American Health Information Community

Biosurveillance Workgroup #9

September 21, 2006

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

Okay, I will begin quickly with roll call for today\'s Biosurveillance
Workgroup meeting.

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

This is Jeff. I just talked to Chip, he said he\'s on hold at that
number and no one is letting him through.

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

He should be through shortly, probably the operator is tied up bringing
in the public lines. Kelly, if it\'s okay with you, I\'ll keep going
with roll call.

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

Sounds like a good idea.

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

On the phone we have David Parramore from the Department of Defense.
Maureen Allen, are you here as a designee for Michael Barr today?

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

That\'s correct.

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

Okay, Maureen Allen for Michael Barr. Leah Devlin from North Carolina.
Mark Rothstein from the University \--

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

Chip is here now. I\'m sorry, they wouldn\'t let me in.

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

Brian Keaton, College of Emergency Physicians. Laura Conn, CDC. Brian
Carnes from Indiana, Adele Morris, from Treasury. Rick Heffernan is in
for Dr. Frieden from New York, Scott Becker from the Association of
Public Health Laboratories, Edward Sondik from CDC. Chip Kahn, Co-chair,
just joined us. Kelly, did you have some members with you, as well?

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

I have John Loonsk here, and John Lumpkin is also joining us today.

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

Is there anybody else we missed? Very quickly, as always, for the
Workgroup members keep your phone muted when not speaking and do try to
introduce yourself, say your name before you make a comment, so those
members of the public following along will know who\'s speaking.

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

Excuse me. This is Leah Devlin, and I will be here until 2:30 and
Dr. Jean-Marie Maillard is here with me.

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

This is Ed Sondik. I\'m going to have to switch from one phone to my car
probably in an hour to get down to the Department. Thanks.

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

Thank you. This is Chip, and let me say we\'re going to try to do two
things today, overall. Actually, three things. We\'re going to have an
update on where we are with our Biosurveillance Data Steering Group.
We\'re going to then review and discuss and I hope come to closure on
our priority areas, and sort of prepare them for heading towards
recommendations, and make sure that we have a sense of where we\'re
grounded there in terms of our immediate areas of work.

And then finally, and John Lumpkin will probably do the heavy lifting
here to introduce it, we\'re going to begin a new process which you have
received materials on, which the other Workgroups are going through as
well as ours. Which will be to go from, I don\'t know, 4 or 5,000 feet
where we\'ll be with our priority setting, up to about 30,000 feet, and
begin a process that probably will take a couple of meetings. Because I
think at some point \-- Kelly, when is the meeting in October of AHIC?

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

October 31.

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

We would hope to finish the process of this longer-term of visioning for
what we want to see the AHIC contribute to public health. We\'d want to
try to continue that over the next several meetings to get that finished
so that a presentation could be made at the October meeting on that
vision. But we\'ll get to that later this afternoon.

Now, we have a lot of time set aside. Unfortunately for me, I\'ve got a
steering committee meeting of the AHQA, and so I will need to leave in
about an hour and 45 minutes or so. Or around 50 minutes. But we will
continue \-- you will continue after that if we still need time to go
through the entire of John\'s presentation and our initial discussion of
that. I hope we can squeeze it all in before I leave, but we may not be
able to. But it\'s important to take as much time as necessary with
that, because John has put in a lot of work. And that\'s an important
activity of ours, as well as dealing with the short-term priorities.

Kelly, should we start with the report, or is there anything I missed?

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

No, I think that\'s it.

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

Okay.

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

Yeah, I think we\'re ready to go to Dr. LaVenture and Dr. Davidson.

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

Good.

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

On the Biosurveillance Data Steering Group. Marty and Art, are you on?

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

This is Marty, I\'m on.

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

And this is Art, I\'m on.

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

So will you proceed.

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

Thank you very much. This is Marty LaVenture, and I want to just say
we\'re very pleased to have an opportunity here to share with you a
little bit of an update of the hard work that all of the committee
members have been working on. And share a little bit of our current
efforts, directions, and what\'s remaining in this process. And I want
to thank you both here, and into the presentation we\'ll list all of the
members, but they have worked \-- thank them for their work and effort,
they have worked very hard, been very engaged throughout the process,
and have been I think committed towards sort of a \-- positive solutions
as we look at some difficult and complex issues in a very short
timeframe.

Art, other thoughts as we get started, from you?

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

No, I just also want to thank ONC for giving us the support to get this
thing together.

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

Terrific. I\'ll get started, and turn over as we go, and comments will
sort of flip back and forth between Art and myself. If we look at slide
two, as you \-- just a reminder to all of us, that this Surveillance
Workgroup was formed to specifically look at the more specific issues
related to the core dataset. And that is we were formed in June, and
this is the recommendation that brought forth that recommendation.

So the first couple of slides here sort of will highlight sort of who we
are, and bring you up to date on that context. Art and I are the
Co-chairs. As we said, we\'ve had a very distinguished, broad set of
individuals that have worked hard to contribute various perspectives in
this process, and a terrific staff from the office, as well.

If we take a look at the next slide, slide four. Just reminds us of the
broad and specific charges that the committee has been charged with. The
broad charge certainly sets forth the core recommendations to \-- for
the committee, for what we should be moving forward with, and we added
both the specific charge as well as in the following slide, highlights
the recommendations for helping us set the context for where we want to
head.

Art, do you have any comments?

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

Just to remind the committee \-- Workgroup, rather, that this is the
recommendation, slide five, and it expands that to include hospitals
here. Hospital utilization data, which was not included in the prior
slide. And that the collaboration with the HITSP Technical Committee
allowed us to bridge and share information through two members that were
on both the HITSP Panel Technical Committee and our group, Ed Barthell
and Eileen Koski. So there is some collaboration between the two groups,
we\'re not going off in different directions.

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

So as we \-- in terms of where we\'ve come from, those are the key
charges that we started with, setting the initial context as well as the
members for the approach. So that\'s where we really began our work of
who we are and what we were charged with doing.

We then, in slide six, sort of outlined a little bit of our approach,
and this slide and the next one will try to highlight how we\'ve
proceeded with that as part of our charge.

And as Art just mentioned, with that formation there were \-- with the
11 members, two of those representatives were from the HITSP, and that,
and building on other work and connecting with other activities was a
hallmark principle that we tried to follow throughout as we focused on
the minimum dataset elements.

And that also carries over to the slide seven that you\'re seeing, that
we tried to summarize the many and complex activities that we worked on
in this short period of time. That there were a number of both drivers
and inputs as reflected on the left side of the slide, things such as
defining the \-- from the basic charge, we looked at the issue of the
scope of work and the data elements, building upon what was provided to
us, and then assembled that into the process of a matrix so we could
examine those data elements. And that became the core output for our
minimum \-- our initial minimum dataset.

Similarly, if you scan down to the line of input that outlines the
notion of the need for context, is another example where the committee,
through a number of discussions, realized that we needed to make some
key preconditions related to our assumptions. So our deliberations could
be clear, that thinking could follow through, and that we would build on
other work that was done. Issues such as definitions. The group adopted,
for example, one of the preconditions was the adoption of the ASTHO
biosurveillance definition as a working definition for our working going
forward, and other types of preconditions. And so those are documented
into about over 15 of those that are assembled together as part of our
work.

So this summarized the initial process, initial inputs process, and what
we hope to be delivering to you soon.

Art, other thoughts or other examples on the chart?

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

I think that one of the things that we really tried to focus on was
defining the functional areas that we\'re trying to address, and I think
I heard that John Loonsk is in the room, and Laura has been part of our
committee, and they prepared to document a while back what are our
functions of preparedness, and we\'ve been able to whittle those down,
kind of go through a balloting and validation process for what are
functional areas that we think the minimum dataset should address. It
obviously cannot address everything, since it is intended to be minimum.

So we are trying to figure out where it fit in sort of the scheme that
John and Laura had produced in a prior article, and we\'ve been able to
get to a final grouping of those for our minimum dataset.

And then as we\'ve mentioned before, the passage of the initial minimum
dataset, and the subsequent versions of that to the HITSP for standards
and harmonization, and to identify the standards. So I think even though
our group continues to meet, HITSP has already been taking the output
from our group and been working with it to present something back to the
public from their point of view.

And then at the very bottom, we\'re targeting not only \-- you know, the
list of the data elements and the functional areas that they pertain to,
but the idea that there needs to be some measure of feasibility as
stated in one of the charges. And what are filtering criteria for the
minimum dataset. And we\'ve asked for expert opinion about that, and are
still working through that expert opinion to determine how to
incorporate that in our final report.

Marty, any other comments about this slide?

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

No, there\'s a lot that\'s packed into this, and each of these cells
have additional detail that we reflected in the report. But we wanted to
try to highlight sort of in this some of the many dimensions of what we
were working on.

Maybe if we can look at one example of that in the next slide, as well.
When we talk about the minimum datasets in the slide eigh, we\'ve
highlighted here the categories for those elements. For example, in the
base facility elements there\'s five particular data items, and some
examples are listed for those. And we systematically worked through each
of the data elements, as grouped in these particular categories.

With each data element our intention was not to change sort of the core
definitions as we received them, but to really add either context or
examples or comments relative to those particular data elements.

So this is a summary of the 61 elements that we\'ve gone through and are
still going through relative to the feasibility element. Other comments,
Art?

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

No, and just also, in terms of filtering, there are many questions that
our group is now deliberating about regarding how to filter \-- what
filtering actually means, and providing some guidance about if there
were 61 elements, it doesn\'t mean that everything would be flowing from
a site in these 61 areas. It may be that just a portion of the data that
is generated from a health care facility would be flowing based on some
filtering criteria.

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

In addition, these elements have been put into a spreadsheet so that
they can be cross-correlated with functional areas, as well. So there\'s
quite a bit of analysis looking at the elements themselves relative to
not only feasibility, but to their functional purpose.

If we could take a look at the next slide, please. This is an example of
some of the functional areas. Art had mentioned later the article by
Dr. Loonsk and by Dr. Conn, and others, that we focused on these
particular functional areas to make sure that we were mapping the data
elements across appropriate functional areas, the early event detection,
the outbreak management, countermeasure and response in particular, so
that use could be correlated with the datasets themselves.

And so these were the ones that we focused on in particular. Art, other
comments on this slide?

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

Right, I think our group was struggling to figure out what would be
possible or should be in our target for the short-term versus the
long-term, and listed here are the ones that in our short-term, and that
would be defined as within the year, as in our basic charge. But it does
not mean that other functional areas are entirely excluded, it\'s just
that in the short-term we thought that if we focused on these three, and
specifically the seven bullets under these three. Because these are not
the full scope of the three functional areas, under early event
detection there are more bullets than we have represented here.

We thought if we could just focus on the short-term, it would help us to
get a little more real about the meaning of the minimum dataset
vis-à-vis biosurveillance activities across multiple jurisdictions. So
this is our short-term list.

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

In the table we include the analysis as it relates to a longer-term
focus, as well. So that can be seen as part of the report, also.

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

This is Chip Kahn, can I just ask a question? In terms of \-- and maybe
you said it, but in terms of what you\'re asking for, is the field \--
are the people that would have to report, do you think they\'ll be
confidence level there they can do what you\'re asking for?

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

That\'s part of our feasibility assessment, that we\'re now receiving
testimony from a variety in the field about what\'s the \-- how likely
is it they\'ll be able to provide these types of data. So that\'s part
of \-- that will be part of our final report.

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

Okay. But I mean, as you go through that, you sort of design this with
the feeling that it would be? I mean, do you think?

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

Well, I think there may be some data elements in the 61 that would be
more difficult. It does not mean that that healthcare facility, if they
can only give 50, would be excluded. You know, that may be something
that they could work toward, but at present, we think that most of these
61 are feasible in some places in the country.

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

Okay, thanks.

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

This is Rick from New York. I notice that reportable disease case
reporting is listed there, and I had understood that this particular
minimum dataset was anonymized without identifiers. I wonder if you\'re
taking the identifying information into account, as well, and that\'s
why that\'s there.

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

No, I think what this is is to get the lead that\'s there\'s something
out there, then you track back to it. It\'s not as if this is the final
report. Again, we didn\'t have enough time to really get into it, but
the 15 preconditions that Marty alluded to earlier really address some
of the concerns about what\'s the difference between this
biosurveillance activity versus traditional epidemiologic and
surveillance activities that occur for communicable disease control.

And we\'re very clear about that in the preconditions based on the ASTHO
definition, that this is not about doing full work in case investigation
and management, it is an adjunct. Nothing more than an adjunct at this
point. And we\'re not expecting that we would have fully identified
information being passed through our jurisdictions. But at the same
time, if one jurisdiction has authority to receive that information,
then the minimum dataset that is being sent on a national level to some
receiving site may be different than the minimum dataset that is being
received at a local site.

So, you know, that\'s one of the preconditions that we\'re trying to
work through.

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

Thanks.

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

Shall we take a look at the next slide, which we I think was \-- Chip
alluded to, as well, the whole notion of some issues that we\'re working
on. We\'re working at both defining, describing in our preconditions,
and making sure that we offer some context for the two notions here. The
one of filtering, that will sort of limit the type of information that
should be passed through from the reporting source to an agency. And the
second issue that we\'re continuing to work on through that expert input
and input from the committee, is really the levels of feasibility that
we\'re talking about in the short-term, long-term, for the data
elements.

So these are both in progress as we\'re working on them, but are
important aspects of the discussions and the report. Art, other thoughts
here?

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

No, I think that\'s very complete, Marty.

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

So if we could go to the final slide, and happy to try to answer
questions that we\'ve had. And as Art mentioned, we\'ve packed many
hours and discussions and pages of documents into a quick thumbnail,
here. And we\'re happy to try to go into additional detail.

We are working on preparing the documents, final \-- continuing analysis
on our expert input for the recommendations, and hope to present that
information on the 31st to AHIC. So we\'ll be back with you with more
complete information and documents as we\'re completing it within \-- on
October 17.

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

This is John Lumpkin, I was wondering if I could ask a question. Looking
at MDS, I see in the first category you have demographic characteristics
of facility. And recognizing that any sort of data collection ought to
be as lean as possible, do you need anything other than the facility ID?
And can\'t you then, from another database, collect the information on
number of beds? Or are you looking for an active bed status?

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

I think that we don\'t know how these base facility elements will be
available. We know that to make an assessment of where we are with
regard to resources, we\'ll need to know how many licensed beds and how
many available beds there are.

I don\'t think that what we have been trying to do is to say the method
by which this is collected. We have presumed the minimal additional data
entry, but we don\'t know that for sure, and that\'s part of our
discussion regarding feasibility.

But we expect that there will be a need to know what are the base
numbers for a facility, if we start deducting beds that have been
admitted patients, you know, have been assigned to those beds, how will
we calculate the number of beds that are available at the end of the
day. Is that something that someone is going to have to do by entering
on a Webpage, or is that something we\'re going to calculate on our
side? I think we haven\'t determined a method yet.

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

Just a followup question. It was my understanding that as of this point
probably a majority of the States, if not all \-- a large proportion,
already have systems in place to monitor beds. So to what extent would
you see this as being either deriving data from that, or would you see
this as a duplicative process of collecting that data?

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

Anywhere we can derive data, we would encourage that to be done. It\'s
not about duplicating that work.

But I don\'t know that all the States have it, there\'s no standard yet
available, this HAvBED or HAV as two methods that have been proposed,
are out there, would this \-- when there is some effort to request the
information from facilities, might we just use that, rather than have a
direct stream of data flowing to the national collection site for all
the rest of the data elements. Maybe we\'ll rely on that, and that will
flow into the national collecting system.

I don\'t think that our focus at this point has been to be on the
\"How,\" it\'s more on the \"What.\"

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

Thank you.

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

This is Leah Devlin. I had that same question, John, thank you for
asking that. We had talked about that a lot in earlier meetings, John. I
think your work has done a lot of good work, you certainly have packed a
lot into your slides, and thank you for that.

I had just a comment on slide nine. I guess one of the issues I think
it\'s always good to lay out there that we use this information for
continual \-- you know, quality improvement and cycling back, that
we\'re going to \-- you know, there\'s evaluation built into every one
of these that goes back to inform our processes. So I don\'t know if you
want to capture that somewhere or not, that was just something that I
thought about in looking at that. It is a big circle.

And then all of which is based in technology, this is going to move us
all so far forward.

Then on slide 15, under the DHS, national planning scenarios, did that
come out of DHS, or did your Workgroup did that? Because you\'ve
separated out biological disease outbreak from biological attack. But
almost each of these has \-- you know, you can have a chemical attack,
but you can also have a chemical, quote unquote, outbreak, if you will.
Maybe they\'re all lumped into natural disasters. But we deal with, you
know, explosions of chemical plants and the public health impact on
that, and where the people are showing up with what kind of symptoms. So
it\'s not an attack, but it\'s an exposure or, you know, all kinds
of \-- you know, the truck that turns over, you could have a
radiological meltdown that\'s not an attack. So I just didn\'t know
where that came from, but it doesn\'t capture all that \-- the scenarios
that are out there.

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

We selected these 5 out of 15.

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

Oh, okay.

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

Just to give us a flavor for the different types of scenarios it seemed
like 15 was too much to handle.

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

Sure I see. Just an example. Okay, thank you.

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

Right, and then if I could just go back to your comment, and I think
Marty and I both totally agree with you about ongoing evaluation
process. And I believe that the fourth of the recommendations from your
workgroup was to set up some sort of evaluation process. And at some
point, either this committee or another committee that would follow this
needs to address that in more detail, be sure that\'s part of the
ongoing process.

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

Thank you I didn\'t remember we have that in there, you\'re right.

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

This is Marty. I absolutely agree with Art. That was an important, I
think, theme that came through this process, that we\'re moving quickly,
and it\'s important to do that, but it\'s important to move on with a
process that will iteratively evaluate how well we\'re doing and improve
the system for constant improvement both particularly around
biosurveillance activities.

And that that cost improvement is really looked on as very important to
absolutely do, but outside the short-term scope of this particular
committee to actually figure it all out. But clearly, a recommended next
step.

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

This is Adele Morris at Treasury. One quick question. Could you
elaborate a little bit on your process for considering feasibility, how
you\'re going to be assessing feasibility?

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

Marty, do you want me to do that?

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

Sure, go ahead and start and I\'ll \--

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

So what we\'ve done is given the proposed minimum dataset list to a
variety of experts that have had an opportunity to testify, and we\'ve
had a number \-- we\'ve had people from New York City, Farzad
Mostashari, we\'ve had people from Regenstrief Institute, we\'ve had
people from \-- we\'ve had APHL \-- or ACLA, and a number from around
the Dallas-Fort Worth area who are doing biosurveillance at this point,
comment on each of the elements. And they look at it in a variety of
ways, and we\'re now collating and sort of summarizing their comments,
and figuring out some of the elements that we have in there, are they
infeasible and do we need to change them. So we\'re looking at those
from the point of view of those who would be providing the data.

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

Okay, are there other questions at this point for Marty and Art?

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

Ed Sondik. I don\'t have any questions, but I just think a tremendous
amount of work has been done in a very short period of time. And I give
everybody credit, great credit.

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

Thank you all. I agree, and it looks like there were very ambitious
deadlines set up, and it looks like we\'re going to make those, so
that\'s very good.

Kelly, should we proceed onto the next item?

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

Yeah, I think so. I also just wanted to thank Art and Marty, they\'ve
put an enormous amount of time over the last three months and have been
really committed to this. And we\'ve also had, you know, involvement not
only from the Data Steering Group members but from the ad hoc group that
we convened to do some of the extra work in between our Workgroup
meetings. So it\'s really been a tremendous effort, and it\'s been great
to see a lot of people from different parts of public health get
together and really be able to do some very good work in a short period
of time.

I just wanted to thank them both for everything that they\'ve
contributed.

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

Right. Okay. Well, if we\'re ready to move on, clearly, from what we
just heard, I think the first portion of the work of this group has been
taking off, and now we\'ll focus for a few minutes on the sort of second
part of our task, and that is to go beyond the immediate project that we
just heard from, and to focus on, at least in terms of the near term,
what are the things that we want to recommend to the AHIC that should be
undertaken.

And if you all remember, we, with John and Kelly\'s guidance, and
others\' guidance, have now come up with a matrix. We at first tried to
take what we\'ve defined as priorities areas on the far left, and narrow
those down, and came to a conclusion basically that instead, under these
main areas on the left, that we should look for tasks and items that
would make sense. And that led to \-- for us to set as priorities. And
that led to the formation of this matrix.

And I guess what I\'d like to do, Kelly, is, since this is the first
time everyone has seen this in this form, this is the first meeting
we\'ve discussed it, can either you or John go through it, particularly
in terms of the last column on the right, where we \-- where we have
potential recommendations and some areas we may need to narrow down?

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

Sure, I can start and then turn over to John. Of course, I can take on
the one piece that I know the most about from my past experience, the
adverse event reporting. And I think Lisa Rovin from FDA is on the line,
so I\'d also invite her to participate as well.

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

Thank you, Kelly.

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

First, just trying to get the description down I think we just tried to
just, you know, describe \-- with adverse reporting we\'re not talking
just exclusively medical products, adverse events, but we\'re
encompassing sort of all types of sorts of medical errors. So you could
be dealing with nosocomial infections, for which there\'s a national
surveillance system in place that CDC administers, in I think over 300
hospitals now.

And even within the realm of medical products, we have medical devices,
biologics, and drugs, prescription and over-the-counter drugs. So
there\'s quite a few sources of adverse events, in terms of exposures or
products or situations that might be associated with the adverse events.

But essentially, we\'re talking about submitting them to public health
authorities in describing these types of programs. And I think we
commented before in our previous meetings that one of the problems we
all recognize is that there\'s a severe amount of underreporting,
primarily because it\'s predominantly a manual system that requires
clinicians to take time out of their day to actually fill out reports
and make an assessment on whether or not there\'s a causal relationship,
and think about severity, and the like.

So it\'s not an automated process, and because of the time and just that
often sometimes clinicians are not trained to be looking for these types
of events, they do not get reported.

So we know there\'s a variety of programs that do exist, we listed some
of the obvious that I think most people are aware of. FDA\'s MedWatch
program, there\'s a new \-- newer effort underway that was enabled
through recent legislation where newly-created organizations called
patient safety organizations will be receiving various types of medical
errors from different providers, and that information will be privileged
when it\'s submitted to these patient safety organizations. So it\'s
encouraging a culture of safety, and that\'s going to be hopefully more
of an up and coming area where we might see more PSOs or this type of
reporting over time.

I also mentioned before, we have the NNIS system that CDC administers,
nosocomial infection reporting, and the USP, U.S. Pharmacopeia, has a
medical \-- or medication errors reporting program. And CDC and FDR are
involved with a vaccine adverse even reporting program.

So in terms of how HIT could enable more automated adverse reporting
process, I think there\'s already a lot of work underway, and I think
FDA and the standards development community have been working for quite
some time on an HL7 message to automate transmission of MedWatch adverse
event reports.

We also talked in our last Workgroup meeting that we could also be
considering ways to automate the reporting of adverse drug events from
electronic health records if over time there was some functionality,
interoperability requirements in place to enable \-- you know,
recognition of some signals or symptoms that might be comparable to a
suspected adverse event.

And that could perhaps be automatically reported to FDA or the
appropriate agency.

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

Kelly?

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

Yeah.

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

This is Adele. A quick question. Looking back at the minimum dataset,
are we confident that the injury codes as they exist now are
sufficiently detailed to parse out the adverse events from other things?

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

Yeah, Adele, this is actually not connected at all to the minimum
dataset. When we had been working on our specific charge in the first
five months of the Workgroup, we really focused on biosurveillance, and
in particular programs that would require the sharing of that minimum
dataset across jurisdictions. But now we\'re really talking about the
broad charge, and sort of how do we enable real-time public health event
monitoring and response management. So we\'re not limiting ourselves to
any kind of constructive minimum dataset, we\'re thinking more broadly
what can we do. So we don\'t need to be restricted in thinking about
what we previously had discussed.

So does that make sense?

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

Yes. I guess the underlying question pertains in that if we want to
target IT to adverse events, are there new codes that would need to be
developed to get those out of the IT systems? Or are the existing codes
sufficient that we can use IT to specifically go after \--

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

Well, I think in terms of whether or not there need to be new standards
named or developed, I think that would be part of the work that would
come out of our considerations. So we\'re just really trying to think at
a conceptual level at what should we be focused on, where are the real
opportunities, and then after we make recommendations on October 31,
then we can \-- you know, think about how this all fits together. If
there is going to be a use case developed in one of these areas, then we
would turn to the Health IT Standards Panel and the Certification
Commission to follow that use case.

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

Got it.

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

So in terms of potential areas for AHIC recommendations, there are a lot
of things we could be considering. And some of those may be an awful lot
to take on, but we could at least, you know, recognize their potential
importance.

I think we mentioned briefly that a lot of the authorities that exist in
the Public Health Service Act currently are \-- or many of them are
typically programmatic, whereas one particular type of surveillance,
whether it\'s for devices or drugs or nosocomial infections, I think we
probably need to be considering if we did want to do some kind of
streamlined automated reporting program down the road, will we need to
have new authority for the agencies, the appropriate public health
agencies to receive that data.

And I think that there is some possibility that there may be different
needs or requirements in electronic environments for mandatory reporting
of adverse events versus voluntary reporting of adverse events.
Mandatory may require, for example, a more definitive set of alerts to
physicians, to let them know that they really should be submitting a
serious adverse event that has not previously been recognized, for
example.

But yet voluntary reporting requirements may be \-- there could be more
flexibility, or may be less stringent requirements in alerting
physicians or reminding physicians of certain hazards.

I think there is some other comments that we received about Federal
agency infrastructure needs need to be considered. So if we do down the
road have electronic health records or a Nationwide Health Information
Network that could automate this kind of functionality, you know, would
the agencies be ready to receive it? Do they have the infrastructure, do
they have the resources to both receive and act on that information?

The Department of Defense got back with some comments saying that they
think it\'s important to ensure compatibility with their reporting
systems, so we could be considering issues around that. We also could be
thinking about how to ensure that the NHIN functional requirements
include adverse event reporting by all entities that are mandated to
report adverse events, and that would include manufacturers.

Then we also heard from FDA about automating EHR prompting, and the
filing of adverse event reports for all medical products, that\'s sort
of related to what we were just talking about.

So that\'s more or less the first section. And perhaps \--

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

Let me ask a question, Kelly, just sort of procedurally, here. Do you
think it\'s best to go through each, and put everything on the table
then for discussion, or discuss each as a block? At least in terms of
any kind of tentacle questions, which way would you want to proceed?

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

Why don\'t we go ahead and talk about the next one. Although I do want
to give Lisa Rovin a chance to modify anything I said, since she\'s a
lot closer to these issues now.

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

This is John Loonsk. Maybe it would be good if we talked about each one
as they\'re fresh in our minds.

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

Okay.

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

Let me say something, then. I think that implicit in this area is the
question of authorities. And I can say this, because I\'m an independent
member of the AHIC, I think it is \-- regardless of what the expectation
of the institution is in terms of its function inside HHS, I think it\'s
incumbent on us, as we do our work, at least the volunteer members, to
see that we at least explore authorities, and where we see that
authorities are not necessarily sufficient, that at least an outline of
how they might be changed to make, in this \-- at least in this case,
certain things work, ought to be explored and made \-- or at least
offered to the AHIC to offer up as recommendations. Does that make
sense?

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

Yeah. Yeah.

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

I guess I\'d like to say from my standpoint, and I\'d really need to ask
my fellow Workgroup members, if that\'s the case, we need to communicate
that to you Kelly, and say that we\'re the ones that are asking for that
to sort of be \-- however we proceed here or in the other areas, we\'re
sort of asking for not just looking at what we can do within what
resources now exist, but what authorities might need to be changed to
make these areas work in way that\'s optimal, considering whether it\'s
these adverse events or other items.

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

This is the other John, Lumpkin. And I think just to add on to that,
there really isn\'t anything about State and even some local
jurisdictions that have legislative authority or mandate to collect
similar kinds of data. And I think we ought to note that, because
particularly for providers across State lines, it creates a environment
where they could have as many as three different levels of government
prescribing different standards and approaches to collecting the same
data.

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

And that\'s a good point. And I think that in all of these areas it
needs to be our intent to figure out either how to do it informally or
formally, so that we could create a single platform for anything we\'re
asking for. Because obviously, the inefficiencies and the requirements
on providers, hospitals and doctors and others, to report to multiple
sources things that are comparable doesn\'t make any sense.

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

This is Leah Devlin. I think you\'re going to find that a lot \-- you
have 50 States, and of course, the authority for these kinds of things
are most often at the State, I would think. You know, we put out
requirements on the locals about reporting, as well as provider
communities, including things like adverse events.

So it is going to be more of a State authority, I think, that you\'re
working with, in terms of State-local. So it does get to that
State-Federal relationship on all of this. Whether you\'re going to
continue to work with these 50 States, or are you going to go to, you
know, the morass of providers out there.

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

This is Chip. I think part of it, and this is \-- I sort of bow to John
Loonsk and Kelly here \-- part of it is the construct of the whole
interoperability that we would sort of get ourselves hooked on to. I
mean, whether that\'s going to be regional, Federal, and how it\'s going
to work. It seems to me has got to be a factor here. Am I missing
something, Kelly, or is that \--

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

I think interoperability is actually being addressed from both sides
right now. Because we have the national level efforts with the Health IT
Standards Panel, but then there\'s also a lot of regional efforts to
have health information exchange and RHIOs get up and started. So
there\'s sort of activities happening on both ends and, you know, we\'re
doing our best I think to make sure that we\'re going to end up in the
right place.

But I think we probably need to be mindful of that as we figure out how
this pieces together.

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

Kelly, this is Brian Keaton. I just have a fairly functional question.
When I look at my copy of this, I have stuff printed in black, red, and
blue. Is that a vagary from Microsoft Word, or was there an intent that
those mean something different?

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

I think staff were just trying to be diligent to show that we had some
comments coming in from Workgroup members, and we wanted to make sure
that we were clearly representing their comments or views. So we just
wanted to differentiate them.

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

Okay, thanks.

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

Unfortunately, I got mine late so it\'s all in black, so \-- okay, are
there any other questions or discussion around these \-- this area? And
I guess what I\'d suggest is then we should \-- if there is, we can have
a discussion. If there\'s not, we proceed to the next area, go through
it, and we\'ll go through each area, and then come back and see how we
want to shape things. But just get everything on the table.

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

This is Adele Morris at Treasury. I guess one way that\'s going to help
me as we go through these is to have a really clear articulation of what
problem our attention on this issue would solve. Like a really clear
problem statement. And then when we look at potential recommendations,
we loop back to that problem statement and say okay, exactly how does
this recommendation address that problem.

And I think we\'ve got the nugget of it here for the adverse event
reporting, in that we believe adverse events are severely underreported.
Looking forward to the AHIC, it might be good to also, you know, put in
there, well, what does that mean for practical purposes in terms of
public health. And then when we have recommendations to \-- for example,
expanded authorities, how would that address that underreporting.

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

Okay, Kelly?

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

I think that makes sense. I think, you know, when we get down to sort of
crafting a letter of recommendation, it would make it much more clear if
we did have some articulation of a problem statement, in addition to
sort of \-- in describing the priority area. And then the recommendation
can be sort of a logical outcome of that, to fix a problem. And I think
it\'s probably up to Chip and Julie Gerberding to make sure that the
importance or the implications of that work get communicated
sufficiently, so that people who aren\'t necessarily public health
people, but healthcare leaders, can understand the impact, potential
impact.

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

Yeah, I think \-- and I guess \-- I think I agree with that, and I guess
I\'d like to sort of add a nuance to what you said. Because I think we
need a problem statement, but almost \-- I would almost rather call it a
situation statement rather than a problem statement. Because in a sense,
here, we\'re talking about areas where, you know, maybe there is a
problem, and nothing is being done. Or it is being handled as best can
be handled under the current circumstances with current authorities and
current ability to gather information. And that what we\'re really
looking at here, both in the short-term, and then obviously when we get
to John\'s presentation later in our longer visioning, at the
opportunities that are now provided by the likelihood of advances in
these new types of records that weren\'t around before.

So I think it\'s in a sense \-- I would like to think of it as taking
advantage of a new resource or a new possibility, rather than simply
sort of having a problem. Does that make sense?

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

Yeah. Yeah, I totally get it.

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

John, do you want to do bidirectional communication?

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

Sure. This is John Loonsk. What I will try to do is articulate what I
feel the sense of the group was in terms of their description of this.
And if other people object to my articulation or what I add to it
afterward, please do so.

The bidirectional communication area was described as including
particularly information being disseminated in an outward fashion to
clinicians for public health purposes.

So the initial \-- some articulations of that would include, for
example, the concept of e-mail alerting. Getting information out in a
rapid fashion around a particular event.

There has been work done in some situations about more collaborative
interactions, where there may be an off \-- a somewhat secure
conversation where people could discuss a problem with the public health
department or among public health departments, it is not open to the
public but it\'s \-- as a discussion, because it\'s so preliminary, but
where they need to discuss things to see if something is going on.

Also including Webpage- and more broadcast-oriented delivery of
information for public health purposes.

And then the group also did discuss at some level the concept of
advancing through probably Webpages and maybe secure Webpages, more
jurisdictionally specific disease and situational information to give
clinicians an idea of what\'s going on in their community. So they know,
for example, has the flu come to their town, and to the extent that it
has. And this is oft-cited but not frequently implemented desire that
many clinicians have, to know more about the data that they report to
public health in the context of it influencing their clinical
decision-making.

And then I think at the far end of this, there was discussion also of
dissemination of information potentially in the form of, for example,
guidelines, and prevention information, that might be implemented in an
electronic clinical system in the context of provision of care.

There are a number of different initiatives and activities in this area,
some of which are listed in the second column. There are some of the
HI \-- sort of health information technology-related issues here include
the fact that there aren\'t really good e-mail directories of
clinicians. That having e-mail directories of clinicians even, you know,
when more and more clinicians use e-mail is a very sensitive issue. How
they\'re used is an issue, from the standpoint of ensuring that this is
not used as a commercial capability, et cetera.

There are also issues related to sort of the entry points into that. So
local public health has needs to express messages to their local \--
those that are involved in clinical care in their environment. States
like to do it in their environment, and there are times when there are
national messages that need to go out. But you sort of need that
cascade. That cascade has been an issue in the past, as well as the
desire that some States and locals express that when information is
coming into their jurisdiction, that they have an opportunity to
contextualize it in the context of their specific jurisdiction.

So with all that being said, I think this is also a ripe \-- there are
opportunities here. I know the FDA has done some work with some of the
burgeoning health communication systems that include clinicians as
members, by way of advancing, for example, drug recall information.
There may actually be some commercial opportunities here where
there\'s \-- the commercial needs and the public sector needs of
population activities could coincide and support this kind of
infrastructure because of the shared need to be able to communicate
information out rapidly.

In terms of the column here on essential areas for AHIC recommendations,
there are analogous issues in the considerations of the Nationwide
Health Information Network as to whether there are needs to have
directories of clinical personnel for authenticating them to access data
in certain contacts, how those would be managed among different
healthcare providers. There\'s lots of complexity there around
cross-privileges, and where the providers are actually providing care,
and when they move from one place to another, when they provide care in
different cases as well.

There are standards issues here, as well, about alerts. And there\'s
been work done in the emergency response context around trying to have a
consistent alerting nomenclature and structure so that the level of
alerts could be articulated, but also there are issues in terms of
roles, what kind of people participate, in what kind of things. And
there are standards issues here as well, as well as infrastructure
issues, as I reported.

I mentioned about actually having electronic access, and being able to
deliver information in context, in time, with an appropriate control
over sensitivity of those data \-- of that information.

So that\'s a quick \--

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

Can I ask a question? I guess here \-- and I\'m just thinking out loud
here, maybe this is actually part of our next discussion, because I\'m
going to be a little futuristic here. But I wonder here whether we
should skip over e-mails as a way of communicating. Because in a sense,
it\'s obsolete for certain purposes. And as soon as we start talking
about whatever this NHIN is going to look like, it seems to me that when
you have electronic records \-- and I\'ll go back to my analogy with
viruses, because I can\'t think of any other analogy. You know, right
now, with viruses, if you sign up for Norton\'s or you sign up for
McAfee, your system, as long as you signed up, does a search, you know,
goes back to \-- you know, Mother McAfee, and then brings in, and they
do a search to make sure you\'ve got all the latest files regarding
viruses.

And it seems to me in terms of the bidirectional communications, should
we consider, in terms \-- and you\'d have to have some infrastructure
here to carry it off, but it seems to me that in terms of certifying the
products that \-- and whether this is for the physicians\' offices or
for the hospitals or for other providers \-- over time, should we
consider having some criteria for the bidirectional communication, and
then once \-- whether it\'s Cerner or McKesson or whoever, if they\'re
selling a product, then they\'ve got a contractual requirement, let\'s
say under that product, that they have to meet all the specifications
that are set out by the certifying agency. And the certifying agency
tells them, well, if you\'re going to have this contract, then you\'ve
got to assure the client that you\'re going to be able to hook into
whatever the \"it\" is, that\'s the central sort of disseminator of
information that would disseminate the kind of information we\'re
talking about, here.

Now, I don\'t know whether that\'s way beyond where we are now,
obviously it is, but structurally, it seems to me that trying to sort of
infiltrate the system through the record \-- or through the actual
systems, rather than, you know, coming up with lists of e-mails, is
going to be a lot more effective over time. Because then when these
virus scans go in, I mean \-- this isn\'t the virus scan, but then it
could check for files to see whether certain patients should be informed
about X, Y, or Z. Not just simply, you know, sort of alerting a doctor
generally to something that he or she needs to know about.

That was sort of long-winded, but what do you think about that?

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

This is John Loonsk. I think that whole area is a very promising area
that is one of the things that a higher state of EHR adoption can be
leveraged for. However, there are some aspects of public health that are
still getting out of using faxes, and some of the drug notification, to
be honest, is still being done with paper mail. And so \-- and this
is \-- and I think it would be a shame if we didn\'t leverage the higher
adoption rate of e-mail communication technology, because I think it\'s
going to still be leading that curve.

And, you know, I think it would be worth further discussion to map which
kinds of activities would work best, and which bin, in which time frame.
But I would \-- my recommendation would be that we don\'t ignore e-mail,
even if we do state out that longer-term vision.

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

Okay, any other thoughts?

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

This is John Lumpkin, let me sort of follow up on that. I agree with
John Loonsk, I think we need to recognize the environment and what it\'s
going to look like the next 5 or 10 years but. I\'m also reminded, this
being the first anniversary of the IBM PC, that when they first wrote
MS-DOS for Windows the thought of having more than 256K on a computer,
or 512, whatever it was, was unthinkable. So there were limits built
into the system that took Microsoft years to work around.

My point being is if we\'re not envisioning the future while we\'re
dealing with current realities, limitations could be built into the
currently-installed, or the soon to be installed electronic health
records that would make this kind of interoperability much more
difficult.

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

This is John Loonsk. I completely agree. I think that\'s really in a
nutshell is exactly why we think we need to do this exercise, and why we
need to do the visioning, but we also need to do some more short-term
prioritization.

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

This is Rick from New York City. In support of Chip\'s suggestion, I had
a chance to talk this through with Farzad yesterday, and we were trying
to think of example recommendations for column four on this item. And
one we came up with was that the certifying authority \-- which I guess
is often CCHIT for health information technology \-- but the certifying
authority shall incorporate public health decision support and
bidirectional communication functionality in their system. It was very
much the same idea that Chip just described. So I think we would support
that

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

This is Brian. Just one other thing to add on to what John Lumpkin had
said. The kids kind of lead news in terms of the technology. I don\'t
get e-mail from my children. I get text messages, I get comments through
chat room, I get a lot of other things. As those technologies tend to
mature we may find there are a lot better ways to do what we\'re doing.
So we need to be cognizant of what the general technology is doing, so
we don\'t paint ourselves into a box.

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

Let me ask the question, Kelly, in terms of the sort of down the line
direction of the consultancy, it seems to me the kind of matters \-- or
the approach sort of in the immediate world that John was talking about
might be within the realm of us sort of finding some group like we just
did with our subgroup, with our data subgroup, to sort of come up with
some rules of the road for that. Whereas the kind of concept I was
talking about I think really would require \-- one, it\'s not possible
now, but two, you know, the techies and some other people that know a
lot more about what you do when you\'re thinking about criteria for
certification. A few years from now, sort of developing criteria that
might make this possible.

But it seems to me that\'s sort of off in some consultancy, or up into
the agencies or different groups like \-- that are informing CCHIT,
whatever it is, so that they can sort of set their exact criteria.

Can we sort of take both paths in terms of what we recommend? In the
sense that the latter it seems to me would be recommending to the ONC
that this should be something that be put on the agenda for \-- you
know, its spending resources and thinking about, as it tries to populate
the \-- all the work that\'s going to populate the specifications in
this certification? Does that make sense?

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

Yeah.

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

Yeah, this is John Loonsk. Just in terms of what it is we\'re doing here
relative to the rest of those processes, I think it is helpful to do a
little bit of thinking about criteria, because it helps us sort of think
forward in terms of how useful it would be to focus on that area. But
for anything that\'s identified here that moves through this process,
there will be a lot more thinking about each aspect of it, whether it be
the data standards or be the certification criteria, et cetera, or the
architectural efforts of the NHIN. So yeah, I think the focus here is
good to think at a high level, but we can know that there\'s a lot more
work that would be done, if something is identified and then put through
the process as a priority.

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

Yeah, in a sense it\'s just acting on the recommendations that get
advanced to the Secretary. That puts everything into motion.

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

Yes, okay. Any more points on bidirectional before we go to the other?
Because I\'d like to get everything out in the next 15 minutes, if we
can, because then I\'ll have about another 15 or 20 minutes. And at
least for my part I actually may miss the last discussion item, which is
critically important, but I\'d like to get through this task, if we can,
in the next half hour or 40 minutes, if we can.

Why don\'t we go to the next, the case reporting.

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

So the next area \-- and I\'m going to pick up the pace a little just to
try to meet \-- the next is case reporting, which the general area is
descriptive of activities that include the notifiable disease reporting
process and systems that have been developed in that regard, wherein the
data that are sought by public health are broader than and oriented to
attempting to define a case of a disease. They frequently include lab
results, but they also can include clinical data. And the traditional
process for this has been that the case report with certain data
elements is identified, and the completion of that case report is used
to identify a case. Which then is \-- the traditional sequence has been
clinical care to local public health, local public health at times
goes \-- then reports to the State public health, and then there\'s a
voluntary system for reporting them on a national level, as well.

The area can include at times, in an emergency situation, managing cases
that may not be a notifiable disease. So for example, when SARS was
first about, there was a need to identify this syndrome complex and to
look for potential cases of this. And at that point in time there was a
need to disseminate information broadly about what a case is, or
possible case is. It may not be a named, notifiable disease at that
time, but there is a need to look for that in the population, and then
to be able to report, track and manage those cases, as well.

It borders on some of the things mentioned previously about outbreak
management in terms of there are times when you have to deal with a lot
of these potential cases. And so one context is the traditional system
of reporting that gets processed through, for example, the national
notifiable disease surveillance process. But there\'s also very
operational needs that occur, particularly at the local and State level,
where when there\'s at times a food outbreak or disease outbreak, that
those possible cases need to be managed, they need to be investigated to
determine where it is, what\'s going on with it, and how to best manage
that event.

In terms of ongoing activities in this regard, the National Electronic
Disease Surveillance System has been an effort to develop standards for
this national network of case reporting, and also among other things, to
try to encourage the connection of lab results to this, because they\'re
so useful in many case reports, it\'s such a critical piece of data. It
also then brings into focus the public health labs, and their
contribution for particular types of lab result testing.

And then also named here is some things that happen after an event,
particularly at times when it\'s a major event, and needs to study that
event subsequently, whether that\'s in the form of a registry to
document who was made ill by the dust of the Trade Center collapse, or
whether it is a research study to determine why an outbreak occurred in
a particular context, and what the best ways of dealing with that in the
future would be. There\'s sort of a natural progression that people have
seen from sort of a new, unknown event, regularized case reporting in
that area, research and followup on it to try to develop public health
processes, and prevention, and deal with management in the future.

There are standards that the National Electronic Disease Surveillance
System and the Public Health Information Network have worked on in the
context of trying to have industry standards for this, HL7 messages and
such for these kind of reports. So one outcome, though, could be to
have, for example, the HITSP process try to endorse or further develop
or come up with different standards, but harmonize those standards and
to give them the additional oomph of that national HITSP imprimatur for
this public-private process that is the Health Information Technology
Standards Panel in this area.

There are also \-- you know, the opportunity exists to have \--
potentially have electronic health records over time begin to more fully
populate case reports rather than just report data that are used for
clinical care. So differentiating the biosurveillance area, where we
were talking almost exclusively about getting clinical data that are
used as part of clinical care, and using those data in the context of
sorting public health. There is this possibility of using either a
hospital infrastructure or a Nationwide Health Information Network-like
infrastructure to actually be able to populate more fully a case report
to meet public health needs for defining that, in an automated way, as a
case report, and then pushing that into the public health system.

So that\'s \-- I\'ll stop there. There\'s more possible suggestions here
for activities to go on, but that\'s the general area of discussion.

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

Okay, do we have a discussion about that, or can \-- okay, let\'s go to
data aggregation.

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

Can I just \--

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

Sure.

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

I just want to toss one area in there, which is that the recent decision
by the Supreme Court in Illinois, in the Southern Illinois versus
Illinois Department of Public Health, would indicate some approach to a
consistent approach to confidentiality and privacy of the information
that\'s collected, is not consistent across disease, not consistent
across States. And so I think that becomes potentially an AHIC area of
attention.

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

Okay. Okay, John, do you want to go to the next one?

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

The next one is response management, I believe. And response management
is inclusive of the area of affecting public health outcomes that
usually fall into the category of treatment, prophylaxis, prevention.
Also potentially isolation, quarantine. But these traditional public
health tools have both information and data management needs associated
with them, as well as, you know, the same kind of issues around the
relationship between the existing infrastructure that does some of these
things on a daily basis, and the emergency needs in a public health
situation where sometimes those \-- the needs change. And whether
that\'s because there\'s been a shortage of flu vaccine or whether
that\'s because the public health \-- the emergency stockpile needs to
be tapped to distribute prophylaxis or treatment, there are a lot of
information management needs associated with affecting outcomes in this
regard.

And another thing to be pointed to here is clearly the work that\'s been
done on immunization registries, although it\'s mostly focused on
childhood immunization, there\'s actually a substantial portion of
immunizations are paid for by the Federal Government. And through
this \-- through childhood immunization program, there are also
registries that \-- and there was actually some very important successes
post-Katrina where registry information from affected States were shared
because they were standardized, and moved into places where evacuees
were located for the purposes of being able to have information on kids
that were now going, you know, to be in those new areas.

And so it\'s another example of some of the things that can be done in
this area and context.

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

Okay. I guess data aggregation?

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

Okay, data aggregation, I must confess that I didn\'t \-- I mean, I
didn\'t completely \-- I think this is sort of a functional area, where
the others are more business areas. But this \-- and we sort of have
talked about data aggregation from the standpoint of the biosurveillance
needs, but with the burgeoning electronic health records infrastructure,
there are a lot of opportunities for using data for \-- to use the term,
mining data to find important public health outcomes. There are
certainly confidentiality issues that come to the fore in that regard,
but there are a huge number of potential benefits that can also accrue
from the use of data, if they\'re adequately standardized. That apples
are apples and oranges are oranges, and that you can then process them
in both \-- in different contexts.

And so I may not have done justice to that, but this was \-- and some
others may want to speak to that, they may have an issue of that as a
category area.

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

Anybody else? Okay, then the last area is the connectivity.

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

Yes, the connectivity between public health, I thought people were sort
of thinking of this as sort of an undergirding infrastructure activity.
But it does talk about public health agencies, and one of the areas that
was identified previously in the biosurveillance-specific charge was
that data are not being shared readily among public health agencies in a
rapid manner in the biosurveillance domain. So I\'m not sure how much of
that was intended in this construct. It sort of for me was a combination
of thinking about infrastructure for a number of these different
activities, and also the more specific thing of sharing data and
these \-- between public health agencies.

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

Okay, now, have it sort of out there, I think we\'re really getting to a
point where we can begin to visualize for each of these areas some
\"its\" rather than sort of the concepts. So I guess the question I have
for you, Kelly, is from a process standpoint, can \-- do we \-- should
we recommend \-- let\'s assume for a second that we\'re interested in
each of these areas, that we\'re interested in narrowing down to one or
two recommendations in sort of that last column for each of these areas
that we think is the most important. And in some ways, from the
description we can see really only have usually \-- although I guess
just the first one has more, but sort of the few priority areas.

From a process standpoint, since we will have another meeting, should we
have everyone think more about this, and sort of come to the next
meeting ready to say let\'s do this over that, over this, or should we
try to work through that now? At least from a process standpoint, I
mean, I need to ask the group whether they have enough of a
conceptualization of each item to do that, have that kind of
conversation. But how did you see it working, Kelly?

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

I think we could go either way. I think if people feel comfortable we
can have the discussion now. I think it\'s also going to fit nicely into
the visioning exercise. So we may have a better sense in terms of
sequence over time about, you know, when will some of the infrastructure
or processes be more institutionalized that could enable, you know, some
of these opportunities we\'ve been talking about more fully.

But, you know, this is the third or fourth time we\'re talking about
this, so people may have already, you know, thought enough about this
where they feel comfortable confirming our original ranking. But we will
be drafting recommendations in October, so we could, you know \-- if the
group feels they need more time, be finalizing our ranking then in the
context of the \-- you know, our previous conversations, but also
informed by how we see the, you know, vision of things moving forward.

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

One of the things I heard you say which I think might be useful is since
today we\'re going to get John\'s presentation, and maybe have at least
an initial conversation about it, and since what we\'re doing now, we
don\'t want to get lost in that other process, but on the other hand, we
want to make sure that it fits in the context of the other process.
Because the other process obviously is the big picture. How do people
feel about, then, sort of ending this discussion now, going to John and
getting a big picture, and then with the understanding that we work
towards the next meeting and everybody sort of think about the sheets
that are in front of them now. And we move, for each of these five
items, to narrowing down what\'s going to be in that final column, which
is what leads to recommendations.

How do people feel about that?

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

I think that\'s a reasonable approach.

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

Okay.

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

Yeah, DOD concurs.

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

Okay, so \--

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

Chip, I do just want to clarify, that the order we previously agreed
upon, that we can revisit in our next, but we\'re not going to have a
huge amount of time \--

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

I hope we\'re not getting off the reservation for letting this happen,
but I think \-- well, let me ask the question a different way, I\'m \--

What if we \-- okay, I guess let me think how to do this. I suppose,
well, let me come back, If that\'s a concern of yours. So then what
you\'re saying then is for the next meeting we really wouldn\'t have
much time to spend on this other than to review the item, so you want me
to have a brief discussion now on each item, just to see whether we
could narrow it down, is that what you\'re saying?

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

I was actually just even suggesting that we revisit just the order that
we settled on before, so people can keep that in their minds as we start
to get into this visioning and hopefully confirm that order. Or decide
against it as we start to flesh out what the next three stages of change
look like.

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

When you say the order, you mean the order of the five items, and then
the items on the last columns, is that what you mean?

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

I actually just meant the overall categories of the priority area,
because before we had decided that bidirectional communications seemed
the like the best short-term opportunity to improve population health.
And then number two was case reporting, three was data aggregation, four
was response management, and five was adverse event reporting.

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

Yeah, but I thought we had moved away from that, with the understanding
that there was so much interaction and the layering of each of those was
such that that was a hard thing to make a decision about, and that we
had sort of punted and said we\'ll include all those areas, but then
under each area we\'re going to go into the last column and decide what
the it is that we ought to be thinking about. I thought that\'s where we
ended up.

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

Well, I mean, that\'s certainly something we can advance, that these are
our five priority areas. But I think it\'s going to be easier for this
office and HITSP and CCHIT and NRS to understand what they might take on
in the next year. And one of the things we\'re trying to avoid is to not
do that in isolation internally here. We want to really hear from other
people what is the best short-term opportunity we should be prioritizing
for 2007.

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

Yeah, but I guess what I was \-- yeah, but I thought \-- let me just say
one more time then, if people on the phone could comment. I thought \--
Ed I think sort of pushed this in the direction of saying we really \--
you know, to sort of come in and make these decisions among the five was
really sort of a problematic approach, and that we might say let\'s look
under the five and look at practical things we could reasonably spend
time on. And that\'s where this last column came from.

And I thought that where we ended up was that in a sense we\'re going to
set priorities in the last column, with the understanding that we\'re
going to proceed probably on each of the five in the matrix, but there
might only be one or two items in the last column that we actually
proceed on.

That was my understanding where we ended up, but I \--

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

I think we \-- as a Workgroup, we can absolutely take that on over the
next, you know, 6 to 12 months, and definitely tackle each issue we
think is important. I think the consideration, though, is for the
purposes of how this \-- how our recommendations then go on to inform
use case development, it\'s helpful for those ONC and, you know, the
standards harmonizers, and the certifiers, and network builders, to know
what they need to do in the next year. And they can\'t take all these
things on so they need some help with sequencing. And we really wanted
to use AHIC to do that priority setting, which is going to be October
31, one of the objectives is \--

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

Okay, let me go back to the group for a second, and say okay, if we were
to narrow down the two sides of the matrix, the left-hand side and the
right-hand side, to a few items on the left, and then obviously we\'ve
got plenty of items on some of these areas that are really fully
populated on the right, we\'d have to narrow that down. Starting on the
right hand side, where are people\'s heads now, considering all the
discussion we\'ve had over the previous weeks? Let\'s say if we have
five items, if we had to narrow it down to two, what are the two at the
top that, from all the discussion we\'ve had, people think we should
focus on? I guess I\'ll just ask for that.

\[silence\]

Okay.

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

The first time around we settled on case reporting and bidirectional,
and I think there was \-- you know, maybe not a clear one or two \--

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

I think the problem is that when you \-- yeah, I guess I get pulled back
to adverse event reporting in some ways, even though I know that seemed
to have a very limited constituency at the time.

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

To add to the \-- to do here, then, I thought response management got a
lot of input previously, and I do think it\'s an important area as well.

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

Yeah, I think that\'s why we headed in the other direction, but I
have \-- but okay, if we\'re going to really be tough here and say you
can\'t have all five, and you could only have two, I mean, maybe we
should just go around the table and see where people are.

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

This is Brian. My prejudice comes out, obviously, as an emergency doc,
but being the group that\'s kind of the frontline, the bidirectional
communication becomes very important. It also becomes very practical,
since we\'ve already got it in place for about 40 percent of the country
using it for ambulance diversions and hospital bed availability and
those types of things. That became a big part of the discussion, and
it\'s part of a number of discussions that are going on outside of AHIC,
in terms of being able to identify ways to not only implement, but to
expand that network.

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

So that\'s a strong statement for bidirectional. Am I hearing \--

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

Can I just ask, Brian, what \-- I\'m not sure I completely understood
what you\'re alluding to, in terms of \-- because it\'s one of my
concerns about bidirectional communication that it seems like a very
broad area, and we may be talking about a multitude of things, there.
But could you just describe a little more about what you were
referencing?

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

One of the advantages of the Web-based system that we\'ve worked with,
an EM system is the biggest one but there\'s a number of State and
regional hospital association type networks that also work the same way.
To be able to identify that a problem exists, via clinician detection
and emergency department. To be able to message public health, to be
able to message back or to message to other emergency departments in
your region. The example we always use is a patient presents with purple
spots on their face. And for me to be able to query the emergency
departments surrounding me, are you seeing people with purple spots. At
the same time, to public health, to public health to be able to expand
it as they need to, and have that communication.

To then be able to provide guidance that, you know, for the next 10
people with purple spots we need you to get these studies, and we think
this looks like thus and so, and we suggest this management to you.

It\'s something that is clinically useful, it\'s clinically doable, and
we\'ve almost got a \-- installed base using the same product for a
little bit different purpose, that it\'s something that we could have up
and running in a three- to six-month period.

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

Thanks.

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

Hello, this is Captain Haberberger from DOD, I just have a point of
clarification. The matrix we have has six priority areas. You\'re
referring to five. Did you combine one or \--

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

That may have just been \--

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

Well, actually we had also in our previous conversation, had thought
that connectivity or public health was pretty diffuse, and more of an
infrastructure area that we wouldn\'t necessarily turn into a use case,
per se.

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

Okay, fine.

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

And I just miscounted. So. Okay, let me say that the squeaky wheel, it
seems to me, ought to rule here, because that\'s all I got. So I think
that bidirectional, which floated up previously as a high priority, and
seems \-- and has some interest on the phone now, why don\'t we just \--
I\'ll just proclaim that\'s one of the priorities.

And then I guess the question, Kelly, is if we\'re going to be tough
here, and narrow this down because we just \-- and I\'m not saying what
the left \-- the right side is, I\'m just speaking of the left side
right now. And we\'re going to narrow our areas so we can be focused.

If I ask for one more, and we sort of limit it to two, and then
obviously we\'re going to have to go to the right side and limit
those \-- that side, too. I mean, that\'s what you\'d like to us come
out with? I mean, here I\'m just speaking sort of procedurally in terms
of the amount of topical space we can sort of handle as a group at this
point.

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

Yeah, I actually think we really just need sort of an order to present
to the Community, for them to consider this. And we can take it from
there, both as a Workgroup and the office.

And I also think, you know, we wouldn\'t be the first Workgroup to do
two different ranking exercises. Now we\'ve had a lot more information,
we\'ve had a lot more discussion, people can be more thoughtful in
coming up with their second round of ranking.

So we could do that by e-mail, and, you know, have some results
presented to everybody in advance of our next meeting in October.

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

Let me make a suggestion, because I sort of \-- one, there are people
who should have an opportunity to participate, who aren\'t on the phone,
and then that would give everybody a chance.

I guess \-- so then we could go back to everybody, you know, tomorrow,
with the list. And I guess the question I\'d ask is, when we ask that
question, is it a question of the five \-- maybe we should drop
connectivity, if we \-- just to prevent confusion

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

Can I just \-- I\'m sorry, (indiscernible) had to leave, this is Mohan
Nair. And he asked me to remind the group that when we talked about
connectivity the first time, on ranking. \--

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

Yes

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

Four of the nine responders had ranked it first. And in total number of
points, this was what came first, also. So I just wanted to remind the
group about that.

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

Okay, then let\'s leave the connectivity on, so it will be the sixth.
And then the question is, although they\'re not all of equal weight, we
do have on the right hand side items that sort of elaborate things that
could be done under each area.

So should we ask people to first rank the left-hand side, and then
second, within each of the blocks on the right-hand side, rank those
potential sort of project areas, as best to articulate it? If we did
that, then we could sort of have two places to sort of launch off from.
Kelly.

Would that be okay?

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

Yeah, I think that does make sense, because some of the examples are
quite different.

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

Okay, let\'s do that, then. And if you could construct the matrix in
such a way in terms of empty boxes, that people could do some kind
of \-- you know, one, two, three, four, five, six rating on the
left-hand side, and then on the right hand side they\'re not the same
number in each box, but do some rating of \-- you know, of which is for
those doing the assessment the highest priorities, then we\'ll go from
there.

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

This is Adele. Can I just ask a question about how we\'ve divided these
five or six things up? And I\'m looking specifically at case reporting
and bidirectional communication.

Is it possible to make a case that case reporting is a special case of
bidirectional communication? The reason I ask that is I\'m looking at
the right-hand side of bidirectional communication, and there\'s stuff
on there about case reporting. Now, that\'s the veterinarian stuff.

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

Well, I suppose it has to do \-- I don\'t know why we did that, frankly,
but if you look at the case reporting, in a sense, I sort of sense on
the right-hand side that one case reporting, as it says here, is a
traditional and routine activity. And two, that on the right-hand side
there\'s some presumption here that it\'s going to be built in \-- that
architecture is going to be figured out that can be done, and then
specifications are going to be built into certification relative to case
reporting. Which I suppose as you\'re pointing out could be a subset of
bidirectional, but it\'s such an important piece of the public health
pie that that activity, you know, sort of stood alone. Is that why we
put it that way, Kelly?

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

Yeah, I think so. I mean, bidirectional is pretty broad, and I don\'t
think many people think of case reporting in the context of
bidirectional communication. So I think from a public health
perspective, they\'re pretty much mutually exclusive. Maybe a tiny
little bit of overlap in a Venn diagram.

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

We\'re getting to the point where I think if I could just take the
privilege of a chair, and just review this, because I think we \-- I
think we\'re at a point where we need to just proceed. And so \--

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

Chip, I\'m sorry, it\'s John Loonsk. I think the way that this
discussion proceeded last time, the one that I think that did drop off
after discussion was this connectivity. Because after we talked about
it, we did an initial polling, but then everyone talked about it and
they were really talking about everything else we were doing in the
other categories. And this was a case where they weren\'t
well-differentiated. And my impression was that it fell off because of
that, because when we started to dissect it further we couldn\'t really
differentiate it significantly from like five of the other things that
we were doing in that regard.

And so I just \-- before people vote it might be worth a couple words,
you know, on that, just to make sure that we don\'t fall into that trap
again.

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

I think we also want to think about it that we\'re going to get into a
lot of issues around connectivity when we start the visioning exercise,
and I think that clearly, over the next year, as we get into our
priority areas, connectivity is going to be instrumental for most of
them.

So if it is really a cross-cutting issue that we could probably take it
on from a variety of perspectives, and even make sure as we present the
vision that it becomes one of the really prominent attributes of the
system that we describe.

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

But you know, if we \-- I guess my \-- if you want to visualize this,
though, when you look at the last column on that \-- on connectivity, if
everyone agrees that the perception here of what this connectivity means
is sort of operationalized of what\'s in that last column, then
basically it\'s saying that information systems for public health
entities ought to be, like electronic health records, and somehow be
interoperable. I mean, that\'s what it says there, if I read it right.

And I guess my question would be \--

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

Chip?

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

Yes.

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

Can I suggest maybe a compromise here? I think there are two areas in
these focus groups, both connectivity and the other one is aggregation
of data, that are important areas. And maybe what they ought to be done
is put into the preamble and say while we believe these two areas are
very important, and that continued work will be done on them, we\'re
going to focus in on the following two areas.

So that we make a recommendation to the full AHIC about the importance
of these areas, without getting into trying to identify concrete tasks
that we\'re suggesting with the other two focus areas.

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

Without sounding like a choir of Johns here, I think that\'s an
excellent idea. Because I think for example the driving the
certification of public health information system is a really good
outcome, it spans all the other areas. And the others are more
functionally oriented, that one and the data aggregation are more
cross-cutting activities that need to be advanced in a general sense.

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

Okay, with \-- can \-- and I know it was brought up a moment ago that
this last area was the highest priority in previous discussions. Is it
okay with everyone if we allow the staff, when they go back and recreate
these matrixes for decision-making, and the prelim, whatever kind of
explanation we put in, because we should put in some explanation that
covers the area that we just discussed that, that we deal with it that
way. Is that okay with everyone?

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

That makes sense.

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

Sounds okay.

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

So I think we\'re clear, then, that the staff will make the changes we
just described, the staff will create some space on the next matrix
we\'ll send out by e-mail, that will allow for prioritization of the
first \-- of the column furthest to the left, and the columns furthest
to the right. And the column furthest to the right. And then why don\'t
we say that staff \-- and Kelly and John will sort of sum all that up,
and I\'ll have a discussion with them prior to the next meeting, and
we\'ll narrow the thing down as best we can. And hopefully, present a
matrix at the next meeting that people can just sign off on, because it
will reflect the preponderance of views.

Is that okay? Okay.

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

Fine by me.

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

Kelly, does that achieve what you need?

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

Yeah, that\'s perfect, thanks.

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

Okay. Now, that being the case \-- and I guess now we\'re going to turn,
then, to John. I would like to do the following, Kelly, which is to,
one, let John do his presentation, and then since I\'m not going to make
it through that, obviously, because I\'ve got to get down to this other
meeting in about seven minutes, to let you and he sort of take over the
moderating chairmanship role for the rest of the meeting.

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

Okay. We\'re happy to do that.

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

Okay. Good. Well, thank, everyone. And John, if you\'d proceed that
would be great.

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

Sure, great. A couple of words of introduction. First is that Don
Berwick, who I think most of us know is a international guru on quality
improvement, says that every system is perfectly designed to achieve the
results it gets.

Second introductory comment is one of the fundamental things I\'ve
learned early on about information systems is that what you want to do
first is to redesign the system, and then automate it. And within that
context, as we\'re looking at the interface between the public health
system, the population health system, and the healthcare system, and the
recommendations that we make, we need to take the approach that what
we\'re thinking about is not how to automate or enable what currently
exists, but how to automate and enable what is possible.

So let me start off by talking through a scenario. This scenario I will
apologize first by saying I unabashedly went to today\'s news, and took
some facts and mixed them in with fiction. So please note that this is a
story. And any relationship to actual news, facts, and so forth are
purely intentionally confusing. So these dates on here are made up.

Let me start out. Let\'s say hypothetically on August 14 of some year,
an individual sees the physician for severe abdominal cramps and bloody
diarrhea. Like any physician who sees a patient like that, there would
be concern that this may be some sort of food-borne illness. A stool
sample is sent to the lab, and the patient gets treated primarily for
the symptoms, since many of these sort of symptom complexes are
associated with viruses or organisms that get cleared by the GI tract in
a normally healthy individual.

Next slide. August 16, two days later, a laboratory result \--
laboratory results come back with *E. coli*, and the physician reports
the case to the local health department. So you know this is fictional
right there.

\[Laughter\]

I\'m sorry, only my public health colleagues are laughing at this one.

The clinical laboratory also files the report, as is required in most
States by law to file a report that they have a reportable illness.
Serotyping is done, and it\'s sent to the State laboratory, and it\'s
found to be O157:H7.

Next slide. A few days later, actually two weeks later, so you\'ve got
these individual cases, a cluster of five cases of *E. coli* were found,
noticed, by the State in Wisconsin. Now, four of them had visited the
county fair, and had been in contact with animals. And I\'m just going
to note, even though they were alerted to this cluster, what really
happened in Wisconsin was four of these cases were totally unrelated to
the subsequent outbreak. And that is also what happens in public health.

The reports were turned in to the county health departments, other
reports were turned into county health departments, and these reports
were sent on to the State Health Department.

Now, for this kind of disease \-- and I\'ll go back to my experience in
Illinois \-- the requirement is that these reports be turned in to the
State Health Department within 30 days.

So this is just to highlight how the current system functions and the
results we get.

Next slide. In the period between September 4 through 8, Wisconsin
starts getting reports from other counties, other than the one where
they had the original five cases. And they begin to think that something
is going on.

Now, let me talk a little bit about what goes on behind the scenes. When
a local health department gets a report \-- now, this doesn\'t happen
all the time in cases of food-borne illnesses, but if they get more than
one report then they think that something may be going on, they will
send somebody out to interview the individual who was sick.

Now, that interview will be an in-person one. They\'ll say, well, what
did you eat. Where did you eat. And given the fact that many of these
diseases will have anywhere from two to six hours for staph to two to
four days for *E. coli*, they\'ve got to go out and ask people what they
had for the last two to four days. I don\'t know about you, but if you
were to ask me what I had four days ago, I\'d be in tough shape to fill
out these reports.

But I point this out because they identify disease, there\'s a lot of
individual shoe level, shoe leather kind of outreach that has to occur.

Next slide. September 8, Wisconsin calls \-- reports to the CDC having
received these reports from the first county, now from other counties
around the State, that they have a cluster. And they\'re beginning to
form a hunch about spinach.

Now, how do these reports occur? Let me go to a State that\'s now
currently near and dear to my heart, because that\'s where I live, New
Jersey. And these are downloaded off the Internet. The first one is this
is a report that\'s filled out for any communicable disease. As you can
see, it is long, and it\'s involved.

People from the health department then take it to the next slide and
complete these forms. The first is a listing of individual people in
each line who were sick, and what their symptoms are. What they\'re
trying to do is sort of take this what appears to be a cluster, and
define whether or not this is actually a cluster. And which cases are
likely to be included in the cluster, and which cases are not.

Then on the next slide, they fill out the next report. And again, they
try to align these so that the names sort of fit. They ask them what
they ate. Because even though someone may attend the same event,
they\'re not necessarily going to eat the same dishes, even if they\'re
all put on the same plate. And you begin to get an idea of what people
ate, and as you can see, things start popping out.

Finally, they use a worksheet, on the next slide, which is where they
list the food item, they identify people who were at the meal or the
event, who were sick, who were not, and they do these complex things I
learned about when I got my M.P.H., and have subsequently forgotten,
that are analysis.

Now, the interesting thing is that a lot of these things are in tools
that have been developed by the Centers for Disease Control, and they
can be done online, and data that has been collected in hard copy can be
transcribed into information systems. It used to be called Epi Info,
what\'s the new name for it? Epi Info? Okay we\'ll use that for the time
being, I thought there was a new system that was up to do this.

Next slide. Now, we\'ve got this thing going on in Wisconsin, we think
something is going on. And the CDC gets a report from Oregon. Five more
cases, with the same DNA fingerprint. And they go \-- you collect this
information about this fingerprint from a system called PulseNet, and
they use something called pulsed-field gel electrophoresis, where they
actually do the DNA fingerprinting. Now, except for the name, that\'s
about all I know. But that\'s about all we really need to know about
this.

Important thing about PulseNet, it is not a national wide system, it is
collected States that are engaged in this sort of activity.

Now what it looks like, next slide, is they get the DNA fingerprinting.
This is not from spinach or anything, this is from an outbreak that
occurred in Illinois while I was there. The important thing is that if
you look at the top part of the slide, these were samples, real samples
from a real outbreak of *E. coli* O157 associated with a barbecue that
was held at a farm, an event called Cornstalk. You see patients \-- food
samples are actually found from refrigerators, and because it was out in
a farm, there were cows in the fields, one of which had been slaughtered
to provide the beef for the barbecue. And you can see that when you look
at these shadows, which are the electrophoresis, you see they all look
the same. Except for the bottom three, which are controls. That\'s kind
of how you do this DNA fingerprinting. So you need to have samples that
run through system, and you can begin to say that this organism that was
found in Oregon looks just like this organism found in Wisconsin, and
found throughout the country.

So following this information, a conference call is scheduled. Next
slide. And these conference calls happen all the time. Our staff, when I
was in the State health department, we probably had three or four times
when people get on the call and say, you know, we\'re seeing these funny
patterns, what are you seeing, let\'s think about it, what\'s the case
definition, do we think we have a problem, do we have enough data to
support a particular item.

There was an outbreak not too long ago, probably about six years ago, I
remember fairly strongly, the initial report came out and people were
making the judgment, and they said it was raspberries in a fruit salad.
Turned out to be strawberries. Well, if you\'re in the raspberry
industry and you have this report coming out saying these raspberries
are causing illness, you\'re going to be pretty mad. So you want to try
to be right in making this. And that requires looking at the data very
carefully. Because the implications of being wrong are dramatic.

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

And sensitivity about those data, about being shared.

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

Right, a lot of sensitivity about the data being shared. Now, let me
talk about one of the problems with being wrong. It\'s \-- you know,
it\'s the kid who cries wolf. Because not only are you concerned
about \-- you know, are you going to pick off the raspberry industry,
but are the public going to believe you the next time you issue a
warning, if you get it wrong too many times.

So after having this conference, double checking the data, the
information gets issued for a call out to consumers. This is a very
complex problem of trying to get the right information to the right
consumers, in a way that they can understand.

And believe it or not, you can\'t \-- you know, if you have a conference
call at 4 o\'clock in the afternoon, someone has got to sit up all night
and try to write this information out in a way that will explain to
consumers what they need to do, or sometimes they take the wrong action.

Next slide. A warning is then issued to consumers, and the suspected
offending item is removed from the shelf. Next slide.

In the case of spinach \-- and this is real data, this is probably like
the one real data thing here. We now have 23 States, 146 individuals; 76
percent of them are hospitalized, 23 percent have developed hemolytic
uremic syndrome. This is bad stuff that happens with *E. coli*, this is
why people die from it. The blood starts hemolyzing, which means the
blood cells break up. The kidneys start going, you know, failing, and
this can have an impact. Those who are most susceptible are those who
are older and those who are younger, the very young. So that\'s kind of
the background.

Let\'s go sort of look at sort of a timeframe for this, next slide. Now,
I had animation for this slide, so I apologize it didn\'t \-- it\'s not
going to work the way I want to. Here\'s the timeline. Patient eats the
contaminated food. Three to four days lag time between when it\'s
ingested. Patient becomes ill, average is one to five days between when
they become ill and when they actually go to see a clinician.

So we\'ve got now anywhere from four to nine days that are totally out
of control of the public health system.

Stool samples collected and sent for diagnosis. This takes one to three
days. And again, this is only quasi somewhat in the realm of public
health, because once a physician is notified that there\'s an outbreak,
that timeframe can be dramatically reduced. Without notification, one to
three days.

Once *E. coli* is identified, the sample then has to go to the public
health laboratory. Let me just sort of talk about this for a second.
Most commercial labs only do a certain level of laboratory testing. DNA
fingerprinting, by and large, is not done at commercial laboratories,
they\'re done by State public health laboratories.

Serotyping frequently is not done by commercial laboratories. So
they\'ll do \-- we\'ve got meningococcus and they\'ll do the cultures
and sensitivities, because that\'s primarily what\'s of interest to the
treating physicians. It\'s this other stuff that\'s important to the
outbreak. So the interface between the clinical labs and the public
health laboratories are very important. And there again, that timeframe
of zero to seven days. If there\'s an identified outbreak, it\'s going
to happen much quicker than if it\'s not.

It goes to the public health laboratory, receives a sample, DNA
fingerprinting occurs, and the case can then be confirmed.

So the range can be anywhere from two days to 14 days. And I point that
out, that it\'s more likely to be closer to two to three days if in fact
the whole system is alerted. And that gets to resource management,
response management, and more like 14 days if it just seems to be a
routine sample. Next slide.

The reason why that\'s important, and this slide comes from the Hopkins
Bioterrorism Center, probably tons of people have already seen this one,
is we have two curves. We have the red curve and we have the green
curve. The red curve is how you do identification of cases based \-- and
ascertainment of cases based upon an enhanced, efficient system.

The green curve is pretty much how the system works between. Currently.
And the area between is excess mortality or morbidity. And so our goal
is to move as close to the red line as we can by heightening the
awareness of the system, having greater functionality, and obviously
better detection.

So how could it work. Next slide. Let\'s suppose this is 2014. In a
world in which we have significant adoption of electronic health
records, both in the clinical setting, in the outpatient setting, as
well as in the hospital. And let\'s go back to the date.

August 16, next slide. First patient is seen for bloody diarrhea and
severe cramping. The doctor is doing his analysis, he gets ready to
write his history and physical, the electronic health record decision
support system says by the way, doctor, you know this is a reportable
case under the infection diseases. Would you like us to file a report
with the public health officials. That doesn\'t happen automatic, it\'s
decisional support, like many aspects.

Detailed information then goes to the local health department. They\'re
the ones who need to send somebody out to visit this individual if it\'s
part of an outbreak. And depending upon how it works, because, you know,
you have to remember that not every area of the country is covered by a
local health department. And so this is going to vary from State to
State, there are many places where there are no local health
departments, and the State health department has to play that role.

So a report then goes to some level of detail, but less than what they
see in a local health department, to the State and to the Centers for
Disease Control. So this happens on the 16th.

Next slide. On the 23rd we begin to see an increase in the incidence of
bloody diarrhea, complex of symptoms and findings, and the laboratory
reports that are now coming in electronically. And so the picture is
becoming clearer, and much quicker.

Identifying that, the CDC, in contact with the local health department,
and with the State health departments, get on that phone and they
identify a case definition, and a questionnaire.

In that two-way communications, information is then sent out to these
electronic health records through that update kind of approach that \--
with McAfee or Norton\'s, that Chip was talking about.

So the case criteria then gets included into the decisional support. Oh,
by the way, doctor, this case now meets the case criteria for this
outbreak of *E. coli*.

Patients who have the symptoms that would lead to being a potential for
this would fill out the questionnaire as part of the intake. What did
you eat last week, what did you \-- I mean, what did you eat yesterday,
what did you eat for lunch, what did you eat for breakfast. That whole
questionnaire I showed you, that a week later in our current system,
this public health worker going to be trying to ask this person about,
in order to find out what may be the food in common that would be the
risk of that.

Patients who have, in that physician\'s practice, those who are
particularly at risk for hemolytic ureMic syndrome \-- the very young,
the very ill, those who are immunocompromised \-- would have special
attention paid to them when they come in to visit with this kind of
symptom complex, all because that notification has come in from the
State and local health department and CDC.

Laboratories are notified to expedite samples to the State lab for DNA
fingerprinting that fits within the case profile. And local and State
and national registries are now established. These registries serve a
number of purposes. One, it helps define the characteristic of this
outbreak, and second it assures that people who have been exposed and
may have disease are being treated appropriately, and they\'re not being
lost to followup.

Next slide. All at the same time, because all this stuff is coming in
and being done electronically.

It\'s been discerned \-- now here\'s a little bit of license \-- the
fact that this particular organism, as nasty as it is and, you know,
high rate of illness and severe illness, can be treated with a new
antibiotic that\'s come on the market. Killotsofem, or if you say it the
other way, "kills lots of em," and so that information is updated in the
electronic health record. So doctors know what\'s the best drug to treat
it based on actual cultural and sensitivity results of this organism.
Response management system is activated and automated, because this
looks like it\'s going to be big. And we need to know where our
inventory of Killotsofem are, this can be done in real-time. Ongoing
assessment of need to activate the national stockpile, if there were
particularly large outbreaks associated with a food item that is found
in one neighborhood or one community or one city, or it\'s a very common
one.

Remember that one of the key components about food outbreaks is that as
our country becomes increasingly industrialized in the production of
food and the management of food, that the risk of fairly large food
outbreaks increases. It used to be that when you ate some hamburger,
that hamburger came from \-- you know, one cow. Cow went to the butcher
shop. The butcher ground the meat, and that\'s where you bought your
hamburger.

Now, in large mass production, you\'re talking about literally millions
of pounds being produced in a run, and it\'s all mixed in together. So
one single contaminated cow can result in literary thousands of people
getting sick.

Some concern about the magnitude of this, so a real-time assessment is
going on between the hospitals and the State health department, and
getting the information about the bed status, the ICU status, and if
there\'s a lot of cases of hemolytic uremic syndrome, dialysis
resources.

Two days later, next slide, additional case reports, and confirmations
indicate this is multi-State. Analysis and questionnaires from multiple
jurisdictions now implicate, one sampled, and in this case it\'s raw
spinach. Warnings are issued by FDA, and warnings are issued through
notices to personal health records. Because people may not hear it on
the news media, but it\'s a way to reach out to people who are thinking,
you know \-- as we think about the potential of personal health records
of helping people develop their shopping list so they can eat healthy.
Well, here\'s an example of a warning that may go on. Updates are issued
as more knowledge occurs through electronic health records.

One of the highlights, and I think one of the processes that we can use
as we go into this visioning section \-- next slide \-- is to think
about where the data flows. And there\'s going to be two states, because
these are important to realize. The state before the outbreak is
identified, and afterwards.

Initially, before the outbreak, the electronic records would send the
details to the local health department. And would send abstracts to the
State health department and the CDC. Because basically, the State needs
to know, are we seeing a multi-jurisdictional problem. They\'re not
going to be sending people out to do the investigations, unless it\'s
one of the States where there aren\'t local health departments every
jurisdiction.

But in that instance \-- and the CDC is not going to need as rich a body
of data about that individual. So it allows the system to respect
privacy, and what information is sent on a need-to-know basis.
Laboratory findings, as they currently go, would go to the local health
department and State health department depending upon, again, the
granularity of that data.

Findings of laboratory results need to go back to the clinician of the
local health department from the State laboratory, as well as to other
State health departments in the CDC.

And all this information will be shared on PulseNet on steroids, which
means that we would have all 50 States and the District of Columbia
participating in PulseNet, and sharing these DNA fingerprints that we
have a much tighter network to detect those.

After the outbreak \-- next slide \-- the data sharing is going to have
to be \-- I actually changed the title of this from not just data, but
also information and knowledge flows. Because I think we need to think
about those in different ways.

EHRs begin to populate State, local and Federal registries for this type
of disease based on questionnaires that people fill out, as we talked
about earlier, upon admission, and more robust clinical data about these
individuals, so that patterns of disease, the severity of illness, can
be determined very rapidly.

Public health officials at each level are able to see granular data for
their jurisdiction, and then they can see analytic data for the entire
outbreak. So they know where they fit, and what the nature of this
problem is.

Next slide. Other information and knowledge flows \-- we\'ll call them
objects \-- are then becoming incorporated into the electronic health
decision support. So this is actually knowledge that flows from the
Centers for Disease Control and the State health department into
individual clinicians practices and to the hospitals, so that the case
data ascertainment can occur in a way that enables us to understand this
outbreak. So that treatment support can be given. So that the
Killotsofem inventory can be managed, and the patient discharge
information can be updated to reflect information that\'s given when the
patient is sent home. About what\'s going on in the outbreak, what they
need to do, that can be updated on a regular basis.

Next slide, the information flows would go from there into the public
health \-- the personal health record. Maybe as a warning from the FDA.
Maybe a list of symptoms. Because a lot of people get worried, the
worried well. Well, I\'ve got these symptoms, I ate something that, you
know, at the store, and now my skin itches. Well, don\'t worry, that\'s
not part of the symptom complex.

But it\'s equally as important to keep the worried well from going to
healthcare as it is to identify those who are sick.

And then also the latest info on Killotsofem, and what it can be used
for, and why you shouldn\'t take it just because you had funny tasting
hamburger or something. Next slide.

Hospitals activate real-time capacity reporting. Pharmacies, wholesalers
begin to send real-time inventory data to public health.

Lastly, next slide, the creation of real-time outbreak registries that
share this data in a way that \-- as a need-to-know so, you know, as
it\'s shared across jurisdictions, the identifiers are going to be
stripped and so forth. Real time, within jurisdictions, within local
health departments, within States, across States, and then to the
national level.

What are some of the policy implications? I think we want in our vision
session to flesh out the issue of how data can and should flow. And then
we also want to look at some of the policy implications as we think
about the higher level recommendations.

The data collected by public health is protected by strong State
legislation or Federal legislation. So that people know that when their
data is being collected, it will be protected from being subpoenaed or
involved in any kind of legislation.

For instance, in Illinois, information has to be protected. And you
don\'t think about it, you say okay, you want it to be protected so that
it \-- you know, can\'t just be viewed by the public. But what about if
it\'s subpoenaed? Okay, well, you know, maybe in some instances. But
what if it\'s being subpoenaed in a divorce proceeding?

Well, who is going to send in their information if they think that
whatever they get about sexually transmitted disease may be accessible
in a divorce proceeding? So we really have to think about a protective
environment for this very sensitive data. That otherwise if we don\'t
have, our public health system will be crippled.

The granularity of the data and identifiers has to be determined by the
need to know. Who needs to know, what are they going to do with the
data, are they doing analysis, how it\'s going to be aggregated or
deidentified.

Next slide. Other policy implications, electronic health records and
personal health records need to be constructed with this functionality
in mind. We talked about that a little bit.

Let me talk a little bit about the business case. Why should they do
this? Well, what I\'m holding up, for those of you on the phone to see,
is a stack of paper. I was going to say it was an inch thick, but it\'s
not. It\'s really only 56 pages. But each one of those 56 pages is taken
off the Website of the State of New Jersey of mandatory reports required
to be filed by hospitals and clinicians, based upon State law. Now, you
can fill out these reports by hand, or they can be automatically
completed by an electronic health record.

And I think the business case for why those should be included in the
construction speaks for itself within that context. We just need to put
in the context, this is something that\'s mandated, the system ought to
be designed thinking about \-- you know, you have to write a chart, so
why not have something that collects data that preserves it from visit
to visit.

Well, that\'s what an electronic health record is for, to do the
clinical aspects of the job the physicians and other clinicians are
doing, as well as hospitals.

Have to think about data sharing between States, and so forth, so that
the data can flow freely.

This is sort of the new environment that\'s sort of thinking at the high
level. And what we hope we could do in the remaining time is spend a
little bit of time, maybe first talking about data flows, whether or not
there are other data flows we want to add, and then some of the policy
implications that we would want to make as recommendations through the
AHIC process, as we\'re looking at the evolution of the system.

What this creates is a new vision, a conceptual model of how the system
can work, for which automation should then facilitate, rather than
automating the current system of interactions that we have in the public
health, healthcare interface. So any questions?

I think they\'re all gone.

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

John, this is Scott Becker from APHL. First of all, that was absolutely
phenomenal. That was a fantastic walk through what should be. I really
don\'t have any comments, other than I \-- you know, I think we\'re all
going to be challenged to figure out how to get from where we are now
with our legacy systems to there, but I really think that just gave a
wonderful vision forward. And using the recent things we\'re still
living through in at least the State labs and certainly the health
agencies is very vivid.

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

This is Kelly Cronin. I think one of the goals is for us to advance a
common vision that we all can support and agree on, on October 31 to the
Secretary. And your presentation was so impressive, I think it would be
particularly helpful to get some feedback from other Workgroup members
about whether or not they share everything that John just articulated.

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

John, this is Brian. There\'s one part that wasn\'t mentioned in your
presentation that has been of concern to me and a lot of clinicians and
that\'s the fact that as more and more data becomes available, we\'re
going to drown in the data and not be able to see the forest for the
trees.

A key component of this future vision has to be how do we use the
technology and the skills and the value of the computer to sort through
that data by rules that we establish, and present us with the
information that we need in a context that we need it. I mean, F-15
pilots have all kinds of data available to them, but they don\'t really
care about how much gas they\'ve got when they have a missile coming at
them. A lot of that artificial intelligence, a lot of that capability,
has to be built into the system, otherwise we\'re going to just bury
people in data.

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

I think that\'s a great point. This is Rick from New York City, and I
also enjoyed the presentation, it\'s very thought-provoking. You know,
it does remind me of some of the early presentations around syndromic
surveillance before we had experience with it, and some of it has been
disappointing. So clearly, there\'s lots of potential but, you know, one
of the things that comes to mind are the number of specific rules that
need to be populated in all the information systems, in order to make
all this happen, and maintaining those rules. And we have some
experience with that, with just electronic laboratory reporting. Each
lab has, you know, its own internal codes. We\'re mapping those to
standard codes, you know, we\'re developing rules on all those standard
codes to try to get a positive electronic lab report to the health
department. Which is obviously you know, the simplest case here.

So it\'s inspiring, it\'s also very complex, and rolling it out is going
to be a tall order.

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

This is Dave Parramore from the DOD. Certainly some great discussion
today. What we\'re delighted to do as part of this group is take these
deliverables for analysis, and help prioritize. We\'ve been having some
ongoing discussions on the DOD side about how we interface with other
government agencies on these types of issues, and we\'ll certainly
provide our feedback when you guys send us this information. Thanks.

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

I think \-- this is John Loonsk \-- I think there\'s an interesting sort
of dichotomy or tension here between two extremes that it\'s important
to tease out in this discussion, and \-- it\'s the up-off-the-rules
concept. At one extreme, where you\'re doing \-- you\'re using the data
that exists in healthcare, and you\'re doing \-- you\'re aggregating
those data, and doing data mining on it, if you will. This is the term,
you\'re processing it, you\'re analyzing large quantities of data.

At the other extreme you\'re pushing rules out to clinical care, so that
just the data, you know \-- and these rules could get highly
complicated, they could eventually \-- they could certainly populate a
case report, they could eventually have artificial intelligence, they
could eventually be updated on a very frequent basis. But just to
recognize that sort of spectrum.

And that flavored into that are the issues and concerns people have
about confidentiality when you aggregate data. But in fact, that\'s part
of what we\'re talking about here, and where we\'ve been talking about
the existing biosurveillance work. It\'s about taking data and trying to
aggregate them so you can analyze them, and you don\'t have to have a
rule out there that does the identification, but that with time, and as
the system matures, and greater capabilities exist, some of the public
health cycle can be pushed out into the care environment, where you get
much more specific data, that the data are more sophisticated, they\'re
more highly processed, and potentially the analysis \-- you know,
there\'s some components of the analysis that are done as they\'re
reported.

So it\'s an interesting spectrum. I don\'t know if that makes sense to
people, but \--

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

Let me sort of follow up, and with the comment about extracting data
from laboratories, and so forth. You know, we all have a vision about
what \-- at least many of us, I assume many of us, have a vision about
what electronic health records will do. If we envision that decisional
support will solely be diced as we do quality improvement measurement,
which is essentially administrative data, which is you take \-- you
know, a 20-minute emergency department visit, and you boil it down
to \-- you know, a six or seven place set of codes. That\'s not telling
you much, and you can\'t really do individual case decisional support on
that kind of \-- of that data.

So you really need to have a way to grab the clinical data as it\'s
coming off \-- you know, out of the brain of the clinicians documenting
their encounter with the patient.

And I think that is the level at which we need to think about tapping.
Now, there are a lot of folks who are spending time figuring out how
decisional support will work, and how to integrate them into electronic
health records. And I think the importance of this vision is to have
them think, as they\'re doing that, how do I plug in some other
intelligence, knowledge, which is what decisional support is about, if
that knowledge comes in from outside the electronic health record,
because of new information that\'s garnered.

Now, you know they\'re doing it, because every time you turn around
professional associations are changing their guidelines. And, you know,
we get new knowledge that says don\'t use drug X, now we\'ve got to use
drug Y.

So if they\'re thinking about that, we also want them to think about how
they would interface with the public health system, and incorporate
knowledge or gains of outbreak information, in the decisional support.

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

And I think \-- you know, I too thought it was a great walk-through, but
it was never intended to represent all facets of this, and what public
health does. And I think one of the areas that\'s worth also emphasizing
is the prevention component, wherein \-- however that information and
knowledge is garnered, developed, processed, whether it\'s through
research or how that material is put out, the many venues through which
it can be put out, and the contextualization of that information in the
context of whether activities on a PHR or activities on an EHR, but the
importance of presenting that information, in the context of activities
that are carried out there.

So whether it be a reminder that someone needs an immunization, because
their record shows they haven\'t had one, or it be something, as you
suggested, that if they have spinach on their shopping list, that they
should be told that they \-- you know, they shouldn\'t necessarily buy
the spinach today, but that all those facets are there.

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

Rick. One last comment from New York City. John Lumpkin, I wonder if you
would comment on whether you have any suggestions for our matrix, either
on the call or even off the call, to John Loonsk and the others who you
are with. From your perspective, do you see any leverage points that
AHIC can exploit in a recommendation?

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

I do. And I will.

\[laughter\]

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

And actually, I think we have an opportunity as we sort of \-- you know,
develop whatever is presented October 31, to highlight some of that. We
can put this all together in the same package. Sorry, I didn\'t mean to
cut you off.

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

No, I was going to \-- well, you know, I think the two basic areas at
this particular point in the matrix that I would view as high priority
is the case reports, and the second being the bidirectional. And the
reason why I pick those two \-- not that there aren\'t others that are
very important \-- you know, my experience has shown that one of the
major aspects of failures of the public health system or being able to
do a good surveillance system is people send the reports all the time
and get nothing back. And until we actually begin to implement
bidirectional \-- you know, you get a report back saying, you know, your
case was one of 15 that were identified as outbreak, you\'re more likely
to report next time. But if it just goes into a black box, it\'s
something that, you know, that\'s an additional burden.

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

Is it fair to say that everyone more or less agrees then with what was
presented as sort of the ideal for 2014 in the scenario?

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

I suspect it\'s like everything else, every time I say "five years
away," five years later it\'s still five years away, but it\'s still a
great vision.

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

I guess the next steps here, perhaps, if we can think about that, you
know, having presented a 2014, which is eight years away, and we think
about the long-term vision, would it make sense, in addition to
presenting to the full AHIC a \-- not only a long-term vision, but also,
you know, what would be the necessary steps we would need in order to
get there? So we would also present sort of a midterm-vision of how
we\'re getting there? If we\'re going to drive from Chicago to
Princeton, New Jersey, you can either swing by Pittsburgh, or you can
swing by the northern route on I-80. Both of them get you there, but
they won\'t necessarily get you there as fast.

So I think it kind of sounds like \-- I\'m going to make an
interpretation of the silence until you stop me, which is that we have
the grid, which gives us sort of the immediate-term recommendation. And
what we want to do, as part of the vision, is to look at now the
mid-term and long-term views that would sort of be logical steps that
would be enabled by some of the short-term visions that we\'re talking
about with the grid. Is that a fair, reasonable way to pull these pieces
together?

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

John, this is Brian. I think the other thing is that this is not
happening in a vacuum. And given the people on the call and the fact
that we understand the work being done by other AHIC groups in the
general direction that we\'re taking as we start to define the
Nationwide Health Information Network, that we identify those parts of
the interval steps that are really in concert with that direction. Or
more importantly, we identify things that we think are important in the
interval steps that are much different, or are not necessarily things
that would be supported by the general direction, so that we can kind of
provide some mid-term or mid-course corrections.

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

Yeah, Brian, that\'s a really good point. This is Kelly. I think we have
been talking about some common assumptions that we would have about the
state of operability and state of adoption, say, in 2010, or what would
be described as a mid-state.

We could assume a certain level of functionality when it comes to
clinical decision support. At that point we\'ll be, you know, four years
into the certification process and there will be, you know, four years
to have the functionality certification criteria for both ambulatory and
inpatient \-- maybe three years for inpatient \-- become more
sophisticated. And we\'ll have, you know, a common architecture for
network services that will most likely be deployed, will be a market
evolving by 2010, if not maturing.

So I think there\'s some sort of logical assumptions that we can make.
We\'ve also talked, at least from electronic health records and personal
health records, we need to have more around this, but we\'ve talked
about perhaps being at, you know, a point on the adoption curve that\'s
much further than we are now, perhaps PHRs that might be around at
midpoint, with EHRs it could be perhaps even higher, they\'re \-- market
is a little bit more mature there. There are some incentives that are
starting to hit the market.

So I think it\'s a really good point that we want to stay connected. And
in fact, we have Larry Bartlett here today, who is the President of HSR
who has been supporting the Community in a variety of ways, and will be
working across the workgroups with us to help us come to sort of a final
common vision that we can present to the Community.

So we hear you loud and clear. We\'re probably in the next week going to
be making sure that as we follow up and take this to the next level,
that we make sure that there are some common assumptions and common
approaches across the groups. The Workgroups.

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

Great.

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

So where do we go from here?

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

Yeah, one thing that we have talked a little bit about, we talked a
little about taking, you know, the areas that you mentioned before, like
case supporting and bidirectional communication, and we could even, you
know, further differentiate that by, you know, PHR and EHR
functionality. And think about how far along might we be in four years,
versus eight years. Again, we don\'t want to get too granular in this
description, but just to understand what are some sort of realistic,
shorter-term accomplishments that we might strive for.

And I don\'t mean to leave adverse event reporting off the list, that
could obviously be a third major category we could focus on in
describing what the evolution might be.

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

Well, you know, thinking about adverse event reporting, to my mind it
just seems like a subset of case reporting. Because the mechanism to
abstract an adverse case is I think going to be very similar to the
process of abstracting a case report of a communicable disease. Or the
process of abstracting a case report for a cancer registry.

You know, there\'s obviously some logic that needs to be put in there to
ascertain \-- to determine, okay, is this a case, and then if it\'s a
case, what data do I have to extract in order to fill out a report. Once
you have that logic model there, what you test that against just becomes
a look-up function rather than another different process.

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

I would agree with that. But it still may be something we want to be
explicit about, so people see it, you know. I think it\'s sort of \-- at
another angle, thinking about advancement, when we\'re thinking about
progression and adoption from \-- first to having EHRs, and then to
networked EHRs, that the concept of \-- from where the data arrives, and
if you think about a case report as a more complicated \-- aggregation
of data than just an individual data element from clinical care, and if
you think about what kinds of capacities ambulatory care sites may have,
and what they might not have, a good discussion point is, well, what
might arrive from a network infrastructure \-- arise from a network
infrastructure, and what might arise from an individual EHR.

So if a lab result from a public health lab is a critical part of, you
know, a case report, or if you know \-- where are those data, where they
arise, is it coming out of several \-- is the case report emanating from
more than one clinical data provider, or not. I mean, those are
interesting things to think about as one is progressing to a more
internetwork world of health data.

Some from the PHR, and some from the EHR. You know, lots of different
permutations.

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

Mark, are you still on?

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

No.

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

You know, I think one of the aspects, it\'s unfortunate Mark is off,
because I think that one of the reality tests of any sort of vision like
this is the \-- those who have some \-- have somewhat the pulse of the
privacy world, and what are the concerns, and how do we \-- you know, if
people don\'t have confidence in the system, then we are at risk of a
system that will not function, and that will drive people away rather
than facilitate their care.

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

No doubt. And I thought it was interesting what you said before, because
it brings up the whole line of thought that, you know, we\'ve been using
coarse descriptors to talk about privacy issues, I think in the general
public dialogue. Coarse descriptors. And it\'s not that that\'s being
critical, but it\'s sort of privacy or no privacy. It\'s sort of people
you know, I can\'t get my data, and the concerns many people have in
that regard. But, you know, from a public health standpoint, there are
needs \-- there are clearly times when data are needed to protect
individuals, for which it\'s \-- you know, my personal preference would
be that someone knew that the person sitting next to me had a highly
contagious disease, and that was being followed up on, and et cetera.

But you identified the need to protect public health data as a necessary
entity, and so there\'s also a balancing between how do you achieve
those outcomes of having data necessary to public health, and is some of
it done through \-- and what\'s done through technology, what\'s done
through regulation, and realistically, and from the standpoint of what
the infrastructure can actually implement, how do we protect it.

There\'s obviously a long history of protecting private information in
public health. You can think about HIV reporting, you can think about
other activities where very sensitive information are protected. But you
also identified some of the issues, there. Which is that if it\'s
subpoenaed, if it\'s \-- for another purpose, you\'re not going to get
at that issue through information technology. You need to get at that
through regulation. And so I mean, maybe part of the message is that the
health IT world advancing, as a critical component of it enhancing the
protection of public health data, as you say, from the standpoint of
other uses, other access to those data, but still ensuring that \-- you
know, developing more granularity on the discussion.

So that public health needs are more clearly understood and recognized.

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

Perhaps maybe we could think about what we think is most important to
focus on to get us further down the road, to say where we want to be in
2010. So given that before we\'ve talked about in the context of case
reporting and bidirectional communication, or even adverse event
reporting, are there some important steps that we need to take to get us
to 2010? And what would they be, and what might that look like?

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

This is Brian. This is the part of the conversation where I really wish
I had Ed Barthell online, because this is where he excels in terms of
trying to pull those milestones together.

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

It would be easy to say the data for case reports of a variety of
circumstances need to be better standardized. Or at least that there has
to be an adoption of common standards for what those data are, so that
the clinical care industry can possibly achieve a more automated
presentation of those data.

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

So we\'re talking about structured terminologies, and other \--

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

Terminologies, there need to be noted that there are differences in what
defines a case in different States. That\'s a big \-- that\'s an area.
But certainly, the terminologies that are used in different contexts to
support those case definitions. Whether it\'s adverse events or whether
it\'s communicable diseases or other syndromes.

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

I think it\'s important that we note that to the extent that we are
looking at trying to abstract data from a clinical record, that the work
that\'s being done and thinking about it in public health should go in
parallel, hand in glove, with the work that\'s being done in
relationship to decision support. And to other kinds of work that\'s
being done. So that we\'re not thinking a set of standards for public
health or structured terminology for public health reporting, but we\'re
building off of other work that\'s being done to develop structured
terminology and approaches. So that it can be a synergistic process
rather than a separate silo.

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

And that\'s certainly in keeping with the construct that (indiscernible)
were advancing, which is to use clinical care industry standards, not to
develop public health standards unto themselves. But since those
initiatives don\'t quite have the public-private imprimatur yet, one of
the things that I\'m trying to suggest is it would be helpful to bring
broader focus on them so that the standards can be agreed to by both
public and private side, and that there can be more general recognition
of what they are.

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

Let me sort of follow that through. As we think about the kinds of
recommendations, then will we think that because of the importance \--
increased importance obviously since the event of October of 2001, that
we think that there is a public interest in facilitating and
accelerating the process of looking at how we abstract certain
information out of clinical records?

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

I think that\'s the large thrust of what the biosurveillance discussion
has been about, is that clinical interface. That, you know, the added
factor here is to think about ways in which public health, using
clinical standards, can get data that are more oriented to its needs
versus going to just taking from clinical care what is available there,
from the \--

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

It\'s only for under certain circumstances for certain needs, not as
sort of the mainstream data dump on a regular basis.

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

Well, let me sort of be less obscure, then, in what I was trying to say.
Not being in government, maybe I can say this. But maybe government
ought to be playing a role in the developments around decisional
support. Recognizing that that\'s going to create the infrastructure to
enable the kind of report. So it puts it in a different light of the
kinds of \-- you know, whether it\'s funding for research through NIH,
of doing that, but by tying together the public health interests, to get
people engaged in public health, or with public health knowledge, as
part of the process of developing the decisional support, recognizing
that they\'re going to need that infrastructure in order to do \-- to
create this vision.

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

John, are you talking more from the standpoint of reverse engineering
the process to be sure the system that\'s built supports what you\'re
looking for?

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

Yeah I\'m not sure reverse engineer is the right term but it\'s using
the end as a way to drive the means. And because the means will lead to
different ends, sometimes there is more \-- there\'s more focused
attention and impetus to achieve one end versus another, but the means
may be a very common effort.

So that decisional support is important, we want to see it happen, but
does it carry the same sort of sense of urgency we have in trying to
protect the health of the public from threats both, you know, natural
and manmade. It may not. But if we see it as an essential step towards
creating that system that can protect the public, then perhaps we begin
to look at the fostering, the development and decisional support in a
different light.

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

Okay.

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

And I think one of the things that, getting back to your business case,
when you\'re looking at EHR certification criteria or potentially, down
the road, network or PHR certification criteria, if we expect for this
kind of logic or decision support to be a requirement over time, how can
we then think realistically how we\'re going to communicate the
importance of this, and be mindful of the value of that when it comes to
the EHR vendor community, and the various people that sit on the
certification board, so that they understand why they need to be
thinking about it in two years, or in three years. You know, what is
clearly the business case from a population health perspective. Can it
be described, if not quantitatively, at least qualitatively.

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

That\'s an interesting problem. I tend to think that when clinicians
think about decision support they\'re really talking about population
and prevention. From their perspective. And that in fact it is a \--
that\'s where the worlds collide. So, you know, whether public health
will be another compelling businesses example there or not, I\'m not
sure. I mean, it is already sort of queued up in the national agenda. It
was a discussion point at a fairly recent Community meeting, it was a
very complicated discussion

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

It was.

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

And it branched \-- and I think it became complicated partly because
people were talking about many, many different things in terms of what
it was and what it represented.

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

But you know similar to what has been discussed from a quality
perspective of clinical decision support, if you start focusing on a
course of inpatient and ambulatory quality measures and you want to make
sure the decision support that\'s being available or being required
through certification over the next two years, for example, is very much
tied, and enables clinicians to meet those particular performance
measures, so they\'re reminded about their screening mammography or
colonoscopy or whatever the measure might be, many of them being process
oriented, but if we can also think about, well, what might some of the
most pressing areas of public health be that \-- where there\'s really a
need, there are certain case definitions that should be incorporated,
and there should be, you know, in the next four years, as a priority, at
a minimum be some kind of functionality for decision support on the most
pressing public health potential threats.

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

Well, it may be a restatement of what John was stating earlier, but
perhaps expressing some of the public health goals would be less of a
lightning rod than the quality goals in terms of decision support. I
mean, is mammography screening a quality measure or is it a prevention
measure?

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

Yeah, there is overlap.

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

The way to articulate that, though, also injects it with more
controversy. Depending on whether you\'re judging someone on the basis
of how well they accomplish their mammography screening versus whether
you\'re just reminding them that they need to do it in a prevention
context.

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

But do people have any thoughts about are there certain kinds of
infection disease threats or certain kinds of decision support that
would be of highest priority that should be communicated to \--

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

Vaccination is, you know, a clear winner here. It\'s easy to articulate,
it leads to other areas of public health endeavor that are important.
You know, it\'s something where a reminder can be extremely helpful.
There are data sharing needs in that regard, but that\'s one.

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

The other use case, just because of the public recognition appeal from
at least my perspective, is the entire pandemic flu and the
bioterrorism, in terms of being able to identify, to be able to respond,
to assess the severity, to guide the treatment, and then to deal with
the resolution and the aftereffect. And it would seem if you aim towards
those, quote, popular use cases in terms of capabilities, that most of
the other, quote, routine things that public health does, would also
fall underneath that structure, and be significantly supported.

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

You know, I think that \-- you know, we have two ends of the spectrum,
which is one is to think about bioterrorism, which is an event that \--
outside of a certain set of circles, I\'d say most people aren\'t
thinking about anymore. Versus thinking about the business case, which
is one of the things that clinicians may most likely have an encounter
with the public health system.

And I think that maybe we could do both. Look at both ends of the
spectrum. You know, maybe look at it in regards to food-borne illness on
one side, I don\'t think there\'s anybody who doesn\'t believe they
aren\'t going to be susceptible to that, you know, multiple times in
their life. And then on the other hand look at it from the perspective
of the \-- you know, oh, my God, I hope it never happens, but we\'ve got
to be prepared anyway.

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

So thoughts on where we can go from here. I think that there may be some
things we can ask the people on the phone to do, in the interim.

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

Maybe I can hop in here, more a question than a suggestion. This is
Larry Bartlett, Kelly had referenced the fact that I\'ll be working with
her and other folks to try to help put these pieces together and paint a
picture. I sat in for the discussion about the prioritization, and I\'m
tickled to sit and listen to John paint a picture of a future system
that \-- and I heard people \-- I actually heard people refer to it in
ways that really did reference pictures, you know, people talking about
it being vivid, and an accurate portrayal of what folks wanted to do.

In terms of \-- I know that there\'s an assignment or a prioritization
effort working with the matrix, and I guess I just want to say
explicitly something that you had touched upon, Kelly. And would I be
right, as I start to think about \-- okay, this is the picture of the
future, prioritization is more from current to next steps, and what does
the AHIC focus on and what use cases are developed. It just seemed to me
that the two have a relationship, certainly.

And I guess if I were on the Workgroup, and I was thinking about okay,
I\'m supposed to put numbers next to the \-- you know, the left column
and the right column, and all that stuff, it seemed to me that the
criteria, as I listened to the discussion, that there were three
criteria that I certainly would have in my mind, and I just want to
throw them out and sort of test them, as I decide how I\'m going to sort
of \-- you know, indicate my priorities.

And one is that what I choose as a high priority contributes to this
future vision. You know, that it fits into this picture. And I think
most of these probably do.

Two, that it\'s sort of early on in the critical path. It may have a
long lead time or you just sort of think for whatever reason, either how
long it takes or how other things are associated with it, or fall in
after with it, it\'s early on in the critical path. And therefore, you
have to get moving on it sooner rather than later.

And three, it seemed to me that \-- and I think you were having this
conversation \-- that AHIC\'s unique role can help make it happen. You
know, there were discussions about what the industry might be doing, and
what might be happening here and there, but I think people have enough
of a sense of this unique role of AHIC and development of use cases and
all might play.

So I just sort of wanted to make that explicit statement, that it seems
as if \-- bubbling out of these two conversations is maybe not just
these three criteria, but certainly three things to consider when people
are filling out their priorities, both in terms of these five areas, as
well as the specific steps that follow.

Because it seems to me that the priorities have to get you to the 2010
intermediate case, and move you along to 2014. But your prioritization
efforts I think at a very operational level really do tie into this big
picture.

Am I right about that?

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

Yes.

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

You know, maybe when stuff goes out to folks, and too bad for the people
that weren\'t on the phone and missed the presentation on the future,
but just, you know, maybe referring them back to the presentation and
just being explicit about keeping these things in mind might help to at
least give them something to think about as they make their
prioritizations.

And the second thing, then I guess that comment on the pictures fitting
together. Kelly and I talked about okay, the end vision for each of the
different Workgroups.

You know, this is a perfect example where you\'ve got folks, the
Consumer Empowerment Group working on PHRs, you\'ve got the EHR folks
doing everything, it just seems to me that if you take, in a current
state, that matrix current state is on the left, future state is on the
right, you put them together \-- I\'m just sort of sitting here putting
paper together \-- and they\'re going to \-- they should overlap. You
can array these things so that the future visions overlap. Fit together.
I mean, you can do that physically.

And that\'s a beautiful conversation to be had, because you guys just
articulated things that you\'ve got to make sure that in 2014, you get
from a PHR. It has that functionality. And from an EHR. From EMRs, it
has that functionality. And there\'s a conversation to be had,
that\'s \-- you know, from a public health, from a biosurveillance
standpoint, it\'s important that your future vision have this
functionality.

And that\'s \-- I just think that you guys, I\'ve heard enough of some
of the other conversations, to know that there is a discussion to be
had, both in terms of the end state, as well as the intermediate state.
These things do \-- these things will fit together. They\'re not sort
of \-- you know, kind of separate and disembodied activities.

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

Yeah I know, absolutely. And I think in particular, over the next couple
of weeks we\'re going to have information we could share on where do we
think PHRs are going to be in 2014, and 2010, because people are already
working on that.

And I think we can \-- you know, take those as inputs into our next
meeting, to be figuring out are we on the same page, and trying to
figure out, you know, how sophisticated and how far down the path in
terms of decision support might we be in four years versus eight years.

Just like I think, you know, in terms of how widespread these activities
might be, might be informed by some common assumptions on where we are
on the adoption curve.

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

Put another way, but I think basically saying a lot of the same things,
that knowing that the business case for some of these public health
activities is going to be hard to advance, it would be helpful to look
at the public health needs, the lens of the more business-oriented needs
of EHRs and PHRs, so that we can insinuate public health outcomes as
those trains roll along.

And so to think about them from there, that standpoint, those lenses,
would be helpful so that we can try to hook the public health outcome on
the back of those activities.

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

Is there any comments from the Workgroup members on what was just said?

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

This is Rick. I thought the three criteria were very helpful. The last
one \--

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

Do you want to reiterate those three criteria?

\[laughter\]

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

This is a reliability check, can I say the same thing twice? What jumped
out at me is that in looking at \-- to be honest with you, five domains
or at least four of the five domains all sort of \-- they\'re a piece of
the future, certainly, actually all. Of the scenario.

But I think it applies with respect to prioritizing the priority areas
as well as the areas of recommendation for the AHIC. And to me, the
three things that jumped out from these two discussions, where I would
be thinking about how do each of those areas in the specific
recommendation contribute to our realizing, to our getting to, that
final vision.

The second thing, I\'d think about which \-- where do they fall in the
critical path. What things either have a long development time \-- 10
years is not all that long, or eight years, or whatever. Either a long
development time, or have to occur up front, so that other important
things necessary for that final vision to be achieved, have to take
place.

And again, there\'s some subjectivity there certainly, and I think to
the extent other people have, you know, different expertise, that\'s a
helpful thing. But where do they fall on critical path, stuff that has
to be done sooner rather than later should be a priority, it seems to
me.

And the third is sort of looking at all the different recommendations
and seeing which of these things have some unique link to the AHIC, and
its roles, its own unique roles and responsibilities, you know, things
that it can do to make things happen, that might not happen as quickly,
if all \-- you know, if it was just the industry, or if it was actually
(indiscernible), just thinking about the AHIC and its Workgroup. Those
are three things that, you know, are not necessarily substantive in
nature, but you can apply them to each of these. And there may be some
things that percolate up to the top of the list, and some \-- you know,
just sort of fall a little bit lower because it\'s not sort of time
critical, or it\'s not necessarily in someone\'s view, you know, that
the AHIC is uniquely capable of making this thing happen. Or it really
doesn\'t fit into the future vision.

So those are the three.

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

This is Rick. I was about to add also that that third one requires a
certain amount of expertise. And I\'m thinking, you know, to figure out
what we can say that really will make a difference. I\'m thinking of a
conference call that happened yesterday organized by CDC, it had 70 or
80 of the IT directors and experts at health departments around the
country, and the CDC PHIN folks talking about public health messaging
and the messaging software that CDC is created and how can they improve
it, and they\'ve got this whole working group, and they\'re going to be
doing \-- you know, they\'re already doing all of this. And it\'s
totally relevant to, you know, case reporting and interoperability, and
a lot of the things we\'re talking about.

I don\'t feel I have the expertise, often, to know, you know, what
button we can push through this AHIC process. I think, you know, John
Loonsk, I think you have a good sense of the broad IT world out there.
That helps a lot, but we \-- figuring out where AHIC can make a
difference is one of the challenges we\'ve had when discussing this
internally here in New York.

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

Yeah, I mean I think from a simplistic perspective it\'s helpful to
think about the mechanisms we already have in place. So what could be
advanced through definitive recognition of names, standards, and
implementation guidance for public health that would have to be
incorporated into information systems or health IT. What can be done
through the certification process, so can requirements for decision
support related to public health be required over time, and certainly
AHIC can make recommendations in that area. Or at least \-- not at a
granular level, but say at a high level there has to be some
consideration given to these public health needs.

And clearly, we\'ve been making a lot of recommendations related to
policy issues, whether it\'s \-- you know, as Chip and others were
alluding to before, the absence of authority, or perhaps the issues
around privacy and security, or variation in mandatory reporting
requirements, there\'s a variety of both policy and technical issues
that could be addressed at the community level. And once they are
specified in recommendations, then, you, know we can figure out the
appropriate vehicles to act on them.

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

I totally agree with everything Kelly said, I would add the architecture
elements on how NHIN advances. But you know, another high level way of
looking at the AHIC is not about what public health does internally as
much \-- that probably isn\'t the area to focus on. It\'s more about
focusing on the overlap between clinical care and public health.

And you know I think there\'s reason to believe that as we get toward
the central vision that overlap is going to get fuzzier and fuzzier, so
we could be planning accordingly. But the area that this apparatus could
help most with is the burgeoning clinical infrastructure, electronic
health records, personal health records, networking healthcare, and just
how public health needs overlap with that.

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

This is Brian. Let me ask a question of the public health folks on the
line, because I really don\'t have the answer.

As we talk about the future vision of public health and the
communication, how does public health change with the changing
demographic. We\'re going to have double the number of people on
Medicare, we\'ll have a vast increase in number of older patients. When
you start talking about adverse events and drug interactions and things
like that, suddenly you have a dramatic increase in the number of old
people on multiple medications, does that change the priorities or
change the emphasis, do we change more to a false prevention than
vaccine administration? I\'m not sure how that changes that or whether
that needs to be in our consideration as we start to plan this 10 or 15
years out.

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

Well, you know, I think that \-- I think you\'re talking about what the
individual pieces are. And if we build the system right, it ought to be
able to respond to the needs at that particular time. And I think
that\'s kind of the vision we\'re trying to get to.

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

I just want to make sure that we\'re not ignoring the obvious, and that
there\'s something big out there that is focused on the geriatric
population that we\'re missing in this entire discussion.

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

Well, you know, potentially there\'s a lot more prevention opportunities
in personalized healthcare than in, you know, than in the traditional
clinical care system. And as those opportunities become available, I
think there are a lot in public health who are interested in taking
advantage of them. Whether that\'s activities in the home or activities,
you know, in a more timely way to avoid \-- so I think that is clear
direction.

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

Like I said, I didn\'t have the answer, I just had the question.

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

Good question, though.

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

Uh-huh. So perhaps we should be thinking about how we can get more
structured input from you all after you\'ve had some time to sort of
digest this conversation today, and John\'s presentation in particular.
And I think John and Larry and I will probably spend some time figuring
out how to best engage you all over the next few weeks to start fleshing
this out a little bit more in advance of our October meeting. And I
think we\'ll also \-- I\'ll also be working with the other Workgroups,
as will Larry, so we can be keeping you in the loop about some of the,
you know, future directions and some of the things that they are
starting to articulate in the way of their visions, specifically with
EHRs and PHRs.

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

This is Larry Bartlett, again. I guess a thought \-- and I just thought
John did such a nice job. From John\'s presentation, I think in some
ways he talked about current scenario, he talked about a future vision.
And it may be helpful, again, to the extent that this is just a tool
that\'s almost sort of kind of a scratch sheet for the different
Workgroups, you know, they\'re all working with a similar type of thing,
it may be that from the presentation material, one of the things that
can be done is in fact just \-- you know, kind of fill out those two
columns with the notion then being \-- and again, it seems to me that
it\'s a little bit tied into your prioritization setting \-- that then
that would leave that middle column to complete in terms of, you know,
kind of with these sets of priorities, what\'s our expectation in terms
of what the mid-state or you know, the 2010 scenario should look like.

And, you know, just take it that next step. I think at your October
meeting it would be great to hear the presentation again, in many ways.
But I think \-- I actually think even to chart \-- even the presentation
materials, you could take both out and sort of really populate this
chart quite nicely.

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

Yeah I think we have a huge amount to start with, to get the current and
the future, I completely agree. I guess the trick is we need to provide
a little bit of structure in our thinking around how we want to
articulate that middle state. And it certainly gives us \-- because
since we\'ve already fleshed out some of the priority areas, those are
really good starting points, but we\'ll probably want to think a little
bit more about how we\'d like to get more specific inputs on what
aspects of bidirectional communication or decision support do we want to
try to articulate.

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

I don\'t think this is an issue, just as much as something to think
about. We should recognize that the specific charge of this working
group is very different than what we\'re now talking about. In a couple
of different ways. And one was that the real drive that the Secretary
put behind the biosurveillance use case, the initial one or the specific
charge in the breakthrough, was around emergency activities. And there
are a lot of different characters for them, but he was thinking
particularly in the larger scale category. You know, very good scenario
that John ran through, is very much a routine public health activity.
And it doesn\'t mean it\'s bad, it doesn\'t mean it\'s less important,
but I just \-- if you look at the priorities we came up with, they were
more flavored toward the emergency side, perhaps.

And so when you look at them in this other lens of looking out in the
future, I\'m just adding the fact that we\'re actually talking about two
slightly different areas, and it\'s important to also factor what that
means.

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

This is Larry Bartlett, again. Again, I guess I\'m just a process guy on
this, but I wonder if there are certain \-- that picture that John went
through, John Lumpkin went through, has a certain set of attributes or
principles or concepts behind it. Would it make \-- I mean, you could do
nothing you wanted, would it make sense to try to change at least on
this chart, or whatever, sort of both a routine public health type of
thing that John went through, and actually sort of try to model that
same type of future for a more catastrophic public health event?

You know, like two parallel but consistent pictures of what you want the
system to do. Or it might not be that, it might be different at a detail
level, but again the constructs may be somewhat similar.

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

One thing that may be interesting to do is, you know, bridging off of
that, is to try to identify in this vision what are the unique aspects
that would be routine work versus emergency work. And then what are the
areas of overlap.

Because, you know, we\'ve early on, you know, after the events of
October 4th and the period after that with anthrax, we spent a fair bit
of time talking about (indiscernible) use, and we never really defined
it. And conceptually, I think if we were to plot out for what it is that
we\'re trying to do for emergency, what it is we\'re trying to do for
routine, you know \-- not that a food-borne outbreak is really routine,
but it\'s more routine. And look at those overlap areas, and obviously
those things in overlap would be of a higher priority. In either vision.

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

Is there any feedback from the group on our ways to move forward? Okay,
well, why don\'t we go ahead, then, and the staff here will try to take
what John has presented today, along with our discussion, and try to do
some of the background work. And I think it\'s safe to say that over the
next week or so we\'ll be back in touch with the Workgroup with a
filled-in matrix, at least with the current and end state, try to think
a little bit more about maybe some differentiation around routine and
emergency situations, with probably John Lumpkin\'s input on that, and
then we\'ll also probably try to incorporate the priority areas into the
matrix, so that when we start describing the mid-state we can get down
to some attributes or \-- both routine and emergency uses or
functionalities that would fall within those priority areas.

And perhaps, you know, we\'d also want to talk about other attributes in
the public health system, but we\'ll certainly take a stab at pulling
this together and sharing it with you all for your further consideration
and input prior to our meeting in October.

So I think we\'re scheduled to meet again on October 17. Initially
we\'re thinking that these vision (indiscernible) would be much more
effective in person, because it\'s hard to have these conceptual
sessions where we\'re thinking about all these different complex ideas,
and imagining what some future perfect state might be, when we\'re all
on the phone. And we have a handful of people here, and I think it\'s
been quite easy for us to sort of communicate with each other, in
person.

So to the extent that any of you are open to traveling on the 17th, I
think that might be a nice option to consider. We also might need to
consider another date, if we do all feel that it\'s important to meet in
person. Because I know at least John Lumpkin has some limitations to
traveling that day.

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

This is Brian, I\'m going to be enjoying my third day as ACEP President
at our scientific assembly in New Orleans that week. So it would be
problematic to join you by phone, but I can guarantee you I won\'t make
in person.

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

No, I understand that.

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

Brian, that\'s not a busy job, is it?

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

It\'s busier every day.

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

We could think about the week before too, which will give us a little
bit more time to pull something together for the October 31 meeting. How
do folks feel about talking over the phone, like we have been, versus
meeting in person?

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

Dave Parramore of the DOD. I was looking at my calendar, I should be
able to attend in person.

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

Okay. Is anyone from North Carolina or New York still on? Because they
would obviously have to travel.

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

This is Rick from New York. I know I\'m involved in the syndromic
surveillance conference. This is the 17th or 18th? I\'m sorry, scratch
that. Conference starts the next day.

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

Kelly, this is Laura. The 17th is the second day of the Nationwide
Health Information Network forum. That would be ending midday. But it
still may be a tough day to \--

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

Everyone will be here for that, right?

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

So maybe what we\'ll consider is getting some feedback on dates. But I
was really just wondering how do folks feel about meeting in person? Is
that important or do you think we can just continue this conversation on
the phone?

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

I personally think these meetings go better when they\'re
person-to-person, they kind of feed off of each other\'s creative
energies, but \-- this is the best alternative.

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

Okay, then why don\'t we try for an in-person meeting the week before,
and we\'ll work on some dates, because we have a pretty packed agenda.
But we\'ll send some dates out to you all and we\'ll see if that might
work. Again we\'ll follow up with our matrix and some further thought on
how we might be describing this mid-state.

I think that\'s more or less the agenda today. I think once we have this
priority setting process and our recommendations are more or less in
place for October 31, we can then start to really think about our
Workgroup activities over the next 6 to 12 months, and determine, you
know, how we\'re going to be taking on these priority areas, in more
depth, and decide, you know, what \-- you know, further environmental
scanner analysis we might need to do before we\'re at the point where we
want to make some more specific recommendations within each of those
priority areas. So we\'ll have some time to drill down on that and get
more organized and figure out what we want to take on first, second and
third.

So you can look forward to probably a more detailed workplan on that
over the next maybe six weeks or so.

So with that, I think if anyone has any final comments, on the process
or next steps or feedback from today, please chime in. Otherwise, we\'ll
go on to public comments.

Matt, can you open up the line for public comments?

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

Sure. If there are members of the public who have been following along
with us on the Webcast you\'ll now see that there\'s a phone number and
some instructions for calling in to make a comment. If we have members
of the public who are actually already with us on the phone, you need
only press star 1 on your touchtone and that will put you in the queue
to make a comment.

Since we\'ve already had the number up for about a minute, we\'ll maybe
give it another 45 seconds for people to work their way through the
operator. And I can jump in and let you know if anybody gets on,
otherwise I\'ll let you know nobody has called in.

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

Does anyone here in person have any comments who is attending? Okay, no.

Well, since we have a little bit of time to wait, I just wanted to thank
John Lumpkin for taking the time out over the last week to put together
such a great presentation, and being very thoughtful about this whole
approach. We know he\'s got a very busy schedule, so it was great of you
to make yourself available to this Workgroup, and we appreciate your
thought leadership.

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

It doesn\'t look like we\'re getting any callers, Kelly.

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

Okay. Great, I think we stand adjourned.

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

Thanks, everybody.

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

Thank you.

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

Thanks.

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

Thank you, bye.