American Health Information Community

Chronic Care Workgroup Meeting #9

September 20, 2006

**Disclaimer**

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

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

Thank you, Matt, we\'ll go ahead and do the participation of who is
online, Matt. Let me tell you who is here in Washington. Tony Trenkle,
Karen Bell, we have Jay Sanders is here, Mohan Nair, and I believe
that\'s that\'s who is everybody here in Washington from the Workgroup.

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

And on the phone we have Michael Crist, Andy Mekelburg, Jeff Rideout,
Paul Nichol, Brian DeVore, and Kathy Bowles. Is there anybody else on
the phone who I\'ve missed? It looks like that\'s everybody. So once
again a quick reminder for the working group members who did call in,
keep your phone muted please when you\'re not speaking, and say your
name before you make a comment so everybody following along can know who
is talking.

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

Okay, thank you. Brian, did you have any words you wanted to say before
we get started?

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

No, I think we\'re good to go. Probably should move ahead.

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

Okay. The first article is the acceptance of minutes from the August
Workgroup meeting. Does anybody have any comments on the August minutes?

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

Move their acceptance.

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

Thank you, Jay. Let\'s move on with the agenda. Karen, you said there
was a little bit of a change in the agenda, did you want to discuss that
at all?

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

Yes, just for a moment. We had on number 5, public testimony review. At
the end of last meeting, there was the request that we have some
additional time to talk about this as we tee up the demonstration
project. So I think that rather than go through the review, your minutes
have all after that in it, and we\'ll use that time to think that
through.

The second piece is that there is an item number 8, called the vision
update, and we\'ll explain that a little as we go through that as well.
But other than that, the agenda should be pretty much as we had planned.

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

Okay, why don\'t we move on to the sixth agenda item, which is the
demonstration project secure messaging. After last meeting, Karen and I
and Colin had talked about the need to get together some of the
participants and the plan associations agreed to join us as well, along
with CMS\'s Office of Research and Development, to look at the criteria
that surrounded a demonstration project, and how you could measure some
of the outcomes related to secure messaging.

We did subsequently have a meeting, and Will Crawford from our Office of
Policy pulled together some criteria which he then presented to the
group and got some feedback from it.

I\'d like to ask Will if he could speak on that a little bit, and then
Karen, if you have some additional thoughts, as well.

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

That will teach me to come to the meeting.

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

And sit at the table, too.

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

What we did was we came up with actually two sets of criteria. One for
use in a structured interview format to gather more information from
plans that have already launched secure messaging pilots, and to try to
answer a couple of key questions, you know, really around, first off,
whether the program improves outcomes for patients; second, whether it
improves efficiency to providers; and then the final piece was whether
that led to cost reduction to payers. We also \-- more specific set of
criteria which I think has been circulated to the Workgroup members
looking at both descriptive measures for secure e-messaging pilots, and
then also some of the very quantitative office efficiency,
outcomes-based, and cost-based analyses that could be applied in the
design of a new secure messaging pilot.

We did take a look at some of the existing CMS pilots that are underway
right now, in the physician group practice area and elsewhere, to try to
determine what we could learn from those ongoing activities. And we\'re
still looking at that to a certain extent. But, you know, these criteria
would primarily draw up the development of a new set of pilot programs.

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

One of the issues that came up that we wanted to get some input from the
Workgroup on was the feedback we got from both the plans and from CMS,
which was the difficulty of separating out, in many of these demos or
pilots, the value of secure messaging as to the project as opposed to
some of the other, I guess communication and other vehicles that are
used by many of these organizations to improve outcomes. Will, did you
want to mention that?

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

Just the physician group practice demonstrations that we\'ve done are
not very prescriptive in what the practices are actually required to do.
I mean, there\'s assured savings model and there\'s an opportunity for
the practices to receive payments for improvements on various
benchmarks. Secure messaging is one way that they could improve those
benchmarks, but it\'s not the only one, it\'s not mandated, and it is
being implemented in those pilots to retrieve sites that are using it as
part of a much larger constellation of workflow changes, and
modifications across the entire group practice setting. So it becomes
very difficult to dis-integrate the secure messaging benefits at least
when looking at it in terms of outcomes measures.

Now, there may still be an opportunity to look at those sites, perhaps
in a somewhat less formal way, and determine what the effects are on
time the physicians are spending on particular tasks or the allocation
of workflow within those practices. That would be a very much
descriptive kind of study rather than a real economically
(Indiscernible).

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

Excuse me just a second, Jay. Somebody \-- okay, I think we\'re okay
now. Go ahead.

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

Yeah, this maybe just (indiscernible) of that, as one of the processes
that would be important, in terms of enhanced compliance, improved
outcomes. But fundamentally, shouldn\'t we be looking at the
demonstration project from the standpoint of the particular need with
respect to a chronic disease?

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

Yes.

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

As an example, with diabetes, one might say the secure messaging
technology be (indiscernible) under a heading \-- (indiscernible) secure
messaging \--

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

Excuse me. Excuse me. Colin, or someone?

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

There\'s a rustling paper.

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

Someone is really rustling paper, I can\'t hear anything.

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

Put it on mute.

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

I think it\'s a headphone issue more than it is paper.

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

Okay.

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

Yeah, one of the things I would be interested in is not necessarily
secure messaging for that diabetic patient, but perhaps looking at their
plantar foot ulcer, and seeing what that foot ulcer is. Because as every
diabetologist knows, that\'s got to be taken care of, and it can be
taken very adequately by the patient. With nurse or doctor input, that
would avoid the transmetatarsal amputation, the BK amputation, the above
ankle amputation, and then rehabilitation and all the costs that go into
that.

The patient with congestive heart failure, yes, the secure messaging
about their breathing, how many (indiscernible), do they get up in the
middle of the night type of thing, is also important. But, you know,
getting the reading on the scale, perhaps listening to their heart and
lung sounds at home, getting their vital signs, are equally as
important. So I\'m wondering if, although we\'ve been spending a lot of
focused time on the issue of secure messaging, maybe we really should be
looking at it, once again, going back to what the critical need is. If I
went to a board certified cardiologist and said okay, what is the
critical need for a patient with congestive heart failure, let them give
me a list. Let the American College of Cardiology give me a list. Let
the American College of Chest Physicians give me the list of patients
with chronic obstructive pulmonary disease. The Diabetes Society giving
me the list. And not their own list, but the practice standards list of
what do you look for in these patients. And then determine from that
(indiscernible) of assessing what their need is, what the technology
might be. I don\'t think it will be more complicated \--

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

Well, we did do this with the (indiscernible) Karen Trudel had gotten
from the DMAA a number of months ago, and that was turned to as part of
the broader charge, but that\'s pretty much what they had said as well,
that there\'s certain \-- you know, you\'ve been saying this for several
meetings now, so I think it\'s been pretty consistent. You\'ve been
saying look at the disease, look at the types of treatments that are
needed to \-- and then what technologies can support that. And I think
that\'s where our broader charge needs to go.

I guess my question to you, Karen, is then how does this tie in with the
recommendations that we\'ve already put forward with secure messaging,
how do we deal with that?

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

I wish I could \-- I knew the answers to all the questions that were out
there, Tony. I think, though, that we do have latitude. The
recommendations that have gone to the Secretary are charged \-- we
certainly have our charge, and as long as we (indiscernible) to our
charge even in a broader scope, then I think we (indiscernible) the
intent of our Workgroup, and we meet our deliverables.

I think that we clearly have learned a lot in the last several months.
To actually just tease out secure messaging as an alternative to an
e-visit all by itself is difficult.

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

Right.

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

It\'s difficult to just study to show the value, because as you said
before, it\'s going \-- the value will be dependent on the patient\'s
needs, and also on the degree to which (indiscernible) workflow and
everything else (indiscernible) included.

So I think that we certainly will need to make \-- and you know, we
still call it secure messaging, but it is that communication between the
patients and his or her clinician that\'s the important piece here.

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

Right.

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

We still need to make that at the heart of whatever we recommend. Or
whatever pilot we design.

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

Absolutely.

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

But it certainly can include all of these other issues that we\'ve been
grappling with, and we all know (indiscernible)

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

Which I think is consistent with some of the work that\'s been looked
into. It\'s looking at it from an overall communication standpoint, and
would be more consistent with the CMS practices, and demos that they\'ve
been doing going to this point. It would be much easier to measure
communications overall, rather than defining an individual part of
communications.

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

Tony or Colin, this is Jeff Rideout. I don\'t know if people attended,
but Paul Tang at the Consumer Empowerment meeting presented some work
we\'ve been doing with Palo Alto on secure messaging that shows quite a
bit of positive benefit yet again, but the somewhat unique feature of it
was we also measured productivity for employees. So I think, you know, I
agree totally with what everybody is saying, that it\'s probably much
better done in the context of a chronic condition, for communication in
general. Or it could be done in the setting of a non-chronic condition
for other measures of avoided cost or, in this case, it was employee
satisfaction in terms of ease of use, things like that. And that might
be another way we link this Workgroup with some of the other
Workgroups\' efforts around some of the common issues.

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

Yeah I think that\'s one of the issues we\'ve grappled with in the past
several months is how closely do we tie the work we\'re doing with the
Consumer Empowerment Workgroup, because they do have a pilot at this
point that they\'re doing which involves chronic care and medication
history, and electronic clipboard. I don\'t know, Karen, do you have any
more \--

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

Tony? This is Brian DeVore, Colin is not on the call, I\'m sitting in
today for him.

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

I\'m sorry, Brian.

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

That\'s all right. Since you refer to Colin, that will end up in the
stratosphere, he won\'t pick up those comments. The only comment I would
have is whatever technology we identify \-- I\'ll sit in Craig\'s mind
set for 10 seconds \-- obviously if you could improve the benefit, you
improve product, ultimately at a higher cost, it doesn\'t help the
system, right? Whatever we do, there\'s a factor in there there\'s got
to be better quality, at a reduced cost. Otherwise the technology \--
whatever we identify as technology that doesn\'t do that, then we\'re
missing one of the key criterias.

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

Well, we showed in that study that Paul quoted, it was like over a five
to one return on the most conservative estimate of claims paid that we
could do.

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

I just didn\'t want the group to lose sight that yeah, we may identify
by telephone \-- the ease (indiscernible) that\'s not the right answer,
but that might be the easiest way to do it, but if that drives costs
higher, at an improved care, we\'ve missed half of the equation.

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

I\'m curious about the other committee, Consumer Empowerment committee,
working on similar activities, and question whether or not we should
work together. Is that an item to be discussed, or is this something to
put on the table somewhere in. Because if the Consumer Empowerment is
focusing on chronic care management \--

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

Well, they\'re not focusing \-- I think the point is they\'re using that
as an example, they\'re really \--

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

For a demonstration project?

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

For a demonstration project with PHRs and diagramming. There are some
points of intersection, it\'s a question of how closely we should join
our efforts to theirs. But theirs is more focused \-- and Karen, you\'ve
been closer to this probably than I have, but has been focused on
developing a PHR that has a medication history and an electronic
clipboard.

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

Got it.

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

For a certain population, in this case they chose the chronic care
population. But they\'re not dealing with some of the issues that Jay
had mentioned, although that could be part of the evaluation criteria
for that pilot.

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

From my standpoint, that would be a critical component.

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

Yeah, I would think so.

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

Not simply consumer empowerment, it\'s consumer action that we really
want to change. A major modification. And that\'s a critical component
of compliance for any chronic disease care position.

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

And I think one of the points of intersection that is important based on
our previous testimony, one of the feedback we got from the various
speakers last time and the time before, was the fact that it was low
participation rate from the users. And of course that ties back to your
thoughts, too, Jay. If we\'re going to really change behavior and use
technology to do that, how do we get the participation rates up. And I
think that as part of the Consumer Empowerment charge, they should be
looking into that as one of their key items. Because if we don\'t get
the participation we need, whether you use secure messaging or some
other technique, it doesn\'t matter. I mean, the important thing is to
get the patient participating in a regular basis to monitor and also to
communicate with the clinician.

So how do we \-- what are your thoughts in terms of how we get to that
point? Because that seemed to be one of the key things coming out of the
testimony that \-- the plans mentioned, also several of the speakers.

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

Yeah, from my experience in working with \-- with the industry I\'m in,
with the insurance industry, trying to get participation of any sort is
fundamentally \"the\" issue. And I think it includes the broader charter
around how do we engage in a different methodology between patient and
clinician, or clinicians, and what is the behavior that you\'re
expecting. Because I think people will participate if they understand
the rules of engagement. If there are no rules of engagement, then it\'s
really subject to the classic entitlement behavior that comes from
patient, and the classic behavior \-- non-behaviors that are conducive
to consumers that come from physicians. And that breakdown has always
been there, and that was registered by the committee but left as a
broader charter. I don\'t know where that goes when it goes into that
bid bucket, but I\'m curious where that is held. If it is in the
Consumer Empowerment area now, then we can rest to have them
recommendation \--

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

Maybe we ought to have them focus on that one area, Karen, to support
our Workgroup. Maybe that\'s something we shouldn\'t deal with as much
as let them do that, and then they support our \-- maybe that\'s a
recommendation, we need to tie \-- one of the broader recommendations
needs to deal with increasing patient involvement.

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

I absolutely agree. I think one of \-- there has been a recommendation
that came out the whole \-- I think we had 26 different recommendations
that really focus on how do we engage patients more, from everything
from literacy standpoint to the cultural standpoint. So I think that \--
and AHRQ has been tasked to do that work. So we should get some followup
in terms of where that\'s heading and bring that back here and have some
more discussion. But it is a critical component for both workgroups.

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

I have 75 percent participation rate from our own employees, 3,600
employees in our own insurance \--

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

What did you do to get them \--

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

I mean, the one thing that is very fundamental in our society, that we
like to buy nonsensical items, and that always stays in the frame of
reference for me when you think about consumers, right? Because when you
get a deal, they\'ll perform. So I gave rewards words, and I came to CMS
and asked for rewards to be allowable to \-- and regulars to employees,
and there was an amount of 25 dollars per human being that you can do by
law, which isn\'t really significant, when you think about it. So
employers can actually add to the reward structure. So I created my own
reward structure within the company, and a system of calculated rewards
layered on top of the reward structure I already created for all of my
members, my 2.8 million members. And it works. I\'m getting 75 percent
participation. The general participation you see in companies for health
and wellness is about 6.

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

Right, I know BIM I know is also using that as an incentive of paying
their employees to use PHRs, so I guess one aspect would be we can have
AARP look as incentives in this area.

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

Incentives, I\'m not suggesting we should have a behavioral psychologist
on the committee, but you know, fear of death \--

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

We have one, Jay.

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

Fear of death has never changed patient behavior. How many times has the
doctor said you keep smoking, you\'re going to die?

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

Right, exactly.

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

If you told them they\'d die tomorrow that would probably change their
behavior. But if they know, oh, it\'s going to be a couple of years from
now, that doesn\'t change your behavior. But the fascinating thing, and
Mohan has really hit the nail on the head, and it was really the
substance of a bunch of discussion that went on in a conference that
Karen and I both attended this past week in Boston, and it relates to
you\'re going to have to provide incentives to move from empowerment to
behavior modification. And what those incentives may be is really the
question, not whether you should have them or not. And it\'s not only
for the consumer-patient, but it\'s on the provider side.

Now, CMS provided a very tangible incentive to get physicians to comply
with HIPAA. They said, folks, by this date, you\'ve got to be
HIPAA-compliant, and if you\'re not, you\'re not going to be paid.
That\'s a negative way, but it\'s a very powerful incentive, and I think
looking at both the negative and positive incentives for both payer and
provider, and perhaps coming from the payer group because it also makes
economic sense for the payer group, is really what we ought to be
looking at.

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

I mean I\'ve physically put reserves to incentivize all members that I
have in the four-State region in the northwest. Every year.

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

Right. Why is pay for performance just for physicians, why doesn\'t it
pay for performance for patients.

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

Good point.

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

I hate to keep throwing up money like it\'s free, but I think that that
is a portion of incentives that \-- if I could counsel the group, the
experience I\'ve had however humble it may be and however narrow it\'s
been, has indicated to me that the size of the incentive is not the
factor. The size of the incentive \-- I mean 25 bucks is not a lot of
pay for the year, but it is causing behavior modification within a
company. So it\'s really about employers being engaged, as well as
government engaged, as well as physician engaged. And we\'ve got to find
some kind of \-- between three of test models that work. And I\'d be
more than willing to help in that because it\'s very raw for me to try
to get consumers engaged. That comes with behavior shift.

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

This is Paul Nichol. I\'d be interesting in hearing from the Palo Alto
Medical Group whether they needed incentives to get their patients to
use the secure messaging. That hasn\'t been my impression.

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

Well, I can tell you on the project I mentioned, the Cisco, and Cisco
actually paid the 75 dollar subscription fee. So the model there is we
paid the fee. You could do it several ways, you know. It\'s included in
Kaiser\'s per member per month with their secure service, which is the
same application, it\'s (indiscernible) my chart, or you could pay for
the Web portion, and have it cover the non-Web visit activity. That
helps the model. But with Palo Alto we just paid the whole thing up
front, and it was oversubscribed the first three weeks.

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

But paid subscription isn\'t the same as an incentive, it\'s really
removing a cost for the patient. I think if patients have access to this
they\'ll use it, from our experience. I\'m interested, we had a big
conference in the VA last week on managing complexity in chronic care,
and it was pretty clear the consensus is that empowerment, patient
participation, are key factors in improving outcomes in chronic care.

It seems like there\'s a huge overlap developing between our group and
the patient empowerment group, but I\'m curious, how are we going to
address that and define which group is going to deal with which piece?

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

I would like to see them deal with this involvement issue, because
they\'re looking at more than just the chronic care population, so I
think it will be helpful to have them take that piece.

Another piece that I\'ve been seeing come out of the testimony that \--
and maybe this gets back to the positive and negative incentives,
but \-- and maybe, Jay, you can answer this, but the whole issue of
workflow. I mean, where some of these \-- when we talked with Linda
Monya (ph) from CMS and some of the demonstration projects and how
secure messaging fit in, she was saying that the people that they were
dealing with, the organizations, the \-- you know, the Ericsons and
others, are not just doing secure messaging, it\'s a whole new way of
doing business. They\'ve got a number of different uses of technologies
and techniques that a lot of the standard care practicers don\'t do. And
I guess my question for you, Jay, is how do we deal with the whole
workflow issue? Some of it maybe is tied to incentives, but are there
other ways to deal with that? Because it seems to me that\'s an
important key around using secure messaging or any of these other
communications or monitoring techniques.

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

I totally agree with you. Workflow will be a key issue, and the initial
perception on the part of everybody is oh, my God, how am I going to
deal with all of this increased information that\'s coming in, how am I
going to deal with the time requirements of it. I think, first of all,
the shortest answer is to say that \-- although it\'s not the best
answer, is that in most of the studies that have been done and which has
been looked at, the workflow has not been enormous. And the physicians,
those who have participated \-- and of course there\'s a motivation
factor there \-- those who have participated have not complained about
the fact that this creates a huge amount of additional time commitment
for them, because the patients don\'t \-- don\'t abuse the system.
Significantly.

Second, I think we need to look at who needs to look at the information
and make a decision. And this is potentially protocol-based, although I
hate to use that term, because everybody gets boxed in, but the
fundamental reality is that a physician doesn\'t need to look at the
majority of these. A nurse or nurse practitioner can be doing that, and
very appropriately so.

Third, we\'re talking about consumer empowerment, patient empowerment.
If we really empower them, we really incentivize them, we should see
over a period of time the use of the technology, not it going up, use of
technology going down. Because in fact, the need to ask a question will
be less, because the patient is now educated as to what they need. When
they see the results of that scale, they\'ll know that something has
gone awry, and they\'ll be empowered enough to do something about it.

Now, this may sound very idealistic. Fundamental reality is it\'s been
demonstrated in other countries to exactly be the case. That patients as
well as primary care physicians use the system less over time to access
either their physician or to access a consultant. Because they\'ve now
been educated on what to do.

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

So you\'re saying that the problem is not as much workflow as it is
education and outreach. Maybe there are some perceptions out there that
need to be dealt with more than actual workflow issues.

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

I\'m saying that, but I\'m also not naive enough to think that there are
not folks out there who would totally disagree with me about the
workflow process. And I think that perhaps needs to be one of the
critical metrics we look at in the demonstration project.

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

Which brings us to this issue of item 6.

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

Right.

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

As we start to (indiscernible) of this project. If we are to assume that
the boundary conditions of this project don\'t account for the workflow,
as you \-- you know, called it, or don\'t account for consumer and
physician empowerment, then what are we going to say? Is the question I
ask. Because I\'m challenged with hooking up to connectors and saying
secure messaging. I\'d like to be able to say that if we are at the
key \-- maybe I\'m missing it, so help me \-- what are the features of
this demonstrating project? If it\'s so closely diagrammed with the
other group we want to make sure we don\'t get too many variables
playing in this equation that we lose the essence of what we\'re trying
to achieve.

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

We\'re trying to achieve the outcome. The outcome is group compliance,
improved quality, decreased costs. I think what we\'re grappling with is
the process to get there.

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

And what are the variables, if I could add to your \--

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

And using though as part of the metric of the evaluation.

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

And the question I keep grappling with is do we rely on the other
committee to develop some of the frameworks, do we develop in parallel a
framework aligned with them?

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

I think the latter probably makes more sense.

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

I do.

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

I would recommend that, too. Because I feel fearful about linking boats
in the course of trying to find a direction. I think that would hinder
both of us, hinder both the committees. Maybe a parallel path could be
valuable.

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

I think one of the things I\'m hearing is that to actually do a study
that looks just at secure messaging and the value of secure messaging is
probably not doable because there are so many other factors involved on
the patient side and the clinician side. And in many ways, in terms of
even the \-- the clinicians who would be interested in doing a study,
may be doing other things that we don\'t know about. So the question
becomes, in my mind, if we are going to do a study to prove the value of
secure messaging, it seems it has to be imbedded in a number of other
factors, as well.

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

I think you\'re right.

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

Karen, this is Jeff. I totally agree. If you go back to the Markle work,
what you see is the advantage of, in this case, PHR adoption is really
the bundle of services, including secure messaging that tends to come
with the creation of PHR. I think to the point of what we do that\'s
complimentary. From a Chronic Care Workgroup perspective, which is our
charter, what is in it for clinicians that secure messaging could be
part of enabling. And I think it kind of brings us back to the original
point that somebody made about we need to focus this on a chronic
condition and how secure messaging as part of that enhances the
clinician\'s ability to provide better outcomes at a lower cost.

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

I totally agree. And you know, this is something I\'ve been championing
for awhile. But let\'s look at practical realities, and let\'s say that
we are told, look, the only thing we can look at initially in the first
step is secure messaging. And we\'re wrestling idea that just looking at
secure messaging may give us \-- may not give us the kind of clean data
that we need to look at.

If we\'re pushed to that point, my recommendation would be then the only
parameter we look at is compliance.

The one thing I know both from being a physician, as well as being in
this area of this enabling technology, is that we have 100 billion
dollar a year minimum problem in the United States secondary to
noncompliance, which translates into readmission into the hospital.
Canada even has a worse problem with that. If that is the case, we also
know that if I actually took the time, had the time, and spoke to the
patient in my office, in their language, by the time they get home, they
retain one-third of the information I\'ve given.

What is so great about a secure message is that the question of did they
hear it and did they retain it, they can go back and look at the message
again, and I think the issue of compliance could be looked at fairly
well scientifically if we just pushed them to a corner and said the only
thing we could look at is secure messaging.

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

No, I\'m just agreeing with you by shaking my head in classic ethnic
fashion, you know, in India it\'s \--

(laughter)

There are too many people already by my miscalculations. I guess I\'m
shaking my head because I\'m saying it\'s such a complex thing, it\'s
multivariate, it\'s just so many influences. And everybody is saying you
can\'t do an ROI on any one of them. So I know where we\'re going,
we\'re going toward the same comment, we can\'t do an ROI on any one of
them. But if we can\'t do an ROI on any one of them, we\'d better find
out what the necessary and sufficient conditions for an effective
relationship between patient and \-- we\'ve got to know the four we\'re
going to go test. Maybe we don\'t know how they influence each other,
because it\'s going to be a very narrow sample in play, but we need to
know there are four or three things we are really testing in a
demonstration project ,right?

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

Much like what is the minimal tool kit that you need. And I think it
gets back to Jay\'s issue, what are the diseases we\'re looking at, what
are the conditions that the clinician needs to look at, and what
does \-- how does technology impact, assist, and if we can isolate each
of them, then that\'s what we should use as part of the demo project. So
a demo that really focuses on that needs to contain this minimal
criteria, then.

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

Right.

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

This is Paul Nichol. I guess I question whether we\'re really looking at
only secure messaging or whether we\'re talking about the availability
of a patient Web portal. Most of the secure messaging systems that I\'m
aware of are really in the context of a portal that allows patients to
do other things besides communicate directly with provider staff. They
can read meds, look at lab and get other results, schedule appointments.

So we might think of it in that context, and certainly any study should
carefully define the context in which the secure messaging is occurring.
My assumption is that it\'s going to be best when it\'s combined with
the Web portal, or personal health record capabilities.

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

But I think you back into that, I think that\'s getting to what Jay was
saying. If these are the technologies you need to be looking at, that
support the monitoring and communication of various conditions, what is
the best vehicle for that? Is it a portal, or should it be treated
separately or in conjunction with several of these? And yes, I look at
some of the demonstration projects that CMS is doing, I think there\'s a
variety. I don\'t know, Will, you\'ve been looking at some of these
models, what are your thoughts? Because you developed some of this
criteria with Anand, do you have any thoughts on that? I\'m going to
bring the microphone down.

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

Tripping over each other her. I\'d also invite Karen Milgate, who is
also here from the CMS Office of Policy, who knows the demonstration
projects a lot better than I do, to comment if she comes up with
anything. But in general, what we were looking \-- what we were looking
at initially in terms of reimbursement processes for secure messaging
was out beyond what the CMS pilots were looking at and what some of the
plans out in the field had begun reimbursing for secure messaging
through, particularly services like Kryptiq or MedStar Health were doing
and what kinds of experience they might have had with measures that show
up in claims data. So particularly, six months after allowing online
messaging for 2,000 practices in the State of Florida, how does \-- how
if at all does billing in those practices differ from what it looked
like at the beginning of the program? So the idea would be to determine
if visits were reduced, if re-hospitalizations could be reduced.
Potentially you could learn a lot about the compliance issues, the
secondary noncompliance stuff in particular.

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

Yeah, I think in terms of on incentives on provider side, it might be
somewhat different than incentives on the provider side in the sense
that I think providers will, especially, be looking for that hopefully
positive incentive, sometimes it won\'t be positive, but if we\'re
really trying to get them not necessarily just to change their workflow,
but to buy into this, then some incentive, whether it\'s fee for service
or some balance of fee for service, capitation, I think there\'s going
to have to be some kind of incentive for physicians to play this game
other than the incentive of providing better care for their patients.
Which should be good enough, but obviously, you know, they\'re trying to
balance multiple objectives, as well.

So exactly how we craft that, you know, looking at some of the other
demonstration projects CMS has right now \-- which I think is mostly
bundled services and extra \-- or capitated or \--

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

Yeah, it is, bundled services, and capitated environment.

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

I think we need to think about that a little bit more because I think
the incentive side \-- it might be easier to provide incentives to
employers or to patients, hey, you know, we\'ll pay the fee for signing
up a PHR and using it, they might use it and you might get great numbers
like 75 percent, but I think on the provider side for them to play, I
think, you know, we need to think a little bit more about how \-- if we
really want to see a big N here, in terms of lots of data, and lots of
data showing compliance \-- changes in compliance or lots of data
showing changes in outcomes, at least with any of these technologies, I
think we need N in terms of numbers of providers providing it, and to
get them to play it, I think we need to get through the incentives.

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

The programs that we looked at outside of CMS were a very simple
provider incentive, which is we will reimburse this amount of money per
visit, and in most cases, they\'ve done some of the work of providing
the infrastructure for secure messaging, usually by contracting out with
another company. The practices still needed to opt into that activity,
and one thing I found very interesting was how many of them actually had
within a relatively short term, short period of time. But there was
nothing in any of those programs that addresses, other than perhaps some
very basic communications, that addressed the patient population at all.
Notification on the Website saying hey, this is available, you can sign
up. That\'s about the extent of it.

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

Certainly from the provider community if they get an extra, you know, a
bonus or fee for service for each kind of secure messaging
communication, that\'s great. But \-- and I brought this up before,
exactly how CMS addresses potential fraud and abuse or potential \--
there\'s some communication messages that just don\'t enhance compliance
or don\'t enhance improvements in quality, and things like that, and
that\'s the problem with these, that they get with just straight fee for
service for every type of communication messaging. So it\'s just \-- we
just need to think through these things.

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

One of the things that the Federal Government likes to do is leverage
what\'s happening in the private sector as much as possible, and
probably vice versa. And I think Eric is on the call.

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

Yeah, I\'m on.

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

I hope you\'ll jump in and help me out on this one, but the chronic care
model has been around for a very long time, and there are parts of the
country, or a lot of different physician offices that have completely
embraced it, some with health information technology, and some without.
And so one of the things that struck me, and I\'d love your input, Eric,
is could we possibly construct a project that was open to practices that
were heavily engaged in the chronic care models, who are not now using
HIT and secure messaging, and offer secure messaging to some? And so we
actually have a care model into which we insinuate the HIT
infrastructure, and then we can evaluate the difference between the two?

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

If we define the criteria for the HIT infrastructure that we\'re going
to have.

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

Right, I figure if that is something that\'s worth discussing, maybe we
could pursue that a bit. But Eric, please jump in.

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

Well, you know, I think that\'s \-- you know, that\'s a good idea. Part
of my question is underlying all this discussion, what sort of time
constraint are we under to come up with not just a study, but when the
study results would be available for decisionmakers.

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

We should have something, it may not be perfect, by the end of 2008.

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

So I\'ve been listening, and I was unfortunately the guy who made all
the noise, sorry about that, and I had two chains of thoughts. One was
listening to the discussion about outcomes, and what we would measure,
what the model would be. I think we should go \-- or consider at least
the crossing the quality chasm outcomes as the ones that are beginning
to be operationalized and are sort of accepted around the definition of
a continuous healing relationship, and so forth. And given the time
constraint, to get information by 2008 that shows much in the way of
change is going to be hard, given the \-- you know, starting something
from scratch. And I was wondering if we might take a two-pronged
approach, which would be there are so many different models out there of
not just secure messaging, but as Paul was saying, different elements of
the use of HIT and PHR, to manage patients with chronic disease.

At the end of the day, could we come up with a descriptive set of
studies of demonstrations that are out there, some in very highly
managed care integrated model, some in \-- you know, not so much
integrated, but a multi-specialty group practice, some in, you know,
smaller units, and then along the other axis we had the other outcomes
that we\'re looking at, and maybe a third axis, the characteristics of
each of the systems ranging from just secure messaging to a lot of the
other compliance support and reminders.

And, you know, we\'re trying InfoRx here at Group Health and finding
that that turns out to be one of the most potent things attached to
secure messaging, is giving somebody a treatment that\'s information at
the time you deliver a secure message, for example. And that\'s
something nobody had really paid much attention to until we begin to see
the uptake.

And then the other study would be the one that you just described about,
you know, actually adding secure messaging to ideal states, and seeing
what the marginal gain is. But I think that would take well into 2008
and beyond, to actually get results.

Does that make sense to people?

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

Can I add \-- this is Andy Mekelburg. We\'re part of the employer group,
Bridges to Excellence, Leapfrog, that have been providing incentives to
both physicians and hospitals who are implementing systems. I\'m just
wondering, you know, whether we can reach out to them to see if they\'ve
got any kind of data or \-- you know, I know we do it city by city, and
maybe there\'s a trial we\'re working on that we could do something in.

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

I\'ll really \-- this is Mohan \-- I\'m challenged with the whole idea
with what are we looking for, and drawing the picture around secure
messaging. And we can expand it to a significant number of variables. An
information portal, as was mentioned prior, connected to an EHR-PHR kind
of environment, where you have a complete set of solutions available to
an individual, and can offer a physician or physicians. Because it\'s
usually not one single episode, when you think about a diabetic, it\'s
multiple connections with multiple clinicians, and a cycle of \-- a
health cycle.

So even measuring costs would be a challenge. And quality, increase in
cost reduction, is not usually one dialogue between one physician and
one patient. It\'s with a family of clinician or clinicians, from
physical therapy all the way to an amputater, who might cut off a leg
because he has to or she has to, due to an ulcer on a leg.

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

There\'s a common denominator there, the common denominator is
hospitalizations.

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

For the chronic \--

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

That\'s the biggest cost.

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

Yes. Yes, well, yes, I agree with that. But my question is that as we
start to pile on a lot of these features that attract the action \-- in
other words, we want that \-- you\'re saying compliance is the action.
The true performance measure of a successful engagement is an increasing
compliance. And we can say a reduction of costs, and an increase in the
quality of interaction. And hence, a better decision as reflected by
claims cost reduction, right? You can draw that map.

Well, if we\'re going to draw that map, we\'d better have a pretty
strong idea of what variables we\'re going to inject in this. And I\'m
struggling, as you are, with how do we frame that.

Karen just brought up an idea that said already a model exists
somewhere. We know it does, right?

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

Right.

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

A chronic care model exists somewhere. Engaged maybe without or with HIT
as a contributing factor. If we were to add that variable, barring
some \-- you know, rejection of the seniors right? They say I don\'t
want this HIT stuff. But if they agree to it and we add that, we could
then see the variable impact. It may be the only variable that we added.

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

As a variable would be \--

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

The devil would be in the details.

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

The devil would be in the details, particularly if it\'s people who
haven\'t used it before, you\'ve got education and training that needs
to be done. And of course there\'s the old Hawthorne effect, too, where
people would be focusing on the use of HIT, because it was something we
would be focusing on. So I mean, you have to control for those types of
things, as well.

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

But I think we can, and the question is that\'s one recommendation.
Another would be create a synthetic environment,

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

Right.

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

One that \-- and what is being said is if you want to come up with
results by 2008, creating a synthetic environment will be a difficult
challenge, right? That\'s what I think is a special point today. And I
think the committee has to decide somewhere in between where we go.
Because I don\'t think we can find the perfect storm. I hope we can, but
we should look for it. I don\'t think you want to find a no storm, which
is \-- you know, create from nothing, and get nothing. Somewhere in
between is that \--

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

But of these different models out there, as Karen said, can\'t you
compare outcomes on these different models, and look at what variables
are different, what types of HIT were being used, for example. And then
start developing a list of what are the minimum uses of HIT you\'d want
in a chronic care model.

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

That would be very, very good.

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

Because one of the things you have \-- Karen, I\'m going back to one of
your recommendation letters. You mention things such as secure
messaging, multimedia education, patient access to notes and reports,
asynchronous messaging mixed with patient encounters attached to an EDR,
ratings for home tests such as glucose level, blood pressure,
cholesterol, and weight. There are a whole slew of factors you could
look across various demonstration models, some of which involve HIT, and
then begin to develop, you know, what are the ones that have shown the
greatest improvements in outcomes. And then start to isolate those
variables depending on how they were used differently in some of these
demonstrations.

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

And that may be particularly helpful given the fact that the IHI, the
improvement group that Don Berwick has done, breakthrough workshops all
over the country, and they\'ve had many, many practitioners signed up to
learn about the chronic care model. The QIOs have inculcated the chronic
care model in many parts of the country. And thirdly, I know that HRSA,
through its primary care bureau, has been working very closely with its
primary care federally funded sites. And the federally funded sites
through HRSA basically are sites that are not just supported by HRSA
moneys, they basically provide care to the commercially insured,
Medicare, Medicaid, a whole gambit of patients.

But they\'ve all been \-- a lot of those have also been inculcated in
the chronic care model and are working it through and are tracking all
of their outcomes, and process measures. So I think it\'s at least a
substrate that we might be able to start working with, to understand
better how HIT interacts. And again, we\'d have to determine, is it a
structured secure message, is it some of these other things, and then we
can maybe tease that out.

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

Yeah, and if it\'s structured secure message, is it done in a portal
environment, how is it, you know, how are a number of things done.

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

This is Eric again. And so what I heard you said was that in doing this,
we\'d end up with more of a descriptive study of characteristics and
traits. But somehow, for each of those types we\'d be looking for
instances where we could at least do before/after or some kind of an
analysis of what happened to persons, be they patients or physicians, in
terms of a series of outcomes, which would possibly be pegged to the IOM
kind of variables, and also begin to get at some costs and, you know,
costs to whom. Costs to the doctor, or costs to the patients, or
deferred costs to whom?

Because I think a lot of what we\'re going to see here is deferred costs
in the way of, you know, how people get their care. And additional costs
in terms of how people are provided that care.

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

Eric, I don\'t know that that would also preclude our ability to move
forward with a pilot of some sort.

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

Oh, no, I think \-- I would just say that time-wise, you know, we need
to get decision-makers some information so the field has something to go
forward with. Because right now, I think it\'s being informed by opinion
more than anything else.

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

And I was just thinking, looking at Washington State, for instance, I\'m
sure, and I know, that there are lots of physicians' practices there
that have adopted the chronic care model, many of which have no HIT
support. You may be able to work with a robust enough number of those
practices, perhaps offer some of the types of secure messaging models
that we\'ve heard about, particularly the last go-around, we can decide
which ones we would like to do, to some of those practices, and then
really see if there\'s a difference in that controlled situation.

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

Sorry to interject \-- I\'m Karen Milgate, I\'m with CMS. I\'m sorry,
I\'m not on the Workgroup, but I did some stuff that I think might help
here. To control some of the other variables, if you could find a
multi-site group practice, so you would have the same basic system, and
see you could control some of the other variables, perhaps at one site
they could put in secure messaging, so that you don\'t have \-- you\'re
just controlling for a lot of the other factors.

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

That\'s a good idea, too.

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

I don\'t think we need to look at \-- you know, you were mentioning
about scale. You know, trying to find large enough that you can have
some impact in terms of the study.

I would recommend an opposite viewpoint, which is all you have to look
for is scalability. The size of it doesn\'t have to be scaled to the
point where it looks like it works. But I think I would recommend we
look at things that are not scaleable, even if it\'s a 5-person
practice, with 20, you know, patients. It\'s not as boring as if it was
diverse enough, not diverse enough to be able to scale.

The variables are just going to be too many. Behaviors \-- when we talk
about behavior modification on the part of three or four players
(indiscernible) in HIT, you already have \-- you know, something that\'s
so fractal you can\'t measure it, it\'s too hard. One of those variables
become a force, the others may follow. You never know. So I think that
even then I would recommend something a little bit more bounded, and it
be driven in the pilot demonstration.

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

I agree, I think I was just going for ultimately division is \-- we\'re
trying to establish something that CMS at the end of the day will say,
well, you know, this is actually something that will improve quality of
care for medical practitioners, and hopefully reduce our cost, and CMS
will take the position where, you know, we might actually pay for some
of this stuff. Ultimately it\'s a demonstration project for CMS to
consider potentially taking it on. And, you know, I would \-- I\'m just
thinking, Tony, I\'d be interested to hear your thoughts, but we\'d
certainly want to have in this demonstration project, you know, whatever
features that CMS thinks is important, that will help CMS determine
whether this is something for the long term, not just for a
demonstration project. That they think this is important.

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

I understand that. You know, we\'ve talked a lot about the outcomes
issue. I guess I\'m \-- and I\'m understanding how we\'re focusing on
secure messaging. I still think getting back to the whole issue of a
bundle of services that are offered, that promote overall outcomes.
Because I think when somebody gets on a computer, they don\'t just do
secure messaging or regular e-mail. Let\'s say, for example, if someone
does that they\'re more likely to purchase goods over the Internet,
they\'re more likely to make travel reservations over the Internet,
they\'re more likely to do a number of things. They\'re not just going
to do one thing and not do it.

So to me to isolate a single variable is \-- I don\'t know how much it
buys you. I think you really need to look at what is a critical number
of variables that gets someone to begin to do something. For example,
when you look at how people use the Internet from various age groups.
Some of the studies of the elderly have looked at things like medical
information, travel information, be able to communicate with relatives,
grandchildren, et cetera. Those are like the key things that get people
to begin to use the Internet, particularly the elderly. I mean, if you
go down different age demographics you get, you know, somewhat different
responses. But I think that\'s what I think we should be looking at
here, is what are the minimal type of criteria that we get someone to
begin to use the, you know, the tools, the communication, the remote
monitoring.

What are \-- and as Jay said, it\'s not related to them dying, but
there\'s obviously other things that should be minimal criteria that
someone says yes, then I\'ll begin to use this. I mean, some of it is
probably, you know, reimbursement incentive types of activities,
something on the provider side, it\'s something that CMS will need to
look at how it ties to outcomes.

But on the patient side, what are the types of things that get them to
begin doing that every day. One of the people at CMS was mentioning a,
something they looked at the other day, there was a product that\'s come
out now that it does some things with medication where it actually, the
patient gets, it\'s a type of monitoring technology that kind of
monitors their use of various medications, and it sends that information
to the physician. It provides details if they haven\'t taken the proper
amount of medications. It also provides information to the patient, as
well.

So for some elderly people who take, who, you know, have chronic
conditions and who take multiple medications, is that something that
would be beneficial to them? It would be beneficial obviously to the
provider and to the clinician, but would it be beneficial to the patient
to know they can actually monitor their usage of medication?

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

There are a number of those technologies out there. One of the first
companies was a company called Informedics, and basically it\'s been
used in a trial of both individuals with mental impairment, to get them
to take their medication, as well as HIV with multiple medication, a
dosage that (indiscernible) be required, showed dramatic enhancement in
compliance.

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

But I mean that\'s the kind of measurements I think we need to be
looking at, rather than just isolating secure messaging in and of
itself. Even though that maybe that\'s part of the suite of services
that we need to provide, it just seems to me.

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

A couple months ago when I think we were initially conceptualizing this,
we said there was secure messaging, the online communication. Then if
you want to go broader, there\'s secure messaging plus administrative
functions. Those are refills, appointments, all those other things. Then
the third was those two plus remote monitoring, some aspect of that.
Fourth was all three of those plus electronic medical record. I think it
might be helpful to go back to those. There\'s a whole suite of just
online communication to the broader. And going back to that and trying
to decide, you know, are there multiple of these things we want to test,
is it just one of these things. And I think I do want to make one point
about outcomes. I really like Jay\'s idea of looking at compliance. If
we want, if we are looking at 2008 to find, you know, to have some
tangible results, boy, it\'s going to be hard to find definite costs
reductions probably by that time.

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

Right.

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

So the question is, well, what does CMS or (indiscernible) think might
be a good proxy for estimating costs, and also improving quality, and I
think compliance. Compliance, I think one, and I think the other thing
is preventable hospitalization. At the end of the day, it\'s preventable
hospitalizations where the cost savings are, in chronic care, as well as
quality improvement, where you don\'t go to the hospital. And somehow,
if we can conceptualize compliance and preventable hospitalization, be
able to measure it and evaluate it, you know, in a focused way. And I
agree, not get too big, but also have it big enough where you\'re going
to have a control group and you need to prove some kind of statistical,
you know, benefit, you know. And if CMS agrees that yeah, these two
things might be good proxies for costs, I think, you know, that might be
something to consider.

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

Yeah, I see those as one and the same.

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

This is Eric Larson. I want to just endorse that idea and amplify it a
little bit, because you know the ILM does have \-- or there have been a
series of papers on avoidable hospitalization. So there is a trend line
that you can get from data on avoidable hospitalization.

And as we think about what AHRQ or CMS might do to solicit somebody to
do this work, we can ask them to tell us how they would design a study
to look at avoidable hospitalizations, or compliance, or both. And not
try to design that part of it as a, you know, an ONCHIT Workgroup.

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

All right, Karen, can you sum up where we\'re at with this discussion?

\[laughter\]

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

Every time I talk to you, you put me on \--

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

I didn\'t say three sentences or less, but I think we\'ve kind of
reached the point where we\'ve come to some agreement, and I just wanted
to \--

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

Right, I think the agreement is we\'ve got a little work to do. But it
has been a very, very good discussion, thank you all for participating.
I think where we\'ve come to is that there is some agreement that we
should first off explore the extent to which there is a standardized
model available around the country, and how that might be able to be the
platform for us to move forward on assessing changes in chronic care.

And from there, we still need to make some decisions about what type of
HIT would be the best approach to go, and we did have these
presentations last time about various options there all the way from
simple structured message to the imbedded in the EHR approach. So we
probably want to look at that a little bit further.

But that also, we need to really think through how we could engage a
third party to really tell us how to focus on what we have agreed, I
think around the table \-- and this is the time for anyone on the call
to disagree with either my little synopsis or conclusions that the
primary outcomes that we\'re going to be looking at are compliance and
hospitalization rates.

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

This is Brian DeVore. Working backwards from deliverable date of
December, if we haven\'t decided on the HIT approach, I mean, at what
point do we \-- is this offline work that two or three individuals will
go and do to figure this out, or \--

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

Well, I think we could spend a little bit more time thinking about that
today, or we could discuss it a little bit more at the next group, or we
could do an offline. And I think one of the options is that if there is
a possibility, we might want to explore all four HIT options. As opposed
to limit it to any one.

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

I would agree with that.

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

I think that makes sense.

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

My concern is that \-- you know, part of the issue is trying to narrow
the focus so we can nail these things, not get too broad. I would agree
with the model to (indiscernible) at least test \-- 

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

Because I don\'t really think we have enough data to suggest that one is
better than another. We have thoughts, we have feelings, we have
opinion, and we have some results in some very specific populations and
geographies, but we don\'t really have a feel for how well, for
instance, this would work in the Medicare population. And that\'s a key
population for us to address.

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

Right.

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

To have ongoing discussion with CMS.

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

Mohan\'s point of (indiscernible), once you bring in the four different
models, the permutations combinations that result from that, sort of
test the (indiscernible) evenly across four models, it essentially
becomes unmanageable. That\'s where we could essentially bring in a
third party, to create (indiscernible). That goes beyond my \-- my
ability to really conceptualize (indiscernible) \--

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

Could I ask the Workgroup members to sort of \-- I\'d be interested in
their opinions on one of these King Solomon types of problems.

Let\'s assume we all agree that incentives are important. Whatever they
may be, incentives are important. But we are told that in this incentive
pot there\'s just X amount of incentives, and we have to decide either
that it goes to the provider, or it goes to the patient.

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

It can be negative or positive incentives.

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

Right. Which would they choose. I mean, I\'d be happy to go first, and
say what I would do, and remember I have an M.D. at the end of my \--

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

We know that.

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

I would go for the patient, and give the incentive to the patient.

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

This is Paul Nichol. I think that the issue for patients is going to be
removing barriers. So if they \-- you know, a fee for signup is paid, I
don\'t view that as an incentive. I think it\'s going to be a little bit
harder to get clinicians involved. So I\'m going to err on the side of
giving clinicians the incentive as long as patients didn\'t have
financial barriers to participation.

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

This is Andy Mekelburg from Verizon. I\'ll just speak as an employer who
spends about 3.5 billion a year on health care. We probably would,
we\'ve been involved with incentives for the providers rather than our
employees. You know, as people are starting to pay a little bit more for
their own healthcare we\'ve been trying to implement our own system. So
I\'d sort of agree with we need to get providers to start adopting these
things.

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

This is Eric Larson. I think for providers, the issue is disincentives.
And I would agree with Paul, that barriers are also probably more
important for this taking off with the patients, and the barrier could
be actually the provider.

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

I hate these King Solomon questions, because they do force priority, and
I respect that a great deal.

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

Could I go back to Karen\'s thing about the two outcomes, being
compliance and hospitalizations? Avoiding hospitalizations? I think that
makes sense, in the sense of the two outcomes that we expect would make
the greatest difference from a cost and patient outcome point of view.
I\'m not sure we\'d want to restrict it, though, to just those two
outcomes. We might want to say make sure that whatever you do in this
project, it addresses those two outcomes. And then, you know, think
about some of the other outcomes that might be pertinent and improved or
worsened if you want to talk about costs, based on addition of this
technology in its various forms.

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

This is Mohan. I\'m struggling with this, because I think that I\'ve
experimented with both from the health plan perspective, and what I\'ve
found is that my whole belief system was around if you can get the
consumer engaged, then the entire value chain will shift. Because the
behavior patterns of the consumer will impact the value change. That\'s
my belief system. The challenge with that belief system is there are
custodians who are still living. A physician is a custodian in a sense,
and so is the employer. The employer is custodian of a great deal of the
health character of the consumer, the so-called consumer. And
consumerism hasn\'t got to a point where they are revolving in the
system and driving the value chain a different way.

So in this project, in this project, in this project, I would claim that
we have to drive towards a model that says a physician or a clinician or
people who are in that service provision have to know what it is first,
then they have to know does it work for me. Does it work for me? And
then they have to say does it work for many? Because it\'s all about
what it is, does it work for me, and then does it work for many. That
cycle cannot be broken.

We have to incentivize that what-it-is learning on the part of the
physician. Because at this point a lot of different opinions, when I
hear providers and physicians speaking, about what this HIT thing is.
And we have to narrow that and incentivize that.

Even though my heart lives in the consumer incentive focus, I would
think that that is really in the charter of driving consumer behavior.
Wherever that lives. If that lives in this committee, then I say we
should focus incentives in that direction. Very strong. If it lives in
the other committee, in Consumer Empowerment, there is where we should,
they should be looking at models for incentives.

Both ways, however, I do believe that there is a disincentive on both
parts not to do this, which is the rising cost, the inability to get
care. The Rand studies that say 56 percent don\'t really do
evidence-based health provision. So the crisis is here. The question is,
how do you create the first step towards a behavior shift? And I think
the employer needs incentives, and I think that the physicians need
incentives to know what this is. Not just to say, you know, let\'s move
towards, get it scaled.

Education is still one of the biggest elements, because there\'s so much
disinformation about this. And we should be spending time about how to
get people educated. Because look at what we\'re doing. We\'re doing
exactly what people go through in rationalizing this. It\'s just at the
point we have the time, they don\'t. They have to serve the patient, or
a consumer has to receive care for themselves or their family.

So I hope I\'m answering your question in a Solomon way, but I\'m really
avoiding the question in the sense that it depends on the charter of
this committee.

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

Well, but even the charter of this committee, we can advise the Consumer
Empowerment Group on looking at various incentives that relate to the
patient. Even if we don\'t do that, that could be one of our
recommendations that the Consumer Empowerment Workgroup, in their PHR
recommendation, the 2.0 recommendation that they\'re doing now, or even
further work that they do, that they take that into account. And we can
help develop the criteria for doing that. I mean \--

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

May I make another recommendation, if I may? About incentive. The word
incentives sometimes gives the impression that it\'s money. And I would
ask the committee to consider other options besides money. There are
many different factors that drive a person to behave a different way.

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

Right.

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

We know this is not personalized, right? I mean, we will drive 10 miles
to get a dollar off a shirt, or a blouse being done in a laundry, when
you know you spent that much in gas. But you still do it because it
looks like a deal. You know. So it\'s not rational incentives, there are
other factors, and I hope the committee really addresses that widespread
concept of incentive, not necessarily narrowly associated with who pays.

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

Well, time and convenience are also, and information, is another one. If
you look at how people use the Internet to do online shopping, for
example, as opposed to going in a store, they might be willing to pay
the same amount of money or even more if you count the shipping. But
because they can do it at a convenient time and place, and be able to
get the customized service that they need, they\'ll do that online
rather than to go. So if you look at something similar with a patient,
what are the time and convenience issues that using HIT would help them
achieve with secure messaging. Where they can, you know, ask questions
or receive information from the clinician at off-hours, for example. Or
get responses where they wouldn\'t have to drive into the office to get
that, or wait for a telephone call to be called back. I mean, those are
the type of things that need to be looked at as well, I think.

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

As long as we understand the breadth of that.

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

You\'d have to define what are some of the criteria under that to look
at.

So where we\'re at then, Karen, just to sum up then, is we need to, and
then getting back to Brian\'s issue, I guess by December we\'re supposed
to prepare a second letter of recommendation on a broader charge. What
do we need to do between now andm I would assume we have to get the
letter pretty well done by the end of November, because it has to be,
what is it, December 12 is the AHIC meeting, where I\'m assuming the
letters would be done.

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

That\'s right.

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

It sounds like we need some additional testimony at the October meeting,
maybe getting more into these various models that we had at the last
month\'s session. We need to maybe look further into this whole use of
incentives, and how it would tie in, what we\'re looking at, and what
the Consumer Empowerment group would be looking at from the patient\'s
side. And then I guess a third area would be tying back to, I keep
getting back to Jay\'s whole issue of tying, you know, disease to the
need to the technology that supports the information need that the
provider has, whether it be remote monitoring or some other type of
communication.

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

Could I just tell a little bit of clarification on Jay\'s point? Because
we talk about the disease, as you know, the CMS calculation has four
diseases.

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

Multiple diseases, right.

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

It\'s really talking about the patient and the set of conditions that
the patient has. Does that make sense? Is that kind of where you\'re
going?

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

Yeah. It would be very difficult to just pick out a pure population of
CHF or a pure population with diabetes.

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

Yeah, I look at my mother-in-law, and she has all four of them, and is
taking probably 20 different medications for them.

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

And the opportunities for interactions, negative interactions, among
medications are probably greater than \--

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

As a matter of fact, as my pharmacology professor told me in medical
school, I still remember this, and seeing him draw the graph. If the
abscissa is number of drugs, and the ordinate is complication, at five
drugs it becomes asymptotic in terms of the likelihood of a drug-drug
interaction.

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

Right. Getting back to the agenda, then, I think we have two things. One
is we need to do some focusing on secure messaging, and how we\'re tied
to the broader charge. We\'ve also talked about some items we need to
support the recommendation letter for the broader charge Is there
anything else we need to do on the secure messaging area at this point?
Do we need to go back to the various demonstration projects that CMS and
the plans had discussed in our telephone call we had last week, Karen?

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

I\'m guessing not. Because we learned a lot on that call, in terms of
the fact that CMS demos are a good place to jump this off and plans are
still focused on very specific things, and we\'re going in a slightly
different direction. But I do think we should go back to the plans. And
don\'t know if there\'s (indiscernible) today, there\'s probably a
listing, we should go back to the plans, and get their input on the
direction that we\'re going right now, and see if they would be willing
to be with us in this process.

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

This is Paul Nichol. I just want to emphasize a point that was just made
about the complexity of patients with chronic illness. At the conference
that we had in the VA last week, it\'s pretty clear that very few of our
patients have only one disease. So using heart failure or diabetes as an
isolated outcome may not give you a true picture of the benefit of your
intervention. Empowerment, improved communication, and increased
participation are a few of the things that work across the spectrum of
diseases in terms of improving outcomes. And so, you know, we may want
to think about the complex patients, and not just focusing on a single
disease entity when we talk about chronic disease.

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

Yeah, I think that makes sense.

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

I think I remember in the first meeting we all had we were discussing
this very topic.

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

Yeah, we were. We\'re kind of getting back to it.

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

Layering of all these.

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

I think it\'s finally coming together.

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

When you get back to where you started, you know you\'ve really got
there.

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

Let\'s sum up, then, for the group. And Karen, I\'ll turn to you, again.

\[laughter\]

The direction we\'re going to go in the next three months, both for the
specific charge and for the broader charge. And it sounds like we\'re
almost evolving the specific charge into being part of the broader
charge, is that correct?

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

That\'s correct. I think we are using the specific charge as the jumping
off point to the broader charge. And I\'m wondering if I might take this
opportunity to jump into 8 for a moment. Jump ahead to 8, and then come
back to 7, which is a nice clear, specific way of ending the meeting.

Many of you who were at the AHIC or listening into the AHIC on the 12th
of September may have heard David mention, Dr. Brailer in his opening
comments, a visioning process that would be occurring in the Workgroups.
I think you know for all intents and purposes, some conversations I\'ve
had with many of you and several of you have had with the facilitator
who is doing this in some of the other Workgroups, have pointed out that
we\'ve essentially done a lot of this work in terms of recognizing that
ultimately, what we\'re looking at is remote virtual care available to
patients specifically with chronic illness, no matter where they are.
And that in order to get that, there are a number of issues we\'ve
identified around financing, around State-based licensure, around
physician adoption, and patient adoption. So you know, there are some
very specific things that we\'re isolating.

So I think we\'ve essentially done most of that work, but what I\'d like
to suggest is that I did have the privilege of attending a conference on
remote care and connecting patients with their clinicians in Boston over
the last two days, as did Jay, and they\'re essentially articulating
those visions and issues pretty well for us, and I think validated where
we\'re going. But I\'m just wondering if you could articulate some of
that, Jay, and see if the Workgroup feels the same way, in which case we
can put together a vision statement and all of that for the next
Workgroup meeting, and you folks can sign it off, or edit it, or
whatever else you choose to do with it.

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

Sure, I\'d be happy to. But with the preface that the likelihood of my,
you know, adequately conveying the superb content and presentation, both
by the presenters, the formal presenters, and the questions and comments
that came from the audience, is going to be very difficult and I\'m sure
I will fall short.

The name of the conference was called Connected Health. It was pulled
together by Partners HealthCare System, which for all practical purposes
was made up of Massachusetts General Hospital and the Brigham and
Women\'s Hospital, a number of community hospitals and affiliations, the
(indiscernible) institute, and put together more specifically by the
Telemedicine program, with its partners, Dr. Joe Kvedar and Dr. Joe
Ternullo. As many of you may recall, Dr. Kvedar gave a presentation to
our group two months ago.

This was really the third conference on the same topic, called Connected
Health, Empowering Care through Communication Technology. And it was
basically an attempt at looking at opportunities, challenges,
(indiscernible) in using communications technology to expand the \--
basically the continuum of care.

If I had to put an overarching statement on it, I would say that in
effect, what they were looking at is moving from a provider-centric
healthcare delivery system, where the provider is defined as the
hospital, and the physician, and the physician\'s office, to a more
patient-centric healthcare delivery system in which the home, the work
site, of the patient, is looked at as the site of care. And perhaps
better stated, they are basically looking at the examination room being
where the patient is, not where the doctor is, or where the hospital is.

And that just \-- that\'s just not a visionary statement, not an
idealistic statement, it\'s a true medical-physiological statement.
Because the question is, is the blood pressure determination better
taken in the patient\'s home or work site, or in the doctor\'s office?
Is the child\'s pulmonary function studies, who has asthma, better taken
in the doctor\'s office, or better taken in the home or in the school,
where they live and are educated?

So that was a major component. And part of the umbilical cord was to
reflect the fact that we\'ve got to stop having medical care being
provided in an episodic or periodic way, and it\'s got to be provided on
a continuous way. And all the implications of both the location and the
continuing component was brought in.

It was very clear that the technologies that would enable this type of
shift are basically off the shelf, for the most part. Now, that you may
take one of one shelf and another off another shelf and try to connect
them together and they won\'t talk to each other, that was made a
specific point. And in fact, the issue of certification and
standardization was a major focus of the discussion with regard to the
enabling technologies.

In fact, there is an enabling organization now that was established in
June of this year, which has grown dramatically. It started as \-- it\'s
called the Continua Health Alliance, and they were a major part of this
conference. In fact, they are continuing their separate conference today
up there. The Continua Health Alliance was made up initially of 22
electronics and health companies who announced a joint effort to help
patients by making high-technology tools work better together. The only
thing I would say is I wouldn\'t use the term high technology in this,
because it\'s no longer high technology. And many of the things that we
need to assess patients are low technology components.

But what they really are doing \-- and let me just for emphasis show you
the importance of this, from the makeup of the Continua Health Alliance.
It\'s made up of Intel, IBM, Cisco, Samsung, Motorola, Philips
Electronics, Medtronics, General Electric, and Partners HealthCare
delivery system. It has since grown, I hope I\'m getting this correctly,
I\'m sure someone will say that\'s the wrong figure, but it\'s grown at
least three times the membership since June of this year, with the same
sort of makeup of quality and size of groups.

And they are looking at addressing virtually all of the issues not only
we\'re looking at in this Workgroup, but with many of the other
Workgroups, particularly the one we\'ve been talking about a lot, the
Consumer Empowerment Group, and trying to look at human factors issues,
the standardization issues, the legal and regulatory components, the
incentivizing aspects of this, who all the stakeholders might be in this
process.

And it was just all to the point, I think the only thing that you have
to be aware of is, of course, all the people who were at the conference
were converts. It\'s a question of who wasn\'t there, that we need to
get their opinions.

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

There\'s one guy. He didn\'t admit it, though.

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

Yeah, right.

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

Keep quiet.

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

\-- how they feel about what happened there. Interestingly enough, when
the audience was queried for an AARP representative, there wasn\'t, as I
recall, there wasn\'t an AARP representative there, and that\'s always
the case. When we talk about the consumer and the patient, and we\'re
thinking about what we\'re going to do for them, they\'re never there.
And that\'s probably because of us, you know, we fall short in who we
expend our (indiscernible).

But just an excellent conference, one that dealt with what we need to
deal with, i.e., outcomes, issues of compliance were brought up, issues
of rehospitalization were brought up, issues of the fact that the
majority of care needs to be given in the home, needs to be given in the
work site. They addressed the privacy and security issues. They
addressed all the payers, from the biggest nonprofit, CMS, to the \--
some of the largest for-profits like Aetna, and there was sort of
generic agreement amongst everybody there that this is the way we need
to go.

Perhaps the only thing \-- and I have to admit, I was the one who asked
a question, that I thought was a little funny, was the fact that during
the Continua presentation, they were talking about what all this
consortium of major employers were going to do for the consumer. It
never got back to the point, and that\'s where I challenged them, of why
aren\'t they looking at themselves as the consumer. Why isn\'t their
director of human resources sitting in the audience, and demonstration
projects that they want us to embrace should be embraced by them.

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

This is Jeff Rideout. Can I answer that, since we\'re part of Continua,
we\'re one of the founding members. Number one, that\'s a very, very
accurate summary of the history. Number two, a number of us have been
asking for more direct consumer representation from the beginning.
Number three, we\'ve approached AARP and ACP about trying to do a
project around the concept like the advanced medical home, where this
would be.

Number four, the group is really designed primarily to standardize and
create guidelines around medical device interoperability, so that the
data is not a rate limiting step on potential reimbursement changes for
those kinds of technologies to be used in nontraditional settings like
the home. And it\'s really the back-end services that are, you know,
would receive data and information from those devices that would really
be able to take off. So the old analogy of beta versus VHS. Well, if we
can solve that one for common medical devices that would be great.

Number five, there are three major use case areas, and only one of them
is around chronic disease, but everybody on Continua realizes that\'s
probably the most important. And I think the answer to your question
about why not the employers, we have talked about it several times in
Continua, and the answer is we all would like to do it, and quite
frankly, our HR department is supportive, because I\'m it, for this
project.

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

We all want you on record \--

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

On record that he talked to himself.

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

Agrees with himself.

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

Yeah. We would pay for this as an extension of our benefits to employees
with chronic conditions.

The challenge always comes back to the biggest payer in the junkyard is
CMS. And what we need to understand is how does that change physician
practice behavior in a way that impacts enough of those patients in that
practice? You know, comes back to the conversation we had the first
week. It\'s like do we want to do a geographic pilot, do we want to do a
disease specific pilot? Well, if you slice it down too many, I just
don\'t have that many chronic care patients that need these kind of
services, I\'ve got a relatively young and healthy population. I know
that\'s different from Verizon and a lot of people, but we still need
the power, the purchasing power and policy power of CMS, particularly
around Medicare patients, to make this really something that the
clinician community is going to stand up and say okay, I get it now, and
I can take on something like the advanced medical home.

John Tooker thinks it\'s a great idea, we\'re just looking for traction.
And traction comes with the money.

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

But Jeff, you are a payer, very much so, and there\'s payment that you
make that you\'re not even calculating, and that\'s, let\'s just take
the Joe Kvedar in his summary statements yesterday, talked about taking
2,000 patients with hypertension and estimating that those 2,000
patients generate approximately 4500 visits to the physician per year at
an average cost of 100 dollars, and that was conservative, 100 dollars
per visit. What was never calculated in that, and which many employers
forget about, is during the two hours that that employee was away
getting their blood pressure taken, they have lost two hours of
productivity.

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

That\'s exactly why we did the work with Palo Alto, and that\'s exactly
why it wasn\'t a pilot, it was everybody that\'s eligible, anybody that
goes to Palo Alto or now any Sutter health affiliate, where there is
secure messaging platform available, Cisco paid for that. So we\'re
trying to say look, this is not about proving the point, yet again if
this kind of enhanced communication can help compliance, save cost and
productivity, this is about how do you move it further, faster. And I
still think even if we do that as a large employer, we\'re still only
hitting at most 2,000 of Palo Alto\'s 200,000 patients. And that\'s kind
of the story wherever we go. So I just want to say I think this all
makes sense, I still think we need employers and CMS behind these kind
of efforts, if it\'s really going to be relevant to the clinician.

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

This is Joyce DuBois from AARP. I\'m sorry to be late, I just joined,
I\'m sitting in for John Rother, and I joined when I heard the speaker
who I don\'t know say that AARP wasn\'t at the meeting that you were
describing.

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

No, no, no; AARP was not part of the founding members of Continua, and I
asked that that group be invited, because we need the consumer
representation.

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

Obviously I agree with that. I mean, I think it\'s really challenging to
bring consumers to the table and to figure out how they belong at the
tables that you are describing. In terms of the kind of input that they
can provide. So we\'d welcome an opportunity to consider that.

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

I did 150 focus groups last year. You know. Double blind focus groups,
and I saw all the tapes of course at my home. No, I didn\'t.

\[laughter\]

And, you know, the research team that worked (indiscernible) findings,
and the findings were really obvious. They were: I\'m a consumer, I need
more data. You know. I need to be able to make better decisions I don\'t
get. Things are too opaque for me to make decisions. I don\'t know the
cost, I don\'t know this, the classic transparency stuff we always hear.
Then we do focus groups on physicians, and they say, well, patients need
to be more active in the engagement. I\'m engaging, but they don\'t
engage. The other side is also obvious, which is physicians are saying
I\'m nervous about the measurement thing, because I don\'t know if you
guys know how to measure me, and those questions come about. On the
EHR/PHR stuff they say, well, I wish I knew what it was because it keeps
morphing, can\'t figure it out.

So I think everyone wants to say the right words. And why isn\'t it rock
bust or win, why aren\'t people standing in line like they stand in line
at Starbucks? There\'s something missing. And that I think is the
charter of this committee.

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

To give everybody coffee, you mean?

\[laughter\]

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

You\'re destroying my eloquence.

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

Addiction.

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

But I think the key is that thing, the missing thing we keep searching
for. We try to throw as many pieces into the mix in the hopes of that
missing thing surfacing. I don\'t think we will ever find the missing
thing. I think what we need to do is find the, like you said, you know,
the necessary conditions whereby you get that.

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

Right. The tipping point that makes you begin to use the service.

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

I think a pilot like we\'re talking about really would drive towards us
understanding what is missing in this combination. We\'ll get three or
four things we put together, and we\'ll discover it ain\'t working, too,
and we\'ll say there must be something else. Then we\'ll add that
variable, and that\'s when I think we\'ll really start thinking on the
committee

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

Let me get back to the agenda here on this. So where are we with the
visioning update, Karen?

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

I think that what we were talking about is I think there\'s no question
that Jay very eloquently reported out the critical points in the
conference, and we really are talking about patient-centric care
anyplace they are, which is essentially virtual care. How do we assure
we provide communications for that to happen? We\'ll take that, we\'ll
take the other comments, and we\'ll put together the first draft of the
vision statement on how this could happen. But the discussion we\'ve
just had about Continua I thought was very helpful. And with Jeff\'s
group being part of this, and many others, and clearly Intel, I think it
would be helpful if we could have presentation and public testimony from
Continua at the next meeting, if that\'s okay.

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

Several things Jay said would also inform the broader charge as well,
Karen. I think the issue of moving to the patient-centric model, moving
to a way where the care is continuous rather than episodic, I think
these are things maybe we should address in the broader charge and
recommendations as well, and maybe we\'ve got enough information that we
can get over the next several months to inform some of the
recommendations related to that.

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

Good. I took very good notes, Jay, but I still might need to call you.

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

Is this an annual conference?

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

Yeah. Yeah.

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

Karen?

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

Yeah.

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

This is Brian DeVore in Seattle. Should you want to engage in Continua,
I know that (indiscernible) asked to do that, too. I happen to sit about
15 feet from David Whitlinger.

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

You\'re breaking up, Brian, we can\'t hear you.

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

I happen to sit about 15 feet from David Whitlinger who is the CEO of
the Continua Group. So if you want me to elbow him at any point to, you
know, provide input on what they\'re doing, I\'d be very happy to do
that.

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

Okay. Well, I think that would be great. You could give him a heads up,
and it\'s October 16. And we will be pulling \-- pretty much the final
discussions we\'ve been having. And just to go back to Tony\'s comments
a little bit earlier, Gloria was kind enough to slip the timeline on to
me here.

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

Now we get real.

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

Now we know the people who do the work over here. November 8 we\'re
going to be finalizing all of our decisions moving forward. On how we
will go through with both, and how we would describe the vision and a
number of other items. But most importantly, it will be an opportunity
for us to essentially go through that draft of recommendations that we
will be making to the AHIC, and then we\'ll obviously have to
just (indiscernible) between November 8 and December 12, when the final
recommendations will be done. So thank you very much, Gloria. You can\'t
make it without your friends, you know.

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

So given that, for the October meeting, what do we need to come to
closure in October, which recommendations are we going to use to begin
to pull together the letter?

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

We need to, we certainly need to come to closure on how we would go
about moving forward with the pilot. So we\'ll get something up together
and might even share it with a number of you beforehand, before that
meeting.

Second thing is that we will need to be fairly clear about how we would
like to describe the broader charge, how we would get to the broader
charge through the vision that we\'ve just articulated. And then
thirdly, we should begin to start crafting, at least thinking through
some of the key recommendations, some of which we\'ve talked about
today. So we will start, we will start that discussion.

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

So I guess getting back to Brian\'s earlier question, do we \-- is there
some work that you want to do in between this meeting and next meeting
with some \-- is ONC going to take the lead on developing some \--

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

We will, yes.

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

Some drafts we can circulate to the Workgroup.

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

The deliverables would be \--

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

Pilot recommendations.

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

And the visioning.

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

The visioning statement, and also crafting some \--

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

Some of the recommendations we talked about.

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

Vision. Recommendations. Okay.

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

And the other piece is we still need to go back to number 7, too. We\'ve
done a lot today, Mohan.

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

Okay, so we\'ve done 6 and we skipped to 8, and Karen, we\'ll \-- I
guess we should move now, since we\'re getting close to 3 o\'clock, we
should move to number 7, then. Do you want to \--

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

Yes, I think this is an opportunity for us to \--

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

Karen?

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

Yes?

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

Sorry to interrupt. This is Jeff, I need to break now, I just want to
let people know I\'ll be off the call.

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

Thank you very much for joining us, Jeff. You all who were on the call
will have to join us come here in Washington.

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

Party.

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

Thank you for joining us today.

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

No problem.

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

I\'ll jump back to 7 for a moment. We had a lot of discussions in
previous meetings about the fact that there are a number of technologies
that are available, and are of use at the present time, with respect to
getting information from the bedside or from the patient\'s phone in to
the clinician.

What we\'ve done is we jotted down a few of the things that that were
talked about, including some from the presentations that were made. We
referred a little bit earlier to Doctors Joe Kvedar and Joe Ternullo\'s
presentation on what Partners was doing, and their need, for instance,
for having at least joint standards for vital signs to be transmitted in
a standardized way that could be certifiable. That actually is something
that came out of the conference as well.

So what we\'re suggesting here, and these are more for discussion rather
than for immediate this is the list, what else are we missing on that
list? What would be the next most important set of priorities that we
really want to move forward with in terms of assuring that there can be
interoperable transmission of information from the bedside or from the
home to the clinician, or in some other format? This is very specific to
the remote care in the chronic care arena.

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

One other recommendation or suggestion, Karen, is remember at that same
meeting that we had where Joe gave a presentation, Adam Darkins also
gave a demonstration. If you actually want to look at the most
comprehensive sort of telehome care initiative, it is in the VA. And
they\'re connecting their telehome care right into their VistA
electronic health care, so we may want to look at what metrics they\'re
using, as well. Because we don\'t necessarily have to, you know,
reinvent the wheel.

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

But either way, we still will need an approach with interoperability
standards.

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

Absolutely.

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

We\'ll need to include those particular critical entities in
certification processes, and move on down the line. And the VA will need
to come to be part of that, as well. That\'s a good point, thanks, Jay.

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

This is Paul Nichol. I\'ve worked with that, and I could certainly get
information if the group is interested.

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

Yes.

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

That would be great.

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

Could we just get a point of clarification on these priorities for the
future, Karen? Is this what you\'re looking at following the broad
charge, is that \-- or what is the \--

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

Well, it certainly can be.

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

Or help inform the broad charge?

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

It\'s helping to inform the broad charge. But it also is looking at what
recommendations will this Workgroup make to the American Health
Information Community. What the priorities are, as we move toward that
broader charge. If we are really moving towards remote virtual care,
what are the first critical steps we need to get there.

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

Okay.

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

I think some of this gets back to I think Jay made this point earlier,
going back to the specialty societies of chronic disease and asking
them, and I think we know to a large extent, but going back and asking
them in providing quality of care, what aspects of remote monitoring
might potentially improve compliance or improve patient care.

And then certainly, you know, for a diabetic ,common readings. Or CHF
patient, weighing scales. For an asthmatic, peak flow. For a patient in
(indiscernible) anticoagulation. We know a lot of the top four, five
high-cost large chronic disease things, but there might be other things
out there. So it would be important to do that inventory, of specialty
societies as well as \-- but I agree, it\'s best to focus on the chronic
conditions and see what\'s in there, rather than doing kind of a broad,
you know, study of what technology is out there. Let\'s not let
technology drive it, lets let the chronic conditions and those involved
with chronic conditions drive it.

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

What we could do, we certainly are going to be hearing from Karen and
the work she\'s done with DMAA, next week, we\'ll be hearing from
Continua next week \-- next month, sorry.

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

Next month.

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

Good thing I was doing a neuro exam on those days. So maybe what we can
do is think through some of the other things that need to be added to
this list over the course of the next several weeks, and then we\'ll
actually go through the prioritization process. So this will need to go
on the agenda for the next meeting.

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

Karen has anyone \-- sorry, Jay.

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

Go ahead.

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

Has anyone considered \-- maybe this is outside of the charter, so you
can kill it immediately \-- the issue that \-- I\'m challenged with
this. Not just about the bar between I\'m healthy, I\'m chronic. But
it\'s the bar between I\'m degrading, and then I become chronic. And if
we are really looking at the objective of avoidable hospitalization and
compliance, shouldn\'t we think a little earlier in the cycle than just
when you are diagnosed as chronic? And should we as a committee be
addressing the band \-- which is already a large band, chronic is a
large band, don\'t get me wrong. There\'s so much in HIT. But if I were
to exaggerate the cartoon I would say I\'m chronic, and then \-- yeah,
I\'m chronic, and now I\'ve got to learn how to use technology. You
know. That\'s the last thing on my mind.

If truly I\'m chronic, I want to see my physician, I want to have a
dialogue, I\'m actively trying to solve this. But the pre-chronic, seems
to be where the research is telling us is where the impacts could occur
for avoidable hospitalizations.

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

Let me just \--

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

Am I overstepping?

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

No, let me underline, do you know, do you know when insulin resistance
first begins, in a patient with type two diabetes? Begins 10 to 15 years
before they become clinically apparent.

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

Is that right?

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

Yeah. Number two. When does a patient become hypertensive? The
fascinating part, and it\'s part of this continuous assessment,
continuous evaluation. My wife is not going to like this, but I know she
walks around with a blood pressure of 90 over 60. That\'s her normal
blood pressure. Okay? And there are a lot of women who have blood
pressures 90 over 60, 100 over 60. All right. When she, when her blood
pressure becomes stabilized at 110, okay, over 70, she\'s hypertensive.
But walk into any doctor\'s office, and they will say she\'s normal. The
problem with our healthcare delivery system right now is it\'s
statistically based, not personally based.

So what you said is totally on line. There is the onset of disease that
is just not clinically apparent by our present clinical parameters. We
have the opportunity, with the kind of things we\'ve talked about at the
conference, that we\'ve talked about at the American Telemedicine
Association for umpty-ump years, to really get into the issue of looking
at the consumer, not the patient, and trying to keep the consumer from
becoming a patient by doing these assessments. 110 over 70 is not a
normal blood pressure in my wife. It may be normal for you, but not in
my wife. And yet every doctor in the world would say oh, normal blood
pressure. And that\'s just one example. One example.

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

So the question I have for the committee, is that an option for
discussion associated with the broader priorities of the future?

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

Well, it also \-- I think so, but I think \-- I think so, but I think it
also gets back to the Consumer Empowerment Workgroup.

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

I know there is a collision.

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

Well, I don\'t know if it\'s collision, but it\'s another point of
intersection that we should coordinate with them. Because they would be
the ones looking at tools that would lead to you deal with some of the
issues that you and Jay were talking about. The fact that if someone has
a PHR and actively monitors their health, then over time they can be
dealing with some of these conditions before they become chronic. I
mean, that\'s \-- or at least, you know, more of an overall monitoring
over time they can be looking at it from an individual standpoint.

And if you have a PHR, and begin using some of these tools before you
get into a situation where it becomes chronic, then it would be, you
know, prevent some of the hospital stays and other types of outcomes we
talked about earlier.

So it seems to me that one of the things we should come out of this
Workgroup today with, Karen, is what are some points of intersection
that we need to explore with the Consumer Empowerment Group, and that
should be maybe a discussion for October, too. Because I think Mohan has
(indiscernible).

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

One of the things I would like to suggest doing, we talked a little bit
about this internally, and God knows on about 9 o\'clock at night we all
decided to give up for awhile. But, you know, we really do need to have
summaries of what each Workgroup is doing across the board, over the
course of the last six months, not just previous Workgroup. That\'s one
thing we talked about doing, we haven\'t had a chance to do yet. But the
other thing we could do is something that we did with the new
Confidentiality, Privacy, and Security Workgroup. They\'re brand new,
they\'re just starting up, so they wanted to hear a very brief 5-minute
summary of what the other Workgroups were doing. So that\'s an
opportunity, we could have someone from Consumer Empowerment come here,
and really just \--

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

That would be great.

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

Ten, 15 minutes telling us what they\'re up to, and vice versa.

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

I think that would be helpful. But I also think just as we decided to
look at privacy and security across a spectrum of Workgroups, we should
look what are the opportunities we have for partnering with them. I
think the summary will help, but maybe between now and next meeting if
we can start saying these are the obvious points of intersection that we
need to explore. I think Mohan has pointed out one of them, looking at
the whole, you know, longitudinal view of a person\'s health, and how we
can tie that in with improving outcomes in the chronic care.

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

But I will say that this is absolutely correct, and we really do need to
do that. On the other side of the coin, if we really think through,
though, about where we\'re going with concepts of virtual care, and what
are the big enablers and big barriers for patients to get, for
information to flow in such a way they get the care that they need,
where they need it, and when they need it, it does encompass that whole
piece. From (indiscernible)

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

Exactly.

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

I think the real charge of this Workgroup is to look at all the
barriers, and enablers, of making sure information can flow so that the
right decisions get made, wherever the patient is. So they won\'t have
to go check into the office all the time.

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

Again, the standards of interoperability, and all the rest of them.
Right.

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

By the way, the one chronic disease that we haven\'t mentioned today, so
we\'ve got to make sure we have it on the record, which is most frequent
in the United States. One third of the population has a chronic illness.
Obesity.

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

Would be obesity.

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

Right. By the way, I have a patentable technology for that. It\'s a
scale; when you step on the scale, the refrigerator locks.

\[laughter\]

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

What a great way to conclude this very productive meeting.

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

Let me know when that company goes public, would you?

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

Karen, do we have more items to cover today before we move to public
comments?

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

I think we\'re okay. Except for the public comments.

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

This is Paul Nichol. I\'m sorry, but I have to drop off for another
call.

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

Thank you, Paul.

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

Thank you, Paul. Matt, are you ready to poll the public?

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

Yeah, there\'s some information up on the slide, if people are following
along on the Webcast they\'ll see a phone number and instructions for
queuing up to make a comment. And if there are some members of the
public already with us on the phone, they need only to press star 1 on
their phone to queue up. And we\'ll wait a minute for people to get
through, and I\'ll jump in and let you know if we have anybody join us.

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

All right, and I would also just like to encourage anyone from the
public who may be listening, who believes that there may be an entity or
group out there that would be appropriate public testimony for the work
that we\'re going to be doing next week, to please let us know.

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

And to e-mail.

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

That\'s right, the e-mail is up there, too.

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

Anybody up yet?

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

Just as a reminder again, the next meeting is October 16. Call
information will be available in the usual timeframe beforehand. There
is a November meeting on the 8th, and then there is an American Health
Information Community meeting on December 12.

And just as a little bit of a reminder, even though the meeting is on
the 12th, all of our materials need to be completed by the 30th of
November. So we have the rest of September, October, and all of November
to complete our work, and that\'s the timeframe at that point.

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

Okay, Matt, do we have any public input?

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

No, we don\'t.

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

Okay, Brian, do you want to move for adjournment?

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

Yeah, I guess we should wrap things up.

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

So move.

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

Okay, thank you everybody.

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

Thank you very much. Good meeting today.