######## [American Health Information Community]{.underline}

**Workgroup on Electronic Health Records**

**Summary of the Web Conference Held Tuesday, May 2, 2006**

######### (5^th^ Web Conference of This Workgroup)

+-----------------------------------------------------------------------+
| ##### Charges for the Electronic Health Record (EHR) Workgroup        |
|                                                                       |
| > **Broad Charge:** Make recommendations to the American Health       |
| > Information Community (the Community) on ways to achieve widespread |
| > adoption of certified EHRs, minimizing gaps in adoption among       |
| > providers.                                                          |
| >                                                                     |
| > **Specific Charge:** Make recommendations to the Community so that  |
| > within 1 year, standardized, widely available, and secure solutions |
| > for accessing current and historical laboratory results and         |
| > interpretations are deployed for clinical care by authorized        |
| > parties.                                                            |
+-----------------------------------------------------------------------+

# Call to Order -- Ms. Lillee Smith-Gelinas and Dr. Jonathan Perlin []{.mark}

Ms. Gelinas called the Web conference to order shortly after 1 p.m. and
noted that she would be chairing the meeting with Dr. Perlin.

# Introduction of Participants 

Meeting participants were introduced. (See the list of participants at
the end of this document.)

# Introductory Remarks -- Ms. Gelinas and Dr. Perlin

Ms. Gelinas and Dr. Perlin explained that although there was no formal
agenda for the day's Web conference, the intent was for EHR Workgroup to
do the following:

-   Review and come to a consensus regarding the Workgroup's letter and
    recommendations to the Deaprtment of Health and Human Services
    (DHHS) Secretary Mike Leavitt regarding the EHR Workgroup's specific
    charge of making current and historical laboratory results and
    interpretations electronically available for clinical care by
    authorized parties, with the goal of presenting them to the May
    16^th^ meeting of the American Health Information Community (AHIC;
    The Community)

-   Hear presentations related to the information needs of first
    responders so that the Workgroup could begin to address the
    Secretary\'s charge to the Workgroup, making recommendations to
    ensure that the critical health information that first responders
    need in disasters or emergency situations can be made available
    electronically.

Ms. Gelinas and Dr. Perlin reported that Dr. David Brailer has resigned
as the National Coordinator for Health Information Technology, and they
thanked him for his excellent leadership. They added that they were very
pleased that he would continue to play an active role in The Community.
Ms. Gelinas and Dr. Perlin also expressed their appreciation to the EHR
Workgroup and the Office of the National Coordinator for Health
Information Technology (ONC) for their hard work and contributions.

# Introductory Remarks -- Dr. Brailer []{.mark}

Dr. Brailer prefaced his remarks by thanking EHR Workgroup members for
their hard work and Dr. Perlin and Ms. Gelinas for their leadership of
the Workgroup. He stated that the EHR Workgroup had really set the
benchmark in terms of making progress on its charges while balancing
both policy and technical issues and long- and short-range issues.

The upcoming May 16 meeting of the Community, Dr. Brailer explained,
will be a major event where The Community moves from the thinking phase
about what to do, to the very specific action phase. The Community will
do three things with respect to the EHR Workgroup's work:

1.  Listen to the EHR Workgroup's recommendations about near-term
    breakthroughs in making lab data electronically available (the
    specific charge). The Community will take one of the following
    actions with respect to each recommendation: endorse it, modify it,
    or send it back to the Workgroup for further consideration.

2.  Provide guidance on any difficult issues that the EHR Workgroup
    would like the Community to help it with.

3.  Give the EHR Workgroup a glimpse of where it will be going after May
    16 . After May 16^th^, the focus will shift to the EHR Workgroup's
    broad charge related to the widespread adoption of certified EHRs.
    That pace will be slower than the frenetic pace required to meet the
    1-year deadline for the Workgroup's specific charge.

    5.  **Review and Discussion of Draft Letter to Secretary Leavitt --
        Dr. Perlin and Dr. Karen Bell**

Dr. Perlin indicated that the first item of business would be to review
and come to a consensus on the EHR Workgroup's draft letter and
recommendations regarding its specific charge to be presented to the
Community on May 16. He stressed that the discussion should be limited
to the intent of the recommendations, not the editing, which would be
done professionally once they had agreed upon the intent.

Dr. Bell explained that the draft letter and recommendations distributed
to EHR Workgroup members for review at this Web conference was a little
different from the previous letter. Workgroup members had given the ONC
staff permission to format the letter consistently with the formatting
of the letters from the other Workgroups. In addition, the ONC staff had
obtained additional information on the Clinical Laboratory Improvement
Amendments of 1988 (CLIA) options and Health Insurance Portability and
Accountability Act (HIPAA) regulatory requirements. The staff had worked
closely with the other Workgroups on the privacy and security
recommendations, so those recommendations had changed in the letter, as
well.

Dr. Perlin asked the EHR Workgroup to review each of the three major
sections of the letter. The first section identified six broad issue
areas related to the EHR Workgroup's specific charge related to the
widespread adoption and availability of electronic laboratory results.
The second section, "Background and Discussion," presented context for
how these issues might be addressed to enable widespread access to
current and historical lab data in a patient-centric fashion. The third
section presented 10 recommendations, with introductory paragraphs,
organized by the six broad issue areas.

## First Section: List of Six Major Issues 

Dr. Perlin first asked for agreement that the list of six major issues
in the first section of the EHR Workgroup's draft letter to Secretary
Leavitt reflected the body of the letter. He noted that the issues had
not changed, with the exception of the addition of Issue #5, related to
the alignment of business cases;

1.  *Provider- and patient-centric models:* Necessary steps in the
    migration from a provider-focused system to a patient-focused system
    with respect to the flow of laboratory information.

2.  *Standards:* Urgent need for endorsed, adopted, and interoperable
    vocabulary, messaging, and implementation standards for laboratory
    results and data exchange.

3.  *CLIA and HIPAA options:* CLIA and HIPAA regulations, which present
    potential barriers to electronic laboratory results data exchange in
    a patient-centric manner, particularly in more stringent States.

4.  *Privacy and security:* Technical considerations relating to privacy
    and security with respect to patient and provider authorization and
    authentication, including accurate patient identification and
    linkage to patient-specific information.

5.  *Advancing adoption:* Aligned business cases for the multiple
    stakeholders involved.

6.  *Assessment, monitoring, and research:* Assessment, monitoring, and
    research of early adopters' experiences and identification of best
    practices.

Mr. Houston said he did not recognize Issue \# 1. Noting that some State
laws specify that the health care provider is the custodian of the
record on behalf of patient, Mr. Houston said he wanted to understand
whether the EHR Workgroup was advocating an information system over
which the patient had total rights or a system structured to allow
information to be available for patient care purposes, regardless of
where a patient isMr. DuBois said the idea was that the information was
moving toward the regional health improvement organization (RHIO) model
-- and he thought that "migration" was the perfect way to say it. Ms.
Gelinas stated that although Issue #1 in the letter talks about "the
evolution from a provider-centered model to a patient-centered model,"
she personally thinks both models will continue to exist. Ms. Pure
agreed. Dr. Perlin noted that getting the information to follow the
patient is a goal. Ms. Gelinas was in agreement with Dr. Perlin, noting
that having a patient-centric system did not eliminate the need for a
provider-centric system.

Dr. Perlin said he thought there was consensus in spirit, if not in
words, and asked Dr. Bell to work on the language to capture the idea
that the provider-centricview is not eliminated by a patient-centric
view.

DECISION: The ONC staff will work on the language for Issue #1 so that
it does not imply that the provider-centic view is eliminated by a
patient-centric view.

## Second Section: Background and Discussion 

Mr. DuBois, as he had at the previous meeting, recommended rephrasing
the sentence that says, "Most labs will only provide results to the
ordering clinician," to say, "Labs are only permitted to provide results
to the ordering clinician." There was no objection.

DECISION: The ONC staff will modify the sentence on page 3 of the
background section of the draft letter to Secretary Leavitt to say,
"Labs are only permitted to provide results to the ordering clinician."

## Third Section: Key Recommendations 

Dr. Perlin asked for comments from EHR Workgroup members on the draft
language for 10 key recommendations in the six key issue areas in the
third section of the EHR Workgroup's draft letter to the Secretary
Leavitt.

### Recommendation on Provider- and Patient-centric Models

The EHR Workgroup considered the following draft recommendation:

***Recommendation 1.0:*** HHS should take immediate steps to facilitate
the adoption and use of endorsed standards and incentives needed for
interoperability of lab results within the current provider-centric
environment. ONC shall work with multiple stakeholders to develop a
detailed work plan to achieve patient-centric information flow of
laboratory data in 2007.

##### Discussion

Dr. Carolyn Clancy suggested adding a deadline for the completion of the
workplan to achieve patient-centric information flow.Dr.. Worzala asked
if there would be more specificity about what is meant by "incentives."
Dr. Bell explained that the specificity appears in Recommendation 5.0
related to the business case.

DECISION: In Recommendation 1.0, set March 31, 2007, as the deadline for
completion of the workplan to achieve patient-centric flow of lab data.

### Recommendations on Standards

The EHR Workgroup considered the following draft recommendations:

***Recommendation 2.0:*** The Health Information Technology Standards
Panel (HITSP) should identify and endorse vocabulary, messaging, and
implementation standards for reporting the most commonly used laboratory
test results by September 2006 so as to be included in the Certification
Commission for Health Information Technology (CCHIT) interoperability
criteria for March 2007 certification. The HITSP must consider CLIA and
HIPAA regulatory requirements as appropriate.

***Recommendation 2.1:*** Federal delivery systems should develop a plan
to adopt the HITSP-endorsed standards for laboratory data
interoperability by December 2006.

***Recommendation 2.2:*** Federal agencies and departments with health
lines of business should include the use of HITSP-approved standards in
their contracting vehicles where applicable.

##### 

##### Discussion 

Dr. Worzala asked if Recommendations 2.1 and 2.2 were targeting the same
Federal delivery systems. Dr. Bell explained that Recommendation 2.1 is
for Federal delivery systems that provide direct care (e.g., the Indian
Health Service, the U.S. Department of Veterans Affairs \[VA\]) while
Recommendation 2.2 is for Federal agencies and departments that use
contracting vehicles (e.g., Medicare, Medicaid). To clarify what was
meant, Dr. Clancy recommended adding "(providing direct patient care)"
after the words "Federal delivery systems" in Recommendation 2.1.

DECISION: In Recommendation 2.1, change the text to read, "Federal
health care delivery systems (those which provide direct patient
care)...."

Dr. Worzala raised a question about whether Medicare and Medicaid would
require or incentivize, for example, small physician offices that
produce lab results to use HITSP-approved under this recommendation. Dr.
Perlin assured her that what was being talked about here was not bedside
tests, but the laboratories that go back and forth with another
organization, such as a laboratory services provider.

Mr. DuBois asked for a change to make it clear that positive incentives
would be used (the carrot) rather than mandates (the stick) to encourage
the adoption of HITSP-endorsed standards.

DECISION: In the paragraph of text right before Recommendations 2.0,
2.1, and 2.2, insert language to indicate that the use of HITSP
standards within the private sector will be encouraged via incentives
rather than a Federal mandate.

DECISION: In Recommendation 2.2, change the text to read, "\...with
health lines of business should include/incentivize...."

### Recommendations on CLIA/HIPAA Options 

The EHR Workgroup considered the following draft recommendations:

***Recommendation 3.0:*** ONC should review the possible models for the
exchange of historical lab information and determine which would require
CLIA/HIPAA guidance, regulatory change, or statute change.

***Recommendation 3.1:*** ONC should engage the National Governors
Association and other State-based organizations to resolve variations in
"authorized persons" under various State clinical laboratory laws, as a
resource for clinical laboratories seeking to define access rights to
electronic laboratory data.

##### Discussion

Mr. Houston said Recommendation 3.0 seemed too vague; he noted that
Recommendation 3.1 talked about the model of patient authorization to
enable the exchange of information. Dr. Bell explained that the first
step is for ONC to look at all the models for the exchange of historical
models that exist and then to bump them against HIPAA and CLIA to see
what is needed (e.g., guidance, regulations, statutory change). The
intent of Recommendation 3.0 is to have ONC's legal support to tell it
what the best approach is. Dr. Perlin suggested adding a deadline for
this recommendation, and Dr. Bell suggested September 30, 2006.

DECISION: In Recommendation 3.0, set September 30, 2006, as the deadline
for completion of the ONC review.

Ms. Pure, as she had in the previous meeting, recommended taking out the
words "clinical lab" before laws in Recommendation 3.1, because these
words are too restrictive. Dr. Clancy pointed out that it is not so much
State statutes that need to be considered as it is commonly accepted
practices (e.g., accepting CLIA to mean that information goes to
ordering physician). Dr. Perlin recommended changing the language to
say, "\...resolve inconsistencies in statutes, regulations, policies,
and practices." He also suggested adding a deadline of December 31,
2006. Finally, Dr. Clancy suggested that language be added to
Recommendation 3.1 to indicate that the intent for ONC to implement
Recommendation 3.0, and only after getting the recommendations, to
engage the National Governors Association.

DECISION: In Recommendation 3.1, add the introductory clause: "Based on
the findings from Recommendation 3.0, by December 31, 2006, ONC
should..." Also change "under various state clinical laboratory laws" to
read "under various state statutes, regulations, policies, and
practices[,]{.underline} as a resource."

Mr. Houston said he thought the EHR Workgroup was making a mistake by
failing to recommend the development of a patient authorization scheme
that would enable patients to preauthorize the release of personal
health information without changes in State laws. Dr. Bell and Mr.
DuBois explained that they had tried to go the patient authorization
route, but a discussion with CLIA expert Lynn Egan led them to conclude
that the patient authorization route would not work. She said that the
assumption that if CLIA is silent, one can do what one wishes, is
incorrect. CLIA says that in the event that the State takes any action,
be it more stringent or less, State law applies; absent it, CLIA
applies. Furthermore, if CLIA is silent, one cannot assume patient
authorization is appropriate; one has to go back and get CLIA guidance.
Mr. Houston said he thought there was an enormous misunderstanding here
--he believes the cornerstone is that the patient has the right to
release lab information to whomever he or she wants. Dr. Bell said that
that would be only if there was a specific State regulation or statute
that allowed that, but at this point, that does not exist. Dr. Bell
indicated that patient authorization of the release of lab data could be
added as one of the models that are examined in Recommendation 3.0.

Mr. Houston said he thought there should be more discussion. He agreed
to Dr. Perlin's recommendation about putting something in the paragraph
before the recommendations, but he wanted to make it very clear that
this should be one of the focus areas.

DECISION: In the explanatory text before the third set of
recommendations, insert text along the lines of the following:
"Exploration and guidance on the patient's role and rights regarding
their authorization of the release of such data is needed."

### Recommendation on Privacy and Security 

The EHR Workgroup considered the following draft recommendation:

***Recommendation 4.0:*** A consumer empowerment subgroup, comprised of
privacy and security members, and members of all AHIC Breakthrough
workgroups should develop a consistent set of recommendations on patient
identification, authentication, and authorization.

##### Discussion

Dr. Perlin noted that EHR Workgroup members Mr. Houston and Mr.
Isenstein had agreed to participate on the consumer empowerment subgroup
that would be developing the consistent set of recommendations on
patient identification, authentication, and access to personal health
information, etc. Dr. Bell reported that on May 1, 2006, the Consumer
Empowerment Workgroup had agreed to add five elements to specify this a
bit more.

DECISION: Change Recommendation 4.0 to read as follows:

*Recommendation 4.0:* A FACA compliant, consumer empowerment subgroup
comprised of privacy and security experts from all Community
Breakthrough Workgroups should report a set of recommendations to the
Community by September 30, 2006. The recommendations should be targeted
to apply to each Workgroup's specific charge and should outline:

1.  Methods of patient identification

2.  Methods for authentication

3.  Methods for controlling access to personal health information

4.  Policies for breaches of personal health information confidentiality

5.  Guidelines for secondary uses of data

6.  A scope of work for a long-term, independent advisory body on
    privacy and security policies.

### Recommendations on Advancing Adoption 

The EHR Workgroup considered the following draft recommendation:

***Recommendation 5.0:*** ONC should assess and develop the business
case for historical laboratory result data sharing across all adoption
models, considering the unique needs and alignment of incentives for all
stakeholders.

##### Discussion 

Dr. Bell asked whether the EHR Workgroup would be willing to change the
actor in this recommendation from just ONC to the broader "HHS, working
with the private sector." Dr. Perlin suggested broadening the language
to "HHS, in collaboration with all key stakeholders" in order to include
agencies other than HHS. Mr. DuBois recommended adding the word
"current" to indicate that business case should be assessed not just for
historical laboratory result data sharing but also for "current"
laboratory result data sharing. []{.mark}

Dr. Clancy raised the question, "Is it the 'business case' or the 'value
proposition' that needs to be developed?" She said she believes it is
the value proposition. Dr. Worzala countered that the business case
needs to be made as well, because the value goes to those other than
those who need to make the investments. Mr. DuBois agreed. Dr. Clancy
said that in the world of quality, they struggle, because there is no
business case for improving diabetes care; the real question ought to
be, "How do we create a business case?" Dr. Worzala agreed. Dr. Perlin
suggested that the recommendation include the needs both to assess the
value proposition and to develop the business case.

DECISION: Change Recommendation 5.0 to read as follows:

> *Recommendation 5.0:* HHS, in collaboration with all key stakeholders,
> should assess the value proposition and develop the business case for
> current and historical laboratory result data sharing across all
> adoption models, considering the unique needs and alignment of
> incentives for all stakeholders.

### Recommendations on Assessment, Monitoring, and Research 

The EHR Workgroup considered the following draft recommendation:

***Recommendation 6.0:*** AHRQ should develop a proposed study
methodology to measure the extent and effectiveness of the adoption of
the first stage of HITSP standards, as well as the adoption and
utilization of aggregated patient-centric data as it becomes available.

***Recommendation 6.1:*** AHRQ should research best practices in the
implementation and utilization of patient-centric laboratory data stores
and how to disseminate this knowledge.

##### Discussion and Decisions 

Dr. Clancy recommended changing the actor from just AHRQ to "AHRQ, in
collaboration with the Centers for Disease Control and Prevention (CDC)
and the Centers for Medicare & Medicaid Services (CMS)" and setting a
deadline of March 31, 2007, for completion of the study methodology. Ms.
Gelinas asked, "If this study addresses first stage of HITSP standards,
is it intuitive that it would go beyond this?" Dr. Clancy said that that
is one of the key questions she would ask a study to investigate.

DECISION: Change Recommendation 6.0 to read as follows:

> *Recommendation 6.0:* By March 31, 2007, AHRQ, in collaboration with
> the CDC and CMS, should develop a proposed study methodology to
> measure the extent and effectiveness of the adoption of the first
> stage of HITSP standards, as well as the adoption and utilization of
> aggregated patient-centric data as it becomes available.

Ms. Gelinas said there are some RHIOs where best practices in
implementing and utilizing patient-centric lab data are in place. To
make the recommendation stronger, she recommends changing the word
"disseminate" to "implement."

DECISION: Change recommendation 6.1 to read as follows:

*Recommendation 6.1:* By December 31, 2007, AHRQ, in collaboration with
the CDC and CMS, should research best practices in the implementation
and utilization of patient-centric laboratory data stores and how to
implement this knowledge.

## Wrap-up of Discussion of Recommendations

Co-chairs Ms. Gelinas and Dr. Perlin said that unless someone on the EHR
Workgroup objected, they would present the recommendations as modified
to HHS Secretary Leavitt and the AHIC on May 16. Dr. Perlin added that
the EHR Workgroup would come back to address some issues related to CLIA
and patient authorization. Dr. Bell said that the ONC staff would brief
HHS Secretary Leavitt on the recommendations the next morning.

Ms. Pure expressed concern that the EHR Workgroup's 10 recommendations,
even if accepted, might not have much real impact on the country in a
year. Dr. Bell reported that Secretary Leavitt had just announced that
one of his nine top priorities in the 1,000 days is the breakthroughs
from the Community, and he will probably be talking about that at the
May 16 meeting. He recognizes that for anything to happen in a short
time period, major gears need to shift. Once we move the bigger gears --
the six issue areas identified on the first page of the EHR Workgroup's
letter to Secretary Leavitt -- the smaller gears will fall into place.

Ms. Gelinas said that in the private sector, they are concerned about
next hurricane season and bird flu, so they want actionable
recommendations. It is important to communicate this to the Secretary.
Dr. Perlin agreed with Ms. Gelinas but added that he is optimistic, in
part because he has been at the VA and knows what is achievable. He
believes that bringing together public and private organizations,
regulatory and operational parties, vendor and providers for a dialogue
about what needs to happen to make the gears turn has laid tremendously
powerful groundwork.

6.  **Presentations Related to First-responder EHRs**

Dr. Perlin indicated that EHR Workgroup members would hear four
presentations by experts on first responders regarding (a) what discrete
elements from EHRs are needed by first responders in disasters or
emergency situations and (b) in what form these elements might be made
available.

## Dr. Edward Barthell, American College of Emergency Physicians 

Dr. Barthell emphasized that it is important that data systems for
emergency medical services (EMS) to be flexible, because the data needs
and mechanisms of first responders will vary by (a) type of first
responder -- fire departments, police departments, EMS, and hospital
emergency departments -- and (b) the nature of the scenario they are
being asked to cope with, whether routine emergency care or a disaster
(e.g., kinetic energy trauma, such as a plane crash; toxic or
radiological exposure, such as sarin in the Tokyo subway; an emerging
infectious disease or pandemic, such as cryptosporidium or influenza).
The following charts presented by Dr. Barthell sum up the main points of
his presentation.

######### Data Needs of First Responders (from Dr. Barthell)

+--------------------+---------------------+----------------------------+
| **Type of first    | ##### Rou           | **Disaster**               |
| responder**        | tine emergency care |                            |
+--------------------+---------------------+----------------------------+
| Prehospital EMS    | Demographics        | Patient ID#                |
|                    |                     |                            |
|                    | Meals -- allergies  | Red-yellow-green (triage)  |
|                    |                     |                            |
|                    | Problem list        | Patient destination (Where |
|                    |                     | can I take the patient?)   |
|                    | Advance directives  |                            |
|                    |                     |                            |
|                    | Patient destination |                            |
|                    | (Where should I     |                            |
|                    | take the patient,   |                            |
|                    | for example, based  |                            |
|                    | on patient          |                            |
|                    | preference?)        |                            |
+--------------------+---------------------+----------------------------+
| Hospital emergency | Demographics -- PMD | Demographics -- ID#        |
| departments        |                     |                            |
|                    | Meals -- allergies  | Meals -- allergies         |
|                    |                     |                            |
|                    | Advance directives  | What is coming?            |
|                    |                     |                            |
|                    | Previous EKG        | Available destinations?    |
|                    |                     |                            |
|                    | What is coming?     |                            |
|                    |                     |                            |
|                    | Available inpatient |                            |
|                    | space?              |                            |
+--------------------+---------------------+----------------------------+

######### Mechanisms for Making Data Available to First Responders (from Dr. Barthell)

+-------------------+--------------------------------------------------+
| ##### Type o      | ##### Mechanism for making data available        |
| f first responder |                                                  |
+-------------------+--------------------------------------------------+
| ####              | Radio notification from dispatch (the primary    |
| # Prehospital EMS | way that emergency medical technicians \[EMTs\]  |
|                   | in the field have any kind of communication or   |
|                   | get any kind of information)                     |
|                   |                                                  |
|                   | Pagers or cell phones (commonly available among  |
|                   | EMTs)                                            |
|                   |                                                  |
|                   | Paper-based charting predominates                |
|                   |                                                  |
|                   | Patient tracking systems evolving, est. \<15%    |
|                   |                                                  |
|                   | Electronic charting systems evolving, est. \<15% |
|                   |                                                  |
|                   | Wireless network access evolving                 |
+-------------------+--------------------------------------------------+
| Hospital          | Registration/ADT systems, est. \>95%             |
| emergency         |                                                  |
| departments       | Internet access now available, est. \>95%        |
|                   |                                                  |
|                   | Web-based capacity/diversion systems common,     |
|                   | est. \>50%                                       |
|                   |                                                  |
|                   | Electronic tracking systems becoming common,     |
|                   | est. \>30%                                       |
|                   |                                                  |
|                   | Electronic physician charting still evolving,    |
|                   | est. \<15%                                       |
+-------------------+--------------------------------------------------+

## LTC David Parramore, Department of Defense (DoD)

Lieutenant Colonel Parramore reported that last year, during Operation
Iraqi Freedom, DoD delivered electronic health systems in the deployed
environment. He said that he really had nothing additional to add to the
requirements put forth by Dr. Barthell. DoD's requirements are
essentially the same.

## Dr. Roxane Townsend, Louisiana Department of Health and Hospitals

Dr. Townsend said she fully agreed with Dr. Barthell's summary of the
essential data elements needed by first responders, she but noted that
the more difficult question is, "How do you create a portable EHR to for
use during anemergency response, especially when, at the time of a
crisis such as Hurricane Katrina, the normal methods of communication
are not available?" (At the Louisiana Superdome after Hurricane Katrina,
for example, they had some emergency power, but the cell towers were
knocked down. The onlything that worked -- and occasionally, not
reliably --was a satellite phone or an 800-MHz radio.)

Dr. Townsend reported that Louisiana has been developing a health
information exchange with funding through a contract with ONC. Although
the system will not be fully robust by the time hurricane season starts
in less than a month, they are locating electronic information that is
already available (e.g., claims data, as proven in KatrinaHealth.org;
data from some major hospitals) and using that to recreate and
reconstruct some of the medical information for a lot of the evacuees.

Many providers in Louisiana are ensuring they have backup systems for
their data as well. The VA system's backup is not local, so they had
their information even though their hospital went down. The Arcadian
Ambulance Service has computers on all of their ambulances statewide;
from their command and control center, therefore, they actually can feed
out information to the ambulance at the point that someone is being
picked up. It helps them with GPS technology and any information that a
caller can give to them or that they can share with the hospital on the
way. Finally, Dr. Townsend reported that the Louisiana Emergency
Response Network, which addresses first responders' needs to know where
to take a patient, is getting more attention in the wake of Hurricane
Katrina.

## Aarron Reinert, Executive Director, Lakes Region EMS (Minnesota) 

Mr. Reinert said the role of EMS is changing in part because of concerns
about effectively responding to manmade or natural disasters. There are
two models of EMS operations in disasters. In the "FedEx model," EMS
prioritizes patients (triage) and delivers them to a hospital. But
probably a better model has EMS managing patients in the field and then
taking only a small set of patients to the hospital.

*EMS Agenda for the Future: Implementation Guide* -- a consensus
document published by the National Highway Traffic Safety Administration
in 1996 -- frames what data elements are needed for EMS to play a larger
role than it has in the past, as both an extension of emergency medicine
and an arm of public health. A dataset encompassing some 500 data
elements -- the National EMS Information System (NEMSIS) -- includes
demographic data, medications, patient's history, allergies, laboratory
values, etc., but also many other variables. Now that the NEMSIS dataset
exists, Mr. Reinert said, the greatest need is for connectivity to allow
EMS to exchange the information in the dataset.

A.  ***Discussion of First-Responder EHR Presentations***

Noting that there seemed to be a fair amount of consensus among the
speakers on what data elements were most important for first responders,
Dr. Bell asked the four presenters to make suggestions to the EHR
Workgroup on what it might do to make communication occur (e.g., where
data reside; how the data can be extracted and made available).

Mr. Reinert explained that the structure of NEMSIS allows the 500 data
elements to move within a region of the State, within a State, or within
multiple States. But first there is a need to figure out how to get the
disparate platforms to communicate so that EMS providers can talk with
the hospital, public health authorities, or any number of responders.
The other thing that is needed is connectivity, because even if the
platforms can communicate, that will do no good without connectivity.
Mr. Reinert said a Web data repository might not be the best solution;
it is important that the data be able to move throughout the system,
whether at a particular disaster scene, a particular region, the dome in
Louisiana, or the hospital in Texas. He noted that if he had had
Internet access in Texas, he would have had full access to all of his
patients' medical records in the information system back in Minnesota.

LTCParramore stated that it is extremely important for hospitals to have
Internet access. In a combat zone such as Iraq, DoD finds that
delivering the Internet to the point of injury or to EMS first
responders is extremely difficult; they generally rely on voice networks
during the evacuation of a patient from the point of injury to the
hospital. At least for DoD, the documentation begins electronically in
earnest at the hospital, and the EHR systems that they tap into on the
Internet are available worldwide.

Dr. Barthell agreed that if we could get Internet access to the
hospitals and have at least voice communication out into the field, that
would be a good way to start. He added that if you look at the types of
data that are in this big NEMSIS dataset, there are two things one is
reviewing: (a) past history data on patients, and (b) data elements that
have to do with documenting a specific encounter. You certainly can
document that encounter, but when it gets to the hospital, it is very
important to have connectivity.

Dr. Perlin reported that the VA had satellite systems developed with
broadband capacity that allowed not only the transmission of medical
data but communication. A member of the audience, CDR Laura Tillery
(RET), noted that on the basis of her experience with DoD and with
medical triaging in Africa and Antarctica, she would recommend putting
into place a contract using commercial satellites during a national
disaster for connectivity. She said that DoD also realized the need to
be able to store and forward information for situational awareness and
for electronic recording of the information.

CDR Tillery (RET) also said that experiences in Iraq and Kosovo
underscored the need for developing an approach to standardizing patient
identification -- especially when a patient is not conscious or coherent
-- so that once the patient's real identity is determined, someone can
go back and put in the correct information. Dr. Perlin agreed that a
standardized approach to a unique patient identifier such as this would
be very useful.

Ms. Gelinas, noting that the private sector has no system of
connectivity like that of DoD or the VA, pointed out that during
Katrina, the best Internet access would not have helped in terms of
accessing patient's medical records, because the physician practices and
hospitals that maintained those records were under water and closed. She
suggested that perhaps the EHR Workgroup could appeal to average
Americans to develop some type of very basic medical record with just a
few key elements (e.g., allergies, medications, major medical
conditions) immediately, so that there will be something if the records
are gone as they were in Katrina.

Dr. Perlin concurred with Ms. Gelinas, adding that a "personal
preparedness document" might be sort of a nascent personal health record
(PHR) such as that being discussed by the Consumer Empowerment
Workgroup. A secure, offsite repository could be developed for storing
basic personal health information (e.g., demography, allergies,
medications, major past history) that would be available broadly with
modest connectivity. Dr. Perlin noted that the VA's "My HealtheVet" Web
site, for example, can be populated with a patient's entire medical
record or less. Ms. Gelinas stated that she liked idea of empowering
Americans to self-populate information.

Colonel Bart Harmon reported that DoD has learned the importance of
ensuring system reliability, system availability, and system
survivability. DoD's data repository that supports EHRs has a backup
site in another State, so even if the even the primary data center were
to be hit by a nuclear weapon, the backup site would continue operating.
When their hospitals were shut down in the hurricane zone, they
evacuated patients to Fort Smith Naval hospital and continued their
chemotherapy from the central data repository. Drawing from DoD's
experience, Colonel Harmon recommended that one requirement in system
certification for PHRs be that the system can survive a disaster.

In preparation for the upcoming hurricane season, which is only about a
month away, Mr. Houston suggested that the best thing might be to
encourage people to put their "personal preparedness documents" on
paper; the paper documents then could be entered electronically into a
system for first responders in the future. Dr. Perlin agreed that
developing a personal preparedness dataset on paper now, with the idea
that the data will be converted into an electronic form in the future,
was an excellent idea, especially given that the hurricane season is
nearly upon us.

Dr. Jim Sorace, turning back to the electronic data system for first
responders, asked, "How will the data system be organized so that first
responders can retrieve information on a patient? Will there be some
sort of national repository for these things, or is there some way that
the data could be made available to an agency running a disaster for a
certain geographical area as needed?" Dr. Barthell said that all these
are questions that EMS providers tried address in NEMSIS. To distribute
the data, they talked about having a State-based system where each State
or region within a State would keep the essential medical dataset and it
would be accessed over the Internet. One approach was using smart cards
that could be read by devices put in ambulances.

Dr. Perlin concluded the discussion, saying that there had been an
excellent discussion of the key data elements that are necessarily for
first responders; the possibility of getting those key elements on paper
as a first step toward an electronic system for first responders; and
good solutions for consolidating personal health information, be it a
PHR, a smart card, or another technology. He noted that Dr. Bell had a
list of some of the data that exist electronically right now (e.g., that
included in KatrinaHealth.org) and asked her to suggest next steps.

Dr. Bell said, first, the EHR Workgroup seemed to have reached a
consensus on some critical elements of data that should be available to
first responders in disasters or emergency situations, so the EHR
Workgroup could go to the Community on May 15^th^ and say that those
elements have been identified. Second, the EHR Workgroup could report
that further work would be done over the course of its next meeting on
recommendations for what format to use for this information. Third, the
EHR Workgroup could report that it would explore ways in which existing
electronic information could be made available at the point of contact,
drawing in part on work done in conjunction with work done by the
Workgroup on its specific charge.

DECISION: ONC will work with EHR Workgroup members over the course of
the next week or so and come up with some broad approaches related to
that it could bring to the HHS Secretary and the Community at May 16^th^
meeting. The EHR Workgroup will make a report along the following lines:

-   "The EHR Workgroup has identified some critical elements of
    information needed by first responders as demographic information,
    medications, allergies, and major health problems.

-   "The EHR Workgroup will explore at its next meeting recommendations
    for what format to use for communicating information to first
    responders.

-   "The EHR Workgroup will explore ways in which existing electronic
    information could be made available to first responders at the point
    of contact (e.g., a PHR, a smart card)."

Dr. Perlin suggested that the ONC staff and volunteers from the EHR
Workgroup mock up a basic, paper-based "personal preparedness PHR," with
the idea that this might be converted into an electronic format in the
near future.

ACTION: Dr. Perlin and Ms. Gelinas, as EHR Workgroup members, will
volunteer to prepare a mockup of a paper-based "personal preparedness
PHR" for presentation at the Workgroup's next meeting. This might be
offered as a first step toward the longer-term goal of developing a
system that will ensure that critical health information that first
responders need when attending to people in a disaster or emergency
situation can be made available electronically.

Mr. DuBois noted that America's Health Insurance Plans (AHIP) has been
developing a universal PHR that an individual can use to provide
information when changing health insurers, and he encouraged the ONC
staff and Workgroup members to talk with AHIP about this. He also
suggested the possibility of having HHS offer a PHR for people who offer
to enroll and input their own prescription and immunization information,
thereby authorizing its inclusion and use.

Dr. Perlin noted that ways to achieve indexed PHRs available under
disaster circumstances, certainly available to individuals, and ways to
interface with the Consumer Empowerment Workgroup would be topics
addressed at the next EHR Workgroup meeting. He asked ONC to report back
to the EHR Workgroup on what sort of electronic health information might
be available for first responders to use in disasters, particularly
tapping into HHS resources around KatrinaHealth.org, and learning from
that. Dr. Bell agreed.

ACTION: ONC staff will report back to the EHR Workgroup at the next
meeting what sort of electronic health information might be available
for first responders to use in disasters, particularly tapping in to HHS
resources around KatrinaHealth.org.

# Public Comments

There were no public comments. The following e-mail address was left up
for half an hour to enable members of the public to send in any comments
they might have: <ehlthrecrods-wkg@hsrnet.com>.

# Concluding Remarks

Ms. Gelinas and Dr. Perlin concluded the meeting, thanking EHR Workgroup
members, presenters, and ONC staff for all their efforts. They noted
that the next meeting of the Community is on Tuesday, May 16, 2006.

**[Workgroup on Electronic Health Records Members]{.underline}**

**[and Designees Participating in the Web Conference]{.underline}**

[]{.mark}

[]{.mark}

Jonathan B. Perlin VA

Co-chair

Lillee Smith Gelinas VHA, Inc.

Co-chair

Karen Bell ONC/HHS

Staff Co-chair

[]{.mark}

Dr. Carolyn Clancy AHRQ

Jason DuBois (for Alan Mertz) American Clinical Laboratory Association

LTC Bart Harmon, M.D. DoD

John Houston National Committee on Vital and Health Statistics

Howard Isenstein (for Chip Kahn) American Federation of Hospitals

Connie Laubenthal (for John Tooker) American College of Physicians

Dr. Blackford Middleton Health Information and Management Systems
Society

Daniel Morreale (for George Lynn) American Hospital Association

Pam Pure McKesson Provider Technologies

Dr. Jim Sorace (for Barry Straube) Centers for Medicare and Medicaid
Services

Chantal Worzala (for George Lynn) American Hospital Association

[]{.mark}

**Presenters**

Dr. Edward Barthell American College of Emergency Physicians

LTC David Parramore DoD

Aarron Reinert Lakes Region EMS

Dr.Roxane Townsend Louisiana Department of Health & Hospitals,

**Others**

Dr. David Brailer ONC/HHS

[]{.mark}

######### 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.*