American Health Information Community

Biosurveillance Data Steering Group

August 8, 2006

2:00 p.m. EDT

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\>\> Okay, you can go ahead and begin the meeting.

\>\> We\'re going to start with a roll call. Is that already
accomplished?

\>\> No, we still need to make a roll call for the public. We can do
that now if you don\'t have any introductory comments.

\>\>Art: Well, welcome once again to everybody. Thanks for joining us.
Marty and I just caught up a few minutes ago about our agenda for today.
We may be making a few little changes to it as we move along, but we
probably should go ahead and get started with the meeting.

\>\> Can you hear me well now, Marty?

\>\> Marty: Yes, I can, Art, that\'s fantastic, and we\'ll continue
building on the work of leading towards both our objectives and meeting
next time. So looking forward to a good call here.

\>\> Art: Right. So if you would please begin with the roll call, we\'ll
just get right into the business of the meeting.

\>\> Absolutely. On the call in addition to both our Co-chairs, Marty
LaVenture and Art Davidson, we have Laura Conn, Bill Stephens, Mark
Rothstein, Ed Barthell, Stephen Henriks, Perry Smith, and Eilenn Koski.
And I believe there are a few members of the group who are in the room
over at LNC.

\>\> Yes, we have Paula Soper, Angela Fix, myself \-- Scott Holter.
Vernette Roberts. (indiscernible) and Judy Sparrow.

\>\> Okay. And just very quickly, to get it out of the way. If you\'re
calling in on a remote line for this, as a member of the Workgroup,
please keep your phone muted when you\'re not speaking, and when you do
have a comment to make, please introduce yourself first.

If you\'re following along on the Webcast as well, please don\'t touch
any of the buttons it advance or reverse the slide. And for the members
of the public that are with us right now, you\'ll always have an
opportunity to ask a question or make a comment at the end of the
meeting.

I believe that\'s it. Co-chairs?

\>\>Art: Very good. Thank you. There were a couple of things that Marty
and I had noticed that might be included on the agenda before we get
into the topics that were listed. There were two documents that were
sent out, I believe it is on the 7th \-- no, on the 4th. From Scott. One
was the Statement of Work, and the other was the summary of the meeting
of the 7th of July.

The first item that Marty and I wanted to just check with, was with
Scott, is that Statement of Work \-- or has that changed at all from the
original? And if so, might you point out any changes that have been
made?

\>\> The one change that was included on this newest edition was the
broad and the specific scope.

\>\> Okay. So that\'s \--

\>\> Those came directly from the functional areas.

\>\> Okay, so just those two paragraphs under the purpose.

\>\> Correct.

\>\> Okay.

\>\> And then per our discussion today on the preconditions, coming up
here in a few minutes, those would also be added to the document at that
point.

\>\> So you\'re expecting that we will be adding them to the scope of
work document?

\>\> Correct. There are assumptions going into that scope of work.

\>\> Okay. Is everybody in agreement with that? Do you understand what
we just said? Any questions?

\>\> No, no, none for me.

\>\> Okay.

\>\> Sounds good, Art.

\>\> Art: So we just wanted to check and make sure. So just those two
paragraphs were added under the purpose. So if you haven\'t read them,
maybe you get a chance to read them, we\'ll probably review this draft
scope of work at our meeting at the end of next week. I believe it\'s
the end of next week. So we\'ll be able to touch back on this at that
point.

The other document was the summary of the session on the 7th, and I
don\'t know if \-- (audio interruption). I don\'t know if anybody had
any comments they wanted to make about these notes from that meeting. Or
any corrections. Okay, great. I just got back from vacation yesterday
and I have not fully read through these. I will promise to do that
within the next day or two and get back to Scott if I think there\'s
anything different but it sounds like the group has already decided this
is pretty complete.

\>\> Perry: This is Perry. I have not had a chance to read them so I\'ll
do the same.

Art: I think we can send comments back to Scott for editing.

\>\> Scott: If you could do that by the end of the week I\'d like to
carry these forward as our official minutes from that meeting.

\>\> Sure. Then maybe we\'ll move back to the stated items in the
agenda. Unless Marty, did you have any more comments?

\>\> Marty: No, that sounds good, Art.

\>\> Art: There\'s another document called the Preconditions Document
that \-- how is that labeled? Yes, "DVSGM_Preconditions_2006." And that
document is one that was prepared by, I think it started with Perry, and
had some changes made by Marty and Ed contributed as well. I got the
sequence right? Marty?

\>\> Marty: That\'s how I recall it. Scott, you had brought those
together. Did you have any other comments on sort of that process?

\>\> Scott: That was it. I was just \-- it was just the two e-mails
coming back and forth.

\>\> Ed: And this is Ed. Mine weren\'t really changing as much as
interpreting some of the terms one way than another way, specifically
with regard to the type of systems we obtain data from.

\>\> So maybe we should run through these and be sure that everybody
fully agrees. I don\'t know which systems you were referring to. Would
that be something that would be referred to in the first bullet point
there in.

\>\> There\'s something about a, we\'re looking for data elements we can
extract from existing systems and I just hope, and I express my hope
that we\'re broad minded in approaching that because there are more than
just traditional legacy systems that we can \-- or new systems coming
out that are existing electronic systems, too. And especially for the
bed reporting stuff, I think that\'s where we\'ll have better luck.

\>\> So more like have bed stuff?

\>\> Exactly.

\>\> Okay.

\>\> New and emerging, is that the concept here?

\>\> Sure, that would capture it.

\>\> That\'s leading edge but not bleeding edge.

\>\> Right.

\>\> So we can add to the to the first bullet point or the numbered
point that would be more than just traditional systems, including new
and emerging data cap tower systems. Would that be appropriate? Or do
you want that to be its own precondition?

\>\> Ed: As far as I\'m concerned, that captures it.

\>\> Okay. And Marty, I guess you did the modification to the second
bullet \-- does that capture what you were looking for?

\>\> Marty: The motion was to try to try the preconditions to that very
first meeting that we had that outlined some of the focus here in terms
of it involves both traditional reportable disease activity as well as
early identification situation awareness. Type of surveillance activity
as well. So it was the intent to try to do that. I\'m not sure, but we
want to make sure, I think, the wording reflects both what we might see,
and the definition discussion which is part of this item as well as in
our scope of work. The concept was to sort of reflect that.

\>\> And I think one of the things that we had spoken a little bit about
before is let\'s see. On our agenda, I guess this area that we\'re in
right now, includes the ASTHO definition. It might be worth pulling up
that document as well, for those of you who have it available so we can
look at that and see that the preconditions that we list are in line
with the definition that ASTHO has provided for biosurveillance.

Has everybody got a copy of that?

\>\> Marty: I think it was sent out in two places. Most recently by
Scott in an e-mail. And it\'s been in the previous meetings, but
embedded in the context of the definitions documents that were sent out.
Scott nicely pulled it out into an e-mail recently.

\>\> So as we kind of work through, Marty and I thought as we work
through this preconditions document, we might want to be looking at the
ASTHO definition to see if the preconditions are lining up with that
definition, or alternatively, comment on whether the ASTHO definition
should maybe not be used by this group. Just kind of put that out there
and see if anybody has any strong feelings one way or the other.

\>\> I found the original preconditions document. I guess I\'m still
looking for the document that has the definitions before I would
comment.

\>\> It was in an e-mail that I just sent out about two hours ago.

\>\> Oh, okay, so let me look at them.

\>\>Perry: This is Perry Smith. If I can comment on the ASTHO
definition. I found it in terms of the scope of work for this committee,
confusing. Because the ASTHO definition in a sense, if I understand what
it\'s saying, talks about the well established public health
surveillance methods, which I take to mean inclusive of case reporting
and outbreak investigation, and a lot of the things that have gone on
before for years. And then kind of equated \-- not equated but put on an
equal footing, with early event detection and situational awareness. And
so in my mind it confuses the issue of the purpose of the minimum
dataset. It makes it more difficult for me to decide what is in and
what\'s out. If we use the ASTHO definition. Because I don\'t think what
we\'re doing is trying to replace all the public health reporting with
the minimum dataset. But the ASTHO definition kind of throws it in and
puts it on a level footing with the early event detection. So I found it
confusing conceptually in terms of our work assignment.

\>\> Bill: This is Bill Stephens. That\'s an interesting perspective. I
guess it didn\'t cause that same level of confusion here because I guess
we\'ve been looking at this biosurveillance in sort of the context that
they talk about that the ASTHO definition talks about there, one is, you
know, sort of a continuum that started out traditionally, public health
started out traditionally from a postdiagnostic level, or at least with
a lot more information than where some of the other biosurveillance data
comes from today. But I still think we look at it here as sort of a
continuum where they become sort of connected or integrated together. So
maybe that\'s where \-- that\'s where the confusion is occurring. I
don\'t look at one as suppressing or as replacing the other. But as
connected and eventually integrated together in one big database. And I
guess I look at our initiative then deciding when we look at all this
together, finally in a broader context, how do we pick and choose what
elements are going to be there. Maybe it goes back to better definition
of the time line, of how the surveillance data accumulates or
aggregates, and some sort of event space or time line that tells us when
all this data, where it comes, from looking at all the different sources
and both sources as well as time line to put this kind of thing
together.

\>\> So Perry, if you would look at the fourth point on this, these data
don\'t have to meet all the need of current data streams that go to
public health, our charge is to develop the minimum dataset. Is there
something in there that we could call out to address your point? I\'m
not interested, if we can avoid it, in writing our own definition. But
we could call out the precondition for the minimum dataset and maybe in
this fourth point, to say that we\'re not trying to replicate or replace
current well established public health surveillance methods. These are
adjuncts, enhancements, or taking advantage of electronic health
information systems that might build on what is already there. Maybe you
feel so strongly that this definition is driving us the wrong way. Maybe
you could comment on that.

\>\> Perry: Well, the public health, as everybody on this call knows,
collects lots of different data from lots of different data streams for
lots of different purposes. And some of it is very detailed, obviously.
And a lot of it is determined by the setting. You know, if it\'s an
outbreak, we\'ll be doing one type of data collection, and if it\'s
routine case reporting, it would be different. And I have this concept
in my mind that what we\'re doing is \-- our goal is not to bring all of
public health data or even most of public health data together with the
deidentified data that we\'re talking about for biosurveillance.

In my mind I have a conceptual distinction between the two. But I\'m
beginning to think that maybe people are thinking about one big dataset
that all gets integrated and leveraged to address all sorts of goals.
And that\'s where I conceptually start to get very foggy in terms of
what our \-- because it really changes the definition of the minimum
data that we\'d need. So I guess I\'m looking on our charge to \-- as
fairly narrow as a part of biosurveillance, that we don\'t need \-- we
as a committee do not need to address all of public health data needs.
We have a very narrowly defined charge, and you know, down the road
we\'ll get into all the other issues of integration and what data might
serve other public health needs. But if we \-- I\'m overwhelmed at the
thought that we might use the ASTHO definition, which is all inclusive
and therefore not helpful to me. So to try to kind of be more specific
in my comments on the fourth point, these data do not have to meet all
the need of current data streams that already go to public health. I\'m
\-- what I\'m thinking is that what we\'re trying to do is to develop a
database, minimum dataset definitions that would promote early
identification of public health events. I\'m going up now to 2A and B.
And situational awareness. And then regarding #3, again, terms of our
narrow charge, all we need to do is be able to provide a link back to
the hospital which would keep the link so that public health at the
local level could go back and identify a case of anthrax, and then do
supplemental data collection as needed for the reportable disease and
for preparedness and for all the other things that happen.

But that wouldn\'t be \-- we don\'t have to worry about that as the
Biosurveillance Data Steering Group, because that\'s a follow-on
activity beyond the minimum dataset. Is that \-- does that help?

\>\> I just want to second that, that I think the best thing we can do
is try to constrain the number of elements. Keep this really focused.

\>\> Right.

\>\> And then have a clear transition where it gets handed off to
traditional investigation and detailed data collection by local and
State public health.

\>\> It would help a lot of people conceptually with what we\'re trying
to do on a national basis in biosurveillance.

\>\> Eileen: I also agree. And I think I go back to what was said a
couple of moments ago about us not wanting to have to redefine. This but
actually, I think we sort of do because if we work with somebody else\'s
definition, then we\'re basically working with their constraints on what
the data needs are. And I think we really do have to constrain this to
what we envision them being used for and not work with somebody else\'s
definition. And Ed and I think have both seen on the ANSI HITSP, a
constant tendency to expand and want to continually grow the dataset.
And I think we have to really struggle to figure out what is something
that is a minimum dataset that we can get real value of, but as Perry
Smith just said, give us an opportunity to figure out should we identify
something of concern. How do you investigate it through more traditional
routes but give us enough data that we can get quickly to provide some
overview situational awareness.

\>\> So then if I go back \--

\>\> Sorry.

\>\> Is that Marty?

\>\> Marty: Yeah, this is Marty. I think the distinction is a definition
of a minimum dataset for the scope versus a definition of
biosurveillance. I guess I\'m comfortable with the biosurveillance
definition. From ASTHO. But I think we should definitely focus the
precondition or the assumptions that we\'re making about what the
purpose of this minimum set and deep constrained and focused. But
realize it is in the context that we\'re talking about a highway and on
that highway we\'re going to define a very minimum cargo set. But we
hope into the future that it will obviously support a broader
capability, and I think that\'s what the broad biosurveillance
definition contributes to that. That we can control in a sense our
precondition statement. As a few folks have mentioned and making sure
that reflects the definition of the minimum dataset work, different from
the biosurveillance work.

\>\> Laura: This is Laura. I agree with you Marty in that context.
Broader charge just as a reminder for the Biosurveillance Workgroup is
about nationwide rapid response management. And I think it is more
inclusive of some of the traditional health reporting mechanisms. I
think what this group is charged with is more specifically out of the
charge of that workgroup and thinking through the minimum dataset that
can help implement and touch forward that specific charge.

\>\> Perry: So Laura, this is Perry Smith. Do you think, then, that the
broader biosurveillance charge includes kind of all the data that you\'d
want to know in an outbreak situation that you were investigating in is
that the concept?

\>\> I mean, we\'ll never know all the data we want to get and be
getting it in real time, obviously, but enabling IT to help in that is I
think in the broader charge. They are talking about outbreak management
broadly case reporting more broadly, and how \-- or what can be done to
enable more efficient reporting of that using advanced IT. But they\'re
definitely not trying to talk about getting all the data all the time to
support it and to be honest we just launched into this broader charge
two meetings ago, so you know, where we\'ll go with it is still on the
table and we\'re still trying to learn what\'s out there across the
federal agencies and other markets in order to determine what path we go
down. But it is a broader scope than just thinking about the situational
awareness of early event detection. And then I think maybe where we\'re
getting confused is the case reporting piece but we\'re not trying to
replace it but add additional information earlier. Using existing
sources that we\'re not all comfortable with knowing how valid they are
and some of those things that we\'ve brought up and the need for
evaluation. Hopefully that helps a little bit.

\>\> Does that give you, Perry, a different perspective, or are you
still feeling uncomfortable and confused by the use of the ASTHO
definition do we need to create a different definition for this? As
Marty pointed out, use this definition and then constrain our work
through the preconditions being a little more explicit?

\>\> Perry: Yeah, no, I liked \-- both Eileen\'s and Marty\'s comments
and I think that\'s fine. I think we can acknowledge the ASTHO
definition and then be clear that we came up with the follow list of
preconditions in making our definitions for this decisions for the
preliminary cut for the minimum dataset. So I\'m comfortable with that.
I think Laura\'s comments, though, are interesting because it does
reveal \-- my discomfort is based on apparently some real confusion and
difference of opinion throughout the nation about what this is going to
do or what the database is going to do. So I think it\'s good that
we\'re being as clear as we can with our sums. But the definition is
fine, as long as we define how we made our own decisions.

\>\> Okay. I mean, I know that we\'ve talked about this before, when Ed
first brought up the idea of early identification, and then situational
awareness. And I think it was Ed that kind of moved on to that third
topic of case reporting in our first call, if I remember correctly. And
I know that there is a lot of concern about whether this can do case
reporting and is that really \-- does that really fall in the
traditional public health surveillance activities, and I mean, I don\'t
know that at this point this group needs to make a firm statement that
it will do case reporting. It\'s possible it might be able to assist
with that. But I think it\'s primarily in the first two areas that
we\'ve been focusing and maybe we could just use some wording to help us
clarify that we\'re primarily focused on those first couple of items. I
mean, we haven\'t even gotten into the other functional areas and who
knows what other ones will be added to this assumption list as we start
looking at the other functional areas from beyond the one that we did on
the last call.

\>\> Bill: Art, this is Bill Stephens. I had another question. I guess
regarding the specific charge on the scope of work for the
biosurveillance steering group. The charge in the first sentence, the
charge will be to identify the requirements for data from ambulatory
care, emergency departments, laboratories necessary for
multijurisdictional biosurveillance programs. There they use the word
biosurveillance programs. So from what I\'m gathering from where we\'re
headed is we\'re defining programs to be in the two functional areas
only. Early detection, and situational awareness. With respect to
minimum dataset definition. Is that correct?

\>\> Well no, I\'m saying that we may define others to be added to the
list here. There has been some hesitancy to add the third one about case
reporting so far. May have others as we go down the other functional
areas from that additional spreadsheet on functional components, I
believe \-- functional areas, that we all voted on. That may add other
items beyond those two that we\'ve been talking, Bill.

\>\> Okay, well, the reason I ask is because in the original
documentation that I got from the \-- to Secretary Leavitt that was
signed by Dr. Gerberding and I think Charles Kahn on May 9, they were
pretty specific about defining in that Biosurveillance Workgroup were
specific in what they defined biosurveillance function to be as we
talked about event detection, situational awareness, they added to that
outbreak management and response management, which does include case
reporting. So if we\'re modifying that I think we need to be specific
about T or if we find that somewhere down the line, that\'s fine, too.
But I\'m just trying to resolve where we\'re headed with respect to that
original definition.

\>\> And I think that\'s what this discussion is about. Is what are the
preconditions or assumptions that this Workgroup has decided to use to
move forward?

\>\> Okay.

\>\> We\'re trying to get that \--

\>\> Ed: This is Ed. I just wanted to say, when we looked at HITSP, case
reporting, it\'s a tremendous can of worms. If you look at, for
instance, the form that a local public health agency may wish to have
filled out for a single salmonella report. It includes data elements
like what restaurants, what context, et cetera, et cetera, they go way
beyond this minimum list that we have here.

\>\> Oh, absolutely. I agree.

\>\> I think we got to draw that line or we\'ll just never get this done
in time.

\>\> Okay.

\>\> Marty: This is Marty. I guess perhaps it\'s the granularity that
we\'re talking about here.

\>\> I think that\'s it.

\>\> Marty: I thought I heard Art say a little bit earlier that we said
we would assist with reportable case reporting not replace or totally
fulfill that if we get an indication of a reportable disease that comes
through this stream, that will assist a report to a State epidemiologist
and will help follow up. It is a minimum set that will go to that State
epidemiologist and aid in the followup which will involve a lot more
detail. At this stage, I think it can assist it. But I don\'t think it
can replace it.

\>\> Yep.

\>\> Perry: You know, this is Perry again. One other thought that I
think underscores the direction the conversation is going. Every State
have their own reporting rules and regulations, and so I don\'t think we
want to go down too far the road of case reporting to biosurveillance
dataset, because it\'s going to not replace, at least in the near
future, local reporting and State reporting. And that will be in formats
and data elements of its own and only adds unnecessary reporting to
include it in this at this point. I would caution that at least for this
first pass and probably for the next several years this will not replace
case reporting. It might assist it. So I\'m comfortable with that, but
we don\'t want to give the impression that this is going to let the
hospitals off the hook for reporting for what they have to do to the
locals. I\'m also tempted to say at this point that the third bullet
should be something like explore the potential role of this data in
assisting, and really constrain it because to Perry\'s point exactly,
every \-- not only every different State but if you look at STD
reporting versus other infectious disease reporting you\'ll have
different data elements and we know we\'re not planning to handle all of
that. So the more we constrain that bull tote what we really hope to get
out of this dataset in that context, I think the better off we\'ll be.

\>\> That sounds good, I like that. How does that sound to everybody
else, that we really back off on putting the emphasis on how this even
will assist, but just explore the potential.

\>\> Yeah, I think that\'s it, and I think it really clarifies that
we\'re still going after that full range of functionality. But we\'re
not trying to comprehend every last detail that every last case report
or reportable disease is going to comprehend.

\>\> Marty: I\'m a little uncomfortable with the potential point of view
I think I understand the direction as to the \-- of the valuable \--
value of the role and identifying that. In fact, I think CC\'s research
project\'s being let soon, or at least the RFPs are out to evaluate the
role with reportable diseases. So I mean there\'s work that\'s going on
there. The intent is to potentially assist in some way. Perhaps Art,
given our time with today; this something we can draft some words off
line with a couple of the committee members, and rework some additional
words, making sure we capture these kinds of intents here?

\>\> I think so. I think so. Unless there\'s some other comment here,
thank you, Marty, we want to stick to time and we\'re beyond it already.

I think you and I, and Scott probably can work out something and
circulate this based on the conversation we\'ve had today. Modify these
eight points and get them out to everybody.

\>\> Could I ask one question about Point 3?

\>\> Yes.

\>\> Before we move on from the eight points. What exactly is the
intention where it says data should be available within 24 hours with
minimal new effort? Is this a comment on expectations or assumptions or
what exactly does that mean?

\>\> Perry: This is Perry. I think those were my words, and I was \-- I
originally wrote those as a guide to myself to say, to try to capture
the intent that we want this to be realistic. We want hospitals or
ambulatory care sites to be able to provide data within 24 hours. So
it\'s a way of reminding ourselves that we have to be realistic and if
something can be made available within 24 hours fairly easily, then it
might be considered to go on the list. But if it\'s going to take 6
months of reprogramming, and hundreds of thousands or millions of
dollars, it\'s probably unrealistic to expect that\'s going to happen
right away. But there may be much better wording. That was just kind of
my way of trying to remind myself that we have to be realistic.

\>\> Eileen: Okay, and this is Eileen again. I agree a thousand percent
with everything you just said. It\'s just I think the terms should be
just kind of to me there\'s a little ambiguity there. And that maybe
something else we might want to wordsmith a little bit. But I\'m
completely \--

\>\> How about is, or are, data are available within 24 hours with
minimum, something like that?

\>\> The data are available that\'s an assumption we\'re making.

\>\> Yeah.

\>\> Yeah, I was trying to capture \-- I was trying to waffle a little
bit by saying with minimum new effort. I realize there\'s going to be a
effort to make this available. It may not be immediately available but
if it\'s easily available that\'s kind of what have I was trying to
capture there.

\>\> Let me think about, maybe I\'ll send an e-mail with a suggestion,
I\'ll think about some wording.

\>\> Scott: This is Scott. I think that\'s an excellent suggestion as
far as if any of you have any suggestions on wordsmithing some of these,
I would encourage you to submit those and get them to the group and
carry these forward to the August 18 meeting. Marty. And as we move
toward the discussion at the next meeting around the issues of
feasibility, I think we may visit this assumption a little bit as well,
so those words and comments, Eileen, will be very helpful.

\>\> Eileen: Okay.

\>\> Perry: Marty, could I slip in something. On #5, it looks like
there\'s some wording that\'s missing. I think there may be a "and"
between "biosurveillance," "other." There\'s something wrong with the
way 5 is worded.

\>\> I agree. We\'ll work on this and circulate another version around
to everybody.

\>\> Okay.

\>\> That sounds good. I think we\'re now only 10 minutes behind on our
\-- no, actually we\'re 20 minutes behind. Very important discussion.
Maybe we should move along to the functional area results. The document
that Scott sent out, it\'s an Excel document labeled "ONC
BDSG_Functional_Areas."

\>\> Ed: I\'ve got to catch a plane at half past the hour, about 45
minutes.

\>\> Would you like to change the order?

\>\> Not to confound things but the part I need to discuss I really need
to discuss before that time.

\>\> Please start, then. We want your input. So we\'ll move, then, to
the next agenda item. Listed at 2:50, even before time. Minimum dataset,
and I think this is where Ed will take over. Talk about the HITSP part.

\>\> Ed: It\'s all tied together. I can tell you that the HITSP group, I
gave them the draft minimum dataset that we\'ve been talking through so
they had a rough idea where we went. One of the things that David Dobbs
did, of HITSP matching our initial draft dataset back to the data
elements that HITSP had identified by pulling out the data elements
listed in the harmonized for biosurveillance and they actually cross
mapped very nicely. We\'re very close. There are a couple of items where
they did not necessarily match directly and I\'d like to go to those
items ask talk them through with everyone. One that was we kind of
reviewed last time, the daily facility summary report, which had the
emission discharge desk every 24 hours. And one comment David made was
the concept of transfers. In other words, some hospitals may be very
busy but they\'re transferring out a lot of their admissions and that
report maybe should include transfers.

\>\> I\'m sorry, Ed. This is Marty. Which line are you on in the
spreadsheet?

\>\> This would be up at the near the top under the resource data
elements and there\'s a daily facility

summary report.

\>\> Okay.

\>\> That has admissions, discharges, deaths in the last 24 hours.

\>\> Terrific. Line 15. We\'re saying one additional item, the number of
transfers in 24 hours. Unless you don\'t think there\'s any value to
that.

\>\> Transfers implying in or out?

\>\> Transfers out outside facilities.

\>\> Okay.

\>\> For example, some of the smaller hospitals, when they get real sick
patients, trauma or sick infectious disease, they don\'t necessarily
admit them, they may transfer them from admission to a tertiary center.

\>\> Do you want to add another line there, Ed?

\>\> Ed: Correct.

\>\> Okay.

\>\> Did you capture that, Scott?

\>\> Scott: I\'m just \-- just want to make sure that I need to add
under data facilities summary report, transfer.

\>\> Correct.

\>\> Within 24 hours.

\>\> Last 24 hours.

\>\> Transfers in the last 24 hours.

\>\> Okay.

\>\>Scott: Done.

\>\> And I\'m sorry, Ed. Is that used for particular purpose in the use
case?

\>\> Ed: Well, it\'s mentioned in the use case.

\>\> I see.

\>\> Track tracking transfer data. And we didn\'t have it anywhere in
our list initially.

\>\> I see, thank you.

\>\> It seemed to be the right place to fit it.

\>\> Laura: This is Laura. I certainly think it fits here, but I wonder
if, Ed, will it capture folks who come into the emergency department and
get transferred without getting admitted to the facility really, because
this is actually not emergency room admissions and discharge, but
hospital \--

\>\> I don\'t know, but that\'s exactly what we\'re trying to capture.

\>\> Right, I\'m just not sure that captures.

\>\> We\'ll have to find that out.

\>\> If we can just make a note to see what we\'re trying to capture is
transfers from the emergency department to another advanced facility, I
think.

\>\> Correct.

\>\> Scott, this is Marty. Could you put that in the comment section
about the field for that line?

\>\> Scott: Sure.

\>\> I think \-- which number are you on on this resource data element
for the transfer issue?

\>\> To be honest, I\'m not sure which version of the spreadsheet
you\'re looking at. Six, 7, 8, 9, somewhere

around there.

\>\> There\'s two versions, one comes from HITSP and one comes from our
group, the biosurveillance. We\'re talking about 6, 7, 8, 9 and adding
the transfer within that data summary report. So on both of these
spreadsheets, actually on the Biosurveillance Data Group, it\'s 7, 8, 9
and 10.

\>\> All right.

\>\> It would be key to comment out what you mean by transfer, because a
lot of transfers in systems refer to within the hospital movement of
people.

\>\> Right. And I think one of the things is that when we hopefully when
we meet we\'ll be able to finalize some definitions for these so that we
won\'t be confused. It sounds like one interpretation what transfers
mean and other, you know, from within a hospital, versus from an ED to
another hospital.

\>\> Right.

\>\> You\'re not worried necessarily about someone going from an ICU, to
a regular floor, for example, which a lot of hospitals will consider a
transfer. But that\'s not the kind of transfers we\'re talking about.

\>\> Eileen: This is Eileen. I would almost think that it\'s sort of a
variation on what the discharge disposition is. Whether the patient is
being discharged to home or to another facility.

\>\> That\'s correct.

\>\> It is. Has anyone looked to see if the data element exists in
current systems? I mean, kind of a condition on an existing element of
discharge. Rather than a unique concept in itself of movement to another
hospital.

\>\> I\'d have to validate that but I think that comes in the normal ADT
streams. It\'s probably under the disposition, discharge disposition. My
recollection it is there, too but I\'ll check that in our system. And
you will see in the patient data element there is a discharge chart
disposition. This is the only question, do you sum that up and put into
the daily facility or summary report. And we thought initially that
would be a useful thing when you\'re getting that 24-hour summary
report. But they will take some work to see if that\'s easily obtained
or not.

\>\> Right.

\>\> The BioSense team may be able to help.

\>\> Lynn: This is Lynn Steel, I just joined the call.

\>\> Hi, Lynn.

\>\> Lynn: Hi.

\>\> So the comment here about whether \-- how is it done in BioSense
now when you\'re trying to figure out something like the dispositions
from a hospital facility? Do you do that at the record level, or do they
roll that up into one value? Like how many transfers may be done from
one facility to another?

\>\> As far as I know, we may be getting disposition only for emergency
department from our emergency department patient.

\>\> That is kind of what we\'re talking about, though, Lynn, is the
concept that patients \-- if a small hospital is very busy and getting
lots of sick patients, which we may want to know about, they\'re going
to get overwhelmed and transfer those people out to other facilities.
And so just having the number of admissions to that facility may not
give you a full view of how many sick people are come into that
hospital.

\>\> Right. I think you\'re right. But I think we can only track
patients from a health care system to within that health care system. We
can look at transfers.

\>\> Capturing that as a disposition, Lynn. The transfer to another
facility. Their discharge disposition. So you can see that.

\>\> Lynn: You can see it within the health care system, not of course
if they are transferred. You would just know they were discharged from
that health care facility. We wouldn\'t know that they were admitted at
the hospital down the street.

\>\> Well, it\'s actually \--

\>\> There\'s a transfer.

\>\> I mean, I can tell you working in the ER, we do that all the time.
We have a certain kind of case that we can\'t admit locally, so we admit
it to another facility. So we set it up as a transfer and I\'d have to
see how that gets quoted out in the ADT system and if it\'s in the
disposition, it\'s not to discharge for followup as an outpatient but
from a facility but transfer to another facility very often a direct
admission to that other facility. So our ER \-- the ER I\'m working in
does the ER workup but the patient gets admitted to a different floor or
facility and doesn\'t go through the ER at the other facility.

\>\> I don\'t know how that\'s tracked in BioSense. I\'ll check.

\>\> Okay.

\>\> Anyway, you didn\'t hear, you may not have heard, Lynn, the HITSP
group, Dave Dobbs did a nice job of comparing the data elements from the
harmonized use to our draft of data elements we\'re developing and see
where they match or didn\'t match. Track and transfer was one of the
things tracked in the use harmonized case.

And I think last time we really didn\'t get into too much of the
specifics on the patient data elements beyond the clinical data. And on
the clinical data, the HITSP group was asking how much clinical data
should we really be trying to capture with this list. And where it
comes, in the harmonized use case a talks about getting triage data but
doesn\'t go into specifics of what triage data is to be included.

And on the one side you could say it\'s just chief complaint. On another
side you could say, well, it\'s chief complaint and vital signs and
nurse\'s notes and lists of symptoms, signs, blah blah blah. So you
could really try to get an awful lot of stuff there. And in the interest
of trying to keep it simple, maybe limit to chief complaint or chief
complaint plus fever. Maybe temperature is the better term. But we did
talk last time about trying to get nurse\'s notes, triage notes, heart
rates, pulse, et cetera. I wanted to talk to that again because that
came up at the HITSP discussion.

\>\> Anybody have ideas? I think that systems that have used chief
complaints, obviously understand the limits of that type of information.
North Carolina has had great experience with using the nursing triage
notes to quickly look at statistical anomaly and have the ability to
have more clinical information. And know that frankly there isn\'t
anything going on. Because the patients are so different.

\>\> And just limiting to chief complaint probably won\'t provide enough
clinical information to make it useful on a routine basis.

\>\> So there need to be additional parameters.

\>\> \-- whether that\'s real-time diagnosis, which is what we\'re
trying to explore getting, or some additional clinical notations. So
it\'s really for \--

\>\> How are they capturing that?

\>\> As text.

\>\> Okay.

\>\> So it\'s all the work that\'s going on around text parsing.

\>\> Didn\'t we also talk about the acuity, I don\'t know what that
actually was called.

\>\> Yeah, there\'s an acuity code, but the coding systems aren\'t
common all the time, one ER to another. The emergency severity index is
the one that \-- it\'s a 5-point scale most places are going to but a
lot are using four-point scales and it will be tricky to get a cross
mapping on that and have it meaningful.

\>\> Ed, are you concerned about using the chief complaint?

\>\> Ed: I think you want to use chief complaint because that\'s easily
obtained. But I think Lynn is speaking to the fact that it also has
limitations and you have to recognize the limitations and which things
we want to recommend. Because I think the things we recommend will drive
the changes in ERs. Most triage information including the initial vital
signs at most ERs is documented on hand by hand on a piece of paper.

So to get that into systems will take some changes. Now, there\'s
probably 10 percent of the ERs across the country that are starting to
document that information electronically. And so you might be able to
start getting that. And if we recommend it, it might help drive some
change in the industry.

\>\> So would that include \-- now, are you saying all the vitals and
the chief complaint being captured, and some electronic format?

\>\> Yeah, or we could recommend that those items be captured. And when
available. And I think if we recommend that and have that as kind of a
national standard, people should work toward T it may encourage more use
of electronic systems at triage, which I\'m certainly in favor of. We
just have to acknowledge that over this next year, even on an ideal
world you may only get that information from 5 or 10 percent of the ERs
in the country.

\>\> Right.

\>\> Perry: This is Perry. I\'m looking at the list of clinical data and
I thought we were saying that diagnosis codes would be part of the
dataset. So I agree we need to do chief complaint because it\'s probably
more readily available. But we\'re not \-- I don\'t think we\'re talking
about taking diagnosis off the list, right?

\>\> Correct.

\>\> Okay.

\>\> Any type of diagnosis. If there\'s a coded real-time \--

\>\> Right.

\>\> Okay.

\>\> And well, I think those of you who were on the call last time heard
my comments. I still don\'t see the bang for the buck to go after vital
signs. I think knowing somebody\'s fever or a normal distribution of
fever, or temperatures, rather, of ED visitors; not very helpful. I
think the diagnosis code is going to be much more helpful. And I might
add that I guess our ad hoc advisory group recommended against fever,
and I\'ve also talked with several people since our last call in public
health here in New York, and they also felt that vital signs were not
worth going after. But I think I was overruled on the last one, so if
folks want it, then I think that\'s fine. But we would probably need to
put it on as a nice to have, but if you can\'t give it to us, it\'s not,
you know \-- I agree, it\'s going to be hard to get it in the first
year.

\>\> So you\'re limiting the vitals at best to just temperature and
leaving off the others?

\>\> Are you asking me?

\>\> Yes, Perry, I mean, if you had \-- you didn\'t even mention any of
the others. You asked your colleagues about temperature \--

\>\> Perry: Temperature, right. We would not, I don\'t think, bother \--
I mean Lynn Steel may have more experience than I or my colleagues who
have commented on. But we don\'t see the value of getting vital signs
including temperature for this database. It\'s much more important to
get the diagnosis codes and whether somebody had a temperature of 99 or
103, I can\'t see how that\'s going to help. So I don\'t think it\'s
worth \--

\>\> If they have he no fever, it may help.

\>\> I thought we \-- where we ended up in our conversation on the last
call is we would add it but make the disclaimer that this was for
evaluation purposes to determine if this was a valuable element to get.
And then as these things are revisited and looked at, if it turns out
that it\'s not, then we would not and recommend it down the road.

\>\> Lynn, do you have any comments about that from the work that has
been done already with BioSense? Has fever, or temperature been used and
how has it been used? And is it \--

\>\> Lynn: I think it has been important for, you know, look at life
illness. Again, if you have clusters of a certain syndrome. Those \--
that additional bit of information has proven to be helpful. I mean,
there have been a number of abstracts in the literature. I guess again,
I think the questions is if it\'s fairly easy to get and it exists in
the system, you know, why not get it. And we know we\'re looking at maim
minimum dataset. But that minimum dataset needs to inform whether you
have a clinical condition in a group of people. So I think the less data
we have, the more danger we\'re going into, and not having the right
information when we need it.

\>\> Perry: Yeah, this is Perry. I just point out that our syndromic
surveillance systems in New York do not have fever and we\'ve tracked
influenza very well with our data. It doesn\'t help on a population
basis of telling when influenza occurs. In fact, we picked up \-- well,
I won\'t go into that just in terms of interest of time. But basically
we didn\'t find fever or temperature was helpful with influenza type
illness or needed because the other things were quite adequate. The
other point I would make is that again, this gets back to our
preconditions. Our third assumption that data are available within 24
hours with minimum new effort. And if we\'re only going \-- if only 5 or
10 percent of people, facilities can provide this information, it
doesn\'t seem to meet that precondition. So that\'s kind of the other
thing that\'s pushing me towards recommending that we not put it on the
list.

\>\> Ed: This is Ed. Maybe it would be reasonable to have our minimum
dataset that we think clearly everyone should focus on. But then have
some other things that are identified at the next focus for study in
terms of whether or not they may be beneficial and maybe this is a group
of things that should be studied. And I think it was Laura that said
maybe that\'s how we should classify it. But acknowledging that (a)
there aren\'t a lot of systems out there collecting this electronically
and (b) it needs to be studied to see what benefit it can have. That
might be another way of deal with this kind of development.

\>\> So are we suggesting that we have another attribute for these
variables, that would be evaluative, an evaluative stage or purpose so
that, for instance, for temperature, it wouldn\'t be in the minimum
dataset as an expectation at the very beginning but for those places
where it were available we would collect it and see if there were ways
that we were able to use it as Laura suggested?

\>\> That sounds fine to me.

\>\> Is that okay, Perry.

\>\> Perry: Yeah.

\>\> That sounds great. So Scott, if you\'re keeping track here, I guess
what this means to me is that the list of that \-- you have in the
minimum dataset, sheet, has another column that says for evaluation or
something along that line, and then the items that were discussed just
now, at least one of the vital signs temperature, but other three had
been mentioned. I don\'t know whether those are included in our desire
for evaluation as well. Lynn, do you have any comments on that? Or have
you just focused on temperature?

\>\> Lynn: Again, we\'re in \-- we are in that evaluation phase for
vital signs for ED patients.

\>\> Okay.

\>\> Lynn: So we\'ll be able to tell you more.

\>\> And Lynn, were you trying for Pulse Ox? Because that came up in the
ad hoc group as potentially important.

\>\> Lynn: Yeah, I think, again, where we\'ve seen that we can get that
data, and I don\'t think \--

\>\> You are trying to get, it okay.

\>\> Yes.

\>\> We kind of consider that the fifth vital sign in the ER.

\>\> Right.

\>\> Okay.

\>\> So we\'ll go ahead and list those five in there, and add another
column, at least we\'ve captured the thoughts that Ed was trying to
convey here in the bit of discussion.

\>\> HITSP, we did talk about even carrying it further, and I get the
sense we can draw the line here at this set of elements we want to have
for the evaluation phase and say even more detailed symptoms or sign,
for example, if the patient has crackles in the left lung base, if it\'s
captured in an electronic system is not the kind of thing we\'re going
to worry about at this time, correct?

\>\> Correct.

\>\> I don\'t think that we would be able to capture that. I don\'t
think that\'s something we want to focus on at this point.

\>\> I wanted to draft pretty clearly within point.

\>\> Yes.

\>\> Okay. Then moving on, there was discussion on lab and radiology
test orders. There is some discussion about radiology in particular,
we\'ve got lab and radiology test orders and down below we have lab and
microbiology results. We don\'t have radiology results. The question is
do we really need to track radiology items at all. For biosurveillance
purposes.

\>\> Wouldn\'t you want to know if people had an x-ray? I mean couldn\'t
you think of a use case where you would want to know that?

\>\> I think that\'s what Ed was saying. You would be able to get the
test orders.

\>\> Right.

\>\> Or were you saying, Ed, not even the test orders?

\>\> Ed: Well, for radiology, I\'m wondering if we need any of them.

\>\> Any of them.

\>\> At least compared to the priority level for some of these other
things.

\>\> Isn\'t it something that\'s already captured in the system, so it
may not that be difficult to pull out the number of chest x-rays that
were ordered.

\>\> Here was the BioSense agency rationale, too. If you get a chief
complaint, have a lot of people presenting with the same chief
complaint, and you don\'t have a real-time clinical diagnosis, because
the system doesn\'t capture that, as you\'ve already recognized, not all
of them will, by understanding the clinical workup might be all that you
have to understand who may indeed be an ill case, as you\'re waiting for
a coded diagnosis that could be late and a couple days old. So again, if
the purpose is that in a situation you want to understand who is the
cluster of patients who might have had diagnostic workups for something,
those radio lab orders are important for that purpose.

\>\> I understand what you\'re saying and I\'m still trying to think if
it would make a difference.

\>\> Steve: This is Steve. I have a question with regards to lab
results, whether it\'s radiology or laboratory and maybe even more as it
relates to the minimum dataset. Is the minimum dataset that we\'re
talking about here, then, a minimum? And a basic minimum that\'s
required? Meaning are we not going to want the dataset if certain
elements cannot be transmitted or aren\'t available? And why wouldn\'t
we want to have those types of data elements if they were available?

\>\> Because you\'ve got people pushing back on a national database
that\'s collecting lots of patient information, and may not have the
need to collect that patient information. So I think we need to have
some justification for collecting the data into a national database.

\>\> Well, the need, I think we\'ve talked about, that\'s the purpose of
the BioSense data program, and wouldn\'t pneumonia as a result of an
x-ray be relevant in that regard, as I would have thought elevated
temperature in X number of patients appear in the emergency rooms would
be relevant.

\>\> Eileen: This is Eileen. When I think about that, though, I think if
you have the results, that\'s tremendously relevant. But simply to know
how many chest x-rays were performed, given the number of different
reasons you do a chest x-ray on a patient coming into an emergency room,
other than suspicion of pneumonia, I\'m just not sure if we\'re
divorcing it from results and just saying we\'re getting the radiology
orders, how useful is that from biosurveillance perspective.

\>\> And I can tell you based on laboratory data, what we call the
numerator and denominator are extremely valuable. And we shouldn\'t be
trying to limit the ability to analyze this data solely by what appears
to us to be relevant. There\'s all kinds of algorithms now that we can
apply to this type of data that finds important information if we have
denominator and numerators. In this case the number of orders and the
number of orders which resulted in a positive.

\>\> Marty: But Ed\'s question is do we have that data for radiology
test orders yet or is this one of those attribute categories that\'s
really penned the evaluation for the minimum dataset at this point?

\>\> I think we\'d be well advised to really try to question ourselves
which of these things are really going to make a difference. Are we
confident they\'re going to make a difference? We think they might make
a difference and need evaluation or they\'re probably not going to make
a difference?

\>\> And how does that get involved in this discussion, meaning do we
then create three datasets, one for all of those three categories? Or
this first round do we create the dataset that would be nice and then
see in various ways of testing which one turns out to be valuable? What
is it we\'re doing? Is it the absolute minimum, and that we must have
it, or are we also seeking for data that we can learn something from?

\>\> I think if it\'s data we don\'t think will have value, it never
gets on list at all. We really only have two categories. One that we\'re
pretty confident will make a difference and we\'re ready to back up Lynn
and her team when they say I need this from a hospital across the
country. And another set that we say we\'re not sure if it will make a
difference or not but we think it might and should be evaluated further.
And then maybe get some tests \-- sentinel sites where you do get that
data and let Lynn\'s team evaluate it and see where it makes a
difference.

\>\> Then I think the data is fairly clear of the number of patients
appearing in emergency room with fever, is a predictor. And it has
correlation with disease. In the same way the number of positive chest
x-rays over the number that have been ordered, there\'s actually two
parameters that are predictive. Both the total number of increase in
order, over time, and the number that are positive.

\>\> Okay, so I\'ve got chest \-- I\'m ready to \-- I\'m encouraging
people to think this through. Not necessarily biased one way or other. I
guess I am when you get beyond chest x-ray and say do we need to check
how many ankle x-rays get tracked and I\'m having a hard time saying you
may want to know that.

\>\> You may want to know during a natural disaster or event that cause
as lot of trauma. Something was said here I want to understand. The
purpose of this is not to have a surveillance national database, but
making recommendations for biosurveillance data that would be useful for
local public health. I mean, that\'s the premise that BioSense is being
built on, right?

\>\> I understand.

\>\> There could be a need locally if there were something very unusual
going on for public health to want to follow up on all the patients who
had potentially x-rays or this lab order during this time period. So
it\'s he not just have to have the data in a national database but to
inform what the local public health investigation would be. To provide
clinical data to start that investigation, instead of how we typically
do it now. Which is go back and get all the information.

\>\> Uh-huh. So I want to make sure when we\'re talking about the use
case and the minimum, it\'s not just for a federal purpose.

\>\> I understand. I also think some of our local public health guys
that I work with, would say I have no interest in knowing how many ankle
x-rays you order on patients on a day-to-day basis.

\>\> Right up until they\'re interested in who might have sought care
for broken bones or something, you know, and we\'ve seen this in the
hurricane response. And I think that\'s another issue, that whether
analytics are performed on these data all the time is one thing. And I
don\'t know who that is that\'s talking, that\'s talking about the
ability to do more analytics on these data. But it\'s also to have data
available that\'s in these clinical systems as it\'s needed. And those
are sort of different uses. They\'re very different uses.

\>\> Marty: This is Marty. And perhaps this is helpful in reflecting
back to our assumptions, I think, about the minimum dataset. I don\'t
know if we have words in there on that. But because are we making a
distinction here between what\'s available on a routine basis all the
time, versus what the minimum dataset might happen in the case of any
particular situation?

\>\> I\'m sorry, Marty, could you repeat that?

\>\> Marty: Sure. Two thoughts. One is I think it\'s reflecting on as we
look at the preconditions, we want to make sure we reflect a bit that
we\'ve described the minimum dataset. That\'s what I\'ve been hearing in
the conversation. The assumptions related to it. But also I guess what
I\'ve been hearing on the lab and radiology test orders is two
directions. One is collecting because it may be available as an order
and we may potentially use it. Versus trying to be more precise such as
chest x-rays or others that are the type of order that makes sense that
we know of may be helpful at this point.

\>\> So if we go back to the five scenarios that we looked at, chest
x-ray would be helpful to one of them, but not all of them, or maybe a
couple of them. So are we still focused on the five different scenarios
which I think is what Lynn is pointing to, that there may be a broader
use of the data beyond something beyond pandemic flu or a biologic
agent. And should we be considering that at this point, or limiting
ourselves? And I think that\'s getting back to what you\'re asking,
Marty. How broad should we be. And I think as a group we decided we
wanted to be broader, at least to be inclusive of the national response
plan scenarios. So although I think it was Perry or Ed who said, you
know, I can\'t imagine any public health worker really wanting to know
about ankle x-rays, but if we\'re true to the five scenarios, how do we
make sure we\'re inclusive of those items?

Ed: When we went through the five scenarios, the orders that we thought
would be of interest, scenarios we\'re particularly cultures, both in
the major hurricane scenario and in the biofood contamination scenario
and I don\'t think we necessarily identified chest x-rays ordered as
being real important in any of those five.

\>\> Now, if there\'s an anthrax outbreak, could you say that chest
x-rays would certainly be of value.

\>\> Right.

\>\> I think that \--

\>\> Perry: This is Perry. I think Marty raised an interesting question,
which I hadn\'t thought about. And that is, at least if I interpreted
Marty\'s comment correctly. I thought Marty, you were making the point
that there is a difference potentially between the data that we might
request for all time, on a continuous basis, in other words, and data
that we might want to request in this dataset, depending upon the
situation. And that in negotiation we could probably think up a "what
if" for many test recognition and result where we might want to know it.
But that leads us down the road of wanting everything. So what was the
answer to that question? I mean, can we \-- or should we specify
elements that would be really good to have, but are not needed on a
continuous basis?

\>\> I actually interpreted Marty\'s question similarly and had me
concerned because I don\'t think we\'re talking about having data turned
on in a specific emergency. I mean, we\'ve already had multiple examples
where that really isn\'t feasible. So we\'re talking about the minimum
that we think public health needs in order to answer some of the early
questions. And once we have something new and we know it, there will be
new data elements, there will be new questions, and follow-up that need
to happen with clinical care, and that will happen in the normal way
that public health does, the public health investigations. But I don\'t
think we\'re going to have systems out there that send 25 data elements
now and if I call and you tell you there\'s an anthrax, then send these
other 6. We\'re not to that level yet. I don\'t know that we\'ll ever be
to that level. But that\'s not within the scope of what we\'re talking
about.

\>\> I don\'t know how technically feasible that would be.

Ed One of the things we should consider is advise HITSP on what data
elements do we want to have standards set up for doing that report. That
doesn\'t mean you can\'t set filters at the facility levels for certain
types of those data and not other types. And those filters certainly
could evolve over time. And you\'d still be using the same underlying
standard for how you (indiscernible) the data.

\>\> Absolutely.

\>\> Marty: That\'s a good point, Ed. One important is reflect that they
are in the minimum dataset, is what I\'m hearing, but we really need to
evaluate if it needs a filter in the case of radiology is what I\'ve
heard questioned at this point in some way. So we\'re interested in
hearing about it, but we need to, we need to make sure at least our job
will be to compare to, as Art said, the scenarios. And if it\'s
reflected there, it should be received. If it\'s not, then it has to be
evaluated relative to the filters. That\'s sort of what we\'ve said was
benchmark. It should be in if it supports the need of both scenarios.

\>\> That principle applies to the lab results as well. If we go to the
five scenarios we looked at, it\'s really micro biology results that is
important in those five scenarios. And not necessarily the other lab.
But if you specify the standard based on this list that we have in our
results reporting, you know, you can turn the filter on or off,
depending upon whether there\'s a determination. You also need CBCs or
electrolytes tests as well. Certainly the microbiology everybody agrees
is the most important thing to send through.

\>\> Marty: Do we have sort of a moving towards a consensus to help
answer Ed\'s question around lab and radiology? Lab and radio lab and
radiology? I\'m not sure which rows are in here, order number frequency
or order test. But I\'ve heard the lab order piece is in. Radiology is
probably in with evaluation of a filter.

\>\> Just so I\'m clear. That would be certain radiology orders, but not
all? So chest x-rays and maybe trauma related?

\>\> We would propose a filter that would match the need of the
scenario. In terms of the minimum dataset. For example, if it\'s chest
x-rays and ankle x-rays but nothing else, then that would meet the
minimum need to fit these five scenarios, that\'s what we would
recommend.

\>\> Well, we can defer setting where the filter gets set. We can say to
HITSP we want to be able to send lab results, radio results, and lab
orders and radio orders, and where that filter is going to be set is yet
to be determined. That\'s the part that\'s going to be evaluated.

\>\> Eileen: This is Eileen. I think also the interesting thing about
setting filters is that that increases dramatically the difficulty on
the part of the person sending, use of data. A lot of work to cut down
the amount of data that you get, while it\'s certainly understandable
because you want a dataset that\'s small enough for people to analyze
and work with and yet big enough to actually yield something, but
you\'re constantly increasing the difficulty of getting it from some
types of sites, depending upon how their data is coded or stored.

\>\> Marty: And this is Marty. I think one of the items on our next
meeting, the next steps, is really discuss options for feasibility. And
I think that what I\'m hearing you saying related to the notion of
filters, we have to look at that as part of our criteria for feasibility
as well.

\>\> Absolutely.

\>\> This is Scott. It also pertains to number 3 on our preconditions
with minimum new effort on the part of clinicians and facilities.

\>\> So for example, we might say that we only need certain radiology
test orders to fulfill the need of these scenarios, but in fact the
feasibility is it\'s going to be easier in the short-term for providers
to provide them all. As an example, I think we\'ve covered everything I
was hoping to cover in terms of relating HITSP\'s work with this
Workgroup at this point.

\>\> So from your point of view, Ed, if \-- do we have anything that\'s
out of MDS, in the current categories? When we look at this list of
categories? When we look at this list? We have two columns: in MDS, and
out of MDS. I\'ve heard of some evaluation as sort of a corollary to the
first column. But which \--

\>\> No, I think the only other difference between the harmonized use
case, and what we\'ve got here for our work in structure is that we\'re
getting into more specifics on the resource availability \-- the bed
categories, and we\'ve talked to the point that you need to know how are
these beds staffed, and not just there\'s a unit that exists and
there\'s three beds empty on that unit. And that changes that concept a
little bit. But it\'s really consistent with the have approach as well.

\>\> We may come back to this and this will get more into this in the
definitions portion, maybe at our face-to-face meeting. Marty and I were
talking about this a little before. It\'s now trying to be captured in
something around staffing problems, but it might be really better to say
how many staffed beds there are, rather than saying how many \-- whether
they\'re having staffing problems. That\'s pretty nondescript.

\>\> I agree. One of the things we can do at a face-to-face meeting is
I\'ll get the actual have specification, is just getting finalized now
through oasis so you can see how that relates to what we\'re trying to
achieve here.

\>\> Okay, that would be great.

\>\> That would be helpful.

\>\> Yeah, that would be very helpful.

\>\> So any other comments from you, Ed, or we\'ve covered most of what
you wanted to cover, or Eileen? I think Eileen was listed on agenda as
well. I haven\'t got my computer out, I\'m now in transit.

\>\> Eileen, are there other things you heard at some of our HITSP
meetings we didn\'t get to here?

\>\> Eileen: I think the main comment I had was there is definitely a
constant push to expand the datasets, and they have definitely been
hoping to get some guidance from us, but I just feel there\'s a lot of
very expansive thinking going on, and so the attempts to constrain what
we\'re doing, we\'re going to need to be very clear about where we
constrain it, why we think that\'s necessary and where we might want to
expand, it depending upon if we see a good rationale for something. But
other than that, nothing very specific at this point.

\>\> So are you saying that if we put something in the out MDS column,
we need to be putting in\' a reason for its exclusion at this point?

\>\> Not necessarily. But I think if we \-- I think as long as we\'re
kind of clear that we understand \-- I don\'t think we have to document
it, but I think that we need to just understand why we feel \-- more on
a generic sense or global sense, what we think is in scope or out of
scope. I don\'t think it\'s at the level of individual data item
particularly.

\>\> Is that something that we should put as one of the preconditions?
Is there a way that we would be able to call out what are our
expectations in that document, and how we develop the MDS, would that be
\--

\>\> I think that is kind of the point of the preconditions document, is
to declare what is our scope, what is our specific charge, and I mean I
think that\'s been what we\'ve been discussing all along.

\>\> And you think that\'s sufficient, then?

\>\> You know, at this point I do.

\>\> Okay.

\>\> Okay, good.

\>\> I mean, I don\'t think anybody is feeling really contentious. I
think they\'re just looking for guidance from us.

\>\> Okay. Well, thank you both. Ed, you probably have to run off to the
plane; is that right?

\>\> I do, I do. But I\'ll be in touch with everybody. Thank you.

\>\> Okay, thank you, Ed.

\>\> Ed: Bye, now.

\>\> Thanks, Ed.

\>\> So should we back up to the functional areas portion of the
discussion? Marty, I\'m now traveling. I\'ll be in the car for about ten
minutes. Maybe you could just kind of start us off there, because I
don\'t have a document in front of me, and I\'m driving.

\>\> Sure, thank you, everybody, on this. We\'ll take the \-- these
minimum data elements at the next meeting, we\'ll be working on it.
Looks like definition. And then the crosswalking those to the functions
as well as verifying what\'s in and what\'s out. So this has been a good
discussion. I\'m sensing most of these are going to be in, but we\'ll
find out.

The next item is we had talked about was the functional area results.
And if you recall, it\'s another spreadsheet, which you can bring up.
This one, Scott has nicely color coordinated. And with green and brown,
I believe, fits on your screen. And this we had made some progress on
and Scott sent it back to have us sort of reconfigure voting of what
should be addressed short-term, long-term or not in scope, was the main
focus of this in terms of functional areas.

Scott, could you perhaps just summarize for a moment on your process for
getting us here?

\>\> Scott: Well, what I did is I combined everybody\'s results and
thank you for getting those back to me. I also added your comments and
everybody\'s comments are included in the note section. I think at the
most we had maybe two comments. Against each element, and if I may,
we\'ll process and if we could run through these where we can see a
clear-cut consensus, maybe discuss for just a little bit on some of
these, move forward and cross some of these off our list, and then save
the discussion on the ones that we do not have a clear-cut consensus for
the in-person meeting on the 18th. If that would be okay with the group.

\>\> So Scott, we can get the not in scope ones that are clear, get
those marked, in particular?

\>\> Scott: Yes.

\>\> Okay.

\>\> Members, does that sound okay?

\>\> Yes.

\>\> Sounds good.

\>\> Sounds good, Scott.

\>\> Sounds good to me.

\>\> Okay, so if we go down to outbreak management, I\'m going to skip 1
to 3 and let's go to 4, data collection, packaging, shipment of critical
environmental assessments. We\'ve come to an agreement that was out of
scope, correct?

\>\> Yep.

\>\> Yes.

\>\> Uh-huh.

\>\> All right. Next page, connecting laboratory systems. Number 2,
receipt management of specimen and sample data. Not in scope. Agreement?

\>\> Yes.

\>\> We\'ll move down to counter measures and response of
administration. Number 7. Links to distribution

vehicles. Not in scope? Yes.

\>\> And we\'ll move to partner communications and alerting. Looks like
all three, 2, 3 and 4 each have a #5 there listed. I\'ll let the group
decide whether you want to carry that forward as not in scope.

\>\> Members, any comments, any reason to not move those to not in
scope?

\>\> No.

\>\> Perry: This is Perry. I voted not in scope, so I would support
that. But obviously somebody voted otherwise.

\>\> Is this the first one under partner communications?

\>\> The second, third and fourth. Multiple channels of distribution.

\>\> And select distribution based on urgency.

\>\> I voted not in scope as well. But certainly the data we\'re talking
about informs these things, that\'s what makes it a bit confusing.

\>\> Right, but that\'s a secondary event.

\>\> I agree.

\>\> I agree.

\>\> Sure.

\>\> We all agree with you there.

\>\> Well, we can look at these again, but unless there\'s a compelling
reason, we\'ve heard, I guess I would suggest we move those to out of
scope at this point. Unless we find come back to the use cases of
functionality that we really missed something.

\>\> Is that okay with folks?

\>\> Sounds okay to me.

\>\> I\'m fine.

\>\> Okay, Scott. Sounds like everyone is nodding.

\>\> Scott: So I\'m going to turn it back over to you to go through the
outbreak management. One and 2 are pretty much across the board. Three
you could possibly make a case for not in scope. Five and 6 are again
kind of across the board. So along with #7 there\'s kind of a clear-cut
not in scope. So I think we need to discuss those a little bit more.

\>\> The other \-- this is Marty. And I think the \-- if we look at
outbreak management, there\'s a possible out of scope is that #3,
exposure source investigation and linking of cases in context to
exposure, versus \-- that was 5 for not no scope. And 1 and 2. Can we
talk about that out of the context of the others? Or how are people
feeling about #3? Any difference from their voting?

\>\> Lynn: This is Lynn again. I may have put one of the 1s or 2s in
there. You know, again, it\'s hard to separate when we know that these
data are going to be used to help kick-start public health
investigations.

\>\> Right.

\>\> Maybe I was looking at it differently. So certainly we want to make
sure the biosurveillance data can initiate exposure source
investigations, whether it \-- it\'s not all that you would need to
develop a capability for source investigation.

\>\> So usefulness for but not required to do it. Not essential to do
it.

\>\> Right.

\>\> Do we look at this in any different way because of that? I mean, I
guess my assumption here and perhaps it should be in a precondition, is
that it could be useful for a variety of functions, but the minimum

dataset should support these functions.

\>\> Right. And my mind that at least those first three would need to be
supported by real-time biosurveillance data.

\>\> Perry: This is Perry. I guess I was one of the ones that voted out
of scope, and I don\'t disagree with anything that\'s just been said.
It\'s the "should be supported" phrase that I think is resulting in the
different votes. When I hear should be supported, that changes the way I
would think about the minimum dataset. I\'d be including a lot more in
it. So these are tough nuances to try to tease out. But in other words,
we do there\'s so much involved in a case investigation during an
outbreak, that I think what we\'re saying is that the minimum dataset
should support it in the sense that it may identify cases, it may point
us in directions, it may \-- to investigate. It may take us to emergency
departments we wouldn\'t otherwise know about. Supported in that
fashion. But are we saying that it would not \-- we don\'t need all the
data that would be collected during an outbreak. And that\'s kind of the
nuance that\'s hard to put into a table like this.

\>\> And as I say, I think it\'s leading to different votes.

\>\> How about contributes to?

\>\> Well, I have no problem \-- yeah, in the comment or the notes part,
you mean?

\>\> Instead of saying it should support, because that has given some,
at least, the impression that it does that entire function.

\>\> Right.

\>\> But we\'re saying this biosurveillance data generally contributes
to or assists with or whatever the language is we decide we want, but
we\'re not talking about it taking over public health investigation by
any means.

\>\> Yeah.

\>\> Right.

\>\> Or case reporting.

\>\> Right, I think my comment was that it informs. Informs all of these
things.

\>\> That\'s fine. As I say, I think at least speaking for myself, I
agree with everything we\'re saying. It\'s just hard to put it into a
grid here, I think. In a sense, everything on this table is informed or
could be informed by biosurveillance, even the minimum datasets. So the
way approach this, and the reason I put things out of scope was that I
kind of felt like I don\'t need to worry about outbreak management
system, and all the data need that go into an outbreak management system
because I know that we will be able to follow back on every case because
that\'s part of our event detection. So I kind of approached it
differently. I don\'t think we\'re in disagreement. It\'s just kind of
the way I\'m thinking about it. So maybe, Marty, this to some degree,
it\'s not important that we pin everything down as long as we all know
what we mean. I think one of our challenges we\'re trying to put in the
short-term first year is making sure we have the data that will support
this function on the left. And so what do we mean by contribute to and
support, I guess is the \-- is this definitional question that I\'m
hearing.

\>\> Well, let me in an attempt to move this along, let me ask, I think
it was Lynn and Laura who were speaking or whoever was just speaking, if
you took this first one, the case investigation management, number one,
out of scope, would that change anything in the minimum dataset, in your
thinking?

\>\> Does putting it in or out of scope change anything in the way you
would approach the minimum dataset? The way I\'m thinking about it, it
doesn\'t.

\>\> I\'d sate way I\'m thinking about it, it does.

\>\> Lynn: And this is Lynn Steel. This is probably why I keep pushing
for more clinical data rather than less. Because anything that can be
provided that exists in hospital IT system that we can help make
standard, advances public health\'s ability to complete the exposure
tracing, complete the investigation. So it\'s providing more data up
front from which to work. So if you say these are not in scope, then it
really is not helping define the use of the biosurveillance data.

\>\> Bill: This is Bill Stephens. Let me add a methodology nuance, that
may \-- it may clarify this or it may confuse it further, I\'m not sure.
But in our case, you know, when we look at the minimum \-- when we talk
minimum datasets, guess I\'m looking at it as something defined as a
standard set that will be collected and in Lynn\'s terminology, it\'s
going to be a clinical, maybe an expand clinical dataset that will be
collected regardless. In our case we\'re just looking for things that
support the expand clinical dataset, such that when we get the pointers,
or the alerts or whatever that tell thaws we need to go to the next
phase, we will actually extract almost a customized set of \-- and
we\'re working on defining that customized set of case records, but we
by no means expect that will be standard or standardized for around the
country. So again, that\'s I didn\'t tends to look at that time as more
of minimum dataset that doesn\'t include the expand things that we will
go after for a specific cases that are minimum dataset will tell us how
to get back to. I guess it\'s the idea of going back, or when you say go
after.

\>\> But it\'s an automated process. It\'s still automated. I didn\'t
mean to imply that it\'s a manual or time consuming thing. It\'s just
that we\'re not continuously collecting data that way. And then you
know, throwing it away and 90 percent of the cases where nothing is
happening, but we\'re only collecting it when we need it as indicated by
earlier vectors in this event cycle.

\>\> What I\'m hearing is that in the whole outbreak management piece,
that if we\'re looking at the minimum dataset, contributed to or
supporting this effort from our first discussion, that it in fact may
not be short-term. But in fact we\'ve included it as part of the areas
that we want to support. So if we call on what our previous discussions
today I guess I would see the 1, 2 and 3 falling into the longer term.
But as contributing to and supporting not \-- but not out of scope. If
they\'re in scope but perhaps not in the immediate term.

\>\> Bill: I originally voted not in scope but under those terms, I
would be willing to change my vote to the 2- to 3-year time frame.

\>\> Thoughts from other members on taking that approach with those
first three?

\>\> Perry: In terms of #3, can someone explaining what that means in
terms of the minimum dataset? How would you exposure sources? Are you
talking about collecting, I don\'t know, food that people ate, or
restaurants where they ate? I\'m not sure what this is.

\>\> Again, to me, this is the way I interpret it, that if there was an
exposure, any kind of numbers of exposures, you would be able to track
similar patients who were hospitalized or appeared with the same
symptoms. So again it\'s information the exposure, base on data elements
that you would have access to. If a, exposure occurred as partner of the
health care associated outbreak, for example.

\>\> What would be the variable be that you would be collecting?

\>\> For exposure?

\>\> It could be just the time and space of people presenting to that
health care facility. So again it\'s providing a jump start on that
investigation. It\'s not \-- and some clinical data that would help
public health rule in and rule out who would need further followup.
It\'s not, as I think everyone said, the sum total exposure of the
investigation.

\>\> I hear what you\'re saying, Perry. Our model up to this point has
primarily been people with some type of symptoms, whereas, if the
exposure source, you are looking at individuals that maybe exposed.

\>\> You would probably look at groups of people with certain symptoms,
based on the suspicion, for an exposure. But again to be able to link
people by place and time and have that available because it comes
through a biosurveillance system, as transmitted data. Would advance how
we do exposure investigation now.

\>\> Eileen: This is Eileen. I\'m sorry about the music before.

\>\> It was lovely.

\>\> I apologize, it was something urgent came up and I wasn\'t aware
you\'d get the music. But if we go back to our original and our specific
charge as we\'re looking at the electronic data sources from which
we\'re getting data to which calling them minimum dataset, is the
information about the source investigation and linking of contact, would
that stuff be expected to be in any of the systems that we\'re looking
at as sources for data? I mean, it seems fairly unlikely that would be a
emergency department, or a hospital, certainly wouldn\'t be in a
clinical laboratory. So I think that\'s why when I looked at this, I
thought it was completely out of scope because I just didn\'t see the
source data existing in our targets for the electronically available
data.

\>\> Art: This is Art, I\'m sorry, I dropped off the call and finally
got back on. Are you hearing me now, or not?

\>\> Yes, Art.

\>\> Art: I look at that, I also voted no on that one, and I think Lynn
is trying to suggest a slightly different definition for this exposure
source investigation than we traditionally look at as kind of a public
health source investigation. I interpret your comments, Lynn, more along
the line of under Early Event Detection Point 3, about the size,
location and you\'re now adding the word timing and spread of a health
event. So I think that you\'re suggesting a more liberal interpretation
of the word exposure source investigation, and I think Perry, if I
understood correct earlier was not hearing that definition.

\>\> I would agree with you, Art. This is Marty. I heard both of those
and that\'s, I think, our challenge with this definition.

\>\> And I agree with your interpretation, yes.

\>\> So I dropped off the call, I don\'t know where we are in this
section. Scott, could you just quickly recap for me where we are here?

\>\> Scott: Yes. We\'ve assigned you, Art, the rest of the MDS. No.
\[Laughter\] We were just basically, we went through real quick and kind
of took off some of the obvious not in scopes. We went back to outbreak
management and in particular 1, 2 and 3, we were discussing whether
those were worth carrying forward for the functional areas or does #3
get not in scope. So I think we need some more discussion, or either
from weigh heard, it needs to be moved to more of a long-term just
because it supports the MDS, but it may not be electronically available,
or feasible or help us move forward, but it\'s a nice to have, and it
would support that longer-term goal.

\>\> Right.

\>\> That\'s kind of where we left it off, I believe.

\>\> I want to be mindful of the time here, because I know Marty need
(indiscernible).

\>\> And which need to have public comment period also.

\>\> We need public comment as well. Maybe you\'re able to now
((indiscernible) as appears to me on this functional area sheet and then
we can circulate that again before the next time we talk. And maybe move
on to the public comment section here, if there are no burning comments
from members of the group. We did go over last time, and I do want to
end on time, if possible. Any comments from the group? I know we\'ve
made a little progress here. We have not completed this sheet, but
we\'re still making progress, each of these calls.

\>\> Art, this is Marty. We have brought 6 into not in scope so. Six
have been removed to the not in scope area, plus I think we\'re at a
good point here for the next meeting to really finish the both what is
in scope and for those that definitely are in and then look at a couple
of these like the #3. That may or may not in scope. But I\'m hearing in
#3, I guess my summary, probably not in scope at this point.

\>\> Let me confirm. In the outbreak \--

\>\> No, 6 more in the whole document.

\>\> Oh, 6 more in the whole document. Okay, great.

\>\> Very good.

\>\> Well, back to our agenda, which \-- (indiscernible) we have some
items listed for the meeting on the 18th. Did anybody have any other
proposed items for us to discuss? At our face to face meeting?

\>\> Eileen: This is Eileen. Both Ed and I have will have come back from
the AAMSI, HITSP meeting so we\'ll obviously give the group a further
update on that. Because we will be finalizing our recommendations at
that meeting or at least that\'s our intention.

\>\> Okay. So we can maybe put putt that as an item on the agenda as
well.

\>\> Art, this is Bill Stephens. On the \-- and maybe this is on the
agenda, but if we\'re finalizing the MDS, when you say for the crosswalk
functions on the bullets, is that sort of basically cross-checking the
MDS against the five scenarios?

\>\> Well, I think it\'s \-- back to the functions \-- I believe, for
the \-- the document we just went through, this functional areas, and
hopefully those are mapped back as well to the five scenarios we
selected from the national response plan.

\>\> Marty: We hope that all of these will make sense together. The
scenarios, the functions and the minimum dataset. So it relates, and I
think what I would add to that is from the call today is the
definitions. We talked a little about making sure that the definitions
are the intent of the meaning of the data category definitions. Is clear
as well.

\>\> Good.

\>\> Let me just quickly ask the group, did everybody see from Joy King
about travel arrangements?

\>\> Yes.

\>\> Okay.

\>\> I would encourage you all to make those arrangements as soon as
possible. Thanks, Scott.

\>\> And that\'s \-- I\'m sorry, I\'ve been out and have hundreds of
e-mails to catch up on. The name again is from?

\>\> Will be from Joy King from Health Sciences Research, I believe.

\>\> Health Systems Research.

\>\> Excuse me.

\>\> I\'ll be looking for that.

\>\> Good. Other comments for the next meeting? Which is next week. And
from the agenda. We\'ll draft up the agenda for that, then and work with
Art to do that. Other next step issues, Art? Are we ready for public
comments?

\>\> Perry: This is Perry. Of could I make a request that it would be
helpful and you may have already done this, and if so I have misplaced
it. Could you circulate a list of all the formal members of the groups
and their affiliations? There\'s still folks on the call that I\'m not
terribly familiar with.

\>\> You\'re not trying to get me kicked off, Perry, are you?
\[Laughter\]

\>\> Perry: No.

\>\> That was a joke.

\>\> I think that\'s very doable. Not a problem.

\>\> Thanks.

\>\> Thanks, Perry. Terrific. Other comments? Or things we need to
prepare for the next meeting from your perspective? All right. All
right, anything else you have?

\>\> Should we open it up for public comment now, gentlemen? I think so,
Art. Are you still there?

\>\> Art: I am here. Can you hear me?

\>\> You\'re fading out a little bit.

\>\> Art: Can you hear me now?

\>\> Yes.

\>\> Yes, should be able to open it up for public comment.

\>\> I\'m in a place where the reception is not so great.

\>\> Please grade and open to public comment.

\>\> If you\'re already on the line as a member of the public, you can
go ahead and press Star 1 right now to indicate that you want to ask a
question. If you have been following along, the broadcast, on the
streaming side of things, you can now dial 1-877-407-3039, and once you
get in to the call, just press Star 1 to indicate that you have a
question. And if you guys want to go ahead and wrap up with final
comments while we\'re getting anybody that may queue up, you can go
ahead and do that.

\>\> Okay. Scott, would you ask joy to send that to me again. I do not
see it in my e-mail.

\>\> From Thomas Mitchell.

\>\> From Thomas \--

\>\> Mitchell.

\>\> Okay, let me try that name.

\>\> Friday around 2:40.

\>\> Did you hear that, Art?

\>\> Art: Yes, now I have. Thank you.

\>\> And please bring some of that dry air from Colorado back with you.

\>\> Art: It\'s been raining some here. It\'s not quite as dry as usual,
but I\'ll do my best.

\>\> Thank you.

\>\> Rain, Art, what\'s that?

\>\> Other feedback from the members. Have the 2-hour calls been all
right, as far as the length? Better than the 4 hours?

\>\> Yes.

\>\> Better.

\>\> Mark: This is Mark Rothstein, let me thank you for letting me lurk
on the call and get up to speed on issues. Appreciate the discussion.

\>\> Thank you very much.

\>\> Thank you everybody.

\>\> Thank you.

\>\> Do we have public comment from outside? We have no members of the
public asking questions, so if you want to go ahead and adjourn the
call, you are welcome to.

\>\> Well, thank you all for your participation today. I look forward to
the face to face meeting, finally meeting all of you, and I think we are
making progress. It\'s slow but steady. I know we\'ll do much better as
a group together having spent this much time working on this so far.
Thank you all for your participation today.

\>\> Thank you, Art.

\>\> Thank you.

\>\> I agree. Thank you all.

\>\> Bye-bye.

\>\> Great comments. We\'re making progress. See you next week.

\>\> Bye-bye.

\>\> Thanks, Marty.

\>\> Thank you, everybody.