few, but it was a starting
point. By about four months later, we had nearly half the hospitals in
the country pledged to participate and beginning to send in their
(indiscernible) and it was at that point that Congress acted to tie the
financial incentives to the reporting of these data. And you know the
magic that happened then. We have nearly 100% of those who are \--
financial incentive reporting these data.

We have turned our attention from getting hospitals to voluntarily
submit the data since there\'s now significant financial incentive, to
really expanding the amount of information that is available and working
hard to try and turn that data into something that really is meaningful
to the public. You see on the right-hand side of the slide some of the
measures we have added and are collecting from most hospitals who are
submitting. The vast majority of these are being reported.

Next slide. And it\'s important to note that the Hospital Quality
Alliance feels very strongly that we need to continue to move to expand
the amount of information and the type of information that is available
on quality. So you see in our next phase we have already begun asking
hospitals to participate in the patient survey, known as HCAHPS, which
collects information on patients\' perceptions of the quality of care
they receive.

We are working hard to get information out on mortality for heart
attack, heart failure and pneumonia, so we can couple the performance
measures with the process measures already displaying \-- we\'re
expanding the amount of information that we\'re collecting on adverse
events that could occur during surgical care, and the steps taken to
prevent those adverse events.

In subsequent phases we\'ve identified, we have pediatric asthma
measures and we\'re working to make that happen. We have other measures
of surgical care improvement that we want to add, we have measures of
critical care processes that we want to add. These are again steps to
prevent bad things from happening to patients in intensive care units or
other critical care units. And we\'re working hard to identify other
measures that are important to the quality of care and should be added.
It is a fundamental premise of HQA that all of the measures we include
will have gone through the National Quality Forum process and be
endorsed by the National Quality Forum before they get included in our
data collection so that we can standardize the measures.

Next slide, please. As we continue to do our work, we have actually come
to the realization as a group that we need to do some of the work that
might be underpinning to our (indiscernible) work, that in fact our
colleagues at the AQA are beginning with, in many respects, they started
their work. We need to find the right infrastructure that will support
this as an ongoing and vital (indiscernible) so we\'re working to
identify the right infrastructure that will sustain our work. We are
working to identify how we can consolidate the data stream to reduce the
simple burden with collecting these data. We\'re trying to get better at
how we analyze and use the data. We are working to either identify a set
of priorities for ourselves, or more recently, the discussions have
turned to working with national organizations like the National Quality
Forum to identify what the appropriate set of priorities would be, of
which we should measure the hospital specific aspects because we need to
focus attention on the critical aspects that will make sense to the
public. And of great importance to us is the recent work through the
steering committee that Carolyn co-chairs, to coordinate our work with
that of the (indiscernible) so we can look broadly at an episode of care
at issues like efficiency and quality of care. That we have
harmonization of our measures so it\'s really \-- reduces the data
collection burden and increases the amount of information we\'re
deriving that we can talk about pricing, and that we might, for work
that the HQA is doing, and the work that we want to do to together, be
able to use the expanded set of pilots to look at some of the key issues
such as efficiency.

Next slide, please. Finally, I want to talk a little about the whole
process. Barry alluded to a little while ago, that in his estimation,
there are a number of organizations that are trying to play in the realm
of setting national goals. That may be true, but as we see, there\'s no
single organization that has that responsibility, and so there is a lot
of work that needs to be done to set a single set of national goals, a
single vision, and continue the improvement framework. Absent that, we
are all struggling.

In contrast, in the dark blue box on this side, you can see there are
lots of efforts under way to increase measures or identify measures, and
endorse measures.

Even more importantly, there are a lot of organizations who are
selecting measures, collecting data, that part is probably over the \--
the activity is an overburden for the system.

We are also working to validate the data and analyze and display the
data within the Hospital Quality Alliance. But there we lack some basic
information. There\'s activity under way but not enough activity. And
then we really need to know more about how to promote attention to the
results, link to improvement strategies, and monitor the impact. So the
things you see in green on this slide are really areas where more
activity is needed, the things you see in shades of blue have activity,
it\'s probably about the right amount but may need some tweaking. And
the things you see in hot pink are really areas where perhaps a
reduction in activity would really enhance the value of what we\'re
doing. I bring this up because as we seek out how to use information
technology, we will assemble (indiscernible) some respects because there
isn\'t a single well-greased system of collecting and using these data
along this continuum. I think because we have stumbled \--
(indiscernible) quality alliance in some respects because we don\'t have
a single national vision. We would be greatly helped by that. And there
are aspects I\'ve talked about already.

I would like to say there is \-- it\'s important work that we have done
in the Hospital Quality Alliance, but one of the things that has been
most important was not really something that\'s visible on our Web site.
It is in fact the work that has gone on largely done by experts
(indiscernible) the Commission and at CMS to really get down to the
nitty-gritty of what we\'re asking people to collect and get
harmonization with \-- across the measures. And that would be important.
But it\'s real harmonization across the data elements. So that when
you\'re asking for someone to collect a patient day, or whether or not a
dose of medication was administered, it\'s defined in the same way,
it\'s clearly visible to people, and they know what you\'re asking them
to record from the medical record. That kind of detailed work is going
to be absolutely critical if we\'re going to try and collect the
information from medical records. And it is hard, hard work.

Carolyn, I would turn it back over to you.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much, Nancy. And I think your last point
about data (indiscernible) is going to be precisely the kind of feedback
we\'ll be needing from this group to inform the use cases and
development of requisite standards. And sadly, most measures aren\'t
developed at quite that level.

**[\>\> Nancy Foster:\
]{.underline}**No.

**[\>\> Carolyn Clancy:\
]{.underline}**I\'m going \-- I\'m attentive to time right now. So by my
watch, 1:35, and I would like us to end our work today, although clearly
we have stuff here to talk about to well into the evening, and I for one
would be very excited about doing so. But I suspect that many of you
have competing appointments at 2:00, if not sooner. So if I could ask
the next presenters to try to aim for about 12 minutes. If you hit 14,
I\'m going to let you know. I\'ll put it that way. And I\'m going it
turn then to Peggy O\'Kane.

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

Since we can\'t ask questions on this, can we through some mechanism
have feedback and I can take my question off line, but I\'m curious
about the integration status, if any activities going between this and
the Leapfrog measures. And if we could find a way to update that by
e-mail, that would be great.

**[\>\> Carolyn Clancy:\
]{.underline}**We\'ll note that, and get that out for both the record as
well as people on this call.

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

Thank you.

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

**[\>\> Peggy O'Kane:\
]{.underline}**Hi. I was for some reason asked to talk about Web-based
tools for quality evaluation. I\'m not really clear why I was asked to
drill down to that level and I have toward the back end of this. But I
thought I\'d start at kind of the general overview level. So I don\'t
see my presentation up.

**[\>\> Matt McCoy:\
]{.underline}**Just one moment, it will be up there.

**[\>\> Peggy O'Kane:\
]{.underline}**Okay. NCQA is a private nonprofit. We\'ve been
independent since 1990. We\'re a 501(c)3. We measure and report on
health care quality. And you know, we\'ve gotten to be quite a
platitude. It was new to get the groups around the table of different
stakeholders and try to converge on a common definition of quality. And
the kind of three things that we very much believe are part of this
agenda are measurement, you know, we obviously can\'t improve what we
don\'t measure, and you know, getting to a robust set of measures is
much more complicated than just specifying what currently goes on, I
think, in health care. There are big issues around the evidence base.
Transparency, and I won\'t go into that. Obviously, the Secretary is
very much behind that. And accountability. And I do think that it really
is always very important to think about who is accountable for what, and
how realistic is it to think that whatever we\'re doing is going to
motivate the kind of behavior that we really want. So I will continue
probably to bring up that issue.

And if you go to the next slide. The NCQA, for whatever we do, we tend
to have a combination of standards for structural and procedural
activities. For example, in \-- and this is mostly referring to our
health plan accreditation program. You know, where we actually do
validate that you meet these standards. That is combined, then, with
HEDIS, the clinical quality measures in HEDIS, as well as CAHPS and
about 40% of the process is driven by how you do so it\'s not just
whether you report. We actually benchmark you and you get scored
according to where you fall in both the national and a regional
distribution.

We have been publicly reporting, as I mentioned, for ten years, and I
think we feel very proud about the results that have been achieved by
the plans with HEDIS. And there\'s been \-- you know HEDIS covers very
heavily and comprehensively prevention and treatment of very important
chronic illnesses like diabetes, heart disease, asthma, and so forth.

If you go to the next slide, that we\'re just showing you over one
5-year span in a number of important measures, you know, this represents
50% improvement in a 5-year period. So while we haven\'t seen this kind
of improvement overall in general health care, these plans really have
figured out \-- my slides are not keeping up with me. Can somebody
advance it? Okay, well, that\'s nice. I don\'t know if there was
something that was supposed to dance on this slide. You can\'t see it
anyway, but what we\'re showing here is immunization for chicken pox,
hypertension control, LDL control. That\'s bad cholesterol control, bad
cholesterol control in diabetes and asthma management. All very
important clinical issues. And again, you know, it takes a lot, and it
takes a lot of resourcefulness on the part of the plans to get to this.

Can we move on to the next one. I think the "X" is making me nervous. In
the course of developing all these programs, and as I mentioned we not
only accredit health plans. We have accreditation for a bunch of
different types of organizations like disease management vendors. We
have recognition programs for medical groups and physicians in diabetes,
you know, who meet criteria for excellence in diabetes care, in heart
and stroke care, and who have systems within their practices called \--
that\'s called physician practice connection.

Over the years we\'ve learned a lot about how to efficiently collect the
data and we have just a hodgepodge here of acronyms of the different
kinds of online submission tools that we\'ve developed so that we can
efficiently collect the data. I think one of the things that I\'m sure
everybody is thinking about, is that we want to be very, very concerned
about the burden of quality reporting, and you know, we\'ve taken that
to heart and that\'s why we\'ve developed these tools.

If you go to the next page, our interactive survey system is the tool
that entities that are accredited by us use to submit the data. And
basically they go on the Web, they fill out the tool and then the tool
actually has a self-scoring mechanism so that they can see how they\'re
doing as they\'re filling it out. And then only when they\'re ready to
submit, do they push a button and it gets submitted to us. There\'s a
firewall between the kind of data entry process and the data submission
process. It\'s very much beloved by the plans that use it, and we do go
on-site and validate everything that\'s submitted. But I think at this
point there are very few surprises with the process, and it really has
allowed organizations to streamline their operations and where there
used to be huge departments that were prepping plans for NCQA
accreditation, it\'s become much more efficient.

The next slide. Is a \-- is somebody advancing these?

**[\>\> Matt McCoy:\
]{.underline}**No, there\'s a slight delay because all the changes are
getting streamed out over the Internet. So it will probably be about 3
seconds to refresh after you say it.

**[\>\> Peggy O'Kane:\
]{.underline}**Okay. The next slide is just a screen shot that shows you
what this thing looks like. You can go ahead and press the next two.
I\'m going to try to skip over some of this stuff in the interest of
time.

So you have copies of this if you\'re interested in looking at that
more. When plans submit HEDIS results to us, which \-- and this is
launched this year, or launching in \'07 \-- we have a new interactive
data submission system. They have been electronically submitting the
data, but this is a Web-based system that goes online, as I said, next
April. And this is for health care organizations to submit their
results, as well as for our certified compliance auditors. HEDIS has a
whole Web of things we\'ve put in place to ensure the validity and the
reliability and the accuracy of the data. So we have a network of
auditors out there that we certify and so this applies to them. We also
have certified software vendors, so a plan can buy software that will
extract HEDIS results from their claims data. And those vendors have to
be certified by us as well. And then NCQA data collection staff also can
use the software.

So again, another screen shot of interest to those interested in detail
but not necessary to the flow of this presentation.

The next \-- the health care organization questionnaire is a project
that we do for Medicare, and this is really a member survey, and you
know, another \-- it\'s another Web-based tool that we use for HEDIS and
for this survey results for the survey results to be submitted to us.

The next is \-- next slide. Member connections. As we have found a way
of refreshing our accreditation process that we\'re actually very proud
of, what we\'ve done in our latest round of ever bringing accreditation
up to where the market seems to be heading, we\'ve created new modules
that are voluntary. We have one for member connection \-- for members. A
second one for care management and improvement, which really expands
beyond our traditional focus on disease management to case management
and wellness programs, and the third area is called physician and
hospital quality. That really is kind of the rules for creating
transparency to the provider level. I think actually it\'s something we
might want to talk about at a future date because I think there\'s a lot
of \-- there\'s been a lot of input into what\'s a fair process for
creating transparency to the provider level.

Anyway, these three modules as I said are voluntary. There were two of
them, the member connections and the care management and improvement,
being rolled into accreditation next year. The physician and hospital
quality, because it\'s a newer module, is not mandatory. But anyway, as
these also have been collected in the same kind of Web-based tool
fashion as the regular accreditation program. So again, I\'m going to
skip past the screen shot. If you could go up to the slide that says
quality compass 2006.

This is a different kind of tool. This is a tool that really contains
all the health plan HEDIS and CAHPS results, for commercial plans. And
it really is used by consultants, by purchasers, by the plans who want
to see how they\'re doing compared to their competitors. And they are
basically using the tool to do that kind of assessment and analysis of
where they stand and where their opportunities for improvement are. So
I\'m not sure what was driving the interest in Web-based tools, and I\'d
be happy to talk about any of this when we get to that point in the
conversation. And thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Peggy, thank you for a terrific presentation and I
recognize that the work that NCQA has been doing is incredibly difficult
to distill in a very, very short presentation. I have a specific
question for you, though, I mean, just to clarify, I think, one aspect
of our specific charge. As it stands today, the new Web-based tool that
you\'re launching in 2007, having an electronic health record wouldn\'t
allow you to simply upload. I mean, you\'d have to do that through a
spreadsheet or actually type in from a printout, am I correct?

**[\>\> Peggy O'Kane:\
]{.underline}**You are correct. But we\'re working on that end of
things, just kind of really at the cutting edge, but that\'s not
something that we\'re prepared to receive at this point. And nobody
really has the capability, even if we were prepared to receive it.

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

**[\>\> Peggy O'Kane:\
]{.underline}**But nobody\'s EHR has the capability of giving us the
data. We're working with some of the vendors and some of the big
organizations to see if we can\'t get that to happen.

**[\>\> Carolyn Clancy:\
]{.underline}**Well, I\'m sure glad that you\'re a part of this
Workgroup, because I think that slide in particular sharpens the focus
for me of a very, very near term deliverable for our work.

**[\>\> Peggy O'Kane:\
]{.underline}**Okay.

**[\>\> Carolyn Clancy:\
]{.underline}**Because I think that would make it much, much easier for
other folks. I know that you\'re right, no products right now are
prepared to do that. And if they were, it would be a one-off sort of
programming effort which wouldn\'t necessarily be comparable to others.

For those of you who got to see the red X slide, as I did, what you
didn\'t see was actually very substantial improvements associated with
public reporting over a 5- or 6-year time frame. And quite honestly
we\'ve seen that collected in our annual \-- reflected in our annual
report on quality health from the hospital side as well. So I\'m going
it turn to Marc Overhage.

**[\>\> Marc Overhage:\
]{.underline}**Thank you, Carolyn.

\[captioner break\]

**[\>\> Marc Overhage:\
]{.underline}**\-- Improvement in cholesterol that you have to capture
those data. So all of this data is gathered together using that INPC
model that I described. Next slide.

And then why don\'t you rapidly move to the next slide after that. And
so in this model all that data are in the vaults and you don\'t get the
benefit of the lovely animation here. But basically on a monthly basis,
a cohort of patients which are essentially all patients in the
marketplace, we executed a query which goes out and uses the knowledge
in that global patient index about where patients have data stored that
DA diamond, disperser/aggregator, I\'m sure you were all waiting to
know, that gathers the data from the different edge proxies, the
different data sources, aggregates them together and delivers it back
into a quality reporting database that we use to develop and deliver the
reports to clinicians.

Next slide. On that next slide, what you\'ll see is an example of \--
and obviously it had to be crafted around to make it more useful for a
slide, but the usual kinds of displays, where are you, in the context of
your peers, and where have and your peers been over the last quarter for
this particular measure.

Next slide. And in addition to that, and obviously this is a fictitious
patient but actually a real reminder, this is reminding the clinician
for this particular patient who they identify as medical record number
99-3, there are various measures for which that patient is either soon
to be eligible or is eligible and leaving to the clinician what to do
about it, of course. But bringing them the information, the prompt and
the specific data that will help them make their decisions about how to
better manage that patient.

Next slide. The start-up for this overall effort, we\'re still in the
start-up phase, but we think we will invest about \$3 million in
developing the infrastructure, partially supported by a grant from the
Fairbanks foundation, partly supported by revenues from our other
clinical services that the health information exchange is delivering.

And we estimate the annual operating cost to be about \$2 million. Not
including the cost of the performance incentives. But there are
significant fixed costs there and we\'re incorporating this into another
community now, for example, and the incremental operational cost to add
that community of about 250,000 patients is very modest.

Next slide, please. That operational funding is come from the health
plans. They have committed to paying between 21 and 25 cents per member
per month for us to aggregate this data and deliver those reports. And
we currently have health plans not including Medicare, that constitute
about 740,000 lives out of the 1.7 million population. So we think
we\'ve reached that critical mass that\'s important for clinicians that
enough plans are all asking for the same set of measures, the same set
of outcomes, to be assessed.

And on the next slide, incenting them for that same set of measures and
outcomes. We start out in the first year and actually this quarter yet,
we\'re getting close to the end but clinicians should be receiving,
primary care clinicians should be receiving primarily \$2,500 for
participating at this stage. And participating means working with us to
help capture point of care tests from their practice but more
importantly spending time with these reports that they\'re getting on a
monthly basis and telling us how they\'re wrong, how to improve them. We
are \-- as we transition into the fourth quarter of this year, fourth
quarter of next year, we will begin to deliver payments for value and in
other words, for \-- while it will provide some latitude among different
payers, incentives to the clinician that will amount to actually our
current estimate is about \$12,000 next year per primary care physician
across all the plans and when you aggregate the incentive plans across
all plans which translates to about 3 to 5% of billing. Next slide and
the last slide, Carolyn, you won\'t have to stop me.

The benefits to the physicians are first of all they get actionable
reminders on their own, summary comparisons both overall and also
segregated into some useful populations. The benefits to health plans in
the market are full detail on their own members, those reminder level
sorts of things, as well as summary information across all patients by
provider by specialty and by population. What we hope happens is
patients get higher care and higher health care efficiency that will
make the investment participants have made and we hope Medicare will be.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much, Marc. That was really terrific
overview. A quick question for you. As I understand this, you are
getting some data electronically from practices that have made
investments in electronic health records.

**[\>\> Marc Overhage:\
]{.underline}**That\'s correct.

**[\>\> Carolyn Clancy:\
]{.underline}**In other cases, people can submit that to a variety of
mechanisms.

**[\>\> Marc Overhage:\
]{.underline}**Correct. And the data from the physician practice such as
like hemoglobin or cholesterol, some coming from electronic medical
record, and others we\'re doing other technology things to capture, and
in a few cases we\'re paying, for example, for medical assistants to
remotely enter using some of the kind of things that Peggy was
describing remote Web-based data entry in a secure fashion.

**[\>\> Carolyn Clancy:\
]{.underline}**Well, I think that, notwithstanding the strength and
development of the Indiana Health Information Exchange, we will probably
be turning back to you certainly later in the discussion, but also as
the work of our group and addressing the specific charge moves forward,
because a big challenge, we\'re not designing the world as we would like
to see it. We\'re actually coming up with recommendations to help us get
from where we are now to where we are all hoping to be. So some of that
is going to involve the use of claims data, potentially enriched by
electronic data elements such as from pharmacy lab and so forth.

**[\>\> Marc Overhage:\
]{.underline}**Sounds good to me.

**[\>\> Carolyn Clancy:\
]{.underline}**Now to Alisa Ray.

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

**[\>\> Mark Leavitt:\
]{.underline}**Yes, I\'m on the line, Alisa should be in the room.

**[\>\> Alisa Ray:\
]{.underline}**I\'m sorry, we had you temporarily on mute here. I\'m
here, I was introducing myself and Mark confirming that he\'s on the
line with me. And we\'re delighted to be here today to talk about HIT
certification and how we can advance your \-- complement and advance
your broad and specific charge to the Workgroup here.

Next slide. Very quickly, we\'ll give a background of who we are and
highlight some milestones of our accomplishments. I want to talk a
little about the current status of our work, both the development, and
some new areas and also the progress we\'ve made with the programs
we\'ve recently launched in the ambulatory domain. Finally, I won\'t go
into a whole lot of detail because we have hundreds of criteria, but I
thought it might be useful for this group to at least highlight a number
of them that are in play that focus specifically on quality measurement
and reporting and show you how those are teed up, if you will, and ready
to further refine and advance. And then of course some time for
questions at the end which will be very useful.

Next slide. Our mission, we\'re solely here to accelerate the adoption
of health IT. Robust IT, robust in terms of the functionality to do what
we expect it to do. And interoperable, I think everyone in this room and
on the phone knows we\'re striving to get to a plug and play world. And
we think we can do that in it a number of ways. First, by reducing the
risks of investing in HIT. Physicians incur a lot of risks and by having
more information on the functionality, security, interoperability
capabilities of the products they\'re investing in, they can make better
purchasing decisions. We think our work can help inform that.

Next, we can, in the same avenue, facilitate interoperability in this
same way by testing them, reporting on them, and driving that into the
marketplace. We can enhance the availability of adoption through
incentives and regulatory relief. I think you\'re aware there\'s
incentives in play out there, HHS regulations, using certification as a
gateway. Also there\'s the potential for exemptions from Stark and
anti-kickback. Again, CCHIT can be a gateway to provide those
incentives.

And also, interoperable health IT can ensure the privacy of personal
health information, which is so important. We\'ve added a little bit
here around the incentive piece to show that we recognize that quality
measurement is a key benefit of electronic health record adoption. But
accompanying that is the incentive, of course \-- incentive of programs
like pay per performance as drivers so those are most effective when you
link the performance to drivers, we want you to know we do, too.

In terms of milestones and key accomplishments, the National Coordinator
called for certification in his original framework back in June of \'04.
Very quickly after that, three not-for-profit HIT membership
organizations formed to \-- or got together to partner and launch CCHIT.
They provided funding, staff support to get us going, soon after that a
number of prominent specialty societies came together to give us some
bridge funding to keep us going before we were actually awarded the
3-year HHS contract, \$7.5 million.

We got right to work and in May we finalized our ambulatory EHR
criteria, which was approved by the AHIC and HHS. We also received a
number of endorsements from key medical societies for our work at that
time, which we\'re very proud of.

Since then, we\'ve been in the field, we\'re actually in a market, we
have ambulatory EHRs that are certified back in July our first batch was
announced, 22 products have been certified.

So slide 4. Allow me to give you a brief overview of the scope of work
that HHS has charged us to do over the three-year term of our contract.
First, we\'re charged to pilot test and roll out a program electronic
health records. We\'ve done that, that\'s live and in the market. Moving
on to October, we\'ve already got much headway under way on developing
and pilot testing EHR certification in the inpatient domain. We\'re just
getting ready to release for public comment our second version of those
criteria, so we've got a head start on that.

Simultaneously, we need to maintain and update the good work we did
around the ambulatory criteria. We update and raise the bar every year,
so that\'s also going on.

In the third year we\'re charged with developing the pilot testing and
testing components for network components through which these EHRs
interoperate. We\'ll begin that work before October of \'07 \-- clearly,
but that\'s the broad scope there. And of course at that point, we\'ll
have work products in two domains, ambulatory and inpatient, that we
need to maintain. Concurrently, HHS has made it very clear that we\'re
expected to transition to becoming a self-sustaining organization and
independent 501, that there is a limit to our contract and our funding.
And so we\'re keeping that in mind as we do our work and develop the
plan. I might add at this point, since these slides were developed, HHS
contacted us and asked us to consider expanding our scope of work. And
to modify our contract to work on developing criteria and certification
programs for specialty EHRs, and some components of personal health
records that complement this current scope very nicely.

Next slide. Shows our current status of where we are. Okay, so you can
think of this as more of the operations piece of our work. The
ambulatory EHR, we conduct quarterly certification on the current
version of the criteria. We have 22 of them out there right now. When we
opened up our application window in August, about 17 more vendors signed
up. We\'ll announce the result of those in inspections in November. We
really take this as a key that we\'re beginning to have some market
recognition and acceptance. The market\'s responding, people are coming,
and seeking our certification.

We are projected, as you can see in May of \'07, to have an update to
our ambulatory program, but also we\'ll be launching the newly developed
EHR inpatient certification.

The next slide shows our time lines for criteria and development. It\'s
important that you all recognize a very transparent process as you can
see by all the microphones here, indicating multiple public comment
periods for each of our development cycles of our work. That\'s a very
important part of our culture. You can see ambulatory and inpatient
network domain schedules. You can see where we are right now. As I\'ve
mentioned, we launched our second round of public comment on inpatient
work but also the refinements and maintenance to the ambulatory
criteria. Our next round of public comment will be actually on the
inspection process itself. In other words, how we\'ll go about testing
against those criteria. And then we\'ll have some pilots and then we\'ll
have another public comment before we actually finalize and go to the
field.

Slide 7. Okay, this is where I don\'t mean to scare you with a lot of
text, but as I said in my opening comments, just to highlight that we
really have made some progress in developing criteria to enable quality
reporting. I\'ve highlighted here in our ambulatory functionality
criteria, again there are hundreds of these, but what I\'m showing here
is that when you see the category and the description, it\'s clearly
around quality measurement. We \-- point number one is the specific
criteria. You can read later. But it\'s specific functionality would
need.

In terms of priorities, we survey the marketplace and you can see
there\'s actually a column that we actually seek the opinion for quality
organizations for each criteria. So do they rank this particular
criteria as low, medium or high in importance?

And you can see here we\'ve got about 8 criteria relating to quality.
From our roadmap column, over where we have previously required, newly
required, you can see most of these 8 are new in \'07. But again,
quality is very important stakeholder group that we manage and gear our
criteria for.

Next slide is number 8. And this is the ambulatory interoperability
criteria. Now, we aren\'t as far along here, and this group recognizes
that HITSP was just getting started last fall and we needed a little
more work on standards, but it\'s important you see that we really do
have some secondary uses of clinical data for quality reporting on our
roadmap for the future. In fact, we\'ve gone ahead and modified our
comments and rationale for having these here to recognize that the AHIC
Quality Workgroup is formed to address and drive these. We made the
edits from the docket IT implementation guides and others to reference
this Workgroup as the driver for standards and specifics.

Slide 9. Getting into inpatient functionality. Very similarly, we\'re
recognizing the broad need for outcome measurement and analysis. There
are multiple criteria. But again we\'re recognizing the AHIC Quality
Workgroup as just one of the stakeholders that needs and drives this.

Slide 9. You can see there\'s much to do in the way of inpatient
interoperability. Again, multiple criteria and things on our roadmap.
Down at the bottom we highlighted quality improvement reporting with a
TBD, and underlining and scoring that the standards implementation
guides aren\'t currently available, but in terms of interoperability
terms, we\'ve really created a plug for this group to socket, if you
will, to this group to plug into that we can work with and drive those
measures and standards that you refine into the marketplace for you.

So to sum up, our CCHIT\'s mission is to accelerate adoption of HIT
initiatives, both benefits and drivers are key elements that are
essential to a broader health IT strategy. We recognize that with you.

Our first product, if you will, our ambulatory EHR certification, it\'s
beginning to take hold in the marketplace. There\'s some acceptance
there. We\'ll have new criteria for ambulatory and also inpatient
criteria under development now. These will all be in play in the
marketplace in May of \'07. Summing it up, I\'d say that the general
criteria for quality measurement have not been included, our roadmap \--
they\'re in our roadmaps, but the specifics are still missing, and we
need this group to act to work with us to refine those firm
requirements. And as I said, we can drive things into the marketplace
then. We look forward to collaborating with you on that.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you very much, Alisa. That was really terrific. And
I should just reinforce that the critical need, or imperative to be on
the agenda or radar screen of the Certification Commission was something
that was repeatedly voiced by proponents of having a Quality Workgroup.
So you\'ve been very squarely within our sights, so to speak.

**[\>\> Alisa Ray:\
]{.underline}**Very good.

**[\>\> Carolyn Clancy:\
]{.underline}**And our last one is Margaret.

**[\>\> Margaret van Amringe:\
]{.underline}**Thank you. I\'ll be brief, and catch up a little bit of
the time here. I was asked to talk about principles for a data
management strategy and with what the Joint Commission has been doing in
that regard. I\'ll give you about a minute and a half of background and
then get to the principles.

I\'m sorry that we don\'t have them to display at this time, because
they\'re still being tinkered with and there may be a few that are being
added. But hopefully between now and the next meeting, we will have
them. And then if there are any discussions at that time we can pick up
from there.

What I think we\'re doing in terms of these principles dovetails very
nicely with what the folks before me have talked about in terms of not
only the only the charge to this group, but in some of the activities
that people are doing.

About a year ago, the Joint Commission internally was discussing the
very impressive progress that was being made toward a national health
information architecture, but also felt that there could be some benefit
nationally to more discussion about a strategy to construct a data
highway that can undergird the collection, aggregation and transmission
of performance measurement data and allow for aggregating those data
across multiple sites and sources when necessary. And of course, given
our major activities in performance measurement, this was a specific
interest of ours, and we felt the attention was less on this particular
part of the quality goals than another.

We also recognized that to have a strategy for a national information
highway for performance measurement, it was going to require having
rules of the road. And I think actually George Isham mentioned the
stewardship board that AQA, and not dissimilar to that but perhaps a
little broader, we saw a number of issues that were important to put on
the table.

Especially because in the environment, there was an increased number of
entities who were now requiring performance measurement and there were
increased expectations about performance measurement, how the data were
going to be used. Traditionally it was quality improvement and
accountability and patient choice, but now there was pay-for-performance
on the table. And there was more interest in actually linking data
sources and using different data sources to compare performance.

So we felt that at this particular point that these increased activities
and expectations demanded that a data infrastructure really be able to
produce standardized credible information that is useful and can be
created in as efficient a manner as possible. So we pulled together an
expert round table, and some of you in this room and on the phone
participated in that. We\'ve had two meetings so far, and we have a
very, very draft white paper which will be the end product of the round
table that will help provide some recommendations about what we need to
do next to have a strategy that can produce the information we\'re
interested in.

As part of that white paper, there\'s a set of principles that are being
worked on at this point. So I will get to those now, and give you kind
of the highlights of those. There are over 20 principles so I\'m not
going to go through each one by any means. Let me say that they are
clustered in three groupings. The first grouping is on the design
characteristics that a data highway would need to have. And in this
particular area we\'re looking at principles such as having standardized
quality controls \-- (audio interruption).

Standardized quality control methods for gathering validating and
aggregating data, and I want to put some emphasis on validating because
data quality (audio interruption).

Data quality is a very important issue for us and I\'m hoping as we have
future discussions of this group we will spend some significant time on
that.

We also believe there needed to be an entity with effective stewardship
over both public and private sector activity in collecting performance
measurement information.

We believe that transparency of the rules of the road that entity would
be working with would be of ultimate performance. Ultimate importance.
Another principle was that the data structure had to support data
standards being developed by the National Health Information Network.
And of course that performance measurement data would be a byproduct of
the care process.

And those were some of the principles in that grouping. A second
grouping was \-- of the three, was accommodating certain needs in this
data highway. In that particular area what we\'re looking at is really
issues such as effectively protecting privacy while assuring broad
access to meaningful and relevant performance measurement data. Also
looking at how we can provide information that gives a longitudinal view
of quality and safety that is across the continuum of care. And we
wanted to be able to permit overviews of performance at national levels,
regional levels and local levels.

The third category is around the qualities and characteristics of the
data highway. It\'s important, of course, that the data are timely and
that the sources of data are credible. But we also believe that there
needs to be a strategy for raising consumer awareness of the public
benefit of the data that are being reported. It\'s existence, of course,
and its benefits.

We wanted to encourage the rapid adoption of information technology
across all health care settings, and to foster accountability for
quality improvement through the performance measurement collection.

And lastly, as an example of another principle that the group was very
concerned about was embracing transparency and engendering trust in
whatever type of system we put together.

So I do believe in the next couple weeks these will be somewhat
finalized in a way that we can send these out and I\'ll try to get them
to Peggy or Kelly so we can provide them to the whole group in case
anyone wants to ask questions about specific ones, or to even suggest
some ones that ought to be added to this endeavor. We hope to have the
white paper with the principles out in November, so that\'s the timing.
And that\'s why it\'s a little bit premature to send it out right at the
moment. But I think we\'ll be nearing that deadline fairly soon.

**[\>\> Carolyn Clancy:\
]{.underline}**Thank you, Margaret. And thanks to all of the presenters.
We\'ve heard really, gotten a very comprehensive overview of the current
landscape of quality measurement and reporting, and also the potential
for health IT to help us accelerate both the reporting for purposes of
accountability and transparency, and also for reporting back to
clinicians. I think between the lines we\'ve heard about some of the
holes in that area. Which I think will become more apparent as we begin
to focus on our specific charge.

But before we get to that conversation, I\'d like to allow a few minutes
for questions or comments.

**[\>\> Helen Darling:\
]{.underline}**Kelly, this is Helen Darling. I had a question for Dr.
Overhage. Does he have \-- he mentioned that he has the ability to get
some of the data through electronic files and otherwise it\'s done in
the usual old-fashioned way. Because of that, does he have information
or data on what the cost, the different costs of the two approaches or
many approaches, I guess, and the benefits and anything that would help
all of us to make the business case for more rapid transformation into
electronic records?

**[\>\> Carolyn Clancy:\
]{.underline}**Marc, are you still on the phone?

**[\>\> Kelly Cronin:\
]{.underline}**He\'s not. And I\'m not sure if he has that specific
data, but I\'m sure he could speak to his own operational cost.

**[\>\> Kelly Cronin:\
]{.underline}**My colleagues who are here with me are nodding
vociferously that he actually does have a lot of that information in
terms of what it costs to collect information using different
strategies. But we can certainly bring that back to the Workgroup.

**[\>\> Helen Darling:\
]{.underline}**That seems to be, as you know, frequently the missing
piece for \-- in so many situations, and as a consequence a lot of
clinicians or administrators aren\'t willing to make the investment and
move ahead until they feel a little more confident about both the cost
and the benefit.

**[\>\> Carolyn Clancy:\
]{.underline}**I think that\'s a very important point. Thank you, Helen.

**[\>\> Helen Darling:\
]{.underline}**Good question for all the AQA pilots.

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

**[\>\> Rick Stephens:\
]{.underline}**This is Rick Stephens. Along those lines, I think that we
have to also recognize there\'s another part of the equation about
motivations that we have to figure out how we put in the system. I can
tell from you the Boeing standpoint, you know, as we look at our costs
going up about \$150 to \$200 million per year, and today we\'re paying
\$1.9 billion for health care costs, we are really motivated to see this
go in place, and so we have to figure out how we align the motivations
of those who are paying in terms of health care costs for our employees,
and those who are providing, the physicians who actually have to go
implement it. And I think we have to think about how that might be
aligned because there\'s certainly motivation on the industry part.

**[\>\> Carolyn Clancy:\
]{.underline}**I think a message that\'s being increasingly heard. Other
comments or questions, either from members of the workgroups or others?

**[\>\> Helen Darling:\
]{.underline}**I just \-- this is Helen again. I\'d just like to build
on that last point, because I do think that it\'s so important. That if
we can find a way to produce the evidence, both for investment purposes
and also what the benefits are, it may be easier to at least in year one
or year two, in the early part of the investment cycle, encouraging
those who are payers, both public and private, to make some of that
investment. But with the expectation that some of the benefits,
including some savings, would accrue back to those same payers, so
basically the investment model.

**[\>\> Carolyn Clancy:\
]{.underline}**Well, I think that makes a lot of sense, Helen, and I
actually think there\'s enough out there now, that we could at least
bring back to this group a preliminary set of what we know. I want to
assure you this won\'t require orthopedic intervention of the material
you\'d be carrying around. It\'s not that deep. But I think between Marc
Overhage and some of the other pilot projects and some work that\'s
going on through the HQA, and others that we can follow up with, we
would at least be able to bring back two pieces of information, or
information in two broad categories, if I\'m understanding you both
correctly. One sort of touches on the return on investment for quality
improvement.

**[\>\> Helen Darling:\
]{.underline}**Right.

**[\>\> Carolyn Clancy:\
]{.underline}**Second is linked to that or derived from that is the
return on investment for investing in the infrastructure.

**[\>\> Helen Darling:\
]{.underline}**Exactly.

**[\>\> Reed Tuckson:\
]{.underline}**Carolyn, this is Reed. I like the direction that we\'re
going here as well. One thing I think that we need to figure out how
we\'re going to have a conversation or discussion about, is that just as
we heard a terrific report by Indiana, which is doing terrific stuff,
there are about 50 of those going on, and each of them have costs, and
so if we\'re going to do a calculation on the \-- invest on the
infrastructure, I think we need to be real clear about the
recommendation or the assumption as to what that actual investment will
be. There has been some work recently now to try to calculate some of
the costs here for multiple stakeholders in these initiatives. And if we
don\'t get a handle on trying to get some order in this, the costs are
just staggering when you add them all up. Individual initiative,
wonderful they may be, by individual initiative.

**[\>\> Kelly Cronin:\
]{.underline}**This is Kelly Cronin. Just to add on that, Reed. We are
actually trying right now to build some cost and revenue models for the
NHIN, and also taking some operational health information exchanges like
Indianapolis, and start to drill down on exactly what are the costs,
looking at variable by variable. You know, what currently is keeping
these organizations in the red, and how \-- what are the start-up costs,
just so you can get to the point where they\'re operational. So I think
that\'s going to fit in nicely to what we\'re doing, and we can use that
to drill down on the return on investment for the infrastructure,
particularly as it pertains to quality reporting.

**[\>\> Carolyn Clancy:\
]{.underline}**Reed, I hear you saying, closing the window on the
premise that we can send the bill for the Nationwide Health Information
Network to United. Is that \--

**[\>\> Reed Tuckson:\
]{.underline}**Actually, you know, it\'s funny, but I think what we\'re
saying is, and I think \-- and obviously is that if the assumption \--
and I want to be clear, and I don\'t know whether or not there\'s time
today to \-- or how we as a committee get to a shared vision, and I want
to certainly be careful in advancing too strong a position, but be one
more of discussion with my colleagues. And that vision in question has
to do with, is our vision of the National Health Information
Infrastructure, one that has multiple activities being sponsored by
individual States or individual State coalitions, multiple activities
sponsored by employer coalitions and so forth and so on, each of which
require an investment in the data analytics, kilobytes of computing
data, investment in refreshing of data on a regular basis, each of which
requires physicians to participate in different ways and so forth and so
on.

So I think what I\'m trying to get to is whether there\'s a shared
assumption of this national infrastructure that says there is an
infrastructure that \-- where you do it once and you do it right, or
does it assume that you\'re going to do it 50 times?

**[\>\> Carolyn Clancy:\
]{.underline}**Well, Reed, you\'ll see further down on the agenda that
there is a time when Kelly is going to talk to us about a shared
visioning exercise, and I\'d like to defer the question because it\'s
incredibly important. At the same time, I think it also illustrates an
issue that we\'re going to have to struggle with and may not have time
to do justice to today, which is by a vision, do we mean where we are
going or how we\'re going to get there. Those two are obviously very
closely intertwined. And how would I say this? The sensitivity around
aggregation of data and data ownership or perceived data ownership and
so forth, I think, will make that very important but also discussion,
but one that we\'d want to be very thoughtful about. So I\'ll that as a
point we want to make sure that we address when we get to the visioning
exercise.

**[\>\> George Isham:\
]{.underline}**I think \-- this is George Isham. I think that Reed\'s
question is framed in an all or none fashion and I think the better
framing would be what components of a national information
infrastructure are best accomplished locally and which are best
accomplished nationally.

**[\>\> Reed Tuckson:\
]{.underline}**I would accept that as a friendly amendment to what I\'m
saying and thank you for advancing the thought.

**[\>\> Carolyn Clancy:\
]{.underline}**To the both of our Workgroup members from Minnesota who
are both above average. Other comments?

**[\>\> Barry Straube:\
]{.underline}**Carolyn, Barry Straube again. And this may set you up for
your next agenda item in part. But I think for those folks on the line
who are not involved with either AQA or HQA, either singly or jointly,
they got a flavor for what the starter core set of measures that were
chosen by those two initiatives. And although we didn\'t hear the
specifics from the Indiana exchange and some of the other presenters,
they also have some starter core sets. I think as we go into the next
discussion items, realize that we\'re going to have this tension between
possibly taking existing measures which were chosen for a number of
reasons, some of them being ease with which we could currently check the
data using administrative data, and/or areas where people were already
investing quality improvement initiatives. I think all of us would agree
that these starter set of measures are likely not to be the key focus in
a year or two, and indeed in some cases aren\'t \-- they\'re actionable
but may not lead to as big a chunk of change as some other measures do.

We\'ve been pushing, of course, from CMS, as have other people, the need
for more comprehensive set of measures, not just focused on a narrow
group of diseases and/or diagnoses. Outcomes measures we\'ve heard
about, efficiency measures. We\'re clearly interested in measures that
will look at care across the continuum, across settings. From our
standpoint, Medicaid is under stressed in terms of the needs there. Plus
special needs populations, covered under our special needs plans, and so
forth. Obviously, pricing and cost comes into this. And then there\'s
the issue of composite measures reporting and how you take
electronically derived measures and maybe wrap them up into composite
measures. So again it\'s going to be, with your next agenda item, people
should know of what the core set is currently that we\'re all using
that\'s great, but we\'re probably going to be inclined to want to try
to adapt that electronically since it\'s already there. But we have to
keep in mind, in the back of our minds, they may be antiquated already
or not as useful as others and we\'re going to have to try to push on
those broader sets quickly.

**[\>\> George Isham:\
]{.underline}**Barry, this is George Isham. I think I made that point
when I made my comment about starter measures. I think that also what\'s
needed, though, is a realistic appreciation for the time frame and the
resources that would stage the work. And much \-- in the way you would
stage any complex activity or endeavor. And I worry about managing
expectations in terms of when we\'ll get to which point, in terms of,
you know, the job being complete or done. And so I just think not only
do we want to keep in mind the fact that what we\'ve got today is a
starter set and it\'s very crude and not very advanced in terms of where
we need to be \-- we also need a plan for how we\'re going to get to the
vision in the future, very thoughtful, very deliberate, aligns resources
and activities and so forth, with the time frames that people can be
held accountable to and can achieve.

**[\>\> Carolyn Clancy:\
]{.underline}**Completely agree, George. That\'s I didn\'t used the word
tension. And it will be a difficult balancing act, I\'m sure, but I
think that\'s one of the prime functions this Workgroup can really help
with.

**[\>\> Carolyn Clancy:\
]{.underline}**Thanks to both of you. Those are important comments. Any
others before we turn to a discussion of the core measures? Great.
We\'re now on item 9 of the agenda, which is to talk about a discussion
of core set of measures. Now, the assumption here has been that the core
set we\'ll be starting with are the measures currently being used and/or
to be in place, although we didn\'t put a date on it, I\'m going to
right now: by the end of calendar year 2006 for the hospitals. So we\'ve
got the AQA, starter set and what\'s being used for the hospitals right
now as what we\'re going to call a core set of measures.

Now, those measures exist and in fact in the case of hospitals are being
widely used as you heard. Our challenge is to figure out and create a
map of what would be necessary to be able to automate the collection of
this information through electronic health records.

Now, having said that, I think we also need to add two other caveats. It
would be lovely, and I\'ve actually made a slide I\'d be happy to share
with anyone, about a finger on a keyboard hitting F7, that\'s our ideal
state, where you hit F7 and all your quality measures are uploaded.
We\'re not there yet. In some cases we\'re going to need information
from electronic health records in addition to \-- from a particular
site, say ambulatory care or hospitals, in addition to information that
may be stored elsewhere. So by way of example, it is easy enough to
imagine a program that identifies which patients in the hospital have
had a heart attack, and then count the number much those who got beta
blockers, and voilà, you\'ve got a rate. And that\'s what you need.

However, the challenge, of course, comes in the fact that the existing
information that\'s in the hospital record, whether electronic or paper,
may not be sufficient to identify those patients who have contra
indications who under no circumstances should be getting a beta blocker
and that information is either in a doctor\'s head or \-- and/or
residing in a piece of paper in his or her office practice. So that\'s
what we mean by thinking about electronic health records in addition to
the challenge of electronic health records plus information derived from
health information exchanges or some other source.

The third dimension of that I\'d want to put on is thinking about claims
data enriched by electronic data elements that can be obtained from
pharmacy data in the very near future and laboratory data in the even
sooner future than that.

So that\'s where we need to go right at this moment. Let me just ask if
there are any questions about bringing us back now to the specific
charge. Fine. So what we have before us is a challenge where we\'ve got
a 26-item \-- or 26-measure starter set from the AQA. We may also want
to talk about whether we want to include the other measures that have
been endorsed by AQA, but are not at this point in time part of the
pilot projects. In addition to that, we\'re talking 21 measures, Nancy?

**[\>\> Kelly Cronin:\
]{.underline}**I\'m thinking it\'s 21, and Nancy had to leave a few
minutes early, if I recall correctly, measures for which we would need
to work up for all of you what are specific data elements required and
where could that information be obtained. Can it be obtained from
electronic health records alone? Can it obtained from electronic health
records but we\'re likely to need other information from other sources
including health information exchanges? And/or could it be obtained from
billing claims and to what extent might electronic clinical information
enrich the use of claims data?

**[\>\> Carolyn Clancy:\
]{.underline}**I hope everyone\'s still with me. I expect loud comments
if we don\'t.

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

I\'m with you.

**[\>\> Carolyn Clancy:\
]{.underline}**Good. So we will bring that information back to this next
meeting for you, and my guess is that we may in particular, Peggy, be
consulting to you make sure we\'ve got this right in terms of the data
elements. Because I think that your group in particular probably has the
most experience in doing this and needing to specify for a whole variety
of vendors in very specific terms, what data elements are needed.

**[\>\> Peggy O'Kane:\
]{.underline}**Right. And we\'d be happy to work with you offline on
that, if you want.

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

**[\>\> Reed Tuckson:\
]{.underline}**But I think \-- this is Reed. So again back to the
fundamental assumptions here. If you assume the AQA/HQA is an
inescapable core of measures that everybody has to respond to, and is
responding to, then that becomes a minimum set that we have to be able
to deal with. And within that set of AQA/HQA measures are some that
require claims based, office-based stuff, some that are office-based,
some claims-based and so forth. The assumption that we then make, and I
think that which you maybe have asked Peggy to do, is come back and
recommend if there are certain things outside of the bounds of the
AQA/HQA activity that would also want to be thrown into this.

**[\>\> Carolyn Clancy:\
]{.underline}**I actually wasn\'t going there, Reed, although I would
envision at a future meeting we might want to go there.

**[\>\> Reed Tuckson:\
]{.underline}**Okay.

**[\>\> Carolyn Clancy:\
]{.underline}**Right now I was focusing on what you were referring to as
the indispensable core, where I was hoping we could leverage enormous
experience from NCQA in being as precise as possible about the data
elements needed.

**[\>\> Reed Tuckson:\
]{.underline}**Okay.

**[\>\> Carolyn Clancy:\
]{.underline}**Because most of the measures, I dare say the majority,
Janet Corrigan might be able to give me an actual percentage, have not
been specified at this level. So in order to figure out how they could
be part of electronic health records that would then be certified by the
Certification Commission in the relatively near future, I don\'t want to
make Mark and Alisa nervous. I want to be on their radar screen and part
of their deliverables. We would need to be that precise.

**[\>\> George Isham:\
]{.underline}**The assumptions are correct. This is George speaking. But
I do need to tell you, I need to sign off at this point.

**[\>\> Carolyn Clancy:\
]{.underline}**Okay, well, thank you very much for participating, and
future unpleasant committee assignments or subcommittee assignments,
you\'re in the lead. I\'m just kidding.

\[laughter\]

**[\>\> George Isham:\
]{.underline}**Thanks, Carolyn, I appreciate that.

**[\>\> Reed Tuckson:\
]{.underline}**So I guess, Carolyn, and you say we\'ll come back to it,
just again, I just want to make sure that \-- or again as we get to a
shared vision, is how do we as a committee envision \-- can you do
everything, or do you have to make certain priorities? And I think
that\'s really the fundamental I\'m just trying to get at. Are we
envisioning a system that can do everything all at once? Because those
things are, again, difficult to do expensive, and so forth.

**[\>\> Carolyn Clancy:\
]{.underline}**Well, I think that ultimately, and this will be part of
the visioning exercise, Reed, we want to be as clear as possible about
what everything means, including measures related to cost and
efficiency, including getting to episodes of care, and a number of other
items that Barry Straube identified. And including very importantly, and
I see this as being a bit down stream, but still very important, trying
to figure out some of the architectural issues around the fact that some
of the high value areas are areas where a number of physician
organizations have made investments in stand-alone registry collection
of data, the Society for Thoracic Surgeons comes to mind immediately,
but there are a number of others. Right now those are completely
stand-alone and not part of anything. Interestingly, their measures have
been endorsed by AQA. So we may get to a piece of that in the relatively
near future, but when we get to visioning, that\'s going to all be part
of it.

**[\>\> Reed Tuckson:\
]{.underline}**Thank you.

**[\>\> Carolyn Clancy:\
]{.underline}**Any other questions or comments on this specific next
step?

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

So Carolyn, this is Rick. Where is that list that everyone\'s referring
to relative to AQA?

**[\>\> Carolyn Clancy:\
]{.underline}**It\'s on the AQA Web site and we will make sure we get it
out to members of the Workgroup. The AQA measures are on the Web site.
We will get you a cleaned up list of this indispensable core, will be
the easier way to say it.

**[\>\> Rick Stephens:\
]{.underline}** That will be helpful, because I interpret as I\'m
listening to the discussion, they tend to be around the physicians and
the work that they do, and when we get to the visioning process, you
know, my sense is we really want to make sure we recognize what all of
the stakeholders are looking for as opposed to one set of stakeholders.
Because I think that\'s going to play a critical role in what the
architecture looks like.

**[\>\> Carolyn Clancy:\
]{.underline}**Yes, and inferring from both you and Reed that you don\'t
want us to lose sight of efficiency issues.

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

Certainly. I\'m a data guy. When I say data, I\'ve got a master\'s in
computer data architectures, so I come with a sense about understanding
the broader system and what the system architecture needs to look like
for what we\'re talking about. So I\'m just trying to make sure I get an
understanding of the language. Efficiency is certainly one of the items,
yes.

**[\>\> Carolyn Clancy:\
]{.underline}**Great. That\'s very helpful. And I\'m thrilled to hear
you\'re a data guy because we need a lot of that on this committee.

**[\>\> Helen Darling:\
]{.underline}**Carolyn, this is Helen. I have one other maybe just a
clarification. What I heard Reed saying, I thought, and a little bit of
the last conversation has been \-- maybe we want to be sure to keep the
broader and more comprehensive vision and as Rick said, make sure we
take into account all stakeholders\' interests. But that in the
short-term, meaning immediately, we may be coming up with a core set of
measures that isn\'t nearly as extensive as we would ultimately want to
have at a different stage. But we want to have the vision and since the
roadmap for the future clear enough so we\'re not making any mistakes or
wasting any time.

**[\>\> Carolyn Clancy:\
]{.underline}**No, that\'s absolutely correct. And I think that tension
is one that we\'re going to have to manage in this Workgroup, and again
one that I\'m quite thankful that the Office of the National Coordinator
and the Community have been managing for over a year, which is keeping
the broad vision and the critical need to move as rapidly as possible in
one part of the screen, but in the other part of the screen identifying
the very discrete steps we can move on right now.

**[\>\> Reed Tuckson:\
]{.underline}**And Helen, this is Reed. I want to say I think you\'ve
captured what I was trying to say. Also, there is an anxiety about
raising these kinds of points on a call like this because you run the
danger of someone thinking that, you know, you don\'t want to do
whatever their pet project is, or whatever, you know, it is. And so I\'m
trying to be extremely, extremely careful in making these points. But I
also do want to put front and center, as you have correctly captured in
your response, that I mean, there are some realities here in terms of
how much money this stuff costs the system, and how do we advance this
in a responsible way so that moves it forward quickly, and also in a
responsible way, and we\'re all responsible people on this call. So I
keep trying to find a way to advance \-- to raise some of these
questions delicately but not gore anybody\'s ox.

**[\>\> Carolyn Clancy:\
]{.underline}**Your delicacy is officially recognized, for the record,
Reed. Thank you.

\[laughter\]

Kelly, do you want to walk us through the next steps?

**[\>\> Kelly Cronin:\
]{.underline}**Sure. I think this is really just referring to sort of
what we have in store over the next couple of months.

Since we heard a fair amount today about the need for more information,
either what already exists out there in the way of trying to figure out
the integration of Leapfrog measures, or try to find more out about what
we know on the return on investment for the infrastructure sort of
beyond the CLT model getting to something more meaningful and tangible
to this group and getting at some of Reed\'s concerns in particular, we
will be meeting as a team, the staff and the senior advisors to this
group, Carolyn, hopefully with your input as well as Rick\'s, to try to
follow up and make sure all of those items get looked at and fed back
into the Workgroup. But I think we also want to make sure in the October
meeting, we\'re able to complement the presentations and the discussion
today to address any of the other outstanding issues that we need to
learn about relevant to the specific charge. And this is in the context
of doing a complete environmental scan to make sure we\'re considering
everything out there before we start really deliberating on what kind of
recommendations we could be making for this specific charge.

I also wanted to note that it looks like October 4 is not going to work
for a meeting date for a couple of key people, so we\'re hoping that
October 5 is going to be viable. And we\'d also really like to encourage
folks to attend in person, since we\'re just getting started and we
found in the six other workgroups that are going on, that when people do
come in person, it really gives a different flavor for the Workgroup and
we\'re able to communicate more easily.

So to the extent that\'s feasible, I\'d encourage everybody to come and
we\'ll also try to confirm the best time for this, based upon your
availability. But I think we likely are going to need a four to
five-hour meeting since we have a fair amount to get to before we can
actually start crafting recommendations.

So we will expect to be sort of trying to solidify some of our thinking
around some of the concepts we talked about today during that next
meeting, so that after that next meeting we can start thinking about
draft recommendations.

But I also wanted to mention that, as already happened with the other
workgroups, we\'re going to be starting a visioning process that is
intended to try to paint a picture of what the ideal world would look
like down the road, with streamlined and automated quality measurement
and reporting of a much broader set of measures. So really addressing
some of the more comprehensive interests that were talked about before,
and agreeing on sort of what are the characteristics or attributes of
the health care system that will adequately describe where we want to
go. And then work from that common vision, which will be at a relatively
high level, and then go backwards. Try to really adequately discuss
where we are today realistically, which I think we\'ve covered a fair
amount on today, and then figure out our interim state. Say it\'s 2010,
where do we think we need to be in 2010? And I think that exercise will
likely put into context a lot of discussion, and trying to figure out
how we work in a world of relatively low EHR adoption. How do we work in
a world where we\'re going to have over time network services being
deployed and the market being created for health information exchange,
but you know, we\'ll be having to make some assumptions about where
we\'ll be not only at 2014, but also at a mid-state, which could be
roughly 2010. So I think as we move from our specific charge to our
broad charge, that should allow us to think collectively on what is \--
what does that path look like going forward. And while we may not over
November and December have the time to do sort of a comprehensive
detailed roadmap, we can at least at a high level discuss it and agree
on it, and then that can really sort of, I think, shape the work that
we\'ll take on over the next year.

**[\>\> Rick Stephens:\
]{.underline}**This is Rick. I want to back up to what you started with.
I mean, is the date set for the 5th? Because you certainly clobbered me.
I was lined up for the 4th.

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

Me, too.

**[\>\> Kelly Cronin:\
]{.underline}**It\'s not absolutely set. We are actually just back and
forth in the last several hours trying to figure out what might be
viable. So Rick, we\'d obviously want to get a date that works for you
as well.

**[\>\> Rick Stephens:\
]{.underline}**Yeah, the 4th worked great. So \-- I planned my life
around it.

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

We did, too.

**[\>\> Kelly Cronin:\
]{.underline}**Yeah, Carolyn, I don\'t know if you have any flexibility
at all, we\'ll try to work that out, offline.

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

**[\>\> Kelly Cronin:\
]{.underline}**We have quite a few scheduling conflicts as you can
imagine with the public meeting this week. We\'ll work it out. And try
to take into account everyone\'s very busy schedules. But since I just
really brushed over the visioning process, and what we might need to be
doing over the next several weeks in the way of a more comprehensive
environmental scan, does anyone have any questions or comments about
that?

**[\>\> Margaret van Amringe:\
]{.underline}**This is Margaret. I\'m a little bit unclear about how we
can help with the hospital measures, for example. There\'s I think 27,
or so, that \-- do you want to us provide the specifications for those,
and how are we going to accomplish getting those into a chart that says
these are good for EHR\-- or these are good only for enhanced EHR.

**[\>\> Carolyn Clancy:\
]{.underline}**I don\'t think you need to do that, Margaret. I think the
staff will take care of that.

**[\>\> Margaret van Amringe:\
]{.underline}**Yeah, I think it would be good to work with you and Nancy
on that, just to understand what we\'re (indiscernible).

**[\>\> Charlene Underwood:\
]{.underline}**This is Charlene. I\'m at point 2 on the starter set
measures. Two things. Actually three points. One, I wanted to kind of
support Secretary Leavitt looking for the rudimentary set of measures,
because from a vendor perspective, doing this incrementally makes it
more achievable for us. Secondly, we would ask, and I don\'t know if
this work has done, there\'s been a lot of detail put into the
measurements. But have they been evaluated for the ability to map
terminology standards? And that again is another piece that would help
us get to measures that are interoperable among systems if that
standardization is done. That may be come out of some of the work of the
pilots, but I think that would be an important piece of information to
know, because that would help us in getting through the HITSP process
and the certification process on that. So I don\'t know if anyone has
that information. But that would be another piece of the environmental
scan that we might need to do.

**[\>\> Kelly Cronin:\
]{.underline}**That\'s a very, very important point, Charlene. Thank
you.

**[\>\> Rick Stephens:\
]{.underline}**Just one other question I\'d ask, this is Rick again. Is
there some documentation about the future process or advising process
we\'re going to use?

**[\>\> Kelly Cronin:\
]{.underline}**Yes, Rick, I can send that to you after the call. I was
going to send it out to the whole group, which is what the other groups
have been working from. I just didn\'t want to overwhelm anyone since
this is our first meeting and we really don\'t have to take that on
until November.

**[\>\> Rick Stephens:\
]{.underline}**I understand. It just helps get everyone mentally
prepared. It will help me.

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

**[\>\> Rick Stephens:\
]{.underline}**I think if you sent it out to the members of the
Workgroup, that would be helpful, Kelly.

**[\>\> Kelly Cronin:\
]{.underline}**Okay, we\'ll do that.

**[\>\> Carolyn Clancy:\
]{.underline}**I think we have a few minutes for public comment.

**[\>\> Matt McCoy:\
]{.underline}**Yeah, I\'ll explain how the public input part works. For
members who are following along with this meeting over the Internet,
you\'ll see up on your screen there\'s a phone number where you can call
in and press star-1 if you would like to make a comment. And I know we
also have a few members of the public who are already dialed in to this
meeting, and just listening along on mute. If you would like to make a
comment, same procedure, just press star-1, you\'re already dialed in to
the correct number. We usually wait about a minute for people to work
their way through the operators during that time I\'ll let you know if
anybody jumps in, otherwise we are probably good to adjourn when that
minute is over.

**[\>\> Helen Darling:\
]{.underline}**Carolyn, while that person is manning the calls, may I
make another comment?

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

Of course.

**[\>\> Helen Darling:\
]{.underline}**This is Helen Darling. I\'m wondering if in assessing
measures and making determinations about which are the most appropriate
to start \-- if the strategic possibility that the sooner we can find
evidence of improvement in quality and savings accruing to everybody,
and you know, more good things happening including money being saved,
the sooner there will be confidence and willingness to move ahead and
making the investment. And if that is a factor that ought to be in \--
at least one of the attributes, those measures that will get us to the
longer vision sooner.

**[\>\> Carolyn Clancy:\
]{.underline}**Well, I think that where we\'re starting, Helen, is to
take a core of measures that have been broadly in use by the hospitals
for a couple of years.

**[\>\> Helen Darling:\
]{.underline}**I see.

**[\>\> Carolyn Clancy:\
]{.underline}**And that are being moved through the first six and then
soon to be a much greater number of pilots. And figure out how do we
automate the collection of that data.

I think what you\'re asking is a very important question in terms of
other information that might be brought to future management
development, which also feeds back to the points that George, Reed and
to some extent Rick, were making, that feeds into the visioning. But I
think it\'s a very important point.

**[\>\> Helen Darling:\
]{.underline}**Okay, thanks.

**[\>\> Matt McCoy:\
]{.underline}**Yeah, I would just like to invite any comments here in
the room since we have several members from the public here in the
building. And I guess there appears to be no one calling in, Carolyn, as
well.

**[\>\> Carolyn Clancy:\
]{.underline}**Great. Well, thank you again, all of you, for your
commitment of time and also for your future commitment of time. And I
very, very much look forward to working with you. Thanks a lot.

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

Thank you.

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

Bye-bye.

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

Bye.

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

Thanks very much, Carolyn.