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**Tenth Meeting of the**

**AMERICAN HEALTH INFORMATION COMMUNITY**

December 12, 2006

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### 

### 

### List of Participants:

### 

[Members:]{.underline}

> ** **
>
>          Secretary Michael Leavitt, Chair
>
>          David Brailer, Ph.D., Vice-Chair
>
>          Deputy Secretary Alex Azar
>
>          Robert Kolodner, M.D.
>
>          Nancy Davenport-Ennis
>
>          Colin Evans *(representing Craig Barrett, Ph.D.)*
>
>          Julie Gerberding, M.D. *(also represented by Ed Sondik,
> M.D.)*
>
>          Ed Goodman *(representing Lillee Smith Gelinas, R.N.)*
>
>          Gail Graham
>
>          Daniel Green *(representing Linda Springer)*
>
>          Douglas Henley, M.D.
>
>          Kevin Hutchinson
>
>          Stephen Jones *(representing William Winkenwerder, Jr.,
> M.D.)*
>
>          Howard Isenstein *(representing Charles Kahn, III)*
>
>          John Menzer                                 
>
>          Leslie Norwalk
>
>          E. Mitch Roob
>
>          Scott Serota
>
>          Steven Simon *(representing Nada Eissa)*

[Presenters:]{.underline}

>          Simon Cohn
>
>          Shannah Koss
>
>          Linda Kloss
>
>          John Loonsk
>
>          Donald Mon  

### 

### TABLE OF CONTENTS

-   Call to Order

-   Introductory Comments

-   Personalized Healthcare Workgroup *(Charges and Members)*

-   State Health Information Exchange Steering Committee Recommendations

-   National Health Information Network (NHIN) Update

-   Update on Standards

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

Dr. Brailer, you can begin.

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

Thank you, and let me welcome everyone to the 10th meeting of the
American Health Information Community. This is our first meeting held
via teleconference, this is an evaluative meeting in that we will be
looking for comments on how this process and medium works as a
discussion vehicle. We will have a number of announcements and some
substantive discussions over the course of the next three hours. And
with that, let me just start with a few procedural comments. First, I\'d
like to remind the members of the community that your phone lines are
open.

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

The secretary is joining the call.

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

Thanks, Denise. Just to remind everyone the community members\' phone
lines are open, so if you could mute your phones when you\'re not
speaking that would be helpful, and also of course unmute your phone
when you do want to speak. Please clearly state your name at the
beginning of any remarks, so that we can make sure to keep the official
record of who is speaking. And those of you that are logged into the
web, don\'t touch any of the controls. Those are there for the staff to
support them, but you can all see them.

Also, if your slides don\'t update according to the discussion, it could
be a bandwidth issue, but it should update within a few seconds.

We will give the public an opportunity to connect in in live discussion
mode at the end for public input, and at that point we will be looking
for comments as usual on the substance of the American Health
Information Community, but also any comments on this format as a
mechanism for holding these meetings.

With that I am told the secretary has joined us, so Secretary Leavitt,
the floor is yours, sir.

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

Thank you, Dr. Brailer. And hello, everyone, I\'m calling you from
Beijing. It is now roughly 9:30 p.m. here, I\'ve just left the home of
the minister of science and technology, where we enjoyed dinner -- in
quite a unique setting. I think it may be among the first times, at
least by his estimation, where a high Chinese government official has
had a United States government official into their home for dinner. It
was very personal, and a delightful experience, we have known this man
for about 10 years, and so it\'s on that basis we got together.

I might add that part of our conversation today at the ministry was on
the subject of standards for health information technology, an interest
on the part of the Chinese in our conversations. Tasked before us today,
of course, is to take another step forward. Given the fact that I am not
there to conduct directly, I\'ve asked Dr. Brailer to do it. I will be
participating in the call today, we have important business to do, and
so Dr. Brailer, I\'ll just simply turn the agenda to you and I\'ll
participate as warranted.

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

Thank you, Mr. Secretary. With that, let me turn to the roll call, and
ask the operator or the senior staff member to get the participants
identified.

**[\>\>JUDY SPARROW (Roll call):]{.underline}**

All right, David Brailer, is on the line. Secretary Leavitt. Ed Goodman?

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

Yes, here from VHA, Inc.

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

Doug Henley.

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

Present.

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

Howard Eisenstein.

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

Present.

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

Scott Serota.

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

Present.

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

Nancy Davenport-Ennis.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Present.

\>\>:

Kevin Hutchinson.

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

Present.

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

Colin Evans for Craig Barrett.

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

Good morning.

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

Mitch Roob.

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

Here.

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

Leslie Norwalk.

Ed Sondik.

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

I\'m here.

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

Gail Graham.

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

Present.

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

Steve Johnson for Dr. Winkenwerder. 

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

Present.

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

Nada Eissa.

Linda Springer.

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

Dan Green here for Linda Springer.

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

Thank you, Dan. Robert Cresanti.

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

And John Menzer.

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

Present.

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

And Alex Azar, deputy secretary here at HHS, I\'ll represent the
Secretary if he\'s not able to be here for all of the call.

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

And Rob Kolodner here in case David has any difficulties here.

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

Okay. And with that, I think, Mr. Secretary, you were going to welcome
John Menzer to the AHIC

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

John, welcome to the AHIC.

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

Thank you very much.

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

How is that for a cue?

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

As they would say in China, ne ho ma.

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

I will look forward to a more formal greeting. Given the nature of our
venue today we\'re deeply appreciative of your willingness to do this
service, and you bring a perspective we very much need, and we\'ll look
forward to your participation and your contributions.

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

I\'m honored to serve, thank you very much for having me.

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

And John, this is David Brailer let me add my welcome and
congratulations as well, we look forward to working with you.

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

Thank you, David, I look forward to working with you, too.

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

Okay. With that, let me turn your attention to the 840 component of the
agenda. We have a few more procedural issues, then we\'re going to turn
immediately to personalized health care.

First, I\'d like to comment that we had a meeting on October 31st, and
those minutes were circulated in the traditional mechanism that they
come to the community members. And I will ask for approval of those
minutes. Is there a first?

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

So moved.

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

And a second?

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

Second.

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

Any opposition? The minutes of October 31st stand approved. So again, we
are on the 10th meeting of the American Health Information Community, it
is a virtual call. I know that we all live in a continuous partial
attention modality, but I do hope that this meeting can command your
attention because we have some very important issues. In fact, three
issues really of materiality at this discussion. The first will be a
follow-up on the state health information exchange presentation
performed by one of the ONC contractors at AHEMA, they gave you a
glimpse and an early read about the directionality of what they were
observing in their state evaluations. Now they\'re coming back with some
very specific recommendations both in Powerpoint and in letter form that
they\'re going to discuss.

Secondly, we\'ll have an update on the NHIN. I think you\'re aware that
there was an announcement that was material to this released early this
week. And this discussion will not only give context to that, but help
understand exactly where we are with that project, and what the
community should be expecting.

And then finally, given the very substantive discussion we had on
October 31st regarding standards, not only in content but in process,
John Loonsk will come back with some follow-up on those discussions,
again in the spirit of giving us directionality for the future. And then
we\'ll have public input.

With that, let me then turn attention to the slides where we\'ll discuss
personalized health care. If I could have the first slide up, please. At
the last meeting you recall we had a panel discussion that helped us
understand the potential for and the issues that would be raised by
having activities around personalized health care, and the electronic
health record. At that time, the community directed staff to support the
formations of a workgroup.

And what you have before you now is the membership list of that
workgroup, followed by advisors and some charges. We really have a
stellar group of people involved with this workgroup, chaired by John
Glaser, who you heard from at the last meeting, and Doug Henley, who of
course is on the community. With members that include leaders from a
variety of entities, several federal agencies, and as you can imagine
there are numerous that touch this topic, major universities and
research organizations, health plans, pharmaceutical companies, and
providers.

And I won\'t review all the names, but I think you would agree with me
that this is really a very strong group of people, and again supported
and advised by Greg Downing. Are there any questions or comments on the
membership list?

Greg, did you want to make comments here?

**[GREG DOWNING:]{.underline}**

Just a few comments, David, that the group has been working with the
chairs, and we have I think been focused primarily on the patient health
care provider interactions as the major working piece. And we\'ve had a
lot of interactions with each of the members, and I think helps to focus
the overall activities that the secretary\'s personalized health care
issue has been bringing to the fore. And I can comment on the charge as
we go forward here.

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

Great. Any comments? Let\'s move forward. This workgroup is supported by
a number of named advisors, and we\'ve also started a mechanism to
identify alternates on some of the critical agencies, given the
continuity of activities that are important.

Let me then turn to the charges. And what we have before you are the
proposed broad charge and specific charge. And just by way of reminder,
consider the specific charge to be the quite narrow task that we would
ask this workgroup to accomplish within one year, preferably within a
nine month period. The broader charge being something that is quite
sweeping that should be the direct extension of that work on the
specific charge. With that let me turn it to Greg to discuss these
charges.

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

Thank you, David, Mr. Secretary, Mr. Deputy Secretary and Dr. Kolodner.
 The group has been working predominantly with the Co-chairs to fashion
specific charges that can be attainable on a two year time line, and the
broad charge is really facilitating information exchange that can
support a broad array of applications in the future, for example on
clinical decision support activities as well as efficacy decisions and
safety aspects. With regard to the specific charge, we\'ve really been
focusing on the establishment of standards for reporting and
incorporation of common medical genomic test data into electronic health
records.

This is a badly needed area that we\'ve been discussing with many
communities now, that there are a number of standard activities already
ongoing, a number of timely publications that are coming out in the next
few months that I think will shed some light on future medical tests as
well as the genomic ones.

So we\'re focused predominantly on identifying those areas that are ripe
for work, and I think we\'ve globally been looking at a number of other
standards organizations internationally that have been working in this
area.

On the broad charges, we have I think some work to do on our first
meeting in January that will help focus on what are the key steps that
are necessary for the electronic health record to enable information
exchange to support these functions.

I won\'t go through the specific aspects of it, but the idea is
basically to be able to allow clinical medical data in the genomic area
to facilitate a broad range of applications for deciding on particular
therapies and the safety aspects of individuals\' health care. And
that\'s really one of the underpinning pieces of the personalized health
care initiatives.

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

Okay, thanks, Greg. With that, let me just turn these charges to the
community for any discussion or comments, as this is a very critical
input into the work of the workgroup, and relate directly to what the
community receives back. Any comments or thoughts here? And again,
please identify yourself before you speak.

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

David, this is Doug Henley. John Glaser and I are were certainly
personally privileged to serve as Co-chairs of this workgroup, and we
look forward to working with Greg and Christian Brenner and others and
the rest of the members of the workgroup to move this forward. And Greg
has very adequately put forth the intent of the specific charge as well
as the broad charge. Again, I think it\'s \-- from the perspective that
John and I bring to this effort, I think it is important to focus
initially on what \-- relative to the AHIC, what are the relative
standards that we need to pay attention to, that will allow these
laboratory tests and their results to be incorporated and transmitted
seamlessly into electronic health records. And then down the road, as
the broad charge alludes to, at what point can we embed in those same
electronic health records, and other electronic tools, clinical
decision-making support tools that will assist a clinician and patients
in making important decisions, health care decisions, about this
information.

So it\'s an exciting group to be involved with, and we look forward to
the opportunity.

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

Thanks, Doug, I appreciate your comments and certainly your willingness
to take on ever more responsibilities with respect to the community
efforts. Any other comments?

Okay, these \-- I think, Greg, you covered the comments in the next
slides, initial workgroup activities, is that correct?

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

Yes.

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

Okay, good. With that, unless there\'s objection, we will treat the
charges to this workgroup in its formalization as agreed to. And I would
comment that this workgroup, as Greg mentioned, is already getting
underway, we\'re expecting this group to have their initial meeting
right after the first of the year. So this is proceeding apace, and I
think you should expect to hear very some interesting things from this
within a relatively short period of time.

Any other comments on personalized health care before we move to state
level health information exchange?

Okay, with that, let me introduce \-- just waiting for the slide \--
introduce Linda Kloss, who will be leading the discussion, and I will
ask Linda to begin her piece, and again, any switch of the speakers, to
identify themselves and to walk through their slides. With that, Linda,
thank you for joining us.

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

Good evening, Secretary Leavitt, and good morning Dr. Brailer, members
of the community, Dr. Kolodner and assistant secretary. Thank you for
this opportunity to brief you on what we\'re calling part two of the
state level health information exchange initiatives research. As you
will recall, on September 11, September 12, at the AHIC meeting we
reported on part one, where we examined roles and emerging best
practices for state level RHIOs, and we presented a version one of a
workbook for use by developing state level health information exchange
initiatives.

We learned a good deal about the roles fundamentally that all of these
organizations were public-private entities, performing roles of
convener, educator, facilitator, some with technology operations, all
with a commitment to advancing quality and transparency in health care.
And we\'ll come back to that issue as we present the second part of our
research. So this slide just recaps the roles that we identified in part
one.

Also, in part one we made several sort of overarching recommendations in
addition to presenting that workbook. We offered five recommendations
for the community. First of all, to look at mechanisms to promote
strategic synergies among states, and between states and federal
efforts. And we\'ll have follow-up on what we learned in terms of how to
advance that goal here this morning.

We also recommended that there be more work on salient financial models,
and a study of those processes or services that state level HIEs were
performing that had lessons for other developing organizations. And
again, we\'ve done more targeted research on that.

Engage in leveraged public and private payers, in the state level health
information exchange initiative. And in follow-up we\'ve focused on
Medicaid, and we\'ll have a report for you on that this morning.

We encourage the advancing the understanding of how state policymakers
and governmental agencies should be involved, and we\'ll have some
recommendations on that. And of course, in September you convened the
state alliance for E-health, which will (Inaudible) this goal.

And finally, we looked at vehicles for support and knowledge sharing
among state-level HIEs. So those were our part one recommendations.

And as you\'ll see on the next slide, these have been carried through in
four targeted studies. Two of them really essentially relating to
organization and communication between the state level efforts and
federal efforts, and how to leverage and enable those, and two of them
more programmatic. And what we\'ll do over this next few moments is
highlight for you the findings and recommendations from three of those
four.

The upper left quadrant, the state level health information exchange and
its relationship to major federal initiatives. The Medicaid program and
health information exchange. And the upper right, the health information
exchange and quality and transparency initiatives.

And it\'s our understanding that the findings relating to financially
sustainable health information exchange services will be presented at a
future AHIC meeting. So today we\'re reporting on state and federal
Medicaid and the quality improvement.

I want to recognize and thank, once again, the steering committee that
has supported this project. This is the same steering committee that
came together for part one, and really has been very committed to not
only helping us refine recommendations, but thinking about kind of
overarching strategies that will move this forward in the spirit of
everything that the community and the secretary is pursuing in health
information technology.

For this project, or set of projects \-- and we really ran these four
studies concurrently \-- they each have their own task leaders and
technical advisors, and the next slide introduces you to those
individuals.

So we\'re going to start with task one, the state level HIE and the
federal initiative, Dr. Don Mon will lead that off, and next we\'ll
present essentially what\'s shown as task three, the Medicaid study, and
then I\'ll return to share with you what we learned about the quality
initiative. So with no further introduction, Dr. Don Mon, please share
with us our findings on coordination of state and major federal
initiatives.

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

Thank you, Linda. If you could advance to the next slide, please, on the
purpose of the task one project.

The purpose of the first task was to explore the potential roles and
interactions between the state level health information exchange
initiatives, or HIEs, and the various major federal health care and HIT
activities. We were asked to provide two deliverables. The first is a
set of recommendations for establishing formal communications among the
states and federal agencies, and the second is a set of documentation on
the barriers and concerns expressed by the state level HIEs that ONC and
other federal agencies could constructively address. Next slide, please.

So the findings surrounded two major areas, the first is in terms of the
validation of our roles. And what were the barriers regarding the
various roles.

The first thing that was uncovered was that the standards harmonized
today are not always the ones most urgently needed by the state level
HIEs. An example of that might be the emergency first responders. While
that is excellent for the public good, the state level HIEs didn\'t find
a current business case in that particular use case.

The second major finding was that the state governments need to be much
more involved in state level HIE initiatives, and Shannah will talk more
about that in the third report.

The third major finding is financial sustainability still remains a top
issue. There\'s a strong relationship between financial sustainability
and lack of alignment in the HIT incentives and the sequence of HIT
activities. And I\'ll get back to that in just a minute.

The other finding was that there\'s no consensus on how thick or thin
the nation-wide health information network should be.

And lastly, in this category, the finding was that state-level HIEs may
be ideal to aggregate secondary data, but there currently is no business
case to support it.

And that ties back to the third bullet point, where if the incentives
were aligned, there could be a business case for the state level HIEs to
work on a common use case. Next slide, please.

So the other set of major complications \-- excuse me, major barriers
surrounding HIT alignment and communication. One of the findings was
there\'s little lessons or sharing of the lessons learned between the
state level HIEs and the federal HIT initiatives. Next, the state
government through state health alliance \-- excuse me, state alliance
for E-health initiatives should leverage, but not disrupt the progress
on a state level.

Next, it\'s unclear whether the legislative branch is fully supportive
of the role of HIT in improving the quality of care.

And lastly, there is no central authority that\'s accountable for the
HIT\'s role in transforming health care, or making key HIT
adoption-related decisions. And that segues into the set of
recommendations.

The state level HIEs clearly saw the need for a transition to a
public-private health information community successor to AHIC. And that
successor to AHIC should develop a transformational agenda by the end of
the first year. Linda will discuss more of that in detail in the FORE
topics, so I\'ll save that discussion for her.

The next set of recommendations surround the use cases. One of the
recommendations is to select, develop and fund the use cases that more
clearly align with the state level HIE business cases. An example of
that would be, as we mentioned earlier, the quality reporting, or the
aggregation of the secondary data.

Another recommendation similar to that is to select, develop and fund
use cases that require the actual exchange of health information. So in
a use case where there is simultaneous public good, but also requires
some transactions to be transmitted across the state, would be useful as
a business case for the SL-HIEs.

And then lastly, the final two here are to align the incentives and
engage the state-level HIEs in the nationwide health information
network. The key point there is that the SL-HIEs could be a place where
the NHIN could be rolled out, if the incentives were properly aligned.

And then the last case, the last recommendation is to implement a formal
communication process between the federal HIT projects and the state
level HIE initiatives. And this might mean a set of formal meetings
between ONC and the state level HIEs, a formal gathering, or at least
some kind of required communication process between the NHIN contractors
and the state-level HIEs to share those kinds of lessons learned that we
talked about earlier.

And that concludes the set of recommendations for this task one. Linda,
I turn it back to you.

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

Actually, Don, it\'s David, could I just interject?

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

Sure, Dr. Brailer.

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

And ask for any discussion. Because these recommendations have been
aired, if you would, somewhat in draft form, or certainly in a more
conceptual manner in the last meeting \-- I\'m sorry, two meetings ago,
and they\'re also accompanied by a letter of recommendation that\'s a
formal letter of transmittal. So I\'d like to stop and ask for the
community members to discuss any of these that are relevant to them, or
have any questions answered before we come to the end.

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

David, this is Mitch Roob. I do have some questions about this.
Primarily, CMS today has enormous, frankly, enormous control in terms of
data, and the development of data architecture around MMIS systems. And
I\'ve mentioned this on a few occasions, and I didn\'t hear that
specifically mentioned here, but as the new \-- as CMS rolled out its
new architecture, this needs to be a part of it.

And honestly, we\'re \-- I\'m in the process of procuring a new
managed \-- rather, a new MMIS system, and I don\'t see those \-- I
don\'t see all those dots being quite connected the way they could be,
to leverage the federal and state investment at this point.

And I just wondered if the committee members had spent any time
reflecting on that, or had had more detailed conversations with the
folks at CMS.

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

Dr. Brailer, I think that is a good lead-in to our task two report on
specific Medicaid.

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

Okay, then let\'s hold that answer over, Mitch, until the next section,
but let me open it again to any questions that are relevant to Don\'s
section.

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

This is Howard Eisenstein from the Federation, my question deals with
sort of the bureaucracy at the state level, you know, over the years of
Medicaid there\'s extremely sophisticated administrative MIS and other
architectures that have been developed to Medicaid. To what extent have
the states been funded by the legislature and have set up these
administrative and MIS architectures to develop health information
exchange and HIT?

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

Again, Secretary Roob and the last speaker, Dr. Brailer, this is Shannah
Kloss, we are going to touch on both MMIS and CMS\'s role in assisting
the states, and particularly the Medicaid programs, in advancing or
engaging in health information exchange at the state level.

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

Okay, Shannah, then let\'s hold that for just a second. Are there any
questions, other questions, other than ones that might be a lead-in to
what sounds like a well-anticipated presentation, Shannah.

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

David, this is Kevin Hutchinson, I have a general question. Is the \--
one, how many state level HIEs, and kind of the definition of a
state-level HIEs, did we find in the study? And is that related to the
term of the RHIOs? Are they one and the same, or are they different?

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

Linda, can you speak to that?

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

I can. The project initially was called state level RHIOs. And the
steering committee just felt there was \-- you know, some confusion,
state level, regional health information, organizations. And chose to
retitle this, at least for purposes of this study, health information
exchange initiatives. State level health information exchange
initiatives.

But understand that the purpose and scope does vary from state to state.
So what we call it perhaps is less important than really getting into
what the role and purpose is.

But we did that to differentiate and to suggest that there may be a
state-level health information exchange initiative, and still within the
state, throughout the state, various regional and local initiatives, and
that would be the way the group envisioned this as developing.

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

And Linda, just to make sure that I put an exclamation point in your
answer, are you proposing criteria by which one can distinguish a state
HIE or RHIO, or whatever it would be called, from one that meets certain
criteria, from one that does not?

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

We described certain roles, but we did not, in our study, describe
criteria.

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

Okay.

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

This is Kevin again. The other question was how many of these did you
find in your study as you were assuming in your recommendation?

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

At the time that we looked in \-- again, this was in the summer \--
there were about 28 states that we looked at. And from that 28, we
selected nine projects to study in more depth. But we know that this is
expanding, and it\'s highly likely there will be some public-private
entity in each state as we continue to move forward.

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

Linda, this was not intended to be a comprehensive study.

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

It was not. It was not.

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

It was in fact, Kevin, a drill-down. But that\'s certainly something
that could follow from that, more of an exhaustive review of the
structures that exist.

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

No, I agree, and I\'m looking forward to the detail of it. I was just
curious, because we know in working with entities like the state level
HIEs or the RHIOs that there are dozens out there. So I was just curious
how many they may have found to exist.

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

It\'s a good question. Okay, any other comments or questions with
respect to Don Mon\'s presentation?

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

Yeah, this is Ed Sondik. On the fourth bullet, which has to do with the
use case for the actual transfer of information, it sounds in a way like
there\'s an option to not do that, to have that use case. And I would
think that would be very important to this. Because if we don\'t do
that, then what are we really going to know about this?

That\'s stunned silence. This is about exchange, isn\'t it? About
transfer. If you don\'t have an idea about how that\'s going to actually
work, understand that, and \--

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

Don, could you comment on why that recommendation exists?

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

Sure, thank you, Dr. Brailer. If you look at the current use cases, they
are scoped in a way that is achievable for the first year. So for
example, if you were to take a look at the registration summary and
medical history, the first year was to just identify what is contained
in a registration summary and what is contained in a medication history.
But that no, scoping did not involve the state level HIEs.

Now, a next step could possibly involve the state \-- could involve
health information exchange, that once that information has been
identified then the next step is to go ahead and exchange it. But the
current \-- but that use case for that current period of time did not
address something that the HIEs felt that they could be actively engaged
in, even at that first stage. And so the challenge is to then to be able
to construct a use case where the HIEs can feel engaged at that point in
time.

A second example is the emergency responder use case. There now
obviously will be some health information exchange again once the
information about what should be transmitted in an emergency first
response, but again, that was a situation where the state level HIEs
just didn\'t feel that it was an immediate use case for them to work on.

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

The overarching recommendation from the steering committee was that the
explicit role of states, some of the \-- that the role be more explicit.
In the design.

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

David, this is John Loonsk, and I think this may be a subject we can
return to later on in the presentation, or in my presentation, in terms
of the standards update where I touch on the next-step processes for the
AHIC priorities getting into use cases for the next year.

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

Let\'s do that, John.

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

I think what Don may be pointing to is the existing use cases were
functionally defined, they are about information exchange, but more
about a particular function. I think one of the things we\'re seeing
with the emergency responder EHR use cases is that it definitely seems
to point to a transfer of care, or summary record need that would
probably be actually very helpful at the state level for state exchange,
as well. But we can talk more about that when we get to that item in
next month\'s AHIC as well.

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

Sure, and recall the underlying motivation in part for this analysis,
and certainly for the state alliance that\'s been recently formed, is to
have a more formal mechanism by which more formalizing entities in the
states can have a dialogue with a national structure like the community.
So that needs at that level have been taken into account, and
implementation coordination can occur. So I think in a way this
recommendation, Ed, speaks to that need to begin having attention to
issues that are seen as relevant at the state level.

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

I\'m glad we had this discussion, because what I was trying to say is it
seems to me this is a necessary step. As opposed to some sort of option,
so I\'m very pleased to see it. Thank you.

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

Good, and just procedurally, there is a draft letter of recommendation
that contains these recommendations that are bulleted here, and we\'ll
be asking AHEMA to take that letter, based on this discussion, and
transmit a final letter of recommendation that the AHIC will take up at
its next meeting to approve or disapprove. And I think this discussion
certainly will get us most of the way towards having that as a decision
point.

Any other comments on this component of the presentation?

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

David this is \--

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

Go ahead.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

David, this is Nancy Davenport-Ennis, and perhaps this is also addressed
in the letter that is being advanced, but in the barriers we had
identified that there\'s no central authority accountable for HIT\'s
role in transforming health care, or making key HIT adoption related
decisions. Perhaps we\'re going to hear more about that in the next
presentation around the state issues. But if not, that is certainly an
area that we would want to have addressed.

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

Yes, and I would comment that the draft letter itself calls for an
updating of the strategic framework to be able to continue to guide
ONC\'s role in doing that central leadership, even though it is not a
central authority, if you would. So I think compositely across this
presentation, Nancy, you\'ll hear more about that.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Thank you.

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

I think there was one other comment.

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

Dave Henley. On the first bullet is there a strategy and timeline for
the transition of AHIC, the community officially disbanding and this
public-private community continuing in its place?

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

Dr. Brailer I might just convey the sense of a steering committee,
because this recommendation emerged from that, that they were really
looking ahead, out ahead, and considering, you know, what mechanism
would, in the longer run, what mechanism of governance, public-private
governance, really, what is a long-range strategy expected to occur over
another decade.

So I was really in the sense of not a specific, certainly, structure
recommendation, but thinking \-- beginning to think forward now.

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

David, this is Mike Leavitt. I certainly have an ambition to have it
complete before the President\'s term is up. So that\'s not too far out
in the future. Which means we would need to begin thinking very
seriously about this soon.

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

Yes.

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

Okay. Any other comments, here? All right, let\'s move on to Shannah to
discuss Medicaid and CMS relating to health information exchange.

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

Thank you, Dr. Brailer. And I want to thank the community for the
opportunity to present and thank both the community and the ONC for
keeping health information exchange at the forefront of the health
policy dialogue applicable to the continued evolution of health care,
improved health care.

I also want to thank my colleagues, in particular Greg Fuller and
Madeline Koenig, who did the majority of the research and writing on
this project. If we could have the next slide, please.

The project was primarily intended to further explore the role of state
Medicaid programs and HIE initiatives. There\'s been many \-- a lot of
research, ours included, previously for AHRQ, that underscores the fact
that with some exceptions, including the secretary with the state, most
Medicaid programs are not heavily involved or involved at all in many of
the emerging state level health information exchange activities, or even
the community level exchange activities.

Consequently, we are looking at what the barriers and drivers to
engagement are, and what might be some of the opportunities for and
value of Medicaid participation. We interviewed the HIE initiatives that
are represented by AHEMA\'s steering committee as well as five
additional HIE initiatives. And I will say, similar to most of what\'s
happening across the country, they represent the same state or array of
readiness. So you have some that still are in a planning stage, most
that are still in a piloting stage, and really only a few that have been
exchanging information for more than a year. Which will become important
in some of the findings

Also in response to two of the earlier comments we did interview some
Medicaid states as well as some parts of CMS, both in the Medicaid
offices of CMS as well as the regional office, to try to get a better
perspective on what is and isn\'t happening with respect to Medicaid and
some of the underlying reasons. If we could turn to the next slide,
please.

So some of the key findings, and we\'ll come to this on the next slide
as well, for the most part represent what the state level HIE initiative
perceive is the reasons for Medicaid\'s lack of involvement, and we\'ll
see that there are some different perspectives that arguably need to
reach a common ground. But first and foremost, most of the initiatives
do see value in the Medicaid agency\'s participation, and would expect
Medicaid to have the same kind of interest, if you will. And I include
myself in this group, we\'ve all \-- all of us who have bought onto the
idea that this is critical, expect other people to just understand why
it would be critical and jump onboard. And clearly that has not yet been
the case with Medicaid.

As I mentioned, they have minimally involved, yet most initiatives, as
well as the Medicaid states who are involved, or even would like to get
involved but feel that they can\'t for a variety of reasons, can play
many roles. And many of the roles that AHEMA has already identified for
the state as well as the roles of any large insurer, in terms of the
data they have, the population they have responsibility for in terms of
care, and making a change in both the quality and cost effectiveness of
that care.

The HIE initiative really needs to start focusing on what is the value
proposition to Medicaid, and how do they help or how do their activities
begin to help address some of the Medicaid business problem. And this is
probably one of the most important aspects of this, Medicaid has its own
program priorities, and first and foremost is paying the claims for
vulnerable populations and ensuring active care for that vulnerable
population. And there\'s not an immediate HIE role in that or
necessarily one, given what each Medicaid program has to concentrate on
from a day-to-day basis.

Having said that, there are definitely vehicles that exist and are
merging to facilitate Medicaid involvement, and we\'ll talk about that
in a minute, and there is this somewhat long-term initiative called the
Medicaid information technology architecture that had been fostered
under the support of CMS as well, that has long-term potential to
facilitate HIE for Medicaid. This would make one clarification that for
the most part we really are talking about the clinical exchange of
information as opposed to the administrative exchange. Because clearly,
Medicaid has been front and center, pursuant to HIPAA, in supporting the
automation of claims and administrative data.

Turning to the next slide on perspectives. This is where I want to
underscore we\'re missing each other a bit between the states and the
state level HIEs, in that again, the initiatives don\'t really
understand why Medicaid doesn\'t see the value proposition in HIE. And I
think, you know, where you set standards where you set, they also see
the administrative and political environment as limiting the receptivity
as opposed to sort of the fundamental core programmatic requirements
that Medicaid faces.

They also experience that Medicaid, even when it is involved or thinking
about getting involved, tends to interpret data sharing laws very
stringently, and therefore often is constrained in terms of what
information might be shared.

And lastly, the systems in many states are still quite cumbersome legacy
systems, and don\'t lend themselves to readily share the information.

Now, on the Medicaid side \-- and each of the Medicaid reasons for lack
of involvement or perspectives on why perhaps why Medicaid is not
involved, sort of reinforce the other. And I\'m going to start with the
second bullet first, which \-- and I\'ve already emphasized this, it\'s
not a priority investment. It\'s not where they are on a daily basis
taken to task in terms of how they\'re delivering the program. Which
maybe isn\'t news, but it is part of why we\'re to a degree missing each
other.

Second, and this goes to the point of the state of most state level
HIEs, they don\'t feel that there\'s a proven value proposition in the
exchanges that are currently in effect. They feel that most of them are
in a somewhat immature state, and for them to turn their time and
resource to engaging with these initiatives, there really needs to be a
clearer value proposition, and some level of assurance at least that
they\'re not going to get criticized for engaging, and ideally that
there would be some understanding that this is a first step, and an
evolving activity that, albeit won\'t show immediate results, still has
critical long-term implications.

Third, and this was an observation not only within the Medicaid states
that we talked to, but also in the CMS Medicaid representatives, that
there\'s limited state and national leadership that supports Medicaid\'s
engagement here. And although there\'s been a lot of very positive
encouragement, and I would say CMS leads the way in terms of its own
activities for fostering HIE \-- HIT adoption and HIE engagement, it
hasn\'t really, you know, extended to encouraging Medicaid, and
promoting Medicaid\'s engagement in the same way, or with the same
emphasis.

And finally \-- and this is no surprise to any of us, certainly, over
the past several years, is that the states are under enormous pressures,
resource pressures and staffing pressures, and that certainly adds to
the inhibition.

So turning to the last slide with respect to recommendations, we make
recommendations to three different \-- the three different entities that
have important roles to play, here. First is with respect to the state
level HIE initiatives. They sort of have to get out of their own shoes a
little bit and think about what is it that\'s going to make the most
difference to a Medicaid program in terms of both cost savings and
efficiency, and what might be some of those initial exchanges that would
bring the most benefit to those programs.

They need to seek out political leadership in the state and Medicaid,
and really offer them a seat at the table, and encourage them to get
engaged as they\'re comfortable in getting engaged. And lastly, work
across the state efforts similar to one of the recommendations I think
that Linda mentioned from the first report and Don emphasized, to help
identify where Medicaid is involved, what the benefit is, and why there
is benefit to engaging.

On the Medicaid side, we encourage Medicaid programs to work with other
state agencies and the state leadership to help identify what really
across the state would be the shared benefit of health information
exchange.

Leveraged contracts and purchasing, you know, Medicaid is one of the
largest purchasers of managed care and often disease management within
the state, and they can certainly, similar to what the executive order
on transparency encourages at the federal level, use those as leverage
points to engage in what is evolving in the state, from an exchange
standpoint. Certainly they can embrace and can be encouraged to embrace
from the federal side the transparency initiatives where the same type
of information on both quality and cost might be shared with respect to
the Medicaid program.

And lastly, and perhaps having some of the greatest impact, work with
Medicare, who is already at the forefront to use health information
exchange to better manage and support one of the hardest to serve
populations, which is the dual eligible. Which is engaged in initiatives
on projects that clearly do meet their needs. So if it\'s not \-- if
everything isn\'t to their liking, perhaps identifying the one program
that would benefit both their beneficiaries and their program needs,
would be ideal.

So lastly, and I\'ll wrap up quickly, CMS and other federal stakeholders
have an important role to play. We\'ve heard consistently that the
states don\'t feel that they have the \-- really not only the okay, but
the endorsement to engage in HIE in the way they might like to, even
when there is an appetite. So articulating support for Medicaid\'s
involvement. Helping to clarify what data sharing is appropriate at
least with federal law, obviously the state laws are the state
responsibility. Creating a central point of contact for Medicaid health
information exchange issues. And to serve in this knowledge \-- you
know, in sort of sharing the knowledge base as well as a clearinghouse
of best practices and successful projects.

And also, working with Medicaid and with the office of national
coordinator as well as the community to help develop the business case.

I would just add the community can help CMS help Medicaid by perhaps
including more Medicaid representation across the workgroups, and
heightening the importance of having that Medicaid perspective, as we
all want to foster these regional and state level exchanges. And with
that, I will conclude.

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

Okay, thanks, Shannah. With that, let me open it to comments and
questions, with a particular note to Mitch and Howard to make sure your
questions were addressed or to give you a chance to reformulate them, if
not. The floor is open.

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

Well, this is Howard again. I did get a nice explanation on the Medicaid
side, but again I\'m wondering at the state level whether it\'s Medicaid
or the public health or some other department on the state level, you
know, who is in charge? I know they probably must vary state by state,
but we\'re trying to create this structure on a local or state level.
Don\'t you have to have the same kind of very well developed
infrastructure at the office of national coordinator, and are states
sort of picking up on this? That\'s kind of my question.

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

I guess from the Medicaid perspective, or some of the other research our
firm has done around RHIOs and state level HIEs, there really is no one
flavor of state level leadership and governance that would work for
every state. And how most of these initiatives have emerged is with some
key stakeholders that are willing to step up to the leadership position
and really encourage the dialogue and invest the resource and time,
prior to there being broad uptake in these activities.

My answer, then I\'ll turn it over to Linda to see if she wants to add
to it, is that, you know, in some states it is the public health agency.
What we\'ve heard repeatedly is if there is a vocal state champion,
regardless of where they sit across those state agencies, that that can
make the difference not only for the state, but also for purposes of
Medicaid\'s involvement. But that there needs to be someone there.

And it certainly does help if the state or the governor establishes or
sets a mission and a goal for the state to do this, but it can happen in
a variety of ways.

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

I would underscore that, but I think there are some specific
recommendations that could enable that to occur. And as Shannah
reported, we think some demonstration of some specific explicit
direction from CMS could help open those doors, and then some further
work by the HIEs themselves in building the business case. And as
Shannah said, stepping out of their own shoes. So we have some specific
recommendations on short term actions.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

This is Nancy Davenport-Ennis, and I have a follow-on question to that,
as we think about the state political leadership. And that is indeed are
we in a process to include the state secretaries of health, and to
determine what their level of support is within their overall program to
integrate HIT into that process?

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

We had specific recommendations with regard to department of health and
other state agencies in collaboration with state level HIEs in our
workbook, so I think that has been a common theme that we need. And
particularly departments of health to be actively engaged in state-level
HIE policy setting and convening.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Thank you.

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

Linda, may I add another point to that?

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

Sure, Don.

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

Thank you. There was another context to that under the task one federal
activities initiative \-- or project. And that is that, as Shannah
mentioned, there are multiple levers that the state government can use.
One of them being Medicaid, others being aggregate reporting, public
health, and so on.

And what came up in the task one report is that all of those various
levers should be used. Because if they are used, then what that provides
for the state level HIEs is that no specific entity bears the sole
burden of trying to fund the SL-HIEs\' efforts, but they contribute to a
pool. And therefore, each initiative, like public health reporting for
the state, or Medicaid transactions, will have their needs addressed,
but their contributions to a common fund will help the sustainability of
the state level HIEs.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Thank you.

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

Okay, other questions or comments? Mitch, did we speak to your issue?

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

Yes, but let\'s remember where \-- when you have them about their
wallets, their hearts and minds will follow. And what successes we have
had here have been based on the use of dollars to help subsidize data
movement. So I think we should not be (inaudible) about it.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

This is Nancy Davenport-Ennis, and I have a follow-on comment to
Mitch\'s observation. I think it also begs for very deliberate
public-private partnership between the state Medicaid programs and other
businesses, and their states, that can help fund some of the activity
that is required here. And to also provide guidance that may be in the
technical area of how they can get their program engaged in this issue.

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

This is Shannah Koss again. I would just add that we do in the full
report identify some important vehicles, including the Medicaid
transformation grants, as opportunities to identify those funds that
will encourage the hearts to follow.

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

Okay.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Thank you.

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

Thank you, Nancy. Any other thoughts or comments at this point before we
turn to section three?

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

David this is Kevin Hutchinson. The only comment I would make is I would
strongly support Medicaid\'s involvement in the state level HIE
initiatives. Just to give a real live example, in the state of Florida
where Medicaid was involved in the deployment and rollout of, for
example, electronic prescribing systems, we saw a rapid acceleration of
physicians\' use of E-prescribing in those markets when Medicaid became
involved in sharing medication history information from their own
databases to these devices in the Florida market.

The one caution I would give to the group, and I\'m very happy to see
that they\'re tightly aligning Medicaid\'s involvement with an overall
state level HIE, is that there was a misunderstanding or misperception
that this was a Medicaid only capability in the sense that they could
only get medication history for Medicaid patients, and they could only
write prescriptions for Medicaid patients.

That limited the overall utilization, but we were very \-- saw very
positive results of physicians getting engaged with the adoption of IT
when Medicaid became engaged in sharing information with physicians.

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

Very helpful thoughts, Kevin, thank you. Anyone else?

Okay, Linda, I think we\'re back to you, then.

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

All right, the final topic we\'ll take up this morning is really the
steering committee\'s response to the very challenging question that the
community put to our group at the September meeting, which was to go
back and explore the relationship between the quality and transparency
initiatives, and state level health information exchange.

We did not do this task as a sort of formal study, as we did the other
three. We collected some data from the nine participating state-level
HIEs, and really organized a dialogue or a discussion of those
organizations. So this really represents a consensus based on the
discussions of the participating steering committee. But I think many of
the findings support and are consistent with what we\'re seeing in other
areas.

The first slide is just a set of numbers, and don\'t take them so
literally, take them as a group, and take them to show that quality
improvement is considered mission critical for state level HIEs. In
fact, one of the numbers that should be here is that 100 percent of the
organizations on our steering committee have quality improvement within
their mission and reason for being.

So quality improvement is mission critical. And of the nine
organizations on the steering committee, five of the nine, or 55
percent, are currently or are planning to be a supplier of data for
performance reporting. A third of them disease \-- supplier of data for
disease or chronic care management. A third of them are currently doing
or planning to actually report performance data to purchasers or payers.
A small, only two of nine are engaged in the public reporting. But as
you see from these numbers, this is really not \-- not a function
that\'s foreign to the state-level HIEs, but is being carried out
differently depending on their state of involvement. And whether the
state-level HIE is an organization that\'s carrying out a role of
actually being a technology, that has \-- an organization that\'s
maintaining databases.

So quality is mission critical. In the next slide we put in, just to
have everybody wake up this morning, this is courtesy of Dr. George Isem
from Health Partners in Minnesota. We used this at a recent AHRQ meeting
on the data collection issues in quality improvement, and it\'s showing
that \-- and certainly what the state-level HIEs are telling us, the cat
here is definitely out of the bag. There is so much data reporting work
already going on in every community and every state, that what was
conveyed to us by the steering committee was a sense of urgency to open
a dialogue and look at what the models are for ensuring that we don\'t
go even further with a data siloing. And we\'ve since got a similar
diagram shared with us by Maine that shows the level of data reporting
in Maine. So again, that underscores the recommendation.

The recommendations are, then, if you\'ll advance to the next slide, the
HHS and AHIC should clearly articulate the need for explicit
coordination between state level HIE and state quality and transparency
initiatives.

While each \-- and do it now. While each state must determine its
preferred model, state level HIEs may be positioned to facilitate cost
effective access to statewide data for quality initiatives. At a
minimum, the group were of the consensus that they need to assist with
data standardization and work to reduce duplicate data acquisition
efforts.

Willing to team with and work with other organizations, and feeling some
urgency to do that.

Also, the group developed some consensus around, you know, a very rough
at this point model that shows where HIEs might logically participate in
this. And we did kind of a five-step process from data capture, if
you\'ll advance the slide, to quality reporting, and for the most part
saw that a data capture role and health information exchange role, of
course, were basic roles for HIE organizations, but some are also taking
on the role of being data aggregator.

It was the consensus of the nine organizations on our steering committee
that generally, they wouldn\'t see the state level HIE in the
information, analytical, or interpretation, or public reporting phase,
but would certainly be working closely with whatever organizations were
the aggregators. And there was some discussion about the analytic task,
and the requirements of that, and perhaps the diversity of that, versus
quality reporting. So we thought that a model such as this might be a
good starting point for looking at what that relationship is, and
formalizing it.

Fourth, formal and funded roles, provide data services to quality
measures, may well be a critical role in sustaining HIEs. Of course, I
think the reasons that Shannah mentioned, it relates to the role with
Medicaid. And some state-level HIEs are now performing this role, and
you\'ll actually hear more about that when you look at financial
sustainability at a future meeting. So this may be absolutely critical,
and in fact if other organizations are moving \-- you know, there are
other entities starting to do some of this aggregation role, it really
may be problematic for HIE, saying it another way.

Recommendation five is the HIE representatives need to be involved both
nationally and certainly through local initiatives in quality planning,
quality reporting, planning.

And a call for broad stakeholder dialogue is urgently needed, to
understand quality and transparency in HIE integration, the business
models, and the governance structures required to support the
relationship between state-level HIE organizations and quality
initiatives. So further work on this is needed to develop models and
best practices.

And finally, we\'ve returned to this issue of, again, I\'m representing
the steering committee\'s thinking that going forward there will
continue to need to be multi-stakeholder coordination. And I express the
concern of the steering committee that we not, you know, fail to plan
what the next coordination, next generation coordinating mechanism might
be, and not risk any slow-down in the initiative.

They envisioned standing working committees, if you will, reporting to a
multi-stakeholder community, and one of those standing committees would
be state level health information exchange, as well as legal,
regulatory, population health, care delivery, the actual impact of
technology on improving care, and standards and certification. So again,
there are some narrative around this recommendation in our report, but
this was I think the work product of the steering committee with all of
their experience and insight into this.

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

Okay, thank you, Linda. Let me open up the floor for discussion on your
last component, and then we will turn to a broader discussion of this in
the few minutes we have remaining. The floor is open.

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

This is Howard from federation, Howard Eisenstein. You mentioned on
recommendation one, explicit coordination. I mean, that\'s all well and
good, but I\'m just wondering how come you didn\'t go a little further
and say, you know, so-and-so should be in charge of \-- how come you
didn\'t go that much further or talk about, you know, any kind of
operational model which is like pay to play, whoever paying can sit at
the table, or kind of construct for how you coordinate?

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

Well, we were, first of all, I think, making the point that we can\'t
see these two initiatives as parallel tracks without explicit connects.
And that there are ways, through contracting mechanisms, to begin to
link our role, let\'s say, for health information exchange in CMS
contracts, and in the work that AHRQ is doing in quality improvement,
and looking for those opportunities to create linkage. Explicitly
looking for those.

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

David, this is Doug Henley.

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

Sure, Doug.

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

I was impressed by \-- you sent it to me once before, but Linda\'s what
I refer to as scattergram of all the work out there going on in the area
of quality measure and reporting. I think that speaks back to the
meeting we had I think two times ago, when we had the panel presentation
about quality reporting and the need \-- not only do we need to have the
necessary standards so that quality measures and reporting can be
imbedded in EHRs, and that\'s a clear role for AHIC ,as we\'ve already
discussed we\'ve got the workgroup addressing that, led by Carolyn
Clancy, but again I think it also addresses the need to have clarity and
consensus around a uniform set of quality measures. That all payers, be
they public, private, state, federal, whatever, are using the same
measures in order to allow the \-- to bring some order out of chaos, but
also to allow the necessary HIT standards to be developed to allow that
reporting, imbedding to occur.

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

I think, Doug, that\'s very much the spirit of this, recognizing that
right now we have two separate sets of railroads moving. One is the
national versus state, and obviously each state is quite different, as
you\'ve heard today.

And secondly, this health IT movement, and the quality movement. And the
AHIC at the national level has begun bridging those by the quality
workgroup, which as you know doesn\'t try to take on the task of
defining the standards, but recognizing that the interplay between
health IT\'s capabilities and promise in those standards is critical, so
that they move together. We don\'t have a parallel way to do that at the
state level.

And I think to Linda\'s question, we have two very immature and highly
variable sets of structures, i.e., quality and health IT at the state
level, that have differing levels of maturity and differing levels of
capability, so we don\'t have one size fits all method. I think the
nuance here is get a process of bringing them together so they\'re more
coordinated, more closely collaborative, and certainly more able to
achieve the goal you laid out, which is being able to implement and move
quickly to not have more confusion but in fact to have less.

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

Yeah, I would agree with that, David, but I would also state that of
course being familiar with, you know, the HQAF, written out of the
combined steering committee, I think that what the federal government
can do, in a very real way, both demonstrating itself and strongly
encouraging if not arm-twisting the private community, is for everybody
to adhere to at least the process that the NQF, national quality forum
has in place, to vet and approve measures in a transparent way. And as
you and others know, there are some measure sets out there that are
developed that are not transparent, they are in black boxes, and they
are proprietary. And in a spirit of moving forward with quality
improvement, that has to be transparent, and the NQF process can allow
that to occur.

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

So Doug, maybe the way to raise this then is in the spirit of \-- as
this goes off and reflects on this final conversation, to come back with
a formal letter of action to the community in January, to ensure that we
think about how to incorporate into the acknowledgment of these state
efforts an evaluation of their participation and follow-on with NQF and
other projects. Is that fair?

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

Sounds good.

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

Okay, good. Other thoughts or comments here?

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

This is Linda, I would just also \-- as we discussed, it\'s not just
adoption of standard measures in the climate, although certainly that\'s
absolutely essential, but it\'s also cost-effective ways of gathering
and handling the data. Which is a different issue, but an issue of great
concern.

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

Other thoughts or comments here?

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

David, this is Kevin Hutchinson. I thought I heard Linda say this, but I
just wanted to give the committee an opportunity again to restate it.
It\'s not the committee\'s purpose or their recommendation to take a
position on how the data is stored. I know there\'s \-- in the industry
there\'s a controversy between a central data repository, if you will,
and community, and then those that are exchanging information from the
sources of the data. And I don\'t believe the committee is recommending
or even taking a position on that, but I just want to get clarity on
that.

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

That\'s correct, but the steering committee is saying that careful
thought needs to be given to the role of \-- you know, the aggregators.
There will be aggregation of secondary data. And how does that relate
to, you know, information exchange. There needs to be thought given to
how the information that\'s been handled for exchange purposes can be
de-identified and used and aggregated for quality purposes. Otherwise we
have absolutely redundant data collection processes. And as we look at
the complexity of the reporting, measurement and reporting activities,
we can just well imagine how financially burdensome that will be.

And also, a great risk to quality of the data. Which again, we touched
on briefly in our committee discussions. But, you know, the reason for
standardizing measures and standardizing processes is to ensure that the
data coming out is useful and of high quality. So we really need a lot
of rigor in these processes, and that suggests fewer \-- you know,
taking steps to reduce the possibility of siloing.

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

Fair enough.

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

Other thoughts or comments here?

Okay, with that, let me thank Linda, Don and Shannah for what is an
outstanding discussion. I think everyone can acknowledge this, this is a
very organizationally complicated area with respect to the varying
degrees of maturity and sophistication of state structures and how they
relate to the federal effort as a time when federal efforts are
continuing to evolve.

This discussion has been very helpful, because we will now ask for a
final recommendation letter to come from the steering committee that
will have action points, again, for the AHIC to recommend to the
Department of Health and Human Services, as well as to other entities,
be they state governments or private sector players.

So that would be on January 23rd, and this discussion, I think, has
really helped bring this to a point of fruition.

With that, let me thank Linda, Don and Shannah and the ONC staff who
worked very hard on this. And unless there\'s another comment, we\'ll
move forward to the NHIN update.

Okay, with that let me turn to John Loonsk and Simon Cohn, who will
discuss the NHIN, where we are, and where we go from here.

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

Thank you, David. And good morning everyone. This presentation, this
part of the AHIC agenda will be broken into two parts. First I\'m going
to give a brief update on where we are with the NHIN and what we expect
the next steps to be, and that is going to be followed by a presentation
by Simon Cohn and Jeff Blair on one of the activities that has gone on
this year around \-- in functional requirements.

So first, a status update.

This year the NHIN activity was marked by the development of four
prototype architectures. We had four consortia that have been working
quite diligently on a number of products throughout this year. They\'ve
identified the standards they need to move forward with health
information exchange.

They have developed and advanced over 1200 functional requirements,
these declarative statements about what systems need to do to advance
this vision of a nation-wide health information network, and that will
be the subject of the second part of this discussion.

They\'ve also been in the process of developing and advancing general
and security architectures. And actually, putting these architectures
into a demonstration in the context of software implementations which
they will be presenting at the January American Health Information
Community, as well as the third NHIN public forum that we will be
holding near the AHIC meeting, also in January.

What that means is they\'re going to present actually to the AHIC and to
this forum the software presentations of the architectures that they\'ve
been working on. And we\'ll go through some scenarios that demonstrate
the kind of functionality and some of the key features and capabilities
that they have put forward in their architectures.

In parallel to that, there will also be discussion of cost revenue
models for network service providers. And this concept of having a
capable technically savvy network company that can help support
information exchange, and what the potential revenues and cost models
are for that type of discussion will be another subject for
presentation, in conjunction with the state level work, the furtherance
of what we\'ve just been hearing about. And in discussion of how it
looks from these four consortias\' perspective around service providers.

So looking forward to January, we\'ll see the culmination of these
efforts both for the presentation of software, very practical and
tangible manifestation of what\'s been going on, as well as discussion
of the business models and how this can be viable.

Then moving into the next steps for the 2007, we are moving from the
step of prototype architectures to what we\'re terming trial
implementations. And there was an announcement last week about the fact
that the intent is, with the next round of the NHIN, to establish a new
procurement that would directly engage state and regional health
information exchange efforts. And bring them together, with the kind of
technical expertise that was developed through these prototypes and
through other technology companies that have been working in this area,
to take another step toward the network-of-networks that the NHIN will
be.

So this is a logical step, not a step to completion of implementation,
but a logical step from the prototype architectures, to trial
implementations, on our way toward the NHIN vision.

We also anticipate that the next round will initiate a collaboration
environment for the NHIN network-of-networks, and the ways in which
these groups can participate in working together to foster interstate
and regional health information exchange, as well as work on some of the
issues that were just presented in the previous discussion.

The vision here is to take a further step toward connecting electronic
health records, but also connecting personal health records and the many
exciting activities that have been discussed in recent weeks, and
advancements in that area, and to foster this network-of-networks that
connects these systems in an appropriate and secure manner.

We anticipate that a piece of this will also include connecting the
federal health systems, as well as targeting state governments in terms
of connections to help establish the specificity of the next steps of
what needs to be done.

So we are excited about the presentations that are going to happen in
January, I think they\'ll be very concrete in terms of the kinds of
functions that can be presented in terms of health information exchange.
And then I think that this next step of moving toward trial
implementations that directly engage state and regional efforts will
really take us further down that road, and bring together the federal,
state, and regional activities in moving this vision forward.

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

Okay, thank you, John, certainly a very helpful presentation. And with
that, are we \-- let me stop and ask for comments or questions, here,
before we then turn to Simon Cohn. Any comments, here?

Okay, Simon, thank you for joining us.

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

Okay, David, thank you very much. And John, thank you for the
introduction. Mr. Secretary, Mr. Deputy Secretary, David, Rob Kolodner,
and members of AHIC, I\'m Simon Cohn, I\'m the associate executive
director of the Permanente Federation of Kaiser Permanente, and chair of
the national committee on vital and health statistics. Let me also
introduce Jeff Blair, who is director of health informatics at Lovelace
Clinic Foundation, and has been vice chair of our NCVHS ad hoc workgroup
on the nation-wide health information network.

While I will be presenting the information included on the slides, I\'ve
asked Jeff to join in for the discussion following.

We are very pleased today to have the opportunity to brief you about a
report we have completed at the request of the office of the national
coordinator on functional requirements needed for the initial definition
of an NHIN. The presentation is at a high level, with more detail in the
appendix. The full report is available on the NCVHS website. Next slide,
please. Next slide, please. Good, okay.

I wanted to start by talking briefly about the NCVHS and our work, then
we\'ll talk about the functional requirements report and our
recommendations, highlighting some of the policy issues and next steps.
Next slide, thank you.

The NCVHS is a statutory public advisory committee to the U.S.
Department of Health and Human Services. We have a 57 year history of
advising on national health information policy including health data,
standards, statistics, privacy, and issues relating to the developing
national health information infrastructure.

There are 18 members, 16 appointed by the Secretary, and two by
Congress. These are leaders and experts in their fields. And obviously,
their fields of expertise range from health information technology, to
health statistics, to clinical, administrative data standards, to
medical informatics, to privacy, to population health.

We have a reputation for open, collaborative processes that bring
together the public and private sectors, and the ability to deliver
timely, thoughtful, practical recommendations. Next slide.

This slide lists some of the areas of our work and expertise. We have an
ongoing congressionally mandated role advising HHS and Congress
regarding HIPAA, including the administrative and financial
transactions, code sets and identifiers, include the national provider
identifier coming forward, and of course, privacy and security.

As part of the HIPAA work we were asked to investigate and make
recommendations on clinical data standards and interoperability. This
work became the core of the consolidated health informatics initiatives
and has been an important input to the work of HIT-SP. We\'ve also
advised CMS and HHS on E-prescribing as requested as part of the
Medicare modernization act.

In addition to our work advising on HIPAA privacy, we have been asked to
provide ongoing advice on privacy and confidentiality as we move into
the world of interoperable HIT and NHIN. One example of that work is a
report released in June relating to privacy, confidentiality, and the
NHIN.

We have also made \-- investigated and made recommendations on a number
of strategic and forward-looking areas, including population health
issues such as shaping a health statistics vision for the 21st century,
a report on personal health, and an important report on developing the
national health information infrastructure. Which called for increased
HHS leadership, and recommended the creation of an office to provide
this leadership and coordination, reporting directly to the secretary.

Finally, we are also pleased to have NCVHS liaisons participating on a
number of the AHIC workgroups that relate to privacy, confidentiality,
as well as consumer empowerment. Next slide.

Okay, let\'s turn to the focus of the briefing. In late spring the NCVHS
was asked to look at the whole issue of functional requirements needed
for a nationwide health information network initiative. Specifically, we
were asked to review and synthesize the results of the first ONC forum
which was focused on functional requirements, and the functional
requirements identified by the prototype consortia contractors. And by
the end of October, to find a set of functional requirements for the
initial definition of an NHIN.

Given the early state of the consortia prototyping work, we all felt
that it was very premature to make any specific architectural
recommendations. But we do bring forth some general principles and
recommendations related to architectural variation. Next slide.

We did this work in a very open process, with a very significant amount
of public input, and I want to thank the many that did testify to us at
hearings and during open conference calls, and also provided written
testimony. Which would include Kevin Hutchinson, as well as our previous
presenter, Don Mon, today. Next slide.

The process used to refine the functional requirements, from 977 in the
original materials supplied by ONC to us, was one that included, as you
could imagine, significant analysis as well as the input from these many
testifiers. We initially consolidated the 977 detailed functional
requirements into a working set of 154 functional requirements. And then
refined that working set into 11 high level sets of functional
requirements.

The report is intended for a broad audience, even though this sounds a
little bit vexing, it is a key educational resource on the NHIN, pulling
a complex subject together in lay language, so that we can bring a
larger audience to the table to discuss the functionality and purpose of
an NHIN. It should also allow discussion around nontechnical issues that
would be related to the NHIN, and help move the conversation beyond
technical folks, to policymakers, business people, and implementers.

The high level functional requirements may also serve as a checklist for
organizations to assure that they are considering all critical elements
for connecting to an NHIN. And finally, they may also serve as a
description of services to be developed by network service providers and
other intermediary entities. Next slide.

Next slide. Thank you. A point I want to emphasize, and I think John
mentioned this previously, the NCVHS report, and our high level
functional requirements, intentionally do not distinguish what must be
done where or by whom. From our perspective, the key question was what
needs to be done within this initiative, and within this system of
systems. These functional requirements are about the entire initiative,
not specific to an entity. Next slide.

Let me briefly address the issue of differences in design. As a
nation-wide health information network is being developed and prototyped
in different locations, a number of different ways systems may interact
and interconnect with one another are being proposed. The NCVHS
recognizes that at times variations can lead to overhead and complexity
that may not be feasible to accommodate. However, where the variations
appear to be compatible with one another, and do not impose undue
burden, the NCVHS recommends that variations be accommodated, and
actually includes them in the functional requirements. Many of these
variations relate to where certain services should be performed. But
where variations exist and they appear to be incompatible with one
another or impose an undue burden, the NCVHS lists the variations and
recommends further study to reconcile incompatibilities.

With that, let me move into the functional requirements, and finally the
policy issues and recommended in the next steps. Next slide.

These are the high level sets of functional requirements. The next
couple of slides discusses the financial requirements in slightly more
detail. Next slide.

Next slide. Thank you. First, the certification. This set of functional
requirements will designate that a user or system qualifies to connect
to an NHIN. A certification process is critical, and we of course note
that the initial development of network certification criteria is part
of plan deliverables from CCHIT.

Next is authentication. This set of functional requirements enables
verification that a user, be it an individual or system, is who they
claim to be. Next slide, please.

The next step is authorization. This set of functional requirements will
give permission to an authenticated user to access data from an NHIN.
Permission may be restricted to specific patients, it may be further
restricted to a portion of their records.

Person identification is next. This set of functional requirements uses
matching and correlation processes to uniquely identify an individual,
and is the key initial step to matching individuals to their health
information.

Location of health information. This set of functional requirements
enables locating where health information exists for a specific
individual. Next slide.

Okay, the next set of functional requirements, even though this looks
somewhat imposing, actually relates only to transport and content
standards. These enable the management of data transfer in an NHIN,
using general IT protocols, security services, and vocabulary standards.
Next.

Data transactions. This set of functional requirements supports the
transmission of data in response to trigger events, such as when a lab
result from a patient is available, or about the availability of beds at
a hospital during a disaster. Next.

Auditing and logging are essential security functionality. This set of
functional requirements monitors and logs access patient information
that enables security incidents to be identified and addressed.

Time sensitive data access is the only performance requirement that we
have included. This functional requirement ensures that responses to
requests for data, such as current medications needed for patient care,
are provided in a timely manner. Next.

Communications. This set of functional requirements supports
interoperability by using message format standards and content standards
that have been identified by HITSP.

The final functional requirement recommended relates to data storage.
This set of functional requirements facilitate the aggregation of data,
and a temporary or permanent storage of data. Exactly what is stored or
where is both an architecture and a policy issue. And it\'s already been
discussed earlier today during this call.

And with that, let\'s turn to some of our findings regarding policy
issues. Next slide.

In our hearings, and during further deliberations, we identified a
number of areas where policy issues will need to be addressed as we
proceed with the NHIN initiative. First, we heard significant
controversy, as Don Mon earlier mentioned, about where in the NHIN
various functional requirements should be performed.

Some testifiers stated the functional requirements should be performed
at the most local level possible, where others felt that at least some
functions should be performed more globally. The NCVHS feels it is too
early to make such determinations, and recommends that HHS utilize the
results of the prototypes, as well as the growing experience with
community health information exchanges, to help make these
determinations. The issues are not just policy, but what works
technically and is scaleable.

Another future issue has to do with determining how to assure ongoing
conformance of entities and their systems to NHIN requirements.

A more near-term issue relates to matching individuals to their
information, which is key to the function and useability of the NHIN.
Most entities collecting and maintaining health information have
implemented master patient indexes to accurately match individuals to
their records, and have manual processes in place to resolve issues.

As we move from a single entity to community health information
exchanges, and now the nation-wide health information initiative, there
will be a need for national leadership and guidance to ensure accurate
matching of individuals to their health information occurs.

Another policy issues relates to authorization, and enabling of
communication of individual permissions concerning specific data. Next
slide.

This slide rounds out our remaining policy issues. While baseline
requirements for privacy and security of personal health information are
provided for by HIPAA, for payers, providers, and clearinghouses, and
their business associates, as we all know, equivalent requirements do
not exist where there may be exchange of health information among
non-covered entities, or their business associates.

Privacy measures at least equal to those in HIPAA should apply in those
instances. The NCVHS has been monitoring this, and our privacy and
confidentiality subcommittee will be holding hearings on this issue in
late January.

Finally, and this relates to increasing public trust. As we move
forward, consideration will be need to be made to developing a public
awareness program educating individuals on their privacy rights, as well
as the benefits of the NHIN initiative.

Final slide. Next. Thanks. So let me end with a couple of next steps
directly related to the functional requirements. As I mentioned, the
document pulls together a very complex subject in lay language, so that
we can bring together a larger audience to the table to discuss the
functionality, purpose and value of the NHIN initiative. Thus, we
recommend that HHS use this document, and the functional requirements,
as a way to help explain and clarify the nature of the initiatives to
other audiences.

Also, since this work is only based on three use cases, and early in
this (inaudible) experience the functional requirements should be
further validated against a broader set of use cases.

Finally, we encourage HHS to continue to refine the functional
requirements, leveraging future work of the NHIN prototype consortia
contractors, and additional industry experience.

In conclusion, we believe that this work has helped build a consensus on
the base functional requirements for the NHIN initiative. These base
functional requirements are a key tool and enabler to support the next
steps in the development of the NHIN.

The NCVHS is pleased to have had the opportunity to assist HHS and the
Office of the National Coordinator in this work. Thank you for your
attention, and we\'re certainly open to questions.

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

Okay, thank you, Simon, I appreciate a very exhaustive and thorough
presentation, and certainly a very small share of what work was done. To
that end, to the community members, and to the public, your materials
contain a much more detailed appendix that enumerates the specific
recommendations and discussion presented by the NCVHS.

I would comment that the recommendations that are being made here are
not recommendations made to the community, these recommendations come
directly from NCVHS to the secretary, and the presentation here, as
Simon described, is so that the community is aware of these discussions
and can have its own independent work as needed.

With that, let\'s open it for questions and comments for Simon and Jeff.
The floor is open.

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

David, this is Kevin Hutchinson. Simon, I would just applaud your
presentation in the sense that you\'ve taken a very complex topic and
very nicely taken it down to the items that are the necessary elements
of an infrastructure for the National Health Information Network, and
I\'m very excited to see that we\'re finally focused on my large topic
of the need for authentication, both from a policy basis, process basis,
and technical basis. But taking it down to the minimum set of necessary
elements to the top 11 elements, I think you did a very, very nice job.

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

This is Howard Eisenstein from the Federation. On slide 26, I mean, I
know this is the third rail we\'re talking about, uniquely identifying
an individual. In your discussions after a lot of public input, did your
panel ever come up with, you know, what \-- I know you\'re not
recommending this, but did you ever come up with a consensus on whether
to do it by using these various identifiers, or a unique ID number?

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

Gosh, let me think how I can informatically address that issue. The
NCVHS has held hearings on this previously, and I think you may remember
that actually the original HIPAA legislation called for a unique
identifier. This was subsequently, after hearings began, pulled back,
and I think Congress has appropriately identified that this is not
something that HHS should be doing significant work on.

The main focus of our hearings in this area was really trying to
identify how good the correlation and matching algorithms were, and
whether or not they would be equal to the task. What we heard \-- and
Jeff, I\'d like you to jump in if I\'m missing anything here, but what
we heard is that the matching algorithms at least in our testimony were
pretty good, but do require generally matching \-- manual processes for
those areas which are in dispute. Obviously, the more additional
identifiers you throw into a matching algorithm, the higher the match
is. And the less manual processes will be required.

Howard, I don\'t know that I\'m answering your question, I may be
dancing around it.

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

We all are dancing around that issue, and we have. And this is, as I
said at the beginning, it is the third rail. But do you feel
comfortable, after all the evidence that was submitted, that the
technology is out there at a pretty high level? I know there have been
experiments and demos, but if HHS adopts your recommendations, you know,
you feel they won\'t be going down the wrong road?

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

This is Jeff, may I contribute to this a little bit?

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

Please.

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

I also have the benefit of being involved in the development of RHIO
with a record locator service at NCVHS, heard testimony from a number of
different health information exchange networks, and in many cases the
development of the record locater service, the success of the matching,
is kind of quantified in two ways. Number one, are you able to reduce
the number of false positive matches, down to essentially zero.

The reason that that becomes almost the critical driver, the critical
measure, is that if you falsely match one patient to another, you have a
patient safety issue. And that is pretty much something that is
unacceptable.

So the other area is where you have a false negative. The false negative
then could have human intervention to try to see if you could do
something to match the patient to their record, with a human being
involved, that would be a very small percentage of the cases, but \--
and it would supplement the initial automated process to match patients
to their records. But at least you don\'t have the risk of
inappropriately indicating a medication to a patient that isn\'t \-- you
know, isn\'t the right patient.

I don\'t know if that helps, but that\'s \-- maybe the one other piece
that I would add to this is that unique patient identifiers are not
perfect, either. In many cases we receive testimony that using
algorithms, as the kinds I described, in many cases are pretty much the
same in terms of a success ratio as a unique patient identifier. The
reason I say unique patient identifier may not always be perfect is we
don\'t have the ability to rely on government-issued identifiers. The
authentication of that person is not perfect, either. So these
algorithms, in fact, are proving very successful.

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

Okay, other questions? The floor is available.

Okay, with that, let me thank you, Simon, and Jeff, and John Loonsk, I
just have one closing question for you. Could you just tie the material
presented by NCVHS, even though those recommendations have just come to
the secretary, to the announcement that was made about the next step
with the NHIN? How has the findings of part one been taken into account
with respect to part two, on a \-- not procedurally, but substantively.

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

Thank you, David. Certainly the work of NCVHS \-- and I must applaud
Simon and Jeff and the rest of the ad hoc working group for doing
something in a relatively short time period that produced such
substantial content \-- will inform the next steps of the NHIN activity.
And there are a number of different products from this year that are
shaping those next steps, and will have a tangible role in the next
procurement. So we would anticipate that beyond the general guidance,
for the fact that there are some architectural commonalities, as well as
reasonable architectural variations that can go forward in an ongoing
way, those are important advancements for the ways in which the next
steps of engaging state and regional health information exchanges will
move forward.

So we both anticipate that the content and the actual substance of these
recommendations will play an important part in the next steps, as well
as the work of HITSP, the work \-- the developing work of CCHIT and the
other products of this years work on the NHIN.

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

Okay.

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

David, this is Ed Sondik, I wonder if I would ask a question.

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

Please.

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

First of all, I think NCVHS has really done a terrific job with this.
And the functional requirements would apply, it seems to me, not only to
the NHIN but to the public health information network as well. And I
wonder if either \-- any of the speakers or John has a comment about how
the two relate. The PHIN, and the NHIN, at this point.

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

Let\'s turn to Simon and Jeff, and then to John.

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

I think my comment brief \-- simply would be that since the NHIN is a
network of networks, I tend to think of the PHIN as really part of the
overall NHIN, so I think it really should apply. Jeff, do you have
additional comments?

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

I would really defer to John Loonsk with respect to the PHIN.

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

I think the first thing to note is the coordination of the acronyms is
perfect. But beyond that, the public health information network has
developed functional requirements as well, they have been working on
implementation level guidance similar to that which the health
information technologies standards panel has been working on relative to
the breakthroughs. And one of the conversations in the context of the
former \-- the workgroup formerly known as biosurveillance, for the
AHIC, has been to talk about how to advance a certification process for
public health, whether that be through the certification commission or
through a new body that is open and can advance those types of
functional requirements for public health information systems, and to
make sure at the same time that they work very tightly with the NHIN
functional requirements, and with the standards coming from HITSP as
well.

And I know that the CDC has made commitments through Dr. Gerberding to
the HITSP standards as being the standards that need to move forward.
Fortunately, they have a high degree of correspondence to the work
that\'s already been done on the public health information network, and
I see these things going forward very \-- in similar paths coming closer
and closer together, and really, the opportunities for harmonizing them
are significant.

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

I do hope that we see these not as parallel, but as directly related so
that there\'s communication. I tend to see a network, you know, a system
of networks is \-- whatever it is you call it, is really what we\'re
after. And I think the public health side will be poorer if it cannot
have access to the information that is available through the NHIN.

But I\'m not sure the situation is vice versa. Because there may be
information that \-- there will be information that is clearly very
privileged. But how these two will work together I think is very
important, and should be on our agenda at some point.

Again, I think that NCVHS has really done a wonderful job in this, I
congratulate them.

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

Perhaps this could be part of the internal evaluation of the
recommendation letter that came from NCVHS, Ed, and I think maybe that
should be relegated to that point unless John has another comment.

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

No, I think they share immediately, you can look at them as sharing
functional requirements, sharing standards and implementation level
guidance, and also sharing the importance of certification process to
move forward. And what we need to do overall is to make sure that those
are all aligned, so that they are indeed cooperating in a network of
networks.

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

Okay, any final comments on this section?

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

David, this is Nancy Davenport-Ennis, and I would like to commend the
work of NCVHS and to the recommendation that Ed Sondik has advanced. And
particularly, David, to your recommendation that trying bring forward in
the letter of recommendation governmentization of NHIN and PHIN will
certainly lead to a very broad level of consistent protection for
patients who are represented in both of those networks in the country.

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

Okay, thank you, Nancy. I\'m sure we\'ll make sure that that\'s
transmitted.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Thank you.

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

Any final comments on the NHIN section? With that, let me ask that
slides and the web presentation be skipped forward to the standards
update, and ask John Loonsk to continue with the floor on this topic.

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

Thank you, David. As a follow-up to the presentation at the last
community meeting, where the health information technology standards
panel presented these three large packages of standards and
implementation level guidance that trace back, if you will, to the
breakthroughs and the use cases that were developed from those
breakthroughs in the last ground, we\'re starting to come around the
full cycle toward closure on how this entire process is working. And
there are a number of things to follow up on in that context.

First, that indeed as was requested by the electronic health record
working group of the AHIC, there is a new use case for the emergency
responder EHR that is available this week. It has gone through two
extensive rounds of public comments, wherein some 400 and 500 comments
were received, and went into that use case to the goal of having it be a
useful tool in feeding the health information technology standards pane,
l next steps of the nationwide health information health network work,
as well as the certification commission work on those goals.

So that is available. And the next step for the American Health
Information Community is to take the \-- the staff is taking the
priorities that have been expressed by the different working groups,
beyond emergency responder EHR, that were presented at the last meeting
in a matrix, and put those priorities into a tangible what we call
prototype use cases. These will be hopefully high-level articulations of
a scenario that can be \-- can include as many of those priorities as
possible in the context of the next steps for feeding this apparatus.

The scenarios will be a topic of discussion at the next community. There
should be some options that we hope that the community can provide
feedback on those priorities, and input on which to go forward first, as
well as refining some of the included priorities. And that that will be
another part of the January community meeting.

By way of another status update, going back to the interoperability
specifications that were advanced by the health information technology
standards panel, HITSP and the certification commission have now
established a joint working group that will work on the timing of
implementation, and other issues related to the coordination of HITSP
and CCHIT. As these interoperability specifications come forward, there
will be an increasing needs for coordination, including very
specifically the timing of the implementation of those interoperability
specifications and their components in certification criteria.

And as we\'re coming to the close of this first cycle, it is laying out
both on the CCHIT side as well as in the context of the implementation
of the executive order around the use of standards in federal systems
and contracts, that the general trend is toward having a year of time
between when implementation level guidance comes available, and when
there can be an expectation of implementation in actual systems.

And so there are two different processes going on, here. One is the
timing with the certification criteria, the other is the timing with the
expectations for implementation in the executive order. And as we move
to closure on this cycle, the implementation of that timing is trending
toward a year of time between implementation level guidance and
implementation.

I think that there will be discussions about specific components of
those standards, about additional timing of components of the
interoperability specifications. They are large packages, they include
many different standards. But that\'s the way that the general \-- it is
generally trending.

The next item to talk about, by way of an update, is a follow-on to the
conversation at the last AHIC, where the discussion of HITSP\'s use of
standards development organization, or SDO content versus nonSDO
content, was part of the discussion. And I think it wasn\'t clear that
it came out in that setting that HITSP, while it does indeed use at
times non-standards development organization content, in the
implementation guidance, relies on readiness criteria that have been
developed to address many of the same needs that people look to in terms
of thinking about SDOs.

Part of the problem here is that the level of detail of the
interoperability specifications, these implementation guides, these
highly detailed cookbooks that describe how standards need to be
implemented, have not always been supported by many of the standards
development organizations. There\'s a lot amount of work there, many of
the SDOs have be working at a higher level, the so-called names
standards level. And although the industry seems to be trending toward
the standards development organizations accepting responsibility for
managing that kind of very detailed content, it is still not the case
that all of those implementation guides are managed by SDOs.

So part of the furtherance of that discussion I think is the commitment
in terms of advancing this process that standard development
organizations should be the target for the material wherever possible,
and that the acceptance of responsibilities for this level of management
of detailed guidance is definitely a goal of the system. But for the
time being, HITSP will have to continue to rely on some non-SDO content,
and rely on the kind of readiness criteria that is developed to specify
and then try to ensure that those who are contributing have an openness
of process, have institutional resources to support the management of
those, and the commitment to support them in an ongoing way. These are
the kinds of criteria they\'ve been using in considering whether
standards and implementation level guidance can be used in the follow-on
activities, and so as things progress, and as standards development
organizations increasingly take responsibility for that level of
detailed guidance, I think there will still be needs to indeed enhance
those criteria, but advance them as well.

Part of this discussion comes from a review that\'s really been done on
the work of the health information technology standards panel over the
course of the first year. If you\'ll remember, HITSP was, in its first
year, developing its process, as well as going through the first round
of standards harmonization, and there were a number of lessons learned
from that process.

First, I have to say that you\'ve all heard John Polamka (ph) speak to
these processes. I must really commend not only John but the staff of
the health information technologies panel for the diligent work they
have done. They are really at the tip of the sword, here, in terms of
advancing the agenda. And as we mentioned previously, not only dealing
with much of the passion around standards, but also dealing with
divergent interests as they come to the very point of determination of
how these standards both are harmonized, and how they are implemented in
great specificity to accomplish these goals.

In the context of the review, not only was the incredible effort
identified, but there were also identified some ways in which some of
the issues that have been suggested and come to the fore around
improving the process for next year can be addressed. And one of those
issues that has been discussed is whether the process that HITSP uses of
in-person participation on technical committees potentially skews the
participation to larger organizations that can support that kind of
ongoing presence.

And I think that we are all interested in making sure that over 260
different organizations that are named participants in HITSP can
participate in this decision-making. And so one goal, and one of the
recommendations that HITSP has come forward with in the context of next
year is to move to virtual meetings, to enable participation by groups
that can\'t necessarily physically travel people to participate, that
have a broader identification of the commitment times and processes in
terms of when the decision points are being made in the various HITSP
working groups and processes, so that those groups that want to
participate can have a certainty that they are aware of when those
decisions are being made.

And to work on possibilities for digests and synopses of technical
committee work, sometimes it\'s very highly detailed and very technical,
but to try to communicate that information out to try to address some of
these issues of skewing. We also think \-- or potential skewing.

We also think that some of these processes can deal with the other issue
that has been brought to the fore, which is the possibility of volunteer
burnout. We identified that thousands of hours were involved in
producing this year\'s work, I think over 12,000, volunteer hours were
involved. And that can be sustained at a certain level, but clearly
moving into the next year, as this process becomes more routinized, some
practices have to be adopted to try to minimize that and to foster the
staff level support wherever possible, so that the volunteer times can
be focused on the decision-making, and making sure that those decisions
are as valid and open as possible around the harmonization of the
standards, and more of the legwork can be done by staff in supporting
those processes.

I think the virtual meetings, the public broadcast of decision-making
time, et cetera, will help in that regard. But there also are
suggestions for advancing the formalization of ongoing technical
committees that cap be more permanently supported in staff, and with
technical committee chairs that can be identified who can have the level
of commitment to supporting these activities in an ongoing way, as well.

And then finally, I think one of the issues that was \-- has been
brought up in the context of the HITSP process was the time for public
comments, and that everyone wished that the public comment periods were
longer. And since this year they will \-- this coming here they will no
longer be developing the process, they\'ll be refining the process at
the same time that they\'re working through the next processes. They
have identified a commitment to indeed extend the period of comment for
those public comments, and for the technical committees to deal with
those public comments, to make sure that those suggestions are also
heard.

So a number of different things in this update. We are I think
presenting now the overall process of how we will get to the harmonized
standards, the input of the breakthroughs coming from the AHIC, the
priorities coming from the workgroups translated into use cases, that
have been set into the HITSP, as well as the other processes, the
identification of the name standards, the development of implementation
of guidance as a specific method of describing exactly how those
standards need to be advanced,

And then the opportunity for developers to work those implementation
guides, the interoperability specifications into their software systems,
to be followed by an expectation both on the federal side and in the
certification criteria of implementation, with testing to assure that
indeed those standards are implemented in ways that assure
interoperability.

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

Okay, thank you, John. And also let me add that as all of you know,
there was a substantial amount of discussion in and around the time that
the HITSP presented its first round of standards. And that these changes
that John has described are part of an evolutionary process that not
only make the standards process cohesive, and functioning with the
highest level of efficiency possible, but to make sure that all the
different constituencies, particularly the user constituencies who
ultimately have to deal with the impacts of these standards, are able to
participate.

And I join John in applauding the work that HITSP has done, and that the
SDOs are doing to be able to have this occur.

With that, let me turn this to discussion from any member of the
community that would like to question John or add other comments.

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

David, this is Doug Henley, again. I too want to thank John for a
wonderful presentation and for the update relative to the HIT standards
panel on the changes that have been made, I think they will go a long
way to facilitating the more open and transparent process, which is
clearly important.

A comment, and I think I heard John correctly, and I know this point was
made on October the 31st, I\'m sorry I couldn\'t be there, but I think
going forward it is important, as I think was stated on October 31st,
that the standards themselves, while the readiness criteria and
implementation guides, whatnot, as John mentioned, might not necessarily
at every time currently come from the SDO, the standards themselves,
though, I think need to come from SDOs. And I think that\'s the intent
and part of the charter of the HIT standards panel to begin with.

So I just make the plea that HITSP deal with \-- as it relates to
standards, electronic standards, and not just the readiness criteria,
that those standards be approved by an SDO before they come to HITSP.

That said, if readiness criteria and other content for implementation
initially have to come from non-SDO \-- you know, venues, that I can see
where that may be necessary and appropriate, in the spirit of time and
speed. But at the same time, if we\'re going to push back to the SDOs,
as I think we should do, and John clearly indicated that was the intent,
to get them involved in this process in terms of maintenance and
implementation, if they\'re willing to take up that mantle and run with
it, then we should listen to them, as well, if they come back with a
different idea about what those readiness criteria and implementation
guides should be, and perhaps that should rule rather than the interim
stuff.

Any comments about that, or thoughts about that, David or John?

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

Yes, this is John. I think that this is a complicated discussion, and in
the large sense we\'re talking about two different levels. One is the
level of the names standards which Doug points to. These are standards
like LOINC and Sno-Med and large standards, if you will. And then the
implementation level guidance.

And I think one of the things that is \-- since HITSP overwhelmingly
pointed to standards that originated in standards development
organizations in their implementation level guidance, one of the things
that they feel they could perhaps do in the coming year is to point more
directly to those standards at times in the existing implementation
guides. And if you\'ll follow me on this, they \-- in the HITSP
implementation level guidance, the so-called interoperability
specifications, at times they pointed to implementation level guidance,
which then pointed to the names standards. And that was perhaps more
circuitous than needed to be, and added to the level of confusion here.

But that there is an opportunity moving forward to be more direct, in
terms of \-- more direct in two ways. One, both being clearer, but as
standards development organizations take over management of
implementation level guidance where possible, that it will be easier to
point and include more of that, and point more directly. So the path to
those name standards would be much clearer.

Saying all that, and that was a mouthful to say, but saying all that,
not all standards are managed by names standards development
organizations. There are some \-- many of them in the United States are
credited by ANSI, and formerly thought of in that way, but there are
some typically in the technical realm and others such as Oasis which
aren\'t necessarily standards development organizations in a classic
sense, and at times are going through processes that are very important
in identifying standards that are important to the overall mission.

So I think the general trend is, one, to wherever possible, use
standards development organization content for the names standards.

Two, be more direct in the implementation level guidance wherever
possible to show where those standards, SDO content, are included.

And three, to encourage the SDOs to take a larger role in the ongoing
management of the implementation level guidance. Because truly, HITSP
doesn\'t want to be in that business in the long term.

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

That\'s helpful, thank you.

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

Doug, this is David. If I could just comment perhaps with a different
dimensionality, but perhaps with the same net effect as John\'s. I\'ll
call everyone\'s attention to the original form of contract between ONC
and HITSP. Or with ANSI as it formed the HITSP panel. Which recognized
up front the need to take the standards community, the SDOs, and the
standards that lay native, in an unchanged way, and to be opportunistic.
But more importantly, an expectation over time, that I think what you
are now hearing from John is this being invoked as we move into 2007,
that HITSP not passively just allow the standards community to exist as
it was a native form, but to take a proactive role in identifying holes,
or gaps in standards, so that the standards community can work together
to not just stitch things together to respond to a use case, but to
anticipate the directional forms of needs of information over time.

And secondly, to begin acknowledging that we don\'t have a streamlined
and cohesive set of SDOs. That HITSP is a thin veneer pulling them
together, and that deeper collaboration and perhaps even structural
alignments with some of the SDOs may be necessary over time to achieve
the goals.

So I think what you\'re beginning to see now is a push towards saying
let\'s move beyond opportunism, and let\'s begin actually identifying
ways to take the five to seven year perspective, and have this become
much more cohesive. And I think it will invoke the circumstance in the
future where there is never a need to have \-- to call upon a standard
that doesn\'t come from an SDO.

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

Thanks, David.

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

Thank you. Other comments, here? Questions for John?

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

David, this is Nancy Davenport-Ennis, just a comment for John. John,
thank you for a wonderful job of summarizing and identifying next steps.
And certainly, to the extent that we can have SDOs involved and then
trying to manage and encourage adoption and implementation of standards
within their spheres of influence, we will be leveraging resources, and
helping to more (inaudible) integrate health information technology
across the United States. So thank you for bringing that to bear in your
discussion and your presentation this afternoon.

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

Thank you. And this \-- I must say that the initial indications from the
SDOs is that they\'re very receptive to moving in these directions. And
so that\'s \-- I must say that they are \-- they are responding very
well so far, and we look forward to continuing to move in that
direction.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

Yeah, thank you for that opportunity for them.

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

Thank you, Nancy.

**[\>\> NANCY DAVENPORT-ENNIS:]{.underline}**

You\'re welcome.

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

Other comments?

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

Hey, David, this is Kevin Hutchinson, just a process question for John.
And I\'m excited to hear that the SDOs are moving in that direction to
take a more active role in the maintenance of the implementation guide.
But when there\'s an implementation guide that\'s recommended by HITSP,
that is supported by an SDO standard, when those \-- if there is a
conflict between the implementation guide and the actual SDO standard,
what is the process for resolving the conflict between the
implementation guide and the standard itself? Is that HITSP\'s role?

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

Well, I\'m not sure I entirely understood the question, Kevin. Usually,
the implementation guides are a further detailing, a constraining of a
standard. And so there are some times when there are, you know, complex
three party issues, such as where CLIA data may sit in a standard, and
where that fits into the implementation level guidance. But in general,
implementation guidance is a further detailing of names standards and
doesn\'t necessarily represent a conflict.

That all being said, the role that HITSP is playing in this \-- in
regard to the overall work in the standards area is to harmonize and
reduce conflicts between standards wherever possible, largely through
the identification of appropriate standards to use in appropriate
contexts. And that\'s where the breakthroughs and the use cases are very
helpful in specifying the context that they need to do their work.

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

Okay, I\'m not suggesting this exists today inside of HITSP, but I have
seen implementation guides, for example, that try to recommend guidance
for implementation of a standard that might take, for example, an
optional field and make it required. Or take a field that can be 100
characters in length, and limit it to 50. For a variety of reasons in
the guidance versus in the standard. And those put the guidance in
conflict with the actual SDO. That\'s what I\'m trying to make sure that
there\'s clarity on. It may not exist in what\'s happened today in
HITSP, it\'s a process question that if it were to come up or if it does
exist today, what\'s the process for resolving the \-- because the
technology vendors are going to be confused by which one to do, the
standard itself or the guide.

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

Yeah, I think that the broad answer to this is that there are iterations
needed between HITSP and the SDOs, and that process has begun, and
that\'s \-- some of the SDO balloting for example has now started to
recognize some of the issues that have come out of the HITSP
harmonization process. So I think in the broad context, what we need to
see is the further refinement of the SDO-HITSP relationships to work
through some of these issues.

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

Thank you.

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

Thank you, Kevin. Further comments or questions for John? With that, I
will thank you, John. Appreciate the work, and again appreciate the very
hard work on the part of HITSP and the SDOs.

With that, it\'s now time to turn to public input. I will ask Matt to
arrange for the public lines to be opened, and for instructions to be
given about queuing for comments.

I will instruct the public that these comments should be free of any
commercial solicitation or advertisement, and we ask you to be brief.
And if you have substantive comments, you\'re welcome to submit them in
writing, as well.

I would also welcome any comments about this teleconference process. And
again, those can be submitted through the appropriate backup procedures
in writing, as well.

With that, Matt, could you instruct us on how to move forward.

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

Thank you, Dr. Brailer. We have members of the public who are listening
to this meeting in two ways, via Web cast, and via telephone. For the
members of the public who are listening via Web cast right now, you\'ll
need to call in to make a comment. You\'ll see a slide on the screen
right now that has a phone number and instructions for queuing up for
comment once you\'re in. You need only press star one ones you\'ve been
connected. Some of you might see there\'s a button on the Web cast that
says Q&A, but please disregard that, we\'re not using that for today\'s
meeting, you\'ll need to call in. For members of the public who are
already dialed in and listening to this meeting over the phone, you need
only press star 1 on your touchtone to get into the question queue.
We\'ll wait at least a minute for people to work their way through the
operator and into the question queue, but I\'ll start opening lines as
they come in.

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

If you have a comment you\'d like to make please either dial in if
you\'re on the web, or if you\'re on the phone, dial star one.

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

We have our first comment. Jen, could you please open Gary Dickenson\'s
line.

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

Line is open, go ahead.

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

Hello, my name is Gary Dickenson, I\'m a consultant representing
Centrify Health. Thank you for the opportunity to provide public
comments in this forum. Our comments are on why we cannot support
HITSP\'s interoperability specifications in their current form, relating
to some of the comments that John Loonsk just alluded to. We have
forwarded our detailed written comments to AHIC\'s staff. They were not
included in the meeting package, but I assume that they will be
available to members of the community going forward.

In any case, for background, we have been affiliated with other
organizations, but are we are long-term supporters of ANSI standards
harmonization, coordination, starting as charter members of the ANSI
health information standards planning panel, HISPP, in 1991, and
continued involvement with its successor, the ANSI health information
standards board, HISB, and now the ANSI HIT-SP.

We have engaged with HIT standards development for almost 18 years. We
have seen the standards touted as the ultimate solution. We have seen
the transition from elemental standards to myriad standards that are
dense and excruciatingly complex. We have seen dominant industry forces
insist that standards only apply at the back end interface without
impact to internal system architectures. We have seen these same
dominant industry forces overwhelm the standards development process,
and preclude the needed balance of consumer interests, providers who
care, and many others.

We have seen a vast array of standard specifications drafted without
benefit of explicit user and technical requirements. We have seen the
implementation of tens, hundreds and thousands of point-to-point
interfaces, yet an encompassing solution remains but a glimmer on the
distant horizon.

When ONC was formed we anticipated the dawning of a new day, AHIC
followed, and breakthroughs became the order of our business. We
embraced this new day. Memories of ANSI\'s previous standards
coordination failures began to fade as HITSP was formed. Many new
stakeholders were engaged. We thrived on the promise at hand. Finally we
had a concentrated focus on standards development and coordination with
backing from top U.S. health care leadership. HITSP became our hope.
HITSP\'s principles of openness, consensus, transparency and due process
never seemed so relevant or appropriate to the task at hand.

At its inception in August 2005, we joined HITSP technical committee
work in anticipation of upcoming ONC use cases. We believed that this
effort would take the broad range of industry requirements and condense
them into a small core set of standards. Extended only when absolutely
necessary to meet the needs of a particular use case.

We believed that this highly concentrate focus would converge on a firm
foundation, not only for upcoming use cases but for immediate and future
industry needs. We believed that marginal strategy of the past would be
recognized, and set aside. For example, moving from point-to-point
transient messaging to end-to-end trusted information flows where health
records would be persistent from the point of service, point of care,
point of record origination, to each ultimate point of record access and
use. We believed that past imbalances of input and participation would
be righted.

As part of our contribution to the HITSP technical committees, we
offered input and advice, seeking to ensure that final HITSP
recommendations for standards selections and harmonization were
rational, robust and complete. We\'re fully vetted through an open
consensus and transparent process. Could be fully justified first to
HITSP at large, and then to ONC and the AHIC. Could be independently
verified based on explicit technical requirements and criteria. Could
form the basis for ongoing coordination with CCHIT certification and
NHIN prototype development. Where forward focused and consideration of
requirements for the persistent legal health record and its life cycle.
Could be focused on a reducibly small set of core standards to ensure
civil specification and implementation.

As time progressed, we came to realize that HITSP was indeed infected by
many of the ills of the past. Use case analysis skipped many key steps.
User and technical requirements were never made explicit, leaving users
and providers to wonder whether their needs had been identified, much
less incorporated, and providing no metric to evaluate standards
recommendations or the conformance of future implementation.

Our goal of breakthroughs melted into a breakdown. We attempted to work
within HITSP to address and resolve these vital issues. We submitted
comments, written comments, four separate times, only to have them
sequestered and suppressed by HITSP or project team leadership on each
occasion.

We have identified 19 areas of concern that are detailed in our written
comments. They are broken into two categories, one which points to
deficiencies in HITSP\'s consensus process, which did not follow the
HITSP charter, and did not follow ANSI essential requirements or
guidelines for development of open consensus standards. We also have
identified deficiencies of HITSP\'s use case analysis, and the
interoperability specifications that were produced.

So I\'m not going to go through these in detail, I obviously don\'t have
time. There are 19 issues we have identified, whether they are process
or analysis related. We have identified what we observed, and the
consequences of these particular deficiencies.

Thank you for your time.

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

Thank you, Gary, and I look forward to reviewing your letter, and I\'m
sure that due attention will be given to the issues raised.

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

Thank you.

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

With that, let me turn back to Matt for open lines.

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

We don\'t have any other comments.

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

I\'ll give the public any other time for comments at this point.

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

I think that people, during the last comment, have had ample time
probably to work their way through the operators and into the comment
queue, so I think we\'re probably safe to adjourn.

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

Okay, thank you. The next meeting of the community, which will be the
11th meeting, will be held on January 23rd. This will be an in-person
meeting in Washington. I actually will be out of the country on personal
travel then, so I will miss the meeting. So I wish you all well during
the important recommendations that come from the workgroups at that
meeting.

With that, we stand adjourned. Thank you all so much for your time
today.