American Health Information Community

Electronic Health Records Workgroup Meeting #17

Friday, July 20, 2007

**Disclaimer**

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

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

Good afternoon, everybody, and welcome to what I understand to be the
17th meeting with, meeting of the AHIC, American Health Information
Community Electronic Health Record Workgroup. On behalf of my co‑chair
Lillee Gelinas and Karen Bell from the Office of the National
Coordinator, want to extend a special welcome to all new members, and
thank our continuing members for their incredible contributions and
their perseverance through what have been some very tough but ultimately
very fruitful discussions.

Just to go back to basics, our charge is to support AHIC and bring
forward recommendations that allow achievement of the primary goal which
is to help the Secretary help HHS move forward the country in terms of
implementation of health records. You may recall that a couple of years
back, the President offered an objective and that was to ensure that
most Americans had electronic health records by 2014. In that time a lot
of progress has occurred technically, a lot of progress has occurred
socially, in terms of really moving forward with standards development,
and recognized organizations for the promulgation of standards in
response to AHIC charges and ultimately the certification of standards.
And I speak, to be less oblique about that, about the Health Information
Technology Standards Panel and their role in, in identifying and, if you
will, anointing standards. The Certification Commission in Health IT to
provide validation that certified software actually comports with the
selected standards. So a lot of progress.

On the other hand, a tremendous amount of work left to do. We still live
in a largely paper-based world. We still live in an environment where
inefficiencies in healthcare exclude other individuals in our society
from using those same resources for getting the healthcare they might
deserve. And in an environment where, alas, lapses in communication of
information means that patients enter environments where their health
records have not followed them or may experience circumstances, even
catastrophic circumstances like hurricanes, where there are not records
of their health, of their treatment, or even of their medications or
allergies. And in this time the entirety of the AHIC has made tremendous
progress identifying ways to provide beginnings to resolving some of
these issues, including the large issue of improving the safety and
quality of healthcare that we would want, not only as leaders in various
aspects of health services but as citizens ourselves, and ultimately
users of healthcare either personally, our families, or our
communities.\
\
So with that let me thank each of you for joining. We are going to go
through introduction to, for the new members, of the new members so that
they learn a little bit about each of us. But before we do that, let me
turn to Lillee Gelinas for any introductory comments she may wish to
offer. Lillee

**[\>\> Lillee Smith Gelinas:]{.underline}**

Thank you, Jon. I think you did a great job teeing this up and want to
commend everyone for their commitment, for those of you that are
continuing on the committee. I also don\'t want you to feel burdened by
the work ahead. It is an exciting time. We have been able, as a group,
to really come together. This is more a team than it is a Workgroup just
doing work because we understand the importance of our work. We
understand the reach of our work. And I\'m really excited to see the new
Workgroup members that will bring new energy and fresh ideas and
perspectives into this work.

But I do have to say that I absolutely couldn\'t be doing this work
without Jon Perlin and Karen Bell. The leadership team leading this
Workgroup, let me just assure all of you, stays in constant
communication. We are constantly striving to meet your needs and the
needs of AHIC, and just want to really set the stage for open
communication, constructive dialog, any ideas that need to come to the
table to advance the agenda. Because at the end of the day, we do want
to assure everyone success.

So with that Jon, I will turn it back to you. The way we are going to
organize this call, and for those of you that are new, Jon usually takes
a section to moderate and then I take a section to moderate and then we
close it at the end. Back to you, Jon.

**[\>\> Jonathan Perlin]{.underline}**

Thank you, Lillee. Let me join you in really thanking Karen Bell and the
Office of the National Coordinator who do truly heroic work behind the
scenes. For those of you who might be in Washington, you could join the
call at the HHS headquarters, and I think you then get a sense of how
much effort is put into coordinating all the material and all of the
programmatic work that needs to move forward to translate this from idea
into a reality. Karen, do you want to offer any introductory comments on
behalf of the Office of the National Coordinator?

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

Just a few, because I think that it is important to commend the
Workgroup for the work done but also moving ahead. There have been a lot
of very strong, very positive, very important recommendations that have
come particularly around the area of helping physician adoption of EHRs.
And as we move into the new area of looking at all of the issues around
inpatient EHR adoption, and they are very different as we all know from
the individual physician office, we really do welcome the new folks on
the Workgroup because it does bring the, those perspectives that are
going to be so important moving forward. So just wanted to refocus in
that direction.

I would also just like to make one further comment because I know a lot
of folks have heard about the work that\'s being done with the
transition of the American Health Information Community. The initial
charter for the American Health Information Community to which all of
our recommendations go, was that it would be transferred into the
public/private sector after a period of time. So we have begun that
work. However, under no, in so size, shape, or form does that mean that
there is any less commitment to the work that you all will be doing and
have done. It really is full steam ahead for the Workgroups to focus on
these charges and make sure that we continue not only through the
transition period, but also into the new time. So I just wanted to allay
anyone\'s concerns about that and also to invite you to the 31st of July
American Health Information Community meeting where the Secretary will
put more emphasis on the importance of the work that\'s being done, now
and into the transition period. Again, thank you all and welcome.

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

Thank you so much, Karen. And let me ask if you and some of the
Workgroup members, that you will find to be very appreciative of the
great work done behind the scenes by your office, and Alicia Bradford
for her tremendous effort. But if you could actually run down the role,
and what I would like to ask people to do is to take 30 seconds, three
or four introductory sentences, and tell us a little bit about your
background and your interests and your aspirations for this group\'s
work. So let me turn to the office to go down the role if you will.

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

Why don\'t we have Jennifer call out the names of those who are on the
telephone and they can do just that, Dr. Perlin.

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

Terrific.

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

And then we will go back to some of the newer members that may not be
with us and we'll tell you who they are.

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

Great. Thanks.

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

I'll just start at the beginning, then. Bonnie Anton.

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

Hi. My background is as a clinical nurse specialist in cardiology. And
my role now is that I wear several hats with the electronic health
record. I\'m at St. Margaret\'s Hospital which is part of University of
Pittsburgh Medical Center. We\'re a community hospital. We have gone,
for the last two years, totally with the electronic health record. We
have all physicians doing orders in, we have all documentation of
orders. Very little is on paper. My role in this whole process was in
terms of educating the physicians as well as nurses and ancillary staff,
and I continue to do that. And presently I\'m also working as project
management, manager for the development of the electronic order set. And
I\'m really interested in being on this committee because I have seen
what it was like when we were all in paper. I\'ve been a nurse long
enough to remember all of that. And also to see what remarkable changes
have occurred. And I\'m interested in sharing and helping in any way I
can.

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

Okay. Gail Arnett, did you want to go ahead?

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

Thank you. My name is Gail Arnett and I\'m the manager of the EHR
Vendors Association, and corporate relations within HIMSS, so I\'ve been
asked to sit in as an alternate today for Jack Price, who is our vice
president. My goal here is to learn more about what\'s going on, report
it back to Jack so that we can continue to be involved because HIMSS is
definitely interested and active in this area.

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

Okay. Laura Cranston.

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

This is Laura. I am with the Pharmacy Quality Alliance which is a
relatively new alliance in, that was started by CMS and a number of
other partners about 15 or 18 months ago. And we are, I\'m pleased to be
part of this group. For a very long time pharmacy feels that it could be
a more active healthcare provider and contribute more to positive
patient outcomes, but we are limited often in the information that we
have available to us at the point of care. So I think an electronic
health record or even a personal medical record would go a long ways in
terms of advancing care, especially because one of the things that we
deal with on a daily basis is that we don\'t have the complete even
medication history for a patient, because most of the time patients shop
around for their prescriptions and don\'t have everything filled at a,
at one particular pharmacy. So an electronic health record or personal
medical record, with a comprehensive medication history, is very high on
the priority list for pharmacy as a profession and PQA is a
consensus-based alliance looking at these types of issues and how we can
better improve quality and part of that is access to integrated medical
information.

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

Okay. Nhan Do.

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

Yes, I am the Chief Medical Information Officer at the Military Health
System. And my background is I\'m an internal medicine physician and
also trained in medical informatics . And my role is, I report and
advise the CIO and our Assistant Secretary of Defense on
clinical informatics strategy. I know for us, 50 to 70 percent of our
care is not direct care to the military system, but to the civilian
community, and most of our community doesn\'t have electronic records.
And I would like to work towards that goal of having that so that way we
can kind of share and get back clinical information that we are
dependent on the civilian community.

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

Peter Elkin.

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

Hello. I\'m Peter Elkin. I\'m professor of medicine at the Mayo Clinic
College of Medicine. I also have been a researcher in
biomedical informatics for the last 26 years and am currently one of the
co‑chairs of the HITSP technical community on population health that\'s
actively researching biosurveillance and also electronic quality
monitoring. In my day job I have a very strong interest in electronic
health records, especially intelligent electronic health
records \[inaudible\] last year in Mayo in this area which brought
together some of the best minds in the country. And I personally have
spent my career committed to advancing intelligent electronic health
records for better practice of medicine and also improved care for
patients and patient safety. So I\'m very excited about the effort and
love to contribute in any way that I can.

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

Linda Fischetti.

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

Hi I\'m Linda Fischetti. I\'m the acting chief health informatics
officer of the Veterans Health Administration. I am a nurse
informaticist. I've been working, I've had the pleasure if working
within the Veterans Health Administration pretty much post-adoption
because they, of course, did the major adoption throughout all
inpatient, outpatient environments a good 7 to 10 years ago. So really
learning what the environment is like post-adoption when you can in fact
reach the gains in the quality of care and the efficiencies and the
improved safety that you have within the environment. I\'m also this
January going to be giving up my role within HL7 as the co‑chair serving
since 2003 on the electronic health record technical committee. But I
hope to continue my stint on the HL7 board if they re‑elect me in
January to continue there. So the value statement and the importance of
this Workgroup is that we've seen you do some amazing work in terms of
already moving alignment within the industry of standards for laboratory
which we were able to take in at HL7. And this is exactly the type of
thing that we need to do to accelerate to our vision of being able to
have an interoperable future where you will be able to have the quality,
efficiency, and safety gains for the nation. So thank you. It\'s an
honor to be asked to be serve on this group, and I look forward to
participating here. Thank you.

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

Howard Isenstein.

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

I\'m Howard Isenstein. I\'m with the Federation of American Hospitals.
Represent \[inaudible\] and \[inaudible\] one is in health information
technology, including ‑‑

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

Howard, this is Karen. You\'re intermittently falling off.

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

Let me pick it up. I have three roles at the Federation. One role is in
HIT, and that is serving on the policy steering group at the eHealth
initiative, as well as the policy working group at national, at NAHIT.
My interest is really in the sort of quality sphere, in helping to drive
vendors to be able to passively report all of the ambulatory and
inpatient quality measures that were being required to put through for
CMS.

I also do some quality work and also serve as the head of public affairs
at the Federation.

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

Mike Kappel.

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

Thank you. I am vice president of government and industry relations for
McKesson Provider Technologies and McKesson Provider Technologies is the
HIT business within McKesson Corporation. Of course in that role I'm
very interested in increasing adoption of health information technology
to improve quality and efficiency of care. Besides the work at McKesson,
McKesson participates in the HIMSS EHR VA so we work with Gail and I\'m
glad to see her on this call. And we participate in NAHIT where I served
as chair of the policy committee, and also in CCHIT where for two years
I\'ve been working on the certification process work group. And now I\'m
serving as co‑chair of the network working group.

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

Robert Smith.

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

Hi, this is Robert Smith. Dr. Robert Smith. I\'m a pulmonary critical
care physician within the VA as well as a professor of medicine at
University of California, San Diego. My background is health informatics
and been involved in the implementation of the electronic medical record
system at San Diego VA, where I\'m associate chief of staff. My current
hats include using informatics and the output of electronic records to
improve quality of care and provide feedback to physicians as a way of
their improving performance. And my interests are in trying to assist in
the implementation of electronic records more globally since I\'ve seen
both the benefits and return on investment of health records in a
comprehensive way that I think is just essential to good patient care
and safety.

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

Okay. Did I miss any Workgroup members on the phone or any designees?
Okay.

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

This is Karen Bell, though. I would just like to add that we have a few
new members that were not able to join us today. But hopefully they will
be with us shortly. One is Andrea Delmotte who is with the American
Nurses Association so we certainly will welcome that input. I think we
are all aware of the fact that when we start talking about hospital
implementation, nurses are a very critical piece. And also Robert Wears
who will be joining us from the University of Florida Health Center as
well. So there are two other members in addition to the ones that we
have here. And a third is Robert Juhasz who is with the American
Osteopathic Association and the Cleveland Clinic so we have a double
representation there.

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

Karen, perhaps a word on your own background, and Lillee as well?

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

All right. Lillee?

**[\>\> Lillee Smith Gelinas:]{.underline}**

Karen, you go first.

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

I\'m Karen Bell. I\'m an internist by trade and the director of the
Office of HIT Adoption in the Office here in Washington. And I basically
became enamored and passionate about the use of electronic health
records quite some time ago, in the early \'90s when I first joined the
old Harvard community health plan which was one of the first
\[inaudible\] HMOs that actually had an electronic health record and has
had one, now that the staff model is spun off, for close to 40 years. So
I saw early on the advantages and became hooked at that point. And I
also had quite a bit of experience in the payer world as well as in the
world of public health and academic medicine. That\'s me in a nutshell.

**[\>\> Jennifer Macellaro]{.underline}**

Karen, this is Jennifer. Can I interrupt for just a second? It looks
like Robert Juhasz has just joined us on the phone.

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

Wonderful. Good.

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

Hello, I\'m Bob Juhasz. I\'m an internist for my day job at the
Cleveland Clinic Foundation where I\'ve been actively involved in
bringing up our electronic medical record at the Cleveland Clinic. I\'m
representing the American Osteopathic Association where I participate on
the board of trustees, as well as a member of the Bureau of Federal
Health Programs.

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

Thank you very much Robert. Welcome.

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

Thank you.

**[\>\> Lillee Smith Gelinas:]{.underline}**

I\'m Lillee Gelinas. I\'m vice president and chief nursing officer for
VHA Inc., the other VHA. We are frequently confused with our Veterans
Health Administration colleagues but we don\'t mind that because we have
tremendous admiration for the Veterans Health Administration. As chief
nursing officer I have responsibility for our nursing programs and just
spent an inordinate amount of time with chief nursing officers across
the hospital. We have 1,401 acute care hospitals and represent 20
percent of all healthcare organizations in the U.S. as well as 30
percent of all U.S. healthcare revenue. I take my job very seriously
since there are thousands, almost 20 percent of the total employed RNs
in the United States are in our 1,401 acute care hospitals.

My interest in health IT was an interesting correlate because when the
Secretary called me to join AHIC, it was right before Hurricane Katrina.
I\'m a native New Orleanian. I had direct experience with 26 members of
my family who were displaced without medical and dental records and the
absolute burden on our family that we went through, particularly with
the very young and the very elderly, and trying to provide care for them
post-Katrina with all medical and dental records being lost. So not only
did this work become even more important for me, but my passion to get
this whole area fixed got heightened especially, as I learned about the
Veterans Healthcare Administration with 68,000 veterans displaced from
Louisiana and Mississippi and not one single medical or dental record
lost in that scenario. So I was living a tremendous conundrum. I greatly
appreciate the opportunity that I have to work hand-in-hand with all
members of the Workgroup on this important work. And I do hope that when
we\'re having a conversation six to nine months from now, that our
conversations will not be introductory, but they will be around the
recommendations and the conclusions we have been able to achieve. So
with that, Jon, I will turn it back to you so we can get started.

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

Thank you, I\'m Jon Perlin. I have really enjoyed the privilege of
working with this group. Day job, I\'m chief medical officer for HCA,
Hospital Corporation of America, which represents about every 20th
admission and I have seen the benefit of technologies like bar-coded
medication administration in terms of improving safety. Before I
joined HCA about 11 months ago I had the great privilege of being
Undersecretary for Health before leaving the VA. But over the decade
preceding working with exceptional colleagues like Linda Fishcetti on
this call, and Rob Kolodner, director of the Office of the National
Coordinator for Health IT, to help translate a vision for
improved effectiveness and efficiency, even compassion health care into
a system which, in my estimation, now looking back with both
objectivity, but I have to tell you longingly, a world that can be. I
think that\'s what so exciting about today\'s call is that kick off of
this second phase of our Electronic Health Record working group, after
we approve the minutes, will really revolve around discussions with
entities that, from a variety of circumstances, have translated vision
into reality. Before we go to them, one order of business, let me ask
for either a motion to adopt the minutes or any comments, recommended
amendments, on the May 22nd meeting.

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

I move to adopt the minutes for the May 22nd meeting.

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

Second.

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

Any opposed? Perfect. Let\'s ‑‑ we will consider those adopted.

I think we have an extraordinary opportunity today to hear from three
institutions as we think about our work ahead. And not only will they
tell us of their success, but I think their process of moving from a
paper‑based world to an electronic world in a variety of circumstances,
large academic health center; a somewhat rural health system, integrated
health system, that also has a provider network and non‑staff affiliated
providers; and a rural hospital with significant challenges presented by
the rural environment and complexities of the health system, I think
will be tremendously instructive in terms of helping us understand how
to realize the vision and the objective that Secretary Leavitt set for
the us at the very beginning. The vision he left for us is that none of
us, if we realize our objectives, will ever need walk into a hospital or
doctor\'s office and fill out a clipboard. So let\'s turn for that
instruction and let me ask our esteemed colleague, Dr. Bill Stead is
online to talk to us first about Vanderbilt.

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

Thank you Jon. I\'m Bill Stead, for those of you that do not know my
voice. I\'m the associate vice chancellor for strategy and
transformation at Vanderbilt Medical Center, where I\'m also the CIO.
And my background is as a nephrologist. All of my research has been in
biomedical informatics. First, just two words about Vanderbilt.
Vanderbilt is a University-owned medical center. The medical center is
made up of the school of medicine, the school of nursing, four
hospitals, and the clinics. The net revenues of Vanderbilt are about 2.2
billion this year. About 78 percent of that is in healthcare. Three of
the four hospitals that are wholly owned admit about 52,000 patients and
we see about 1.2 million outpatient visits. That\'s the order of
magnitude of the enterprise I\'m dealing with.

I ‑‑ yes. I\'m sorry. Should I proceed?

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

Please do. I think there may have been a mix‑up on the line, but please
continue.

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

Thank you. I wanted to make five points in my brief time with the group
today, if possible. The first of those points is that I do not think of
the problems that we face as an information technology adoption problem.
In essence, I think it is a problem about how we adopt new approaches to
healthcare decision-making, how we adopt systems approaches to care that
result in reproducible outcomes. So IT is necessary but it is not
sufficient. And I put in a couple of slides into the PowerPoint to just
make the point of the magnitude of that problem because I think it still
surprises people when they really think about it.

The first one of those shows the number of facts that currently are
involved in individual healthcare decisions and the number that we
expect to be involved in decisions with the scientific advances that are
near at hand. In essence, today\'s healthcare works fairly well without
having to make more than, without having to juggle more than five facts
in a single decision, and that happens to be the cognitive limit of a
human. I\'m not talking about the number they have to recall but the
number they have to juggle. With structural genetics, just single
nucleotide polymorphisms, for example, we expect that to go up to about
10. We then expect a log increase to 100 as we add in functional
genomics. And another log increase as we fully take advantage of the
opportunity of proteomics. I think people are aware that\'s happening,
I\'m not sure they realize how fast it is happening. As best we can tell
with today\'s technology, you will be able to do relevant whole body
sequencing by 2014 for the same price we can currently do a whole body
CT. So we think that we face changes that simply will destroy the single
human expert\'s ability to handle decision making.

The next couple of slides show at high level what we mean about the
change to systemness. Right now the bulk of the cognitive energy of the
healthcare system is spent working around the lack of a healthcare
system. We spend a little bit of time, usually committee time, you know,
late at night, early in the morning, working on systematic improvements.

As sort of shown in the next slide, we envision that balance of effort,
cognitive effort of the healthcare team to shift. We think most of the
time will be spent actually in systematic, evidence‑based system design.
Not information system design but practice design. And we think a
relatively smaller amount of our energy will be spent on flexing that
system for the individual patient. So when you talk to people at
Vanderbilt and you talk about our IT strategy, we have worried about
what strategies might work with this magnitude of change. So that\'s
really the first point I want to put on the table.

The second point is if you take that view, I hope that you will agree
that we are talking about a journey, not a destination. In our hands,
and I think in the literature, whenever you insert IT into the old way
of practice, you get as many unexpected, untoward effects as you get
wins. And to be successful, you have got to iteratively and continuously
evolve peoples\' roles, the process, and the technology to
have constant, data‑driven improvement.

The next slide lays out the sequence that Vanderbilt has moved through
this change over the past 16 years. I won\'t really walk through the
details of that except to just point out the first step of that was
taken in \'89 when we started the data-driven pathways, and it got
robust in \'91. We got into, you know, physician order entry in 1994,
and really completed that work in early 2000. Electronic patient chart
in 1996. And you see our most recent, from the things that really, what
we are trying to do around disease management tools for patient and
therefore to drive to proactive improvement. So it\'s been a long
journey.

As we have gone through that journey, as is shown by the next sort of
flywheel slide, we have gotten a lot of scar tissue about the number of
things it takes to work in tandem to get the improvement people want. We
started with decision support. And prior to decision support, you know,
we would do what we should do maybe 10 to 20 percent of the time. With
decision support, you see us bump that up to the 40 to 60 percent range.
Nowhere close to the 100 percent performance that the lay public might
expect. But those decision support tools have created additional data
resources about what people are doing, which, when we pair with
algorithms that let us do informatics-based surveillance, we are
actually able to see the system problems that interfere with us doing
what we want to do and we are able to use that surveillance to enhance
the decision support. And that iterative cycle moves us into the 80, 90,
100 percent range over time.

To just sort of give you a little glimpse of what that means without
going down into systems, the next couple of slides are the type of
decision support that we provide through the decision support order
entry tool that we developed here that we since licensed from McKesson
that they have distributed as Horizon Expert Order. And it in essence
helps you, figures out what problem you\'re trying to solve and then
let\'s you edit by exception-editing the best practice around that
problem. That kind of tool will get us to the 40 to 60 percent range of
improvement.

The next little slide is a dashboard. Shows what we mean by sort of
real‑time surveillance where we step up above the workflow-level
decision support, and we actually provide an integrated view of the net
result of everything that\'s happening for a patient with red, yellow,
and green flags to let us know whether the combination of people,
process, and tools has yet achieved the results we need for our patient
or, if not, what we need to improve, so that people can fix that in
real‑time, not as, through an after‑the‑fact report.

And then I show you the little table that shows how we actively are
making these two very different views of working fit together. So we
have voluntary reporting for adverse drug events, and we have also got
algorithmic-driven surveillance for adverse drug events. When both of
those very different modes ‑‑ we know we get under‑reporting from
voluntary reporting, we know our surveillance will over‑report because
we are looking for flags, signs of adverse drug events like giving
glucose after insulin. But when both of those say we don\'t have a
problem, we probably actually don\'t have a problem. If both of them
show we do have a problem, then that means that we had a problem that
made it through our decision support to actually end up affecting a
patient, and yet it is in an area where we knew we were having trouble.
And that then means we need to add rules that help us escalate. In
situations where we, where the voluntary reporting shows we have a
problem and we didn\'t pick it up on surveillance, we know we need an
entirely new rule. And in the other cell where we are dealing with a
negative voluntary report and a positive sign from the algorithm, we
have either got an over‑report of the surveillance or an under‑report of
the algorithm. We need to go in and actually test that out with a human
monitor. So what we are actually doing is systematically working the
high volume events and the high volume areas to systematically drive to
improve performance and improve decision support. So that\'s what I mean
by the journey.

The third point is that if you\'re going to take this tack, if you are
going to treat it as a journey of iterative improvement, then the
technical approach that you take really matters. Most of the systems
that are currently available use techniques that have developed over the
years in data processing and automation. In, you know, in my words, they
regularize a relatively simple set of data to automate a complex
process, in that way, if people will put the data in right, they will
make that process absolutely reproducible. That works extremely well at
microsystems, small piece, parts of the healthcare system such as, you
know, automating a particular function in the pharmacy where it is a
microsystem process. It doesn\'t work well at the macrosystem level,
across systems, which is what a lot of the problems this working group
hopes to solve with electronic health records. And my, an example of
sort of a clarification of what I mean, is with data processing kind of
approaches, we ask one person to put information into the computer so
that other people can use it. That\'s actually not the right model for
use of this technology at a macro scale. What we need to be doing is
using the computer to produce the information for humans in the first
place. And I think the example of an informatics solution that works
that way is Google. It lets you answer questions by just walking across
a variety of digital pieces of information that none of those sources to
information were in fact designed to let you answer. So that\'s an
example of something that works at the macro scale. And our electronic
patient chart is in essence a secure Google.

The one sort of slide I put in about our architecture, because I think
it is important, is that what we have done is to de‑couple management of
our information as an enterprise asset, independent of any of the
systems that automate our facilities. We have a lot of the systems, as
you see in the middle bar there, that automate facilities and we use
them as transaction processors but we externalize the data so that we
are not, so our information, if you will, is not held hostage in those
systems. And we externalize it in real‑time and it\'s that external
repository that our clinical users go to in real‑time. Similarly, we
have made relatively simple, role-specific user interfaces that set up
on top of all these systems and work, you know, and work with the users.
Those user interfaces can be rapidly changed, unlike the transaction
processors which have to be kept very consistent from a business point
of view. That would obviously take a lot more discussion to make clear
but I just put the idea on the table.

The fourth point is, at least in our hands, and I think others', the
majority of the effort around what we think of as adoption is outside of
the IT shop. We have many teams in our institution that do the practice
improvement work. I just put the make‑up of one of those as a slide in
here, the team we have that facilitates the work of the various practice
groups, as they try to develop evidence-based order sets, and as they
try to fix those order sets as they get data about what works and
doesn\'t work. And you can see it\'s got nurses, its case managers,
it\'s got pharmacy, it\'s got people from biomedical informatics, it\'s
got people from administration and the library. It is a team that
essentially has nobody on it that you would think of as part of an IT
shop in most organizations.

The fifth point is that the financial returns here are not
straightforward. I found it helpful to think about the returns as
occurring in three basic buckets and I put each of those buckets on a
different slide. The first are the easiest to understand and book. They
are the direct returns that take out expense so that can drop to the
bottom line. You know, getting rid of film as we use PAKs drops straight
to the bottom line. Getting rid of overtime drops straight to the bottom
line.

The second bucket are things where we improve productivity but the drop
to the bottom line is indirect, either because it involves parts of an
FTE or because it involves something where we simply, you know, don\'t
have a good way of measuring the impact on productivity. In that
particular case what I\'ve worked with in Vanderbilt to try to get
people to do is to get, even though they cannot quantify the whole
improvement, get\'s get some part, maybe it is only 10 percent of what
we are trying to manage to that we will in fact book in that zone.

The third bucket are the real reasons we want to do this technology.
It\'s where the real value is. How do we make better management choices,
how do we achieve the right long‑term outcomes, the right, as opposed to
necessarily the most profitable, utilization of profit centers, and the
right transparency and patient engagement. Within the Vanderbilt world,
what we have had to do is to keep the cost of what we do low enough that
the direct savings will pay for it, because that\'s where we actually
get the money to pay for it. The ‑‑ those savings would not be worth the
organizational energy that it takes to achieve it. But they're how we
pay for it and then it is the third bucket, the things around our
quality outcomes, that are why we spend the organizational energy this
way. So that\'s a very high fly‑over, Jon. I don\'t know how, whether
you want to, me to try to respond to questions, I know we were a little
late starting into this block, or whether you would just like to move to
the next presentation.

**[\>\> Lillee Smith Gelinas:]{.underline}**

I think we should take questions Jon, don\'t you?

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

Yes, thank you, Lillee, still getting my mute back. Bill, thank you very
much. Just terrific work and you eloquently make the point. It is not
the technology. It is the desire to move forward. It is the people. It
is the systems. It is building the adoption toward promoting better
medicine, better healthcare. Let\'s open it for questions. There is a
lot of material to discuss in that terrific presentation.

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

Jon, as everyone is forming their questions, and I agree with
outstanding, meaty information in a short period of time. Dr. Stead, if
you were recommending to this group, knowing that we have a charge here
to facilitate the adoption of health IT in the acute care setting, what
would you be recommending to us that perhaps would focus our work?
Because we certainly don\'t want to feel like we are the gnat on the
ankle of an elephant, although that\'s what it does feel like. But we
are really struck that if we can really focus on the right issues, we
can achieve success much sooner. So based on your enormous experience
here, are there any very succinct, clear areas with which you would
recommend to us we need to focus?

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

Well ‑‑

**[\>\> Lillee Smith Gelinas:]{.underline}**

Or things we should not do? You know, the most important things are
sometimes, don\'t do this because we tried it and it doesn\'t work.

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

Well, I think there are things that would be very helpful. I think that,
that as a group you should come to grips with the real questions, what I
believe is the real question, which is, do you want to try to drive the
inpatient world forward from the perspective of IT or, given your rich
understanding of IT, do you want to drive the inpatient work forward
based on how you enable certain outcomes you want to achieve with IT? I
think that\'s really the fulcrum around which what you do will center.
For example, there is no ‑‑ I mean, it is almost impossible to get a
meaningful benchmark of adverse drug events that can actually let a
place understand where they stand. Some places report errors per
admission, others report errors per order, others report errors per
administration. There is no consistency about what the errors are. So I
would think that one thing we could do would be to think about whether
there, where there's something like that that might help.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Because, you know, as you say that, there are so many hospitals in
America that have adopted the strategy of, you know, zero harm and zero
preventable deaths through a period of time, because that\'s where the
payers and the consumers are going, all preventable harm and death. And
I\'m just struck that I see so many boards putting that goal out there
and have no clue how to get there.

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

Well, and they ‑‑ and so whenever I work with somebody, I try to keep
them from having a goal that they cannot measure. And, you know, it has
taken us a year to get agreement across our clinical enterprise of how
we are going to measure adverse drug events. Because we are actually
now, we are discovering that, you know, since we have got most of the
early wind kind of things. We have got CPOE. We are well through a lot
of the bar code med administration. But, you know, if you really look at
the length of time people are in our hospital without having therapeutic
levels or having over‑therapeutic levels, that may or may not reach the
level of something that people would normally report as an adverse drug
event, it is actually beginning to look like that may be a huge
opportunity for actually improving, you know, frankly, our morbidity and
mortality.

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

Bill, let me ask you, in terms of policy terms that HHS or even Congress
could support, if you were to operationalize that, would that mean
certain quality measurements that would require health IT, health IT
just being the vehicle, but the quality measurement being the focus to
create a forcing function towards adoption?

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

Absolutely.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Yes, Jon.

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

Absolutely. Because in every, every time we ‑‑ you know, I mean, the
disconnect I see in my own shop and other people, we have a problem, we
can see how a system would help us solve that problem, we get approval
to buy the system, and then the task becomes implementing the system,
not solving the problem.

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

I think that\'s, you know, very good guidance.

Let me ask you about one other piece then. I think all of us have
reticence about over‑specifying how the problem is solved, but at the
same time, I think speaking for myself, extremely impatient that we are
not moving quite as swiftly as we might in using the technologies that
would solve these problems. So do you think there needs to be a date
certain for implementation towards the second step, towards answering
the quality measures, the government policy?

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

I think that there should be a date certain for achieving measurable,
measurable quality goals that everybody would agree were impactful. I
think that\'s, I think that line does need to be put in the sand. I
think that doing that will force a change in our information technology
strategies. You know, I am personally quite comfortable that if the
government funded everybody to buy all of today\'s healthcare IT,
quality would not improve very much. And partly that\'s because it is
not driven by the quality goal, which is clearly necessary, but also
partly because most of that IT is designed to work at a microsystem
level and we are dealing with a macrosystem problem. So I really do
think people need to come to grips with this difference between data
processing and Google and figure out ‑‑ and again, you know me well
enough to know I\'m not against data processing, what I\'m in favor of
is using each of the techniques at the right place in the system. And I
think as a country we don\'t have our hands around how to do that. And I
think we need, I think we need to understand that. And if your working
group could shed some light on that, I think it would help.

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

Terrific comments. Let me make sure, see if there are any member
comments to what Dr. Stead has just addressed, that you need measurable
goals in terms of quality. And to quote Don Berwick, soon is not a time.

**[\>\> Lillee Smith Gelinas:]{.underline}**

M\'hmm.

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

Okay, more discussion with the next presentation. I think Dr. Stead
indicated Vanderbilt is really an extraordinary environment in many,
many ways. And perhaps our thinking that that may be, you know, true in
an academic. But let\'s take a look at a cross‑section where, I believe,
people have come to similar or at least parallel conclusions about
solving the problems of improving care as the goal, and would tell you
that my learning from Rob Kolodner is a parallel. It is not the
technology. It is the problem you\'re trying to solve that should drive.
So I think there are just some terrific lessons that you have offered us
and a lot more for consideration in terms of the \[inaudible\] so on
behalf of the working group, I want to think you, Bill Stead, for that
presentation. Please stay with us. We would appreciate your comments on
what\'s coming up.

Let\'s switch now to the Geisinger Health System. Dr. Jim Walker will
introduce Geisinger. Many of you may be aware of Geisinger in terms of
the recent attention Geisinger got because they, perhaps in an
unprecedented fashion, now offer a limited warranty model. I hope Jim
Walker will explain that. But the point really being that they say, hey,
we have an obligation and are on the line to produce certain quality
outcomes. So the problem they are trying to solve in their system is not
technology for technology\'s sake, but technology to support honoring a
warranty that promises we\'ll get it right. Jim Walker, are you online?

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

Yes I am. Jim Walker, I\'m an internist by training and Chief Medical
Information Officer, Geisinger Health System. I will go through the
first couple of slides quickly. We serve 40 counties in Pennsylvania. We
have five helicopters. Trauma 1 at one of the hospitals. We have three
hospitals and about 30,000 discharges a year. Forty-one clinic sites
throughout those counties, 70 specialties, 670 physicians, and we write
about 2.4 million prescriptions per year. About a two billion dollar a
year company.

You can see the map there with fair coverage of rural central
Pennsylvania.

Our clinical information systems, the next slide, include outpatient EHR
which is used by all clinicians for all activities and had been for
about five years. Our inpatient EHR has results, registration, nursing
documentation, and the ED and most of the OR live. And we are going live
with order management which includes order entry and physician
documentation in our largest hospital in October and finishing
inpatient, or that phase in inpatient, in 2008. We also have a patient
health record in which 82,000 patients fundamentally see an extract of
their electronic health record, exchange secure messaging with their
physician practice, get clinical decision reminders, are able to
schedule their own appointments electronically. And we are in the first
phases of patient interview on that, patient interview and E‑visits.
Then we have an outreach EHR that serves the 9,000 or so physicians in
our region who are not Geisinger providers. We send about 250,000 clinic
notes out within 24 hours each year and have a number of other services.
We are also building a regional health information exchange and do
extensive research on EHR benefits and information-optimized care
processes.

The things I wanted to talk to today briefly are, first, a goal worthy
of the cost, something about what Bill was talking about earlier. As we
have gone through what for us now is about a 12 year process one of the
things we have realized, as Bill said, is that putting IT in is not a
goal worthy of the cost of doing it.

And we have come the last couple of years to really think of the IT, of
HIT generally, as a tool we use to transform the way we provide care.
And the elements of that that are particularly important are
reimbursable performance, by which we mean high quality performance that
we can report to whomever can receive the report. The next element is a
high‑touch patient experience, so that the result of automation and
process redesign is the patients feel more known, more cared for, more
connected than they have ever felt before. And of course we want to
produce safe and effective processes. And Jon was talking about the
CABG, which is the first Provencare that we are doing in the in‑patient
side. And there, there are 40 process steps that have been proven to
decrease your risk of having complications when you have an open heart
surgery. And we guarantee that we will do all of those every time and
have data to support the fact that if we do that, and we have for the
last four months running been at 100 percent, we can afford to say to
payers, which we are starting to do, that if there are any complications
of the surgery we will take care of those complications at no added
cost. Clearly another important goal is to decrease the unit cost of
care. We are not going to decrease the cost of healthcare obviously. But
we do have the goal of decreasing the unit cost of performing a CABG
where all of the performance measures are met, or meeting all of a
diabetic patient's needs at 30 to 40 percent reduced cost. And then
finally, and I didn\'t get patients ‑‑ I did, yes. Finally it has to be
an employee satisfier. Our docs, nurses, and everyone else are working
just about as hard as people can work. What we want to do is change the
way people work so people work more effectively, not harder.

The next slide, organizational capabilities, is a reflection on the
process we have been through for the last 12 years. It has become clear
to us that there are core competencies that our organization in large
measure has had to either create or enhance substantially to implement
an EHR that\'s actually effective and more important to move beyond that
to really create transformative care processes. One is the ability to do
care process transformation, to have the disciplines, to have a group of
people who are committed to doing it and be able to execute that. A
genuine patient safety culture where you have a lot of people whose, one
of whose primary concerns is making sure that all of the new processes
we create really do enhance patient safety, because obviously with this
kind of really fundamental change, there is the potential for harm.
Incentives are critical, and one of the advantages that healthcare
systems have over smaller organizations is that we have been able to
create internal incentives that we hope are the harbingers of societal
incentives for providing higher quality, reportable quality care. Human
factors engineering is a critical issue, both from the process redesign
standpoint and from the HIT standpoint. There has been relatively little
impact of professional human factors engineering on healthcare, and
that\'s certainly one of the reasons that we have some of the safety and
consistency issues that we have. And we have both outsourced some of
that and developed a good deal of that in the course of doing this work.
Project management is obvious, and experienced information systems staff
is critically important. You know, as Bill said, if we gave everyone
enough money to buy EHRs, that wouldn\'t guarantee quality. And part of
the reason is, because if you did that there wouldn\'t be enough
experienced expert information systems people available to help do the
process reengineering and the business analysis and the incentive
creation that would make it effective.

Just a little bit on our organizational strategy. One of the things that
we started early but have tried to get better and better at is really
creating organization-wide strategy teams that include everyone from the
executive suite literally to housekeeping. So that as we design these
programs they really represent an organizational consensus about how we
need to improve and how we really want to do care provision. And
obviously executive leadership that is sophisticated and passionate
about this becomes critical.\
\
I just quickly want to talk about physician champions. They are talked
about a lot. But what I want to say really is that we've found that it
takes a village to raise an EHR. We had a very important founding
champion. We have had a CIO for the last six years who is sophisticated
and passionate about HIT being at the heart of our transformation
efforts. And then lots of other physician champions.

And then on the next slide you will see a whole lot of non‑physician
champions who are absolutely critical to making sure that the EHR is
really helping us drive toward improved quality and not just another
plumbing project.

I will move past that to the next slide on interdisciplinary
implementation. We depend critically on having strategy teams, control
teams, and feedback teams, and then optimization teams, all of which
include physicians, nurses, techs, administrative people, both front
desk and managers, all of whom make sure that what we develop really
works for patients and all of the caregiver team.

I want to talk just quickly about scope of practice team because \-- and
there is the next slide on that. I think this is something that may be
more of a problem in Pennsylvania. I don\'t know. As we have implemented
the EHR and the other clinical information systems we have run into just
a myriad of issues about scope of practice, that audiologists, audiology
techs have to be able to order one thing and only one thing, but in our
system that means that they have to be able to order any orderable in
the catalog. And we have put together a team that includes all of those
people you see on the slide, who look at the issues that the EHR raises
in terms of who needs to do what and who must do what and who signs what
and who sees what and who gets a copy of what. And those teams have
probably put in about three or four hundred person-hours now trying to
match our workflow needs with Pennsylvania and Federal law and
efficiency realities to come up with a set of rules that, for the most
part, help people do their jobs effectively.

And then finally, on organization and user readiness there is a positive
experience of using HIT. One of the things that we found, we were told
early on that we should just do everything all at once, and people would
get through it and we would be over that and on to the next thing. We
tried that in a couple of, the first two clinics we implemented in the
outpatient setting and just broke them up in business, just made them
unable to work, and have moved from that to a phased implementation plan
where we start with things like lab results and e‑mailing, that are easy
to learn, that have obvious paybacks for people and spread out the
learning that\'s required so that as people then are asked to do harder
things like documentation and order entry, they, first of all, developed
a lot of skills and, second, have started to experience the power of
having information that they need when they need it.

I\'m going to talk a little bit about more about fitting the EHR to the
work, and then obviously just using it makes an enormous difference. One
of the things that probably has national implications ‑‑ and Bill can
comment on this afterwards ‑‑ is we found that it takes, well, within
three months users, clinician users, are back at their pre‑go-live
revenue production. But it really takes 5 or 10 years of repeated
training and workflow analysis and redesign and EHR redesign for people
to get really, really good at it and get to the point that they really
are working faster and better than they could have worked before.

The next slide I go back to fitting the EHR to the work. This is
something that may look obvious, is ‑‑ and I don\'t know any statistics,
but my anecdotal sense is that in lots of places, and lots of places
that are well‑known and well‑financed, workflow analysis and workflow
redesign are blighted. And particularly the development of specialized
tools for all of the different specialties and nurses and respiratory
therapists and technicians, all of the different care team members, this
takes a lot of time, a lot of dedicated people. We have 140 people
supporting our EHR implementation, and have been for 12 years now, to
build the sorts of tools that make it possible for people to work
rapidly and at high quality levels.

And then finally I want to talk about incentives just for a moment.
There are a number of incentives that we have created internally that
encourage and reward use of the EHR. Performance assessment, and that
includes training all physicians in how to make the EHR an asset with
patients and doing careful patient assessment of their satisfaction,
having pay for performance internally that can only be achieved in a
practical sense using HIT, and of course we are waiting for bated breath
for external incentives to become more of a reality. Transformation
opportunities, one of the interesting things we have seen happen is that
we attract a whole different kind of physician and physician leader than
we did before we had a fully implemented EHR. So that people come to us
now saying this is really exciting, with this platform, I could create a
virtual practice of the 60 urology practices in our region and provide
them services and make it easy for them to transfer patients to us and
create a genuine virtual practice. And that has enormous implications
for our organization. How you would quantify that, I have no idea. And
then finally who receives incentives? One of the things we have found is
that many incentives should be directed to care teams, not to
individuals, whereas others really are appropriately directed to
individuals. And then obviously we need, and do provide incentives to
managers and to our HIT teams so that what we have tried to do is create
a coherent set of incentives that sort of roll up from one level of the
organization to the next so that we really have people playing toward
the same goal.

Then I want to talk just a little bit about clinically astute IT. That
is a hard thing to create. And I want to propose at least that the CIO
needs to be like Bill and be clinically astute, or you just almost
inevitably end up with the kind of turf fight in between IT and HIT that
produces, well, some well‑known disasters with uptime and other things.
You need people who really understand process reengineering. Now that
wouldn\'t have to be in IT, but the reality for us was that it started
in IT and that IT is in the process of training the rest of the
organization to sort of take that role over. And we are probably 50
percent of the way through that transition. Business analysis is
similar. We had to develop that skill to implement an EHR effectively,
and, both because of the example and because the EHR makes it necessary
that you can do business analysis to really get any value out of it,
that has become something that, in many ways, IT has helped to teach the
rest of the organization. And then the other things are obvious there, I
think. I will go on to the next slide with operations‑led HIT.

It is probably inevitable that an EHR project starts out as an IT
project, at least in important ways. Certainly did in our place at any
rate. But from the beginning we have tried to make it a shared project
that really is led by operations. And over ‑‑ and it\'s taken most of 10
years. Over about 10 years we have really gotten to the point that
operations feels comfortable doing needs assessments, prioritizing
projects, leading control teams that manage the implementation process,
leading optimization teams. We call them EHR optimization teams. They
are really process optimization teams. They are responsible for
outpatient and inpatient and specialties.

Then I want to talk just briefly about how much software does matter.
People say rightly that software is the least of it. But as Bill said,
it still matters a great deal. We have taken, in many ways, almost the
opposite approach that Vanderbilt has. Partly because it is feasible for
us, and Vanderbilt\'s model probably would not be. So that we have a
highly integrated commercial software system. We have 286 clinical
applications, but the bulk of our clinical systems are all provided by
one provider. Now, that gives us the benefit of market discipline so
that the vendor has to listen to all of us, and our business needs,
which we get better and better at expressing. We benefit from a
community of users who are facing the same sorts of issues, and working,
using the tools to achieve those. That\'s an enormously powerful
learning experience for us.

And then just the integration is very important to us, that\'s the next
slide. HIT integration. Because it simplifies a whole set of things so
that one of the reasons we have an integrated patient health record is
that the way the software is designed it is integrated with the rest of
the EHR. So that instead of it being a separate development process for
us, it was a matter of implementing another module of the EHR software,
at least from the technology standpoint.

The next slide is about knowledge management. One of the things that we
are not doing as well as we are going to be doing it in a year is
knowledge management. And I\'m taking sort of an idiosyncratic slant at
it. We have scores of projects, and we need groupware to keep lots of
project team members and managers of projects aware of who is doing what
and what\'s due and where all of those projects are. We have hundreds of
team members. We have thousands of rules and tools which need careful
curation, and semi‑automated curation, or it just becomes unfeasible,
and so we are just in the process of identifying software and starting
to really get systematic about that. Currently our process for doing
that is ignorant and extremely people-intensive. The knowledge products
that are available, we find suboptimal to our needs and so have to do a
lot of that ourselves but are looking for and helping to develop
knowledge products that are more usable out of the box, particularly
when you think on a national level in terms of 20,000 physician
practices and 5,000 hospitals. Many of these tools are going to have to
become a lot easier to use, either that or just be built into augmented
EHR products for many organizations to be able to implement them and
particularly to maintain them.

So I will go to the next slide and talk just, in the final couple of
minutes, on EHR safety. One of the things that we have realized is that
the EHR has substantial potential to cause adverse effects, just like
any other intervention does. And what we have tried to do is focus on
safety flaws. And you see the definition there on the slide.

The reason we focus on flaws is in the next slide, in that pyramid. It
is well known in other industries, for every system malfunction there
are hundreds, literally, of safety flaws in the system. And then for
every 20 or 50 or so system malfunctions, there is an adverse event to
somebody. And so what we are trying to do is identify those system
safety flaws before they become either system malfunctions or adverse
events, although of course we track those also.

And what we do with that is, as we are implementing and configuring, we
try to either fix the software ‑‑ this is the next slide ‑‑ or change
the process, or simply omit the feature. There have been scores of times
we have just haven\'t implemented software features that we did not
think we could create a safe workflow for. The largest example of that
is, when we started the inpatient project, the team started trying to
map safe work processes that involve the EHR and the pharmacy system and
concluded that we could not do it, and have replaced what is the
industry standard pharmacy system with the pharmacy system that
integrates with our EHR. And then of course training users and sometimes
just replacing the software as I said. And certainly tracking the
hundreds of flaws that we've found, either to their resolution or so
that we know what kinds of things to look for next.

And just quickly, one of the important things that we found about flaws
in our system is that they typically, that most of them go well beyond
CPOE or any other single system. We find lots of the flaws at the
interactions between, for instance, order entry and pharmacy and eMAR,
the Electronic Medical Administration Record. Similarly between our
inpatient and outpatient systems. It is characteristic for us to turn on
something in inpatient and find that it's blown up something in
outpatient. So our organization spends several thousand person hours a
year testing for this and other kinds of problems before we go live with
these. And then we still have what I think is, well, should be industry
standard practice, a 24 by 7 support team that identifies, fixes, and
distributes error corrections every time we go live. And how long that
center works just depends on how quickly we get rid of all the problems.
Finally back to human factors engineering. We are trying to learn how to
create processes that are validated as safe and effective before we
implement them into our clinics, using things like prospective risk
analysis and other human factors engineering tools. So I think I will
stop there and invite discussion.

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

Let me thank you very, very much for a terrific presentation and just
phenomenal work. Let me take the co‑chair\'s prerogative of the first
question. I think there are two things that are instructive to us in
terms of forming our thinking, what we might do through the Workgroup
and AHIC, Secretary, and they relate to creating the conditions for
moving forward electronic health records toward an end. Two things that
I think really stand out in your presentation are the role of leadership
and the role of incentives. In terms of leadership, you personally,
your CEO Glenn Steele, chief medical officer Bruce Hamory, Ron Paulus,
Frank Trembulak, you have an extraordinary team, and there is some sort
of environment that you as a team create. What can be learned from your
experience in terms of telegraphing leadership that might upscale to the
country and be useable and, second, that same sort of scaling of
incentives. How would that play out, do you see it similarly to what
Dr. Stead described a moment ago?

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

Right. As far as the leadership, Geisinger is a remarkable place. I\'ve
been there six years. It has a long-time history of being remarkably
collegial, and though not entirely free, obviously, remarkably free of
turf warfare. Many of the leaders that you named have been there a long
time. The organization is large enough to be able to contemplate this
kind of project, because the costs are, you know, just of the testing,
are enormous, but small enough and face-to-face enough that I think
people like Glenn and Ron and even Bruce and I, came because it\'s the
kind of organization that you can imagine being able to transform the
way healthcare is provided in a fairly general way. We have a large
region that we at least feel responsible for. If we don\'t provide a lot
of these services, nobody will. And HIT really develops its power when
you\'re trying to link geographically disparate people into a meaningful
system. I guess that\'s, in a way, was the first stage of our trying to
create, you know, virtual teams that could manage really high quality
processes without having to meet face-to-face all the time. So I think
it\'s a number of factors, perhaps many of which are fairly
unreproducible.

I think as far as incentives go, what I would say is that \-- exactly
what Bill said. I mean, you get what you pay for, and if we can, and
I\'m confident that we can, figure out how to pay for quality, then I
think it\'s a reasonable bet that\'s what we\'ll get. If we pay for HIT,
we\'ll probably just get a lot of arguments about the definition of HIT.

I think the other thing that I see as one of the themes that comes out
of this is that we need to find ways to enable organizations like ours,
and Bill\'s and others, to share what they\'ve developed. In our case,
at a cost basis, with other organizations. There's just so much of this
\-- I think you can get that sense from Bill\'s and my presentation \--
that\'s going to be beyond the capacity of most healthcare organizations
to create processes and EHRs that really are effective for improving
quality, decreasing cost, and maintaining safety, that somehow we have
to figure out ways like this VistA to share what\'s been developed and
to share it in ways that provide incentives to keep the systems current
and improving in terms of their capacity.

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

Okay. Well, let me ask if there are any other questions or comments for
Dr. Walker.

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

This is Karen Bell. Two things. One thing, a sidebar, I really would
like to introduce Andrea Delmotte who I know joined the call just a
little bit ago, so that everyone is aware she has joined us, and welcome
Andrea.

Secondly, I just wanted to ask you specifically whether, or the degree
to which, you think your learning is applicable to small hospitals,
small community hospitals, small rural hospitals, and what would be the
most important elements of your experience that could be generalized to
that particular environment?

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

Good question. Thank you. One of our three hospitals is a 80 or so bed
community hospital. And in our work building the regional health
information exchange, all of the hospitals that we\'re working with are
small, most on the order of 50 to 70 beds. So we have learned a lot
about the constraints that those hospitals work under, particularly when
it comes to HIT. We started with the health exchange saying to, you
know, offering to people to say, you know, well we\'ll work with you and
bring teams out to help you do these things and then build consensus and
go ahead and build the system out. And what they said to us is no, we
don\'t have enough time for that even if you provide the resource. You
need to build it and just let us vet it. And so there\'s \-- you know,
most of these places have three or four HIT staff and if one of them
goes on vacation, then they\'re just in emergency mode. Even when we
bring resources and services that they very much want to develop and
use, it\'s really no surprise at all when a month or two goes by that we
can\'t get any response from them to build things. So I think we really
need to be serious about how resource-limited these hospitals are. And,
you know, capital, but more particularly expert HIT people and then
particularly if you start talking about business analysis and workflow
redesign. We just, we have a really large problem that we\'re going to
have to find some way of sharing with them but at a low enough cost way
that it\'s workable. And I think that is, the things that we have
learned and are publishing in various venues about how to try to enable
small hospitals to achieve some of their HIT goals are generalizable.

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

Okay. Thank you very much. And thank you again very much for an
excellent presentation.

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

Thank you.

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

At this juncture in the afternoon, let me add my thanks to both the
first two presenters, and I think Dr. Karen Bell\'s question of
translation to other environments that they\'re not part of a system,
perhaps rural, perhaps with different economic means, will really be
addressed next presentation. For introduction of that ,and to take the
gavel for the rest of the call, let me turn to Lillee Gelinas.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Thank you, Jon. And the first two presentations were beautifully done.
For our Workgroup, for us to get centered on this work, let\'s remember
that we have the challenge of looking at the entire landscape to
understand issues and then be able to make appropriate recommendations.
As was just really well illustrated by Dr. Walker, there are many
organizations in the United States whose capacity to buy health IT right
now is \-- it\'s not there. There is not the capacity. One barrier, and
this is particularly for small or rural hospitals, is the cost of buying
systems.

So to address this particular barrier, we\'ve invited the Midland
Memorial story to this Workgroup. Midland Memorial Hospital is the only
not-for-profit hospital in Midland County, Texas. It was established,
opened its doors, in 1950, as a community-owned, 75-bed hospital. And
when you think about their history as well, they\'ve been a part of VHA
since 1986.

Margaret Robinson will be doing the presentation today. Margaret is vice
president for patient care services, she\'s a registered nurse and has
nursing as well as a number of other departments reporting to her. She
has been enormously gracious going across the VHA system, talking about
the Midland story, the good, the bad and the ugly. And how Midland used
the VA VistA system, to actually not only implement an IT system, but
two, the previous two presentations by Dr. Stead and Dr. Walker, their
goal was a financial challenge as well as a clinical quality challenge.
And I just would like to let you know, and I want you to be thinking
about the fact as you listen to Margaret, that for three years in a row
now, Midland Memorial has won the VHA leadership award for clinical
excellence. So as you listen to Margaret, I want you to think about
their history, steeped in history, and think about how difficult their
journey has been and how the implementation of VistA, known as
OpenVistA, which has morphed into EDITH, and she will tell you who EDITH
is, I think you\'ll find that this really is a success story we need to
take very seriously. I\'ve known Margaret for many years, she\'s been
enormously gracious in the nursing initiative and it\'s a privilege to
know her. So Margaret, I\'ll turn it over to you now. Welcome.

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

Thank you, Lillee. Can you verify you can hear me?

**[\>\> Lillee Smith Gelinas:]{.underline}**

Yes.

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

Great, thank you. And I also have David Whiles in the room with me.
He\'s director of information technology. As Lillee said in her opening
comments, which were most gracious, I am a registered nurse by
background, and I will readily admit that I am
information-technology-challenged, and so many of you may have questions
that I wouldn\'t even know how to respond. But I certainly can tell our
story from the standpoint of clinical implementation and the impact that
it has on the clinical world. Again, as Lillee mentioned, I have
responsibility for nursing, but at this point in my career, all of the
clinical departments, so I\'ve had to look at pharmacy, cardiopulmonary,
radiology, and other areas as well. We are a 320-bed community hospital,
and we wound up we believe successfully modifying the VA hospital\'s
information system for use in the private sector. There is a component
of this that is free, but it is not without a cost, as many of the other
presenters have spoken to. But the software itself is available under
the Freedom of Information Act and then we\'ve used consulting services
to assist in actually implementing it. And I must credit David Whiles
with actually identifying this opportunity for us as we face some of our
challenges. The VA software has been implemented not only in, throughout
the United States, but it has been adopted internationally by hospitals
in Finland and in the Mexican federal health system as well.

We wouldn\'t consider ourselves rural, but comparatively I suspect we
are. We are 250 miles between Dallas and El Paso, and so midpoint
between those two major population bases. We have many community
hospitals around us that are much more similar to what Dr. Walker
described as 30 to 50-bed institutions, but we do serve as a referral
for many of those facilities. We are licensed for 320 beds and we are on
2 physical sites. The main campus is a full-service acute care facility,
and our west campus offers women\'s and children\'s services. We have a
medical staff of about 200, probably what is unique in our community is
that we have very little managed care. We do have some preferred
provider options, and the majority of our physicians are in independent
practice, or in very small groups of two or three physicians. We do have
a major outpatient imaging facility. Our average daily census is about
150. Inpatient admissions range around 11,000, and our ER visits are
about 50,000-plus a year and we probably see more growth in our ER
visits as we have a shortage of primary care physicians in the community
and more and more patients access as primary care through the emergency
department.

Our IT story actually begins with not a particularly pretty picture,
that in November of 2002, we had lost 6.3 million dollars. That actually
was our third consecutive year of financial losses from operation. We
had 24 million dollars cash on hand, that\'s approximately 60 days. And
we had major computer systems, including pharmacy, lab, and our overall
HIS system that were sunsetting in the near future. We had massive
capital needs, not only in looking at a new medical office building and
bringing up some technology, but we had, we are still working on how to
look at a replacement program for our facility as the core of the
building was built in the \'50s and \'60s and needs replacing. And we
also had a new CEO who came on board at that time.

The IT strategy was to head off the coming crisis, to try to manage with
very limited capital funding. We initially had McKesson present \-- do
an assessment, an enterprise assessment of what it would cost us to
replace our system. And that comprehensive analysis suggested that it
would be a minimum of 20 million dollars. And to be absolutely honest,
we couldn\'t afford it. There was no way that we could take that dollar
amount and divide it amongst our competing capital needs and remain in
operation. And so David Whiles, our information director of technology
began \-- specialist, began to look at what other options might be out
there.

One of those that he identified was the VistA system. It is a
comprehensive electronic health record. It was first developed in the
mid-1970s. It\'s currently used in 172 VA hospitals, and has extensive
outpatient clinic application in over 850 clinics. It is continuously
updated through the Veterans\' Administration, and its open source code
was available under the Freedom of Information Act.

Now, it is not a panacea. It was clearly developed to meet the
Veterans\' Administration needs. So some of the areas that we have found
to be shortcomings in a community hospital include the emergency
services, particularly trauma; obstetrics; nursery and pediatrics;
surgery; and flow sheet technology.

We\'ve partnered with an organization called Medsphere, which is a small
consulting firm founded in, in Southern California, founded by two
physicians, who actually were struck as they went through their medical
training in Southern California that the community hospitals had a
rather sparse patient record, electronic record, and when they did their
clinical rotations at the Veterans hospital, how much more robust that
experience was. Since then, their team, they have added Ken Kizer, as
\-- and have many Veterans\' Administration IT staff who have joined
them.

Our process begins when David goes to the WorldVistA conference in June
and tries to identify more information about it, and he then brought
back conceptually this idea to the executive staff. We then went out in
the fall of \'03 to make site visits. Initially at our local VA
hospital, and I must admit with the wide geographic dispersion, it\'s
fairly easy and inexpensive to get a group onsite to get some basic
ideas. And then we looked to select another VA in Texas that had bigger
application than our local VA facility. We had a hands-on demonstration
of the VA with the Medsphere staff participating in that. And then we
also went through an enterprise assessment that included not only
Medsphere as our consulting agency, but also Deloitte Consulting. And
one of the things we were particularly concerned about as an executive
team at that time was we\'re doing something else no one else has done.
What \-- were we prepared, what would be our exit strategies if we found
out this didn\'t work? And that we could predefine those so that we
would not invest a significant amount of our time and money if we did
not think we could be successful.

The next slide you see the VistA project budget, and with no cost for
the software license, the consulting was our most significant expense.
And then you look at other hardware. We had to put in a complete
wireless infrastructure in both buildings, as we did not have any of
that. And then other interfaces. And you see that our original
conversion looked at 7 million dollars. Now, as an executive staff,
then, we were comparing that to the 20 million dollars McKesson brought
forward. And we in essence said seven million dollars over three years,
that's two, two and a half million dollars a year, that is something
that we can manage within our financial limitation. And we proceeded to
embark on the project. I have no doubt we\'ve spent more than seven
million dollars. And I think one of my advices would be that once you
embark on this the technology becomes embraced and you find more and
more applications and needs that you don\'t really appreciate when you
first go out on the project.

We proceeded in November of \'04 to get project approval and worked in
the early part of \'05 for infrastructure and development. And then we
began our software modification and training. And this is listed as
current because I believe that our system is really a dynamic system,
and we are constantly looking at how to improve it and to maximize the
application for the clinicians, whether that be physicians or nursing
staff or others. By some of the descriptors, I suspect we\'ve been quite
aggressive, but we did go live initially with our pharmacy system in
October of \'05, the laboratory order entry in November of \'05, and
then we went housewide on order entry in December of 05.

We do call our system EDITH. We have a naming contest with our employees
and it stands for Electronic Data and Information Technology for
Healthcare. And we do enjoy the fact that EDITH has a name and we
believe she has a personality as well. And we have another acronym we
use, which is NED, and NED is Non-EDITH Documents, and this is basically
paperwork that we\'re required to scan into the EDITH system in order to
have a complete medical record. So EDITH and NED run our lives at the
moment.

We began our first go-live with the computerized patient record in
December of \'05. That was on an orthopedic unit, and we had them up for
about 60 days before we progressed beyond that. And we completed the
implementation first at the main campus and then moved to the west
campus. Because it\'s a different building, serves a different patient
population, and has different support systems, we really needed to treat
that as almost a secondary site go-live, because there\'s elements that
can be transferable and other components that are completely unique to
that building. In September of \'06, we began bar code medication
administration, and on February \'07, we declared ourselves paper-light,
which means we have some remnants of paper that still exist, but the
overall goal is that everything that needs to be accessed by any member
of the clinical team should be in the electronic form, whether it\'s
entered in the electronic form or scanned into the document.

So with our current status, we do have our computerized patient record
implementation complete, we have BCMA complete on both campuses, and we
have computerized physician order entry available. We have the majority
of physicians complying and that probably is still our biggest
challenge, and I\'ll talk about that a little bit later. We have many
systems improvements that are still on go, including remote access from
physicians offices, pathology interface, for pathology report, and then
trying to streamline the nursing documentation system, and particularly
a flowchart approach. And then focusing on physician adoption.

I think as one looks at planning for implementation, it\'s important to
take a long view, and as the other presenters have alluded to, really
consider what your goals are and then step back from those goals and
look at component parts for implementation. It was a learning for us to
realize that IT, nursing, and physicians look at the chart or the
computerized patient record differently. I think that even between
physicians and nurses, we rapidly began to appreciate that there are
components of the medical record that physicians are in all the time,
and others that nurses are in all the time. And they\'re gleaning
different elements out of that. So when you\'re trying to look at an
electronic solution, you have to consider all of those stakeholders.
Development of protocols and standing orders, I don\'t think we did
enough of the physician-specific standing orders prior to our go-live.
That still is an area that we find new needs on a regular basis for
putting in order sets that are specific for physicians. And clearly the
better you can define system before you go live, then the better the
training can be during that process.

From an equipment and space perspective, we tended to underestimate our
computer and scanner needs. Electrical supply and storage for computers,
that\'s probably as we look at building a new patient tower in the next
three to five years, one of the biggest things we\'ll be looking at is
making sure that we have adequate electrical supply outlets and
appropriate storage cubbies for computers so they\'re not cluttering the
hallways. There\'s increased need for the counter space in the nursing
stations because computers take up more space than the chart did. And
then computer training rooms.

We did a fair amount on computer training, but I think we clearly had
learnings on that as well. Identifying in advance what the computer
knowledge of the staff is prior to going into any electronic medical
record is important. And what we found is if we asked the staff if they
knew how to use the Internet, they tended to say yes, but that meant
that they could retrieve their boarding pass or order from the catalog
online. And those that really \-- that really wasn\'t the same skill set
that was needed for managing an electronic medical record. But if they
had any knowledge of any software program, whether it be Office, Excel,
PowerPoint, they were better able to make that conversion to the
computerized medical record. In our first round of training on the
medical record, we actually did initial two-hour training and then
intended to do more on-the-job training, and I \-- a lot of the clinical
staff felt that they really didn\'t \-- they needed to perform and
didn\'t have all the tools with them. When we went live on bar code
medication administration, we did eight hours of training before we
turned that system on with each of the nursing staff, and they felt much
more comfortable with the expectations that were put forward to them.
Although, remember they also had had almost six months to a year on
computerized patient records, so they were more familiar with the whole
computer process at that point. And we have required that they complete
our formal computer training before we give them access to the system.
That was a safety feature that was important to us. So we don\'t allow
supervisors to give them access if they haven\'t gone through the
training.

On their computer training, matching the training sessions to the skill
levels of the participants, those that clearly knew how to navigate
sometimes felt that they were being slowed down by those that were still
trying to figure out how a mouse worked. We set as a goal that 80
percent of the staff had to complete training before we went go-live in
any particular area. We had numerous unanticipated training needs. We
have 200 LVNs and RN students who come through our facility in a
12-month period of time and we really hadn\'t adequately pre-thought how
we were going to bring them up to speed to function in our facility. In
addition, there are case managers, quality management staff, agency
staff that also needed training in order to retrieve information out of
the medical record. And we\'ve had a lot of success matching trainers to
the skill level of the participant. So we have trainers that are nurses,
unit coordinators, respiratory therapists, pharmacists, physical
therapists, and they all contributed to the training.

The information technology staff included a project manager and she has
both nursing and IT background. We have clinical analysts that, actually
they\'re now part of the IT staff, but all of them came from clinical
positions in the institution, whether that be registered nurse, pharmacy
tech, respiratory therapist. And we had super-users at the unit level.

Physician adoption is clearly I think an important part of a
computerized patient record, and there\'s many institutions that have
failed in their efforts because of resistance from physicians. Early on
in the process we established the physician advisory commission for the
electronic record. We had early adopters or champions who built their
order sets and would go live on the system and were fully committed to
making it happen. We do one-on-one custom training and development with
physicians, both at our institution and the IT staff have also gone to
their homes and offices to set up remote access. I think that\'s
probably been one of the most positive pieces from the physician
perspective, is that they can from their office or home get access to
the complete patient record if they get a call or a concern. The
electronic signature is also a positive for them. It avoids trips to
medical records and medical record deficiencies, so they\'re happy with
that. Overall their adoption has probably been slower than we would
like. We were talking about this in the last few weeks, that we got
through probably 40 to 60 percent of the physicians in the initial
period and we have plateaued and we\'re going to have to go back and
kind of reenergize our efforts with those physicians that still have
figured out ways to not get engaged in the process. The time commitment
for both learning and customization is daunting. There\'s a lot of
activity that\'s involved on both the IT staff and the clinical staff to
do that. We did come up with a professional service agreement to pay
physicians for the time that they needed to spend to train and/or
develop and be part of the electronic record. And I think that helped
with our \-- those that were early converters. And basically it was a
thousand dollars that we would pay them and that was viewed as 250
dollars an hour, four hours of training, for them to become familiar
with the health record and for any time that they might spend. And it
was capped at that dollar amount. But in order for them to actually be
\-- receive that reimbursement, they had to demonstrate that 40 percent
of their orders were being entered by them and they had to do, 100
percent of their transcription had to be electronically signed. So I
think that that helped, requiring that they meet some goals, and we
certainly have had physicians whose have chosen to \-- or probably have
become earlier adopters because they knew they were being compensated
for their time spent in training.

Some of our lessons learned. Physician buy-in is hard. Remote access was
vital for us. There is that natural resistance to change, a significant
time commitment. One-on-one attention with the physicians, particularly,
I think became important. We wound up deploying the clinical analyst to
be out on the floors at the time the physicians were making rounds and
our goal initially was first day, one patient, second day, two patients,
and see if we could progress them through. And you must have
enthusiastic and unwavering support from leaders in order to make this
happen. It\'s important not to skimp on hardware. And facility changes
are also a big issue. More computers mean bigger nursing stations, and
space requirements.

Conversion is challenging for staff at all levels. Again, there is this
natural resistance to change. The older staff may not be as
computer-friendly, although I don\'t wish to stereotype because there
are some older staff who have very savvy about it. It does create
difference in work routines and that is something that everyone winds up
having to adjust to. An example in the nursing world was that the
admission assessment, it takes them almost twice as long to complete it
because they have to go through the screens and they perceive it as
being slower. But we also found that probably the nurses were skipping
some of the screens, and now that it\'s all mandatory, that we\'re
getting a more complete medical record than we had before. And it is
forcing us to look at what really matters. A hybrid environment
exacerbated the situation and what I mean by hybrid here was that when
we had part of it on paper and part of it electronic it was very
confusing, because those physicians that were using the electronic
record exclusively had no idea when a consultant came in and hand-wrote
a consulting note or dictated a consulting note that was on the paper
chart. And that ultimately, we felt we had more safety concerns with
that hybrid electronic-paper record, and that forced us more quickly to
move to everything must be in the electronic record and if it is
written, it must be scanned so those that are using the electronic
record completely would have access to it. I think it\'s a natural human
tendency to blame the system for everything that\'s gone wrong over the
last two or three years. So EDITH did it at our institution.

Some of our outcomes that are truly measurable, the chart is available
to all clinicians, and that is just wonderful. Case managers, quality
management, respiratory therapy, physicians, nurses, can all be on the
chart simultaneously. The only feature that is locked out is order entry
can only be performed by one physician at a time. Legibility of
physician order entry, you know, it\'s one of those things when you\'re
in the paper world you just accept the fact that legibility is an issue
and it occurs to us now that we don\'t even talk about that anymore.
Remote access for electronic signature and review has been a real
positive outcome for us. And I think generally we\'re improving our
documentation because we really have mechanisms by which to mandate that
those fields be completed.

Some final thoughts on why we did it. We were really driven because our
systems were expiring and we had to do something. Our financial
condition was limited, and VistA really presented an option that allowed
us to replace those core systems but also to begin to look at truly a
patient record that would allow us to look at safety issues and quality
issues. And those were extremely important. I think one of the most
important early discussions we had particularly around bar code
medication administration was were we going to build a system for
efficiency or were we going to build a system for patient safety? And we
fundamentally said that we would look at designing this system with
patient safety in mind. And sometimes that means that the efficiency is
not always there. We are tying our physicians to our information system
and while we are the sole provider in the community and we don\'t have
competition per se, I certainly could see in a community that had
multiple facilities that physician linkage to our system would be an
advantage to our institution because the access of data is just so much
more easy to identify. And finally, we really wanted to make a
meaningful contribution to the healthcare industry, and we believed by
implementing this system we could potentially provide an opportunity for
other facilities, particularly those that might be small health systems
or free-standing facilities that were 300 beds or less, because we, that
is the market that we think this product uniquely fits in, because we
don\'t have the capital resources or the larger information technology
staff to manage bigger systems. And with that I\'ll open it to questions
that either David or I will try to answer.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Thank you so much. We really appreciate your presentation today. I
failed at the beginning to make it clear that another challenge for us
in the EHR Workgroup area is in the private sector, where for the most
part the physicians in community-based hospitals are not part of a
closed system such as in VistA, or in the Veterans\' Administration, or
in Kaiser Permanente, for instance. So hearing at least the success of
Midland Memorial in implementing VistA in the private sector at least
gives us a guidepost to follow.

And David, is it true you just down loaded the VistA software off the VA
Website and it was that easy?

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

Almost. I actually had somebody give me a CD, so it didn\'t take four
days to download.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Wow. But it was very easy from your standpoint?

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

Once I got into it, yes, it was reasonably easy to get it to the point I
could get into the system. Once I got into the system I quickly
discovered I didn\'t know anything about it. So it\'s easy to install on
your PC, moderately easy to actually bring the system up, and beyond
that it\'s a three- or four-year learning experience.

**[\>\> Lillee Smith Gelinas:]{.underline}**

But would you say that it is not unlike the IT implementation of other
organizations, what you\'ve described here seems very typical, and one
of the reasons I wanted Margaret to go through what she did, it just
seems like a typical implementation path and there was nothing out of
the ordinary or, you know, just crazy about implementing VistA.

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

No, not at all. I think the most difficult part, you know, or unique
part, really, and it\'s really not that unique, was the fact that we
retained our legacy registration, front-end ADT registration system and
our back-end billing system because both of those components were,
particularly the billing side, was somewhat lacking in terms of the
VistA functionality. So, you know, a big challenge on the front-end
during the first few months was having Medsphere develop, design, and
implement all of the interfaces required for interfacing that front-end
registration so that it would create the patient visit record in VistA
at the, at that time, and then developing and identifying those
chargeable trigger points and then having them do the programming for
interfacing the chargeable events back to our patient accounting system.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Got it.

What questions from the Workgroup do we have?

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

This is Howard. I have two questions. One is what is the level of
interest you\'re hearing from other hospitals, and the other way to
phrase that question is how come you\'re the only ones if this is so
good and easy? My second question is are you going to be implementing
the Indian Health Service software for like pediatrics and other things
that you didn\'t find in the VA system?

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

I think I can address that. We were the first, but I\'m glad to say
we\'re no longer the only, hospitals in the U.S. There\'s several other
organizations that either have already gone live or are in the process
of implementing VistA. I just noticed an article the other day that a
company by the name of Blue Cliff, Incorporated out of Hawaii has landed
two contracts to install inpatient systems in the United States. So \--

**[\>\> Lillee Smith Gelinas:]{.underline}**

But would you say to his point, he asked you for the level of interest.
Do you get calls or people inquiring?

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

We get \-- it kind of comes in spurts. I have gotten a number of calls
from other institutions, many of them just cold calls, some of them
directed to me by Medsphere. But I\'ve probably had a total of, I would
guess at least 20-plus calls from other institutions throughout the
United States over the course of the last couple of years that are
interested in what we\'re doing, and some of them very keenly
interested.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Howard, I would also answer that I\'ve only been with Margaret on a
couple of these, she\'s done a lot more. But I would say, and Margaret
keep me honest here, okay, 100 percent of the time, and we also play the
VistA video at the same time when she\'s presenting, there\'s no one in
the room that knew this existed. There is a huge knowledge gap in the
private sector about this capability.

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

Lillee, I would agree with you, and particularly on the clinical side.
You know, even if I had been aware of it, it\'s not the kind of thing I
would know how to go about doing without IT support. So I think that it
needs to be better known across the country and both on the information
technology side and on the clinical side. But I haven\'t \-- the
clinicians that I\'ve either demonstrated the program to or made
presentations, have all found the, the functionality of VistA to, in
general, at least meet their minimum expectations. And my personal
belief is every software system is going to have its strengths and
weaknesses. And you just acknowledge that. And it\'s, you know, some
other proprietary system might have a workflow system that works better,
but for us, we have something and if I had to wait until we could afford
a proprietary system, we\'d still have nothing. And that\'s just
functionally how I look at it. But I think it\'s not well-known across
the country that it\'s available outside the VA system or that it would
have application.

The other two comments I would make, because the earlier speaker spoke
about user groups and that. And there is a national meeting annually for
the Veterans\' Administration system, the VistA system. And they invite
participants from non-VA hospitals to attend. And I think as they
continue to make that known and available, that will provide an
opportunity for greater knowledge about the system and its
functionality. And if functions, it works very much like a users group
would nationally.

And then the other is that even though the system is brought up in all
these VAs it is customized to the patient population that is served in
each of those facilities. And so there are hundreds of institutions that
you can network with that will provide you insight into how they
addressed specific issues. And we have found the VA staff most obliging
in site visits or telephone calls to say how are you handling this kind
of issue. So while we are a small group that has done it in the private
sector, I feel like we have a wealth of information available to us via
the VA hospitals. And we found the management structure there very
supportive of wanting to share their story.

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

Lillee, this is Karen Bell. I\'m very impressed with the success stories
that we\'ve heard today. I know that there are a few other, particularly
our new members on the group, that also have very successful systems and
what I\'d like to do if we have a few moments is to ask the three
presenters and perhaps some of our new Workgroup members that come from
large successful systems too, or even small systems, what the biggest
challenge was to moving forward. Was it workforce, was it physicians,
was it the technology? What was the one biggest area that required most
of the thought and the biggest barrier to overcome?

**[\>\> Lillee Smith Gelinas:]{.underline}**

Great question. Dr. Stead, are you with us?

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

Might have to go back and catch him later.

**[\>\> Lillee Smith Gelinas;]{.underline}**

Dr. Walker.

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

Yeah, I\'m here.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Number one. And brief.

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

Yeah. I think probably organization buy-in. Physicians are clearly a key
part of that. But getting all of the organization, giving lots of people
a genuine opportunity to decide where we wanted to go, what kind of
thing we needed, what kind of tool we needed, and then having lots of
those people involved in the selection of the tools, is probably the
thing that required the most energy and would be the hardest for any
organization to do.

**[\>\> Lillee Smith Gelinas:]{.underline}**

And Dr. Walker, since you had mentioned VistA, did the VistA Midland
presentation answer the questions that you had, or just your general
thinking about availability?

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

Well, I had a \-- I wasn't going to bring this up, but since you asked
\-- we looked at VistA as a method of providing something to
non-Geisinger physicians in our region. And the conclusion of our
technical people was that we couldn\'t afford to maintain the back-end.
And I heard that, then that Intermountain Health had come to the same
conclusion. This would have been 2006, they probably looked at it in
2004. So I guess I\'m interested, you haven\'t found it difficult to
maintain the back-end of it?

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

Well, I guess you could take that from two perspectives, one would be
software and the other would be hardware. Hardware, no, we\'ve not found
any problem whatsoever. As to the software, that\'s one of the reasons
that we still engage Medsphere for our support services, is that one of
their contractual tasks is to take all of the patches that are released
on a regular basis by the VA and keep us up-to-date and current and in
synch with the VA release. So we\'ve basically farmed that out to a
third party. So I can\'t really address the scope or difficulty of
maintaining that patch release. I know it\'s not a trivial process.

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

But it sounds like the cost must be acceptable to you?

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

Oh, yes. Yeah. That\'s part of the support contract.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Karen, you may better know the new Workgroup members who have systems.
If you\'d like to call on them for their opinion.

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

Well, hopefully it won\'t put them on the spot, but I certainly know
that Cleveland Clinic and the Mayo, University of Pittsburgh have done a
lot in this area, and at least give them the opportunity to answer that
question as well, if you\'d like. But don\'t feel that we\'re putting
you on the spot.

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

I\'d like to comment, it\'s Bonnie from the University of Pittsburgh. I
agree with physician buy-in. It is so, so very important. And we have
struggled with some physicians who were not early adopters. And we, too,
went with the one-to-one \-- we have rounders out on the unit so if they
get stuck putting a order in, they can call us, we go right up to them
and help them. But several speakers brought up a really interesting
point and I think it\'s very important and that is executive leadership.
I think it was Jim said it was sophisticated and passionate. And
Margaret said it was enthusiasm and enthusiastic support from leaders.
And I really found that was so very important. And it\'s just not at the
beginning. It\'s continuous. So when you have some issues,
administration comes in and supports you. And they\'re very visible and
I just wanted to make that point because I thought it was interesting
that the speakers mentioned that and we also found that very important.

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

Thank you, Bonnie. Peter, or Robert, any comment at this point?

**[\>\> Lillee Smith Gelinas:]{.underline}**

Margaret and Jim, how about you, the biggest challenge?

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

This is Margaret. I think the biggest challenge was really looking at
all our processes and trying to imagine what they\'re like in an
electronic system while we\'re still in the paper system. You know, you
really approach your work differently, and that was the piece that we
continue to spend time on, really, is how can we improve it even more.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Even to the point where you had to name the non-electronic system as
NED, so you have EDITH and NED.

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

That\'s right. And then the hybrid. When we had a paper chart and the
docs had the option, or the nurses were charting electronically but then
the docs that didn\'t want to use the electronic record, we were having
to print the nursing documentation. And that was creating busy work for
everybody, and so it forced us to say we\'re going to officially have an
electronic record.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Any comments from Peter or Robert? Okay.

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

I\'ll just make one comment \-- this is Dr. Smith, Robert Smith \--
which is that I just can\'t emphasize enough the ways in which
electronic health records have an impact on an organization and really
focus you on your clinical care delivery processes. It\'s not the
technology, as Dr. Stead was saying before, it\'s how the technology
supports the clinical processes. But one of the things that we\'ve
learned and I think all of the sites that have learned that have brought
electronic health records up and have them running, is how disparate
many of the processes are in an institution and by implementing
electronic solutions and automation, you\'re kind of forced to revisit
all of those things that you thought were moving smoothly and
consistently and kind of bring them into a common framework. And it ends
up being a more interesting and process-driven approach than you might
anticipate.

**[\>\> Lillee Smith Gelinas:]{.underline}**

One final question and we need to move on with the agenda because we\'re
under tremendous time constraint here.

Did Midland Memorial, were you able to track any clinical quality
improvements specifically pre-EDITH and post-EDITH?

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

We have not \-- indirectly we have, through our Joint Commission
periodic performance review, you know, where we\'ve been looking at our
compliance on Joint Commission standards. And we clearly can tell on
some of those elements such as PRN effectiveness and that, that our
documentation is better in the electronic system, because we\'ve set up
templates to prompt what information needs to be provided. So that has
clearly assisted. We also have worked on building physician order sets
that incorporate evidence-based practice and I think that helps in
compliance with the bundling guidelines, if you will, for the variety of
diagnoses and/or treatment. So I don\'t have anything, Lillee, that I
could quantify that says we saw this percentage improvement. We haven\'t
looked at it that way. But I know that we have seen improvements in our
documentation overall.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Just curious to me, you've begin to win VHA leadership awards and
previously you hadn\'t.

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

Yeah, absolutely right. And in addition to the VHA, we\'ve also received
awards from, from the American Heart Association for the Get With the
Guidelines for heart and stroke, for MI and storke, and so, you know, I
think clearly we have a more focused effort on quality indicators and
how to improve those measures.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay. Well, I want to thank all of the presenters, and for all of you
that have implemented systems, I think your advice and counsel is
extremely important to us going forward. As always, we learn so much
from all of and you from our collective conversations, and please don\'t
let, Dr. Stead, Dr. Walker, the Midland story, let this be a one point,
a one presentation wonder type of scenario, as you understand what the
Workgroup is trying to consider, please feel free to advise us after
this call you may think of something that was relevant to our discussion
that is didn\'t get brought up. And we would be very interested in your
continuing guidance because your learnings are very much informing what
our work is. So thank you very much.

I\'m going to turn now to Karen Bell and Judy Sparrow and ask you for
some guidance on the agenda here. We always end on time for those of you
that are new to the Workgroup, you\'re not going to have to worry about
that if you're looking at the agenda. But we do need some agenda
management and recommendations from staff on how to work through the
most pressing issues in order for us to get to 3:50 Eastern Standard
Time for public input.

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

Thank you very much, Lillee. We\'re going to have to do one thing, and
that is have a brief presentation on the use case scenario because that
will be presented at the AHIC on the 31st. However, I would like to just
make sure that everyone is aware of the fact that we did not have a
quorum for the August 14th meeting of the EHR Workgroup. So there will
be no August 14th meeting. However, throughout the month of August, we
at ONC will be very busy, because as you may recall and everyone on the
Workgroup may recall, the Workgroup had tendered a recommendation to the
AHIC that had to do with tying reimbursement changes to the use and
process change associated with certified EHRs.

What we would like to suggest, and this is an item for you, Lillee, to
discuss with the Workgroup and then perhaps get consensus on or a vote
on, rather than have a town hall in the middle of August with many
others coming to state their thoughts, perhaps it would be more
effective and more efficient for us to put the recommendation in the
Federal Register and elicit public comment that way, assuring that there
is wide public knowledge that that is out there, so that we can then
pull that information together and bring it to the September Workgroup
meeting. So I would just suggest given the timeframe and given the fact
that so many people are away in the middle of August, that this might be
the most effective and efficient way of collecting public input on the
proposed recommendation 4.0 that was made by the Workgroup earlier.

**[\>\> Lillee Smith Gelinas:]{.underline}**

And you know, for the new Workgroup members they might not be familiar
with 4.0, or what the task at hand is.

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

That\'s correct. And we sent out to everyone a little bit earlier that
recommendation itself, and I\'m sure you\'ve got it right in front of
you. Alicia, I have it right here. It\'s, perhaps you could put it up on
the screen for everyone, HHS should develop a schedule for implementing
differential reimbursement to Medicare physicians for use and non-use of
EHRs, in this case it would be certified. While we would defer to
Departmental expertise, we note that this might be achieved by paying
full Medicare rates and market-basket updates, and possibly an EHR
premium, to physicians using EHRs, or hospitals if we\'re referring to
the market-based updates, while physicians using paper-based records are
reimbursed at discounted rates achieved by non-qualification for full
updates or other measures. So that was the recommendation made to the
American Health Information Community in April, on April 24th, and again
we were advised to get a lot more public input on this sort of a
recommendation before we went back to the Community with any changes or
updates to it.

So the question that I would pose to you all is the degree \-- whether
or not you would be comfortable with getting public input through the
Federal Register process and wide dissemination of input, as opposed to
having a town hall conducted. Any comments from \--

**[\>\> Lillee Smith Gelinas:]{.underline}**

What\'s the silence about? Well, Jon, I\'m sure you may have an opinion.

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

Well, I was just reflecting. I\'m sorry we haven\'t provoked more
conversation. I think our speakers have been terrific and frankly
provocative but I do think there\'s a nexus between what Karen just
offered and what we heard very clearly from all three of our presenters.
My own experience in VA would tell me that leadership is important, as
are incentives. And I think this last discussion would suggest that here
we have an example of a potential structuring of incentives that I for
one see as a facilitating condition. I think that in the transparency
agenda, as has been expressed thus far, in addition to encouraging the
direct adoption of health IT, there is a structure that requires
measurement. I know that partners in this endeavor, National Quality
Forum specifically, are working toward structural measures, consistent
standards for reporting of quality are being developed by our quality,
on the Quality measurement Workgroup of AHIC. And so in that, I mean, I
think there is a terrific juxtaposition of the recommendations, the
enabling conditions, context, that three extraordinarily successful and
extraordinarily different environments found as keys toward achieving a
transformation to an electronic world.

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

This is Linda Fischetti from VHA. I\'m going to reserve comment on the
content at this moment. Thank you for that compelling statement, Jon. I
haven\'t read the associated notes of the discussion of the meetings.
What I would like to do, though, is make a comment on process. And I
think Karen, in fact, it\'s an excellent idea to use whatever forum we
have available to us to be able to seek public comment during this
period of time. So I would like to support the process that you
recommend.

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

Thank you, Linda. Any other comments on that?

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

It\'s Bonnie from University of Pittsburgh. I, too, would support the
process. Because if the Federal Register would give you the opportunity
to get public input during the, August, I fully would support it.

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

Thank you.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Karen, do you think that \-- you know, I don\'t know because I don\'t
work in the government, but does the Federal Register process produce
sufficient comments and sufficient field input to truly inform wise
decisions?

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

It does if we \-- I believe that it does if we cast a wide enough net
and assure that there is enough public information sharing that it is in
the Federal Register and how to reach it. So we would very clearly reach
out to multiple organizations and bring it to their attention.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay, I\'m struck with the hope that everyone is still on call, to have
that much silence.

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

Karen, this is Mike Kappel. I\'d have to agree with Lillee on the point
that for private industry itself, I think as long as there is adequate
way to publicize the existence of the Federal Register, the existence of
that would be helpful. And of course both through the Workgroup, we do
have a fair number of professional associations, but if we could also
make sure that at the next Community meeting that it was announced that
this was part of the process, and that if there was any mechanism to
alert the, for lack of anything better, the trade press, that this was
going to be published and that comments were welcome, I think I would
feel better about it. But there\'s an awful lot of country on the other
side of Washington that doesn\'t pay a lot of attention to the Federal
Register, whether they should or shouldn\'t.

**[\>\> Lillee Smith Gelinas:]{.underline}**

That was truly my only fear, is to what degree outside the government
will we \-- and that\'s the sector we truly need to make sure is really
aware that this process is going on. So it\'s more a marketing process
issue, I think, rather than an input process issue.

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

Again, perhaps announcing it at the next Community meeting at the end of
this month would at least alert the industry press that it was out there
and then everyone who participates or pays attention to the Community
would at least be aware of it.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Could we do, that Karen?

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

We will be doing that.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay, good.

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

I think that\'s the issue. We have not done the process yet because we
wanted to bring it to the Workgroup and have everyone weigh in. But
clearly the points you are making are absolutely necessary to make this
successful. And one of the things we do do, when we elicit public
comment in this way, we track where we get the public comment, as well
as what it is. So if in fact it appears that we have not had broad input
or significant amount of input, then we will know that it may not be the
\-- we may need to do something else.

**[\>\> Lillee Smith Gelinas:]{.underline}**

I think I\'ve heard consensus here, haven\'t you, Jon?

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

I agree.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Yeah. So I think we have a plan, Karen.

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

Okay, then we will move forward with that in August and bring that back
to the Workgroup meeting in September.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay, great.

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

And then lastly, before we turn this over to the use case folks, I did
want to thank those of you who did provide input on the priority areas
for clinical decision support or its new name, knowledge management. And
if anyone else on the call who has not provided, from the Workgroup who
has not provided any input, please feel free to do so. There\'s still
time. And again, as we move forward with thinking about how best to
support knowledge management and clinical decision support, in reference
to the work that was done by AMIA earlier on and is on their Website in
terms of the clinical decision support road map, the two questions that
we are asking to you consider are if we were to fund any projects in the
area of clinical decision support, what might they be. And secondly,
what would be the measurable goals of clinical decision support? So
again, please feel \-- anyone who did not respond, please feel free to
do so.

And with that, we will \-- we have, I think we have enough time left for
use case discussion and we will also at the next meeting move forward
with some of the focus areas and perhaps we\'ll do some of that work
offline with you, Jon and Lillee.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay.

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

Okay?

**[\>\> Lillee Smith Gelinas:]{.underline}**

Uh-huh.

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

Thank you. And I know that we\'re again running little short on time, so
Alicia, I think I\'ll turn this to you. I know you\'re there in
Washington, and I think Ken Gebhart is there to present the use case?

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

He\'s here, and anxious to get started.

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

Okay.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Let\'s go.

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

How much time would you like me to spend on this? I realize you\'re
under a lot of time pressure.

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

We need at least five minutes for public input.

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

So \--

**[\>\> Lillle Smith Gelinas:]{.underline}**

You've got 15 minutes.

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

Thank you. I just wanted to make sure I didn\'t overrun your
opportunity. Thank you very much for the opportunity to talk with you.
What I\'d like to do is briefly update you on our use case development
activities that are under way, and also call your attention to an e-mail
that you received from Judy Sparrow on Monday, that asked for your help
to provide some input about the use cases that are currently in
development. We will be taking the feedback from all the Workgroups and
the AHIC members, synthesizing that and providing it as a discussion
item during the July 31st AHIC meeting. So I just wanted to call your
attention to that.

So first let me go to this AHIC priorities and use case roadmap slide,
briefly, this slide, if you\'re looking at the webcast, I'm sorry it\'s
difficult to read so I\'ve got to point out a couple things that are on
the slide. This was introduced by Dr. Loonsk in the last AHIC meeting so
in that context it\'s familiar. On the left in the blue boxes are use
cases that we\'ve already developed and published. You may remember that
in the January AHIC meeting this year, we asked AHIC to prioritize a set
of use cases, we brought a number of them to the group, and the result
of that was that we prioritized and have now completed consumer access
to clinical information, medication management, and quality use cases.
Those were published in June. In December, last year, we also published
the emergency responder EHR use case, so in terms of the activities that
are feeding the national agenda for standardization, certification,
NHIN, and policy development, et cetera, those are all in flight and in
their various areas to begin subsequent activities.

In the January meeting we also introduced the use cases that is are in
the center of this diagram, remote monitoring, remote consultation,
referrals and transfer of care, personalized healthcare, public health
case reporting, and response management. Although these were not
prioritized for immediate development in the January discussion, the
Secretary and the AHIC asked to us lean forward and get these done this
year so that they would be ready to go as the national agenda activities
are ready to take them. We actually have use case development under way
in these and I\'ll talk more about that in a moment.

On the right side of this diagram is a large list in tiny type,
admittedly very difficult to read but we have other version that are
more digestible. But the point is, these are all the unmet needs that
were identified back in October last year when all the Workgroups put
forth their sense of priorities and needs around use case development.
Concurrently with our development activities for the use cases in the
center of this picture this year, we\'re going to also go through a
process with each of the Workgroups to ask them to refresh those needs,
taking another look at what\'s important, prioritize and bring that back
to, through a process to identify the use cases that we develop next
year. So it's two activities going on at the same time: we\'ll develop
the use cases in the center, and we will ask for your input on what the
priorities are for subsequent development.

I want to go to the next page just briefly and talk about our
development cycle and then we\'ll go look at one use case in particular.
This second slide talks about our development timeline and our process.
So we are currently doing our research and scoping activities for those
six use cases I just mentioned. We have requests out to all of the AHIC
members and the AHIC Workgroup members for comments about our initial
high-level draft descriptions of those use cases which came out in
Judy\'s e-mail on Monday, and we will synthesize your feedback from that
and have that help inform our decisions about the scope and boundaries
of this use case. In mid-August we expect to be able to publish the
draft prototype use cases based on that feedback and research and that
will go through a four-week public comment period and we will then
create a draft detailed use case, which takes us around five weeks to
do. That will go through a four-week public comment period. We\'ll
disposition those comments and produce the final use case. Our timing
here is to get those use cases completed in December so they\'re ready
to go to feed the national agenda activities, in particular HITSP, which
is generally the first step in the process.

So that\'s the high level fly-by, trying to respect our time boundaries
here. I\'m going to refer to one in particular, the referrals and
transfer of care use case, which would seem to be in the heart of the
EHR world. But you\'ll be invited to comment on all the use cases,
there\'s a simple form that we've suggested you might use as a mechanism
to provide feedback, but there\'s also \-- you can feel free to edit it
directly. So I want to talk about this use case for a second and then
talk about criteria.

This use case, as we understood the need, reflects on two key things.
One is how to communicate information between a referring physician and
a consulting physician, as well as the consulting physician providing
information back to the referring physician. So that\'s one aspect of
this. We\'re thinking that this is largely focused on the ambulatory
care world rather than the inpatient acute world, but we would certainly
welcome your feedback about that when you read the write-up, it happens
to be on page 8 of the handout that Judy sent out. You\'ll see there\'s
a section called working assumptions and we really would appreciate if
you look at those and give us your thoughts about those. That\'s a key
assumption.

We also have in this one the transfer of care component of this
activity, thinking more of transitions between, say, acute and long-term
care, emergent and acute care. There\'s a number of flavors here that
you can think of that all come into play when there\'s a need for some
form of a summary record, if you want to think of that, one way to think
about the dataset, to be able to communicate clearly the patient status,
the problems, the other things around the patient that are relevant. So
that\'s the second one. We are thinking again this is between care
settings, not intra-hospital but rather inter-hospital might be a way to
think of it. We\'d welcome your feedback there as well.

So when you have a chance to look at these, you\'ll see that we have
just a simple short narrative that we appreciate your feedback on.
Anything that jumped out at you, scoping questions, comments, even if
you have process concerns or questions, please feel free to send those
in as well.

I did want to mention one other thing. Going back to the roadmap slide
and this process by which we will prioritize the needs after these use
cases, in the packet is also a request for you to take a look at a set
of criteria that we used in the January AHIC prioritizing process, and
give us your feedback on whether you think those criteria are
appropriate or if you have requirements you\'d like to suggest to those
criteria for the use as we go through the process of refreshing the
needs in each Workgroup and prioritizing them for the follow-on use
cases. So in very short form, that\'s what we\'re hoping you\'ll be able
to help us with. What kind of questions can I answer?

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

I just wanted to point out that I\'ve been hearing that there may be
problems with people trying to unmute lines.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Uh-huh.

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

If that\'s case, I know we\'re looking into it. If there is a case and
people would like to know a little bit more about this or have some
comment about these use cases before they go to the AHIC on the 31st,
please let us know. And if there is problems with the line, we apologize
and as I say, we\'re looking into it right now.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Okay.

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

Thank you very much.

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

Thank you.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Thank you.

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

Thank you, Karen.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Since we do have a few minutes here, is there anything else here,
identification of future agenda items, we should tackle, Karen?

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

Well, I think if we do have a few more moments, it would be helpful to
think a little bit about these five particular areas that we had talked
about before and the discussion around some of the major obstacles seem
to indicate that clearly organizational, cultural-type issues focus on
some of the really big juggernauts and particularly, I think that\'s
particularly important in the hospital environment and I suspect that
both you and Jonathan would be able to speak to that as well. Training
workforce is such a big one and what I would like to suggest is that
perhaps at our next meeting we could begin to start looking at these
cultural issues, workforce issues. And perhaps have a panel of folks
coming to the Workgroup who can begin to address those.

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

I think that\'s a terrific idea, Karen. You know, it\'s interesting, I
think people understand what the implications are, but I think \-- there
was an article I caught within the last day or so that said that
two-thirds of Americans don\'t know what a personal health record is,
don\'t know necessarily what the benefits might be, so I think there is
everything from awareness level to how does this next generation
incorporate these two tools? Within the healthcare arena itself, I think
it\'s pretty interesting. I recall on AHIC, or the Electronic Health
Record Workgroup, we took testimony from Harris, and working in our
favor are younger cohorts of health professionals. In this instance that
Harris cited, physicians, where physicians under 35 were more likely to
affiliate with wired environments, 35, or 45, generally preferred and
there was, there was one factor working in our favor. But I think the
overall point that there still is an educational void, not only at the
level of awareness and understanding, but in terms of the people with
the technical skills to serve all necessary roles from the fundamental
hardware requirements to the clinical informatics requirements that I
think were also very explicitly articulated and all three case
presentations today are necessary.

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

Thank you.

**[\>\> Lillee Smith Gelinas:]{.underline}**

I agree.

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

Thank you very much, Jon. So I take that as at least some direction we
can go in for starting the new \-- this new area that we\'re in. Okay.
Are we ready to go into public comment?

**[\>\> Lillee Smith Gelinas:]{.underline}**

I think we are.

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

Okay, Jennifer, can you bring in the public, please.

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

Sure. You\'ll see a slide in just a second that has the number for
people to call in if they\'ve been listening over the Web. People who
are already dialed in just need to press star-1 to alert the operator.
And there\'s an e-mail address at the bottom of the slide if people
would like to write in comments after the meeting. And I will check back
with you in a minute or two.

**[\>\> Lillee Smith Gelinas:]{.underline}**

That will be great. The slide is up now, and the number is
1-877-705-6066. If anyone has a question or comment, we welcome them.

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

And we will definitely be back in full swing, we\'ll make sure all our
systems are working at the next meeting in September. Which will be a
pretty robust one. We\'ll talk a little about the follow-up at the
AHICs, we will have the information that we\'ve got in from the Federal
Register process, and some decisions can be made then about whether we
need to do more.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Great.

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

And then we\'ll dive into the organizational, cultural issues. I really
was struck that in at least the hospital sector, that does seem to be
the big one.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Uh-huh. Looks like no public comment?

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

No, we don\'t have anyone calling in on phone today.

**[\>\> Lillee Smith Gelinas:]{.underline}**

No one is calling in? Okay. Jon, or Karen, anything else to come before
the good of the group?

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

Nothing from me, thank you.

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

And not from us today, thank you.

**[\>\> Lillee Smith Gelinas:]{.underline}**

Well, I really would like to one more time welcome the new Workgroup
members to the group, I remember what my first Workgroup conference call
meeting was like. It can be daunting. The amount of paper that comes in
can be daunting. And we greatly appreciate your ability to help us get
to the important issues and be able to really do the very best work that
we collectively can. So on behalf of my co-chair, Dr. Jonathan Perlin,
and our staff, Dr. Karen Bell and all the ONC staff, I\'d like to thank
our speakers, in addition, for very informative, very helpful
presentations today. I thought we had a great kickoff to the Electronic
Health Record Workgroup focus on inpatient, acute care, electronic
health records. Everyone have a great day, goodbye for now.

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

Bye-bye.

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

Thank you, all.

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

Bye-bye now.