American Health Information Community

Chronic Care Workgroup Meeting

March 22, 2006

1 p.m. EDT

**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.*

\>\> Moderator: \-- the call to order. I can mention that when we review
the call-in procedure.

\>\> Tony: Okay. Great.

\>\> Moderator: Okay. And, Matt, your line.

\>\> Matt: Thanks. Tony, you can go ahead.

\>\> Tony: Okay. Good afternoon. This is Tony Trenkle from CMS and Brian
Devore from Intel. We\'re getting ready to call the meeting to order
here. I will ask now, Karen Bell, if you could have your staff review
the call-in procedures and the FACA guidelines please.

\>\> Karen: Thank you. Matt, would you do the call-in procedure please?

\>\> Matt: Sure. This time, for all Workgroup members, you have an open
line throughout the conference, which means that you can speak at any
time. The only thing that we ask is, when you are not speaking, please
keep your line muted so we don\'t get any chatter during the conference.
And when you do come on, since you won't be announced, please identify
yourself so we know who is speaking. Additionally, if you are logged
into the Webcast interface as a Workgroup member, please don\'t touch
any of the controls, because any changes you make to the display will be
streamed live to everybody who's watching it. Karen, do you want to
review the FACA guidelines before we do a roll call?

\>\> Karen: Yes, I'll do that.

\>\> Matt: Okay.

\>\> Karen: I just wanted to underline the fact that only the Workgroup
members are allowed to participate in today\'s call, except for the
public call-in period at the end, during which time everyone can
contribute. We do have a number of presenters today. They will be
available for questions and answers during the time of their
presentation. But any other comments they may have will be added in with
the public comments at the end.

In addition to commenting and addition to today\'s call, there is
information that can be received in a number of other sources. Number 1
is our Web site. Our Web site makes available to the public all of the
materials, the minutes, the discussions, and any documents that have
been thoroughly vetted by the Workgroup and are ready for recommendation
to the American Health Information Community.

In addition to that, we also have documents that are in development and
may be discussed from time to time at these meetings. Those are not yet
available for public comment; they are work in progress. As a advisory
committee to another Federal advisory committee, the American Health
Information Community \-- all recommendations go directly to the
American Health Information Community. They do not go to the public.
They do not go to the Secretary or to any other Federal entities. So
this Committee, or this Workgroup, functions to provide information and
recommendations only to the American Health Information Community.

From time to time, members of this Workgroup may be asked to give
presentations in other venues, and in those circumstances, it is clearly
appropriate to present anything that is on the public Web site. However,
anything that is still in deliberation or still in discussion should be
withheld. And if, by any chance, anyone is sharing personal opinions
from his or her constituency group, that certainly must be underlined as
such. So as a Workgroup member, the only information that can be shared
in a presentation venue is that which is available on the public Web
site.

So I just wanted to make sure that all of those guidelines were clear. A
number of questions have come up around some of them over the course of
the last few weeks, and wanted to articulate them before we move into
the meat of this meeting. And I think I will turn this back to you now,
Matt, and you can begin by the introduction of the participants. And we
will start by having the members in the room introduce themselves, if
that is all right. Thank you very much.

\>\> David: Karen, it's David Brailer. I'm here with you now.

\>\> Karen: Oh, good. Thank you, David. Brent, would you be willing to
make a few comments then as soon as we have gone through the
introductions?

\>\> Brent: That would be great.

\>\> Karen: Thank you.

\>\> Jay: Good afternoon, everyone. This is Dr. Jay Sanders, and I\'m
from the Global Telemedicine Group and also President Emeritus of the
American Telemedicine Association.

\>\> Giovanni: Good afternoon. This is Giovanni Colella. I\'m the
President and CEO of RelayHealth.

\>\> Matt: Is that it for the room?

\>\> Karen: Yes.

\>\> Matt: Okay. Joining us on the phone we have Mike Krist; Joe
Gifford, who is a designee today for Mohan Nair; Mary Naylor; Paul
Nichol, who is a designee today representing Department of VA; Jeff
Rideout; Joyce Dubow, who is a designee today for John Rosser
representing AARP; and we have co-chairing the meeting today Brian
Devore from Intel and Tony Trenkle representing CMS.

\>\> Karen: Thank you. Dr. Brailer, could you open the meeting with your
comments please?

\>\> David: Sure, Karen. Let me thank everybody for taking time to
participate in today\'s call and also just a special thanks to all of
you that have contributed to the Workgroup or as Co-chairs or in some
other capacity. I know that we have taken a large amount of your time,
but the importance of this topic and the critical nature of the
Workgroup's deliberations is something that is very much worth that
time.

We\'ve made great progress. At the last American Health Information
Community, there was a substantive discussion about the topic of this
Workgroup as well as others, and that discussion was really focused on
how do we go about getting something done that can be both visible in
the short term and give us a real foundation for growth in the long
term. And there is no place that has more importance in the emergence of
both short-term and long-term solutions than in the area of chronic care
and particularly in the area of how we use technology to move us away
from the treatment and cure paradigm \-- treatment paradigm into the
prevention and cure paradigm. And I think this \-- even though this
topic that we\'re looking at for the near-term breakthrough was quite
small, secure messaging, we see this being the beginning of a very long
movement of the industry towards ways that can allow more remote
services and more access to services around the patient rather than
making them come around health care itself.

You have a lot of work to do between now and 60 days from now, when on
May 16 the Workgroup will present to the American Health Information
Community. You have to go from where you are to be able to come forward
with a variety of specific actionable recommendations that can be made
from the American Health Information Community and to the Department of
Health and Human Services. They should be focused very much on this
near-term breakthrough of secure messaging. This is not only because we
want to stay focused on that narrow topic but because we see that as a
precedent for many of the things that come to follow after it. This
near-term breakthrough needs to have recommendations made in May or, if
not, in the meeting immediately following, if we're able \-- if we would
be able then to have time to develop the policy changes that are needed
to see something that could be visible to the American public from a
year after the time that we announced it, which was last January. So for
us to have something next January, we have to be able to have
recommendations in May that gives us a chance to make the long-term
changes that are needed and policies or regulations or other processes
within the Department.

I hope that while the Workgroup goes through its task, that it thinks
about its challenge being one of making recommendations. It is not an
operational body, obviously. It is there to essentially make advice and
to tell the Department and others what it thinks they should do. But I
hope the pallet that you use is painted broadly. Certainly the
Government needs to have advice about how it is that it has intelligent
policies on this topic. But I think that you should feel challenged to
give advice to any other constituent or segment of the industry: what
consumers could do, what doctors should do, what health plans, whatever
it might be. And I say that because even though the FACA is
traditionally chartered to be an advisory body to the Department, and
that is your primary obligation, we\'ve set this up as a private-public
partnership, for these workgroups are bringing together the best minds
of government and private-sector thinking in this topic, and we
recognize that it takes the coordinated actions of government and
private sector to have the kinds of results that we all want to have.
Therefore, I hope you will take that challenge and think about who
should do what.

Now, after we get these recommendations through this process, we can
then have a chance to turn to some of the much bigger, broader topics in
the broader charge. But I do hope, in the short term, you will stay very
focused to help us get needed actions around this short-term
breakthrough so we can begin actually getting traction on this for the
American public. I\'m really proud to have you all working on this
topic. This is something that has been overdue for change, and I think
it is time for us to really step up to the plate. So with that, let me
again say, "Thank you very much." Thank the Co-chairs for their very,
very good work and the staff of both of them, who have worked so hard
for this and my staff that have supported this process. I just encourage
you very much to think critically and diligently about what it is we can
do here. Thank you, Karen.

\>\> Karen: Thank you. Tony?

\>\> Tony: Yeah, thank you, David. I think next on the agenda, we're
going to move towards a recap of the previous meeting and review of
acceptance of minutes from the February 23 meeting. Has everyone gotten
a copy of the February 23 meeting minutes to review?

[\>\>]{.mark} Yes.

\>\> Tony: Are there any comments? Okay, if there are no comments, I
would move that we accept the minutes of the 23rd meeting.

[\>\>]{.mark} So move.

[\>\>]{.mark} Seconded.

\>\> Tony: Next, we\'d like to move on to the action items. We had a
number of action items from the previous Workgroup meeting, and we can
go over them just briefly. Many of these, Karen, are yours. Would you
like to go through your action items first?

\>\> Karen: I certainly can. Starting on page 11, my first task was to
put together a list of potential opportunities for existing
infrastructures that existed around the country with respect to secure
messaging. We are well underway on that project, and we will be sharing
the details of it in a preliminary report with the Workgroup members
over the course of the next week or 2. We\'ve not yet completed the
task, but we have been able to move forward with it quite a bit. So I
apologize for not being able to present it formally today; it is still a
work in progress.

\>\> Tony: Okay; thank you, Karen. I guess the second one was on the
issue of standards and interoperability that Dr. Barrett had raised.

\>\> Karen: Yes, and the response to that is that the use cases on \--
for this particular \-- for all of the various workgroups have been sent
forth to our infrastructure contractors, those involved with
interoperability and those involved with standards, the HITSP channel.
While there was not a specific use case for secure messaging, many of
the issues that are relevant to secure messaging were also defined by
the other workgroups. So we anticipate that the \-- our infrastructure
contracts, again, those that are involved with the standards and
interoperability, will be reviewing those issues \-- reviewing those use
cases, and we hope to be setting up a meeting shortly with the
infrastructure contractors and for the various workgroups at one time to
address those issues, because they are truly cross-connecting across all
workgroups.

\>\> Tony: Okay. Thank you, Karen. There\'s a couple items in the next
steps that I believe \-- one was the brief summary of the Workgroup\'s
activities, and a project management overview of possible solutions that
can be involved in the next year, and an updated list of Workgroup
members.

\>\> Karen: The updated list of Workgroup members should have been made
available to everyone. We do have some new names on the list. This is
the final list. We do not anticipate any further additions or changes.
And that list is available or will be available on our Web site. The
project management overview has been deferred because of the importance
of developing these high-level recommendations that Dr. Brailer
mentioned a little bit earlier. As we move forward with these
recommendations, then, we will be more in a position to move forward
with the broader charge and the workplan around that.

And then lastly, in terms of possible solutions and tools in
populations, we have gathered for you today a number of presenters that
we believe will begin to address some of those issues and concerns and
will lead to a lively discussion about the development of the possible
recommendations. And what I would like to close with in terms of our
action items is that, building on Dr. Brailer\'s comments, we clearly
need to develop a list of high-level recommendations that will describe
an entity that will perform a very specific action, and I would also add
the \-- why that action is so important. As we move forward with that
discussion, we have gleaned and pulled together a number of discussion
points \-- topic discussion points that will hopefully lead to what will
be the deliverable at the end of this meeting. And that is a list of
recommendation\-- and I\'m calling them concepts, because over the
course of the next 6 weeks, we will need to flesh these out, do all of
the appropriate wordsmithing, and develop a letter of recommendation no
later than May 1 for the Secretary or for the AHIC and then to the
Secretary.

And I\'m just going to jump forward for a moment to Number 9, because
there is a list of timelines here that will be important for us to
follow. As we develop the concepts, we will also be outlining the
outstanding issues and a plan for resolution, and this needs to be done
by April 14 so that by the week of April 17, we can have at least the
first draft of the detailed recommendations in a letter format so that
the entire Workgroup will share, review, edit, comment on the week of
the 24th, so that by May 1, as I said earlier, we can finalize a letter
and some slides.

So that\'s my followup on the action items. And thank you, Tony.

\>\> Tony: Okay. Just one other thing on the action items: there was an
action item from \-- for CMS for Herb Kuhn to find out whether CMS has
similar types of programs working with RHIOs. Unfortunately, Herb could
not be here today; however, he did give me an update. They did do some
research into the current programs that we have, and they are not
currently working with the RHIOs, but there is some interest from some
of the program participants in potentially working with a RHIO if that
opportunity presented itself.

I believe the only other item before we get to the presentations is a
recap of the AHIC. And Karen, if you don\'t mind, I\'d like to just give
some feedback from Mark from the AHIC meeting, Mark McClellan, who
unfortunately could not attend today. Most of his comments are pretty
similar to some of the discussions we had last meeting. There was a lot
of feedback from the AHIC on leveraging existing programs for secure
messaging, which coincides with some of the comments we had on
geographically based efforts that would take advantage of existing
infrastructures. Second, \[[indiscernible]{.mark}\] secure messaging as
part of overall health IT and a single or separate approach \-- one of
the comments, I believe, that Dr. Brailer had made, that secure
messaging can work most effectively as part of a PHR or EHR. One of the
questions that Dr. McClellan had is, can we incorporate something like
this in our upcoming initiative? The issue of reimbursement is a major
one. And I know, Karen, we're going to be discussing that later on. That
was another point that came up in the AHIC discussion, and also getting
the patient involved, showing the opportunity for patients to save, can
\-- and can also provide incentives for adoption. So those were Mark
McClellan\'s comments that he felt came out of some of the AHIC
discussion. I don\'t know if there's any additional discussion, Brian,
that you or any of the Workgroup members who were at the AHIC might have
as well at this point.

\>\> Brian: We\'re pretty much in line with your assessment at this
point. Karen, there is one point, Karen, on the \-- kind of a
housekeeping issue, backing up to the membership of the group. I think
most of this is on your Web site, but is there a way you can get this
distributed to the Workgroup members?

\>\> Karen: Absolutely.

\>\> Brian: A little more detail? There is some stuff that may not be
available to the public or we may not want to have available for the
contact information that would be nice to have.

\>\> Karen: Absolutely. And I do apologize; I thought it went out with
your packet.

\>\> Tony: I don\'t think we received it, Karen.

\>\> Karen: Okay. Then it will be momentarily in your hands. Thank you.

\>\> Tony: Is there any other feedback on the AHIC presentation before I
turn it back to Karen for the presentations? Okay, Karen, did you want
to introduce the presenters, then?

\>\> Karen: Yes, I\'d be happy to. Thank you, Tony. We have for you a
series of six short presentations today. And the thought was that we
would start with the very broad presentation, thinking about really who
are the chronic care patients that are in our charge and how can their
needs best be met. From there, we will begin to have presentations from
physician community, from payer community and others. But I\'d like to
start off by introducing Dr. Joanne Lynn, who is from CMS as well as
also from the RAND Corporation, to describe for us a model that really
defines chronic care patients from a very different perspective. Thank
you, Joanne.

\>\> Joanne: Glad to be here. Are the slides up? I see them now. Can
people hear all right with the mic?

\>\> [Tony]{.mark}: Yes.

\>\> Joanne: Okay. I\'m going to \-- I know most people on the call,
like me, spend most of their time pretty much up in the details of
whatever it is we are trying to do. This little presentation will invite
you to step back a little bit and think pretty broadly about the
populations we\'re trying to serve, because I think that you will find
it is very useful in imagining the priorities of the different kinds of
people and therefore what kinds of things health information technology
might serve. I\'ll give you a short history of how we got into this.

Next slide. \[Quiet discussion of how to progress the slide show.\]
There we go. They are rather magically showing up for me here.

Most of us who have done any clinical work know that the first
categorization we think patients have is sort of age, gender, and
disease. And so we think in terms of \-- and I\'ve drawn it here \-- the
rows of disease by disease by disease. When you get out in the world of
trying to make practice work, you discover that instead it\'s like the
next slide, which is setting by setting. So we think in terms of paying
hospitals or working in a nursing home. We organize most of health care
by setting. And as all of you know, if you look at the next slide, what
we really have now is a huge number of people who are running up most of
our bills who have multiple chronic conditions and who need multiple
settings of care. And one of their problems with this is, we don\'t have
a way of think being this population. We\'ve thought about "Is this the
best nursing home for dementia care?" or "This is the best hospital for
heart failure care" or measures of quality in those sorts of settings
and also the ways we pay for things. But now we have people who have
multiple conditions, need multiple settings, and we don\'t have a way to
think about what is really optimal care.

So, we\'ve been working some on what that could be. And the better
concept clearly can\'t reflect exactly how we now arrange providers, and
we can\'t set up systems that defend the current dysfunctions; that is,
keep things in their rows or columns. We can, however, become quite
patient centered and anchor in the service to the patient. We can\'t
have \-- one by one, build a care system around each individual patient.
But there are shared priorities and groups of patients, and so the most
creative idea going here is enabling the point-of-service customization,
but with the background of building a system around the shared
priorities of groups. And so we\'ve tried this out fairly extensively
and serious illness in the last years of life, which is a huge
proportion of Medicare\'s endeavor.

Next slide. And very interestingly, it turns out that most people on any
given day are healthy, and what you want from the health care system on
a day you are healthy is not much. You want standby 911 and some
prevention services occasionally. But you don\'t really want your doctor
involved in your life, and you don\'t really do very much in terms of
your own care, except for lifestyle and self-care kinds of activities.
As you go along in life, and for a few of us most of the time, you have
some mild, chronic conditions, the kinds of things you live with,
asthma, diabetes, hypertension. With some upkeep, you mostly live pretty
well. And still you don\'t want the health care system involved in your
life in any ongoing way. And what is really striking, of course, is that
almost all of us get a tour through the last little sliver, and the last
little sliver is less than a couple percent for the under-65 crowd. But
for the over-65 crowd, it gets to be more like (depending exactly how
you define it) something like 6 to 10 percent at any given time. And
almost all of us get a tour through it. It could be that there are just
hundreds of ways to travel through this piece of your life.

But it turns out that almost all of us end up with one of these three,
and \-- give me the next slide \-- I will just walk you through the
three pretty quickly. The first one is the prototypical dying course,
where the y-axis here is people going from very high function to low
function and the x is time, and the left side of the diagram is where
you start getting sick, and the right side is where you are dead. And
people go along really doing pretty well until some point in time in
which they, in the language that I grew up with in West Virginia, start
"failing." And when somebody says, "John is failing now," you better go
visit him, because he\'s not going to be around long. It turns out that
for most solid-tumor cancers, for example, almost all real loss of
function, taking to bed, doing badly, is in the last couple months of
life. So it is fairly concentrated. This was the image behind hospice,
and it's the only image put forward in the movies. So all of dying is
the model. Only about 20 percent of people actually follow that model.
Slightly more follow this one, which is going in and out of the
hospital, the revolving-door patients. The heart failure, lung failure
patients are the most common, but other organ system failures as well,
where there is a background slow decline, but the big thing that marks
the course is these enormous exacerbations and then a rather sudden
dying. And disease management does a decent job at trying to reduce the
number of exacerbations, but we also need advanced care planning and
mobilizing services to home for the end-of-life courses. And that one is
probably now about 25 percent of the population.

Most common already is the end of this dwindling course. This is the
multifactorial frailty. About half of us who follow this course have
dementia, long term, many years of self-care disability. The big
services needed are family support, personal care, keeping the skin
intact, just enduring with the patient and family through the whole
course. And already, about 45 percent of us follow this course. And to
the extent that we are better at delaying the onset of cancer and heart
disease, we will have more and more in this course.

The real charm to this, if you see the next slide, is that if you build
a care system around three different obstacle designs, you would cover
almost everybody. And there are counties in Sweden that have designed
care systems around Esther with colon cancer, Esther with heart failure,
Esther with dementia. And it turns out that if you build a care system
in which everyone can count on good care, almost everybody can. That is
profoundly simplified. And it also is commonplace in ordinary business.
Think if you were managing Marriott hotels. Would you build just one
kind of hotel? Of course not, although that is how we built the health
care system: one kind of health care system. And you can\'t wait to
design the hotel until the sleepy person shows up looking for a room.
You know, you can't just say, "Well, let's design it radically around
every person's individual preferences." The trick is to design different
hotels around the priorities of the likely population. So you build a
different hotel in an interstate interchange or a resort or a downtown
business location, and then you customize so you still can get a fax
sent at a resort, but it is not going to be in your room. Same kind of
thinking works for health care. If you build systems around a few
populations and still customized at the point of care, it looks as if
you could do a very good job at serving almost everybody. So this is a
sort of intermediate between radically patient-centered care and kind of
a one-size-fits-all to create an interface of finding the relevant
subpopulation.

And the eight that look like it may be enough to work with are the
healthy, the moms and babies, the people who are truly acutely ill \--
now, this is not hospitalization, because most of hospitalization is for
chronic conditions. This is the people who truly were healthy just a
short time before and for whom we have something to offer that will
return them to health. The chronic conditions that you live with are the
fourth population, the sort of hypertension and asthma. The fifth
population are people who are quite disabled on an everyday basis,
needing help in their ordinary lives, never going to be substantially
better than that, but are also quite stable and are going to live a long
time. The sixth population, seventh, and eighth are the ones I have just
gone through. It looks as if you could classify almost all people at any
point in time into one of these eight populations. They have shared
priorities, and they have shared providers. So it gives you a really
strong way in which to think about relevant populations.

This is an initial estimate of the numbers of people who are in each
population in the whole country. The dollars per person per year \-- you
have to make some generalizing assumptions to come up with this; it is a
first guess or first estimate, and then of course multiplying those as
to how much money we are spending where. And often, if people look at
this, it is quite illuminating just sort of where the money really is;
also, of course, who it is who is paying for it. So Medicare, for
example, is the dominant provider for the fifth, sixth, seventh, and
eighth population. There \-- it probably shares the fourth, and the
first, second, and third are mostly out of Medicare. The VA has a
similar population. Medicaid, of course, picks up huge numbers of moms
and babies. So the commercial populations are heavily the first, second,
third, and about half of the fourth. So to the extent that Medicare is
following the lead of commercial populations and deciding how to deal
with quality measures or payment issues, they\'re missing that
Medicare\'s main focus needs to be on those last four populations,
which, if you look at them, are a huge proportion of the overall
expenditures.

Go ahead; next slide. Next slide. There we go. If you look at the
Institute of Medicine's \[[indiscernible]{.mark}\], for Care, you get
these six, and you can array these six against the eight populations and
end up mapping quality for all populations. Go ahead; next slide. And
here is just a couple examples of one or another of the populations. How
much money is spent on them is in the heading. And then if you look on
the list, you see the IOM aims. The second column gives you a
population-based interpretation of what those aims would mean for that
population and then some of what would occur to at least me and the
group that is working with me as the HIT opportunities. What is
striking, as you start looking at these, is they are somewhat different:
that the heavy priority in serious chronic conditions on continuity is
not really as strong on acute or healthy populations, so that the kinds
of things that are important to achieve in each population may be rather
different.

Go ahead and show the second of these. Next slide. And this is the
difference \-- this is the organ system failure of the seventh
population, the sort of erratic course, and the kinds of things that
would arise there. I think if you just look at the two \-- first and
seventh, how people would interpret the IOM aims and then what kind of
things that leads into as information technology opportunities, you will
see that they are different enough to be an important organizing
principle.

Go ahead to the next slide. So here are some of the common themes for
HIT that go across all of them. And of course, all of you know these.
These were more put here to remind you of the kinds of thing that become
important. Some of the things that may not be in your usual list is that
for some of our populations, 24-7 communication is just terribly
important. For some of the population, being able to access their care
plan and continuity is terribly important. For others,
self-actualization and managing themselves are much more important.

Go on to the last \-- the next slide. Again, one of your standard lists
was the kinds of issues that go into trying to figure out how to apply
these across these populations. You can take each of these issues and
try to figure them out population by population. And then the last
slide. I like closing with this map from the 1600s just as a reminder
that we have a lot to learn. In the 1600s, the Age of Exploration,
people were proud of having figured out the world was round and still
making a lot of mistakes, and that is pretty much where we are in trying
to figure out how to build a care system that is going to match a
population in which double the number of those last few populations with
a tremendous load of serious illness coming at us with the aging of the
population and trying to put in place the infrastructure we need in
order to serve that population in time.

Thanks, and I\'ll be glad to take comments or questions.

\>\> Karen: The floor is open. Thank you very much, Joanne. Jay?

\>\> Jay: This is Jay Sanders. Joanne, just a suggestion: in your slide
matrix, claims of excellence fall under "Crosshatch. You have your final
column saying "Etc." And if I were to make this slide, with all
humility, it would be the "Etc." column, which is probably the most
important setting, because to me, the most important setting for caring
for a patient is not in my office and not in a hospital. It\'s where
they live and work. It\'s their home. And in fact, me seeing them \--
and I think I mentioned this last time \-- seeing them in my office is
almost a reflection of the fact there was something wrong in the care
process.

So we need to get away from almost perceptually viewing the care process
from a structural standpoint on the location, as opposed to a more
continuous spectrum of \-- the care process goes on all the time, and it
is predominantly from a time standpoint occurring outside the office and
outside the ER, which is at home. So I probably would put under "Etc."
\-- because you have all the other places listed \-- I would put "Home."

\>\> Joanne: But let me agree with you on one part but push back a
little on a different part. I certainly agree that the continuity and
the care process needs to be continuous, that there is just outrageous
waste and error in the handoff and lack of handoffs and the kind of
acceptance of failure to plan ahead or even have a plan in place. That
part I would certainly agree with. I think that the \-- it is a
different thing in the eight populations to apply your idea of seeing
care where the person lives and works, to use your phrase; that the
healthy person who really needs basic health information, a little bit
of prevention activity \-- the health care system shouldn\'t be very
much a part of their life. It should be, in a sense, on standby. And
\[[indiscernible]{.mark}\] hit by a truck or has had a terrible fever in
the night, there ought to be a way to get the services you need. But
really, people should live their lives. And I think much of actually
chronic conditions works that way once you have the person understanding
their chronic condition and managing it well. We\'re on standby in the
health care system. We shouldn\'t really be easily entrenched in their
lives. But there is a piece of time for almost all of us, for all of the
life for some people and for the end of life for all of us, in which we
are very sick. And the health care system becomes very important in
everything else we can do.

So it is not quite the case to have the image that it is all happening
sort of \-- it is happening where the person is living, but the person
may in fact be living a great deal of times in hospitals, in nursing
homes, in SNS. The end of life now on average is 2 to 3 years of
self-care disability. So if most of us face a substantial period of time
in which, on an everyday basis, someone has to be feeding us or changing
our clothes or taking care of our skin or something like that, to the
extent that we continue to call that part of health care and not somehow
part of supportive housing or something, that is a really intimate
connection and the health care really does have to be there with you. I
would agree that it is not generally in the office. But I think this
kind of laying out of the populations at stake to help illuminate how
you would see it differently mobilizing services to where the person is.

\>\> Karen: Is there any other questions or comments?

\>\> Brian: Yeah, this is Brian Devore at Intel. Excellent presentation.
There's a couple questions I had, trying to \[[indiscernible]{.mark}\]
comments that would be in line with what Dr. Barrett would do, although
they are probably not as well-thought-out. As you have broken down your
populations by healthy, can you offer clarification? One of the things
that, obviously, the Workgroup has focused on is treating those with
current chronic conditions. How do we improve that? I\'m interested in
your population, Number 1, which is healthy. Do you have a breakdown as
to how that 170 million would break down? I think there is a huge
percentage of population which we could label even "prechronic" or
"prediagnosed" chronic conditions or "worried well," which people would
consider themselves healthy but concerned that they are heading off into
a bad space. Do you have any kind of information as to how that care \--
that category is broken down? Because I think if the Workgroup just
focuses on who is currently chronic and how they improve that, there is
a wave coming in that group, Number 1, that would be potentially labeled
healthy which is going to drift into the lower categories quickly. I'm
not sure I am making myself clear, but \--

\>\> Joanne: The principle by which we sorted these populations was
really by having shared priorities and shared needs for a certain model
of care. So it\'s easier in many ways to see the paradigmatic case than
it is to parse out exactly where you place a boundary. You could say
that everybody with a risk factor in a sense has a chronic condition.
But I think that since all of us have risk factors, it is not terribly
helpful to sort everybody into having some kind of a chronic condition.

So if you think of the sort of ordinary person with no particularly
diagnosed illness and no felt illness and who is, you know, pursuing an
ordinary life shows up at the doctor, you know, every once in a while
either with an injury or with a sort of routine checkup, that\'s the
sort of paradigmatic case. And some of those people will have risk
factors, and the doctor may well be smart enough to say, "You really
ought to stop smoking," or, "You really ought to lose weight," or, "You
ought to exercise more," or whatever or, you know, "Given your family
history of diabetes, there are some things you could do to try to reduce
your risk." But I think that the fact that this would be almost all the
office space, these are almost all ambulatory people, these are almost
all people who can readily get information off the Web or in printed
form or in other public venues, makes them a group that has a shared set
of service needs and a shared set of priorities. The transition to
having a chronic condition would be where a person has identifiable
condition that requires that they exercise attention to the upkeep in an
ongoing way. So they need, for example, group education on how to manage
diabetes, or they need \-- they would really benefit from having a
hotline to call as soon as they started feeling the least bit short of
breath, so that exactly where to draw the boundary is going to take
spinning out of this and for exactly what purposes. But here you would
want to have much more self-care education, group support, classroom
teaching, those sorts of things in Category 4. I think you find the same
thing around many of the categories, that you would not necessarily want
to spend a lot of time at this point exactly on the boundaries but to
think about the paradigmatic case in the middle. Is that helpful?

\>\> Brian: Yes, I just \-- that was the biggest number I just wanted to
see, thinking down the road several years as to how that number shifts.

[\>\>]{.mark} Can I comment on that? I don\'t mean to confuse the issue,
but the whole issue of what we\'re defining as healthy is going to be
totally redefined shortly. Fundamentally, from a genomic standpoint,
once you come in and give your blood and have a genomic profile, you
will have a much better idea of what the concept of healthy is. That is
Number 1. Number 2, there is a whole group of, quote, \"healthy people\"
out there right now who don\'t know it, nor does the health care
delivery system know it, but they are not healthy. They actually have
\-- they already have beginning insulin resistance. We know from a
scientific standpoint that patients with type II diabetes actually
develop their insulin resistance metabolically upwards of 10 to 20 years
before they become clinically apparent. Number 2, we know the whole
issue of hypertension and what is normal and what isn\'t is totally up
for grabs today. As an example, if \-- I know my wife\'s not going to
allow me \-- not going to like that I\'m mentioning this, but my wife\'s
blood pressure is 90/60, normally. If she came into the doctor\'s office
with a blood pressure of 110/70, that doctor would define her blood
pressure as being totally normal. Yet in fact, it\'s not, because her
normal blood pressure is 90/60, and over a period of years, that blood
pressure is going up within the normal range. Do we call that "normal,"
or do we call that "prehypertension"? We really don\'t know, and I think
it\'s a \-- it\'s difficult, as reflected in your question and in the
response, to really define what healthy means and put a number to it.

\>\> Joanne: Let me just respond briefly. I don't want to take up the
issue that you laid out, but to only point out that in many ways, the
charm of this laying out of it is this direct \-- that kind of question.
So yes, you could redefine things so that you had essentially no healthy
and everybody had a chronic condition. You'd just then have implications
on what you do with it. But the laying out this way turns out to be very
fertile in focusing the questions that are useful.

\>\> Karen: And I think particularly, Joanne, your construct allows us
to recognize that the chronically ill fall in multiple categories. Each
of them have different needs, but all of them have needs, as Dr. Sanford
suggested \-- I\'m sorry: Dr. Sanders suggested \-- for remote care. And
clearly, the ability to communicate with one\'s physician-clinician is a
very important piece of that. And in the interest of time, I\'m going to
ask if we can move on now to the voice of the physician-clinicians. Dr.
Michael Barr, who is familiar with the Workgroup construct, because he
has done biosurveillance work, is going to give a brief presentation
from the American College of Physicians on the physician\'s perspective
with respect to remote care and secure messaging. Are you available? Are
you on the line, Michael?

\>\> Michael: Yes, I am; thank you. Can everybody hear me all right? I
presume if you can\'t, you will let me know. Thanks for this opportunity
to address the Workgroup today. Speak for the next few minutes about a
model of health care, which the college refers to as the advanced
medical home. And while the model is ideal for patients with chronic
conditions, it is meant to be applicable for all patients and
populations, such as those just discussed by Dr. Lynn.

Our model incorporates many of the elements expressed by our colleagues
in pediatrics and family medicine. It is based in part on the chronic
care model developed by Dr. Ed Wagner and his colleagues at Group Health
Cooperative. We extend the principles and describe the voluntary
practice qualification process and the reimbursement framework, which we
intend to explore further in a paper scheduled for release early this
year.

First, I want to describe the model on the imperative for exploring the
ideas and then describe how the use of health information technology and
in particular secure messaging is integral to the successful
implementation of the full model, and you've already sort of spoken to
some of those issues with respect to trying to reach the patients in
each of their locations where they reside. The key principle underlining
the advanced medical home is the acknowledgment that the best quality of
care is provided not in episodic illness or in complaint-based care, but
through patient-centered, physician-guided care that is cost efficient,
longitudinal, and accomplishes and values both the art and science of
medicine. This is the type of medicine most physicians want to deliver
and most people want to receive, and a person is \-- You are advancing
my slides too fast.

Unfortunately, our current environment doesn\'t support such a model,
and we are reaping the consequences of not living up to this
expectation: variability and quality, cost, satisfaction, the projected
collapse of primary care across the United States resulting in a
shortage of primary care physicians just as Baby Boomers reach the age
of 65. The National Resident Managing Program occurred last weekend; it
indicates stable number of U.S. medical school graduates entering
internal medicine residency training programs. However, data from
internal medicine residents indicate a continuing trend for those
residents to pursue medical subspecialties over primary care. Fewer
students are expressing interest in primary care as a career, and data
from residency questionnaires administered in 2005 found that only 20
percent of residents graduating were planning careers in internal
medicine, compared with 54 percent in 1998.

There are likely many reasons, but the educational debt occurred by
medical students compared with the economics of primary care, the
perceived practice hassles associated with cognitive medicine, and
lifestyle issues are probably at the core of medical student choices.
The advanced medical home and the call for changes in reimbursement are
just two of our advocacy efforts aimed at addressing these critical
issues.

And now we can advance the slide. With this brief background, let me
describe the advanced medical home in a bit more detail, which I
summarized in just a few bullets. The full paper is online, and I've
provided the link to this paper and other [agency]{.mark} references on
my last slide. The advanced medical home is a system-based care model
which practices organized delivery of care for all patients according to
the care model, which includes team-based care. They use evidence-based
medicine and clinical decision support tools to drive appropriate care
decisions. They coordinate care and partnerships with patients and
families. They provide enhanced and convenient access to care, which
would include secure messaging, and the provision of appropriate
non-face-to-face clinical care as described by one of the callers
earlier. They would identify and measure key quality indicators, such as
those endorsed by the Ambulatory Care Quality Alliance, and use health
information technology to promote quality, safety, security of
information, and health information exchange. Men also participate in
programs to provide feedback on performance and accept accountability
for process improvements and outcomes. These last two bullets are key,
because the college envisions a voluntary qualification process for
practices that adopt the model, which is an entry pass to enhanced
reimbursement. While it is conceivable the practices could use
paper-based systems peppered with components of health information
technology, it is likely that only until health information technologies
are embedded in part of the everyday workflow that practices would be
able to achieve the highest level of health care described in this model
and be able to provide true transparency into the structure, process,
and outcomes measures that both the public and peers want to assess.

Next slide. The reimbursement framework we had described is two core
precepts. It should acknowledge the value of both providing and
receiving coordinated care and a system that incorporates these elements
and also align incentives so that physicians and patients would choose
medical practices that deliver care according to these concepts. We
believe that the reimbursement system should provide enhanced
compensation to support practices that voluntarily qualify for the
advanced medical home designation and deliver care according to the key
attributes, and that such a system should provide patients incentives to
select qualified practices as their medical home.

Next slide. So the components of such a compensation model would include
an incremental strategy for reimbursing \-- reimbursement starting with
a link to infrastructure development, then reporting of quality and cost
measures, and ultimately reward practices for their performance and
outcomes. It would recognize coordination of care across all the domains
which people access health care, and we've already had a nice discussion
about that \-- would support the adoption and use of health information
technology for quality improvement. A key point here is that we envision
such support as a condition upon participation and quality improvement
and reporting programs which, in turn, would require that health
information technology adopted would support such reporting of data. It
would include payment for provision of enhanced communication access,
such as our secure messaging and telephone consultation, and remote
monitoring of clinical data. There should also be nonmonetary
incentives, such as reduce administrative requirements for qualified
practices. And from the patient perspective, one quick example of being
\-- of incentives we envision could be enhanced coverage or broader
coverage than is typical and reduced coinsurance for people to select to
receive care in an advanced medical home.

Next slide. This slide is a simple list highlighting the ways in which
secure messaging can and should be used in support of patient care.
Communication is key to the advanced medical home model, both between
the patient and his or her family with the practice, between
hospital-based physicians and ambulatory care practices, with
consultants and outsourced support services such as enhanced answering
service companies, disease management contractors, consultants, remote
monitoring agencies, and others. Messaging is critical to eliminating
the drop-off of quality and information as patients transition from one
domain of the health care system to another. The advanced medical home
emphasizes the patient-physician relationships and central coordination
role of qualified practices to avoid further fragmentation of care,
especially for those with chronic conditions. It also provides a
framework to reimburse and support primary care physicians and
specialists who choose to restructure their practices and participate in
quality and reporting programs. Implemented correctly, we believe that
this model and the corresponding reimbursement framework has the
potential to enhance the quality of care; drive health information
technology adoption; respond to the calls for transparency with respect
to quality and cost of care; and, we also hope, revitalize primary care
by attracting medical students and residents who are now choosing
subspecialty medicine rather than primary care.

And I'll stop there. The last slide has some references to speak to that
highlight \-- take you directly to the particular papers and other
statements, and I'm happy to answer any questions.

\>\> Mary: This is Mary Naylor. I really like the way that you have laid
out this work and this role. I also wanted to highlight that on \-- our
team here at Penn has been testing a model of advanced practice nurse
and nurse physician collaboration that is exactly modeled on some of the
premises here. We've had four NIH clinical trials that have tested the
approach to this model. It reinforces your core elements, but it also
helps us to understand that there are many models of care that enable us
to achieve these outcomes. So clearly, the nurses played a major role in
care coordination, working in collaboration with physicians. Our
clinical trial findings across all of our studies have demonstrated
improved quality outcomes and decreased health care cost, substantial
health care savings, when compared to traditional care. So as we look at
these as a framework for thinking about secure messaging, we ought to be
thinking about how this approach can be \[screech\] \-- I think that was
for me \-- accessible to many different types of providers, many
different models of care, especially those that \-- for whom we have a
rigorous science base.

\>\> Michael: I agree with you. I think that the emphasis here is also
on team-based care, of course, recognizing that 20 percent of our
physicians in the College or practicing physicians that are members of
the College are still in solo practice and 50 percent are in practices
of under five physicians. When we talk to them about teams, sometimes it
is a little difficult explaining. But I think this model would drive
appropriately new models of care where there are more interactions
between different types of health care providers and where they are all
working toward the same goal, of course, taking care of the patient
across all these different domains. And the more you have those kind of
teams, the more important the kind of messaging we're talking about
becomes.

[\>\>]{.mark} Great.

\>\> Joe: Hi, this is Dr. Gifford at \-- Joe Gifford at Regions Group,
Dr. Barr, and thank you so much for this presentation.

If we're interested in taking cost out of the system, I \-- it leads us
to ask \-- to pose this question. If you're actually looking to de\-- to
eliminate the visit model of primary care, I \-- it appears that in your
position paper, that the reimbursement and the revenue changes are
oriented towards making PCPs whole in this new world. That is, if I
don\'t have so many visits, you have to make me whole with a different
revenue model. And I guess we\'d ask you what would be the point of view
of your \-- of the ACP or view \-- if we suggested that that might not
happen, that that might add cost and that really \-- what would happen
if we learned only one-third of docs are good at chronic care, and that
those one-third of docs had their caseload go way up and their revenues
certainly made whole, and they have a different infrastructure
underneath them, but the two-thirds of PCPs lost those patients and
actually lost residents?

\>\> Michael: Well, I mean, it is a complicated question, and I don't
have an easy, quick answer. I think one of the concerns, of course, we
have is that we already project some access issues with the decrease in
primary care and not just internal medicine, family medicine,
pediatrics, and I think we need to raise all boats. And I think one of
the efforts to colleges is trying to make \-- is to try and educate our
members about "This is the direction you need to go to provide health
care in a way that we\'re describing and be accountable to the outcomes;
you need to get health information technology." But the environment to
some degree isn\'t right for many of these physicians, who are in
essence small businesses and trying to make ends meet.

So we would be concerned about anything that would potentially reduce
access as physicians choose not to go into primary care for a model that
would further erode the reimbursement base. We think that there are
plenty of costs wrung out of the system, and there may be \-- there may
wind up being redistribution of some revenue to put the value where it
needs to be placed. I\'m not sure I\'m answering your question entirely,
but I think in essence, we would be concerned about something that
disenfranchised further primary care physicians and those considering
entering those kinds of practices.

\>\> Joe: I think you've accurately put your finger on what we \-- this
committee would consider a barrier or a serious issue, which is that
your constituency wants all boats to be raised, and the purchasers
behind the scenes are saying there is not enough water to go around, and
that is a serious issue for this committee. So thank you very much for
\--

\>\> Michael: You\'re welcome. I, of course, wanted \-- if you read the
paper, we do call for demonstrations and pilots on this, because there
needs to be some modeling with hard data and results using technology
and different stages of technology adoption to see how \-- what is
required and what is essential. One of the projects that we\'re also
leading here is a new center for practice innovation, which was a grant
funded by the Physicians Foundation for Health Systems Excellence. We're
going to pilot some of these strategies and 25 to 50 practices across
the country and learn from it. We\'re going to model some of the
financial impact of what they adopt, what they don\'t adopt, some of the
quality metrics, and we\'re also looking to do this a little further and
more in depth with partners.

\>\> Karen: Michael, this is Karen Bell in Washington. What I\'m
wondering is, what percent of health care dollars right at the moment is
going towards primary care physicians? And if this sort of a model were
in place, where would the savings come from?

\>\> Michael: Well, I can't \-- I don\'t have that statistic for you,
Karen; I don\'t have that at my fingertips. I think the goal here would
be to take a good look at the system and the costs and where they are
being accrued, and, you know, there is high variability, as you know,
between \-- or I should say negative correlation between cost and
quality. And trying to improve that equation is what we\'re aiming to
do. So I don\'t have a good number for you.

\>\> Jeff: This is Jeff Rideout from Cisco. Some of the experience we
had with systems of health information technology being available
through secure messaging suggests that the offset is significant and it
is usually in the decrement in pharmaceutical prescriptions and/or the
higher cost of offices that can otherwise be handled synchronous through
secure messaging. So \--

\>\> Karen: Thank you. Any other questions of Michael?

Well, we\'ve heard from the patient population. We\'ve heard from the
provider, i.e., physician populations and the nurse practitioners. And I
think that everyone would agree that the third leg of the stool is
payer, and we have a presentation now with Blue Cross Blue Shield of
California that has been working with RelayHealth, and Dr. Giovanni
Colella is going to give us a perspective from the payer point of view.
Are you all set to go, Giovanni?

\>\> Giovanni: I'm all set to go. First of all, thank you very much. I
just want to specify, I\'m the CEO of RelayHealth, so I'm more from the
private-sector point of view, although we work very closely with the
payer and obviously with Blue Shield of California. I want to thank you
very much for inviting me. And we have been at this since the year \--
what is it now \-- 2000, so 6 years. We have scars on our back, know a
little bit how this works, and I will try to make a long story short,
but people argue that an Italian can\'t do that. I will try hard.

This has been a very interesting 6 years. And just to give you, first of
all, a framework of who is using the system and how many people, there
is currently 5,800.

Please next slide. Thank you. I have to get used to this magic of slides
appearing in front of me without controlling it. Thank you very much.

There is currently 5,800 physicians actively using the system, and by
"actively using it," we mean physicians that are communicating with
their patients. There are actually many more systems \-- physicians that
have signed up for this, but we don\'t count them because we can\'t run
statistics against the physicians if they are not using it with a
certain intensity. For the \[[indiscernible]{.mark}\], I just looked
this morning; it's 5,892, but who is counting? And 530,000 consumers
that are using the service \-- that, I wasn't able to get it up to
speed. I'm more focused on how many doctors. The reason I\'m focused
that much on how many doctors as the CEO of the company already gives
you \-- gives away what the gist of all this is. And that is that the
real challenge that we are going to face in front of us is doctor the
option. I mean, there is a lot of concerns about abuse of this and use
of this. So the biggest issue we found in the past 6 years is really to
get doctors to start using it, and that is a challenge we have in front
of us every day.

We launched a partnership with Blue Shield of California \-- this was in
the year 2000 \-- and they sponsored a landmark research study. And the
results were quite impressive. I mean, they were impressive even for a
true believer like myself in this. We showed an office-based cost
reduction of \$1.50 PMPM in a very high consumer
\[[indiscernible]{.mark}\] satisfaction. I'm not going to dwell too much
on the study now. This is published on our Web site. We advertise it all
over. I pretty much walk around with that study in my pocket, so I can
give it out if you want. And we rolled \-- Blue Shield at that point
decided to roll it out to broad members base across the HMO and PPO
product lines. And at that point, we \-- our company somewhat
quote-unquote "took off." There is a little grandiosity in that, because
with 5,000 physicians using it, talking about taking off is sort of
funny. But at this point, we are working with six Blue plans, three
regional plans. We will hopefully start working very soon, and by the
end of Q2, we plan to announce we are working with two national plans
and quite a few medical groups and big academic medical centers:
Stanford, Hopkins Care Group \-- actually I\'ve noticed that whoever
prepared the slide for me left out my alma mater, and it's Columbia,
which is working within \-- quite a few physicians at Columbia
University are doing that.

Let me give you a quick overview \-- could you please give the next
slide? Thank you \-- a quick overview of what we do. And in this slide,
please focus on the fact that you will see that there is a trick to all
of this, and there is a little-known secret that not everything in
communication is reimbursable. And that really creates a very
interesting dynamic in a very strategic issue on getting doctors to
adopt. You will see that we have a reimbursable piece of this, which is
called the webVisit, and then there is a lot of other stuff that comes
free to consumers and is really not reimbursed to the doctor either. So
the reimbursable services, the webVisit \-- I will just quickly give you
an idea of what this is and how the concept started. The webVisit is
really a series of questions driven by some type of intelligent branch
logic in which a patient signs up through a secure Web site to
communicate with their physician. And I insist on the word: it has to be
\"their" physician. One of the things I\'m strongly \-- until I'm going
to be running the company, we will always live by the fact that it has
to be "your" doctor or "your" care manager or "your" nurse, but somebody
that knows you and not a doctor in the box.

And with that also comes a lot of free services that get used quite a
bit. Patients use the personal health record, and actually, the
interesting thing is, when they start communicating with their doctor,
the personal health record actually gets populated \-- believe it or
not, really gets populated by active usage, so taking data from the
messages and from communication with the physician that enrich the
personal health record as the communication continues. And very
important chronic care reminders \-- automated chronic care reminders
\-- they can do refills; e-scripts; or, you know, make it electronically
with all the pharmacies in the United States, appointment requests,
referrals, lab test reporting. Each one of these would require a lot of
explanation exactly what they are. But to give you an idea, the entire
gestalt of the system is \-- the webVisit is only the Trojan horse that
really gets the buy-in from a behavioral standpoint of the physician,
because there is reimbursement for that. There is a lot of other
"stuff," in quotes. that comes with it that makes the system very
robust.

And last but not least important, with all these patients using it and
physicians using it, what we noticed after a while was "surprise,
surprise" to all of us that the chronic population was using it much
more. People that are healthy usually don\'t particularly care
communicating with their doctor too frequently, and they're not going to
spend the time to go align and send messages or things like that. So it
became very interesting, immediately as it appeared to us, that without
even wanting it, we had created a disease management system that allowed
us to bring the doctor or the care manager or the nurse \-- and I insist
on this, because it is very important to understand that this is
something that, although it's centered around the physician, can be used
by all the providers of care with that patient and so brings really back
the physician to what the original role was, to coordinate and lead the
care, but brings very knowledgeable professionals to then help in that.
And we created a PHR record with that.

So I just put this slide, you know, the webVisit review, just to give
you an idea briefly of what happens. And here the physician gets the
personal health record of the patient which a \-- with a message. But
the message is not a rambling message that goes on \-- you know, the
doorknob syndrome, each one of us which practices seeing that, right?
The patient goes on for half an hour and, at the end of the half hour,
tells you, "Oh, by the way, I have excruciating chest pain," and so you
start all over again. No, this cannot happen with this message; it's
actually very detailed, very to the point. And physicians \-- the 6,000
physicians that are using it actually love it, because it saves time and
it makes them have a very precise information on what that patient is
looking for.

Interesting, at that point, we started launching prescheduled care
reminders. I think here, what fascinates me of this and gets me up every
morning excited about what we\'re doing is the fact that this is just
tip of the iceberg. I mean, we\'re really now starting to scratch the
surface, and as was said before me and very appropriately, we have no
idea. We are still dealing with the fact that the world is flat and
trying to figure out how to make it round. It is \-- there is so much
going on on the chronic side that we can do with this system. The way I
like to look in a nutshell is from a business standpoint. We're like \--
we \-- all we\'re doing by doing this is, we\'ve put the cables into the
doctor's system and connect the doctor and the patient. And now we can
push so much content through that cable that it\'s just exciting to look
at it.

I personally \-- and I\'ll end; I only have a few slides \-- but I
personally went to this myself recently. Both my father and my mother,
who live in Italy, are treated by physicians in the United States.
Unfortunately, my mother just passed away, but they were treated by
physicians in the United States through the use of our system. And we
were coordinating the care between my sister, the care manager, and the
nurse that was taking care of my mother with advanced Alzheimer\'s,
saving us time, cost, emotional burden, and \-- you know, you name it,
and it was there. So it really \-- I really saw the power of this. And
the prescheduled care reminders that my father is getting for his
hypertension have achieved that fact that a 76-year-old Italian man who
has never been on a diet in his entire life has actually managed now to
lose weight and try to stay in shape, because he gets a reminder from
his own physician regularly. And he is exceedingly excited about that,
because he feels that his physician is actually really taking care of
him.

I\'ll end by saying that there is a value proposition for both payers
and providers on this. It\'s pretty obvious this cost savings \-- the
studies have shown that we could dwell for hours on \-- there was a very
appropriate question about where do the cost savings come from. Jeff has
outlined very clearly what we have seen, this office visit substitution.
But then, on top of that, there is really the fact that a lot of
ancillary services that are very expensive get avoided, because there is
a constant followup with the patient. So you create a whole different
environment for care. It is a wonderful platform from chronic care and
community-based initiatives. I really say "wonderful," because it allows
you and allows the physician and allows the health plan, by the way \--
they own the claims, and we \-- like it or not, claims are the still the
best way to do predictive modeling and to try to understand where there
are gaps in care and where we can reach out to patients and find out of
that. It also creates for the payer market different
\[[indiscernible]{.mark}\]. You know, Blue Shield really went far with
this. And there\'s a lot of member satisfaction. I mean, at this stage,
I\'m 48; I\'m right on the edge of the age 50, when we start costing the
system a lot. And I am demanding that my doctor communicates with me
through the use of messaging. I mean, just \-- the Baby Boomers are just
all \-- for us, it is unconceivable that we can communicate with our
priest or rabbi, our accountant, our lawyer, anybody we want and not
with our physician this way. From the provider standpoint, there's quite
a few studies out there show efficiency, clinical productivity, revenue
potential. I mean, this has become first a revenue potential through the
webVisit; believe it or not, the webVisit is costing very little. Think
about it. There is an average of 2.2 office visits per year. We have
average of 1.8 webVisits per year. It's really not that much used. The
webVisit is the interesting piece that gets the doctor to start using
the overall system. Where really there is revenue opportunities here is
on the pay-for-performance initiatives. And that is what we are really
seeing; that is where the incentives really get aligned. I mean, I hate
the term "pay-for-performance," but it is a wonderful platform, and this
is one of the many technologies \-- and it's only one of the many
technologies \-- that can help you do that.

And interoperability for the provider is of key importance. There is a
lot of argument. Should this be part of the medical record? Should this
be part of the personal health record? My position here and the position
of our company, which \-- I have been wrong many times, so this may be
just one of them, but we need to be interoperable. Seven, 8, 9 percent,
depending on statistics you look at, are use \-- of doctors in the
United States are using electronic medical records. It will grow. We
really hope it will grow. In the meantime, this is deployable, and it
takes about 15 minutes to start using our system. And it takes us
service people about 4 to 5 hours to train a whole practice on the
workflow management to do this. So it is a predecessor to the PHR
deployment.

Conclusion from this and recommendations. There\'s several commercial,
available secure messaging systems. So, you know, needless to say, you
should look at all of them. There are some really good ones, some less
good ones. There are really some very, very good people working on this
for many years, good even if they are competitors; I have to admit that:
they are really good. Blue Shield of California is the plan that started
with this, and they're really innovators, but we have quite a few plans
that are now working with us.

I would say that in the private sector, my \-- major challenge now is
not convincing a health plan to pay for it. Our pipeline is the
strongest I\'ve seen it in years of health plans that are asking us to
sign up. We are actually turning down health plans, because we are
looking at geographic concentration. The biggest issue is the third
bullet point: physician adoption. That is the biggest challenge. And
keep in mind that if you want to use this system with physicians to
promote chronic care, you have to have the physician having \-- the
physician needs to have a big share of their practice that is using it.
It is very difficult to go to a physician and tell them, "Well, use this
with your four diabetic patients and, you know, six hypertensive
patients," and it gets only 5 percent of your practice. They are just
not going to change their workflow and way of using it if it is just for
those patients.

It happens naturally that when 2,000 talented physicians start using it,
guess what: the 80 or 100 that will use it most are the ones that are
\-- the ones that we need to communicate with their doctor. It has to be
interoperable. It has strong potential to reduce health care costs and
improving health and chronic care outcomes. I think that this is
something that needs to obviously people need to kick the tires and test
it, but that is why it brings me to the fact that I would strongly
recommend pilots on this. And you know, as a vendor here, I would tell
you: having CMS support and reimbursement on this will have a really
dramatic effect on adoption and impact. A question I get \-- I speak to
doctor practices every day, and every day, I get the question, "Well,
where is CMS on this? What does CMS want to do on this?" So I obviously
recommend that CMS at least considers a pilot on this so we can study
the macro- and the microeconomics of this in more detail. I thank you
very much. And I actually did manage to make a long story short.
Unbelievable.

\>\> Karen: Thank you very much, Giovanni. Excellent presentation. And
now the floor is open for questions of Dr. Colella.

\>\> Joyce: This is Joyce Dubow. I have a couple questions. First, is
\-- are the services that are available to the patient available if a
webVisit has not been initiated?

\>\> Giovanni: Yes, let me \-- yes, it is a modular system, so you could
theoretically use the system and just turn off the webVisit and just
give the other services to the patients. Yes.

\>\> Joyce: That's within the control of the physician?

\>\> Giovanni: That is in the control of the physician, correct.

\>\> Joyce: So that theoretically, if a patient hasn\'t requested a
webVisit with her doctor, then she might not have available the
additional services, the transactional services?

\>\> Giovanni: I don\'t know if I really understand the question. So if
a patient has not done a webVisit with the physician, they may not have
the other \--

\>\> Joyce: Suppose she had a routine office visit but wanted to take
advantage of some of, you know, the appointment requests, referral
requests online, the transactional kinds of things. That would be
available to the patient nonetheless?

\>\> Giovanni: Absolutely. And that is actually what is used quite a bit
for followup, appointment scheduling, and labs. Absolutely.

\>\> Joyce: The second question I have is whether you have any
experience with this system with an older population \-- with Medicare
beneficiaries, for example; whether they actually access the system to
use the Web tools to \--

\>\> Giovanni: That is a great question. I thank you for asking me this,
because it gives me the opportunity besides my father and my mother, who
used it quite a bit, but I think those are two biased data points.
Although I've made storylines, I\'ve been a consultant at BCG for many
years, so we learned to make data points --- entire regression analysis
on one data point. And so I could answer that question based on those
two data points, but no, the thing is this: yes, I was quite surprised.
When I started the company \-- well, let me start \-- I\'m not the
founder, but I feel like it. When we started the company, we really
thought that this was going to be a system for, you know, the 40- to
50-year-olds and usually well-educated. Well, we are finding out that
the over 65 that are using it are, first of all, the fastest growing,
and it is enormous. It's incredible. I don\'t have exactly the numbers,
and I can give them to you, but it\'s used quite a bit, and it is
growing really fast in that patient population.

\>\> Joyce: Thank you.

\>\> Jeff: This is Jeff Rideout from Cisco. By way of personal
disclaimer, I was the Chief Medical Officer at Blue Shield that's helped
implement this program, but I\'m happy to lend my experience to the
Workgroup if this type of service is of interest in our recommendations.
And we\'re actually working now with our payers as well as our large
providers to try to extend the rollout of this kind of service,
including RelayHealth, for our employees in the coming year, so I have
some familiarity with it.

And also, by way of apology, I need to drop off for about an hour, and
then I will come back on. Okay?

\>\> Karen: Okay.

\>\> Tony: This is Tony Trenkle from CMS. I want to make the point once
again that CMS reimbursement for secure messaging is not on the table
for this discussion. We had asked that that point be removed from this
discussion, so I\'m going to make the point again that it is not on the
table. There does need to be discussion about reimbursement, but it is
not focused on CMS reimbursement. I will make that point once again.

\>\> Karen: I would like to point out, Tony, that the slide does not say
"CMS," and our presenters are expressing their own points of view. Any
other comments or questions?

\>\> Mohan: Yeah. This is Mohan Nair. For those who are not familiar
with my background, I\'m the Chief Marketing Executive and Executive
Vice President for Regence Blue Cross Blue Shield here for the four-Sate
region \-- not all of the Blue Shield but a portion of the Blue Shield
Blue Cross network here in the four-State region. I noticed the speaker
addressed the issues of Blues. Can you be specific about which Blues
were the ones that are adopting or have adopted the technology thus far?

\>\> Giovanni: Yeah. Let me go by memory here. So let\'s start from the
East Coast. We have Empire, Blue Cross Blue Shield of Massachusetts,
Blue Cross Blue Shield of Florida, Fall\-- no Fallon health plan is not
a Blue; we have Blue Shield of California; we have Wellpoint, which was,
you know, Blue Cross; Anthem; in your region, we have \-- well, there's
a pilot \-- no, it's not a Blue, so I take it back. I'm sorry. I think
that\'s it on the Blues.

\>\> Mohan: Thank you. My second question is, I noticed that in the
presenter\'s presentation, which I think is cohesive, I would like to
challenge a concept and would like the committee to address it. This
concept of value \-- I noticed that there\'s significant slides on value
to the payer and value to the physic\-- I\'m losing it \-- the
providers. I would like to address the issue of value specifically to a
patient or a would-be patient. And what exactly are the two or three
immediate return elements that you can see occur with this adoption? And
what kinds of individuals pick this up beyond others?

\>\> Giovanni: Yeah. Good question. I think I touched it tangentially.
It's a very good point, and actually, I should probably put it in the
slide, because the patient comes first here. First of all, it depends on
what time \-- the time value of \-- you know, the value of time and how
do you monetize that. I mean, the number one thing is access and the
time it takes to have this access and what type of patients use it most.
What I said is, we really see a dramatic drift towards chronic
population \-- the chronic population, which is very interesting. The
one that you really don\'t capture the value is disease management
program, so not the really, really, really sick. You really see a
patient population here who has diabetes; hypertension; who \-- very
interesting that I was going to ask the question in the beginning \--
mentally ill; emotional patients, patients with emotional disorders, and
then you see a lot of patients, you know, with their children \--
pediatric and, you know, women at work and things like that. I \-- we
have all that breakdown. I will be happy to send it to the committee at
any time. But that sort of captures what is the immediate value: access;
time; and, you know, then there is an unquantifiable psychological value
that I just went through myself with my family of having access to your
caretaker directly and knowing that you don\'t have to sit there for a
callback, but it is ubiquitous and asynchronous, and you can get it when
you need it, and you know it\'s going to happen.

\>\> Mohan: The motivation for my statement or question is founded on
the concept that payers always are asked to endorse a cost savings and a
value from that cost savings over any technological implementation that
anyone wants to do. I think it is very important to look at value
associated with the actual users of the technology in being able to get
them to adopt actual changed behavior, and that has to be driven through
the member; i.e., the individual who is the patient or the would-be
patient. I\'d like the committee to address that issue specifically when
we think about technology adoption in real powerful terms so that we
know exactly how we get widespread adoption, as is required by the
Workgroup\'s charter.

\>\> Jay: Well, this is Jay Sanders. I think the literature is rich.
Certainly in the generic literature of telemedicine, that has
significantly shown a dramatic enhancement in compliance on the part of
the patient, resulting in decreased rehospitalization. There are
multiple studies that have been done both in chronic disease patient
population and the elderly for congestive heart failure, for chronic
obstructive lung disease, for hypertension, and in the younger age group
in terms of asthma. So if you are looking at that as a behavioral
modification and as a value to the patient, that would be one area.

\>\> Mohan: Yeah, I appreciate that. I appreciate that. I would like to
frame a further point if I may, if I\'m allowed to, Mr. Chairman. Is \--
the question I\'m asking is really \-- the literature does show that,
and I do endorse that very strongly. The issue is, does the literature
enable more use from people who are chronically requiring care? How do
we enable that? Beyond the technology, we do have to address how we get
adoption, and it is not driven by literature; it is driven by consumer
behavior, hoping that we can get to that point at some point, agnostic
of the technology choices really fundamental about behavior change.

\>\> Brian: This is Brian Devore. One of the \-- based on your point on
value, one of the key components I think being left out is \-- maybe I'm
not seeing it \-- is value to \-- if the funders of health care \-- CMS
on one side, but it would be the private employers who see benefit by
approved populations of their employees. There should be
\[[indiscernible]{.mark}\] chronic conditions. So what are your ways \--
how do you spur adoption? That's a component that we potentially could
look at, is the employer piece, which \-- put that on the table.

\>\> Karen: Are there any other questions or comments about this part of
the presentation?

All right. In that case, we will move on. As I\'ve indicated, we've
heard a little bit about patients, a little bit from physicians, a
little bit from the payer community. And I think that what we are
hearing is that there clearly is value or appears to be value in the
system, including a positive financial ROI. However, that's not the only
outcome. And I think that what we are looking for are two other
presentations coming up shortly. One is by Danny Sands. And if you are
ready to go, Dr. Sands, we will ask you to talk a little bit about
really what are the guidelines for use of secure messaging, because it
certainly can be used in many different ways. And if we are thinking
about using it in any type of constructive format, could you move
forward with your presentation, please?

\>\> Danny: Yes. This is Danny Sands. I\'m on, except I\'m in an
airport, and I just arrived. I don\'t know if there is another
presentation that can come first. I am just getting my computer set up
for the presentation. You can either give me a couple minutes or place
another presentation here. I\'m sorry for that.

\>\> Karen: Well, I will just ask if John Linkous is available to talk
with us a little bit about the evaluation methodology \-- all the types
of outcomes. Are you ready to go, John?

\>\> John: Sure, I can talk.

\>\> Karen: Okay.

\>\> John: I am always available to talk, as my staff tells me.

\>\> Karen: All right. In that case, can we move the slide to \-- we\'re
all set to go? Okay.

\>\> John: Great.

\>\> Karen: You will finish up in a little bit, Danny, before we go into
the HIPAA issues.

\>\> Danny: Thanks. I will be ready in just a couple minutes.

\>\> Karen: Thank you.

\>\> John: Well, let me talk a little bit about \-- I'll have to talk a
bit about \-- evaluate secure messaging. Start out by saying a little
confession: I am a long-time user of probably insecure messaging with
both my general physician and dentist, that we are pen pals, I guess,
over the Internet. But I\'m ashamed to say that neither of them get paid
for it. So I think I have a little something to make up for. I was
intrigued. And I\'m sorry, Dr. Colella stepped out for a moment, because
he gave a reference that he is limiting the participation of doctors
who, quote, \"knows you\" in his presentation. And there is a question
that I have for him at some point about what he considers \"knows you.\"
There is a lot of State legislatures who have weighed in on that lately,
saying "knows you" means they have to have an in-person physical exam of
the patient before there can be anything done online. And I think that
is a concern, though as we move forward, that is one of the things I
would hope that this group might address in terms of that issue.

I\'m a little wary when we talk about evaluation questions by
policymakers and really what is behind it. Many years ago, there was
something in Washington called the evaluability assessment. I don\'t
know if anybody remembers that. That is a great thing. A lot of
consultants made a lot of money off of it. But basically, it was a
theory that before we evaluate a program, we have to figure out why it
was done to begin with. Let\'s look at what it was evaluated for,
because in terms of public policy, why Congress adopted something and
that program actually died, is why nobody knows about it now, because
they found out with all the programs they were evaluating, there was no
agreement on why Congress agreed to actually have the program to begin
with. So there was a lot of questions, and as we get into this, I\'m
just a little afraid as we get into evaluation, we might end up with the
same thing.

We can move to the next slide. When we look at evaluation of
telemedicine as a whole, certainly in secure messaging, there is really
three factors that are looked at. We certainly touched upon a couple of
them already. And those are access, cost, and the quality. And there
have been studies done that touch upon all three; some of them kind of
blur over one or the other. And I think it is important to keep those
three in mind, because they interrelate.

And so I\'m going to probably do this presentation by asking more
questions than providing information. Again, I think it is really
critical to this group, as you get into assessing secure messaging and
what works and what doesn\'t, to look at some of the factors. For
example, we turn to the next slide on cost. The big question is, cost
savings for whom? And I think we already touched on that.

Again, the next slide. There are really four factors in evaluating the
cost. First, of course, is for the patient. Is the patient saving money
or gaining value over some alternative way of getting the health care,
either looking it up online, going into an in-person visit, going to a
hospital, going to an emergency room or parent care? Is there savings in
terms of travel and in terms of the \[[indiscernible]{.mark}\] time for
the patient? What is the evaluation of that?

We move next to the provider and "Are their cost savings for the
provider itself?", meaning reduced overhead cost and moving to online
messaging in some cases or perhaps reduced time, or otherwise known also
as improved productivity. Can you see a number of patients very quickly
and provide services to those patients using secure messaging?

And the next slide. We go to the number one, which probably a lot of
folks on the table are looking at, and that is cost savings for the
payer, in which case we are really talking about reduced cost for the
provider services. And that may imply paying something to the health
care professionals that may be at some rates different than you would if
somebody was coming into the hospital or into their office. It may also
lead to reduced hospitalization or reduced cost due to reduction in some
associate type of illnesses or extended care. If you get into chronic
care populations, it could very well be, as studies have shown, that
secure messaging allows you to see and monitor that patient on a regular
basis. That also \-- and let me digress for just a moment \-- gets into
the issue of what really is secure messaging and how does it relate to
such issues as remote monitoring, transtelephonic monitoring that has
been going on and has been approved by Medicare, although I am not
getting into Medicare at the moment, but also approved by many other
payers. That is an ongoing, essentially, gathering of information from
the patient. It is not as an alternative to going in to see the
physician and gathering the electronic means and going into some kind of
a reading or diagnostic testing facility and getting feedback from the
physician that way. And it is also related indirectly to storing forward
telemedicine, where images are sent and consultations are being made. So
at what point is secure messaging being used for information, health
information, checking up with the patient? At what point are we talking
about consultations and diagnoses being done? Very significant
differences when you talk about payment, when you talk about results and
outcomes. Finally, the other cost factor is for the community as a
whole, which is a little bit harder to measure perhaps, but if you look
at total health care cost reductions through improved health status and
improved health access, I think those are factors as well.

So we look to the \-- next slide, please \-- on quality. There are three
factors primarily used in looking at the evaluation of quality: one is
diagnostic accuracy \-- when someone talks to someone or provides
information via e-mail, how close are you looking at that diagnostic
accuracy; of course timeliness, which we all assume would be improved
using secure messaging; and the appropriateness of care, the
appropriateness of the advice or services that are delivered by the
health care provider.

And finally, we get into the next slide, Access, and factors, again, for
access, and that's usually factors that look at timeliness; how often is
the patient able to see or how quickly can the patient see the provider;
and will the patient have contact with primary provider, which they
otherwise might not have; and as well, contact with specialists and
specialty care. Again, with telemedicine, the evaluations have shown
that it has been a significant factor for evaluation. In, finally, the
next slide, we also look at the perception, and this is in telemedicine
\-- been really critical for the early part of looking at activities
such as secure messaging, and that is patient acceptance and
satisfaction. Is the patient accepting of this? Is the patient
satisfied? For studies \-- again, I put an advertisement in that
telemedicine has been uniformly positive for telemedicine. But you look
at the other side of \[[indiscernible]{.mark}\] provider acceptance and
satisfaction: is this being accepted? Is this \-- and certainly, the
presentation before mine spoke to that as an important area.

And then we go to the next slide and then the next slide right after
that. Critical questions to answer first. And this is really the most
important part of what I wanted to leave. One, what are you evaluating,
and why are you evaluating? Are you evaluating the concept of secure
messaging? In other words, is a group like this or some other entity \--
are you looking at evaluating secure messaging to decide if you want to
reimburse, whether you want to get involved in secure messaging? That is
very different than looking at evaluation and assessment of secure
messaging as a way to look at the ongoing services that are being
provided, building it into the service itself, which then would
facilitate program improvements along the way.

Next slide. Of course, what are we evaluating? Are you providing secure
messaging, and are you looking at it as a way to triage services \-- in
other words, avoid hospitalization? That is a very significant cost
factor, but another area of, of course, secure messaging is looking at
it as a tool for followup care or for chronic care. Those may not have
quite the same impact in terms of cost in and of itself, but they are
certainly another important factor. In the next slide \-- also evaluate
how. Are we looking at secure message and comparing with traditional
forms of delivery? In other words, are we using a \-- looking at secure
messaging and comparing it to what the cost and the quality and the
access would be for going into the office \-- in-office visits? Is that
the control group? Is secure messaging then equal to or supposed to be
looked at as equal to, or maybe as a distinct type of delivery of,
medical care? And if it is distinct, then maybe its effect on cost and
access and quality aren\'t necessarily directly comparable to an
in-house \-- in-office visit but certainly very comparable to what the
overall health care might be of the patient as they move forward.

And my last slide is about trade-offs, and this is, I know, a favorite
of Jay\'s. And I think it is really critical, as we move forward and we
talk about access, quality, and cost, that although a huge emphasis of a
lot of folks have been on cost, that alone is a very dangerous element
to rely upon, because you get trade-offs back and forth. And as the
chart shows here, it could be that if the costs are going to increase
and the quality decreases, that is something you don\'t want to go
through. And equally, if the costs to the payer are going to decline
considerably and the quality goes up and the quality of care, well, that
is an obvious "yes." But you get in the middle, or you get to
corresponding activities where perhaps there\'s higher costs involved in
providing secure messaging but the quality of care and the access to
care is significantly improved, then where do you go? Does that mean
that secure messaging is a good thing or a bad thing? And who has the
higher costs? These are important questions before you get into looking
at secure messaging as a good or bad thing, that you need to look at
some of the priorities that policymakers and CEOs and Chief Medical
Officers have as they look to the populations, and that is a trade-off
between quality, cost, and overall access to care. So with that, I leave
it open. If there are questions, I\'d be glad to \-- or we can move
along. Thanks.

\>\> Karen: Thanks very much, John. The floor is open.

\>\> Joyce: This is Joyce Dubow again. I really appreciate the questions
that you raised with respect to the evaluation and what questions we
ask. I just must make note of the recent mark evidence report on
telemedicine to the Medicare population. I know we are not talking about
Medicare reimbursement, but again, we are talking about a diverse
population, and going back to Joanne Lynn\'s presentation, in terms of
the population that would be most affected by this type of secure
messaging, I think there is no question that some of the transactional
services are very appealing to patients and to their caregivers. I think
that the questions about access and quality with respect to care are
open questions still, and I think we need more evidence that this is an
appropriate route for wholesale adoption.

\>\> Jay: Yes. And \-- this is Jay Sanders, and this relates to the
complexity of the analysis of the cost issue. I just want to mention one
study that was reported in the archives of family practice. I guess it
was about three or four years ago. The senior author was Barb Johnston,
who at that time was a nurse practitioner with the Northern Kaiser
Oakland Health Care System. And they were looking at a tele-home care
project, in which they put in a fairly sophisticated tele-home
technology/telemedicine system. And they looked at a patient population
\-- chronic illness, predominantly congestive heart failure \-- over a
year period of time. And what they found, interestingly enough, was that
the cost for the tele-home care versus their control group without the
technology was, not surprisingly, higher than the traditional
no-technology home care system. But the overall health care cost was
one-half over that period of 1 year versus the control population,
basically because while the home care component cost was higher, the
dramatic reduction in rehospitalization basically dwarfed the higher
cost for the technology, and therefore, there was a halving of the total
health care cost.

\>\> John: This is John. Let me just add one comment to what Joyce said,
and I think it\'s certainly appreciated \-- her comments. I do want to
point out: when you look at telemedicine as a whole, there isn\'t a
whole. That telemedicine is so hugely variationed \-- such a huge
variation in what is telemedicine, what is remote care, anything from
offsite radiology reading of images or pathology specimens to ongoing
diagnostics or remote monitoring of care in the homes or as patients
move about to secure messaging to robotic surgery. And so in some areas,
indeed, the studies are not clear in terms of the efficacy or
cost-effectiveness of care. But I would say also, in other areas of
telemedicine, it is quite clear, and many of the studies have been quite
proven. And so I think it is very important that we don\'t throw the
baby out with the bath water, that we got to make distinctions when we
move ahead, and the same thing with secure messaging: that I hope we
don\'t look at secure messaging as representative of all of telemedicine
from either point of view.

\>\> Joyce: I take your point. I\'m not suggesting in any way that we do
that. I mean, it clearly has advantages for many, many parts of the
population. But I just think that we do need to look at the equivocal
evidence in a lot of areas and take those into account, and I thought
your questions about evaluation were very important.

\>\> John: Thanks.

\>\> Karen: Thank you. I would also add that the work group requested
last time information from the IOM on evaluating telemedicine and
tele-health. We\'ve made available on the Web the summary which is
publicly available from that document, which was put, I believe, in
1996; is that correct? I\'m looking at this \--

[\>\>]{.mark} I think it was \'98.

\>\> Karen: \'99. Okay. Thank you very much. Time flies. So that summary
is available, and thank you very much, John, for your very robust
presentation and the discussion. Are we ready to go back, Dr. Sands, to
\--

\>\> Danny: I\'m ready.

\>\> Karen: The presentation on guidelines? Because I know that there is
a very robust set of guidelines around the use of secure messaging, and
I think it would be helpful if you could share that with the group.
Thank you.

\>\> Danny: Sure. I would be happy to. So I'm going to talk \-- I have
been asked to talk to the committee, and by the way, thank you for the
invitation. This is a certainly important topic for me and has been for
many years. And I\'m going to be talking about electronic communication,
longitudinal care, and specifically aspects of the guidelines and
policies. I am a physician. I practice internal medicine at Beth Israel
Deaconess Medical Center, an affiliate with Harvard Medical School, and
the chief medical officer of Vicks Corporation. I\'ve been using e-mail
in my practice for quite a few years. Now I just need advice on how to
advance here, like this \-- I've got this here.

\>\> Matt: Just say so and they will be advanced.

\>\> Danny: I got it; I got \-- no, I got it. I figured it out, I think.
Okay, so I think it's important to understand that guidelines are the
basis on which we build policies and how we implement the guidelines,
how we actually practice it sort of at the top here. A little cartoon to
illustrate that point. The first set of guidelines that ever existed
were guidelines that I helped develop for the American Medical
Informatics Association. And we published these in January of 1998. And
it was very interesting and sort of ahead of the curve; nobody was
really interested in them back then. Later, many people became
interested about 9 months later.

I was \-- I developed a set of guidelines after community input from a
lot of different parties from the \-- for the Massachusetts Data
Consortium, and these are also available on the Web. There were some
guidelines developed the same year by Kaiser in northern California. And
then the American Medical Association has done a few things, I believe,
to guidelines. They also have a policy on ethical guidelines. And the
company met them in \-- I think earlier on and later in 2005 came up
with a set of guidelines as well. These are certainly all available, and
in fact, I have a Web site where all these things are linked as well.

On the next slide, I'm going to talk about \-- so what I've shown you is
that these guidelines \-- is that \-- I don't want to go into detail
about all these guidelines. They really are \-- basically have some of
the same rules in them. There are some minor variations. So I'm going to
talk about briefly \-- there is probably more that you want to read
later, and we're just going to go over some of this quickly.

I've clustered the policies in the different categories. So the first
category is medical-legal. I think it's very important that users
understand the appropriate versus the inappropriate use of electronic
communication. I am not talking about \-- broadly about other
telemedicine things. I'm talking about asynchronous electronic
communication, which is what I have been using in my practice for many
years, and I know a number of people on the call are interested in this
as well.

It is important that you use Web messaging or encrypted e-mail rather
than insecure e-mail when that is practical. We are going to talk about
what HIPAA has to say about that in a few minutes. Provide electronic
care only to established patients who agree to this point of
communication. I think this is certainly a common plank in many of these
guidelines. You've got to know who you are dealing with: just like many
of us would be uncomfortable taking care of patients on the telephone
that we had never met, anything would apply to electronic communication.
It's important that you come to an agreement with your \-- with patients
so that you \-- both you and your patients understand the guidelines.
And have them save copies of both the agreement and messages in the
patient's record. When you are using your computer to protect patient
confidentiality, you need to log off of computers that are in use in the
practice; use password-protected screensavers; and if you are sending to
a group of patients, you want to hide the names of the recipients when
sending it to these patients. You should use the BCC function so that
people don\'t see each other\'s names and e-mail addresses.

On the social and practical front, messages most effectively should be
routed to the appropriate personnel in the practice. What we mean by
this is that messages \-- the physician, if they have a point of
contact, should not be the only point of contact. Physicians should feel
free to share this with other members of their office staff as
necessary. But it is important to inform patients that other staff or
other health care providers might be reading their messages as well. And
you need to be honest with them about who is going to be the primary
point of contact. Senders need to identify themselves and the patients
in the messages. For example, someone might be sending me a message on
behalf of a patient. It might be a patient\'s daughter who is caring for
an elderly patient. You need to establish guidelines for message
turnaround time and enforce these guidelines within your office. And you
need to include prior communications threads in the message replies. You
shouldn\'t reply in a vacuum; you need to give some context there. There
should be generally one topic per message. And you need to feel free to
revoke access of patients who breach these policies repeatedly.

Going to the next slide, Other Issues of Policy, if you are confronted
with an electronic message from a patient that does not lend itself to
electronic response because it is inappropriate, it\'s not \-- well,
there are many reasons why that might be \-- it is important that we
explain to the patient through telephone, when it is appropriate, that
alternate channels of care delivery must be used. What I mean by that is
that, you know, if a patient is using, for example, unencrypted e-mail
and sending something that is very confidential, you shouldn\'t repeat
the sin by communicating back with them through e-mail using the same
channel of communication. So that is when you pick up the phone. This
\-- I can tell you stories of situations in which this becomes very
important. A patient lets you know about something that might be urgent,
you shouldn\'t e-mail them back; you need to really take advantage of an
alternate synchronous channel of communication. It is important that you
verify patients' e-mail addresses when they come into the office or when
you are communicating with them, This is just like any contact
information that you have. You always maintain a list of the patient's
phone number and their next of kin and all this information. And it is
important that you communicate policies to your staff and to patients,
and this Web site that I've linked there is a Web site that I\'ve
maintained for many years. It links to guidelines and practical rules
about how to use e-mail in commercial care at a noncommercial site.

So there are many useful things that we can do with simple asynchronous
communication, and I should point out, before I go on to this, that some
of the rules that I just put up, some of the policies, can be enforced
depending on what technology. The technology can actually enforce these
rules. So what I mean by that is that if you are using a portal that is
dedicated to patient-provider communication, that may actually
automatically enforce some of the rules for you so that you actually
don\'t have to do it in some other way,if you're using a secure e-mail
or regular e-mail.

So administrators and, you know, anybody who has used these \-- any of
these, any of you \-- I'm sorry \-- any of you who have used electronic
communication to communicate with your provider or if you are a provider
to communicate with your patient knows that so many useful uses of this.
You have prescription refills, appointment requests, managed care
referrals, phone address, insurance changes \-- all these things are
great and very straightforward. But then there are a lot of clinical
uses, and of course, this is certainly more interest to most of the
committee. Virtually any nonurgent medical issue can be very efficiently
handled through this. Obviously, you may reach a point where you say,
you know, "We\'re going to have to have a phone conversation about this,
or you are going to have to come into my office, because I can\'t take
care of this through e-mail," but many times you really can. You can
certainly get started on taking care of issues. Also, monitoring patient
illness, chronic illness, and therapy is really wonderful. Rather than
saying to the patient, "Call me in 2 weeks and let me know how you are
doing," I can say to the patient, "Send me an electronic message in 2
weeks and tell me how you are doing." You can monitor therapy that way.
Chronic illness is wonderful, because I can avert a patient visit \--
routine patient visit by using electronic communication. For example, I
can \-- I just did this last Friday when I was seeing a patient. She did
not want to come in for a blood pressure check in 3 months, which she
needed to do, because I wasn't quite sure where she was going. She asked
if it was okay if she had these checked at home, and she just
electronic-messaged me with the information. And of course, that is
perfectly appropriate. And as long as we know the patients we are
dealing with, this is a wonderful use of the technology.

Also, setting an agenda is a very important topic, and it's topic that
we don\'t talk about enough. We have 15 minutes or so to take care of a
patient in most cases regardless of how many chronic illnesses they may
have. It is very important that we use that time effectively. So
negotiating an agenda up front becomes important thing to do as
preparation for a visit. And negotiating this agenda through an
asynchronous communication over the week before the meeting is really a
wonderful thing, and I find that very useful. And finally, postvisit
followup.

So then there are, of course, inappropriate uses, and any of us would
know this. I didn\'t mean to do that; sorry about that. I\'m going back
a slide. So inappropriate uses include anything that is a medical
emergency, anything that is time sensitive, any issue requiring lengthy
messages or long volumes of messages. Many providers are concerned and
very scared about using this technology in their practice, because they
think that \-- first of all, they think they are going to get bombarded
with messages, and second, they think they are going to get very long
messages from patients. My advice to clinicians is that if it hurts,
they are doing it wrong. So that if a message is lengthy, taking a long
time to read, a long time to understand, or if it is requiring a lot of
back and forth, that is when it is time to substitute a different
channel of communication. Obviously, communicating bad news is something
that should not be done through e-mail; nor should it be done over the
phone in general. That needs to be done in person. You know, something
that is sensitive, meaning it contains information about psychiatric
illness, substance abuse, domestic violence, drug abuse, HIV, those
sorts of things, should only be done if you have a secure system; that
is, if you have a system that is either secure e-mail, it's encrypted
e-mail, or you have a communication portal that is secure. In regular
e-mail, you do not want to do those things.

Now the next topic is the issue of whether text is meant to be free. I'm
waiting for my slide to change. Here it is. Is text meant to be free? So
it is a very interesting thing. If you walk into an exam room and you
observe a doctor and a patient communicating, their communication is
free text. That is the way they communicate. Free text is rich, a very
rich information exchange that takes place. People are comfortable with
free text. It is very interesting that although they are comfortable
with it, many times when we're using electronic systems, we try to
shoehorn the conversations into a structured model, and it is often hard
to do that without losing important content. I would say that there are
two different approaches to doing electronic messaging, particularly if
there is a portal involved, which can force structured communication.
One is that all communication should be free text. The other is that
most communication should be structured, or all communication should be
structured. So again, the comfort level for free text is much higher. I
think that forcing people to structure their thoughts is perhaps an
impediment to communication. I think there are things that get lost that
way, because not everything fits into these nice cubbyholes. I think
that free text is certainly great for soft issues, issues that are
emotional or are not quite black or white. The white has many shades of
meaning. Structured text is, of course, very strong when it comes to
hard issues. You know, then we have blood pressure management using
structured text. It is more efficient, because I can then use that in my
other electronic system. If the problem types are \-- if there are many
problems or the problem isn\'t clear to the patient, then free text
becomes much more useful. And structured text, though, is useful when
there is a single, identifiable issue, and it is clear to the sender
what it is they are communicating about.

And counterbilling is another interesting area, where if you are using
free text and you want to try to bill for this, it may require an extra
step. This is very similar to when we bill for a real face-to-face
visit. We have to sort of break this down and figure out how to bill for
that encounter, whereas if you are using structured text, this may be
automated.

So the next question I have is \-- question that always comes up when I
talk about this is, does the HIPAA security rules allow for sending
electronic protected health information in an e-mail or over the
Internet? If so, what protections must be applied? And I am not going to
read this to you, but you can see the URL at the bottom of the page. And
the answer is, you don\'t really have to use secure communications if
you have policies in place that explain why it is not practical for you
to use this. And I would add that patients need to understand that the
communication is not secure. I think that now that \-- there is another
question in their frequently asked questions, which is up here: "Is
mandatory encryption in the HIPAA security rules?" So I would say,
though, today, although it is fine to use insecure and normal e-mail for
communication, I think that most of us would believe that whenever
possible, you should use encrypted communication or a secure messaging
portal. But I think that it is important that you all read this
information on your own so that you can make your judgments about it and
not say unconditionally that you need secure e-mail, because that is a
barrier. Portals and security are a barrier.

I\'m going to close with a couple quotes from my patients. This is a
60\-- a \-- SF; he was a 61-year-old male minister with diabetes and
chronic pain syndrome. And he wrote to me, "I have a lot of medical
issues. This e-mail system has left me feeling comfortable and in good
hands. Otherwise I would feel as cold, depleted, and alone as the
lifeless tree in my front yard in the deepest of winter." And this
patient has many medical issues.

And then the last comment I have is from another patient, who is a
lawyer with hypertension, overweight, and prosthetic hypertrophy. And he
says, "Exchanges by e-mail are the next best thing to a house call." And
with that, I will see if there are any questions. Thank you very much.

\>\> Jay: This is Jay Sanders. I just want to underline your last two
comments, your last two slides from your patient, with reference to a
question that was brought up in a previous presentation about value to
the patient. And we should never, ever underestimate the sense of social
interaction that these messages provide to the patient, particularly the
elderly population. They actually look at this as the social event of
their day, and it gives them a great sense of security. And if we\'re
going to list values, I think we ought to put that very high on the
list.

\>\> Danny: You are right, Jay. And I think there are two aspects of
this. One is, I think the committee needs to understand that is
crucially important. This is very important for more than just social
reasons, but it's sort of a way for them to reach out and have some
connection, whether it is through live monitoring or whether it is
through, you know, knowing they have this lifeline they can reach out
to. But the flip side of the coin is that when physicians hear that,
they kind of freak out, Jay, and I\'m sure you heard as well, which is
that, you know, "Oh my God, my patients have nothing better to do. They
are old and isolated, and they are going to be e-mailing me all the
time." And of course, we know from work that I've done and others in the
field that, actually, that doesn\'t really take place, and it is
important that we send a clear message to clinicians that that does not
take place. It is important to the patient, but it's not like they are
doing it all the time.

\>\> Tony: And we heard the results from RelayHealth.

\>\> Danny: Yeah. And in our situation, we track these things as well.
By that, I mean Beth Israel Deaconess. We find that for every 100
patients registered on a system, it generates fewer than one message a
day for a physician. So it is really not a lot.

\>\> Tony: Right.

\>\> Giovanni: Okay, we need \-- sorry; this is Gio. Danny, thank you
very much for the great presentation. We\'ve seen at RelayHealth, it \--
we've seen it grow a little bit versus what Danny is saying in terms of
amount of messages, but absolutely we've never seen an abuse of this.
There is a lot of respect. I think actually the biggest surprise was, as
physicians, we have this egocentric view of the world that everybody
wants to reach out to us and they are going to be all over us. And
actually, it turns out the patients don\'t particularly care to
communicate with us. If they have to do it, they will do it, but
otherwise, forget it; there is better things to do during the day. So
that really was one of the many surprises that I found.

Last but not least important, Mohan \-- I think is your name \-- you
raised a good issue about what is the real value for members. And I
think this is something \-- in my previous life, I was a psychiatrist
and neurologist by training. And I really realized one of the things \--
one of the biggest values for the patient in all of this is the fact
that they feel taken care of. I mean, there is an enormous behavioral
component to this, the power of one message. I mean, I\'ve seen this
with my mother in terminal stage. I've seen this with my father in Italy
getting a message in English that it takes him 15 minutes to translate.
The power of one message to a 76-year-old who's spending his day,
really, reading newspapers and sort of thinking of what tomorrow's going
to look like \-- it is enormous. Enormous. And we need to keep that in
mind, too. I mean, that's part of what delivering care is all about.

\>\> Danny: I totally agree with you, Giovanni. Thanks for those
comments. Yeah, I see this all the time. You know, many patients choose
me because I can communicate with them electronically and other
physicians who do this kind of thing. It is really very powerful.

\>\> Karen: Are there any other questions or comments of Dr. Sands?
Well, you did bring up the interesting point of HIPAA, and I believe
that Susan McAndrew is on the line; is that correct?

\>\> Susan: Yes; can you hear me?

\>\> Karen: Certainly, Susan. Susan is from the Office of Civil Rights
as our basic HIPAA expert. So I thought it would be appropriate, Susan,
if you could also underline what HIPAA has to say about secure messaging
\-- perhaps I should say unsecured e-mail \-- and how the information
gleaned from this can be used in the clinical setting.

\>\> Susan: Okay. I will have to qualify that request in just a small
way. What I can talk about with great authority is what the privacy rule
would look at in terms of these communications. I think, though, with
regard to the secure messaging itself and how these \-- how the
information needs to be protected as it is going from point to point, as
the slides that Dr. Sands put up show, that\'s really in the purview of
the \-- of CMS and in particular Tony Trenkle's shop. And so with regard
to what the security rule has to say with how you go about \-- what are
the standards for securing that messaging, that\'s really something that
Tony will need to address.

But I can say, you know, from the privacy rules point of view, we would
protect the information that comes into the hands of either a covered
health plan or a covered health care provider, and I assume in most of
these communications, we are dealing with a provider. Not all health
care providers are covered by the privacy rule, but any of those that
are engaging in electronic transactions, including billing a private
payer or public payer electronically, would be subject to the HIPAA
requirements both in terms of how they do that electronic communication,
that electronic billing activity, as well as compliance with the privacy
rule with respect to both their electronic and paper records.

The good news is, of course, in most of the communications that have
been set out today and that you all are looking at, would \-- there is
really no privacy impediment to these communications. The privacy rule
would look at both the purpose of the release of information as well as
to whom it is released. Clearly, there is no impediment for a covered
entity, a covered health care provider, from telling the individual
about his own information. And so you can freely share that
individual\'s information with the individual him or herself.

With regard to other communications, there is also no privacy rule issue
that would \-- with the sharing of information \-- identifiable
information for treatment purposes, as between providers. And this would
be any provider, whether they\'re covered by the rule or not. So the
information \-- there were references to potential referrals, or you can
collaborate, or you can bring in \-- you can have consultations with
providers from remote locations. All of that \-- all those treatment
communications between providers would be allowed without needing to
have the individual\'s consent or written authorization.

In addition, the privacy rules are structured in such a way that we
really don\'t \-- we don\'t care. We don\'t focus on the means of
communication. So it doesn\'t really matter for privacy rule purposes
whether the communication is being done person-to-person, over the
phone, by e-mail or telecommunications, telemedicine, all of that \--
all of those types of communications would be subject to privacy rule
protections, provided that it involves communications by a covered
health care provider.

I would only, in addition, comment there was \-- the other thing the
privacy rule does not really make a distinction about is the sensitivity
of the information, with the possible exception of psychotherapy notes.
Any information that is identifiable to the individual requires the same
level of protection under the privacy rule. So there is no
supersensitive information. We protect all information that\'s
identifiable alike. That\'s not to say that with regard to your
day-to-day practices that it \-- that you can provide additional
protection for certain types of information that you deal with. The
privacy rule is really \-- is there just to establish a uniform Federal
floor of protections, and there\'s no prohibition on entities going over
and above those protections with regard to any particular subset of
information or just raising the level of protection for all information.
And it may also be that there is a State law that may govern a
particular type of information or limit a particular type of
communication. There again, the privacy rule would defer to a State or
other Federal law that is more stringent than what the privacy rule
would require, that is more protective than what the privacy rule
standard is.

So with those comments, I mean, if there are any particular questions
about how the privacy rule may apply to these situations I would be
happy to answer them. Otherwise, if your questions are really going to
be standards for securing the messaging, I would defer those to Tony.

\>\> Karen: Thank you very much, Susan. Are there any questions for
Susan at this point or for Tony?

\>\> Mohan: This is Mohan Nair. I want to congratulate the presenters,
because Tony specifically covered issues that were behavioral in nature,
and I do appreciate them, because that seems to be where I seem to be
centering on. And I also appreciate the commentary regarding the
awareness of consumer-oriented behavior in the face of technological
advance that we are all looking at.

I have a few questions, and I will try to make them brief. One \-- and
this is for Tony particularly on the area of consumer behavior \-- what
behaviors are required to be different on the part of the consumer in
working with email-based secure or insecure messaging, and what behavior
differences are you expecting the physician to perform besides
pre-agenda setting, overcoming the fear of too much e-mail, and the
ability to optimize an office visit?

\>\> Danny: I\'m sorry, who was that question for?

\>\> Mohan: This is for the gentleman from Harvard.

\>\> Danny: Oh, that is me. I\'m sorry, because you had said Tony there.

\>\> Mohan: I'm sorry, wrong name.

\>\> Danny: That\'s okay. So can you just paraphrase the question for
me? I was listening, but not as intently as I should have, since that
wasn\'t directed to me.

\>\> Mohan: Especially since I wasn\'t mentioning your name correctly.
Again, I want to congratulate you for your presentation. You brought
some insight into the concept of change of behavior to the \-- from the
consumer side and from the physician side, for making text-based or
structured text-based communication work for purposes we\'re talking
about here in the committee. What behavior changes are you believing
need to happen on the consumer side, as well as on the physician side,
for establishing effective visits, both "e-" as well as office. You had
mentioned pre-agenda settings. You had mentioned the ability to dialog
with effectiveness. What other \-- and you have also mentioned the fear
base of clinicians worrying about too much e-mail. But what behavior
changes are you expecting? For example, are you expecting a consumer to
be knowledgeable in their dialog between the physician and the consumer?

\>\> Danny: Well, I think those are really important questions. So
clearly, there needs to be first a dialog about this, but I think you're
looking \-- you know, in other words, we have to both agree that this
can be used. But I think we need to move to a mindset where we're
learning how to use this communication in our practices and that
patients will learn how to use it as well. So in \-- my experience,
which is like many of my colleagues, is that I got out of medical school
and starting taking care of patients in residency, and all I knew was
how to take care of patients face to face. And I would all of a sudden
have phone messages from patients, and I talked to them on the phone,
and they'd expect to be treated, which, of course, as a new medical
school graduate, I felt was just preposterous. How could I take care of
a patient over the phone? However, with time, of course, we all use how
to use this telephone in our practice. There are no medical practices
that I have ever heard of that don't have telephones. Many of them don't
use them effectively, but that is another issue. So people learn how to
use this in their practices, and patients learn to \-- you know, how to
and when to use the telephone. I think we need to get to the point
culturally where the same thing is true for asynchronous communication;
that is that both patients and clinicians need to understand how, you
know \-- how the technology can be most effectively used, when it is
best used, when it is not so useful, what are the limitations of this
technology. Right now, we're in a very funny time, because, you know,
with a few exceptions you have heard about today, I think, this is not a
technology that is used for the majority of communication. And because
of that, we have this problem with people not understanding how to use
this. You know, patients, like, start using this and not quite know how
to go about it. I have patients who just start using it, and there is a
learning curve there, both for the patients and for the physicians in
their practices in how to use it most effectively. The other problem
with the startup time is that we have a heterogeneity problem, which is
that a lot of messages are still coming in through telephone, even
things that are better handled electronically. And so it is hard
culturally to adapt to that, because from a workforce standpoint, I'm
still spending most of my time \-- maybe spending most of my time doing
phone message responses rather than learning how to ramp up on this
technology.

So I think it is important for patients to both learn how to use this
\-- I think patients \-- our patients need to be asking us about this. I
think patients should be pushing their clinicians to start using this
technology, and I think we need to be educating clinicians about how to
use this technology in their practices most effectively and what its
role is in relation to the other communication technologies: the fax,
the phone, the visit, and so on.

\>\> Mohan: Thank you.

\>\> Danny: Does that answer your question?

\>\> Mohan: Yes, it does. Yes, it does. I mean, it is a difficult
question to answer. And let me just make the comment that the health
care system seems extremely broken today, and beating it up with secure
communications \-- or insecure communications \-- may even further break
it unless we look for behavioral shifts that allow for the system to be
healed in some way.

\>\> Danny: Well, I think that's why it's important to optimize \-- the
issues that can be taken care of electronically should be taken care of
through this technology. So if we can take care of the things
electronically that should be done this way, if they are better off done
through the phone, it is that way. You are right: in the beginning when
people start using this, I think there is a ramp-up period. I think
Giovanni could talk to that as well. But people tend to pick up on this
pretty quickly, and I think after a month or so of using it, they really
\-- they've already learned where it can be best applied. So yes, I
think every time you introduce a new technology to a practice, there is
some disruption for a short while. That can range from perhaps a month
or a few weeks for electronic communication to 6 months for an
electronic medical record. But I think ultimately we recover the
inefficiencies that occur initially, and I don't think we really broke
the whole system.

\>\> Paul: This is Paul Nichol of Department of Veterans Affairs. I
think the other piece of this is, we don't always know in advance what
behavior changes are going to be needed, and it is useful to identify
the early adopters or clinical champions and learn from their experience
and try to have them involved with the rollout of adoption by others in
their sort of immediate practice area.

\>\> Jay: Yes. This is Jay Sanders. You know, this is \-- this specific
question really has to be put under the umbrella of emerging-era issue,
and that is, this is a totally new communication mode, really a social
scientist just looking at how we communicate, not just in health care,
but how we communicate today. We're learning so much more from a
behavioral standpoint about how people interact and interface and
communicate with this technology.

I don't really think that health care is \-- you may disagree with me
\-- is any more special than the behavioral ways in which we are
learning to use the Internet. As a personal example, I talk more with my
children now over the Internet than I ever did before over the
telephone. And the fascinating thing is, they tell me jokes over the
Internet they never would tell me in person. And although it's funny,
but that's the fundamental reality of the social interaction. And I can
only see it \-- maybe I'm biased; I can only see it as an enhancement
and particularly from an educational standpoint. The more we tend to
communicate with our patients, the more we get the point across that we
try to tell them in the office about what their disease process is, why
they need to take this particular medication, why they need to take it
in this particular time frame; the more they learn about what their
condition is. So to me, the more the interaction that occurs, the more
the education that occurs.

\>\> Mohan: This is Mohan. Let the minutes note that a fellow committee
member has recommended that all committee members be replaced by
16-year-olds so that we can speed up the discussion.

\>\> Danny: And tell better jokes. I would recommend to the committee,
if you haven't seen it \-- I wrote a paper with Tom Delbanco in April of
2004 in the Journal of Medicine that talked about some of the cultural
issues involved in this type of communication. So check it out.

\>\> Giovanni: Yeah. Mohan, this is Gio again. I \-- this is a question
for you, because I followed your logic all the way through, and then at
the end, there was a twist to it that I really didn't \-- I just
probably missed the link there. So if you could help me, when you said
that this could actually increase the amount of problems in the health
care system, I sort of missed how we came to that conclusion. And
obviously, I'm biased, so I would like to challenge it, but I would like
to \-- I mean, you make some very good comments, and I am trying to
follow the flow as to how we get to that. You know, I just want to add
one thing in terms of how the cultural impact of this is. I have a
document that I would like to send around to the committee, which was, I
think, dated 1952 or '53. I mean, we're not talking centuries ago. And
it was a group of doctors with the AMA sending out some guidance on how
to use the telephone with their patients, and very interesting \-- they
recommend not give out their phone number, because patients may use it.
So it was quite intelligent, and it was the same type of cultural
resistance, in my opinion, that we're seeing now.

One thing we've seen at RelayHealth is \-- and again, it is definitely
biased. I mean, we are still talking to the propeller heads of doctors
that really want to do this. So I am completely in \-- with you when you
say may be bias from a doctor's standpoint that are doing this. But we
have not \-- I mean, we've seen much ado about nothing. I mean, we did
not see destructive behavior in their practice or major changes of
patterns. Most of the doctors that we're talking to are really used to
doing things online. This is not really the introduction of a new
technology; this is just a slightly new way of communicating with their
patients with a huge impact on the patients out of the equation. But
I'll stop here, and I would like to ask how you came to the conclusion
this would actually increase the problems in our medical system.

\>\> Mohan: I'm not implying, by the way \-- thank you for the
commentary \-- I'm not implying, by the way, that secure messaging or
messaging of any sort would only increase problems. I believe that it
would solve some of the challenges that we see in the medical system and
in the health care system. But we are all here because the health care
system is teetering on broken or is already broken. And the questions at
hand is, what are the drivers of it, and how can we enable the positive
drivers to solve some of these problems? But speeding up communication,
as you can see in my own personal life, does not really mean that the
quality of the communication improves. Speeding up interactivity doesn't
mean a dialog occurs. And what has happened in the past is the cultural
flow, where physicians and health plans like ourselves sort of play big
brother to the patient and sort of manage the patient's health by
sporadic, asynchronous, sometimes indirected conversation, where the
patient feels a victim of the scenario. What we want, I am hoping, in
this dialog is to create an environment in a small way that allows for
the patient to be empowered as a consumer to make decisions with the
physician and with the circle of influence that they work with on their
health that they participate.

Now, as we look at secure messaging and we replicate the dialog that is
happening today associated with voice-to-voice or phone-to-voice
communications, we may actually speed up nothing. What we want to do is
solve a broken system, and I'm hoping that secure messaging, or frankly
nonsecure messaging, of any sort in a way and a \-- transforms a
cultural communication between patient, clinician \-- and clinician with
each other. And what I've heard today is one step in that focus, but it
is laced with significant cultural changes that need to be optimized by
the committee and addressed by the committee, not just say, "Let's
disconnect dots and see what we'll see." I hope I'm coming across in an
effective way. It is a difficult topic you are challenging me on, but
it's one that we spend our lives discussing.

\>\> Mary: This is Mary Naylor. I really appreciate your comments, and
actually, you're coming across quite clearly. I have another question
for Dr. Sands. The population with whom we deal with often are
individuals with multiple chronic conditions, on average six or seven,
and they are being cared for by a range of providers: multiple
physicians, multiple nurses and therapists, etc. Have you worked with
the context of secure messaging in a \-- have you explored from the
consumer's perspective what it will be like to be receiving multiple
messages from multiple physicians in response to questions and sometimes
those answers are in conflict with recommendations from others, etc.?

\>\> Danny: I have not studied it. I can give you anecdotal information,
which is that in the institution in which I practice, at Beth Israel
Deaconess, we use a secure messaging portal, and different special\--
many different specialists are part of this, as well as primary care
doctors like myself. And it is nice for patients who have one place to
go for all of their medical communication. But in terms of the conflicts
that might develop, I don't think that that part of it is any different
than what we see with phones and letter communication today. I think it
is just another channel of communication, in my opinion.

\>\> Mary: Okay.

\>\> Karen: Any other comments, questions? Is there anything or any
major area that we neglected to cover today? I know that there can be
the opportunity for a lot more indepth discussion in every single one of
these presentations. And I was very clear they each have to be in a very
short time frame, and so I really want to stress how appreciative we are
that everyone kept to a short time frame and still managed to put in a
huge amount of information. But, so thank you very much, everyone.

But having said that, is there any major area that anyone on the
Workgroup would be interested in hearing about that we did not cover
today?

All right. If you are all still with us, then, I think this part of the
Workgroup meeting has been concluded, and I'll turn this agenda back
over to you, Tony.

\>\> Tony: Thank you, Karen. I think the next steps that you wanted to
proceed on were the process of beginning to develop recommendations.
Earlier in the meeting, you discussed the timeline that needed to be met
in order to finalize a letter that needed to be sent to the Secretary
and a presentation at the AHIC meeting on May the 16th. And I think
probably now is a time to begin looking at some of the recommendations
that the Workgroup would be interested in moving forward. I think, as
you and I had talked offline, this seems to be more of a formidable
process than what we had done preliminarily for the last AHIC meeting on
March the 7th. I know you have had some suggestions, Karen, that you had
based on some of the previous conversations. It sounds like coming up
today, there was certainly an issue about addressing some of the
cultural issues related to the union of the secure messaging as well. So
I think at this point, would you like to begin to talk about some of
these topics for discussion that you would come up with, and then we can
maybe turn to some of the other issues that came up in today's
discussion as well?

\>\> Karen: Okay. And I will start off by going back to Dr. Brailer's
points a little bit earlier. We're really looking for those high-level
actions and a concept in a concept format so that we can have further
discussion of about exactly what entity or who would be responsible for
that action and why. And before we get into these topics \-- and there
is a slide \-- not this one; this is what we just mentioned; the next
one, Topics for Discussion \-- that should really have a question mark
instead of a bullet in front of each of these five high-level topics,
because they are here primarily as question marks. They were derived
from previous discussions from this Workgroup, as well as actually from
some other workgroups as well. And they are here on the table for a very
open dialog amongst all of us. And I would like to stress the fact that
this is a Federal advisory committee. It is a public committee, and
everyone is free to express their own points of view, and would
encourage everyone to do that, even though there may be conflicting
points of views about a number of different things. This is a open
committee.

So with that, I'll go through some of these, and maybe we could have
some discussion on each one from the perspective that the concept is
something that would be embraced, and then we can go forward in future
discussions over the course of the next several weeks. And we'll talk a
little bit about it at the end, how we might actually make that happen.

The first is related to the fact that I think we recognize that if we
are to move forward with secure messaging, it involves time and
expertise of many professionals, primarily physicians or practitioners
who are caring for their patients. Time and expertise is reimbursed in
the physician's office setting, but if we are talking about remote care,
then we may need to be thinking about reimbursement policies and
mechanisms. And in order to do that, we need to develop, or we may need
to develop, an evidence base for an informed decision about
reimbursement policies. And again, here we're not necessarily talking
about reimbursement in a specific way. Here we're basically talking
about an evidence base to come up with informed recommendations on
policy.

So that would be the first possible recommendation concept that I
suggest we spend a little bit of time discussing. And if there's anyone
who feels strongly that this should not be a reimbursement policy,
please feel free to \-- I'm sorry \-- this should not be one of our
recommendations in some size, shape, or form, please feel free to state
that.

\>\> Mary: Well, I would appreciate if maybe you could provide the
rationale for including it in the recommendation. I mean, when we talk
about services such as telephone services provided, other forms of
communication, we don't have those explicit modes of communication
incorporated. So I was just wondering if someone could provide a
rational.

\>\> Karen: Well, I will jump back into that. Again, this is Karen Bell.
Our specific charge is around secure messaging.

\>\> Mary: Right.

\>\> Karen: And at the previous meeting, we basically had a definition
for secure messaging, which we could change. But if we stay with that
and we stay with the specific charge, clearly the situation that I
mentioned earlier could \-- would \-- is very definitely applicable. It
takes physician time; it takes physician expertise; and in some size,
shape, or form, you should consider whether there is a strong-enough
evidence for reimbursement and the type of reimbursement policies that
might ultimately address the concerns.

\>\> Mary: Okay. So I misunderstood. You are talking then about point 1,
the need for an evidence base for this. Is that correct?

\>\> Karen: Evidence base for informed reimbursement policies, yes.

\>\> Mary: Okay.

\>\> Joyce: Karen, I'd like to know what you mean by an evidence base.
Are you looking to see whether we can gather data on the practice of
reimbursing for secure messaging? I mean, what exactly are you looking
for in terms of evidence? I'm not clear.

\>\> Karen: I think that there are multiple ways that we can look at
outcomes. Some of them are cost outcomes, as we have heard today from
John. What exactly would be? And we don't know the answer today; I don't
know the answer today; I don't think anyone does. What would be those
outcomes? What would be those pieces \-- maybe possibly even structure
or process pieces \-- that would be the baseline that could be
considered for reimbursement? And who should make those determinations?

\>\> Joyce: Well, it feels to me that you are going into this with an
assumption that there ought to be reimbursement. It seems to me we that
ought to go in agnostically and make some determination as to whether it
is appropriate or not rather than predetermine the outcome.

\>\> Karen: That is fine, but I think that if \-- it is difficult to
really determine whether it should be reimbursement or not reimbursement
unless you have a strong database to suggest one way or the other.

\>\> Joyce: Well, that is why I asked whether you are looking to do some
kind of survey to see what is actually in practice now so that we have a
better handle on, you know, whether there are situations where secure
messaging occurs in the absence of direct reimbursement and, you know,
what describe those environments, as well as describe those environments
where there is in fact reimbursement, so that we have an understanding
of the lay of the land.

\>\> Karen: I think we could \-- that is clearly within the purview of
this. And again, as I said before, this will require a lot more work
over the next 6 weeks to determine how we want to phrase this
recommendation and who should actually do that work. But the concept is
that we need \-- if there \-- we're going to make a statement about
reimbursement policies or reimbursement, we really do need to have a
strong evidence base for it. Giovanni has suggested he'd like to comment
on this. Dr. Colella?

\>\> Giovanni: Please call me Gio like everybody does. I \-- it's very
\-- this is exactly the right questions to be asked, and I could just
offer some experience of, you know, the 5,000 physicians that are using
it with us in the years that we've been doing it in both reimbursed and
nonreimbursed environments. Let's not forget that we work \-- I mean,
people didn't just go on the Internet and download our system and start
working with it. It is incredibly more difficult to get doctors' options
if this is not reimbursed. I mean, period, end of story. It's just that
the change is dramatic. That is why we are focusing most on our
initiatives now in regions where health pay \-- where health plans are
reimbursing. It becomes a psychological and a practical barrier to
adoption, and you will see, working with this, that the real big
challenge is not member adoption, and at the end of the day, it's not
going to be that much pain, because the reimbursement issue \-- because
you will notice that there are significant cost savings that come with
this. The real barrier where everybody will struggle with is getting
doctors, getting 600,000 physicians in the United States, to adopt the
new technology or to adopt a technology without being paid to do it when
they feel that they are providing a real professional service. And they
can document. I mean, the argument against reimbursement for phone calls
was the lack of documentation, and this is clearly documented by the
physicians. So it is going to be a challenge if we don't reimburse to
get doctors to do it.

\>\> Tony: This is Tony Trenkle. Getting away from the question of
whether or not to reimburse, I think what Karen's point is \-- and maybe
the words need to be changed somewhat \-- is development and evidence
base for informed reimbursement policies, whether you do or don't
reimburse, and under what circumstances has to be based on evidence and
data. And I think that's what Karen is getting at here, and as I say,
maybe the words need to be changed somewhat to make it sound less like a
ringing endorsement for reimbursement rather than saying that, you know,
developing the evidence base and then making informed policies based on
that \-- I think that is the key here.

\>\> Karen: I'm okay with that.

\>\> Mohan: This is Mohan. I'm okay with that, too, Tony. I think that
is a really strong discussion point.

\>\> Brian: This is Brian at Intel. Possibly get hard evidence or get
hard information around whether we should be paying for results or not
just to be paying for the use of the technology.

\>\> Mary: I also agree with that. I like the notion that we would
examine under what conditions and in what context we \-- secure
messaging can be optimized to achieve high quality and increased access
and cost savings, because then it leaves open the questions about who
should be reimbursed, what context of care should be reimbursed, not
making any a priori assumptions about that.

\>\> Mohan: Yeah, and by the way, I can jump to the conclusion very
rapidly \-- and this is Mohan Nair \-- that the conclusions will come
but the payer will have to pay, because they have the biggest gain in
all analysis possible, to which I will respond: I agree that somebody
has to pay, and the payers are always being asked to pay, because they
think that is where the money is. The bottom line is, it is really not
the payer's money. It is the money coming from members who pay for the
service. In other words, in the end, it comes from the end consumer
again.

\>\> Karen: Yes. It always does.

\>\> Mohan: And the key point that I would like to cut the conversation
in half over so that we devise this committee in dialog is the fact that
we will jump into payments before we address value. And if physicians do
not see value in doing this for the end result of improving care and
payers are going to have to pay, then we have done something wrong with
adoption, because the value is not being seen on the part of pretty much
all the physicians. And somewhere in there is an answer that we have to
find. I am not implying that as a payer myself, that I would. I am
implying, however, that I'd like to see value in the mix so that we can
create adoption.

\>\> Paul: This is Paul Nichol. I very much agree with that. I'm sorry;
I'm going to have to drop off and go to clinic at this point. I will
catch up with the minutes and the next meeting. Thank you.

\[Jay and Karen start talking at once.\]

\>\> Karen: Go ahead.

\>\> Jay: Yeah. This is Jay Sanders. I just want to make sure that I'm
understanding what we're discussing at this point. Are we looking at
doing an evaluation of value, cost, quality, access with respect to
secure messaging to justify \-- if the results come out positive, to
justify reimbursement for it? Is that what I'm hearing?

\>\> Karen: I think the issue here is to look at all of those things \--
the cost, the value \-- so that various entities can make an informed
decision. And when I say informed decision of various entities, it may
not be the payer. It may be the patient. It may be an employer. There
may be others who determine that the value is great enough in their
particular stakeholder group that it would be worth reimbursing for. But
I don't think that we can move forward and say that any particular group
is going to end up paying for something without having the value come
back to them without essentially having a return on whatever investment
they're making. And they may define value in different ways, but this is
a way of developing that evidence base so a patient, an employer, a
consumer, a health plan, a public payer can basically say it is not only
in our best business to do this, but it's in the best business of the
patient and physician, and there is value all around.

\>\> Danny: If that is the case, I raise my hand in the affirmative, and
I totally agree with that. The only proviso I have, or footnote, is
really, what is our control group? Because the fundamental reality is,
the only control group we have is our present health care delivery
system, which has never been evaluated. And it's something that I deal
with when I'm constantly talking to payers about telemedicine. They're
always asking me, "Well, we need to get this data and that data," which
I totally agree with. But I ask them, "Okay, where is the data for the
use of the ultrasound? Where is the data for the use of the CAT scan?
Where is the data for the MRI? Where is the data for the Swan-Ganz
catheter?" And all of those were reimbursed long before there was any
data. As a matter of fact, there is still question about whether the
Swan-Ganz catheter that's put in every patient in the intensive care
unit is of any value. So I'm not disagreeing, I totally agree, but I
hope we apply the same standards to every technology that we're using.

\>\> Joyce: I just want to come back to the point that Tony made, and
that is that we need to develop some approach to help us better
understand how we could reach an informed reimbursement policy so that
we can look at this as subjectively as possible. I think it will cover
what we're talking about, but I just think that that should be the end
objective, that we want to be able to make an informed recommendation
around reimbursement.

\>\> Mohan: May I \-- this is Mohan; may I make a suggestion? I heard a
very good definition that all of us agreed to, which is the \-- and I'm
paraphrasing it very badly \-- which is looking to see the drivers of
the need to reimburse and look to see whether reimbursement is a
necessary function in enabling this technology to use. I'm okay with
that. I also believe that we ought to look at the reason why we're
looking at reimbursement, which is to get adoption. And if there are
other factors for adoption besides reimbursement, we ought to look into
that, too.

\>\> Karen: I would also add that reimbursement comes in many different
formats.

\>\> Mohan: Right.

\>\> Karen: It can be part of this; it can be part of \-- it was
mentioned earlier \-- a pay-for-performance. There are multiple ways
that reimbursements can be described. So again, when we're talking about
an evidence base for informed reimbursement policies, it really includes
looking at different reimbursement methods as well.

\>\> Jay: Tony, this is Jay Sanders. Are you familiar with the Columbia
University IDEATel project?

\>\> Tony: No, I'm not, Jay.

\>\> Jay: Okay, this is one that you fund for \$28 billion through
Columbia for a telemedicine diabetes project to look at both the
application of the technology for patients in urban, Spanish Harlem, as
well as in rural upstate New York, with a control population. I'm just
wondering if we can take a look at the items that are being utilized to
assess quality of care in the experimental group versus the control
group and see whether or not that gives us a good basis upon which to
use similar types of evaluative criteria.

\>\> Karen: I would also just add that there is some information about
this project along with the paper you mentioned earlier, Mohan, the one
that you did with Tom Delbanco on the Web site \-- Danny Sands, I'm
sorry \-- on the Web site. Thank you.

\>\> Tony: Yeah, well, I can take a look at that for you, Jay. One other
thing I want to point out \-- and some of the discussion has been
occurring \-- the whole issue of reimbursement for adoption versus
reimbursement based upon outcomes, I think, is something that we need to
think about as well, in terms of the recommendations, and that's where I
get back to where Karen's evidence base for informed reimbursement. I
think one of the concerns that Dr. McClellan has, and I know \-- and Jay
has kind of said that in some of his discussion \-- is, we have concerns
about paying for something just because it is a technology versus
something that shows improved outcomes whether it be financial or a
health quality outcome. And I think it's part of this evidence base that
is something we need to take a look at. Is secure messaging in and of
itself or secure messaging combined with other technologies or other
types of communications a way of improving outcomes? And I know some of
this, Karen, gets into the broader charge, but I think it also need to
be part of the evidence base if you are really talking about informed
reimbursement.

\>\> Karen: Agree. Thank you, Tony.

Understanding that there is a lot of wordsmithing that is going to have
to happen around this, is there anyone who feels that the concept needs
to come off the list? Can we leave it there for future work?

Not hearing a whole lot of objection, so I will leave it there for now.
Wordsmithing to come.

The second one has to do with the fact that right now, there are
circumstances where secure messaging is being reimbursed. Do we believe
that there should be or could be a set of guidelines that are specific
and auditable for those circumstances? Or do we believe that whatever
the market is choosing to do in this area, we should leave be? In other
words, is there a need for specific and audible guidelines for those
parties that choose to reimburse with secure messaging?

\>\> Joyce: Doesn\'t that sort of prejudge the response to the data that
we find in the first bullet?

\>\> Karen: Well, this is \-- as I said before, 1 percent of the
physicians in this country right now are using secure messaging, and
most of them are getting reimbursed. Do we want to have clearer
guidelines for what is reimbursable and what is not reimbursable or
those situations where it is currently in use and being reimbursed?

\>\> Tony: Yeah, Karen, this is Tony. I have to agree with the
individual. I can\'t remember your name, but \--

\>\> Joyce: Joyce.

\>\> Tony: Joyce. Yeah, I have to agree with Joyce, basically. I think
part of the answer to Number 2 really lies in Number 1 with the evidence
base, and I\'m \-- I guess I\'m not clear on why we would adopt 2 as a
recommendation before we had an evidence base that really said what was
informed reimbursement policies.

\>\> Karen: Okay. Is everyone in agreement that this should come off,
then, or does anyone feel strongly that because we do have, again, 1
percent of our physicians doing this and reimbursed for it, we might
want to preempt guidelines? If people don\'t feel strongly about that,
then this will come off.

\>\> [Jay]{.mark}: I think it is a subset.

\>\> Karen: Okay.

\>\> Jay: Yeah, I guess \-- this is Jay Sanders. I guess it goes without
saying that we ought to survey the physician and payer communities that
are now reimbursing for secure messaging and look at what their
guidelines are, their evaluative criteria, to see the basis upon which
they\'re doing it and/or continuing it.

\>\> Karen: And Jay \--

\>\> Mohan: I agree with Jay on this. And can I also add with that, if I
can follow onto it \-- I guess I will go down fighting on the idea of
value, but if we\'re going to do the survey, another question would be,
what do you get out of it? And what does the patient get out of it? And
what are they willing to pay for? Because the patient is ultimately
paying for that messaging, and it would be interesting to know what the
top three reasons are, and I\'m sure comfort is one of them, but I think
we want to get to the next level of dialog on value.

\>\> [Mary]{.mark}: When you do that survey, I also would be interested
in knowing if secure messaging is an integral part of setup care
processes for which they are receiving reimbursement, or they are
receiving reimbursement directly for this technology \-- the use of this
technology.

\>\> Karen: Okay. So we\'re building out a very robust recommendation
here. The hardest part is going to figure out who is going to do it.
We'll worry about that one later.

\>\> Mohan: They will have to reimburse for that, too.

\>\> Karen: The next one is whether or not we need to promulgate any
type of HIPAA security guidance regarding secure messaging. We have some
information today. The clinician community may still be somewhat
confused about it. There could be a recommendation if the Workgroup
believes that it is necessary that the Federal Government put out more
information or clarity \--

\>\> Tony: Clarification.

\>\> Karen: Clarification around HIPAA.

\>\> [Mary]{.mark}: I like this idea very much. I thought the
presentations today were very helpful, and I think it would be very
helpful to a number of communities' stakeholders.

\>\> Mohan: Hear, hear.

\>\> Karen: Okay. No dissenting votes?

\>\> Tony: Well, I\'m not going to be dissenting votes, Karen, but as
one who will probably have to be putting out this guideline, yeah, I
want to do a little more research into how we arrived at this \-- you
know, the information we have now, which I think Dr. Sands laid out very
well, and then get back to you on that. But I can understand if there is
some need for further clarification, we will need to undertake that
option.

\>\> Karen: Okay. Sorry about that. I forgot that you'd probably be the
handholder for that one.

\>\> Tony: I don\'t think there is a "probably" about it; I think we
would be.

\>\> Karen: Next on the list was a question about the malpractice risk
\-- the decrease in malpractice risk. I think at our last Workgroup
meeting, the issue of malpractice risk was addressed from the
perspective that most clinicians feel this might be \-- secure messaging
might actually increase their risk. That was essentially countered by
the fact that we understand from a number of malpractice providers that
the risk likely will go down, because secure messaging documents in the
patient record the transaction that has occurred. However, there is a
lot of misconception about that. So the thought here was that someone
might develop and promulgate physician statements regarding decreased
malpractice risk and cost associated with the \-- malpractice cost, not
health care cost \-- associated with the use of secure messaging if
endorsed guidelines are used.

Recommendations \--

\>\> Tony: Yes.

\>\> Karen: I would recommend looking at the last two bullets that we
might want to consider just broadening the topic to be an explicit
review of the facilitators and barriers to \-- even if they are
perceived in actual barriers \-- to the use of the technology. Because I
think that they are broader than the two that are listed.

\>\> Joyce: I think that is a good point.

\>\> Karen: All right. Understanding \--

\>\> Jay: Karen, one question that will probably come up from both the
defense and plaintiff side in malpractice will be whether or not you
consider secure message a part of the medical record. All making the
assumption that \-- at least I am \-- that it is part of the medical
record. I think clarification on that issue would be important.

\>\> Karen: Uh-huh. What I\'m hearing is that we do need someone \-- we
haven\'t decided who yet \-- would need to provide information on an
explicit review of the barriers and enablers of secure messaging. I
think that is a very good suggestion. We\'ll add that to the list.
However, I\'m wondering if these two pieces, the one on malpractice and
the issues that have been brought up, and State-based licensure, which
is also a huge issue, might be separate recommendations, understanding
they are only two of what may be more.

\>\> Tony: Or you could make it one recommendation and say "including
but not limited to these two areas," Karen, one way or the other. But I
think you are right: they did come up specifically, so they should be
addressed as well as the larger issue about barriers.

\>\> Karen: Okay.

\>\> Mohan: The other thing in the area of risk, if I may \-- this is
Mohan \-- if we talk about the broader concept of risk, is the risk of
miscommunication using communication technology, which is, when a
patient communicates with a physician, it is not usually \-- it is not
always just a one-to-one. It could be a one-to-many dialog between
patient and many physicians or many caregivers or many people in the
health care environment. How do we create an environment that allows for
a formalism that protects the patient as well as the physician in this
process? A physician could be dialoging with a patient who is dialoging
with another physician. And how does a physician, you know, contain the
sacredness of the conversation in the style?

\>\> Karen: That is a point well-taken, and I think maybe that's where
we might be able to do a little bit more research, perhaps, with some of
the malpractice companies, see what their thoughts are on that, or
someone will. You also mentioned cultural issues. Is there some way you
could, Mohan \-- some way you would like to frame a concept, a
recommendation concept, around cultural issues \-- cultural change?

\>\> Mohan: Right. The safest thing is to call it cultural issues, but I
really would frame it in two categories. One is, what is the behavior
change? We need to kind of understand the behavior expected change on
the part of the clinician and the physician \-- I mean the clinician and
the patient, if you want to call it a patient, because the patient will
have to behave differently in the dialog, just as much as the physician
has to set the agenda of the dialog, so well-organized in the
presentations prior. And we have to kind of \-- I don\'t know whether we
set guidelines, but we certainly have to acknowledge the difference in
behavior and understand that behavior in a more effective way.

\>\> Jay: I\'m also wondering \-- and this was brought up, I think, at
our first meeting that we had about the digital divide. Think about the
perception in which we find \-- I\'m coming to a hypothetical conclusion
\-- we find that secure messaging is a value. It improves quality of
care. It improves access. It decreases cost. It\'s reimbursed. And now
there are people who don\'t have access to secure messaging because they
don\'t have a computer. We\'re going to have to deal with a significant
negative feeling on that. Maybe that\'s just my own individual view on
that, but I think we just need to be aware of that.

\>\> Mohan: That would be a second item. I mean, actually that would be
a separate bullet, wouldn\'t it? Beyond the cultural issue. Or are you
categorizing it under the cultural category?

\>\> Jay: Yeah. I was going to lump it, but maybe it ought to be
identified as a separate issue.

\>\> Tony: So \-- this is Tony, Jay. So what you are talking about is a
perceived or actual difference in the quality of care related to whether
someone has access to be able to do secure messaging or not, so that
would kind of be a cultural issue but also more of an economic issue of
some sort?

\>\> Jay: Exactly. Yeah.

\>\> Karen: [Are you sure]{.mark} equity \--

\>\> Jay: I would not only say quality, but I would say access.

\>\> Tony: Right.

\>\> Karen: Equitable care? It is an issue of equity.

\>\> Jay: Right. Equity. Right.

\>\> Karen: We also \-- in looking at the facilitators and barriers
associated with the issue, the issue of literacy is something I think
that we need to at least explore.

\>\> Mohan: Yes, yes, I endorse that so much. And that, I think, falls
in the category of consumer behavior as well.

\>\> Karen: Yes. Well, let me just ask again \-- you know, I raised this
last time, but as we are exploring this, we are considering the use of
this technology by more than just physician providers, correct? I mean,
more than \-- because we constantly use the word "physician," but the
language, I think, is really looking at what are the \-- what range of
clinicians might be, in a given context, very well-positioned to achieve
the goals associated with secure messaging that \-- and that does
include range of nonphysician providers.

\>\> Joyce: I absolutely agree. I think the word is "clinician," but I
think the intent of the specific charge is that a practitioner's taking
care of the patients directly rather than a third party source \--

\>\> Karen: I only say that because nurse practitioners do do that, and
so \--

\>\> Mohan: Yeah. Of course. And we would include pharmacies and, you
know, a wide variety of \--

\>\> Karen: Excellent.

\>\> Mohan: Individuals, would we not? I\'m asking a question.

\>\> Karen: Oh.

\>\> Jay: Well, you know, in certain States like Florida, pharmacists
not only can give out advice; they can write prescriptions. So my
feeling is a broad one. Anything that will facilitate, you know,
compliance on the part of the patient, provide them empowerment, we
ought to support.

\>\> Karen: And many of the studies on telemedicine that have
demonstrated such great outcomes are those studies that are, you know,
directed by other than physician providers. So I think that, you know,
nurse practitioners similarly, in many States, are able to prescribe
medications and so on. So I think we should use the language of health
care provider that can, as you said in the charge \-- that can take
responsibility for patients.

\>\> Joyce: Who is actually caring for the patient in some size, shape,
or form.

\>\> Tony: Right.

\>\> Karen: All right. Now the next piece of work is actually going to
probably be our most difficult. That\'s to really craft these
recommendations \-- l should say probably most difficult \-- are we
missing any?

\>\> Tony: Yeah, Karen, I was going to say the same thing before we
craft them. I was going to ask Brian this, because I know one of the
issues that Craig has continued to bring up is the whole issue of not
only interoperability but also the issue of infrastructure, and if
we\'re going to have this done on a widespread scale, obviously some of
it gets into adoption strategies and things of that sort. But is there
something from your perspective that you think that Craig would want to
have added to this in terms of the recommendations that deal with
infrastructure and ensuring that the infrastructure is available for
this to be adopted on a wide scale?

\>\> Brian: \[Indiscernible, cutting out\] \-- common denominator, which
was dialog, right? \[Indiscernible\] \--

\>\> Karen: Brian, we can\'t hear you.

\>\> Brian: I think Craig\'s only recommendation or comment on that was
we should work to the lowest common denominator on technology, which is
just using dialup, right? Or, Tony, am I misunderstanding your question?

\>\> Tony: Yeah, I think the point that he was trying to make is that
secure messaging obviously is available in a variety of formats
depending on how people define secure messaging. Is there an
infrastructure issue if we take certain successful programs and say,
"We\'d like to have these duplicated," maybe based on some of this
background work that Karen\'s shop is going to be doing. I think that\'s
where he was getting at; at least, that is from my discussions that
I\'ve heard him talk about.

\>\> Mike: Okay. So Tony, this is Mike Krist from LabCorp. I would like
to offer a recommendation in that regard related to interoperability.
Something for the committee to consider: Should we have a recommendation
around the standards or the \-- for the secure communication so that it
does allow for interoperability with a variety of EMRs?

\>\> Tony: Yeah, I think that address probably what Craig was looking
for.

\>\> Jay: I think \-- this is Jay Sanders. We were discussing the whole
issue at the last meeting about whether the message is part of the
electronic medical record. I think most of us felt yes, it is, and
therefore it would fit under the entire interoperability focus that we
now have vis-à-vis the RHIOs.

\>\> Tony: Right. One of the questions that we discussed last time was
the whole issue of making sure that tied into the overall workflow, and
that \-- I think some of this will get at that as well.

\>\> Jay: Right.

\>\> Karen: Okay. Thank you. I would just add that there are some issues
around authentication, authorizations, identifying patients, etc. that
are common to every single workgroup. So those are being addressed
separately as a separate set of recommendations. So we\'re looking very
specifically for those \-- for this particular workgroup, and clearly
the need to have interoperable \-- and standards that can be
interoperable with the health records is very appropriate. So add that
to the list, too. Do we \-- have we pretty much captured everything at
this point?

\>\> Brian: Karen, this is Brian again. Do you have a limit on the
number of actual tasks you want to go off and try to tackle, if this is
something that we\'re going to do within a year time frame?

\>\> Karen: Well, the recommendations have to be made by May 1. But the
recommendations are what needs to get done and who will need to do it.
We don\'t have to do the work in the next 6 weeks, but we do have to
craft the recommendation and be very clear about who, what it is, and
why it is important and why it is of value. So just as an example, we
were just talking about interoperability. In order for this to happen,
we may need to craft a recommendation that basically recommends that
HITSP, the standards panel, develop a set of standards which will allow
for secure messaging in terms of the vocabulary, in terms of the
transmission standard, in terms of an implementation, so that that
secure message can be part of an electronic health record. And then as
corollary to that, there would be a recommendation that electronic
health records as part of their technology and their infrastructure be
able to accept these secure messages.

That would lead to a recommendation that the certification commission
include that in its certification criteria for electronic health records
in the future. So that is kind of how this could play out, just as an
example.

\>\> Tony: Yeah, Karen, this is Tony. I think you made a good point with
me yesterday when we were talking about the recommendations. I think you
said there is two sets of recommendations: those about how to actually
roll out the breakthrough, such as leveraging existing programs,
building upon a geographic base; and those which address the larger
issues, such as the ones we\'ve been talking about now. And I guess from
the letter perspective \-- and I\'m just trying to get some
clarification, not only for myself but also for the Workgroup \-- from
the letter perspective, I\'m assuming that you will want to focus on the
latter, the larger issues that deal with secure messaging, not as \--
that would also obviously impact a specific, meeting the charge in the
next year, but also larger issues around secure messaging. That would
get more into the letter that would go to the Secretary, whereas part of
the presentation or the AHIC would not include that but also continuing
to build upon what specific activities need to be done to make the
charge within the next year. Is that \-- am I reading that correctly?

\>\> Karen: I think you are, Tony. And just to recapitulate, the bottom
line is the letter for May 1 really should be about those high-level
recommendations that somebody needs to do in order to enable secure
messaging to become widespread. And within that context, those
recommendations will likely also address a lot of the issues that will
come up for other forms of remote care as well, which is the larger
charge.

\>\> Mohan: You know \-- this is Mohan. In looking at the discussion, I
just \-- are we to formulate the language of the recommendation in the
dialog? Or are we to outline the issues that we need to formulate the
recommendation around?

\>\> Karen: Um, today, it\'s just to come to agreement on the concept in
each recommendation, what the issues are. Over the course of the next 6
weeks \-- and maybe this is a good time to get into the process \-- we
will need to have much more clarity about exactly how to word each
recommendation and who will do it and who will recommend who will do it.
The way we anticipate that this will be happening is essentially by a
lot of e-mail work, a lot of virtual work amongst the Workgroup. Our
staff here will take this conversation to the next level, clean up what
could be the beginning of the recommendation, present some options about
who might actually be engaged to move forward with them, and then we\'ll
have to have a lot of, as I say, e-mail dialog over the course of the
next 6 weeks. There may be issues that may come up that haven\'t been
addressed yet that we\'ll need to address, and the timeline for all of
that, as I said, is quite tight, because we\'ll need a first draft of
these initial high-level recommendations by the 14^th^ so we can start
getting them into a more readable format by the 17th. Some time \-- and
you will be contacted over the course of the next 24-48 hours by our
staff here, either Lynette Roberts or Gloria Cohen, about some possible
dates where we may be able to meet again in April sometime around the
20th or 21st or a couple of days thereafter to have a Workgroup meeting
with as many members as possible to really go the next level and slash
those recommendations out further so that by May 1, everyone is
comfortable with them.

But so today, just to recapitulate, today we want to have an agreement
on the basic recommendation concepts. And what we have so far are the
one about developing the evidence base. We\'re holding a little bit on
the HIPAA security guidance. Tony\'s going to come back and give us some
more feedback on that. We do have a recommendation for someone to really
describe the barriers and enablers to widespread adoption of secure
messaging and also more specifically within that to address the
malpractice issue and State licensure issue. Then there were the
additional recommendations \-- high-level recommendations on the
standard to make secure messaging interoperable with electronic health
records and part of the medical record. And then lastly, there was the
issue to address cultural concerns as well, and then I think what we
also made \-- the issue of equity as a last recommendation.

\>\> Mohan: The issue of bandwidth address \-- I mean, the technology
infrastructure \-- was that \-- did I miss that?

\>\> Karen: What do you mean by bandwidth?

\>\> Mohan: I\'m not meaning bandwidth; I mean the technology
infrastructure. There was a question to it. So was that in that
recommendation also?

\>\> Karen: I believe it was. It's the interoperability one where \--

\>\> Mohan: Okay.

\>\> Karen: The interoperable electronic health record.

\>\> Mohan: Okay. Great. The question I have to, you know, to spur the
even further is, do we as a committee believe you need standards around
\-- do we believe you need standards around secure messaging as a choice
of technology? Do we need to address technological guidelines to
technology vendors in terms of how to do this stuff?

\>\> Jay: It would be part of the interoperability.

\>\> Mohan: Well, the deeper question is, do we believe as a committee
that we want that to happen as part of \-- yeah, you can call it \--
Jay, you are right; it is part of the interoperability. But do we
believe that is the purview of the committee?

\>\> Jay: It may not be the purview of the committee, but by definition
or by the fact that interoperability will be a component of this, it
will drive the technology. I mean, I\'m not going to make a technology
that is not interoperable.

\>\> Mohan: Okay.

\>\> Jay: The fax industry found that out in the early \'70s.

\>\> Karen: Well, the other side of the coin is that we can \-- will
start this preliminary work on this and that, you know, future
discussions can change things, move things. I mean, nothing is patched
in stone today. This is the starting point. We\'re trying to capture
everything that might be possible so that we can start framing what will
be a very robust piece of work over the course of the next month and a
half.

\[Indiscernible, audio cutting out\] \-- take the proof and the
recommendations to heart, and we'll start our piece of work, and we'll
get stuff back to you probably by next Monday. Right, Richard?

\>\> Richard: Oh.

\>\> Mohan: Oh, I'm impressed. I'm impressed.

\>\> Jay: Richard just took his sedative.

\>\> Richard: But don't worry; I got it through my Blackberry e-mail.

\>\> Mohan: I'm impressed.

\>\> Tony: Okay, Karen, then have we completed the next steps? Is the
Workgroup \-- let me ask this one question: Is the Workgroup clear on
what these recommendations are about? Brian, do you have any thoughts on
that in terms of \-- maybe, Karen, it might be helpful to describe just
a moment what the \-- in terms of pocket committee, what a letter to the
Secretary is and how that works.

\>\> Karen: It is actually a letter to the American Health Information
Community

\>\> Tony: Right. Okay.

\>\> Karen: It will go to the American Health Information Community, and
the American Health Information Community will review it, and
ultimately, it will \-- recommendations will go to the Secretary. But we
are looking for not just a short presentation for the May meeting; we
are looking for recommendations to come in strong letter format.

\>\> Tony: So basically \-- I mean I'm just trying to play this out for
the Workgroup's \-- if a recommendation came in, let's just say if the
rec\-- I'm not even going to use the security and electronic secure
messaging, but let's just use an example that they came with a
recommendation about addressing the cultural concerns, and it
recommended that they \-- one of the government organizations do some
research into that. That would then go to the AHIC, where they would
say, "We agree; that makes sense to do that." And then it would go to
the Secretary, where it would be specifically assigned with a timeline.
I mean, I think one of the concerns I'm seeing with some of the
Workgroup is, I don't think they want to see a bunch of studies being
done. So I think what they \-- maybe one of the issues here is, can you
kind of break down how this would work and how this would tie into the
overall charge?

\>\> Karen: I think the \-- the best example is the one perhaps we've
just used, or \-- and it is very similar to what actually came out of
the EHR Laboratory workgroup yesterday: the very specific
recommendations that we'll probably still spend 6 weeks crafting to the
Health Information Technology Standards Panel to develop specific
standards around vocabulary, transition, and implementation of message
detail or secure message detail. The timeline for that, the degree to
which that can happen, will obviously have other drivers to it. But the
\-- if the American Health Information Community believed that this is a
very important step to take in order for secure messaging to be widely
accepted, then that recommendation would go to the Secretary, and the
Secretary would then make that recommendation to us to move forward with
our contractors on that.

\>\> Tony: And this would have to be done by January of next year, or
how does that tie into that?

\>\> Karen: Not necessarily. Clearly, some things will be a higher
priority than others. And the American Health Information Community will
probably have to prioritize. If we \-- if multiple recommendations
regarding HITSP come in, then clearly they will need to be prioritized.
Some of them may need to be funded. So the recommendation \-- standards
of recommendation \-- the AHIC then decides what to do with it, how to
prioritize it. The Secretary then makes decisions about what comes from
the agency, because it is simply \-- it's an advisory body and cannot
mandate or implement. So there are a number of steps along the way. But
it all starts here in this Workgroup.

\>\> Tony: Right. I understand. I'm just \-- I just want to make sure
that people in the Workgroup are clear on what their role is and what's
going to happen to these recommendations once we clear up the
wordsmithing and other activities needed to finalize them.

\>\> Karen: Thank you, Tony.

\>\> Tony: Okay. Are there any other comments? Karen, are we finished
with the next steps now? Are we at a point now we can move to public
input, or do you have anything else you want to mention at this point?

\>\> Karen: No, it is appropriate to move on. Thanks. Thank you.

\>\> Matt: If there are any members of the public who are on the phone
right now and want to make a comment, please press star 1. For those
following on the Web, you will see instructions on the screen about
making a comment.

Karen and Tony, as always, we will give a few minutes for people to get
through the operators. And then if we see no one is calling in, I will
let you know and you can adjourn from there.

\>\> Tony: Okay.

\>\> Brian: This is Brian Devore. Can you hear me?

\>\> Karen: Yes.

\>\> Brian: I think what might be a good exercise to end this with after
we've heard from the public would be to do a positive-negative delta. We
haven't really heard back from this group based upon what they think is
working in these calls, what's not working, and things they would
change. I think one thing that would change this time is having open
lines. I have to admit, you know, I'm still fuzzy a little bit on the
process. I think there is some clarity that Tony is asking if you can
provide us, so I think this would come just a little bit from not a
member of the Workgroup; I just happen to support somebody who is in it.
But I just want to make sure that everybody is clear on what is expected
of them if they feel their contributions are landing on open ears and
things they would change to help facilitate maybe a better meeting next
time. Or if things are going fine, then that is great: you will have
good feedback, and you won't need to change anything.

\>\> Karen: Thank you, Brian; that is a great idea. Do we have any
public comments?

\>\> Matt: Yeah, we do, actually. Operator, would you please open the
line for Thomas Leary?

\>\> Thomas: Hi, this is Tom Leary with [Tims]{.mark}. One, appreciate
the opportunity to listen in, and two, wanted to get clarification on
\-- I respect the FACA rules, and this being a workgroup. What are we
allowed to or not allowed to tell our members, you know, with respect to
some of these deliberations? Just out of \-- respect everyone on this
call, your professionalism; want to bring that level of professionalism
from [Tims]{.mark} as well. So appreciate the insight.

\>\> Karen: Hello, Tom; it is Karen Bell, and I will very that question
for you. This is a public call. Anything that has transpired on this
call you are welcome to share in a public venue. There will be
transcripts, and there will be summaries, which will be available as
well to the public. And there are a number of items on our Web site that
have been referred to in the call that are available to the public as
well, and you are certainly free to share those.

\>\> Thomas: Thank you, Karen.

\>\> Matt: That is it for public comments now, Karen, if you want to
move forward with Brian's suggestion or if you want to wait a little bit
longer.

\>\> Karen: Well, if there are no more public comments, I think we could
certainly move ahead, and you will let us know if anyone else calls in.

\>\> Matt: I will do that.

\>\> Karen: Brian, do you want to lead that discussion?

\>\> Brian: Again, you know, it's just a housekeeping issue, not really
around content, but I guess my question would be, are these going well?
Are people receiving information in a timely manner prior to the
meeting? I know some things arrived today. I didn't get a chance to open
them until just before the meeting, having the meeting minutes to
reference from last time, you know, not having those available to me
when I called in. It's, you know \-- certainly, that is my fault for not
printing them out. I guess I would just open it up for comments to see
if anybody has ways we can improve or things that are not working well.

\>\> [Jay]{.mark}: I'm good. People vote with their feet typically, so
if things aren't going well, they just won't show up. But I guess we can
kind of wait and see down the line if more and more people are
represented by, you know \-- actual members don't show, there might be
possible connection there.

\>\> Mohan: On the contrary \-- this is Mohan \-- I think that the
efficiency in which you guys are running this is exemplary, and I
appreciate the updates and things of that nature on a regular basis.

\>\> Joyce: Brian, this is Joyce. I don't think that the failure of the
principals to be at the meeting is a reflection of how the meeting is
conducted. I think it is a reflection of their very, very busy
calendars. So I don't think it should be misconstrued.

\>\> Brian: No, nothing is \-- no offense taken there. I just want to be
aware that if people aren't here, it is still priority, I guess, is the
question.

\>\> Karen: Well, I \-- this is Karen Bell. I would like to indicate
that we will be getting information out in advance better in the future.
We've been suffering from what I suspect everybody has: a lack of staff,
as well as the need to support four workgroups \-- essentially, it's
been every couple of weeks at this point. It's been a very tight time
frame. We have a lot of work to do in the next 6 weeks, but we have a
nice hiatus in terms of being able to prepare for that. There's no AHIC
in the interim, and the Workgroup is \-- the next Workgroup meeting will
be probably another month or so from now. So I do apologize for getting
things out at the last minute. it's been difficult to even get it out at
that point, but at least we have gotten it out, and again, hopefully,
you will be receiving all of your information within a week in advance
in the future. So you can hold me to that, if you like.

\>\> Tony: This is Tony. I just want to make another point, following up
on that. If at any time there is any concerns that any of the Workgroup
members have, they are certainly welcome to not only talk Karen, but
also to myself or Mark McClellan or Craig or Brian as Craig's
representative. And we haven't gotten that type of feedback yet, but
obviously, if there is concerns, I think it would be helpful to bring it
to everybody sooner rather than later, and I'm sure Karen would
appreciate that as well. So if there is problems that need to be fixed,
you know, we can get them fixed before there's \-- you know, creates
additional concerns.

\>\> Danny: Move the meeting adjourned.

\>\> Karen: Okay. Any other comments?

\>\> Matt: No comments coming in from the public.

\>\> Karen: Okay.

\>\> Tony: Okay, then I say we go ahead and adjourn the meeting. Brian?

\>\> Brian: I concur.

\>\> Tony: Okay.

\>\> Karen: Thank you. Thank you all.