American Health Information Community

Chronic Care Workgroup Meeting #11

November 8, 2006

**Disclaimer**

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

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

Okay, Judy, you can go ahead.

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

Good afternoon, everybody, and welcome to the 11th meeting of the
Chronic Care Workgroup. Just a reminder, I\'ll let you know that these
meetings are designed to meet the requirements of the Federal Advisory
Committee Act, which means all of these meetings are conducted in the
public domain. They have been registered with the Federal Register, and
the meetings are broadcast over the Internet, recorded and transcribed.
So I would just ask all our group members when you speak, to identify
yourselves, and speak clearly and distinctly for the recorders. The
public will be allowed a comment period at the end of the meeting.

Let\'s see, who is in the room today with me is Jay Sanders, anyone else
of the other Workgroup members, would you care to introduce yourself? I
think that\'s it. Matt, if you want to introduce who is on the phone.

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

Yes, on the phone today, Mike Crist from LabCorp. Brian DeVore and Craig
Barrett from Intel. Eric Larson from Group Health. Jeff Rideout from
Cisco Systems. Tony Trenkle from CMS. And Mohan Nair from Regence Group.

Anybody else? Just a quick reminder to all the Workgroup members who are
on the phone please keep muted when you\'re not speaking, and for those
members in the room and on the phone, try to say your name before you
make any comments so that people who are listening along to this over
the Web can know who is speaking.

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

This is Anand Parekh, HHS, calling in as well.

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

Excuse me. Okay Judy.

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

Karen?

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

I believe that if Colin and Tony are on the line they may want to make
some opening remarks and move forward with acceptance of the meeting
minutes.

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

All right.

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

I have no specific remarks, I\'m certainly willing to move acceptance of
the meeting minutes.

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

I second that.

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

Okay. Any other comments about the minutes or any concerns registered by
anyone from the Workgroup?

Hearing none, I\'ll take that as a mandate to move on. And would like to
just introduce to you, number four, to the fact that we have Sandeep
Wadhwa in the room, and he is the Vice President of government strategic
programs of McKesson, and Chair of the Disease Management Association of
America. He will be talking with us today about how health IT can
support the care of patients with chronic illnesses in multiple
different ways, and I know that this is an area that we have been
looking forward to for some time, because clearly, there are many
entities that are doing management in this space and engaging patients
in multiple ways, so this I think is going to be a nice capstone to a
lot of the information we\'ve received to date. So I\'d like to turn
this over to you now, thank you.

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

Thank you. I\'m joined today with Tracey Moorhead, who is the executive
director of the Disease Management Association. My name again is Sandeep
Wadhwa, and I am an internist and geriatrician turned population health
advocate, and have been working for McKesson for the past seven or eight
years really on how we can realize the chronic care model from a
population perspective. And how can the disease management industry or
movement really serve as a catalyst to actualize a lot of the components
of the chronic care model, of which health care IT is a very important
part of our efforts.

So I think before I dive into some case studies I\'ll speak to a couple
different examples, I thought I\'d just give a few minutes of where we
kind of see ourselves fitting in and what we kind of see ourselves
doing, and then I\'ll dive into the case studies and then would welcome
your questions, as I do have experience running McKesson\'s disease
management programs, and also have been on the board of DMAA for six
years now and have a very good perspective of the profession\'s scope of
services.

But we really do see ourselves as taking \-- in our initial inception,
very focused on how do you get better outcomes for chronically ill
populations, those with chronic conditions. And I think we were struck
maybe seven years ago by the presence of evidence-based guidelines and
how long it took for those to get translated into practice.

And a lot of the genesis for what we did was to translate those
guidelines into clinical decisions, support interventions to take
directly to patients. And do that to patients largely through combining
nurse call centers with patient empowerment strategies, and using a
clinical decision support coupled with a data warehouse, so we could do
population-based measurement.

And we took that proposition, and I think a lot of the healthcare payers
realized that there was a gap in how we structure healthcare to not
really serve the needs of the chronically ill. I have the luxury of
being able to spend, I have a little practice at University of Colorado
where I can spend up to an hour with my patients, they\'re all, you
don\'t get to be old in my world until you\'re above 75. Really, 85 is
when we care. If you\'re 65 to 75, we will generally turf you back to an
internist.

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

Pediatrician.

\[laughter\]

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

Pediatrician, exactly, that\'s, we really had, in geriatrics have had
the benefit of having extended visits, and I think what we were
recognizing was that there wasn\'t a financing mechanism to really
support patients of chronic conditions effectively.

And so part of our value equation was to go to payers and say we will
take accountability for improving the health status of your chronically
ill population by serving as a patient empowerment agent. And through
this, we actually expect avoidable and inappropriate utilization to go
down. Which is always a fantastic claim, that you can invest in a
disease management program, and reduce avoidable hospitalizations in a
very short timeframe. The payers are looking for a one year return,
which forced us to focus on conditions like heart failure and asthma.
And critical to what we were doing was a combination of a couple of
these different aspects.

I would say that was the model that many of us employed in 1998 to about
2003 or so, and maybe around that time \-- and it grew like wildfire, it
is now over a billion dollars are being spent on disease management
programs, and almost all of the commercial payers have some element of
disease management, the employers are demanding these kinds of
interventions. And very interestingly, and what we\'ll talk about in our
case studies, is Medicaid and Medicare are now looking at these models
of care.

And what\'s attractive or has been attractive is this notion that
they\'re self-financing. That they can actually fund themselves for this
narrow set, because hospitalizations, avoidable hospitalizations are 20
to 30 percent of the spend. And if you can invest, in our calculus
we\'ll generally ask for four or five percent of expected claims, and
guarantee 10 percent reductions. And so that is a rough calculus of how
the economics of this work.

Maybe about three to five years ago, after a decent body of evidence, I
think a lot of us recognized that a patient empowerment nurse call
center, with an IT infrastructure that was I think very much focused on
taking payer data, and payer claims data, and then combining that with a
nurse interview, had a real limitation.

And that limitation was it wasn\'t integrated into the practice. It
wasn\'t integrated into the caring physician\'s treatment plan. And it
was siloed from that. And I think that three to five years ago there was
a sense that we had reached, not a plateau, but that there was a good
investment here, but really, how do you get the other hand clapping.
That there is this exciting payer-patient intervention, but it wasn\'t
tied to the doctor.

And this has really led I think in the past three years to this notion
of realizing the advanced medical home vision that both the American
College of Physicians and the American Academy of Family Physicians have
been very much promoting. And I think the disease management industry,
or folks where we sit really view ourselves as being that catalyst. That
we will take a lot of the financial risk and investment to realize these
systems of care, demonstrate their value to the patients, the doctors,
and the payers, and the employers, and then kind of let policy flow from
that.

So that has been I think a really exciting model of a population
innovation, where we can do things without needing to go through a
procurement cycle, or wait for regulation or legislation to follow us.
And that certainly has allowed a lot of (inaudible) about 25 of them are
doing disease management programs, to invest in their chronically ill
population. And a lot of what we\'re able to do is make that budget
neutral or budget negative, which makes it kind of an easier sell.

So just before I get on this, then I\'ll get off the soapbox.

This notion of the advanced medical home, which to me is really maybe an
updating of Dr. Wagner\'s chronic care model, I would find a lot of
those elements to be the same. But to us there is this connection
between payer database, patient empowerment, and the medical home that
are, we\'re trying to solve for. And we found that we\'ve been able to
take accountability for large populations and deploy different
strategies. Whether it\'s a rural population, an urban population, a
very small practice, no managed care, high managed care. With all of
those constraints, how do you get an outcome for a particular payer?

These models I\'ll talk to you right now I think speak to the vision of
practical innovation, and the realization of the advanced medical home
concept. I hope I\'m provoking some thoughts, and we\'ll get through
this, and we\'ll welcome your reactions. We can go to the next slide.

So just pick a couple of case studies in three geographies. Do they all
border the Mississippi River? I think they do. One would be that what
we\'re doing with Medicare on the fee for service program around the
Medicare health support program, another from another partner
organization in DMAA, XLHealth and their experience, and finally a
Medicaid fee for service. And we chose some of these cases very much on
purpose, that the innovation doesn\'t need to always take place in the
private sector, with private payers, but we\'re, what really excites me
about these populations is their vulnerability, that is both the
vulnerability of the population in terms of their poverty, their age,
and their disability in terms of the disabled population. But we\'re
finding there\'s a vulnerability of the providers caring for these
patients. That it is, the reimbursement structure for Medicaid in this
country is, is essentially reliant upon safety net providers, and the
community health organizations, and very dedicated physicians and
providers. And we really see ourselves as how do we empower the
providers to deliver the care that they want to deliver for a complex,
frail population.

That, now, gets a little beyond IT. Our basic vision as articulated in
the medical home concept is you can do that with office support,
incentives, pay for participation, and finally, technology. And I\'ll
focus really in on the technology. But our sense is it\'s fun to focus
on the vulnerability populations. They need it the most, they cost the
most, they suffer the most, and if it can self-finance itself, that
makes it all the more worthwhile. So I\'ll go to the next slide.

We can go to the \-- oh it\'s done remotely? I never know what the
system is. Give it a second to self-propagate.

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

At least it\'s better than having someone else remotely \-- to having
the pictures in the room and you being remote. We\'ve had to do that on
a number of occasions.

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

Yeah, we talked about that option.

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

You can probably just go ahead.

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

All right. You mean because I have in front of me Tracey \-- thank you.

Medicare health support, just a word about Medicare health support
organizations. This was part of the Medicare Modernization Act Section
721 called for the Secretary to start these chronic care improvement
programs in 10 sites for patients with heart failure and diabetes.

In the fee for service setting, there was ultimately eight awardees, and
the accountability here was to reduce med expenditures against a control
group by five percent, improve clinical metrics for this population, and
improve provider and beneficiary satisfaction. So it was a wonderful
amalgamation of quality access, satisfaction, utilization, and financial
metrics. And the five percent savings had to be in excess of what CMS
was paying for.

And so each of us were awarded, McKesson was awarded, we were awarded
Mississippi, we very consciously went to the poorest state in the
country, one of the most rural. Fewest number of physicians, Montana I
think actually is the lowest number of physicians per 100,000, but \-- 

And so each of us designed different interventions to improve the health
status of this population. And for us, what was so exciting was we were
able to get Medicare data, claims data, as well as, well, we were for a
little while able to get Part D data, I\'m still working through that
with our comrades, in how to get that going again. Able to feed
information, claims data, back to providers, help establish a medical
home. And then what we really wanted to do was strengthen that medical
home with information that we were getting from the claims, as well as
information that the nurse or the care managers were getting about what
the patient was doing at their home.

And this was all facilitated, in our case, by a chronic care patient
registry system. The next example, we can go to the next slide. There is
someone who is advancing the slides? Okay, great. All right, I was \--
clarify that.

So I\'ve kind of spoken to the different elements of this. This was, we
launched this program with the ACP and the AAFP, and the American
Geriatric Society, and University of Mississippi and Dr. Dean Jones was
an integral part of this proposal, as well. And it\'s a holistic view of
the patient.

So they used heart failure and diabetes to get in, but really you were
responsible for addressing all of their comorbidities, whether they were
depressed or demented, or in this case in Medicare there\'s a lot of
under 65 who are on Medicare who are schizophrenic. So it didn\'t matter
what the comorbidities were, this is a holistic intervention. But they
needed some entry criteria. We can go to the next slide.

So we really used, in terms of IT for this program, several things.
Obviously, there\'s a core IT infrastructure that we use to do patient
identification, stratification, and an integrated patient repository of
different inputs. But we were shooting out and are shooting out to
physicians a very light-touch patient registry system. And the, and
it\'s free to the providers, and we\'re supporting its installation on
its use. And so our staff are doing this.

And we are investing in this because we think we\'re going to get a
return out of it. So everything that we\'re doing \-- not everything,
there\'s a little bit of, there\'s some investments we make that aren\'t
ROI, but they help get good partnerships going. But this was one that we
really feel like self-funds. It\'s part of our intervention that we want
to be able to communicate information that we\'re gathering, on
different care teams as well as claims information, and also force a
conversation around a checklist against the evidence.

Now, we\'re also tying this to a pay for participation, and pay for
chronic care form. Which speaks more to a P-for-P in Medicare, less for
IT, but this tool facilitates payment reform as well for Medicare.

And we\'ve designed this, and I\'d say there were practices that jumped
right on this, they wanted this. And there were other practices that
said you\'re going to have to deal with us with facts. And so that
worked, too. So we needed to create a system that wasn\'t single
threaded on one particular intervention, but also was cognizant of other
modalities to share information. And so we\'ve created some redundancy
in this model. Next slide.

The other form of technology that we\'ve been deploying in this setting
is remote monitoring. And particularly for our heart failure patients.
We\'ve \-- there\'s about five to ten percent of our heart failure
patients who we don\'t feel are, are coachable, from a self-management
perspective, either them or their caregivers. And we essentially are
toeing to do one thing, which is stand on the scale which gives us a
result. And a lot of our models have to do with self-management skill
training, but we recognize that not all patients are going to be at that
level of readiness. It may be because of their social support, it may be
because of their education, it may be because of the severity of their
disease. And so we have, and we\'ve also plugged in a personal emergency
response system as well, with that complex, the other elements of our
system, so the patient can essentially press a button and speak to a
nurse on demand. And this has been, I think, a widespread deployment for
most of the disease management community, has been the use of
telemonitoring devices on, to augment what other parts of our
intervention can do. Next slide.

Just a word on what our colleagues to the north are doing. XLHealth is
doing a similar program in Tennessee. A lot of these programs are
centered in real areas of need, which, and part of that is that we think
that there\'s a lot of opportunity for putting in a chronic care
infrastructure to reduce utilization in the acute care infrastructure,
and so this is another area where there\'s that similar type of model.

Their team also has the use of a local pharmacist, and they are a little
bit more aggressive. Our intervention focused on a chronic care
registry. They\'re actually deploying an electronic health record, we
can go to the next slide. And it has a pretty (indiscernible) clinical
information system, where the notions are the same in terms of there
essentially being no or little cost to the providers to adopt these
solutions, and that investment is essentially borne by the payers. And
we are serving as an intermediary to the payers in that regard, but all
around this notion of improving health, and reducing avoidable events.
We can go to the next slide.

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

Could we just clarify? Because I wasn\'t sure who was actually getting
the electronic health records. It\'s the docs themselves?

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

It\'s the docs themselves, it\'s the groups, yes. And in this case, the
McKesson model is more around a medical home, the XL model has a little
bit more of a reach into the specialists as well. And they\'re really
trying to get a community of information exchange. They are very focused
on duplication that can occur inadvertently through poor communication,
from provider to provider.

I\'d say these are all different flavors of ice cream, maybe, or
different forms of martial arts, and our intervention is very concerned
with the transitions from inpatient to hospital \-- I mean hospital back
to the community, nursing home into the hospital, and how we manage
those transitions. Sir?

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

Just a question for you. Do you have any information on number of
(indiscernible) patients which are connected to the physicians?

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

To the physician practices?

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

Right.

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

No, I \-- it\'s interesting \-- no, I don\'t know. Do you mean from an
IT perspective?

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

Right. What\'s the records go back and forth.

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

Right, our sense is a lot of that communication is done by paper, by
letter or by fax. And we haven\'t seen a lot of that tried to make that
electronic.

And like us, they\'re also using, in this case, a talking scale to
provide some feedback, I think that\'s their graphic. They always make
the feet very attractive. Spending a lot of time looking at feet. I
don\'t think that\'s the feet, the foot of our typical beneficiary. But
in any case \-- nor do I think that\'s our typical average weight, at a
cozy 110.

But these are just maybe two forms of IT that gets integrated into a
common view for typically either a nurse manager working with a medical
home, around how do we take a team-based approach to caring for a
chronically ill patient, and how does IT facilitate that communication.

And then the last example is a program we got started in Illinois,
Medicaid population. And this is a group of about 120,000 disabled
Medicaid recipients, of which I\'d say 30 to 50 percent have a severe
mental illness, whether it\'s schizophrenia, or a psychotic disorder.
And the other half are just disabled from some other condition. Huge,
huge prevalences of the common chronics.

In this case we are deploying two types of technology. We\'re
replicating that patient registry, but we also wanted to do a provider
portal. Which is just a less intense of an install than a registry, and
gives the providers, in this case, it\'s a lot of the community health
centers, access to the claims data, as well as our care managers\'
experience.

So there\'s a, part of the signal I\'m sending is that there are varying
degrees of intensity that speak to a community\'s readiness from the EHR
to a registry to in this case a physician portal, that we all think have
value. And what we\'re also excited about is using the Internet for very
vulnerable populations. And that gives us a chance to promote a kind of
asynchronous learning. The patients can go on to the Website, and
essentially get the whole content package that we\'re offering at their
leisure, and they have access to health trackers, they can ask questions
of their nurse, and it gives them another way of connecting.

Now, that being said, if we had five percent of our population using
that, we would be thrilled. So we still think the adoption on some of
these technologies, in more vulnerable groups, is low, but we anticipate
that those will increase. The notion is that we\'re hitting our,
hitting \-- we\'re building this infrastructure, and finding the areas
that will stick for the participants or their caregivers.

So my last slide is just kind of a reiteration of what I\'ve been
saying. We\'ve been very excited by the way that our industry can help
serve as a catalyst, a funder, a tester, a learning lab for IT to
improve the health of chronic care populations. We\'ve been very
interested in this interface of adoption, and how we can use incentives
and support to promote the adoption.

We see a lot of attention being focused on the medical home, and we\'re
very excited by that. We\'re probably also very interested in the
nursing home and the hospital, and how we bring those two groups into
the equation, particularly for Medicare. And we\'re really seeing
in-home telemonitoring becoming a fabric of a standard disease
management offering. And those are my few comments, I\'ll welcome your
questions on anything I\'ve touched or anything that I haven\'t touched
that would be of interest to you.

So thank you.

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

Thank you very much. And you certainly have opened up lots of questions
in my mind, but before I jump in I\'d like to open the floor for
discussion for any questions or comments for Dr. Wadhwa.

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

This is Jeff Rideout from Cisco. For the Workgroup members it will
probably sound like a broken record, but could you outline again the
incentive and/or reimbursement that goes with these programs? Is it all
based on incentive, or is there some telehealth reimbursement to the
physicians involved?

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

Well, there is incentives. Most of these programs don\'t have incentives
to the providers for these programs. There are some notable exceptions.

So in Pennsylvania Medicaid, there are incentives for their
participation, and they get , they\'re paid to participate and have
their patients participate in these types of programs. And likewise, in
our Medicare program, there\'s also an incentive, and I think it\'s, it
is our preference to create those incentives, because I think we\'re
cognizant that if there\'s extra time associated with delivering chronic
care, that is, we think should be reimbursable. So we see a lot of that
going on, on the private sector side. I\'ve got more experience on the
government side, Dr. Rideout, but I would say it is not common yet.

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

So in these programs there\'s no physician reimbursement for services
provided?

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

There is in the Mississippi program.

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

Okay, so is it following the pattern that is recommended in the advanced
home documentation?

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

That\'s exactly right. It\'s in accordance with the ACP and the, we
tried to replicate the chronic care management fee that the AAFP was
promoting, the American Academy of Family Physicians, in that there was
a bundle of services associated with participating, and so we thought
that that was a very appropriate construct. Part of the vision here is
how do you strengthen the cognitive specialties or the primary care
specialties for the complex work that they do, caring for a very frail
population.

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

Thank you.

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

Any other questions or comments?

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

This is Jay Sanders. What results do you have?

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

Thank you, yes. So we\'ve, there is, there\'s a body of evidence, I
think there\'s a preponderance of nonrandomized control trial evidence
that speak to utilization reduction in the 10 to 30 percent range, and
ROIs, just straight ROIs of I\'d say a break-even to about 2.5 to 1.

And I\'d say there\'s a cottage industry in publishing these
nonrandomized control trials, so what\'s very exciting is some of the
Medicare work that\'s going on now, where we\'re testing these
interventions in a randomized setting. And so I think we\'ll have some
prospective randomized results, at least for phase 1, that could be as
soon as a year. And there is a, and a lot of this work does build up of
NIH-sponsored research that I think is essentially in the translation,
and now we\'re executing on work that Dr. Michael Rich has done or a
number of folks have done in academic centers, and how do you take that
to community center. So I\'m excited by the rigor that Medicare in
particular is requesting of these interventions.

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

One of the questions I have, and I\'m going to \-- actually it\'s just
one, so I\'m going to play off of Jay\'s question, is that as you look
at these different types of models, you describe the earlier model as
really siloed from practice. And you\'ve described here several
different models, ones where it sounds to me. and I do need to verify
this, that you truly do engage the physician. The physician has the
electronic health record, the information goes into the record, and
it\'s really the patient monitoring all of this.

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

Yes.

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

I\'m sorry it\'s really the physician managing and monitoring all of
this. Then you have other situations where you\'ve got a nurse dealing
with the disease registry, and then engaging the physician separately.
Have you been able to, in your own work, begin to see if there\'s one
model that seems to be more productive in terms of outcomes than others?

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

No. Part of our issue is we\'ve got accountability for the entire
population. So there is \-- and we\'ve got provider groups that have no
interest in engaging with us. But we\'re still accountable to the payer
for those patients, and we think that those patients should benefit from
education and self-management skills, and know the value of aspirant
(ph) if they\'ve got diabetes. So it\'s very hard for us to tease that
out.

Part of our plan with CMS study is to do a series of secondary analysis
to answer that question. I\'ll say here\'s our \-- so I don\'t have a
great evidence-based answer for you \-- here\'s our, here is my
non-evidence-based answer. Is when we look at not integrating the
physician, we don\'t make a dent in prescribing behavior. We\'re not
seeing increases in ACE inhibitors or prescription. But we see a lot of
patients that we think are activated, and know how to manage their
symptoms. And we\'re getting a lot of that cough that might actually be
asthma, and interfacing with the system much better.

My sense is we\'ve, in the absence of this model, we\'ve succeeded in
creating a more empowered patient and caregiver, but we really haven\'t
changed provider behavior. And that\'s where I\'d like to say I can do
1.5 to 1 ROI, but to get to above a 2 to 0, I really need a provider.

Now, all of that\'s going to wash itself out. Our fantasy is that we
stop talking about cost savings and talk about cost effectiveness,
because we\'ve been able to take the avoidable hospitalizations out of
the system. And then we\'re investing in chronic care not because it
saves money, but because it\'s the right thing to do.

But that is harder to sell with legislatures, and, we make other
decisions in healthcare on cost effectiveness. Unfortunately, for
disease management, we make those decisions on cost savings. Which I
think is, I think, Jay, maybe back to your point is the evidence.
Whereas if I think the evidence was stronger then people would be
willing to say okay, this is worth investing, and the returns are in
quality years gained.

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

This is Jay. Although I\'m very encouraged by what you just said, not
discouraged, in terms of your statement that you really haven\'t been
able to change physician behavior, but you\'ve been able to change
patient behavior. When push comes to shove, the most critical thing is
changing patient behavior.

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

Yeah, and Jay, I think that is, I think, I\'m speaking in, I\'ve got,
you know, plenty of counterexamples of changing physician behavior, and
you get these physician advocates, but I think that was, part of this
whole movement arose from this notion of power to the people, in terms
of really helping patients understand much more what the natural course
of their disease is. Whether the medication they\'re taking, the 100
questions that you don\'t think to ask, or you feel nervous to ask, or
you don\'t know how to ask. That piece is very satisfying, that there\'s
an economic model that supports those types of investments. I think
it\'s, we find that those are, we get less of a return for richer
populations, frankly. I mean, the employees. But you take our
participation rates, and the industry\'s participation rates for the
poor, the disabled, and the elderly, are so much higher than our
commercial rates. There\'s so much, there\'s this real sense of
isolation, that you\'re able to address through a proactive model, than
a reactive model, which is I\'m going to see my doctor when I\'m sick.
So I thank you for that statement, Jay. That\'s how we\'re doing.

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

This is Eric Larson from Group Health. You may have said it, but could
you either tell us what you have observed around actual interfacing with
electronic medical records, or secure messaging, or some of the tools
that, you know, we\'ve written about in terms of downloading, I guess it
wouldn\'t be appropriate in this population, but we talked about
spirometry, asthma, and blood glucoses, and diabetes, and so forth.

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

Sure. So there is a, it\'s foundational in our interventions to have
secure messaging between patients and nurse managers that is generally
supported through devices, secure Web modalities.

And I think of Tracey, almost all of the membership have made secure
messaging integral to how we communicate, the nurse managers in
particular, communicate with patients. And then the adoption rates vary
accordingly.

This other wave of how we\'re integrating that information to the
doctor\'s office is also occurring, it tends to occur, Dr. Larson, with
the office manager, who is pulling that data down. And in our
constraint, I think it\'s Dr. Rideout\'s question, that if there\'s
something in it for the office, they are more proactive in pulling that
information that may be sitting on the Web. Or we\'ll prompt through a
phone reminder that there\'s some information for them to see. So I feel
like that linkage is still in its infancy as opposed to the patient to
disease management organization.

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

Part of the reason I was asking is because you have this case management
fee built in.

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

Yes.

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

And their performance as I understand is going to be judged by whether
they meet cost targets and disease management outcomes. So you would
think if things like secure messaging or other ways of using the
electronic record would prevent visits, in this setting at least you\'d
expect some doctor-based behavior that would say it\'s in my interest if
I can provide some information asynchronously to a patient, and save a
visit, and save blah, blah, blah. I mean, is that happening?

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

Not really. Because the doctors are, they aren\'t as much as part of the
risk pool as the disease management organizations. So I think there\'s
another set of demonstration projects coming up from CMS, the 646
demonstrations, that I think are attempting that exact hypothesis,
Dr. Larson, on can we reduce avoidable office visits, through these
technologies.

In our model, this is much more driven, it\'s almost a, we\'re really
trying to encourage more visits, frankly, than less visits, and I do
agree that there is an opportunity to reduce avoidable office visits.

Some of this is the dynamics of our population, which are 50, 60 percent
inpatient, and only 10, 20 percent office visits. So we can \-- and
frankly, a lot of those office visits aren\'t with a medical home. They
are amongst eight other providers. So part of our vision was to reduce
some specialist visits, potentially, by really trying to send our care
to the medical home. But I think your question will be answered in that
646, or addressed in that 646 demonstration. I\'m looking at the CMS.

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

Yeah, Karen, are we going to get some people from that demonstration
before that group eventually, or do you know?

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

I think we probably should, I\'m looking at someone from CMS right now.

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

And I\'m looking at the phone behind which Tony is sitting, so \--

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

Yeah, this is Tony, we could certainly get some people to speak on the
646, if you\'d like.

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

The physician group practice, which has had a year now, almost two years
of experience, that group may speak to Dr. Larson\'s point very well.

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

Yeah, we\'ve actually been talking pretty regularly with them. Karen, if
you want to have Linda Magno or somebody from that shop talk, we can
do \-- we can arrange for that.

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

That would be great, thanks, we\'ll probably do that at the next
meeting. Thank you. And the 721, as well. But you\'re actually
representing the 721 demo?

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

721, I\'d say I\'m representing the \-- a lot of the commercial payer
organizations that are doing this. Largely to the employer groups. I
think we\'ve got several folks on the phone call who probably have
employer-sponsored disease management programs, that community, and the
Medicaid community.

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

I\'m going to ask you a relatively difficult question, so you can
deflect it if you choose, but I think one of the issues that someone
brought up a little bit earlier is how do you actually think about
providing reimbursement or payment to physicians for their time and
expertise. Right now we have a fee for service system, and I think we
all agree that that\'s one of the reasons that we have a fragmented
system that doesn\'t meet the needs of anyone right now.

What type of reimbursement models have you \-- you mentioned a little
bit about pay for participation, pay for performance. With all the
experience that you\'ve had, would you go so far as to suggest
reimbursement models that you think might work for primary care, so that
we can, we might be able to move this agenda forward where there can be
more reliance on remote care, and better communication?

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

Yeah, I\'ll stand up on some kind of a pulpit for that question. So yes,
I\'ll take that question, and it\'s probably just me talking here,
so \--

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

That\'s okay.

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

I am much more excited \-- I\'m much more interested in promoting the
notion of pay for participation, frankly, than pay for performance. We
have found that the notion of a chronic care management fee, the
completion of a chronic care registry, I mean a chronic care form,
reimbursing for things like that, I\'m not necessarily paying for
outcomes, but I\'m paying for a mindset to think of your patients
proactively, comprehensively, and to pay for the activities associated
with being the team-lead in terms of the medical home. That a lot of the
interventions that we\'re doing are team based, they deploy social
workers, nurses, case managers, and we act as the quarterback in the
absence of the doctor acting as the quarterback, or \--

And I understand. So we think that there is an appropriate payment for
this participation in the chronic care model.

Now, it\'s easy for me to say that because we end up \-- we\'re the
accountable party, so we make sure that that doesn\'t turn into a payola
in terms of inappropriateness. So we are the, I never know what is the
right terminology, but we rate limit the, we\'re watching over that
system to make sure no one is, there isn\'t an outlier.

But we think that investment pays for itself, and we\'re monitoring
that. The disease management organizations or chronic care, Medicare
health supporting organizations monitor that to make sure it doesn\'t
turn into all of a sudden a billion dollar payment stream. Maybe in this
book, maybe a billion is a right number. But whatever the number is,
there is an accountable party making sure you\'re checking that against
the other area that you\'re expecting to get reductions from.

So the reason I\'m not as enamored with the pay for performance piece is
it just, it seems maybe that\'s a phase 2, maybe that\'s downstream. We
get into big, big debates about the sample sizes, of what is adequate.
We get into big debates about what are the right measurement criteria.
We get in debates on who really is the medical home. And I think we are
making a bet that there is an investment in primary care that we are
confident is a good bet.

And frankly, it\'s a good bet to us. We can reduce costs in our nurse
manager model. I don\'t \-- none of us are married to this big lumpy
infrastructure that exists outside. We think that it is appropriate for
those who don\'t have any medical home, who don\'t have any access, who
don\'t have \-- there\'s just not enough care, so there\'s this notion
of a system. So, you know, Ms. Bell, I think that \-- I hope I\'m
conveying my preference in terms of participation, over performance.

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

That\'s very helpful. I don\'t mean to be taking up all the time here,
but I have one more question on my mind, and then we\'ll see if it\'s
time to wrap up. This one has to do with the fact that particularly
through your role at the CMA you\'ve been working with multiple entities
to do chronic care management, disease management, who have looked at
multiple interventions.

Now, the question I have is are there some that are very successful as a
stand-alone, are there some that you actually have to have a package of
interventions with? And you submit the medical home is a package of
interventions.

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

Absolutely.

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

And communication is one piece of that. So I\'m just wondering if you
could also comment from all your experience, and from your colleagues as
well, how you put together the components versus the package.

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

Yeah, and it\'s a great question, and I don\'t have an easy answer,
other than we have found that we are able to successfully offer just
components of the intervention. It\'s very, I\'d say it\'s largely
dependent on the characteristics of the population, the patient
population.

And it\'s somewhat dependent on the characteristics of the provider
population, but I think the most experience is around getting components
by patient. And that is largely a function of this growing up in a
private payer market where they, disease management didn\'t have enough
of any one doctor\'s panel to be all that significant.

I think those of us who are doing big fee for service programs, you
start to get some share in a Medicaid community health center, or in a
Medicare program, and all of a sudden you open your eyes to the medical
home. So let me just offer a couple of thoughts.

We go very light touch for our, for the technology companies employees.
They\'re just, that is a low investment. We do a lot more mailings, and
internet, education, and we don\'t need to do as many phone calls.

When you deal with a retiree population, it\'s a different set of
components. So I think we\'ve found that depending on the education
level, the income level, the age, there is a sweep, all we\'re
trying \-- our whole issue is to get the least intervention to get the
most ROI. So we don\'t want to over-engineer a solution in terms of too
many components. Because there\'s someone else who will offer a better
value to, you know, to that purchaser.

So I hope that gets somewhat at your question. I do think there are \--
the quick thing would be less sick, less components; more sick, more
components. But no one kind of \--

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

It doesn\'t really fall out that way, is what you\'re saying.

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

Yeah.

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

Okay. Thank you very much. Are there any other questions or comments?

Well, I really would like to thank you so much. We\'ll probably hear
more from you at another point in time, and we will bring in some of
the \-- Linda Magno on the 646 demo as well.

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

And it\'s our pleasure, thank you for inviting us. And please let us
know how any one of us can help you in the success of your project.

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

Thank you, again. And good luck with yours, as well.

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

Thank you.

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

Tony, Craig, we do have Kelly Cronin in the room. Is it all right if we
move ahead with her presentation on what the Consumer Empowerment
Workgroup is doing?

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

Please do.

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

Thank you.

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

Thanks, Karen. I should say I don\'t actually have a formal
presentation, but I thought it would be helpful just to have a chance
for us to talk about our respective work and perhaps discuss some of the
areas of overlap, and ways we could be addressing them in a synergistic
way, or perhaps in a more coordinated way. Particularly as it pertains
to online consultation and secure messaging.

And I actually should offer that Justine Handelman who is a Workgroup
member and Will Crawford, who has really been involved in the Workgroup
efforts, are both here, so I\'d invite them to add anything at any point
in time.

I think it might be helpful just to touch on a little bit of what we\'ve
been working on in the last five months, so you know sort of where
we\'ve focused our efforts since the May 16 recommendations. And since
our broad charge is to make recommendations to encourage the adoption of
a longitudinal, consumer-centric, affordable, and interoperable personal
health record, we, you know, looked at that as a pretty daunting charge,
just like your charge, broad charge, and realized that we didn\'t have
enough information back in June, when we were starting to embark on
this. And decided at that time that we needed a pretty good
environmental scan that was likely going to go beyond our three- or
four-hour conference calls on a monthly basis.

So we set up two different all-day public meetings, where we held a
variety of organized panels, and had a variety of testimony around given
subjects that were most pressing so us. So sort of the critical
components or our major issues. And we also funded a contract to
actually do a more thorough environmental scan of the marketplace
because we recognized that it\'s virtually impossible, even through
longer public meetings and a lot of testimony, to have a handle on
what\'s happening in terms of innovation and successes and failures,
when in every given month we\'re hearing more and more that\'s going on
in this space across both providers and technology firms.

So with all that, I think we\'ve come to a fairly good place in the last
month, where we went through our visioning process, and had a lot of
good exchange of ideas on what we really see the future holding for this
area. More from an ideal perspective, not \-- we got reality-based when
we talk about the incremental change for the next few years, but
starting off and trying to paint the picture of where we ideally would
like to be somewhere between 2014 and 2020, not really being definitive
to a time point, but we settled on this idea of obviously a PHR, as a
tool that facilitates the creation of personalized experiences of
healthcare not only promoting health and wellness, but also supporting
the healthcare of an individual.

And I think some of the concepts that we talked about that are relevant
to your work included, in the ultimate vision, that there would be tools
to communicate with authorized stakeholders, and, you know, the
individuals\' health experience or interaction with the healthcare
system. And that there also would be decision support tools through
which they could understand the risks and the benefits of various
pathways of actions. Both actions they would take as individuals, and
also, you know, shared decision-making that they might encounter with
their clinicians or healthcare team.

And this general concept of being connected to the healthcare team, not
necessarily a primary care physician, not necessarily someone, you know,
as a point of contact in a hospital, but really every provider that
might have a significant role in that person\'s healthcare should be
able to be connected in some way, in a meaningful, real-time way, with
that patient, to improve their health and healthcare experience.

And then when we started to think more specifically about the components
of the vision, we also \-- and actually, you know, focusing on the
interaction with the healthcare system, we thought that there really
needed to be a viable PHR options existing for all patient populations.
So there would obviously need to be a strong competitive marketplace
that would emerge over the next several years.

But that that marketplace would serve a variety of needs, whether they
be, you know, specific to a given set of diseases, could be chronic
diseases, it could be acute, it could be more prevention- or
wellness-oriented, there could be multi-lingual, sensitive to health
literacy, really touching a lot of different populations, and obviously
there\'s a lot of diversity in the markets across the U.S.

And that PHRs really should provide a convenient and reliable means of
sharing their personal health information between the members of the
healthcare system. There has been a lot of discussion about the NHIN
enabling that, and while it\'s not universally I think, you know, agreed
on or figured out in terms of what would the role of the NHIN service
provider be, you know, in providing that information, or RHIO providing
that information, I think certainly there\'s a lot of people that are
recognizing that vendors may be acting on behalf of consumers, and
accessing that data. And if there is a record locater service through an
NHIN service provider or RHIO, that they could be certainly acting as a
way of collecting or aggregating all that data as it\'s needed so that a
patient truly could have a longitudinal record over time.

That would be more comprehensive than the current state, which is really
either self-entered data, or perhaps data that would be entered or
prepopulated from claims. Which is of short-term utility, but not
without its limitations.

So we also talked about, in the end state, a majority of consumers
having access to interoperable PHRs, comprehensive tools to engage in
self-management that would be complementary to or either perhaps part of
care management models. I think that\'s probably also something that\'s
comparable to what you have been talking about.

There was a lot of consideration around the level and type of consumer
control of their health information. Obviously this is an instrumental
part of what needs to happen over the next many years. And we tried to
get into some specificity there.

We had a pretty good conversation around what HIPAA is enabling, in
terms of giving rights to access data, but then the realities of what
some consumers are experiencing was not being able to have timely access
to data, in part perhaps it was suggested because there\'s a fear of
liability with some providers. And some of the early work coming out of
the RTI contract has been sort of confirmation that perhaps the
interpretation of HIPAA is perhaps restricting some consumers, at least
timely access to their data. So there might be an outreach element,
there.

We talked a lot about the roles of stakeholders, consumers, providers,
purchasers, payers, policymakers. And then probably spent most of our
time on enablers and barriers, realizing that, you know, this ultimately
is a tool that\'s going to lead us to a common understanding of what
needs to happen and you know, what should our recommendations be.

So when we got into enablers and barriers, one of the ones that I think
again is relevant to this Workgroup was the need for demonstrations and
case studies that clearly demonstrate the value and build the evidence
base for interoperable PHRs, and in a way that it also shows how a
combination of incentives could be aligned to drive adoption.

And as a component there\'s been a lot of discussion, right now it\'s
really a barrier, which is really the extensive conversations you all
had in the first four to five months, that we don\'t have the right
reimbursement environment to encourage the integration of EHRs and PHRs,
at least in short term, with structured e-mail and secure messaging.

You know, in our group it\'s been called online consultation, there\'s a
variety of ways to discuss this. But that\'s been looked at as a fairly
significant barrier. When you\'re talking about at least the model where
the personal health record is tethered to or integrated with an
electronic health record.

And we, I think as a Workgroup in general, have not really been wedded
to any given architecture, but we do recognize the value of having
meaningful clinical data in a personal health record, and really wanted
\-- the easiest ways to get that at this point is to have it somehow
interoperable with an electronic health record, or to be able to start
with a prepopulated record that, it may be prepopulated claims data, but
it\'s done in such a way where there could be a way for patients to
recognize or make notes of where they think there\'s a discrepancy, and
there could be some errors of commission or omission.

So that\'s sort of I think some of the more important aspects of the
vision that we went through over the last two months or so. And then I
also wanted to touch on where we\'re sort of headed in terms of making
recommendations.

We, again, have been focused on sort of these major critical components,
and those being interoperability, functionality, consumer awareness, and
engagement. As a part of that we\'ve also been considering health
literacy, and the need to really effectively communicate and engage
consumers. And we\'ve also talked a fair amount about business models,
heard a lot of testimony of environmental scan, focused on that as well,
and then legal and policy issues.

We aren\'t really thinking about any set of recommendations around
functionality, primarily because I think there\'s pretty good agreement
that the market is going to innovate, and really deliver over time the
functionality that\'s needed to vest our patients. And there\'s nothing
that we can see at this point doing to encourage that, it\'s really
going to be a matter of experience and what consumers respond to.

But in terms of interoperability, there\'s been a lot of discussion
around certification, and the need to make sure that the data that is in
personal health records is portable. So that if they are \-- if it\'s a
plan-based PHR, if it\'s employer based PHR, if it\'s a stand-alone
vendor or if it\'s integrated with a provider or physician\'s office, it
just needs to be that patient\'s record over time. And that they would
have to be able to follow them.

So to get there is, we talked a lot about what requirements would be
reasonable to consider with certification. And so far, based on all the
vendor input we\'ve had through testimony and most of the Workgroup
discussions, we\'re leaning towards certification starting off just for
interoperability criteria, and also privacy and security criteria,
recognizing that privacy and security also quickly gets into the policy
realm, not just technical standards or criteria.

So that\'s \-- I think we\'re probably going to be talking more in the
next three weeks around recommendations around that, to refine it, but
that\'s where our thinking is right now.

And as a part of that, it could be sort of an early precursor to having
some interoperability between EHRs and PHRs, and a lot of the HL7 work
to develop the functional model and conformance criteria for personal
health records is focused on that, so there is something to build off
of. And that\'s actually how the EHR certification process started. The
HL7 bit and EHR functional model which then led into CCHIT\'s work. So
in some ways it\'s comparable to have that involved.

We also have recognized that if we are going to be seeing a lot of early
innovation and progress around prepopulated PHRs that we have to address
the data integrity issue. And with claims data, no one I think has the
solution yet, but we recognize the issue and will probably be talking
more about how to maybe make the data a little bit more clean and
reliable if that is going to be a priori source of data in the short
term.

In terms of consumer engagement, this is a fairly challenging issue,
because there\'s a relatively low awareness of personal health records
in the public. And while, you know, some surveys suggested that there\'s
a fair amount of people that would like to have access to one, and we
have tried to do sort of a quick summary of the literature, here,
there\'s really \-- we\'re not quite ready yet for a major social
marketing campaign.

This has been considered by AMI and AHRQ and Markle over the last couple
of years, and everyone has sort of come up with the same conclusion, and
when we revisited it two months ago we\'re still in the same place, so
we\'re not really ready for a public education campaign. But the social
marketing experts who have really looked at this have been suggesting
that we probably need some kind of public-private campaign that\'s
focused on a given disease area. And that\'s done in the context of a
pilot. And I think this is very consistent with our ideas around a
breakthrough. And if we learn from that, if we learn how to work
together across the volunteer health organizations and some of the
agencies that could, you know, help with development of communication
materials, I think we might be able to figure out how we might be able
to roll out something on a larger scale. So at this point we\'re more
thinking about how do we learn how to work together, build the right
messaging, know what the right messaging is, which will require some
probably qualitative research, to really get consumers aware and engaged
in how important this is, and how, what it really could do for them.

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

Kelly?

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

Yeah.

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

This is Craig Barrett. Just on that last point, you seem to be saying
that PHRs, EHRs, et cetera, no broad-based dissemination, but just focus
on a whether it\'s asthma or diabetes or some particular illness?

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

Yeah, one of the experts we had in testifying to us recommended that we
start with a specific disease to really figure out how to make this
work. And really, really engage them, really get through to them. And
then learn from that experience to build something broader. And I think
people seem to respond to that, although we haven\'t, you know, gotten
to the point where we have a draft recommendation around that.

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

It seems to have lots of implications, because you\'re automatically
focusing then on a relatively small portion of the population, which is
widely distributed.

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

Yeah, I think, I think we probably need to think about how we\'d make in
a relevant to a broader population, if we were to go down that path.
Because the idea would be to build on that whole effort to make it more
applicable across a broader, you know, geographic area, and more diverse
group.

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

I applaud your last statement, which is if there is a proposal to focus
on a narrow segment, thought should be given to how to at least scale
that out to a much broader segment. Otherwise, it may just end up as a
nice local experiment, in one area, and not have the broad
applicability.

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

Right. Yeah, I think the other thing we\'ll be able to learn from, the
National Health Council is working with AHIC, and I think the Blues now,
to start this type of program. And we are thinking we could probably
either potentially build off of that, we have a planning meeting
scheduled in a couple of weeks to explore that, where we\'d hit, you
know, multiple regions in the country, and probably multiple types of
populations that probably would then enable us to be more scaleable. But
those are great comments, thank you.

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

This is Jay. Have you (inaudible) or spoken to Steve Downs at Robert
Wood Johnson Foundation?

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

We have talked to him about lots of things they\'re doing. And it\'s
exciting, the work they\'re involved in. In fact, one of the things I
didn\'t mention but we have spent some time on is the need to have sort
of patient-centric product development, where there\'s a lot of focus
early on about what does a consumer really want, when you\'re thinking
about software. And actually, just on Monday we had a really interesting
testimony from Intuit, who has a huge amount of experience in this
space, and they\'ve already done research on 1,400 consumers, including
home visits, where they follow people home and actually observe how they
deal with all of their healthcare issues from home and what kind of
tools would best enable them to, you know, to minimize their pain. Look
at pain points, in particular.

And I think they have, they probably have a slight bias toward the
administrative aspects of healthcare, but they certainly looked at
broader issues, in general. And I think that we are going to be able to
learn from a lot of the market based experience. They in particular have
that sort of consumer-centric focus to developing their products. And I
think that\'s what RWJ is doing, as well. Also Peace Health, we have had
testimony from Peace Health and others they\'re working with, so yeah.

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

Kelly, could I just talk \-- this is Karen \-- about your research into
the tethered model for PHRs, because that\'s an opportunity where there
are some places, there aren\'t many, but there are some where it\'s been
in effect for some time. Have you been able to get any good outcome
measures from that, in terms of how well it\'s used in specific
populations, and how it improves care?

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

That\'s a great question, and we talked a lot about it on Monday because
we had the results of the environmental scan that looked not only at the
tethered model but they looked at the stand-alones, as well. And there
are some experiences, Cleveland Clinic and Palo Alto have sizeable
patient populations enrolled at this point. And I don\'t think there\'s
definitive outcomes data.

And when Altarum, who did the environmental scan, looked for proxies of
utilization, they really couldn\'t find anything that\'s reliable across
any of the types of PHR service providers. So we don\'t really have a
good measure of usage, utilization, or of outcomes at this point. But I
think that Paul Tang, who is a Workgroup member, has presented on his
experience, which is very impressive. They have 70,000 patients, and
they\'re really \-- I mean ,there\'s not only anecdotal experiences that
are \-- you know, sort of transforming the way patients are interacting
with their physicians, and taking more responsibility for their own
care. But I think he probably has some early results, too, and we
probably need to follow up with him to see what definitive outcomes he
might have to offer. And certainly he\'s a prolific researcher, too, so
the data will be coming, I\'m sure.

But yeah, that\'s a good question, and I imagine Cleveland Clinic has
got a plan to measure their impact, as well. But there\'s a lot of
excitement on the tethered model but that\'s balanced with the need to
really keep consumers at the center. And there\'s certainly a lot of
advocates out there for having a completely personally controlled PHR. I
think at this point it\'s clear the market is innovating around a
variety of solutions. We did find on the environmental scan there\'s far
more stand-alone PHRs out there than there are integrated. But yet
there\'s probably more functionality being offered with the integrated
or tethered model and more data elements because of the connectedness.

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

Kelly, this is Eric Larson at Group Health. When you talked a little bit
about social marketing, and then you\'re obviously saying that these EHR
groups are doing some kind of marketing, do you have a \-- you know,
this is a Chronic Care Workgroup. Do you have a sense or would you just
opine where the market is? And I sort of ask the question because we
thought at Group Health that the market for our secure messaging and
MyGroupHealth would be in sort of this savvy younger consumers, and what
we find, I guess not to our surprise when you think about it, is it is
people with chronic illness that have the greatest need and the greatest
use of what is for us an integrated secure messaging system.

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

Yeah, there\'s been a fair amount of discussion over the last 10 months,
I think, about what would be sort of the natural segment of the market
to focus on to really get traction. There\'s been some discussion around
parents of sick children or just parents in general that are motivated
to keep a longitudinal record for their children. Certainly chronically
ill and Medicare beneficiaries have been sort of a repetitive theme that
would be really valuable to focus on.

I don\'t know that we\'ve heard very much through the environmental scan
or through testimony that there\'s real traction or penetration in the
market within given disease areas, or given segments of the market.

I think we have heard from some employers, that not only through their
HRA, the health risk assessments, that they\'re offering some of the
like combined wellness packages they\'re offering in conjunction with
the PHRs, that that would probably naturally offer some benefits to type
II diabetics, particularly if they offer management around that. We
heard from the Omaha Packing Company, for example, a mid-sized employer
that has a really successful disease management, wellness, and PHR
program in a Latino population.

So I think that a lot of that is sort of depending on who is providing
the services. If it is an employer or a health plan that has a
particular objective to reach a chronically ill patient population to
better \-- you know, improve efficiency, you know, and reach a variety
of goals, then they\'re more likely to offer services and target those
populations. I don\'t think that the stand-alone vendors have been
thinking as much about sort of disease-based marketing strategy. But
it\'s an interesting question.

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

Go ahead.

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

Well, I guess to me it seems like the greatest gain may not be in a
single disease, but in a \-- this population which is the sort of more
at risk, which would be the Medicare and so forth. And I think we\'re
quite surprised at the number of seniors who have opted into something
that we thought was for younger people.

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

Yeah, we \-- you know, the other thing that we have done I think was
very helpful in the last few months was tried to convene a group of Feds
across the agencies that are really engaged in this whole agenda. And so
Will Crawford, and others across AHRQ and CDC and NCI and HRSA, tried to
think through well, what would be sort of the government policy levers,
or program levers that we could consider to move this forward. And we
talked a lot about Medicare, and Medicaid, too.

But unfortunately while Medicaid might be a very desirable population to
target for a variety of perspectives, what we were thinking about were
sort of practical things we could do in the short term, and the Medicaid
data may not be, might not be ready to go at this point from a quality
perspective, and just from the infrastructure perspective. Although I
think maybe some states would be more apt to take that on than others.

So I think in considering that, we obviously could, at least from a
government perspective, try to focus on the beneficiaries that we serve
through various programs. And certainly, Tony and Will have a lot going
on with their efforts in general in CMS, who I think over the next
couple of years will likely see a lot of traction with the Medicare
population.

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

Kelly, this is Tony, I had a question for you. One of the reasons we
wanted you to come and speak today was to talk about some of the areas
of synergy between the two Workgroups, and you\'ve mentioned a number of
them. And I guess my question is, from here on forward, how can we
better tie the efforts of the two Workgroups together so that we can
leverage each other\'s work, and not be, you know, engaged in activities
that may be somewhat redundant.

I know that Lorraine Doo from my office, who is on your Workgroup, had
mentioned you had talked about this had come up in your Workgroup, as
well, and there had been a discussion of having the co-chairs of
different AHIC Workgroups getting together to look for areas of common
synergy that could be kind of co-developed, or maybe there\'s certain
expertise that some of our recommendations, for example the ones
concerning patient education and involvement, might be better handled
out of your Workgroup as opposed to ours. Did you have any thoughts on
that?

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

Yeah, we\'ve been thinking a lot about that activity. While we have some
clearly areas of common concern, and could probably have \-- you know,
as we move forward drafting recommendations, that would be
complementary. This is just one of probably five major areas where
there\'s some overlap and need for coordination. So I think the
co-chairs' meeting is one that we\'ll probably pursue.

But I think in the short term, internally, we\'ve been trying to develop
a tracking system, so that when we have items on an agenda, or in
testimony, or that come up in deliberations, that we, you know, document
the need to follow up with the other group, and figure out how it\'s
going to be addressed either in tandem or who takes it on. So we have
sort of a definitive action on who is going to, you know, track that
item.

And I think in this particular instance, secure messaging is \-- the
home is this group. But we recognize it as a barrier, potentially, to
connecting clinicians to their personal \-- and patients, in terms of
communication between a PHR and an EHR and the people themselves. So
we\'ll want to be supportive of everything that you do to advance secure
messaging.

And perhaps the immediate followup there is for me to just continually
update the group with where you all are, in trying to make sure that we
do have the right agenda to, either through demonstration programs or
breakthroughs, to build the evidence base, and that the evidence base is
being synthesized such that, you know, we can start to think about the
next step, which would probably be coverage analysis.

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

Because we\'ve moved beyond just secure messaging to overall
communications and remote monitoring. Both of which, from what we\'ve
heard from speakers and from what I\'ve also heard from the
Confidentiality, Privacy, and Security Workgroup, were very much tied to
a PHR-type environment in many cases.

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

Yeah, I think in some cases. We didn\'t \-- in our deliberations to
date, we, at least in Consumer Empowerment, we have not really focused
on remote technologies. So I think the interoperability issues around
them, the policy issues around them, the workflow issues around them, in
terms of enabling, you know, various types of device monitoring, for
example, to be incorporated into the workflow of a physician\'s office,
we haven\'t really touched on any of that.

But I think as your thoughts and ideas and draft recommendations
develop, we\'ll certainly have to monitor that. And as there are
increasing amount of overlap with how that pertains to the personal
health records, you know, we can try to figure out a way to make sure
that we\'re not being duplicative.

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

Okay. Yeah, I think that makes a lot of sense.

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

Yeah, I think a lot of the coordination at this point is going to fall
on ONC and the people who are really doing the work behind the scenes to
get these Workgroups, you know, the resources they need, and the staff
support they need. Because we are the ones who can most easily see the
areas of overlap, that\'s why we\'ve tried to start this tracking
system. And we have internal, you know, meetings on a regular basis to
try to figure out how we\'re going to work across the Workgroups. And
when areas like clinical research and population health come up in
particular, there\'s been cross-cutting across many of the groups, we
have to figure out a whole new probably process to figure out how we\'re
going to coordinate those.

So we can (inaudible) more definitive mechanisms I think in the near
term, but right now it\'s primarily through staff, through our internal
work to support these groups. And then in the near future we\'ll also
likely have a co-chairs call or meeting so we can talk at a higher
level, too, about how to put this together.

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

Because I think at some point you get to the point where you finish with
recommendations and you need to begin to do some implementation, and one
of the areas of common synergy is the Consumer Empowerment\'s work on
medication history and electronic clipboards, specifically with a
chronic care population, as it\'s mentioned in your recommendation.

And it seems to me that there\'s other areas of recommendations that
could be applied to expand beyond just one Workgroup, so that these
Workgroups don\'t just become self-perpetuating, but at some point you
reach a point where you begin to focus on the recommendations, and the
doing, as opposed to continuing to develop evidence and develop
recommendations.

And I\'m starting to feel at this point that I don\'t think it makes a
lot of sense for these Workgroups to go on forever, and there needs to
be some sort of coordination or some type of activity that provides for
a more efficient use of resources and actually begins to focus on
meeting some of the recommendations.

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

Yeah, I think \-- I mean, I can speak for three other groups, they plan
on providing recommendations in January, and then moving on to bigger
issues that they need to take more time to consider. So I think people
are very much focused on moving ahead, and we do absolutely need to
think about efficiency and the best way to piece this all together. And
I think the co-chairs call would be a good time to think through that a
little more carefully.

But I think we also need to caution that, you know, the Secretary and
right now David Brailer as Vice Chair, they really are sort of the
decision-makers when it comes to how we\'re going to make this all work.
So I think we should think about, you know, collectively about what our
ideas are, about, you know, improving our work across all of these
areas. Because we obviously don\'t want to duplicate efforts and ask
people to spend more time on issues that are not \-- where it\'s not
warranted.

But I think most of our charges right now are discrete enough that, and
there\'s a fair amount of complexity within them, that they do warrant a
pretty serious effort to get recommendations that sufficiently address
them.

And, you know, however long that takes, it\'s really up to you all to,
you know, to work out your own process.

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

This is Karen, and I might jump in. I think one of the things that is
quite clear is that right now there is a provider view of electronic
health information, and that\'s a legal entity, for all intents and
purposes, and needs to be some legal way of maintaining a medical record
electronically. Then there\'s the patient view, and that doesn\'t always
need to include the provider. Patients can have their own approach to
managing their own care totally without a provider, and many healthy
people do.

Where I think this Workgroup is focusing is that, is the communication
between the two. And there are some aspects of consumer empowerment, but
not all, that focus on that communication, as well. And so that\'s
really that area that we need to make sure that we have better
coordination on moving forward. And decide how to manage it moving
forward.

Any other questions or comments for Kelly? Well, thank you so much, that
was very helpful, and certainly gives us lots of food for thought.

Tony, Craig, anything else that you would like to add at this time? Or
should we jump into the gap analysis?

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

No, I have nothing further. Craig?

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

Nothing further.

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

Okay. In your packet you have a summary of all the activities this
Workgroup has been doing over the last five months, and it sounds like
the Consumer Empowerment Workgroup did a whole lot. Well, guess what, so
did we.

And, you know, this particular document probably should have draft
written all over it, because it is certainly not a final summary. If you
read it, you\'ll see that there are a couple of duplications. It needs a
lot more review.

But its main purpose isn\'t to be a final document, but to elicit
discussion. Because what, as we\'ve discussed before, we are trying to
accomplish now is to think about the recommendations, if any, that this
Workgroup would like to make to the American Health Information
Community at the early part of 2007. We don\'t have to do them in
January, we don\'t have to do them even in February. We can do them at a
timeframe that really does work for us.

And of course the EHR Workgroup probably won\'t be getting theirs in
January, they\'ll probably be getting theirs in a little bit later, they
don\'t have to all come in this one lump sum.

But as we think about possible recommendations, we thought that it would
be helpful to think about in two different ways. Number one, we\'ve
already got some recommendations out there. We all know what those are,
many of those are being worked on and being developed as we go along.
And there are similar recommendations that have come from other
Workgroups and are moving forward, and those are specifically around the
privacy and security and others. So what we have here is a thought,
well, if we\'ve already got recommendations out there, are there any
others we need to put forth? And if we do need to put them forth, in
what areas?

So what \-- Cindy, I give you a lot of credit for this. She\'s done a
yeoman\'s job in pulling this document together. And what this
represents is looking at the five big issues that we\'ve talked about,
the business case, financial issues, some of the adoption issues, some
of the medical-legal issues, et cetera. And we\'ve pulled in little
synopses that are more brain teasers for you, just little ticklers,
reminders of the testimonies that we\'ve heard in these specific areas.

So that we can do two things. Number one, if we do need to make more
recommendations, this can help us inform those recommendations; and
secondly, if we need to hear more testimony, you know, we just talked a
little bit earlier about needing to go hear more from the CMS demos,
then we need to identify that so we can tee that up for our next
meeting, which is in January. Do we have a date yet for the January
meeting?

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

Actually \--

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

Anyway it will come back later, it\'s in January.

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

January 30.

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

Oh, the 30th?

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

Sorry, hold on. January 25.

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

January 25 we have. So with that in mind, I think everyone has a copy of
this document? It\'s being posted on the Web, as well. And I would
invite the chairs to review with us, and walk through with us, as well
as myself, I\'ll help as well, the various issues, such as the
financial, cultural, et cetera. Some of the points that have been made.
And to think through whether or not we should be considering further
recommendations in each of these areas. And then, think through whether
or not we need to hear more.

So with that in mind I\'ll just start off by asking first if there are
any questions, or concerns about the process, or about the document
itself.

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

I\'m trying to find the hard copy. This is Craig. Where is it?

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

You need the hard copy on the Web?

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

Just give me the name of the document. It was sent out?

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

It\'s called the draft summary of testimony.

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

This is Mohan Nair, I\'m challenged to find the document as well.

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

It should be in the attachments.

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

Karen, this is Tony. While people are looking for the document, can I
just get from you what the purpose of this is? Is this to inform the
broader charge that we\'re looking at now, so that these are the various
testimonies we\'ve had? Because some of these actually deal with the
more specific charge. So I\'m trying to get clear from you what the
purpose of the exercise we\'re doing now. Is that to help inform the
broader charge?

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

The broader charge, and if there\'s any more information that helps us
with the specific charge, that as well. I mean, this is an opportunity
for us to retrospectively look at all the richness of the information
that\'s been shared with us, and use it to make a next batch of
recommendations to the AHIC, and then ultimately up to the Secretary. On
either specific or broad charge.

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

This is Mohan Nair, I just found the document. It didn\'t have a title
on it, that\'s why I got confused.

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

I found it as well.

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

Yeah. Yeah.

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

This is Eric Larson from Group Health. I\'ll just add a comment, because
I did have it right from the start of this discussion, and as I look
through it, kind of a little bit on the fly, so I may have missed
something, but one of the things that I heard in the presentations today
was that the people who are in this business are way ahead of our
public. And this whole issue of are we going to say something about the
public readiness, or how we envision the adoption of some of the
utilities that people have described in the testimony to us.

And again, I think it\'s both the providers, we\'ve heard a lot about
that, but we haven\'t heard as much about the average person in the
street, or \-- and how that might happen. And I think Karen or somebody
talked about the two extremes, where, you know, people are buying these
things, and owning them themselves, and just saying I am my medical
record, and I own it, and I\'m going to manage this thing, and be a very
independent buyer, versus people who might be likely to sign in, if you
will, to something that\'s ready-made by an employer or an insurer, or
another kind of purchaser. Or the government, for that matter.

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

You\'re absolutely right, we do not have very much testimony on the
independent buyer, at all. And I\'m wondering at this point whether we
would be able to get that here, or whether we would need to actually
commission an environmental scan to find out what the independent buyer
actually thinks and feels about this sort of thing. Is there anyone on
the call that would like to comment on how we think we might be able to
get that input?

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

To a degree, does it depend on whether you\'re looking for general
cross-section of the population, or you\'re looking at a specific
subset? We talked a little earlier about the possibility of focusing
EHRs on a narrow disease element of the population and not a general
cross-section.

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

Or at least a population of chronic care, chronic illness.

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

Yeah.

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

I\'m wondering, we have the benefit of having Dr. Wadhwa at the table
with us. Do you have anything you think you might be able to add to
that, in terms of your experience with people who may be purchasing
information on management of their own disease processes themselves, or
not?

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

I guess in our experience it\'s \-- that community is usually provided
that on behalf of an employer group or the payer. So I think that we\'ve
got experiences, many of us, but the direct to consumer market, that
I\'m less familiar with, that\'s the WebMD type of business model,
Karen.

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

This is Mohan Nair. I\'m relatively familiar with the direct to consumer
market. Being a health plan, we have a number of members who are working
directly with us and with the challenges associated with that market.
What would \-- what is \-- if I may ask the question, what is the
objective of receiving testimony associated with that area? Is it to
understand adoption cycles? Is it to understand their need, and wants,
in specific areas, in the Chronic Care Workgroup? I would like to have
some clarification on the objectives around there. I see a deep need for
understanding that market, but specific to chronic care, what is the
objective for receiving testimony?

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

Well, I\'m not sure that I can give a very convincing answer, because my
belief is that it\'s a very limited market, and it is mostly going to be
through, you know, persons that have an interest, you know, because
they\'re in the business. And so it\'s going to be coming from
providers, or from integrated delivery systems, or from purchasers.

So my question is, do we want to, in our report, say that? Because \--
and would we have a basis for saying that, other than the opinion of the
members of the Workgroup? But I don\'t know that we need to get
testimony to that effect if we all agree that that\'s the situation.

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

The only other \-- this is Karen \-- the only other part that might help
inform that is some of the testimony that came from one of the models
that we explored. It was the Netter model, where we heard that patients
were not particularly inclined to engage with communication with their
clinicians unless it met an immediate need for them, i.e., they needed a
prescription refill, or they wanted to make an appointment, or there was
some immediate need that they had which would initiate the
communication.

And once they were initiated and responded to, then it opened the door
for a number of other different things. But from the perspective of
fostering communication between patients and their care providers, there
needed to be something very specific to the patient that brought them
the immediate value.

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

Not unlike every other aspect of information technology.

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

Uh-huh. Sure, and the actual adoption and use is predicated on immediate
need. And I think one of the issues we\'re grappling with is that in
chronic care, need is probably a fairly prevalent driver. People with
chronic care take multiple medications, they do need prescription
refills, they do need to be making contact with their providers.

So I don\'t think that\'s such an issue for this particular market. But
in terms of using remote devices in general, remote communication in
general, it may be more difficult for the healthier population.

As we look at this in a little bit greater detail, I\'m going to
actually ask a few questions, if I might, to stimulate some more thought
and conversation.

Under financial issues, now, we certainly recognize that there are
issues with reimbursement, if clinicians are spending time on care for
which they\'re not reimbursed.

We heard a lot about what is being done in terms of demonstration
projects, what could be done in terms of demonstration projects, and
we\'re certainly moving forward with trying to develop at least a straw
man proposal for what something \-- our own could look like.

But one of the things that we didn\'t hear very much about is different
reimbursement methodologies for physicians. We all know about fee for
service. We haven\'t heard very much about capitation except for another
company accepting risk, such as the disease management companies we
heard about today.

We\'ve heard a little bit about the advanced practice model from Michael
Barr. And I\'m wondering whether it might be of interest to the group to
understand a little bit more about physician reimbursement, bring in
some medical economics that have spent quite a bit of time publishing on
physician reimbursements, and different methodologies, and what the
various incentives are around those reimbursement strategies.

Is that something that the group would find interesting? And helpful, in
terms of focusing any additional \-- because this is the point, here \--
would it be helpful in terms of focusing any additional recommendations
around the financial model? Or as a business model for the AHIC?

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

All the conversations we\'ve had in the past, which get back to paying
for quality or paying for performance, have to combine that direction
with these different models of reimbursement?

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

I\'m not prescribing, I\'m suggesting that we could look at that,
that\'s something that someone could talk to us about. I think we heard
also today about a payment for participation. I mean, so there are
multiple different ways that one can add reimbursement to an existing
fee for service model. But I think the bigger question is, are there
other models that would be more appropriate or interesting for us to
look at?

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

Tony, I\'ll yield to you guys on this, but I\'ve heard so much about
paying for performance as opposed to paying for service from HHS and
CMS, that I presume that you guys would like to have this tightly
coupled in any conversation that we have.

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

Yeah, Craig, I agree with that. The other area I want to direct Karen\'s
attention to was in the recommendations we made for the specific charge.
We talked about recommendation 1, that says that HHS shall develop and
regularly update the basis from form reimbursement policies with respect
to secure messaging, and this should include monitoring and reporting
the effect of secure messaging on costs, quality of care,
patient/caregiver satisfaction. And I think we need to be doing
something to develop that recommendation. So if this is something that
would support that, maybe that\'s something that we could have in terms
of the testimony. But I\'m not clear of what your objective is in
further testimony in this area.

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

Well, my thought was that it could help inform that discussion a little
bit. Because right now there really isn\'t a very good database at all
on reimbursement for secure messaging. I mean, we\'ve pretty much heard
everything that\'s happening in the field right now, and there\'s very
little else. There\'s a lot of studies that consistently come forth, and
maybe, Jay, you would like to talk about those, and maybe we should
think a little bit more about doing a meta-analysis or doing a more of a
literature review on all of the new information that\'s coming out on
the value of secure messaging. Do you think that would be of value, Jay?

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

Yeah, I do, I was going to recommend \-- the last thing I should be
doing is discussing economics of any kind, as my children will tell you.

But there are two people who have been in this field for a long time who
might be very, very helpful to us. One is Rashi Fein from Yale, and the
other is Uwe Reinhardt from Princeton. And I think they would give us a
perspective from both ends of the pendulum. So if I were being asked to
make recommendations for individuals who might provide us some insights,
those would be \-- those would be two.

I also once again want to put in a plug, this is not facetious, and I
didn\'t make the comment facetiously previously, that we constantly keep
talking about paying for performance for physicians, and I really think
we ought to be looking at the other end of the pendulum, in terms of
paying for performance for patients.

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

Okay. Karen, I\'m not going to address Jay\'s second point, because he
has made that point before, but I guess I\'m not clear as to why we need
further testimony in this area when we\'ve already turned in a
recommendation. And I\'m just trying to wonder the purpose of the
Workgroup to continue to hear testimony over and over again about
different aspects of secure messaging and reimbursement, or have we
given our recommendation to the Secretary and to the AHIC which has been
adopted, and that they\'re supposed to move \-- HHS is supposed to move
forward with that. I\'m not clear as to what value are we getting by
having further testimony in this area.

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

Let me just clarify again, Tony. I think the issue is we\'re not just
thinking about secure messaging here, we\'re thinking about
reimbursement models for multiple forms of remote care. And right now,
we have a fee for service model. And even if you add on pay for
participation, pay for quality, pay for performance, anything you want
to do, it\'s an add-on. And it\'s still a basic fee for service model.
And if we\'re really going to move forward to an arena where we can
really take advantage of all of the benefits of providing care
virtually, and having the electronic support, information support to do
that, we might want to also consider other types of reimbursement
models.

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

Okay, but then let\'s consider \--

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

That\'s why I was thinking of perhaps having someone \-- and thank you
for naming those names, like Fein or Reinhardt \-- to come in and really
talk to us about how, what kinds of models are out there for physician
reimbursement, and what, how do they drive certain types of care in
certain directions.

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

Okay, I think if we do it on a broader sense that would be fine, I just
don\'t want to limit it strictly to secure messaging.

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

Right. Okay. So that\'s the question before the Workgroup. Would that be
of value, and would that help us think through either a refined or a new
recommendation about reimbursement models?

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

I think it would \-- this is Eric Larson \-- I think, I know I have my
personal ideas about that, I\'ve studied this for decades, really. But I
think it might help the group as a whole to have a conversation with an
expert, so we could find out if we have, you know, can come up with some
kind of a recommendation from the group, or if we simply have a bunch of
opinionated people on our group.

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

Let\'s stipulate that we have the latter, but maybe we might change our
minds.

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

Yeah, right.

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

But as long as the presentation is, I guess kind of a, let\'s say a best
practices overview, as opposed to just looking at one idea, I\'m all for
it.

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

I would agree with Craig, a best practices would work, not just bringing
in opinions, but somebody who does give an overview.

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

And I think really that\'s what we\'re looking at, how does this
salaried physician practice differ from one who is functioning under
partial capitation, or full risk, or fee for service, with no risk. You
know, there are \-- and then there are the multiple variations of types
of reimbursement. And I think that\'s really what we\'re thinking about,
what is the best reimbursement, given the kind of models that we\'re
thinking about for the future. So I think I heard that at least there is
some interest in the group to do that?

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

You\'ve heard enthusiastic response, Karen.

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

Okay.

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

As long as you get the topic right.

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

I\'ll do my best. All right, we will go ahead and set that up for
January. And also think through \-- ask us all to think through anything
else that might come to mind as you review this testimony again in your
own time frame. As to whether or not there\'s anything else that would
be helpful.

Okay. On the cultural issues. We have a lot of testimony there, too. It
goes on for several pages. We heard a lot about the various different
populations that may or may not have more or less need for remote care,
and use of electronic technologies, and we also heard about some of the
issues surrounding the adoption. And I think that\'s what this is really
about, the adoption, and cultural change necessary on both, but on
primarily the provider side, to move forward with. But here\'s where on
the 16th of August we did hear from Ed Fotsch, and basically said that
any kind of patient engagement does need to be inserted in the
patient-provider relationship, and does need to be predicated on
something that the patients themselves need.

So there\'s an awful lot here on these several pages. Perhaps, again,
this is something that you could all do offline, and come back in
January thinking about any recommendations that you think would be
helpful for us to make in addition to what\'s previously occurred. Given
all of the additional information we have, for either the broader or the
narrower charge.

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

Karen, this is Anand, sorry I don\'t have this document in front of me.
But did we ever hear testimony on medical liability issues, whether
it\'s remote monitoring, or secure messaging, and if that\'s part of the
information gathering for a physician, and part of their clinical care
processes? You know, what about situations where providers, you know,
they might not see secure messages, and they might be held liable for
things that they don\'t pick up. Have we heard anything or talked about
medical liability specifically as relates to these two things?

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

Actually, the next big issue is about medical-legal issues, and we did
hear from Daniel Sands at the BID, because Daniel is a big supporter and
big user of secure messaging for some time, about some of the
medical-legal issues that have occurred that he\'s addressed. And how
he\'s been able to mitigate that in his practice. What we haven\'t heard
from is anyone with a J.D. after their name, who can really address the
malpractice issues that could come from this. And we identified that
actually as the big gap in the EHR Workgroup just yesterday. And I agree
with you, I think it\'s a gap here as well.

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

This is Jay. There is an individual who could act as a resource either
individually or get us to the best resource. That\'s Bob Waters, with
the Center for Telemedicine Law. And he\'s here in Washington. He\'d be
someone you could speak to.

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

That would be great. So everyone else, would everyone else agree that
that might be a very helpful piece of information, and particularly
around crafting a possible recommendation?

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

Yes.

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

Yeah, I\'m okay with that, this is Mohan.

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

Okay.

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

Yes.

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

We\'re good to go.

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

I have a broader question, this is Mohan again. And may have missed the
last session, so please forgive me if I re-ask a question, and you know
how to shut me up. What are the issues, what are the actions associated
with the broader issues that we have put on the table prior, as we work
through these, work through our recommendation? How do the broader
issues around \-- that cover most of the other areas of focus, as well,
get addressed?

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

Well, if I\'m understanding correctly, Mohan, there\'s the broad charge.
But what we\'ve pretty much come up with is that whether you\'re
adopting a communication technology, or whether you\'re adopting a
PHR and EHR, there are five basic broad issues that we\'re looking at.
First is the business case financial issues, there are the medical legal
issues, we just started talking a little bit about, the cultural issues,
some technical issues that we have here, as well, and then those around
privacy and security. So we\'re really looking at those five big issues.

And thinking through, given all the testimony that we\'ve heard, whether
or not we should be making recommendations within the spheres of those
five issues that will either remove a big barrier or help push forward
our particular agenda, which is to make remote care essentially
available to patients with chronic illness.

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

Are they, each Workgroup addressing the broader issues in their own
sphere, and then recommending that upwards?

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

What each Workgroup is doing is addressing them in their own sphere. We
will be looking at cross-Workgroup recommendations, so that in the same
way that we looked at privacy and security and focused on a few things
in every Workgroup, and that led to the Confidentiality, Privacy and
Security Workgroup working on these issues as a joint one. We\'ll do the
same thing on this go-around as well.

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

Okay. Thank you.

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

Okay, speaking of privacy, security and confidentiality, we did make
some recommendations on that the last time around, it did lead to the
new Workgroup, and one of the things that perhaps might be helpful is to
get an update from that Workgroup. To see if the needs of the broader
charge are met by the work that they\'re doing at this point. Is that
okay with everyone? Was that something that would be helpful?

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

Yes

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

Yes.

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

Okay, and we\'re going to go back, because we missed one area, and that
was the technical issues. And again, we\'ve had a lot of good testimony,
not only on the kinds of technologies that are out there, capped just
last, just a couple weeks ago \-- I keep forgetting we\'ve gone "bing,
bing" on these two sets of Workgroups, and we won\'t have another until
January \-- but capped just a few weeks ago by the excellent
presentation that we had from the Continua people.

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

David Whitlinger.

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

Yeah, David Whitlinger, a few notes of which are captured here as well.

So I would leave to my technical colleagues to ask whether we\'ve missed
anything on that arena or not. And is there anyone else we should be
hearing from. We\'ve heard about the various types of models of secure
messaging, we\'ve heard about various devices, how they\'re being used
in multiple settings. We\'ve heard from large delivery systems, we\'ve
heard from smaller delivery systems, we\'ve heard from vendors.

Are we missing anybody? That could help us formulate our
recommendations?

How about if we leave this, and anyone else who has some ideas can come
forward with them. And we will ping you, don\'t worry. We\'ll follow up
with you to see if you have any other thoughts.

Okay. I think we\'ve been through this document. And everyone is going
to have to do a little bit more homework on it, and get back to us again
if there\'s anything that we\'ve missed.

So thank you very much.

Tony, Craig, are we ready to bring in the public?

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

No, before we do, Karen, actually, could you walk through the calendar
of the next several months of what you see the Workgroup doing in terms
of the broad charge recommendations, and anything else over the next \--
because I notice we just got a calendar for the next five months, and
I\'m just trying to understand what is going to be the activities of the
Workgroup as you see it over the next several months.

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

Well, I think that\'s going to be determined by how you as chairs feel
about moving forward, and how the work of this Workgroup integrates with
the Consumer Empowerment Workgroup. So actually now I\'m actually
thinking short-tem. I\'m thinking that we will have a little bit more
testimony as we described in January. Over the course of the next
several months, because it really is going to be a couple of months
before we meet again, you\'ll have an opportunity to review this in
greater detail. We will get back to you, we\'ll have some e-mail
coverage, discussion.

And at the January meeting, we will also start thinking about those
areas where we might want to start formulating recommendations. And then
once those recommendations are formulated, and are ready to go, then we
will make a decision, or hopefully by that time you will have made the
decision about how we will move forward with the Workgroup, and again,
how it relates to Consumer Empowerment.

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

Okay, Craig, did you have any thoughts?

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

No, I\'m, I\'m fine.

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

I would ask everyone on the call to also consider whether or not you
feel that we\'ve met the broad charge and the specific charge. What we
needed to do. And I\'m not asking for an evaluation at the moment, but
that will help us determine where we will go, moving forward, as well.
Okay?

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

Okay, thank you, Karen.

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

Thank you.

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

Craig, do you want to invite public testimony now?

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

Yes, let\'s proceed.

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

Okay, there\'s instructions on the screen for people following the
Webcast to make public testimony. And if anybody has already called in,
just press star 1 on your phone, and that will put you into the queue
for comment. I will give about a minute for people to get through, and I
will jump in and let the co-chairmen know if anybody does call.

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

How long do we need to wait to see if public calls in?

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

Give it another 15 seconds, make sure we don\'t get anybody else.

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

Okay.

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

Or anybody, I should say. Okay, it doesn\'t look like anybody is calling
in.

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

Okay, I guess that concludes our call for the afternoon.

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

Happy Thanksgiving, everyone.

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

Thank you, and you too as well.

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

Thank you,

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

Bye-bye, now.