American Health Information Community

Electronic Health Records Workgroup #12

January 11, 2007

**Disclaimer**

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

**\>\> Matt McCoy:**

Okay, we\'re set to get going.

**\>\>**

Great.

**\>\> Jonathan Perlin:**

Good morning, everybody, this is Jon Perlin and let me first start. And
joining with my co-chair, Lillee and welcoming you and to thanks you for
your participation and hope everyone had good holidays, that your new
year is off to a great start.

Let me turn to Matt or to the office there just to complete roll call,
and do we have a quorum?

**\>\> Matt McCoy:**

I\'ll just read off who we have on the phone and then I\'ll let you
introduce \-- I know you have a big group there with you today.

On the phone we have Bart Harmon from the Department of Defense. Jason
Dubois from the American Clinical Laboratory Association. John Tooker
from the American College of Physicians. Both our co-chairs, Lillee
Gelinas and Dr. Jonathan Perlin. Ken Waldbillig from EMC. Howard
Eisenstein from the Federation of American Hospitals. John Houston,
NCVHS; Jon White from AHRQ; Mike Kappel, McKesson; Blackford Middleton
from HIMSS. And James Sorache is here for Barry Straube today from CMS.

Are there other folks on the phone who I missed?

Okay, Karen.

**\>\> Karen Bell:**

Yes, actually I\'m here as the lone person that\'s on the list, but we
do have in the room with us a number of presenters for which we are very
grateful for their time and commitment. Rather than introduce them all
right now, I will introduce them at the time that they\'re actually
going to be doing the presentations, if I might.

**\>\> Matt McCoy:**

Okay, and no other workgroup members there with you?

**\>\> Karen Bell:**

No.

**\>\> Matt McCoy:**

And a quick reminder about the way these things work since it\'s been a
while since we did the last one. For everybody on the phone, please keep
muted when you\'re not speaking so we don\'t get a lot of extra noise.
When you do come in to say something, say your name first so other
members on the phone and members of the public know who will be
speaking. Later on we\'ll be demonstratinging a couple of EHRs and
you\'ll be seeing a little different version of the webcast than we\'ve
used in the past but I think I\'ll wait until we get there and walk
everybody through it when the time comes.

**\>\> Jonathan Perlin:**

Terrific. Thank you all for the introductions. We have an absolutely
terrific agenda today from the perspective of learning how a number of
systems have implemented technologies very successfully. I make this
point not only to commend the represented organizations for their
leadership but to take us back to our initial charge.

How do we advise AHIC, how do we synthesize the learnings to help
increase the adoption and implementation of electronic health records?
And so I think we need to set for us with this great learning
opportunity that we have in terms of overcoming legal and regulatory
hurdles, in terms of seeing some benchmark federal implementations of
electronic health records. Next time we\'ll see some implementations in
the private sector. And some of the E-prescribing. How do we learn what
helps in each of these environments to surmount some of the obstacles
that continue to either be or perceived to be obstacles in the public
and private environment toward the implementation of electronic health
records?

So I\'d ask each of the workgroup members to help me with an assignment,
to help Lillee and I with a task, which is that I\'d ask you as we go
through these presentations to be thinking of your top three
recommendations to surmounting what you believe to be environmental
obstacles to broader adoption of electronic health records. That would
require two parts. One, it implies identification of an obstacle or
barrier. But two, it also involves identifying an insight that will help
us move the ball down field in terms of making recommendations to the
overall community and to the secretary, to help achieve our objective of
rapid adoption, implementation of electronic health records.

Let me turn to Lillee because I know you may want to comment on this as
well, because of a shared passion for really the ability to improve
quality and efficiency and safety.

**\>\> Lillee Smith Gelinas:**

Thank you, Jonathan, and we absolutely want to make sure we synthesize
what we\'re hearing and learning in our call today in order to make
clear and crisp recommendations that are actionable. So I just want to
reiterate what Jon said, it is so important for us to constantly go back
to our broad charge and our specific charge and make sure we have
progress. We\'re certainly into the second year of operations here and
want to make sure that we\'re remaining relevant to the process. Thank
you, Jon.

**\>\> Jonathan Perlin:**

Thank you, Lillee. And I think all of us will take that as a task. So we
will have not only an agenda, but we will have a moment for some summary
either after each of the blocks not only for the usual comment, but
really looking forward to synthesizing these learnings into, as Lillee
said, crystal recommendations to community and to the secretary.

Let\'s take a moment and I know people likely had a chance to look over
the minutes. Let me hear any amendments, corrections, recommendations,
or motions for approval.

**\>\> Ken Waldbilligs:**

This is Ken W. A motion to approve.

**\>\> Jonathan Perlin:**

Thank you. Are there any comments anyone would like to make on the
minutes?

**\>\> Lillee Smith Gelinas:**

It\'s Lillee. I want to commend the staff because I can see Christmas
occurring if I look at the minutes occurring from the first workgroup. I
greatly appreciate the succinctness of staff action. I would second the
motion for approval, and have \-- ask for a caveat in that the staff
circle back to the workgroup and give us a status on the 11 action items
that came out of the November meeting, so we can assure where we are
able to scratch that one off, where there still may be gaps, and what
operationally we need to do to address the actions. I thought the
workgroup did a great job in distilling what the actions from the
workgroup meeting needed to be. Staff did a great job picking up those
actions. If we could just circle back and get the status. Thank you.

**\>\> Jonathan Perlin:**

Thank you, Lillee. I think that\'s a great recommendation there, so
unless there are any objections, let\'s consider the minutes approved
with proviso the staff will come back next time on the status of the
open action items. And a loop to close there.

Let us then, by way of segue, then, into really a nice framing of
thinking about how to encourage the adoption, the discussion, the
baseline, of EHR adoption measurement. Certainly this has been occurring
through a number of our meetings, the great work that Carolyn Clancy,
Dave Blumenthal have done, and in the agenda today you see a web link to
the Robert Wood Johnson Foundation in terms of the information that\'s
available there and considering the information base. And I believe it
was last time, perhaps the meeting before Helga R, from the Office of
National Coordinator, as well as reports from the commonwealth fund, all
looking at the state of adoption in United States and in fact
internationally, and certainly necessary descriptor of the environment
for us to be able to understand not only where we are but how we
accelerate this adoption of electronic health records.

So welcome, Karen.

**\>\> Karen Bell:**

Thank you, so much. It\'s a pleasure to be here in the new year and a
pleasure to be here with all of you. Before I jump into that, Dr.
Perlin, though, I would just like to perform the usual role of our
office and remind everyone that this is a FACA. It is a federal advisory
committee subject to that act, and as such it is open to the public and
there will be public comment, and every comment that is made here is
available to the public. So that just needs to be clarified up front.

And from that, I would like to meet your challenge and explain to you a
little bit about the position that the secretary has taken with respect
to accepting a baseline EHR adoption rate of 10% in the physician
community in the United States.

As you know, and you have just mentioned, there have been a number of
studies that have articulated adoption rates as high as 25% and some
significantly lower than the 10. The Robert Wood Johnson link that you
have on your agenda basically is a result of a report that has has
standardized the definition of EHR adoption. And that standardized
definition not just \-- does not just include the presence of an EHR in
a physician\'s office, but the actual use of four basic components that
the IOM articulated some time ago. And those are the ability to order
lab results and obtain lab results. The ability to order prescriptions,
and lastly the fourth is the ability to keep track of progress notes.

So those are four very, very basic functionalities, but when one looks
at all of the surveys that are published and apply those criteria, the
rate turned out to be much lower than we believed it to be. We\'ve been
working with a 17% baseline, but we have re-baselined to 10% and the
secretary is accepting that baseline for 2006 as the baseline from which
we work with a target of 51% using the same measurement methodology for
2014.

So I just wanted to make sure that everyone understands why it is 10%
and what that actually means in terms of meeting the presidential goal.
It means we have a long way to go. So your concentration, a little bit
earlier, on the need for recommendations to address barriers and to move
forward with enablers is even more important.

I would also like to just remind everyone that we have a meeting on
March \-- I\'m sorry. On February 22^nd^, in preparation for
recommendations formation in March. We have been working, actually very
hard over the last several weeks to pull together the richness of the
presentations that we have had to date so that it will be a little bit
easier, we hope, for you all to formulate those recommendations so that
you will be asked to do a little homework between now and February 2nd.

You will be receiving one page, or actually several pages of
consolidated discussion in the five major areas that the Blumenthal
group articulated. The financial area, medical/legal area, technical
area, privacy and security, and work flow cultural. These five areas.
We\'ve again pulled together all of the presentation material, all of
the discussion material in these areas with the hope that you will find
this a good platform for your discussions and for your thoughts on the
barriers and the enablers.

And there\'s one more thing that I would also like to share with the
group, and that\'s that our office has also been very engaged with
pulling together all of the good feedback that\'s come from all of the
workgroups on how we may move forward with priorities over the course of
the next year or two.

To that end, a series of about nine different \-- and I\'m going to call
them use cases, or priorities for moving forward, will be presented to
the American Health Information Community on the 23rd of January. All of
the workgroup co-chairs will see these beforehand and there will be a
representative from the workgroups who will be discussing the various
perspectives. The provider perspective, the patient perspective, and
then what we are now calling the other perspective for these particular
scenarios.

Dr. Blackford Middleton has agreed to provide the provider perspective
on these, and he will undoubtedly be contacting some of you before that
actual presentation. And there will be, again, the prioritization
amongst all of these scenarios at the AHIC meeting to move forward. So
there will be more information on that come to all of you again just
before the meeting on the 23rd of January.

**\>\> Blackford Middleton:**

Karen, it\'s Blackford here. I want to say how privileged and honored I
am to represent the group.

**\>\> Karen Bell:**

Thank you, Blackford, I\'m glad you\'re with us and very delighted that
you can do this for us.

Now, lastly, I would also like to introduce Alicia Bradford who is here
with me, because she is going to move on to the last piece of discussion
that this office will be contributing to this afternoon. One of the
things that you know we have been oft to do is to demonstrate the value
of the ability to access historical lab data by all providers taking
care of a given patient. There are many barriers to this, not the least
of which are state-based barriers, CLIA barriers, technical barriers.
However, we\'ve been working very hard to address most of those, and in
our report in February we will come back to you with all of the
follow-up from your previous recommendations and also the items that we
have outlined here today in last meeting\'s minutes.

So in order to move forward, though, with the demonstration of the value
we have to have a clear way of defining what value is. And so we\'ve
been working with a number of people, both internally and externally to
move forward in that direction. And with your permission, I would like
to turn now to Alicia who will talk a little about how that process is
going.

**\>\> Alicia Bradford:**

Thanks, Karen. In your packet from \-- for today\'s meeting you received
the very draft pilot planning, one and a half page document that
reflects the discussion that Karen and I have had with those federal
agencies such as ARC, given their extensive history with research in
this area. And also some members from the workgroup and others regarding
how best to demonstrate this value. What we\'ve learned from the
workgroup\'s testimony and other areas, other work done in this area.
And any potential metrics. And believe it or not, it was fairly hard to
come up with a metric. So you\'ll see several, under the four
categories, we felt these metrics could fall into. Quality, patient,
state, satisfaction, provider satisfaction, and cost we have several
areas we think that this could be impacted such as adverse drug events,
and improved timeliness of results. But we still need a little
assistance in coming up with some potential metrics. So I would ask that
the workgroup members take a look at this and give me any feedback they
have regarding potential metrics or direction we think these four
categories are going into regarding value. And if they can give me
comments back by the 30th, I\'ll turn that around with a very high level
scope of work regarding the use of this demonstration, and again ask for
your feedback on that also. Feedback on that also.

**\>\> Jonathan Perlin:**

Alicia, thank you very much for that introduction, and Karen as well for
the introduction to the Robert Wood Johnson Foundation publication.

Let me just open the floor for a moment for any comments from the
members of the group on either the adoption baseline or the lab metrics.

**\>\> Jason DuBois:**

This is Jason Dubois with AHRQ. I had a question about the metrics work.

**\>\>**

Yes?

**\>\> Jason DuBois:**

That is the study that\'s going to be performed by this, is that going
to be a (indiscernible) study and AHRQ one? I know that all of our
discussions, I guess seemingly lead together road map for what you\'d
like to be studied, but could you talk a little bit more about that?

**\>\> Karen Bell:**

I\'ll jump in and answer that one, if I might. This is Karen Bell. The
hope here is that we will be able to show the value of access to true
historical laboratory information so that a patient who is seeing a
physician will know that physician has access with their permission,
obviously, to the full range of their laboratory data, not simply what
that physician has just ordered.

And we believe that that will bring value to a number of different
entities and we\'re defining actually provider as both the provider of
care and the laboratory provider as well. So we are looking to see what
value this will bring to the laboratories.

**\>\>** Is that something that you guys are going to do, Dr. Bell,
that\'s not that you\'re passing it off to another agency?

**\>\> Karen Bell:**

We\'ll be the owners of that study.

**\>\>**

Okay.

**\>\> Karen Bell:**

We will contract it out, but we will be the contractor for that study.

**\>\>**

Great, because I think there is a lot of evidence, quite frankly, out
there, not the least of which is the Indianapolis being an example of,
you know, the physician-ordered test historically captured by the RIO,
making it available to other entities.

**\>\> Karen Bell:**

That\'s correct, and we will be looking to leverage work that\'s already
been done, and add to that. We certainly don\'t want to be redundant.

**\>\>** Blackford Middleton:

Karen, it\'s Blackford. I refer back to the CITL study on
interoperability, too.

**\>\> Karen Bell:**

Absolutely, thank you.

**\>\> Ken Waldbilligs:**

Hi, this is Ken W. How is it planned to capture the informed consent?

**\>\> Karen Bell:**

At this particular point in time we\'re continuing to work with some of
the other entities that are working on this right now within the NHIN
contracted piece, and also in the privacy and security realm. So at this
point I can\'t tell you exactly how it\'s going to happen, it\'s still
ongoing work.

**\>\> Jonathan Perlin:**

Any other questions for either Dr. Bill or Alicia Bradford?

**\>\> Lillee Smith Gelinas:**

This is Lillee for Dr. Bell. On the Robert wood Johnson publication, I
know the one action item is altering the baseline. But I\'m curious to
know if the ONC staff, in reading that, were there any other explicit
ideas for recommendations around adoption, or is there anything that we
really need to change in our thinking? Not just, you know, what the
number of the rate of adoption was, but if you just go to the Robert
Wood Johnson Foundation website, there are a number of publications
they\'ve put out on EHRs and health information technology. So I\'m just
wondering if you, as staff, have recommendations to us as the workgroup
on any other implications other than just changing the baseline date?

**\>\> Karen Bell:**

Thank you very much, Lillee. I think that\'s a very good opportunity for
me to suggest that the structure on which we are basing our
recommendations actually came from this work, understanding that there
are barriers in the financial arena and others as well. And I think that
what you are suggesting could be for us to, in addition to summarizing
the information that we\'ve gleaned from so many good presenters over
the course of the past year or so, to also summarize some of the
findings that did come from that report, because many of them are very
consistent with the direction we are going in. And if we have missed a
few, then I think that will certainly help us in our analysis. So we
will produce a report on that as well.

**\>\>**

That would be great. Something short and sweet. But I don\'t know how
you feel, but it\'s almost like a fire hose effect of all the
information now coming out around EHRs and a number of groups making
recommendations, and I just want to make sure we\'re sweeping the
landscape, we have a really good idea of everything that\'s out there
and we\'re making our recommendations accordingly.

**\>\>**

Will do. Thank you so much for the idea.

**\>\> Jonathan Perlin:**

Karen, I think your answer to that comment is really a perfect segue to
the body of the meeting and to our presenters. I think in fairness I
should note that this terrific report, the executive summary of which is
immediately at the URL, the web link that\'s on the agenda, it\'s
produced not only by the Robert Wood Johnson Foundation but the
Massachusetts hospital and the George Washington University. I say it\'s
a perfect segue that you\'ve teed up because in fact in chapter 5 of the
report they note that there are four factors that they believe drive the
EHR adoption in the research. They note one is financial incentives and
barriers. And indeed we\'re not covering that today, but the other three
are explicitly the three areas that are on the agenda this afternoon.

The first is laws and regulations. The second, the state of technology.
And the third, organizational influences. So that is laid out in chapter
5 of the report as the four areas driving adoption, and three of those
four, legal, regulatory, state of technology and organizational will
constitute the bulk of this meeting.

So without further adieu, let\'s look to the first area, one that\'s
certainly interesting and challenging from policy perspective and help
to take us back to our task for this meeting which is synthesize out of
the experience of others recommendation to identify not only potential
barriers but means to surmount those barriers and drive the adoption and
implementation.

Let me turn back to you, then, Karen, to introduce your three stellar
speakers in this area.

**\>\> Karen Bell:**

Well, I do so with pleasure and I\'m going to start by introducing our
panel moderator. Melissa Goldstein is from George Washington University
and she will be moderating the panel that we have here today. And I\'d
like to introduce Michael Kidney, who is a partner with Hogan & Hartson.
Mark Tatelbaum who is the general counsel for George Washington
University Medical Faculty Associates. And Bruce Wolff who is a partner
with Manatt\-- is that correct \-- Manatt, Phelps, & Phillips, here in
Washington.

I would also add that we have in the room Dr. Bruce \-- I\'m sorry, Dr.
David Kibbey who is with the person American Academy of Family Practice
who has a great interest in this. And while his presentation is coming a
little bit later, 3:15, I would also invite him to comment as well.

So without further adieu, I\'d like to turn this over to you, Melissa if
I may.

**\>\> Melissa Goldstein:**

Good afternoon, everyone. As you\'ve just heard my name is Melissa
Goldstein and I\'m on the faculty of the Department of Health Policy and
the School of Public Health and Health Services at George Washington
University.

My colleagues and I would first like to thank the workgroup for inviting
us to speak today regarding barriers, physician adoption of electronic
health records. I\'d like to start by telling you a little bit more
about the practices of my colleagues who will then briefly describe
their own involvement with Health IT and electronic health records, as
well as particular issues they want to bring to the workgroup\'s
attention.

We then plan to spend the remainder of the session on questions and
answers from members of the workgroup.

First I would like to introduce Michael Kidney who is a partner at the
Washington, D.C. law firm of Hogan & Hartson. The practice focuses on
product liability litigation and class action defense work and personal
injury law. His product liability practice involves a variety of
products including pharmaceuticals, medical devices, and biologics.

Next I would like to introduce Mark Tatelbaum, general counsel at the
George Washington University Medical Faculty associates. Mark currently
directs the legal services for faculty practice plan including over 275
physicians, 975 employees, and 35 specialties. He supervises on average
25 litigation cases at a time in areas such as medical malpractice.
Manages corporate insurance policies including those for professional
liability insurance. Directs risk management and directs contracting for
information technology. His previous work includes health industry legal
experience in a large law firm, and with the judge advocate general
corps.

Finally let me introduce Bruce Wolff, a partner at the firm of Manatt,
Phelps, & Phillips. Bruce has been in private law practice in New York
City and Washington, D.C. for over 30 years, during which time he has
represented numerous managed care organizations, academic medical
centers, hospitals, physician groups and other providers. Most recently,
he has been involved in various RIO and other HIT for a diverse array of
clients throughout the country. Bruce previously served as general
counsel for health matters at Aetna and special assistant to the,
secretary and deputy assistant secretary for legislation at the U.S.
Department of Health, Education and Welfare.

Michael, I thought perhaps we could move to you first for a few words.

**\>\> Michael Kidney:**

That would be great, Melissa. I, as Melissa mentioned, my practice is
focused on tort law. And within that I have two focuses. One is
defending companies that have been subject to a lawsuit, and also
working with a variety of entities, everyone from \-- shall I pull this
down? Everyone from hospitals to universities to pharmaceutical
manufacturers, to everyone else in this field who is trying to reduce
their potential toward liability by looking into the proverbial crystal
ball and seeing what\'s coming ahead.

I would like to identify three issues that I think would be helpful for
us to include in our discussion today. One is the increased potential
liability of physicians, hospitals and other medical providers arising
from the adoption of electronic health records.

Right now, there is not a tremendous amount of case law out there
regarding potential liability arising from the need to search for or
review medical records. However, there are at least three published
opinions on that right now. And one of the published opinions that
discuss this is issue notes that one of the factors that a court should
look at in determining whether a medical provider has breached any duty
is the extent to which those medical records, prior medical records, are
available to the medical provider in question.

It flows from this opinion that as the community adopts and incorporates
electronic health records, the burden on physicians and other medical
providers is potentially going to increase exponentially because now
rather than just having a duty to look for readily accessible hard copy
medical records that are, say, available in that particular institution,
now the medical provider in question has to access \-- has to have some
way of accessing and reviewing potentially a potentially large volume of
material available through electronic health records.

As I think about this issue, I think there are particular challenges
for, say, a new patient. Because if you\'re a medical provider and a new
patient is coming to your office, that presents a different set of
challenges, obviously, from a patient that you\'ve been seeing for some
time.

What should a provider do, for example if a person comes to them and in
response to the questionnaire says that they have a \-- they have been
treating with a range of other doctors, perhaps in other cities where
they recently moved from, and were diagnosed with a whole list of
maladies. Should that medical provider then be required to say well hold
on I need to go review all of your medical records and postpone the
appointment so they have time to review these voluminous medical
records?

With existing patients, if an existing patient comes in and says
they\'ve been treating with a specialist, should the primary care
physician or another specialist who has a practice that is relevant to
the other specialist be expected to then turn around and go and review
again certain electronic health records?

My personal feeling, looking into the crystal ball is, one solution here
is \-- has to be an organization to the electronic health record that is
going to make it very easy for a physician to review the electronic
health records quickly and to look at the electronic health records at
the tree top level before determining to what extent the physician or
other medical provider has to dig down deeper.

If any electronic health record system doesn\'t permit that, I think
there\'s going to be a real problem and a very serious barrier to
adoption as physicians push back, because at the moment they \--
arguably, the moment they accept access to these electronic health
records, the duties upon them are going to increase.

So for example, segregation of diagnoses in a particular screen,
segregation of significant discharge summaries from the hospital, for
recent significant medical procedures, I think is key and there should
be an easy way for a physician or other medical provider to review those
important documents apart from having to go through progress notes which
often are not going to be very helpful to a physician.

A second issue I think we should consider is increased liabilities for
physicians to keep electronic health records properly updated. Of
course, for all the reasons I\'ve just said, if physician resident going
to increasingly rely on electronic health records, what should the duty
be on medical providers and \-- who are seeing patients on a regular
basis \-- to (indiscernible) electronic health records.

What if the patient suddenly gets and moves to another town and it turns
out their medical provider hasn\'t been regularly updating their
electronic health records? I could certainly see a court is going to
potentially impose liability on the prior medical provider because the
prior medical provider is going to be on notice that the electronic
health records are increasingly accepted, that there\'s going to be
increasing reliance on them and to the detriment of the patient if they
aren\'t properly updated.

Likewise, if important information is kept in the progress notes and not
in another field, can we really expect busy medical providers to read
every progress note in the future? I think not. And there may be
potential liability for a doctor who updates the medical records but
doesn\'t do it in a way in which the information is put into the proper
category.

Also question what sort of liability would the courts impose on, say, a
hospital or a university or other institution that has \-- that has,
say, a outage in the computer system over a period of time where
electronic health records aren\'t available, or where there\'s a \--
there are problems with a computer program where certain screens are not
available, or they\'re placed in the wrong field.

And last, after giving that you parade of horribles, although I think
they are very real and I think likely avenues of increased liability,
the good news is that there should also be decreased liability to the
extent, for everyone in the field, to the extent that the system works
well, there should be after the adoption of electronic health records,
decreased likelihood of adverse events. And whenever we have decreased
likelihood of adverse events, so too do we have decreased liability.
Because without adverse events, there can be no liability.

Thank you.

**\>\> Melissa Goldstein:**

I thought Mark maybe you could give us the institutional perspective
now.

**\>\> Mark Tatelbaum:**

Sure, thanks, Melissa. As Melissa mentioned I\'m Mark Tatelbaum, general
counsel of George Washington Medical Faculty Associates. Thank you for
the opportunity to share my thoughts on this issue. By way of background
I\'m aware some of you may be familiar with our organization, but we are
the separately incorporated faculty practice plan of the George
Washington university medical center.

I guess our numbers have increased a little bit since the blush I gave
to Melissa. We now have over 300 physicians across 41 medical and
surgical sub specialties, and 670 support staff in addition to that.
Those over 300 physicians. We currently have a robust, fully operational
electronic health record.

We earnestly began the implementation process of the EHR back in 2004.
Our CEO believed then, as he does today, that technology would be the
key to success in the competitive health care environment, and that it
would enhance the quality and reduce costs over time.

He viewed the EHR as an important aspect to this and wanted the MFA,
Medical Faculty Association, to be the leader in implementation. From
the legal, in-house legal perspective, frankly he was not all that
concerned about legal implications, and the legal factors did not weigh
heavily on his decision to implement. He thought it was that important
for the organization and the delivery of care that we were providing.

Within 30 days, the MFA was able to implement an EHR for 100 of our
physicians, 130 residents and 175 support staff. Today the entire MFA is
operational. 5100 square feet was in our building used to house paper
medical records is now dedicated to clinical use and to physician
offices as necessary.

And we to date have saved over \$1 million in support staff costs
through implementation of our EHR.

We have fully realized our return on investment currently.

From my perspective, as the in-house lawyer, I\'m very supportive of
having the electronic health record. And I believe the benefits far
outweigh the risks. The documentation of our physician tends to be much
better. Records are much more easily accessible and retrievable. The EHR
also helps to facilitate quality of care, payor reviews, corporate
compliance and internal audit initiatives, risk management, and
litigation defenses. It\'s much easier for my staff to be able to go
into the electronic health record, down load the record and print it
into paper to produce it for defense purposes, than to having to search
for across 15 different medical records rooms per specialty in hopes the
paper files are as well organized as it is automatically organized in
the electronic health record.

With respect to some of Michael kidney\'s points, I understand the risks
about potential liability that some provider groups may be concerned
about. And I would appreciate copies of those cases.

And I do think that there is going to be an increased burden to do
documentation. I suggest that it\'s also peer pressure among other
physicians who review that record to ensure that the documentation is
good, and I don\'t necessarily believe that it\'s any different in the
electronic record environment than it is in the paper record
environment.

And I think that the legibility in the paper \-- in the electronic
record is far \-- surpasses the legibility in the paper record, and the
lab results that you can see that come in automatically is much more
enhanced. And our physicians do have access to prior records that they
could have had from visits in other areas. Drug allergies, drug recalls
get sent out to people that are on particular drugs. So from a quality
of care perspective, it greatly enhances that.

Whether that increases the standard of care as more providers are \--
get up on electronic record, I think it very well may. I don\'t think
that that is necessarily a bad thing. And some people debate currently
whether you have the obligations in the paper world to do the same
thing, it\'s just not as easily done.

So as far as the standard of care goes, I perceive the standard of care
as an evolving level that evolves as the state of medicine evolves, and
it reflects the current state of medicine. And if an electronic record
becomes the norm and how people use it and operate it becomes the norm,
then I think that will become (indiscernible). Again, I don\'t think
necessarily that\'s a bad thing.

As far as legal issues, I think it relates to privacy and security and
ensuring that that you have an electronic format is adequately
protected. I believe those same risks were there in the paper world,
people could have gone into a medical records room and pulled a file,
people would take files and leave them on car seats. Not in our
organization, of course, but I\'ve heard stories about that.

So that is an issue. I think the issue concerning that in the electronic
world is the perceived potential that that information that is
improperly obtained, it can be more widely distributed more quickly.

You can\'t \-- it\'s not \-- you can\'t forward it by e-mail, so I\'m
not sure how it would work that way. And you could always scan a paper
record into a PDF format and e-mail that, too. So I don\'t believe, that
being said, that the privacy and security risks are outweighing the
benefits of using an electronic health record.

As far as hurdles to adoption, and I know this is \-- I think a topic
that is not going to be discussed today, I think ultimately it\'s
financial. I think that in the current health care environment with
federal reimbursement, either remaining the same or being cut, with
increases in provider expenses, including but not limited to malpractice
and labor expenses, and other areas of expense, and also given that now
that vendors have had some successes in implementing it, I doubt
they\'re going to be as flexible on price as they may have been for some
of the early adopters while they were working through some of the
glitches.

So I think for the particularly the smaller groups that the financial
aspect of the capital contribution to invest in electronic health
records is probably the most likely obstacle that they face.

That\'s all I have in my prepared statement. Thank you, Melissa. I\'m
happy to answer any questions.

**\>\> Melissa Goldstein:**

Bruce, you have a lot of experience with RIOs and growing HIT
organizations, I thought maybe you could tell us about that.

**\>\> Bruce Wolff:**

Sure. Let me make a couple comments. And much of this comes from the
context of being involved with organizations that are exchanging data as
opposed to collecting and using it within their own organization. But
nonetheless, my major thesis today is both to agree and slightly
disagree, but to start out with a proposition that says there are no
insurmountable legal barriers to doing any of this.

There are perceptual problems, there are \-- there is the natural
skittishness of taking on a new process, a new technology, a new way of
conducting your affairs. But even as we talked about already some of the
difficulties that may \-- things that may pose a liability creating
events for a physician or a physician group utilizing an electronic
health record, whether it\'s an outage or or inability to access
something or having to go through progress notes as opposed to having a
summary screen, all of those things exist already in the medical field.
There are missing records, there are fires, there are people
transferring. All of these things happen already. I think the real
question is getting over the perceptual hurdle on the legal side, not
necessarily having to invent new ways of doing business or new ways of
measuring culpability.

That said, I did look \-- I want to comment a little bit, not in
criticism, but just as kind of a launching pad, and I\'ll have the
advantage of going last so I\'ll take Mark and Michael\'s comments as
well. Professor Terry recently addressed you all with respect to a
series of legal concerns and issues. And if I take his four categories
of comments, I\'d like to comment back. Not because I necessarily
disagree that those aren\'t issues, but because they are things, I
think, that can both be accommodated and addressed.

His first concern that he pointed out, and I do this on the basis,
frankly, of news reports, not of having read his testimony, was one that
we\'ve already alluded to. The problem of having to gather more
information, look in more places, and being inundated with information.
Well, the reality is that exists for, A, all professions, can\'t tell
you the number of sources databases we all have to check now that we
never did in either Thomas Jefferson\'s time or even when I began
practicing. For prior opinions, whether \-- or regulations or advisories
or program manuals or what have you.

And it\'s not necessarily a bad thing to have more information if the
whole notion of malpractice is bad decisions. More information ought to
help. And it is, I think, as was alluded to, harder to do when you\'ve
got scattered paper in different places. It is easier to lose it when
you\'ve got scattered paper.

I don\'t think the challenge is that you\'ve got too much data. And I
love the idea of focusing on summary and conclusatory materials in order
to avoid having to go through progress notes, because after all when \--
I know when my physician looks at when he picks up, even his own notes.
And has to skim back through.

I love that idea. But what \-- and I think the challenge already exists
for physicians, clearly in terms of missing stuff. What always strikes
me is the man or woman who is on call. What access do they have today to
stuff that\'s in the chart? To things that the practice \-- the practice
or he or she already knows but doesn\'t remember with respect to the
client. Those challenges I think already exist in terms of the need to
get as much information as you possibly can at the time you\'re making a
decision with respect to a patient. So I don\'t think that issue is
really very different. I think as was just said, I think it should be
easier and better decision making.

I think the one place where there may be a significant challenge adds
enormous cost to the system is what do you do about old records,
pre-date the installation of the electronic health record. How much has
to be scanned and if\' it\'s scanned, how accessible is it to the
provider at the point of care? Versus what is in the electronic
database. And I think \-- I mean, to the extent that people agree that
that\'s a barrier, that may be something worth addressing from a legal
theory perspective. Because I worry about what\'s in the paper record,
not available to the man or woman either practicing remotely or even
practicing at a terminal.

The second thing that was \-- that professor Terry indicated was
potential liability for dealing with inaccurate information entered into
the system. By others or by the decision support system. Again, I would
submit that is an issue that already faces lots of people. I mean, there
are lots of \-- (indiscernible) a patient\'s chart. There are lots of
things being sent by other physicians, there are lots of things being
sent by other \-- by persons making other diagnostics, whether they\'re
labs or otherwise.

To the extent that \-- and so again, I would submit that\'s not a
different liability from one that the physician communities already
encountering, but to the extent that it is perceived as a major problem,
not clear whether it should be or not. That may be an area to think
about, privilege, in terms of the ability to rely on information entered
into the system from other sources. I mean, begin drilling down on that
issue and if it is someone in the practice, should you excuse the error,
versus someone entering it from outside. That whole business.

But I can see a sense that you\'re going to get an enormous amount of
additional information you didn\'t previously have. And certainly in the
physician support area, which I think we all think will be wonderful in
terms of getting best practices out into the marketplace and to the
physician\'s desk that much earlier.

To the extent that you relied and \-- on someone who is reputable and
you\'ve done due diligence about who it is that is assembling this
stuff, the fact that they did an update, didn\'t put some articles in,
came up with the wrong \-- it seems to me they probably need to be some
kind of \-- some thought given around at least relaxing for some period
of time that issue.

The third, which I can respect but I don\'t think is, again, different,
was you may in searching electronic health record discover that someone
else treating the patient for a different condition has made a
misdiagnosis. I don\'t think that\'s any different from anything else
that anybody is facing today.

And the fourth area was, this one I can respect because I think it is in
the sense of volume that the number \-- that electronic health records
databases, et cetera, are \-- will be more searchable, searched by more
people, identification of areas will be made that are not now, and if
you believe the statistics we\'ve all seen for years and years now, lots
of instances of medical error will be discovered that currently lie
dormant and people will be subjected review scrutiny, et cetera.

That may be real, but I think you then have to answer from a public
policy perspective more than anything, from a couple of perspectives.
Number one, maybe it isn\'t so bad to discover more areas in the system,
doesn\'t necessarily mean liability creating events, but it may be
sentinel events that could help those practices or otherwise.

Number two, there was \-- there was a reference, and I\'ve not \-- I\'ve
not looked at the underlying \-- the data or even where it came from, in
a (indiscernible) report to AT SP in July in terms of 70% of malpractice
cases settled are settled because of lack of clinical data in the
physician\'s record.

If there\'s any sense that those numbers are reasonably close, then
there really may begin to be a public policy and an economic balance
between those cases that are brought because of data finds versus those
that are solved by contemporaneous entry in an online situation of data.

And the last, which I think was Professor Terry\'s conclusion, or maybe
a parting shot, was a statement that we may need to do more to beef up
patient security and privacy protections. And that\'s \-- I mean,
that\'s a tough issue. I absolutely agree with the comment that was made
that the barriers here are much more financial, organizational, public
policy perception on privacy and security than legal.

But while I have the floor for a second, let me toot a horn in one
respect. On the whole patient privacy, security issue, I mean, I think
we\'ve grown up with a body of laws that focus on the laws regulating
what a provider can do or not do with a record. As we start tightening,
doing other things with that, it all continues to focus on the onus and
burden on what the provider does with the record.

There\'s a very interesting recommendation from the California health
foundation to Governor Schwartzenegger recently about thinking about
this issue from a different perspective, which is a consumer protection
issue, and beginning to think about it from the perspective of can I
empower consumers to own their data in a way they can have it
transferred to some custodian of their choice, and impose the rules and
requirements on the custodian, a centralized custodian of records, as a
way of beginning to protect the patient and move some of the onus on
compliance and transfer of records, and who has access and checking on
informed consent, et cetera, away from individual providers on a case by
case.

I think we\'ve all monopolized the floor enough and I think the whole
notion here was to make this interactive.

**\>\> Jonathan Perlin:**

Let me thank the entire group for just terrific presentations. Melissa,
do you have any summary comments that you\'d like to make before we open
the floor for questions?

**\>\> Melissa Goldstein:**

Only that my aim in choosing these panelists was to provide the members
of the workgroup with a variety of different practice ideas. As you can
tell, these three attorneys have vast experience in different kinds of
health care organizations, and I thought they could give you that they
could give you perspectives from their own practice and that you might,
for instance, evolving standards of care with Michael or the
institutional basis of choosing EHRs as a way to go from Mark, and that
sort of thing.

That was my goal, and I hope it has been helpful to you, it\'s been very
helpful to me to hear the panelists.

**\>\> Jonathan Perlin:**

Thank you. I believe your goal was realized, and wonderful to have the
\-- some of the \-- both experience but also some contrasting viewpoints
in terms of both creating new opportunity for risk and liability as well
as resolving current situation that is arise in a nonelectronic world.

Let me open to members for questions \-- (poor audio) \--
recommendations for overcoming and identifying barriers, overcoming them
and facilitating adoption.

**\>\> David Kibbe:**

Jonathan.

**\>\> Jonathan Perlin:**

Yes.

**\>\> David Kibbe:**

David Kibbey. I have a question.

**\>\> Jonathan Perlin:**

Please, go ahead.

**\>\> David Kibbe:**

First of all, Jonathan and other committee members, thank you for
inviting me today and I\'m delighted to be here and participate.

I\'m very interested in this issue of standard of care and what is
becoming the standard of care. I\'ve got two questions here, maybe more,
but \-- one is Mike, in your presentation, you talked about the
availability or accessibility of electronic information and seemed to
imply that there is an increased obligation to summarize and have
available to one information in electronic format. And the assumption
underlying that may be that electronic information is somehow more
available than paper is. And what immediately comes to mind is that
there are certain situations where, for example, in the Veterans\'
Administration, if a person were treated only within the Veterans\'
Administration, that \-- there would be no question about that. But the
availability of data electronically is more available than it would have
been, or had been when it\'s paper.

On the other hand, I think that in the environment and the
community-based health care where we are seeing proliferation of health
information technology throughout the system, I would question whether
that in fact was the case. Just because it\'s electronic, it may
actually be less available than \-- and I like very much your idea about
the summary part of it.

So my question in that is, is that assumption actually working itself
out in case law? The second question was, to what extent do the claims
of the vendors play a role in this liability? Having been an expert
witness in a suit in which two vendors were disputing over the meaning
of the word connectivity and interoperability, I realize that this is a
real issue that now is getting to the point where people are suing each
other over it. And those terms are poorly defined, or at least
disputable.

So to what extent will physician whose purchase electronic health
records, for example, from vendors who say their product is
interoperable or is connectible influence this \-- of \-- issue what
have becomes standard of care.

**\>\>**

Let me take a stab at least at your first question. I think the existing
case law makes quite clear that the standard of care will change and is
dependent on the availability of health information. So if \-- and there
are \-- there is at least one published opinion that says, and was
decided in the context of an institution and so your analogy to the VA
is right on, if a medical provider is located at an institution, and
that medical provider has easy access to medical records from another
part of the institution, that medical provider is under a duty to go and
get those medical records. That in fact the particular court said it
would have taken this provider five minutes to, the testimony was, to go
and retrieve the records from the central file room, and so as Bruce
said, in some ways this is the same issue. But in some ways it\'s
different when you move to the community context, because having been
through many depositions of medical providers at the community level, it
is quite frankly, rare for a physician practicing in the community if
they have a new patient come in to them, to take the time to say, well,
I\'m going to gather all the medical records from your prior medical
providers. And so those physicians very much, as you probably know, rely
on an oral medical history taken from the patient. And one thing that I
think is very important to emphasize here, and two things that I see
happening is, as those medical records become available electronically,
those community physicians are going to have to \-- and the case law I
think \-- I have no doubt the case law is going to impose upon them \--
a duty to check those electronic health records from others. And I think
something that is \-- should not be underestimated is well Bruce is
absolutely right that to some extent \-- to many extents a lot of these
issues and duties already exist today. I think what we\'re going to see,
though; a quality take the \-- a quantitative difference in the extent
to which these duties play out in the \-- for example, for the community
medical provider who is relying right now on oral history, that is
probably going to \-- if the community medical provider now finds that
he has access to electronic health records, that community medical
provider will probably rely lesson the histories. Which makes the
electronic records that much more important to be reliable.

**\>\> Mark Tatelbaum:**

Can I add on to that? This is Mark Tatelbaum speaking. I agree with what
Michael is saying. I still am, obviously, what we\'ve said before about
the comparison to the paper record. I think the same issue is still
prevalent with paper and whether there is an obligation to have the
patient come in with their prior history. And their prior records. I
think that there is the perception with the electronic records there\'s
going to be a lot easier, but then again you\'re circling back to the
financial constraints.

Is a provider, in his 15 minutes or 30 minutes that is allocated by a
managed care, or to see a new patient, going to have the time and the
wherewithal to go through either a paper record, if the patient brought
with them, or an electronic record, no matter how well it is organized
and sorted out, to go through all of their history.

And again it circles back to the practice of the providers and what they
are \-- how they practice medicine, in taking oral histories from
patients, and whether they have any reason to doubt what the patient is
telling them and they\'re coming \-- forming their doctor-patient
relationship with the patient but then they\'re going to say I don\'t
believe you in what you\'re telling me in our oral history. I want to
verify it in your prior records. That cuts both ways. I think it\'s also
helpful to see prior records, and it would be terrific if any physician,
paper or electronic, had a full understanding of the prior history.
Quality of care and minimization of liability.

**\>\>**

I totally agree, and I also agree that right now the main barrier is
financial. And one thing to consider is, though, that if there are just
a handful of decisions in America that are \-- all it takes is two or
three decisions. Finding liability on a basis that medical providers
perceive is unreasonable, that then you have your community-based
medical provider, who right now the only major barrier is financial,
faced with the not only a financial barrier, but now I hear through the
grapevine that there\'s a legal problem and they hear about the analogy
New Mexico McDonald\'s coffee case and I can tell you that much of my
practice is spent with entities who are \-- have this \-- right or wrong
\-- perception that the tort liability system has run amok and that they
are taking actions right now that five years from now might get them
into trouble for reasons that they had no way of foreseeing. And so they
are constantly coming and saying basically how do we avoid becoming
ticking actions now that will later get us into trouble. And they are
very concerned that the tort liability system lacks a basis of
rationality. And I constantly \-- I think one issue that lawyers have to
do is remind clients that yes, there are a couple of crazy opinions out
there and crazy judges, but that doesn\'t necessarily \-- that certainly
doesn\'t reflect the American legal system. But I think a very real risk
is we have to be \-- encourage the group to try to prevent those first
couple of crazy decisions from coming out because that\'s going to
affect the extent to which the electronic health records are accepted by
community-based providers.

**\>\> Ken Waldbilligs:**

This is Ken W. from EMC. I have a question.

**\>\> Jonathan Perlin:**

Go ahead, Ken.

**\>\>**

Could you speak up a little bit.

**\>\> Ken Waldbilligs:**

This is Ken from EMC. I have a question regarding \-- many times in the
case law you find specific phraseology that becomes kind of a compelling
event to the industry, and in this case I\'m wondering if any of the
three presenters, and thank you all for the tremendous education here
that you provided to the workgroup and myself personally. The question
is, provided \-- the availability of the information, right, that is if
in fact it\'s readily available, does that drive the physician\'s
culpability or not? The term readily available.

**\>\>**

Because if the community physician doesn\'t have access because it\'s
not readily available \--

**\>\>**

I think it does. If the \-- right now the community physicians don\'t
have medical records readily available to them from prior medical
providers, for all intents and purposes. And so the electronic health
\-- the statewide spread adoption of electronic health records will make
those readily available to our community physicians.

**\>\>**

Michael, does it get back to the \-- correct me if I\'m wrong, but my
understanding was that it went back to a reasonableness. You get back to
the standard of care, it\'s what a reasonable person in that position
would do. So I mean, again, I think from the standard of care
perspective, and I absolutely agree that we want to kind of prevent any
kind of case law that would deter the implementation of the electronic
health record, but it\'s going to come \-- ultimately down to what \--
the reasonable provider did in a given situation, with a readily
available record, whether it be paper or electronic, although the fact
is going to be if you have it electronically, it\'s probably going to be
more readily available.

**\>\>**

I agree.

**\>\> John Houston:**

This is John Houston. Can I ask a question?

**\>\> Jonathan Perlin:**

Please go ahead, John.

**\>\> John Houston:**

a couple questions. I want to follow up one point, the first. What
happens if the volume of information is such that is available that a
physician says, it\'s going to take me ten minutes to go through this
person\'s history, I don\'t have ten minutes to spend on each patient in
order to completely evaluate their electronic medical record. And how
does that affect liability? I guess you have to apply the reasonableness
standard. But still I think you can get overwhelmed by information, and
I think that can be an issue.

**\>\>**

I think there\'s no question you can get overwhelmed by information, but
I think that may be the nature of the beast where we are. The one thing
I wanted to comment both on this question and the readily available, is
I don\'t think it is going to be an answer for avoiding liability to put
one\'s head in the sand and say I won\'t get this because it\'s going to
either give me more information than I can possibly digest. Or I won\'t
\-- I don\'t have to deal with readily available if it\'s not available
to me. I just won\'t get it. I won\'t \-- if, I think as is inevitable,
one is practicing in a community where there is a RIO, a data exchange,
where it is \-- the data exchange capability is available to me, it will
be as culpable to not participate, I would suggest, in the evolving
standard of care, to not connect as to deny the existence of MRI
technology. You just can\'t avoid it.

Now, can we help in terms of structuring what it is that represents
reasonable care for a physician in a patient encounter to look at, and
what is \-- and what is a reasonable standard? Probably. I mean, it\'s
going to evolve in case law, but it\'s also, I would suggest, something
that various of the practitioner societies could gainfully embrace as
something that they\'re prepared to help do. I mean, what, after all is
a reasonable medical history? Do I have to spend ten minutes with a new
patient or half hour with a new patient? 45 minutes? Is it enough if my
nurse practitioner does it? Or do I have to do it? Do I have to review
it? We\'ve been through these issues with respect to the gathering of
information.

I don\'t think the challenge here is legal so much as it is figuring out
how we can construct something that will work in practice.

**\>\>**

That\'s my point. But at some point somebody in practice is going to
say, I only have so much time.

**\>\>**

Jonathan, I wonder if I could jump in.

**\>\> Jonathan Perlin:**

Go ahead.

**\>\>**

I enjoy the conversation and appreciate the legal counsel and very
insightful analysis and presentation as well. I\'m also being educated.
I guess I just would like to underscore a couple of thoughts and maybe
ask a couple of questions.

The current state, from a clinician\'s perspective and perhaps echoing
other thoughts David Kibbey has alluded to, we live in a state of
incomplete information all the time, and evidence would suggest that in
paper-based and even in electronic worlds, it\'s still a case of
incomplete information at the point of care at the time of clinical
decision making. In some paper-based worlds, 81% of information relevant
to a case not being available within the same institution using paper
records, in another analysis in electronic record context 40% of a
provider\'s \-- of the patient\'s prescriptions not being known to the
primary care treating physician.

So that\'s kind of where we are. And I think the uncertainty actually
that we will have to face going forward even in a connected world is
going to persist. And there\'s a couple of reasons. One, even the
context of a RIO, information sharing and exchange policies are in a
state of huge flux and there\'s a fair amount of politics and economics,
of course, around information exchange may preclude a seamlessly
interoperable RIO context, if if you will, so that alone may cause
incomplete information base for any patient care visit at any time.

Secondly, it\'s not clear that the RIO is necessarily going to be the
architecture with which information is going to be exchanged going
forward in all cases in the sense that in some environments it may
really actually finally be patient-controlled in the sense of a PHR type
architecture wherein the patient is going to have the authority and the
privilege, if you will, of determining what information will be released
to the provider at the point of care even if it\'s an electronic PHR.

This is no different than the current world. When you sit with the
patient and take a history, they tell what you they want you to know. I
don\'t think it\'s actually dissimilar than other decision making under
certain financial consideration, loan making, what have you, you have an
incomplete picture of a patient\'s financial background. I would suggest
that this is actually \-- uncertainty is something we\'re going to have
to live with even in a connected world. And I think the lawyers have
already alluded to, perhaps, limiting liability, tort reform, and
perhaps practice redefinition or usual and customary practice to help
limit liability here and avoid the problem from the physician\'s point
of view.

**\>\> Jonathan Perlin:**

Blackford, I think both in the interest of time and the eloquence of
your comments, that\'s a great note on which to close this portion of
the discussion.

As an individual who personally has practiced both in a paper-based
environment and essentially paperless environment, I didn\'t see the
challenges as that different. And indeed, even the paper-based
environment, one, makes decisions about the depth of information, that
they feel they need to answer an issue, certainly in a paperless
environment, the electronic health record world, the same decisions are
made and calibrated, just as you said, as to what the patient broad
forward.

Never the less, I think the point Mr. Kidney brought forward at the
outset, we do live in a society which is litigious. The challenge in
terms of implementation or both the manifest and the perceived concerns
about liability and the barriers that both the manifest and the
perceived do place in their path.

I think increasingly, unfortunately there\'s a broader body of
literature that highlights the discontinuities that occur in the absence
of management of information and indeed the intent of the electronic
health records, thus the genesis for this group and its goal of
expediting adoption of \-- or helping the secretary and the country
expedite adoption of electronic health records.

So to our task for today, I\'d ask the members of the workgroup to
consider what we\'ve just heard and as you put together your list,
identify what you perceive to be from a legal and regulatory
environment, the primary obstacles to implementation and then the
activities that you\'d recommend to overcome those obstacles. And with
respect to this discussion obstacles that may already be manifest or
obstacles that may be perceived as a sort of future liability.

Let me stop now and turn to Lillee, but first I want to thank Melissa
Goldstein, Michael Kidney, Mark Teitelbaum and Bruce Wolf really for
terrifically informative and obviously provocative discussion that helps
us attend to the areas that have been identified as areas that need
attention in moving toward adoption.

Lillee?

**\>\> Lillee Smith Gelinas:**

Jon, thank you. I know we are just a few minutes behind here. I would
like to put a question on the table related to the other panel that will
have to be answered in writing, and not verbally since we\'re out of
time. But I\'d like to know from the panel what the effects of the
Katrina after action report and the devastating effects of losing over 2
million patient records will result, and how we as a workgroup need to
consider, because then all these issues that have been considered, there
has been no reference whatsoever to probably new case law that\'s going
to develop out of the fact that there are over half million United
States Americans now who have no medical or dental record whatsoever, it
was completely destroyed in either Rita or Katrina.

So I just, if someone could put something together in writing for us,
because I think our lives around policy are forever changed because of
Katrina, and I did not see that referred to at all. It was only the
Veterans\' Administration that was in a position to have not lost
anything.

And with that, I will take over the agenda here to talk about the state
of the technology. I want to applaud the ONC staff because Jon and I
have talked about how do we speed adoption by learning about best
practices and by systems that are already in place from which we could
draw conclusion.

Being in the private sector it\'s very clear to me that the government
sector in terms of IT, is much further along than the private sector.
And we have much to learn.

I have had the privilege of seeing at least vista out of the VA
demonstrated, I have walked the halls of VA hospitals and tried to learn
the system, it is a superior system and I would tell you in our VHA,
there is tremendous interest, and I want to thank our VA colleagues for
getting over 100 copies of the vista CD to me so I can cascade the
success.

So to begin the EHR demonstration panel, Karen, would you also like to
tee up the introductions since you\'re actually there in Washington and
I\'m not?

**\>\> Alicia Bradford:**

Hi, it\'s Alicia. Karen stepped out. For the VA it will be Dr. Smith and
Dr. Fletcher and they\'re not here in ONC with us. I believe they\'re
over at the \-- a few blocks over at the D.C. VA.

**\>\>**

Alicia \--

**\>\> Matt McCoy:**

This is Matt. If I could talk everybody through what\'s going to happen,
I think Dr. Smith you are on the phone with Dr. Fletcher, correct?

**\>\>** That is correct, we are here. And I think we should be \--

**\>\> Matt McCoy:** I\'m going to explain for everybody. And what I\'m
saying right now applies to both members of the public who are logged in
about to watch this, and members of the workgroup. The setup is the
same.

So if you\'re looking at your webcast right now, depending upon your
pop-up setting, you either got another window just open on your browser
or you got a message in the middle of the webcast that says to open your
web conference window and join the meeting, click here.

So everybody should click there and Dr. Smith I\'m just going to ask you
to hold on for a couple of seconds while that roster on the right-hand
side populates with names as people join.

And if anybody has \-- I\'m going to do a little bit more explaining. If
anybody has a question, we\'re going to do Dr. Smith\'s presentation and
one more like this and certainly people can jump in. This is the first
time we\'ve demoed the technology. But you know, you\'ll get a different
window opening to see this demonstration and you might notice your
computer is lagging behind the presentation. Be patient, it should catch
up as it gets going, and if for any reason the windows shut down during
Dr. Smith\'s presentation, close out your browser and log back in the
way you did before.

Dr. Smith, are you getting names populating now in that window?

**\>\>**

Hang on, I may be in the wrong place. I thought I had our \-- yes, I am.
I see all 43 attendees populating.

**\>\> Matt McCoy:**

So everybody now should be looking at something that says nothing is
currently published or shared. Dr. Smith I\'ll ask to you click the icon
and start your demonstration.

**\>\>**

That would be the icon for application sharing.

**\>\> Matt McCoy:**

That\'s correct, the two screens in the upper left-hand corner.

Depending upon everybody\'s individual connection speed there will be a
little variation. We\'ll not all have screens refresh entirely at the
same time but we should be seeing Dr. Smith and Dr. Fletcher\'s
PowerPoint right now. So gentlemen, I think you can begin.

**\>\>**

Excellent. First I\'d like to thank the organizers and the chairs for
giving us the opportunity to show what we\'re doing. I was also very
interested in the preceding discussion since we\'ve been in a position
in the Department of Veterans Affairs of grappling with many of those
issues and certainly as a clinician, as Dr. Perlin alluded to, from my
perspective, the access and transparency of the medical record, the
advantage of that so outweigh all of the other considerations that I
think we\'re at the point where we will be moving ahead and the excuse
of not having access will not be sufficient to prevent liability.

But what we wanted to do is take the opportunity today, myself and I\'m
here with Dr. Ross Fletcher who is the chief of staff of the Department
of Veterans Affairs medical center at Washington, D.C, to show you as
briefly as we can the implementation of electronic health records within
the VA. And I\'d like to say that there is also a video that was alluded
to by the chair that will be posted on the website shortly. It wasn\'t
quite able to be digitized in time for the presentation today, but I
believe it will be there by Monday, also will show much of what we\'re
going to be showing today.

So from the 50,000-foot view of VHA, VHA is composed of 150-plus medical
centers, large hospitals, to smaller across the United States, some 800
satellite clinics and these are organized into regional networks. There
are more than 5 million, or veterans users of the system, approximately
50 million outpatient visits per year, over 500,000 admissions per year.
And defined missions which include the care of those patients, medical
research, medical education. And we do have a salary staff physician
model and essentially a capitated care model.

(indiscernible) systems and technology architecture. And in its current
usage, which we\'ll show you, it has over 1.8 billion orders in the
system, both at 1 million per day, 200 million images, 500 million
documents, 500 million medications administered using bar coding at the
point of care. 700 million vital signs, 1 million lab results per day,
and 200 million outpatient prescriptions dispensed yearly.

So it\'s a system which is deployed throughout the VA, utilized on a day
by day basis for all aspects of care. CPRS is the flagship, if you will,
of that system. It stands for the Computerized Patient Record System,
and in its current iteration it\'s a Delphi view looking at a database.
It\'s built upon component results, those are various reporting systems
of laboratory, pharmacy and radiology that have been developed over many
years within VA. But there\'s been a complete implementation of a
graphical user interface since approximately mid to late 1998.

There are many, many iterations of this. It\'s grown over time and been
developed really through the feedback of clinicians and users and we\'re
currently on version 27, which has been released and available. There is
an edition and next generation version which is more web-based under
development and is the intent for future.

In addition to this basic electronic medical record system, there are a
number of partner applications that are under this umbrella of vista.

And one of the things that I would really want to emphasize is that this
has been modified, refined and ready made usable in the crucible of a
decade of continuous use by more than 50,000 physicians and some 60,000
nursing staff. Again on a day by day basis. So it has been in place, it
has been in use and those of us who work in the VA I think no longer in
are a position where we would be willing or even able to step backwards
in time to a paper-based record and certainly the trainees that come
through my medical center in San Diego want to know why they can\'t have
this everywhere.

I\'m going to turn the floor over to Dr. Fletcher and we\'re going to
actually do a live documentation, or a live demonstration, rather, of
CPRS. Let me make sure I exit out of this window correctly. I\'m going
to turn the floor over to him.

**\>\>** I, too, have enjoyed the conversation, and it\'s been very good
and I would like to say that this huge organization was recently
superbly run by Dr. Perlin who is chairing this session. Thank you for
inviting us.

What you see on the page initially here is the cover sheet which is
present for every patient. It has all of the patient\'s active problems,
which can be looked at and all of his medications. All of his allergies.
Many of the alerts. And the vital signs, the vital signs are easily
looked at over time in a graphic way. This man is obviously going in the
wrong direction. And I\'ll wait for just a second because it looks like
I\'m up and you\'re not yet. But we\'ll \-- we have a way of seeing
whether you can see it.

I\'ll wait for another second. Or two.

**\>\> Matt McCoy:**

I think, Dr. Fletcher, as you move through, it people\'s computers will
get caught up based on their individual connection speed. So if thank
you keep moving deliberately through it, everybody should catch up
eventually.

**\>\>**

Okay, even if I shut the window down, right?

**\>\> Matt McCoy:**

Well, you should \-- you should keep the EHR application open that\'s
open now and just keep working through it. I wouldn\'t close any
additional windows right now.

**\>\>**

It would be useful to center the application on the screen, part of it
is cut off.

**\>\>**

It should be centered on the screen unless you\'re in a different view
than we are. Is it just cut off on the right side?

**\>\>**

Yes.

**\>\>**

Yes. On the monitor that we\'re looking at it isn\'t, but on the screen
I\'m looking at, it is. I can probably fix that in just a second.

More available?

**\>\>**

Yes, thank you.

**\>\>**

All right. The tabs that you see on the bottom are what make \-- part of
what makes it so user friendly. They are similar to in characteristic to
the text sheet and in that if I wanted to see my problems list, I would
click on the problem tab. If if I wanted to see all the medications the
patients had, I would click on that and I would see both outpatient and
in-patient. In other words, this record is one record for an individual
patient no matter where he is seen and we do have remote views to be
able to see what has gone on in Miami or California, if the patient has
been there. But we will look at our local view which is in our instance
anything that\'s happened in our local clinical areas, the C box, and
the hospital itself.

If I click on orders, I can go into any of the orders over here on the
left. Is imaging. And I then can move to general radiology. And ask for
a chest x-ray. And once I have the chest x-ray up by filling in the
history and physical, changing the transport, if I wish, I can accept
the order and this is now able to be seen in our x-ray department,
waiting for the patient to come to that department. When the patient
comes, the x-ray is done.

I think things are still working at your end. Is that correct?

**\>\>**

That\'s correct.

**\>\>**

Good. I might have to check, because our monitor seems to be a little
behind.

So I will not accept that order. As you can see, I can order anything
else as well. There are medicines outpatient, medicines in-patient.
Actually, I can list all the patient\'s non-VA medicines as all. I can
put in herbals and things he may be getting over the counter. There will
be order checks on all these medications.

The other \-- the next area, which is hardest to become available for
doctors is the note signing area, and I\'m now bringing up all my notes,
note creation area. And I can look at any of the notes I wish. And I can
scroll through those notes. The icon to the left in the note tab
actually indicates that there might be images available, and let me open
that window up at this moment in time.

By going to the tools, I can open vista imaging display. I don\'t know
why it\'s not coming up. Now, good. And you can see that around this
text chart I now have many of the images for patient. There\'s an x-ray
visible. And an electrocardiogram. If I actually click on one of these
notes, I can see the images on the bottom coming up.

If I clicked on one of those images, I would actually be able to see the
image displayed and I will take it fairly slow through the display.
Because I\'m sure this will not \-- if I was going fast this would not
transport. But once I get to the critical image for this display, is
right about now, one can see \--

**\>\>**

Widow maker.

**\>\>**

Yeah, widow maker. This isn\'t quite the vessel for the widow maker. The
anterior descending is the one that really kills. But this is the
inferior right coronary artery, and the inferior wall would be out if
that closed down, and just to show that to a patient gets his consent
pretty fast for trying to take it out and we then put in a balloon, blow
it up, and the image that we now see is much more complete. And actually
for the patient to see that result is also valuable to him.

I will move to another patient. And we\'ll go to the cover sheet once
again. And to labs. The labs, you discussed how it would be difficult to
see lab work because there\'s so much to see. If you get three feet of
charts, which we sometimes do in our patients because they come back to
see us so often, it is almost impossible. I have moved over to the lab
screen, I think you\'re just about there. Are you \-- yes. Yes, one or
two more screens and you\'ll be there.

And if I pull up for this patient several of the lab values, and say I
want this list, and then can say I want all the results on \-- for the
patient, and this will go back some period of time, and I simply then
have to ask for the graphic display, so I will now click on. And then if
I am looking at his white count, for all results,.

**\>\>** Excuse me, this is Karen Bell in Washington. I\'m wondering in
the interest of time, if we might move a little bit quicker rather than
slower, because we have about five more minutes for the entire VA
presentation, including the quality discussion.

**\>\>**

Okay. We can move very fast.

**\>\> Karen Bell:**

Thank you.

**\>\>**

This is the cover sheet of a patient if \-- if you take a look at this
patient, which identifies how we can look at lots of results from lots
of different places all at once, if I click again on all results, you
can see that this patient came in very weak and emaciated, actually
paralyzed in both legs. We did do a white count and it was elevated and
he had Lyme disease, which we corrected, then he started having other
problems which I can simply zoom in on over on the right side of the
screen, and enlarge. And you can see he had a pleural effusion that we
were able to drain. The effusion came back very fast, we drained it
again and then followed it very carefully. The very interesting part is
that this is one month at a time, many, many values and if I click on
any of them, you can see this is a telecare upload for those values.

So we have on the same screen the values for weight done in the
hospital, done in the clinic, and done at home. All in one continuous
line, which makes it much simpler to review, and assess. And that makes
\-- that\'s part of why the record is working so well. The
electrocardiogram is nicely seen.

One other view is what the patient is able to see in his own home. He
has a personal health record which contains many of the things that we
have discussed already on the cover sheet. He has appointments, his
reminders, prescriptions, problem list, and he can take this record
which actually contains many of his lab reports as well as his notes to
any doctor outside the VA to be seen.

This particular view he has on a web base at home is something that will
contain every visit that he has had anywhere in the VA system, be it in
Miami or Washington, D.C.. So it actually becomes a record that can be
shared by the patient with any provider.

I think I\'ll stop right there and we\'ll move on. Thanks.

**\>\>**

Let me \-- I apologize. I think that wasn\'t quite as seamless as we
were hoping for. I hope that people got at least a sense of what the
system is able to provide in terms of functionality and the V-cast or
video cast of things that\'s going to be available shortly and posted on
the workgroup\'s website.

One of the things I really wanted to emphasize and that Dr. Fletcher I
think began to hint at, is the use of the information once it becomes
available in electronic format for quality improvement purposes. And
I\'ve selected a few examples of some of those quality improvement
efforts and these are by no means comprehensive. In fact, it is just the
minimalist \-- most minimal tip of the iceberg. This particular slide
shows allergy documentation in the system beginning from the time at
which the CPRS was implemented or shortly thereafter, where on the
in-patient side which are the red bars, things perhaps weren\'t too bad,
but if you look at the outpatient side, really the physicians were not
documenting. And by moving to a complete order entry system, by moving
to complete documentation of medications across the board and requiring
a much more interaction with the electronic system, you can see a
substantial increase in documentation of allergy.

This seems like maybe a trivial point but it can\'t be emphasized enough
that having the transparency of information, providing feedback to the
individuals involved, and then moving along, can lead to dramatic system
change.

Similarly, this is a slide \-- this happens to be from San Diego rather
than overall in VA because this is something I\'ve been tracking there
for a long period of time. And you can see a number of benchmarks as
well as our historical implementation of the electronic record. And
there are three different lines on this graph. The one that I want to
emphasize first is this purple line that shows provider order entry
usage. And this is defined by actual entry by the clinician and
signature by the clinician. Not written by somebody else, not a verbal
order, not a telephone order. And it excludes a relatively small number
of things like schedule 2 narcotics. But otherwise a look at all the
orders entered into the system by physicians. And we implemented CPRS in
San Diego in late 1998. We\'re using it for review purposes largely for
the six to eight months and then began provider order entry efforts. Ups
and downs. I\'m showing this at not high resolutions. There\' are larger
peaks and valleys as we learned the problems of provider order entry but
over time have achieved and continue to have approximately 95% to 97%
provider order entry, again signed, entered by the provider and signed
by the provider in the electronic system. With no one else being
involved.

The green bar graph, the green line graph, rather, shows percentages of
in-patient medications using BCMA, another project that the VA has
developed where bar coding is used at the point of care to match up the
patient\'s medication due list, d-u-e, and medications are not given
unless the system checks that the correct order, the correct dose,
correct route, correct patient, are all matching up. And you can see
that that began somewhat later than CPRS, and POE implementation and
moved along quite rapidly.

The final graph, in red, are self-reported medication errors in our
system. And I hope you can see that although we had some issues
initially with the implementation of POE, and perhaps even with the
implementation of BCMA, that after those projects were completed, we\'ve
had approximately a 75% reduction from baseline in medication errors in
the system. And that really translates to a phenomenal cost reduction
overall that even if nothing else was done, I think pays for an
electronic medical record system on a very broad basis.

There are other systems that are available that can be used to track
support \-- track support and support care standards. This happens to be
an example of the straight seclusion and DNR report. This addresses a
number of different joint commission standards and availability of
reports like this to leaders in the organization and to managers on
wards, cannot be overemphasized.

Similarly, that kind of effort has led to significant reductions in
restraint use. This again, are examples from San Diego, but similar
examples are available at probably every VA in the system. This
illustrates in different words, ICU, acute med surge, extended care
units, psychiatry, overall reduction in restraints, templates and
automated reporting to leadership.

In addition, as Dr. Fletcher alluded to, there are clinical reminders
available at the cover sheet and also in the context of documentation.
Those prompt providers when help measures are needed for patients and
then reports can be constructed from their use that allow verification
of diagnoses, appropriate treatment interventions, identify patients who
need specific intervention and then the data can be aggregated at the
facility or the national revel with the use of standard terminology and
then allow preventive health measures to be aggregated and compared. And
those prompts for care are linked to structured data entry tools. And
this is just a very simple example of one possible reminder report. The
slide is getting a little old now we\'ve been doing this quite a long
time that shows again in our facility the number of patients who should
have had it, the number who had not had it completed at the time the
report was run, and a number of other interventions. I\'m not going to
discuss these in detail but to give you an example of how at a broad
level this happened to be a look at one month time and all of the
patients that were seen in the system over 10,000 we can look at some
measures of quality.

In it San Diego, and elsewhere, we dramatically expanded the use of
those kinds of reporting tools and generate provider feedback on a
regular basis. This is an example of reports that we sent to our
clinicians on a monthly basis that show a number of different health
promotion, interventions that are expected and it shows the particular
clinicians number of patients that they saw in that time frame, which
this intervention was applicable to. How many still had that
intervention due, what their particular performance was and compared it
to the facility average and to their team.

And these kinds of report cards albeit painful when first implemented,
can have a tremendous role in, again, changing behavior and improving
performance. And these direct prompts to providers at the point of care
for intervention and the tools for monitoring performance and continuing
feedback to providers and to leadership, definitely lead to system
change.

This is an example at a very broad level and this is my last slide of
just comparison between VA and HETIS for what the VA has been able to
achieve for a number of different quality comparisons in breast cancer,
cervical cancer screening, colorectal cancer, lipid control, beta
blocker usage and other measures and acute coronary syndrome, diabetes
control and measures, including eye exam, retinal exam, renal exam,
hypertension control, et cetera. And I think you can see that VA has
been a quality leader in all of these measures in comparison to any
benchmark that might be available. And this is due in no small part to
the use of the electronic medical record system, clearly the
intervention of individuals such as Dr. Perlin in roles of leadership
and the use of performance measurement systems as management tools are
part of that change as well.

But the importance of the access to the information and the ability to
track and aggregate it cannot be overemphasized. So I\'m going to stop
at this point and unshare things so that we can turn the floor over.

**\>\>**

Thank you, Dr. Smith and Dr. Fletcher. That was enormously informative.
I do want to encourage the workgroup that when the vista video is live,
that you view it, that should be an action from today\'s meeting. It\'s
only about eight minutes, it\'s very crisp and details the VA IT system
as a quality improvement tool, not just a communication tool.

So thank you so much. Let\'s move rapidly to the presentation by Dr.
Howard Hayes of the Indian Health Service. Dr. Hayes, are you ready?

**\>\>**

I am. Matt, I\'m on the page where I\'ve selected the slide presentation
and it says the slide are there, but I actually can\'t see anything.

**\>\> Matt McCoy:**

Okay, you should be able to click the first one. If you see all the
slides, each one of those \--

**\>\>**

Right.

**\>\>**

Hyper linked.

**\>\>**

I\'ve clicked the first slide.

**\>\> Matt McCoy:**

Okay.

**\>\>**

And.

(captioner break)

**\>\>**

We\'ve changed the medication management function somewhat in response
to the need of our users to make it easier to sort and display the
medications and easier to select a group of medicines and process them
at a visit. So you make sure you selected all the chronic medicines and
have reviewed each one before you let the patient go that day.

Slide 20 is another sort of busy window, showing our patient education
component. The background shows the education, the education that\'s
been delivered to the patient. The dialogue in the middle is the
education dialogue component where you actually document the patient
education. We have in IHS a manual of several hundred patient education
topics, and each one is associated with an outcome and a standard. You
have to meet the standard in order to take the credit for that
education.

Nor particular one, asthma medications, if I want to see weigh need to
teach the patient about, I lick click on a link and pops up the dialogue
that says this is what you need to talk about in order to document
asthma medication education. And this is a standard code book in IHS.

Slide 21 is a view of one of the ways you can lay out the diagnosis page
where we\'ve got the problem list on the left and you can click on those
and bring them into the visit diagnosis for today or you can add a
diagnosis for today from a pick list on the bottom, or you can do an ICD
search on a diagnosis and populate the visit diagnosis or what we call
the purpose of visit for that encounter.

Slide 21, since we see a different clientele than the VA, we obviously
have to do development in other areas. We have development some released
and some ongoing, and well child care we deployed the CDC growth charts
in our electronic record and paper-based application. We collect breast
feeding information. Have an application on the verge of release to do
anticipatory guidance and developmental screening and a vast knowledge
base of information to help providers that are seeing pediatric patients
to know what to look for and what to ask and what to teach at the time
of the encounter.

We also have prenatal care in early development, a large database of
data point that are collected at the initial prenatal visit and
subsequent visits that will be stored and carry over to future
encounters. And we\'re developing a flowchart capability to display
those.

We also have a behavioral health system application which was developed
in the 1990s which allows you to fully document one on one patient
encounters, group encounters, and various health factors and other
things related to behavior health. Aked modest treatment planning
capability, and case management information. And this is fully
integrated with our medical system, slide 24 is screen shot of the group
encounter dialogue for our behavioral health graphical application.

Matt, are we still good?

**\>\> Matt McCoy:**

Yes.

**\>\>**

Okay. Slide 25 and we\'re getting close to the end here. Case management
applications have been part of the RPM S system for a number of years.
These are registry-based systems that contain performance indicators and
reminders and population-based reporting because as I mentioned, we are
interested in population care in Indian Health Service. We have an
immunization application and including in the past few years development
of an immunization data exchange with several dates, so that we exchange
information about pediatric information with the states to make sure our
records are up to date and theirs are as well.

We have a diabetes management system, asthma management, women\'s
health, just released a HIV management system, a working on a cardiac
management system, and our \-- in the process of integrating all these
into an application we call I-care or integrated case management.

Slide 26, the integrated case management application is graphical
interface for fully integrated case management system, it contains
decision support and patient management for multiple chronic conditions,
with nationally designed preventive disease specific reminders.
Customizable patient panels, I I can create my own panels of patients I
want to be specifically following.

And the application allows you to do quick performance views sort of
like what was described a few minutes ago in vista, but these are
performance views that a provider can call up at any time to say how am
I doing with my patients in this particular panel? And we will be
incorporating our disease-specific registry systems into this
application.

So the slide 27 basically shows for a given patient, for example, the
different reminder they might be eligible for and how you\'re doing on
them.

But the next slide allows to you call up a whole panel of patients and
say how many of this panel are in the denominator for this intervention
or this performance indicator. How many are in the numerator and how am
I doing on those? And so this is not a very representative patient
panel, but it allows me to call up for any panel that I\'ve defined or
has been created for me, how am I doing with my patients on that? And
that\'s an application that will be released in the next two or three
months.

The last topic I\'ll talk about is our clinical reporting system. The
Indian Health Service is required to report on a number of performance
indicators for the Government Performance Results Act, HETIS and others.
And the clinical reporting system tracks multiple performance measures
for local use as wells as for our national reporting, and we have a GUI
(ph) and a menu-based version of this application and this is the 7th
year of the CRS application.

We use identical logic and all facilities to ensure comparable
performance data across all facilities and the logic is updated
annually. We put out two versions a year to reflect changes in new
performance measures and the way \-- the logic definitions. And the
local facilities use these reports to guide their own care, but also to
\-- or their own performance evaluation, but also to provide information
for the national reporting.

And slide 31 just as an example, in the 2006 version we had 21 treatment
prevention medication that we selected for the government performance
results act, we had 23 other key clinical measures, 21 HETIS measures,
23 elder care measures, and if you take the different numerators and
rather the different denominator that are part of these measures, we
have close to 200 different performance measures that we evaluate.

And slide 32 is a \-- just a sample of a report where you can look at a
\-- the third column over is the baseline which we usually have 2000 as
the baseline. The second column is the previous year, and the first
column is the current year. That allows you to see how you\'re doing \--
and you can drill this down to basically down to the provider level, but
how the site is doing on performance on each of these indicators, and
then the last columns are basically what are our goals and how close are
we to those?

So that\'s an overall view of the system. Our electronic health record,
our case management systems and our performance reporting system. And I
hope that that sort of covers the need for this discussion today.

**\>\>**

It did, Dr. Hayes, thank you very much. And it is very apparent that
there are outstanding examples of excellent patient care occurring and
that\'s exactly what we\'re trying to get out and learn about today.

Let\'s move to the Department of Defense, with Colonel Bart Harmon,
Colonel Harmon, are you with us?

**\>\>**

Yes, I am. We\'re now transitioning to bringing the live demo up for
you. My name is Bart Harmon, I\'m the Chief Medical Information Officer
for the U.S. Military Health System. And I think what I\'ll do is forgo
any PowerPoint slides and try to make the points that I would have made
with the PowerPoint in the context of the live demo, and leave it to
anyone who wishes to review the PowerPoints off line for some of the
additional facts that are in the PowerPoints if that\'s okay.

**\>\>**

Fine.

**\>\>**

We\'re now starting up the application.

**\>\>**

Let me ask, Karen, do we have a slide that just shows threes three
presentations and what\'s similar? Or maybe that could be an action for
this segment because I thought Dr. Hayes side by side was also very
helpful.

**\>\>**

We do not have anything in particular here that could be an action item,
Lillee.

**\>\>**

Okay, thank you.

**\>\>**

I can just start profiling what I\'ll talk about, absence the system is
starting up here. You\'ll see some interesting contrasts with what
you\'ve seen already with the military and some of those contrasts are
driven by different characteristics of our organization and our mission.

As with Indian health, we take care of not only active duty military but
we do family care, so you also see obstetrics and pediatrics support in
our functions.

We\'re fairly heavily driven in our most modern applications to move
toward commercial off the shelf software, which is an important theme
for us now. A couple of other characteristics that are important are
that we deploy teams into the health care settings and combat zones, and
so our medical applications need to have the same look and feel, the
screen work flows in a large tertiary care medical center, in a small
workgroup set up in tents in Iraq, and even an individual laptop in Iraq
and we require that the software be actually able to queue up records
when communication lines are temporarily unavailable and then stream
those off to our intermediate communications when communications become
available.

One extra twist for us is we need to be able to feed in the combat
setting command and control systems, much in the way that you would feed
health surveillance systems here in the peacetime setting. And some of
those data streams come back in an unclassified manner into the
long-term health record, and some need to pass data up into classified
systems for the theater command and control.

Even before September 11th, we were well aware of our mission to detect
use of chemical and biological weapons and we also do have an integrated
dental health enterprise. So in contrast to much of health care in the
U.S, we consider the medical and dental records to be part of an overall
electronic health record, and actually the dental functions is the next
block of functions to be deployed worldwide.

I mention all that because you\'ll see some things that we did that are
different than you\'ll see in some health enterprises, and there were
reasons for them. What I\'d like to demonstrate and what\'s on line now
is our first block in the modernization of our functions.

If you look in our laboratories, radiology departments, for example,
you\'ll see function that is we actually developed based on starting
point within veterans health, much as Indian health did. In recent
years, though, because of our need to move data in and out of combat
zones, we\'ve chosen to modernize our applications starting at the
database level, with relational databases, move towards commercial
systems and components, and as we buy those components, we buy them in
such a way that we can control the integration so that we can handle
some of the secondary reporting real-time behind the scenes, so
providers don\'t have to be aware of that.

What I\'ll show you now is installed worldwide in 70 hospitals, slightly
over 400 clinics, supporting just over 8 million of our 9.1 million
patients, and the functions are live in the hands of about 55,000 users.
And we\'re using these to collect about 100,000 encounters a day,
upwards of 100,000 in most days. These are functions that are installed
enterprise-wide and the functions you\'ll see are consistently installed
across the enterprise.

The first screen you see here, you notice on the left that you can
navigate around in an almost an outlook file folder type format on the
left side of the screen. The right portion of this screen, the action
part, is what we term health history. We actually reuse this concept
from Veterans Health, we thought it was a very nice display of very good
summary information on a patient.

Because we have our centralized clinic repository, the items you see in
these lists are one list of lab results, one list of vital signs, one
problem list, from health care delivered anywhere in the world. We pull
it together in a very patient-centric, come to this screen to see
everything that\'s available in our repository on the patients, to try
to integrate that record.

You\'ll also see, if you were to go to a live site \-- by the way, this
is training data. We\'re not using live patient data here and
compromising privacy. I have been at Walter Reed and you can see on
these screens where you\'ll have data elements that were collected in
Iraq, some from Germany and some from Walter Reed. They just show up one
after another in these same lists. You don\'t need to move around to
pull together data from different parts of the world.

I think that was especially important to us because of our global
mission and the fact that we move our people all over the world on a
very regular basis. We order them to move. We don\'t just accommodate
them choosing to move. And in the case of Hurricane Katrina, we actually
flew some of our patients from the hurricane zone up to Portsmouth Naval
Hospital and there wasn\'t backup tape needed. Those patients continued
their chemotherapy protocol at Portsmouth on the live system because it
was stored in that one central data repository.

From here you notice on the left-hand side of this screen, you can also
go into individual problem list, medications, allergies, get more detail
on the medication list for example, in-patient and outpatient.
Patient\'s allergies going to previous encounters for example. I would
like to click over on the left here on the patient\'s problem list and
just show you from here I\'ll jump to the end of the story.

As we document encounters, we\'ve pushed to a fairly highly structured
form of documentation in which we document structured symptoms and
physical exam findings, and also if a provider does medication order
entry, laboratory radiology order entry in the context of a problem, the
system maintains the association with that problem and with that
encounter, and what that does is without ever maintaining a problem
list, we can now use the problem list to navigate the patient\'s
electronic health record. Which I think will be helpful in the context
of the legal discussion earlier.

What you see on the screen now is the problem list. The first item is
diabetes melitis, and you can see one of the associated encounter and
one associated medication. No one put this on the problem list. It was
put here as a byproduct of documenting a clinical note.

If you look down to the middle of the screen, you\'ll see sinusitis with
one procedure and one encounter, and I\'ll just scroll down a little bit
and give you a few seconds. If we look down to hyperlipidemia, you see
two associated encounters. One medication, and two associated labs.

So we\'ve basically used the structure and the associativity of the way
we collect the data to construct a problem-oriented way of managing and
viewing the record, which for us is a huge step forward, especially as
our patients are moving around so much. As our patients move, it\'s
relatively uncommon for a patient to see the same provider on a regular
basis. The providers and the patients move pretty consistently.

What I\'d like to do now is give you a brief view of the tools that
allow us to collect this data, because the data has to be collected in a
structured way in order for this to be possible.

So I\'ll go to the left and click on the current encounter. What you see
here is again because we have a lot of data on the patient, each
provider can configure \-- it\'s come up \-- the top part of the
encounter note, which is what\'s coming up on your screen, lets the
provider decide whether they want the patient\'s problem list,
allergies, medications, recent lab results, automatically posted in the
top of their note so they spend their time validating information rather
than collecting it.

You see a section for screening information, for vital signs. I won\'t
go into collecting vitals, but it\'s possible to collect them, to graph
them over time. I wanted to go briefly to the SO to, which is the
structured documentation tool we purchased and integrated and what\'s
coming up on your screen is a note where I\'ve already selected an upper
respiratory function template. And as this template is on line, this is
a trivial example because I wanted to keep it short, but we can document
that a person has a nasal discharge, maybe some drainage down the
throat, a sore throat, but the rest of the findings are negative. I
believe those are coming across.

Can go into review of systems and do similar things. Say that they\'re
feeling poorly, have a bit of a headache, stuffy nose, and sneezing, but
in our standard internal practice for this type of condition, the rest
of the findings are negative. So I can go up to auto negative and drop
the rest of those findings in.

What you see on the right-hand side of this screen is the note that\'s
resulting from the clicking on the left. Now, each item that\'s
documented on the left, hyperlinked on the right, has a numeric concept
identifier sitting behind it in the database. This will be useful in a
couple of ways, but I\'ll show you in a minute \-- one I\'ll show you
next.

Let\'s say we were seeing this patient and they said, you know, I came
in for a common cold but up haven\'t seen me in follow-up for a while.
We can go to previous encounters, which I\'ll click on the left. We get
a list of a patient\'s previous encounters, which you should see coming
up. And I can highlight the last time I saw them for diabetes, scroll
through the note where I saw them for diabetes. And say, you know,
let\'s just go ahead and do the follow-up this visit rather than have
you come back.

We can right click on the previous note, click copy forward. Now, what
the structure allows us to do is to not only copy that forward as a copy
of the note. It allows us to bring that note forward \-- wouldn\'t you
know, in the middle of a demo, I need to close this and come right back
in here.

What it allows us to do is to bring that forward as a template. Sorry,
wouldn\'t you know, the nervousness of doing a demo. When we come back
into this note again, to add the things that we want to add, what
happens is we\'ve now got that previous note brought forward as a
documentation template within this note, and it eliminates any
duplication in the findings.

If you have note templates as text documents, and you try to merge them
together, you have to manually deconflict the duplicate items. By using
this copied forward template, now what we\'re doing is looking at the
left-hand side of this screen, which is the documentation part of the
screen, through the lens of the previous note. The red items are the
ones \-- the red item is the one that I already documented in the common
cold template.

The ones that are yellow are the findings that I documented weeks or
months ago in the previous diabetes template, but you notice from the
right-hand side none of those findings are documented for today. We\'re
not copying the content of the note forward. We\'re bringing the old
note forward as a template and deconflicting it.

So this is one example where we can now say that, you know, the findings
were all the same as they were last time. Same thing when we go to
review of systems. You can see that the yellow findings were what we
documented previously in the diabetes, and the rest are for common cold.
So here is reuse within one set of encounters based on structure.

What I\'d like to do now is go to an assessment and plan. Within this
encounter, we can document diagnoses, like common cold. We can document
procedures. We can do live order entry for lab, and pharmacy. As we do
these things, I\'ll use an order set for time sake.

As we order things, of course you wouldn\'t order Amoxicillin for a
common cold, but it\'s helpful for illustration purposes. I can send
these orders off, and this is live order entry going offer to the
laboratory, radiology pharmacy, with medication, medication, and
medication allergy interaction checking. And as you\'ll see coming up at
the top of the screen, we maintain the associations between the
encounter, the problem, the meds, the labs and the rads that were
documented for that problem. Giving us the explicit association that
makes that problem-oriented the view of the record possible once the
encounter is documented. The provider doesn\'t do anything to put this
on the problem list. It goes there as a byproduct of doing the
documenting.

The structure also allows us to go to the disposition screen. I\'ll skip
the top half. The bottom half is another view of that same structured
note we documented with the pluses and minuses. And the system can add
up the history items, the review of systems items, the physical exam
items at the bottom of this screen, and default any evaluation and
management code for the provider, so that if they\'ve written a complete
note in the structured manner, they don\'t need to be bothered with the
overhead of documenting the evaluation and management code.

In addition, these types of functions set us up with the association
between data elements and the level of structure to do true
symptom-based surveillance. You\'ll hear about syndromic, and again,
part of the reason we\'re compelled to do that is because of our focus
on monitoring our installations, especially in combat zones, for low
level effects of chemical and biological weapons use, and needing the
early warning symptoms when our people are exposed to toxic things in
the environment that they\'re moving through very rapidly.

I think I probably better cut it off at that point for the sake of time
except maybe to show you briefly the immunization screen. This allows us
to document immunizations to track them, know when the next
immunizations are due, to build profiles of immunizations so as an
active duty army person, I would have an active duty army profile
that\'s driven from the personnel system interface. We would have
profiles for Southeast Asia, Southwest Asia, that as groups of people
are deployed, you activate the protocol for that part of the world and
suddenly all those people show up as needing a particular profile of
immunizations.

I\'m probably touching on about 15, 20% of the functions but wanted to
give you a flavor of what we do here.

We also, if you\'re ever questioning why we do some things and not
others, that\'s a byproduct of our very structured investment portfolio
process. The functions that you see here, and enhancements to these
functions compete with medical logistics functions that make sure that
we can order operating room kits from a combat zone and have a
consistent supply of medical logistics, consistent supplies of frozen
blood, for example. So basically we have what we have because we decided
to have it, and we don\'t have what we don\'t have because we explicitly
decided not to have it.

And I\'d be happy to answer any questions, but that\'s a very brief
overview of the ambulatory portion of our newly modernized electronic
health record. And we have additional modules coming.

**\>\> Lillee Smith Gelinas:**

Thank you, Colonel Harmon. Karen, I\'m thinking that we need to move
rapidly to the organizational piece. I\'m doing a time check it. We have
about 30 minutes left in the workgroup meeting; isn\'t that correct?

**\>\> Karen Bell:**

That is correct, Lillee. And I can, as you suggested, we will pull
together a little review of all of these of the similarities and
differences for the next workgroup.

**\>\>**

That\'s would be great.

**\>\> Karen Bell:**

Thank you.

**\>\>**

Let\'s move now to the organization \--

**\>\> Howard Eisenstein:**

I\'m sorry, this is Howard Eisenstein. Could I suggest when you put that
comparison together, put the emphasis on the ambulatory so like there\'s
the Vista Office, so we\'re not just \-- you looked at an in-patient but
compared \-- you know, vis-a-vis the small or medium practitioner, which
is what we\'re trying to do.

**\>\>**

So make sure we have acute care and outpatient care and \--

**\>\>**

Yeah.

**\>\>**

Great.

**\>\>**

Absolutely, we\'ll separate those out. Good idea, thanks.

**\>\>**

The thing that strikes me the most is it\'s very clear these are three
best practices, and software, and operations that exist now. They\'re
not vapor wear and there\'s already quality of care being measured as a
result of the implementation of those systems. Thanks to you all.

The organizational component that we wanted to discuss today had to do
with E-prescribing, and we were going to have Chuck Parker and Dr.
Kibbey address us here.

Are you doing this together with the same PowerPoint? I only have one
PowerPoint presentation here, I think.

**\>\>**

Actually, they\'re not. Chuck Parker is doing his remotely in
Massachusetts, and he has his presentation. And David Kibbey is here in
the office with us in Washington, and he\'ll make some comments from the
presentation here, and that will ultimately be available on the web.
Again, I just wanted to underline the fact that this is in response to
the question that was raised at one of our previous meetings about the
degree to which standard-alone E-prescribing can and \-- and could lead
to an increased rate of full EHR adoption.

So with that, I\'m hoping that you\'re on the line, Chuck?

**\>\>**

Yes, I am.

**\>\>**

Could you go ahead?

**\>\>**

Sure, thank you. And I\'d like to say thank you for the American Health
Information Community for inviting me to participate today. The
presentation today should be relatively short. I will try to hit some of
the highlights. If you will go ahead and change the slides, I don\'t
have access to changing the slides here.

What I want to address here is basically taking a look at this from a
notes in the field and what we\'ve seen with the docket project,
particularly in Massachusetts where we\'re working with about 1200
physicians to date across the state. Certainly, and this particular area
we know why E-prescribing is of value for patient safety, med
reconciliation standpoint. The drug to drug interaction and legibility
that it enhances. But there\'s business process efficiencies gained as
well from formulary management and the use of effective alternatives
indication of medications so that the appropriate use of generic drugs
where appropriate.

There\'s an improved patient experience that we\'re also seeing as well
from the standard that there\'s less confusion about having to do rework
from formulary management standpoints so the patient is actually at the
pharmacy and being able to receive the appropriate prescription and
time.

In addition since there\'s no rework from the legibility standpoint as
well, you\'re also seeing that happen faster. And then there\'s also
definitely the cost reductions within the system itself as well. That
are inherent with the formulary management activity overall.

Some of the things we\'re seeing, and by definition today I need to
break these up into three different categories. And when we talk about
E-prescribing as a component. There\'s the stand-alone applications,
which are typically those handheld devices that are prescription writer
applications that have some integration to some degree with practice
management systems. Not directly with an EHR. Some of these examples
include the ZicsCore (ph) pocket scrip application and the Doctor First
Arcopia (ph) application, typically using either a PDA-type of device or
a small remote device to achieve the actual signature and acquisition of
the information from the physician office.

There are modularized systems as well which are independent modules of
EMR. These tend to be stand-alone applications that are sold as separate
modules of the electronic medical record systems. Some of these examples
include the all-scripts touchworks and ECW is finishing up a beta test
of for E-prescribing as well. And then there are the actual electronic
medical records themselves that have the full-blown basically
E-prescribing componentry built into the overall application itself.

And there are numerous examples of these now that CCHIT is certifying
these types of applications. Particularly those that have Sure Scrips
certification behind them. These are the basis which we\'ll talk more
and give you more basis what we\'re seeing in the field.

Slide 4, what we\'re seeing in this area in the physician offices, that
this process does offer a significant improvement with the \--
particularly with a combination of where SureScripts and capabilities
and abilities are in place and RxHub is in place. Reduction of the
refill process is typically to a four-step process that completely
eliminates the front office involvement. Which is what we see from the
field today is about 30% of the time that front office staff in a
physician office take up.

We\'re also seeing small practices basically where they can improve this
and really improve their work flows when they can incorporate everybody
inside the practice in this so it includes their MAs, nurse
practitioners in addition to the physician offices.

There are incentives that are currently out there, we\'re seeing those
incentives in place. Particularly in our private payor community here in
Massachusetts, but also across other application and basically payor
organizations where they\'re providing incentives to utilize these
systems. Obviously that \-- utilizing that cost savings to the system
and the formulary management standards, you know, the payors themselves
have less rework in that sense having to manage through the formularies
and having basically less rejected claims and having to basically
adjudicate those claims in the back end.

There\'s also the legibility that\'s improved and the rework is
completely reduced in that sense as well. However, when we take a look
at this, the small offices particularly have a lack of technical
knowledge and they typically can get into the bad selection process.
Here again, taking a look at obviously docket created to assist small to
medium practices with these type of decisions and provide that
assistance and we\'re still seeing that evidenced today in the field
where these smaller practices just don\'t have the technology and
capabilities inherent within their practice Mike the appropriate
decisions.

In some cases we\'re also seeing, the selection process by larger groups
where we are participating \-- whether (indiscernible) in essence payor
organizations where the selection processes taking place at a higher
level and seeing less likelihood of the adoption taking place in that
sense in that the physicians feel this is a forced solution for them in
that sense.

What we\'re seeing from the field today is that \-- and this is kind of
a cautionary tale that I want to put out there is that stand-alone
E-prescribing is a plateauing technology. What we\'re seeing today is
that the current technologies that are stand alone components that
basically built to address E-prescribing don\'t involve the full
practice. Don\'t integrate the medical record, a full medical record
very well. And that the legal record actually does remain in a paper
process. So when you end up with a legal record on paper process, you
actually create a duplicate work flow system where you\'re dealing half
in electronic world for the prescribing component but having to print
that record out and place it as part of the paper.

And that\'s what we\'re seeing as a system issue today when we get into
the systems where there\'s only stand alone applications.

In addition to that, most of the applications, not saying all thaws this
is not a trend and we\'re actually seeing this improve overall with the
prescription applications out there, but most don\'t allow simple drug
to allergy checking because that\'s information that has to be loaded
from a separate resource and typically these systems were weren\'t built
to take a look at the allergy component of that just basically the drug
to drug checking as well.

What we also see is that from \-- because of the dual work flow issues
that happen within the practices, particularly in the ambulatory, when
you reach a stuck or fail limitation they usually don\'t restart and
it\'s difficult to get them to go back in at that that sense.

We\'ve had several pilots here where in essence the private payors have
handed out the technology for free for a year. And typically after 18
months we\'ve seen the adoption rate drop to in the neighborhood of 25
to 30% for the ambulatory care practices. While not saying that\'s not a
success, that\'s certainly not a stellar example of where you want to be
overall from \-- in these projects.

Now, I do differentiate that from an in-patient setting in that we do
see a hire rate of success where this work flow can fit into a much
broader organizational structure. Specifically talking about the
ambulatory structure today in the field.

What we see here is also a question with the smaller docs and this is
across the board, but also larger groups. It\'s how do we participate,
what incentive program do we participate in. Do we work with the
hospital, IPA, you know, are there issues we\'ll have have to pay
attention to. And also the payors have different incentive programs for
participation and E-prescribing as well.

I think the important thing to note is on the stand-alone side, is that
there is no easy path to transition to full EMR. And the reason for that
is the lab \-- the standards don\'t exist today to transfer that
information either into HL7 format or exportation of the database in a
standardized systemic way into the electronic medical record.

At this point some of these \-- some of the stand alone applications
have created partnerships with individual EHR applications that do allow
in essence a growth into the individual applications but it\'s not a
wholesale across the market process by which you can necessarily get the
information directly out of the handheld device into the systems that
\-- a doctor would be able to jump into for a full blown EHR.
Particularly in the CCHIT vendor approved list here. What we\'re seeing
is no standards for export of records and in those cases where it is,
those transitions are extremely costly for organizations to actually get
that data out. Get those medications and formulary information out and
into an electronic medical record system directly.

On slide 6, though, this is not all bad news and it\'s not what I want
to present here. Is that what we do see is those physician whose are
either using the modular applications, in essence components of a full
blown EHR or are using EHRs and turning on the E-prescribing component
first that we\'re seeing that they have higher degree of success, that
we\'re seeing some significant utilization in that sense.

First off is there\'s simply more robust patient information. You can
actually dot allergy checking, look that up against their individual
patient record as well and see particularly from a care management
aspect, what aspect these individual medications may actually have as a
part of care as opposed to just a drug to drug check.

It can also be linked to the lab information so that we can also see
that in the sense of if we come back with a particular CHF result
that\'s bad, we can adjust the medications appropriately as well.

The alerts can be clinically driven because they actually now have
clinical decision support as a portion of this. And we can also take a
look at from the condition standpoint age, weight and be assessed a bit
more clearly as well.

What we\'re really talking about, though, is that from an overall
implication standpoint it can be applied more evidence-based guidelines
when we look at these chronic conditions and it becomes truly part of
the actual legal record.

So we talk about this from a modularized application standpoint and
fully \-- EMR, it is one of the simplest work flows we talk about from a
physician office standpoint. And typically what we do is what we\'re
seeing in the field today is that steering away from the actual
individual standard stand alone E-prescribing applications to using an
EHR componentry aspect in that sense that this would be the first piece
of the puzzle that you would bring up as part of the electronic health
record. And the reason that we\'re looking at and pushing that is we\'re
seeing that the incentives for the use of EHR are actually coming \--
and matching the points of where we can actually get a physician office
into an electronic medical record and get this work flow turned on as
the first piece of the puzzle for them. And then they can actually,
because most of the EHR vendors are certified by these payor systems as
well, they can actually take advantage of those particular bonus that is
were typically being paid for just the E-prescribing components as well.

Some relatively quick information that I wanted to provide to the group
today, this is basically the end of the presentation that I have. But I
would certainly invite some questions about this. This is certainly in
essence just a view from what we have seen currently within our field
here in Massachusetts.

**\>\>** Thank you so much. We have only 15 minutes left and I\'m sorry,
I don\'t think there\'s going to be time for Dr. Kibbey\'s presentation
as well as public comment. So we, as Jon, we are going to have to talk
about how this committee is going to have a chance to dialogue and
prioritize.

So if we could move to David Kibbey. David, it is wonderful to have you
with us. Are you ready?

**\>\>**

Hello ?

**\>\>**

I think maybe.

**\>\> Matt McCoy:**

I think maybe somebody has their phone on mute? You know what, \--

**\>\>**

Did we lose him?

**\>\> Matt McCoy:**

Lillee, I\'m looking up and it looks like ONC got disconnected so they
may be in the process of dialing back in right now.

**\>\>**

Okay. Thank you.

**\>\> Jon White:**

While we\'re waiting, this is Jon White. One quick comment.

**\>\>**

Please, yes.

**\>\>**

We\'ve been thinking about E-prescribing a lot lately with the CMS
pilots. One thing I mention, it\'s funny because it comes from
Massachusetts particularly. A barrier that did not get mentioned in the
presentation is pharmacies readiness to accept electronically
prescriptions.

**\>\>**

Good point. Without going into.

**\>\>**

Without going into it in depth.

**\>\>**

That\'s why \--

**\>\>**

I think that\'s why I specifically mentioned where SureScripts
compatibility exists. I wasn\'t trying to go into the pharmacy side.
That\'s been a legal issue with the fact of how we actually have a
compatibility from a legal stature of being able to transmit
electronically directly through a SureScripts type of clearinghouse.

**\>\>**

Yes, but. Even if if if a pharmacy is SureScripts certified that
doesn\'t mean they have their work flow set to be able to \-- work flow
is part of the SureScripts certification but it doesn\'t necessarily
mean that they do a good job of getting the prescriptions
electronically. You know, it\'s a barrier that can be overcome but it\'s
a a barrier.

**\>\>**

I apologize, somehow we lost the connection and Dr. Kibbey is back.

**\>\>**

Okay, great, let\'s jump right in. We only have a few minutes left.

**\>\>**

Neglect hear I said before?

**\>\>**

None.

**\>\>**

I\'ll start from the beginning. We were carrying on as though you were
hearing us, and I apologize.

First of all, thank you very much for inviting me to talk this afternoon
about this issue of EHR adoption in physician groups. I\'m going to give
your eyes a rest. I have a PowerPoint presentation which is being
e-mailed to all of you as we speak. But I have a very slow connection to
the Internet here and it\'s taking a while.

I\'d also like to thank Chuck for his excellent presentation, because I
would agree everything he said basically and I think that his comments
were very insightful with respect not only to what\'s happening with the
standard-alone E-prescribing applications and electronic health records,
but how physicians in general are approaching them.

What I\'d like to do is dig a little deeper and talk about the
experience that we\'re having with EHR adoption among family physicians
in this country, and what I\'m going to talk to you about is a shortened
version of a talk I have given called the ecology of health information
technology, understanding the market for electronic health records and
EMRs and ambulatory care.

It\'s becoming really clear that family physicians as a group and as a
specialty have behaved significantly differently with respect to their
purchase and use of electronic health records over the last four years.
I think the good news there is perhaps there\'s some lessons to be
learned by the behavior of family physicians and what we\'ve done from
the American academy of family physicians\' point of view to improve
their experience with electronic health records. But I think it\'s also
becoming clear ace work with other medical specialties societies, that
their purchasing behavior and their \-- some cases their attitudes
toward electronic health records and information technology are quite
different.

So with that caveat, I would like to go ahead and talk with you a little
bit about what we\'ve done and how we\'ve done it and where we are now.

The first point I\'d like to make is that the ambulatory care
environment for electronic health records is very, very different from
the environment for hospitals and large enterprises. But having said
that, there is no question \-- there\'s a clear convergence with respect
to what electronic health records used by physicians look like. The
screens, the user interface, the organization of the information is
strikingly similar among the records you just saw from the DOD, and the
Veterans\' Administration, but of also I showed you the top 10 or 12
health record application that\'s are being sold to groups and medical
practices and family medicine, internal medicine, and cardiology, for
example, by those companies, you\'d say gee, this is very familiar. And
it\'s starting to look \-- they\'re starting to look a lot alike, which
is happening very fast.

On the other hand, it\'s really true that the small practice and their
behavior towards electronic health records is not the same as a
hospital-based system.

We started the center for health information technology at the American
academy of family physicians in 2003. I was the director of the center
for the first three and a half years. I\'ve just left that position and
now work part time for the American academy of family physicians. I
think it\'s important to understand that we started out with an approach
here which was about clinical care. What we\'ve been trying to do is
help our members acquire and use electronic health records that are
affordable and standards-based for the purposes of improving quality
enhancing safety and making gains and efficiency, and we\'ve, from the
very beginning looked at the electronic health record as a central
nervous system of the family practice.

So the emphasis from the very beginning has been on the connectivity of
the software application used in the doctor\'s office with outside
sources of information, and as it turns out one of the most important
has become the pharmacy and the E-prescribing route of delivery and
acceptance of information, exchange of information.

When I took over that job, or started that job in 2003, we had a
listserv with approximately 100 doctors on it. We now have somewhere in
the neighborhood of 1200 physicians in our EMR list serve, representing
somewhere in the neighborhood of 1500 practices, and we have pretty good
data on over 2500 medical practices among our membership using
electronic health records now.

So we have seen this social network, these very, very valuable in terms
of the transparency of information that these doctors are able to share
with one another. We started a consumer\'s reports like application in
June of 2004, and up until about June of 2005 I think we had something
like 35 product reviews. There are now almost 800 product reviews by
family physicians who use those products. It\'s very consumer reports.

That has been big difference to our membership. They\'ve been able to
access this information and find a physician like them and practice like
theirs and to get a tremendous amount of information about the vendor or
the price, the quality of the service, after purchase and so forth.
That\'s made a huge difference. We have pretty good data now that would
indicate that among our 60,000 actively practicing members, somewhere
above 30% are now using an electronic health record from a commercial
vendor. And the most recent survey we did of 3500 family physicians in
December of 2006 just last month, showed in a nonscientific survey,
sampling method, that 47% of that respondents were using electronic
health record. Another 19 were implementing an electronic health record
and had not done so fully. 11% were in the process of selecting an EHR
vendor. And 25% roughly were preparing their practices. And that left
about 10% of that respondents who were not involved in electronic health
records and indicated that they would not purchase electronic health
records.

So this group of physicians, I can, is increasingly different than the
national norm, perhaps, is the best way to say it. Because family
physician resident only about 16,000 members of AFP, 35 or 40% of our
members using electronic health records doesn\'t really change the
national averages. And I think that\'s very important to understand.

There\'s something going on here that\'s different.

We track the practices around the country using electronic health
records and the vendors they use and where they\'re located.
Interestingly enough, about 25% of those practices are located in rural
areas. And that goes against some of the conventional wisdom about
physician using electronic health records in underserved or rural areas.

Just a point of information, the average cost for physician per year to
our best estimate is about \$7,000 per doctor per year. It\'s very
difficult to get that information and make it make sense, but this
includes hardware and software, ongoing maintenance costs and training.
And the question that I always ask when I\'m talking with family
physicians or any other doctors, is that affordable. And of course the
answer is, well, if you can stop doing your \-- all of your charts on
paper and you can stop doing all your transcriptions which are usually
more than \$10,000 per doctor per year, the return on investment is very
high. So there\'s a lot of issues here about whether the ROI is 6 months
a year or 18 months.

I think that just a contrast between 2003 and 2007, in 2003 we had about
10% of our members using electronic health records. We think that\'s up
to about 40% now. In 2003, the market conditions were very inefficient.
Vendors couldn\'t find buyers and vice versa. There was a very high cost
of sales that of course the vendors transferred then to their customers.
And there was poor or nonexistent information about price quality and
service after sales.

In 2007, we have much more efficient market conditions for doctors and
small and medium sized medical practices, and of course we haven\'t been
the only cause of that. The center for \-- the certification process has
been a big part of that. And as you\'ve just heard, the docket projects
have done a wonderful job in some places in providing that information
about price, service, quality, and helping the practices make the
transformation smoothly and quickly.

I think in 2003 most purchasers of electronic health records among our
membership anyway were focused on electronic documentation of their
clinical. Experience most purchasers now are focused on work flows and
one of the most important pieces of work flow is E-prescribing. And
whether you are doing that completely electronically, using SureScripts,
or through fax modem, it\'s still can create significant efficiencies
within the practice. And if we could have laboratory interface and
connectivity anywhere near the level of the E-prescribing, we\'d be in
great shape.

I think in 2003 we saw very large predominance, electronic medical firms
in 2007 one of the big changes is all of the major companies now who in
their past sold to very large hospital systems, integrated delivery
systems have entered the market with products for small, medium sized
medical practices and although not all of them are doing well
commercially, they are certainly exerting their influence on the market
and that will be felt even more the next couple of years.

That gets know E-prescribing. I would have to agree with Chuck. We
haven\'t done any surveying with our members with respect to
E-prescribing and their electronic health records because we had so many
points of opportunities to talk to our focus groups. Electronic health
record listserv and consistently told us over again we are not
interested in a single purpose application that we are going to have to
turn over or abandon completely. They have consistently said we\'re
looking for electronic health records in which a component includes the
E-prescribing capabilities and is very good.

So I would agree with Chuck that there are plenty of practices that have
rolled out their transformation to an electronic health record
incrementally, starting with or making one of the first components to
turn on, it is pretty clear from our experience that the stand alone
E-prescribing activities are probably not preferred in the marketplace.

Now, one of my caveats with respect to that statement would be that I\'m
not sure whether other specialty groups as they get more interested in
electronic medical records and start to purchase these systems, will
behave differently than family physicians have done over the past three
years. I don\'t think so. But this is \-- as Chuck was also pointed out,
there\'s a lot of things going on in this marketplace right now. A lot
of pressures and a lot of opportunities. And it\'s hard to predict what
will happen.

**\>\>**

Thank you very, very much, David. That was a very, very helpful response
as was Chuck\'s to the question. We are running very low on time. We do
have a few moments for questions and then we\'ll have a brief public
comment period.

Before I turn this back to Lillee, I wanted to comment that the panel of
presenters on the medical/legal issues are aware of the fact their time
was quite limited as well. And if any workgroup members have any further
questions of them, those can be directed to me, I will send them to
Melissa and they will query back to the panel and it will come back to
the workgroup and become public record. Any unanswered questions you
have of the medical/legal team, let us know and we\'ll respond to them
in a public venue.

Lillee, would you like to lead \-- or Jonathan, lead the discussion on
any questions \--

**\>\>**

Karen, I\'m really glad you brought up that because I really don\'t want
the urgent to drive out the important. And these were highly important
topics with very knowledgeable speakers, and we had an urgent time line
we were working against. So I am curious to know from the workgroup your
questions as well as any advice for prioritization and advice to the
staff so we can formulate our recommendations to AHIC.

**\>\> Howard Eisenstein:**

This is Howard Eisenstein from the Hospital Federation. Going back to
the first presentation on legal, I do think some kind of education
component \-- my recommendation would be some kind of education
component, you know, here is the Draconian possibility and here is the
reality. Some kind of educational piece to physicians, telling them
here\'s the down sides, the upsides, some kind of very short five-pager.
I think would help increase adoption. Because you\'ve seen the worst
case scenario and see people say it\'s not that bad. At least that will,
giving them information, I think will help them give them a little more
security.

My second recommendation is again that would increase sort of adoption
would be, it wasn\'t in the presentations but sort of the ASP model.
Let\'s have an update of that and let\'s \-- of how ASPs are doing and
also an update of how office vista is doing, because we haven\'t heard
much about that lately and I would say those would be two things I would
like \-- if successful, those would accelerate adoption.

**\>\>**

Really good recommendations. Other comments? It looks like there couple
of action items, Karen, we need to make sure we are on top of, and I
think if we could \-- I\'ll ask the ONC staff for recommendations here
because we really haven\'t had a time for synthesis and analysis of what
we\'ve heard.

**\>\>**

Karen, Lillee, we are putting together a synthesis of literally all of
the presentations that have occurred over the course of the last several
months, and so since last March, the last batch of recommendations. We
will incorporate the information that we\'ve received today in those and
be sending that out to everyone within the next week or two so there
will be some homework everyone is going to have to do in terms of
looking at these documents and being \-- and thinking through how they
might want to synthesize recommendations in all five areas.

**\>\>**

Okay. Thank you.

Let\'s go to public comments here. Matt, if you\'ll open lines and see
if we have any members of the public that would like to weigh in.

**\>\> Matt McCoy:** There\'s destructions on the webcast and anyone who
dialed in, press star-1. I\'ve had the slide up for 30 seconds and
we\'ll give it another 30 seconds and see if anybody gets in.

**\>\>**

Anything, Matt?

**\>\> Matt McCoy:**

Give it another 15, sometimes takes a little while for people to get
through. I want to make sure everybody has a chance, but it doesn\'t
look like it.

**\>\>**

While they do, that I want to compliment everyone for an outstanding
informational session. This really has put a number of issues in front
of us. And I know I have just greatly benefitted personally. I think the
workgroup has benefited as a team, and as we weigh in on the different
issues. One of the things that strikes me is I have an enormous sense of
optimism as I leave this workgroup meeting today, because we\'ve had
great counsel from our legal and regulatory colleagues. We\'ve had
really robust demonstrations of technology already in place. With the
caveat. And to the recommendation that we make sure that perhaps in the
next workgroup we explore the ambulatory components of these three
demonstrations more robustly. And we\'ve also had a tremendous update on
the status of E-prescribing. I was very encouraged by Dr. Kibbey talked
about in terms of past where we were, current where we are, that was
very, very helpful until our thinking just to get a sense of adoption is
occurring.

So Matt, is there \-- no.

**\>\> Matt McCoy:**

No, not today.

**\>\>**

Jon, any closing comments from you?

**\>\> Jonathan Perlin:**

Let me thank you for your leadership and the ONC staff, a great
organization and all the presenters, too. I join you in feeling a sense
of optimism but also the need for us to synthesize the lessons.

I recall Don B.\'s great phrase, he said the great thing about
benchmarks is that they\'re not theoretical. And today we saw
implementations. Not concepts, not plans. Implementation \-- successful
implementations with a number of technologies. And I would join you
Lillee in challenging us as a workgroup to synthesize the identification
of the barriers that each of the implementations faced, and extract the
salient lessons so we can provide those concisely to the broader AHIC
and to the secretary as recommendations to overcome those same barriers.
And enhance and expedite the implementation in the country.

**\>\>**

Absolutely.

With that, let me thank Dr. Perlin. He is really a tremendous
professional to work with, and we both enjoy co chairing this work.
Thanks to the ONC staff, all of you in Washington, and thanks to
everyone that has joined us for this virtual workgroup meeting today. We
look forward to our future meeting, and let me just bid you all a good
day. Bye-bye.

**\>\>**

Bye-bye.

**\>\>**

Thank you.

**\>\>**

Thank you.