American Health Information Community

Chronic Care Workgroup Meeting

May 3, 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.*

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

I\'ll start with a quick roll call, then I\'ll turn it over to the
Co-chairs. Joining us on the phone call today for the Chronic Care
Workgroup meeting we have Mike Crist from LabCorp of America, Mary
Naylor from the University of Pennsylvania, Mohan Nair from the Regence
Group. Our Co-chairs are Tony Trenkle from CMS, and Colin Evans who is
acting today for Craig Barrett from Intel. I believe there are one or
two Workgroup members at ONC, you can go ahead and introduce yourselves.

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

Hi, this is Jay Sanders.

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

Anyone else?

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

This is Andy Meckelburg from Verizon.

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

And we have Dr. David Brailer joining us on the phone, as well.

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

Okay, thank you, Matt. I guess we\'ll go ahead and begin. Before we
start, Dr. Brailer, did you want to say a few words?

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

Thanks, Tony, I would. I would like to give everyone a sense about where
we are, and I think you know quite well, but you\'re very close to the
May 16 deadline that has come up with the American Health Information
Community to hear your recommendation. And I\'ve seen and watched how
much hard work everyone has put into this, and more than anything I just
had a couple of key messages.

First, thank you all very, very much for an incredible effort. This has
really made remarkable progress in a short period of time, and I promise
you that the work that you\'ve done will be well received. We\'ve
already geared up, the agency is to receive your recommendations as well
as the others, others from the other workgroups, so that we can turn
these around quickly as the Secretary has directed.

To that end, we\'re going to ask that your final efforts here this week
be aimed at bringing any polish and precision to the specific short-term
recommendations that will be transmitted and recommended on May 16. And
we really see three categories of issues being raised by this group.

First are those specific short-term recommendations. I know you\'re far
along with that, with your draft letter. Those, if approved, would then
be transmitted directly to the department or to the other agents who are
being called upon to take actions by the Office of the National
Coordinator.

Second are any large issues, issues that you find conceptually the group
is divided on or issues that require the AHIC to give you discussion and
guidance. It\'s possible they\'ll choose to give feedback on
recommendations they don\'t pass forward, but if you have large issues
we hope that you\'ll call those out.

And then the PowerPoint presentations that your Co-chairs will give,
we\'d like to have those teased out. And we\'re obviously looking for
those so we can do agenda management at this point.

And finally, we\'re looking for any illumination of what the larger
recommendations might be. We call those evolving recommendations. Things
that you\'re not prepared to say with specificity what the
recommendation is, but remember, you\'ll be turning soon from the
short-term recommendations for short-term specific charges, to the
broader issues, about remote monitoring and other related services in
chronic care management. And at that point, anything that you do have
that you\'d like to just again give a first looked at will be well
received to help the AHIC members come along.

The other major issue that I\'ll raise is that the May 16 meeting
represents a turning point, as well, in that we have really been pushing
you very, very, very hard for urgent turnarounds and very rapid work,
and we understand that this is the nature of what we\'re trying to do to
get these one year deliverables done. If we don\'t have recommendations
by May, or certainly by June, it\'s not likely we can take the actions
needed to get the results.

But the quid pro quo of that is that as we move into the larger, broader
charge and into the focus of getting a broader set of activities
underway, we recognize that A, more time can be taken, it can be more
substantive and more evidentiary in terms of how your dialogs are
guided.

So we are going to promise that we\'re going to slow down a little bit
and not push you quite so hard so that we can get these broader issues
to unfold at the time that they need.

So you\'ll see that reflected in agendas, and timing of calls, et
cetera. We\'re not letting you all off the hook, there\'s still a lot of
work to do, but we do recognize that this level of intensity and
simultaneity of action isn\'t sustainable.

Again, I promise you the efforts you have put in are going to be very
well received, but we recognize the constraints on the process going
forward.

With that, I\'d like to just thank Tony and Colin standing in for
Co-chairs, they\'ve done great work. And that\'s all for me, thanks,
Tony.

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

Thank you, David. Colin, do we want to next move to the actual letter
here to go over any last discussions on the five recommendations?

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

Yes, I think we should go through those systematically and just make
sure we\'re all on the same page. One question that comes to my mind,
listening to Dr. Brailer there, is in terms of breaking down the issue
into specific short-term recommendations, larger issues, large, maybe we
should think of those three categories as we look at these
recommendations. It\'s not clear that we\'ve necessarily thought about
them in that sort of \-- you know, topology of recommendations. I think
as we go through them, to the extent we could filter them into these
categories, which are the ones we thought ought to be immediately
actionable by the department or by contractors; which ones are really we
think need to be on a longer lead time, you know, slower build, I think
that might be useful to at least talk about that as we go through them.

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

Yeah, and if there are other issues that need to be vetted, or begin to
vet as we begin to transition more to the broader charge discussions, I
think that\'s a good idea.

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

We may have sort of filtered already for the short term, just because of
the charge, so just letting some of those others through the net, to
begin talking about them actually might be a good idea, for future
meetings and such.

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

Fine. I think what we should do, then, is begin walking through the
different recommendations. Does everybody on the call have a copy of the
latest draft letter that Gloria sent out on Monday evening?

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

Yes.

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

Yes.

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

Okay, so I don\'t think we need to reread these again then, do we?

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

I don\'t think so.

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

Colin, do we want to start then with Recommendation 1?

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

Why not? Which is the sort of thorny topic of reimbursement, we have
three sort of sub\--

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

Could I interrupt a second? This is Jay Sanders. Just prior to that,
under the background and discussion, which start on page one, top of
page two, that first sentence which says further, as technology
continues to find new and better ways to gather and transmit
information, there will be even greater opportunity to meet patient
needs for care wherever and whenever they require the time and expertise
of their physician or clinician.

I know it\'s probably implicit, but I would also like to underline here
that secure messaging is going to provide the physician a much more
consistent and comprehensive and accurate information base for them to
understand their patient disease process.

So it\'s not simply a help for patients, it\'s a great help for
physicians as well.

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

Thank you, Jay, that\'s noted.

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

And also one other just sort of editorial, it talks about the Institute
of Medicine and American Telehealth Association, that should read
American Telemedicine Association. That\'s the official name.

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

Okay.

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

This is Mohan Nair. As I\'m looking at the document and I\'ve been
reviewing the document dated 5/1, discussions that prior had happened,
the work that I\'ve been doing with the subgroups associated with
patient value doesn\'t seem to be reflected in any of these pages. Am I
missing something, did I make a mistake somewhere? There were certain
elements of inspection that follows, and I don\'t know when to interrupt
the flow to discuss them.

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

I think probably, Mohan, the best way to do that would be to go through
the letter, and then look at where there might be gaps missing. And I
know Karen is going to get on the call later, but my recollection \--
and maybe, Colin, you can help, or anybody else who was on the last
call, was that I thought that was going to be moved to a larger venue.
Although it probably should still be reflected here because the
authentication, as I notice, is still reflected in this document as
well.

So that\'s something I think we need to take up a little later on.

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

Sounds good. Sorry for the interruption.

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

That\'s okay, Mohan. So your assumption is that would be part the sort
of preamble to this thing, to be more comprehensive in terms of what the
benefits of improved communication would be? Or do you think that would
tie to specific recommendations in the document?

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

Based on the discussion last time, Colin, I thought that the consensus
was \-- or at least what Karen had imparted, was that this was an
overarching issue that went beyond just this particular Workgroup, and
it would also tie into consumer empowerment as well. So I was assuming
it would be reflected not only here, but also in that document, as well.
But why don\'t we \-- I think maybe we should table it until Karen gets
on the call, and we can get maybe some feedback from her.

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

Tony, this is David. I could actually comment on that, just to let you
move on.

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

Okay.

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

There was discussion to that about consolidating these, and the Consumer
Empowerment Workgroup will be putting forward a recommendation that
would call for the AHIC to establish a subcommittee under consumer
empowerment to look at these issues with delegates from each of the
other workgroups. We thought that would be the most practical way to go
about having this cross-cutting issue addressed without creating the new
bureaucracy of another workgroup or another issue. So this would be
discussed by the AHIC, and presumably acted on to create that group. But
then we would ask you all to designate some participants in that.

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

I guess one question on that, David, for a consistency check. I know
you\'re planning to do something in privacy and security through a
subgroup, as well, and I notice that is mentioned in this letter here.
Do we need to also mention in the letter that this value issue that
Mohan has been bringing to the table should also be part of the letter,
and that if it mentioned what you just said, that it will become part of
the subgroups under consumer empowerment?

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

I think if you all object to that, then I think we should hear that
here, and we can take it into account. But if you\'re agreeable to that,
then I think we can certainly act on it that way.

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

It just seems consistent with what we put under privacy and security,
that it mentions a FACA subgroup would be \-- 

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

Exactly.

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

Mohan, does that satisfy your concern? Or maybe you can work with Karen
offline on some of the language?

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

I would be glad to. I thought I already did, that\'s why I\'m confused.
When Karen comes on board we can maybe get some clarification, if you
don\'t mind indulging me a little bit.

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

Sure, that\'s fine.

**[\>\> MOHAN:]{.underline}** As far as working with subgroups, that\'s
more a mechanical issue. I just want to make sure that patient value
equation and patient clinician value equation is reflected in our
workgroup review, because it is fundamental that we have that as a core
dependency.

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

Right. If you look at Recommendation 5, it talks about \-- this is for
privacy and security, it talks about a FACA-compliant consumer
empowerment subgroup composed of privacy and security experts shall
report a set of recommendations to the community, and they shall be
targeted to apply to each workgroup\'s specific charge and should
outline, and it goes through the various \-- it would seem like \-- I
thought on discussion last time this was going to be treated that way,
which is pretty much confirmed by David. But I think we probably can get
some further clarification from Karen.

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

Thank you for indulging me on this one.

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

Sure. Okay, Colin?

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

Is everyone else okay? I sort of assumed we could straight by \-- this
is background discussion, but assuming that we need to make more
implicit \-- more explicit the underlying \-- you know, value for
physicians, shall we go on to the recommendation? This is about
reimbursement, there are three recommendations, here. Does anybody want
to comment on those? We\'ve had a chance to view those offline. Are
these recommendations do we believe consistent with what we should be
taking forward? Anyone want to comment on that?

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

This is Eric Larson. I was part of the group that put that together, and
we\'re fine with what\'s here.

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

One comment as I reread it, I probably should have commented earlier, it
seems to me the three recommendations just from a presentation
standpoint, it seems the third one, 1.2, seems to me to be sort of more
action oriented, whereas the first two are more sort of analytical
oriented. I don\'t know if there\'s any value in putting the last one
first, just because it seems to be the most impactful in terms of
actually recommending concrete things to be done as opposed to more
analysis to be done. That\'s just maybe a star question as I read it, it
seems the meatiest one was the third one, it seemed to me as I read it.
Does anyone want to comment on that?

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

This is Mohan Nair. I think all three of them have analytical nature, I
think recommendation one and two sounds a little more meaty but if you
read it carefully, it says public and private payers should contribute,
it sounds like they should contribute reimbursement, but what it says,
it should contribute to the evidence. So it is analytic still.

Colin, are you seeing something different than that?

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

No, I just read it, it seemed to me \--

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

Seemed a little more punchy?

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

Yeah, exactly. Just a star question, anyway, I\'m with you.

Okay, hearing no comments on that. Moving onto the Section 2, Medical
Liability and Licensure. Any other comments on that one?

Actually, kind of opposite reaction to this one, which is this one
seems \-- it seems quite a significant \-- you know, vague
recommendation, you know, essentially. Convene agencies.

Develop and adopt new licensing alternatives. That seems like a rather
large undertaking. I wonder if actually there\'s kind of a halfway step
to that one that would be \-- you know, kind of ease. Does anybody feel
that\'s quite a substantial recommendation, here, in terms of the size
and complexity of the task that we\'re recommending we embark on? Are
there some sort of intermediate steps that might be a way to sort of get
into that one more easily?

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

What are your thoughts? This is Jay Sanders.

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

This is Eric Larson from Group Health. And I don\'t think we have any
choice but to do this, and I\'m not sure we can get \-- three baby steps
is going to get the job done, because it is happening as we speak, and
we basically need this as quickly as HHS could convene the groups.

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

Okay.

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

Eric Larson, whoever it was that spoke, whoever it was, the line is
coming through very, very faint.

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

I\'m sorry, I\'m on a pay phone, I couldn\'t get my other phone to work.
I\'m in Boston.

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

Okay, everybody is comfortable with this as written?

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

I think, Colin, and I agree with you, some this the devil is in the
detail, and obviously there are \-- under this. But in terms of the
overall recommendation it seems like, like Eric was saying, I would
agree with him, it\'s something that we\'ve all pretty much agreed needs
to be done. So how you get to that point will have to be developed more,
but as a recommendation, I think it can stand pretty well on its own.

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

Okay.

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

Yes, this is Paul Nichol, I would also strongly agree with that.

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

This is Jay Sanders. Unfortunately I have to agree from the standpoint
of stepping in all the potholes related to this in 1985, and have dealt
with this both on a national and international basis. And I wish there
were a more practical intermediary way to deal with it, but
unfortunately there\'s not.

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

Okay.

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

Okay, any more discussion on Recommendation 2? Now, the discussion also
should include, I think, based on our meeting last time, also any of the
language leading up to the recommendation, as well. If there\'s anything
you see that needs to be added to provide further explanation related to
the recommendation, we also need to add that, as well.

So focus mainly on the recommendations, but if there are some additional
words that might help clarify this \-- I don\'t know, Colin, if anything
you would say that you might want to add additional discussion up front
to address some of your concerns?

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

Not really. I mean, I think the preamble states the case pretty crisply,
actually. Sort of states that there\'s a \-- you know, licensure is a
sort of barrier to interstate technology adoption, and adds the issue of
biosurveillance, I think it actually quite crisply states what the
lead-in to it is.

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

Okay. Do we want to move on to 3?

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

Sure. So #3, Standards for System-supporting Secure Patient-clinician
Messaging, two recommendations. Any comments or clarifications on those
two?

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

This is Mike Crist, I was part of the work subgroup that put these
together, I think they capture the essence of what we were getting at.

Maybe the title of it, Roman Numeral 3, that speaks to just the system
supporting the messaging, and the two recommendations, the two key
areas, are the message itself has to be standardized, and then all
systems that use that message need to have a certification process to
kind of give them the stamp of approval that they will work with the
standard message.

So \--

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

The heading should say standards and certification for systems
supporting secure \--

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

Yes, it\'s standards for the message itself and for the systems
supporting secure patient-clinician communication.

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

So standards for messaging and systems \-- I\'m sorry, reorder the same
words? Standards for system \-- for message and system supporting, I\'m
trying to make sure \-- you\'re saying there\'s two aspects of standards
there which \--

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

It might be splitting hairs a little bit, it might be a little nitpicky.

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

We could say standards for secure messaging and supporting systems.

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

That would work.

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

Number 3 will read standards for secure patient-clinician messaging, and
supporting systems.

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

Good.

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

There you go.

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

I like that one, too. This is Mohan.

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

Okay, moving rapidly, consumer and clinician access, two
recommendations, one for AHRQ, 4.1 for HHS, action for HHS. Any comments
or clarifications on those two?

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

I guess one question I might have on Recommendation 4, how can the
Secretary have the private-sector report on Internet availability to
providers across the country. If this is a recommendation being sent to
the Secretary, as his lead of AHIC. I mean, I guess they could
voluntarily report on it, but he doesn\'t have any authority to command
anybody to report on internet availability to providers. So I\'m not
clear \--

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

I see, and the term "private sector" is a pretty vague term.

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

Yeah, what do they mean by that. That\'s my only concern with that.

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

Tony and Colin, this is David. Just to maybe illuminate on those kinds
of recommendations, I do agree it should go beyond saying the private
sector which is quite sweeping. But in the spirit of AHIC not being just
an advisory committee but really a workgroup of public and private,
there are a number of agents that are being called on outside of the
government to do things, recognizing that we don\'t have the authority
to command them to do that. In fact, what will happen is the Office of
the National Coordinator will communicate with whatever parties it might
be, in some cases it might be health plans or doctors associations, or
in this case, if you can identify what the specific agent is, and ask
them to voluntarily report what they know, and come back to the AHIC at
some point.

So I think there are two parts of it. One, who should it be. And
secondly, should this be something that is line item for someone to take
notice of.

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

So shall we change the language somewhat to say that HHS shall work with
the private sector, and name some other specific organizations that they
should work with, to report on Internet availability? Rather than saying
the private sector shall report?

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

I think that\'s a step in the right direction. I think the question is,
is it medical associations? They\'re probably in the best position to
know what the connectivity capabilities of doctors are.

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

So maybe HHS shall work with the appropriate organizations to report on
internet availability? Or something of that sort?

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

Exactly.

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

Okay, maybe we can wordsmith that a little bit. Anybody else have any
comments on 4.1?

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

I would say the second part the plan as a company that\'s \-- working
for a company that\'s been working pretty hard on broadband availability
and support for it. And report on a timetable to make internet available
uniformly, that seems quite a large task to assume. This industry alone
is going to \-- you know, sort of accelerate broadband deployment to the
levels that are common in other countries? I think that\'s quite a big
charge that\'s got lots of other people implied in it.

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

This is Andy Meckelburg from Verizon. We are working to pass the new
telecommunications bill in a week or so.

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

This is Mohan. We\'re really focusing on internet capability between
clinician and patient, correct? But also it would be interesting to, in
this recommendation \-- I don\'t want to add to the recommendation, but
I assume within the recommendation is the frame of reference that says
we want to know what\'s working, what\'s not, in the country today.

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

This is Andy. When we were working on this recommendation, really, the
key is the first part of the recommendation to understand the barriers,
which are probably less the actual availability of the broadband or, you
know, Internet services. About more of the people\'s reluctance to use
it or lack of knowledge or inability. That seemed to be more of where
we\'re going with it. Versus, you know, doesn\'t have to be at
someone\'s house, could be at a senior center, library, that type of
thing.

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

Is it access we\'re talking about \-- the word "Computer Access," as the
title, "Consumer and Clinical Access."

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

That\'s what we were going at.

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

So this recommendation is primarily around availability of the
technology, but not the methodology of communication.

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

Yeah, this is a larger issue than just our Workgroup. So I would suggest
we either look at it more specifically in terms of availability
pertaining to secure messaging, or this becomes a larger issue that
needs to be tied in with consumer empowerment. Because I think just
saying internet availability, just by itself, is not going to deal with
the issue of access.

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

I also heard Andy \-- is it Andy? Say that \-- the words \-- you used
didn\'t quite match this paragraph, because you said and understand the
barriers, or something. There is a plan to fix it, but there\'s an
intermediate step, which is what are the real \-- is it costs, is it
expense, is it performance? What are the issues that need to get fixed?

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

Yes. Yes. That was the real key was the Recommendation 4.0, was to
understand why people, you know, would not be able to access electronic
messaging, more so than the internet.

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

Yeah, this is Paul Nichol. I think this recommendation is a reality
check for all of us to know how well the other recommendations can in
fact be implemented. So if as a result of this review we found that
access is much more limited than we are assuming, we either need to
improve the access or rethink the focus.

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

Is 4.1 really superfluous, given the way 4.0 reads? We need to
understand the current state of play here, and understand the current
barriers and drivers.

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

This is Eric Larson. I read 4.0 as being more the consumer and 4.1 being
the provider. And they\'re slightly different questions \-- not just
slightly, they\'re very different questions. If you look at
international comparisons, it\'s really interesting to think about our
country versus other countries in this regard.

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

I\'m supportive of that last comment, because it does reflect that 4.1
being provider \-- communication.

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

I think 4.0, you\'re right, is specifically consumer oriented, the
patient end of things. 4.1 being to providers. I just think we need to
make sure 4.1 has got similar kind of words in it that say what are the
barriers to providers having better and more timely access to the
appropriate technology, rather than mandating that we drive a timetable,
which I think is beyond the ability of this group to mandate.

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

Right. I think it should be broader than the Internet, just the
technology necessary to have secure messaging, which obviously includes
the Internet, but also \--

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

I would agree with you on the secure messaging piece, because really the
Internet is available pretty much everywhere, it\'s really broadband
that\'s not everywhere yet.

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

Correct.

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

So I would \-- I would agree with you to try to limit this more to the
secure messaging.

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

Okay.

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

To keep it specific to our particular charge.

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

I remember back at one of our first meetings we were talking about the
medium and the technology, we pretty much agreed that it\'s not about
broadband, it\'s more about just keep it focused on secure messaging.

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

Right. Andy, can you take a crack at rewriting this, then, based on the
discussion?

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

Yeah. I\'d probably just substitute secure messaging availability to
providers.

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

But then the other part of it is, are we recommending that HHS reports
on a plan, and timetable, to make it available uniformly? I mean, I
think that shouldn\'t this more or less say what are the barriers in
recommendations for making it more available uniformly. I think is sort
of more in the spirit of what we should be saying, here.

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

This is Eric Larson, I actually disagree with that. I think there\'s \--
this group early on in some of our discussions said we can\'t imagine
practicing medicine and delivering services without this capacity, and I
think this should be a strong recommendation, and by setting a plan and
a timetable, we\'re really saying I think the way we feel. And I also
think that aligns with some of the statements that have come out of
David\'s office and the President itself. So I don\'t see how we can
back off on this. Because it feels like we want to back off on it at the
last minute.

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

Would people be comfortable really just sort of changing Internet
availability, to availability of secure messaging?

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

I would be. This is Eric Larson.

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

And then we can keep really the rest of the language the same.

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

I\'m okay with it, this is Mohan Nair. I\'m also listening carefully to
the previous comment about this being a larger issue than just chronic
care management. And that access and availability and methodology become
key factors to almost all elements, all subgroups.

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

Right, that\'s correct. I guess the question is whether we want to have
a specific recommendation here that addresses that particular charge, or
is this something that needs to be brought up to a larger access issue.
I guess that\'s something that the group needs to think about at this
point.

Because there are certainly issues involving larger access, but there\'s
also specific issues related to the accessibility of secure messaging,
as well. So do we want to narrow this recommendation, or do we want to
make it part of a larger recommendation, similar to what we did with
privacy and security?

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

I would assume, taking Mohan\'s point, that this would be a common
thread for many if not all the other workgroups. Do we know if that is
the case? Would we be the one driving this, or is this going to pop up
in other places, too? I don\'t know if Karen \--

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

It goes to David\'s point, David Brailer\'s point about does the group
need guidance on larger issues, and this is one of those large issues.

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

Yes, this is something that you could put in the category of discussion
if you\'re not prepared to formulate a final and specific
recommendation. Or if you want more time yourselves, because Friday is
an absolute hard deadline for this letter to be completed. And whatever
you can\'t put in it has an opportunity to come back, but not at the May
16 meeting.

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

I think the question is at least on Recommendation 4.0, is this
something that is sort of broader for the group? It appears that this
definitely hits what we need, in the chronic care people need that, but
also you\'re right, it definitely affects sort of the bigger picture
outside of chronic care. So it\'s one of these \-- David maybe could
give us some guidance. Should this be highlighted as one the rest of the
groups should look at as well?

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

This is Paul Nichol. I think you actually have to ask both questions. I
think you need to know about access to the Internet, in general, and
then specific access to secure messaging, for instance, in
Recommendation 4.1. We can\'t assume that access to the Internet
necessarily means you have access to secure messaging. But we get a
better idea of the scope of the problem if everyone could access the
Internet or all the providers had Internet access but not secure
messaging. It\'s a different problem than if we\'re stuck with basic
Internet access issues. So I think you have to ask both questions.

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

I think a lot is it\'s not Internet access as much as it is broadband
access, because that allows you to do some of the things that we talked
about and the other workgroups have talked about as well.

So do we want to have a larger recommendation focused on access that we
put as an issue for the AHIC to be looking at as a whole, and then have
a more specific recommendation for secure messaging, here?

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

Tony, can I make a recommendation to the recommendation?

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

Go ahead, Mohan.

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

I propose we stay with what we have here, which is very specific, with
the adjustment already proposed, which is secure messaging. I propose we
recommend a larger, broader issue of total access to broadband, as a
long-term or shall I say longer-horizon issue, specific to the whole
technological framework that\'s necessary for us to be effective in the
country.

I don\'t think mixing the two would give us any advantage.

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

So are you recommending that we do something similar to Recommendation 5
where we assume this would be a cross-cutting issue for all of the
workgroups, and it becomes a basic assumption for all of us that high
performance, high reliability communication exists for consumer
empowerment as well as chronic care and the rest of them?

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

I recommend that on a broader issue. But as far as Recommendation 4.0
and 4.1, I say we stay with it, with the specifics of not Internet, but
secure messaging.

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

This is Paul Nichol. I would agree with that recommendation.

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

I would, too. This is Eric.

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

Mary Ellen. I agree.

**[\>\> ANDY:]{.underline}**

This is Andy. I agree, because that\'s exactly consistent, where our
leaders sort of focused at this first meeting, saying let\'s stay away
from broadband right now, let\'s worry about secure messaging. But I
like the idea of looking at it as the bigger picture.

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

As a tactical matter, we\'d add, after privacy and security, add Roman
Numeral 6, Broadband Communication, as being an overall category of
cross-cutting issues, is that where we\'re going?

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

Broadband access.

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

I wouldn\'t put \-- is that a cross-cutting issue that we put a 6, or do
we put it in another document?

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

This is Eric. I think we should try to meet this deadline and just
refine what we\'ve got here, rather than open a whole new topic.

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

Yeah, I think we can put that as another issue, but doesn\'t have to be
in this letter here.

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

This is Jay Sanders. One of the things that \-- first of all, I agree
with what has been said. There\'s another group within government, going
to be very, very interested in the whole issue of access, and that\'s
the FCC related to the universal service line. And that\'s something
that the Secretary and the chairman of the FCC may want to sit down and
talk about. Because this is an open jury to the FCC to make
recommendations on further changes in the rules and regulations of the
universal service line.

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

Right. I think \-- I think the discussion here kind of ties back to what
David had said earlier, this is an issue that we can\'t really come to
conclusion, here, today, but it\'s something that we need to make sure
gets raised at the appropriate way to the AHIC, I think, it sounds like.
Rather than imported into this letter here. Is everybody agreeable with
that?

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

Yes.

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

I think that would be very useful. One other comment I would make, to
those of you that want a factoid from history, the health IT was
launched the same day as the President launched a nationwide broadband
initiative. And the interdependencies of the two were certainly not lost
on us. In fact, we collaborated very closely to have these two efforts
move forward. This is a great counterpoint to come back and ask where
are we and what else do we need to do to move this forward. But still
you should maintain your recommendation, I think it\'s a great idea.

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

Let me test one thing, this is Colin. We\'re saying because of the time
pressure to complete this letter by Friday we don\'t believe that it\'s
appropriate, or feasible, to craft a sixth point, here, to talk about
this broadband communication issue. So what is the mechanism for us
actually taking that forward, as a concern we have?

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

Remember there are three categories, Colin. You have these specific
recommendations which are relevant to the short-term objectives. You
have another category on the other end of evolving recommendations,
which is giving a glimpse at where you\'re heading that you can invite
discussion from AHIC on, and therefore guidance. There\'s a middle
category that you want to flag a particular issue that\'s controversial,
that requires guidance, that you do want this group to begin thinking
about. And I would suggest this goes there. And we\'ll preserve time in
the agenda for that specific discussion to happen. They won\'t take
action, but I think you\'ll hear the discussion, and that will give you
I think the chance to go back and revisit this with that information. So
that\'s what you want \--

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

Yeah, I was actually asking about \-- I understand that, I was asking a
dumber question than that, actually, which was does it go in the Word
document here or in the PowerPoint.

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

Yeah, it goes in the PowerPoint. Yeah, this letter is kind of a formal
legal letter that is about recommendations.

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

So we would basically \-- the PowerPoint for the 16th would summarize
this letter, and then have the second or third \-- you know, section at
the end where we have these other things. I guess then the mechanical
question is, "How would we craft the other \--"

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

If you all would just state the question or issue, the staff will take
that and put it into a PowerPoint and run it by your Co-chairs.

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

We\'ll ask Karen I guess to do that.

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

If I heard this right, this is Mohan, we\'re staying with 4.0, 4.1,
we\'re changing the word "Internet" to "broadband" \--

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

Secure messaging.

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

And we\'re closed, right?

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

Let me read 4.1 as I have it now based on all the comments: HHS will
work with the appropriate organizations for report on secure messaging
availability to providers across the country and report on a plan and
timetable to make secure messaging available uniformly.

Is that where we want to go on this recommendation?

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

Sounds good.

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

That sounds good.

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

I think so.

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

I\'m in.

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

Okay, Colin, I guess we\'ll move on to 5, then, one of these overarching
issues.

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

Privacy, security. You can read the document. Open up for discussion on
this one. I think sort of the assumption here is we think there\'s a
critical element to success of the recommendation we\'re making, but we
believe this is a \-- you know, cross-cutting issue across other groups,
and expected to be dealt with as such.

Any other \--

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

This is Paul Nichol. I was on the subgroup that helped put this
together, and this is in keeping with what we agreed to last time, I
think. It definitely needs to have the group as is described in 5.0 put
together, and I think that would result in a much stronger product.

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

This is Mohan Nair. As I read this document, it does \-- it is a broader
issue, but it does pretty much say that e-mail is less effective than a
secure portal.

In other words, it goes to the details of exactly which technological
frameworks work.

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

And you\'re saying it should or should not do it?

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

I\'m saying is that the intent of the subgroup?

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

That was the intent of the subgroup, feeling that there were a number of
confidentiality, security issues with e-mail, and that a secure
messaging portal or some secure environment would be more appropriate.

I think the specifics of that, again, could be recommended by this
subgroup.

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

This is Colin, I had a similar reaction to Mohan\'s, doesn\'t seem to be
deciding what the technology should be. It\'s obviously in the preamble,
not in the recommendation, but I had a similar reaction. There are
plenty of ways to skin this cat, so, you know, we should leave the
choice of technology in the recommendations to be as open as possible,
rather than imply that we have a particular \-- you know, prejudice or
bent as to technology I think as we get into this. That was my reaction
to it, anyway.

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

What if we put a modifier in that second sentence there in the
paragraph, \"at present.\" A secure portal. And that would somehow
acknowledge that we don\'t know what could be in the future.

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

Either that or a technology such as a secure portal, something like
that, to just indicate \-- I think the intent of the subgroup was to
move away from routine e-mail, because of the issues of trying to figure
out who is sending it, and a variety of other problems that the group
saw with that.

The secure portal at the present time is the most common capability that
is used, but certainly the intent is not to be restrictive, as new
technologies become available.

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

I think it\'s a key point, I think we just need to leave the options
open for the geeks to look like this and come with smart ideas how to
solve the problem that give people lots of choice in how to do this.

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

I think it makes sense, too. I think you have to make it more flexible
to bring in other technological solutions that people have.

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

I forget who said it but it was sort of the idea at the moment, current
technology, seems to be the way to do things. But we\'re looking \-- you
know, we would be open to other recommendations as this group got its
teeth into the problem.

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

I\'ve got to tell you the first paragraph \-- the second paragraph
basically says it. The first line says authentication is the most
important thing. We need a high level of assurance that the sender of
the information is in fact the authority. By the default that implies
e-mail is not that source.

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

Right. Again, the group just wanted to emphasize that would it be
appropriate to modify that second sentence in that paragraph to say \--

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

For now.

**[\>\> PAUL:]{.underline}**

\-- technologies such as secure portals should be considered in place of
common e-mail, because they facilitate, blah, blah, blah?

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

I\'m okay with the modifier. I just don\'t want the \-- here\'s my
agenda. My agenda is I don\'t want them to think the portal is the
answer, either.

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

Yes, and that was not the intent of the subgroup. The intent of the
subgroup was to emphasize that e-mail has problems.

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

Yeah, it does. So if there\'s any way to frame that, that reflects the
balance of what we just discussed, I\'d be supportive.

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

Rather than focus on the portal, maybe we might want to note that common
e-mail lacks certain things that may be found in things such as \-- I\'m
trying to paraphrase this now, but maybe we should start with what are
the deficiencies in e-mail that would be potentially mitigated by other
technologies such as a secure portal. Maybe that\'s \--

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

I don\'t know. I think you could delete that second sentence completely,
I think we\'d probably solve the problem.

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

Actually I don\'t know if we really need the second sentence, actually.

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

If I may make a counterrecommendation, I think removing that line is
fine, if you would add at the end of the first sentence in the second
paragraph the word "for the information\" and state "beyond regular
e-mail authentication or identification.\" And if you just said the word
"beyond e-mail," they\'ll know that it has not to be e-mail systems.

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

I don\'t find that very helpful. I think probably we should just stick
with \-- the first sentence I think says it all.

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

Okay.

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

I think the recommendation is the most important piece of this, anyway.

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

Yeah, maybe we should pass on that.

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

Okay.

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

The recommendation should be supported by the information that comes in
the preamble, and it creates more of an issue than it solves, and we
should probably just delete it.

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

Now, the recommendation does not state that e-mail is not acceptable.

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

Well, I don\'t know that we should make that statement, that e-mail is
not acceptable. I think \--

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

I\'m sorry, Mohan, I think you were saying that it shouldn\'t state
that? So \--

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

I\'m trying to support the subgroup that put this together. There was
emphasis in the subgroup associated with e-mail not being the choice.
And if you want that to flow into the recommendation, it\'s not there.

I\'m comfortable stating the conditions and requirements, assuming the
technologists really understand that e-mail is not the best form of
authentication.

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

We\'re saying e-mail today does not meet the needs of the first sentence
in the paragraph.

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

Correct.

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

But that\'s not to say someone couldn\'t find ways to devise e-mail-like
systems that would in fact deliver appropriate authentication, that
would guarantee that who sent it was who you thought it was and who
received it is who should receive it. There are different ways to solve
that problem.

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

Right. We\'re talking here is about secure messaging rather than just
e-mail, anyway.

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

Absolutely.

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

I think we\'re safe on this recommendation.

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

Again, I think the issue is in the absence of secure messaging systems,
many physicians currently use regular e-mail for this communication. So
it\'s \-- and there are actually some who advocate that. So it\'s just a
question of whether you think the group needs more direction in that
regard or whether you think that first paragraph \-- or the first
sentence there in the second paragraph would exclude routine e-mail.

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

Paul, I think if you build a list of requirements, and some of the
requirements that are discussed in the second sentence here would be
listed among them, that would certainly rule out common e-mail, then.
Wouldn\'t you think so? I mean, if it\'s tied to requirements and
potential solutions, if common e-mail doesn\'t meet some of those
requirements, then you wouldn\'t \-- that wouldn\'t come out as a
recommendation.

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

So rather \-- to change that second sentence rather than mentioning
secure portal or whatever, just say something like technology used
should facilitate the authentication process, et cetera, et cetera?

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

Yeah, right. If you\'re going to use it, use \-- state what requirements
need to be met. Not specifically secure portal or common e-mail, just
say that \-- or get rid of it altogether, and just have the group look
at requirements, and it would naturally fall out from the requirements,
because it wouldn\'t meet some of these mentioned in sentence #2.

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

So the two recommendations are to change sentence two just to read
technology developed should facilitate the identification and
authentication process, provide a more acceptable level of security, and
create opportunities for structured data entry not routinely available
in common e-mail systems. Or just delete it?

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

I thought the way that sounded is perfectly okay to me, Paul, that
sounded about right.

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

Could you say that again, Paul?

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

Technology developed should facilitate the identification,
authentication process, provide a more acceptable level of security, and
create opportunities for structured data entry not routinely available
in common e-mail systems.

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

Yeah, that\'s good.

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

I think that sounds good.

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

The only thing that worries me about this whole privacy security issue,
and this is probably a controversial point, but the totally secure
system is likely to be completely unusable. So I think allowing
flexibility of the system to adapt to circumstances is something I think
we should also be \-- we should be careful we shouldn\'t lock out, you
know, good enough technology in cases for certain circumstances because
we\'re trying to protect, you know, the perfect world here.

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

A balance between usability and privacy and security.

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

I\'m sure in many cases patients and doctors may well exchange
information that frankly they wouldn\'t care if someone overheard them
talking about it publicly in the waiting room. I\'m not suggesting all
communications are that way, but there may be cases that \--

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

This is Eric Larson. I think that last comment is one I agree with. I\'m
not sure we gain anything by being overly specific, here, because we\'re
basically asking somebody else in a recommendation to work on this, and
we\'ve given them the charge and outline, so to somehow put something
into an official letter that\'s this specific could be more than we want
to do.

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

Yeah, I don\'t know where to go with this, but it seems that if we \--
something in here should be \-- when there\'s a range of use cases of
information, some obviously, unless it\'s completely bullet-proof
secure, privacy-wise, people should not use it, but in many other case
I\'m sure people would be a little more relaxed. And particularly
something that was more usable, that might actually help adoption of
technology, in use cases where it\'s not \-- you know, people are a
little more \-- you know, sanguine about where the data might end up.

I think something in here that says that provides flexibility of use or
opt-in cases, or \-- you know, sort of range of capabilities is what
we\'re looking for at the end of the day.

I think might be better than just saying every single communication has
to have \-- you know, three levels of encryption and \-- you know,
several levels of authentication because we \-- you know, we don\'t want
a million in one chance of it escaping. Some data might be like that,
but not all of it.

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

Yeah I think a very important point that needs to be put in here is we
don\'t want to come up with a solution that inhibits the use of secure
messaging, we\'re looking for something that promotes the use of it. So
we have to make sure we have in here the issues of flexibility and
usability, depending on risk conditions or whatever caveats you want to
use.

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

Absolutely.

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

Otherwise you wind up with the PKI solution for everything.

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

There are a lot of data about me medically that I\'d want everybody to
know. Blood group, allergies, those kind of things, I wouldn\'t want any
of that to be a secret.

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

Here is where the issue of privacy and security becomes an interesting
dialogue. Do people know what is private and secure, do they know what
is not private and secure in the business? Are there guidelines that
allow for this communication to occur? As a physician and as a patient,
and I\'m talking to you via e-mail versus secure messaging, do I know
what I can say in e-mail or what I can\'t say unsecure \-- you know, et
cetera, et cetera?

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

I\'m not sure where you\'re going with that, Mohan. Is that a rhetorical
question?

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

Yeah, it is, it\'s rhetorical, because I\'m talking out loud here. Maybe
other people who are clinicians know what to say on an e-mail versus
what to say on a secure messaging line.

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

This is Eric Larson, and this will be the last comment I\'m going to
make for awhile, but I think the level of knowledge there is highly
variable. I think within medical staffs and medical groups people
attempt to make these kinds of practices as compliant as possible with
what should be private and secure. But we know it\'s not perfect, and
that\'s part of the reason why I think we should be a little bit careful
about being too specific about this recommendation. Because it\'s
definitely a moving target, and as people become more sophisticated,
conceivable, we can do a better job as clinicians distinguishing things
that are private from those that may not be.

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

How does that reflect \-- this is Mo \-- on the Recommendation 5.0?
Should well leave it the way it is, or should we add something that is
less restrictive, or do you believe it\'s too restrictive the way it
stands?

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

One way you could read this is if we\'d like the Workgroup to recommend
and should outline, you know, available methods of patient
identification or authentication, blah, blah. And I can imagine one
outcome of this set of recommendations will be kind of a matrix of
available technologies, which would have a range \-- you know, some of
which would be 100 percent secure, some of which \-- you know, not. And
maybe in fact that is a natural outcome of this Workgroup
recommendation, which is that \-- and based on this range of technology,
I could imagine a subsequent discussion in which we would then have to
have some other recommendations or some use restrictions around that.

So in these circumstances only these technologies must be used, but in
others, there\'s a broader range of choices. That give perhaps an
easier, faster, easier cheaper way of implementing some of these things.
To make this naturally sort of a range of choices, I\'d personally like
to call that out that more explicitly, saying we are really looking for
a range of available technologies and their pros and cons rather than a
proscriptive, definitive recommendation, this shall be the technology. I
mean \--

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

This is Paul Nichol. Perhaps based on this discussion we should take out
the second sentence in paragraph two completely and add a recommendation
that the \-- the recommendations should outline appropriate technologies
to support secure messaging, access to health information, and the other
areas that are covered by the workgroups.

So just ask \-- rather than prescribe anything, ask for recommendations
about what technology best supports these activities.

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

Which technologies best support each case, is that what you were saying?

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

Yeah, I was focusing specifically on the secure messaging and access to
health information, which is our charge, but \--

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

I\'d be comfortable with that. This is Colin.

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

It seems that that is the least restrictive, and it asks the workgroup
that we\'re charging to specifically outline the kinds of technology
that they\'re talking about, and perhaps they\'ll come back and say if
you\'re going to talk about, you know, nonsensitive issues, common
e-mail is fine. If you\'re going to talk about issues that need to be
kept confidential, you need a different technology with a higher level
of security. Let the group come back with those recommendations.

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

Yeah, I think that makes sense. I do want to make sure we keep in the
usability and flexibility, because I get concerned when I read
Recommendation 5, when it says it\'s a group composed of privacy and
security experts. I think you need to have some people with some
business process knowledge, on that workgroup as well. Because if you
end up with just a bunch of security people, they\'re going to look for
the most secure solution, not necessarily the one that makes the most
business sense and usability sense.

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

Yeah, that\'s a very good point, I think you probably need to augment
that with clinician and patient representatives. Otherwise \-- that\'s a
good point.

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

Yeah, this is Kelly Cronin. I\'ve actually been trying to support the
Consumer Empowerment Workgroup in crafting this, and I think everything
that you\'re saying has actually been captured in their deliberations,
and even in the preamble for the Consumer Empowerment Letter, we
reference the idea of meeting sort of practical application of these
technologies, or authentication or security solutions. So that people do
have sort of that real world element.

But even in practical terms as we\'ve been thinking through how this
might \-- if it is recognized by the community, and endorsed, how we
would actually get this together, and we really do want to make sure we
have both the clinical, technical, and legal expertise necessary to be
crafting \-- you know, recommendations that are going to be
encompassing \-- you know, all of the issues that have been covered by
each workgroup.

So we\'re on the same page, we just need to make sure the words reflect
that.

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

Yeah, the other thing I would recommend on this, Kelly, is there\'s been
a lot of body of knowledge built up in this area, not only in the health
care industry, but in other areas, as well. And this group needs to take
advantage of the body of evidence that has been built up that could be
used to drive some of these recommendations, as well. They don\'t need
to start from a blank slate, here.

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

Right.

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

You mean from financial services or from other industries and so forth.

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

Right, exactly.

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

So if we change \-- leave the second sentence of the second paragraph
alone based on the last revision, and just mainly tweak the
recommendation a little bit, A, to include privacy and \-- you know,
appropriate patient and clinician representatives in the sort of
recommendation, and then somehow capture the thought that we\'re looking
for a \-- you know, range of technologies that might be applicable in
different cases, as being the desired outcome of this thing, would that
work for us? And then Kelly is obviously going to have senate
reconciliation thing to go on between us and the different workgroups.
Or should we just cut and paste the words from the other workgroup, if
they\'ve already got them \-- they\'ve captured this thought. I\'m not
sure what basically \--

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

We\'ve been sort of tweaking hour by hour, and we can certainly make
sure that those words get incorporated in each letter. So I think that
it\'s a good observation, and while it was probably in the preamble of
another, it didn\'t really make it into the recommendation. So I think
it\'s important to be consistent and make sure we capture that point.

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

So if we say \-- okay, so we need to wordsmith this recommendation to
capture these thoughts, and go forward that way.

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

Right, but from what I just heard you\'re saying comprised of privacy
and security experts, along with appropriate \-- we could say experts or
representatives, with clinical \-- or clinical expertise.

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

Yes, representing clinical and patient interests.

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

Right. Right, okay.

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

Or something of that sort.

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

I think the rest of this sort of works, outlines methods of, that says
there are multiple methods, multiple mechanisms. This recommendation
naturally leads to a range of choices. I don\'t think we have to \-- at
least that\'s the way it reads to me. I think the way we present it
needs to sort of reflect that. If we need to put a \-- a sentence on the
end that says, you know, the expectation is a range of \-- you know,
technology choices that might fit different circumstances at different
levels of \-- you know, privacy and security. That might be overstating
it, but I think that\'s the spirit of what we\'ve been talking about.

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

It seems like you could just add that as a bullet under the
recommendation, methods for authentication, mechanisms to ensure data
integrity, a range of technologies that are appropriate to support the
applications of the various areas carved by the workgroups.

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

Yeah, I\'m okay with that.

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

That will work, I think.

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

Another bullet or sentence on the end to say \--

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

I think the intent is not to be technology oriented, I think we\'re
trying to have the policy determined so that the technology can enable
policy. It\'s going to be a challenge to make sure we\'re covering those
technology and policy in the deliberations, and having sort of a
balanced discussion across the various perspectives, but that we clearly
are looking at this with a policy hat on, and not necessarily from a
technology perspective.

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

Yeah, I think you want policies that support the range of solutions that
are best, most appropriate, for the particular type of interaction. And
I think that gets kind of back to our discussion last time, when we
talked about \-- you know, in-person proofing, and how that may not be
appropriate, something like it kind of talks about that the policies
need to support a variety of solutions based on the type of transaction,
or something of that sort.

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

Any other discussion on this?

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

You\'re just eliminating the second sentence in the preamble paragraph,
right?

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

I thought we just agreed to \-- I\'m okay with eliminating it, but I
thought the rewording it the last time around worked kind of well, too.

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

You\'ve got a good rewording Paul, if you want to \--

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

I thought that worked. And change the recommendation, I had two changes
to the recommendation. One is to add along with patient and
clinician \-- experts, whatever, to go along with privacy security
experts, so there some balance there, then probably a sentence on the
end that says we\'re looking for a range \-- you know, we expect that a
range of technologies will be recommended for different levels of
stringency and use case, that\'s kind of the last sentence of the thing.

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

Do we want to specifically include experts from the other service
industries, like finance, commerce? Or we can just leave it neutral?

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

Yeah, I think that we probably will solicit written testimony and oral
testimony. It\'s again the community recognizes and wants to act on this
and we\'ve been trying to figure out how we can have comprehensive
public input through that process. Likely have Federal Register notice
that would go out like they have for all the other workgroups, but we
can explicitly solicit public input. Because some of these issues are so
challenging to take on, and if we really want to produce something by
the end of September, we\'re going to have a lot of really intensive,
long meetings that will be \-- we\'ll have an awful lot of prep time
ahead to schedule with public input from many different parties,
including other industries.

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

I think speaking for Craig here, Craig, you know, represents a \-- you
know, a broad run of technology companies, I think he could certainly
bring to bear expertise from companies that don\'t just operate in the
health care field to talk about \-- and I think that was one of his \--
you know, intentions at the beginning of this Workgroup, that we would
draw extensively on expertise in financial services or in \-- and in
retail, and other areas that have got a concern about \-- you know,
commerce in general, concern about privacy and security of information.
I think we can bring that to bear quite easily.

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

Right.

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

So we\'ve come to the signature page, so I think we must be done. So
should we \-- perhaps, Tony, we should talk about \-- if this lecture is
due for completion by the end of the week, we probably should get pretty
specific about actions required to close the changes to wording and make
sure this document is done and tied up by Friday, right?

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

Right, maybe we need to go back through these specific actions, and then
we can turn to the other issues that David raised to see if there\'s
anything that people want to talk about.

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

I gather Karen has not \-- has Karen joined us? I didn\'t hear Karen.

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

No, but we can still maybe address Mohan\'s concern about the value.

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

Yeah, there\'s Mohan\'s comment, that\'s one.

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

And the broadband issue is another one that we raised. But do you want
to walk through the document? I don\'t think we have any issues on #1.

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

No, but there was a comment I didn\'t write it \-- that said it\'s in
the top paragraph on page 1, that said we should \-- the assumption was
it was implicit, not just that secure messaging gives better value to
patients, but also provides value to physicians in gathering and
maintaining better information about patients, right? That was sort
of \-- I forget who made the comment, but I think the intention was it
be made more explicit in that first paragraph, right?

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

Kelly, has someone from ONC been tracking this pretty closely? Can they
kind of walk through where we recommended changes? Is there someone \--

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

I\'ve been in and out trying to \-- a little bit. I guess I only heard
secure messaging needs to \-- or I think it\'s the top paragraph on the
second page, we need to incorporate how it provides physicians with a
more comprehensive understanding of the disease process, so it\'s
another source of information for them to draw from, to better
understand the patient\'s needs.

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

I think that captures the spirit, if we could add that in that first \--
that top paragraph, I think that would capture the concern that was
raised in the meeting.

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

I believe, Jay, you raised that issue.

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

Yeah, I did.

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

And I think there was also agreement to revise #3 to standards for
secure patient-clinician messaging, and supporting systems.

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

Yep.

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

Richard, do you have any other changes you\'ve been tracking?

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

Well, we suggested a change to 4.1 so that \-- I think, Tony, you had
the words captured for that one.

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

Yeah I\'ve got 4.1. The other, we \-- we were change \-- on \-- back in
the preamble, we were changing the telehealth to telemedicine.

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

Oh, yeah, telemedicine yes you\'re right.

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

Do you want us to read out what we have for 4.1?

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

Yeah.

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

4.1 we have HHS will work with the appropriate organizations to report
on secure messaging availability to providers across the country, and
report on a plan and timetable to make secure messaging available
uniformly.

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

Right, and the broadband is moved into a larger issue.

Okay, then #5.

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

Tony, I would just point out if we want to solicit specific discussion
by the community on that broadband issue, I think the FCC issue might be
sort of ripe for discussion particularly since they might be open to
regulatory changes right now. And since Jay sits on the board of the
universal \-- service fund, it\'s probably a great item to bring back to
the Workgroup, with community input.

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

Okay.

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

But in terms of referring and reporting out to the AHIC meeting on the
16th, we probably need to agree on how that gets onto the \-- you know,
PowerPoint between now and May 16, and who drafts that and how we do
that.

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

Yeah, I don\'t know how you\'re planning to do the PowerPoint for the
16th, but \--

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

Let\'s talk about that maybe before we go through the rest of the detail
changes, then circle back and say how are we going to \-- what\'s the
expectation, who does what between now and the 16th. I think that\'s
something we need to close on.

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

Okay, we just finished on \--

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

4\.

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

We just finished on 4, correct.

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

Right, and then \-- 4 I think had the rewording of that second sentence.
I didn\'t write it \-- I wasn\'t writing it down as it was read.

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

Paul has \-- Paul can give the rewording on the second sentence.

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

Yeah, if I can remember. It was pretty simple.

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

Don\'t you hate it when you\'re smart for a few seconds?

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

You said something about technologies may \--

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

Yes, it\'s the technology developed should facilitate the identification
and authentication process, and the rest of the sentence is the same.

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

Bingo.

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

Paul was smart.

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

For a minute.

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

And Colin, you had just gone over the ones in Recommendation 5.

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

Yes, I assumed after privacy and security experts we\'re going to add
along with patient and \-- you know, clinician.

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

Expertise or \--

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

Yes, expertise, something like that. At the end \-- I wouldn\'t put
another bullet, because the bullet list is sort of another technical
thing. Maybe put another sentence at the end that said, you know, the
recommendations should provide a range of \-- you know, choices of
technology to adapt to different circumstances, or something like that.
It\'s sort of the expectation of the Workgroup.

We\'ll have to wordsmith anyway, when we combine it with others.

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

The only other one we had changed to \-- I\'m just going back to it now,
was #3, and we changed the title on #3 to be \--

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

Yeah, didn\'t you just go over that, Kelly, I think you captured that.

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

Yeah, we got that.

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

Okay, fine.

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

Any gap I\'ve got is Mohan\'s opening issue, which is that you said for
completeness reasons, Mohan, that patient value doesn\'t seem to be
reflected in the overall comments, perhaps you could say a little bit
more about that.

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

I really bored the group for so many months talking about that, but in a
nutshell, we had argued for patient value to be quantified in some shape
or form, and understood. And we had also argued for workflow to be
quantified.

The workflow I assume is reflected in the Reimbursement section, where
we can understand how the work changes, given this new technological
environment, and how that workflow can be optimized.

The Value section has been looking for a home, in the sense where when
you have a different environment where consumers and clinicians
experience a different communication methodology, that methodology has
to be dependent on the value.

Patients seeing value, either be it in time savings or access
capabilities or peace of mind. Physicians seeing value in similar or
different ways. That value has to be understood at least so we can
tailor these solutions to derive such value. And that is not reflected
in this arena of the recommendation.

Did I say that appropriately, committee?

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

This is Paul Nichol, and that was one of the things that we actually did
add to that last privacy and security, I think that we tried to put the
patient focus back there in that first paragraph under 5. I don\'t know
if it\'s a common thread throughout all the rest of the \-- all the rest
of the recommendations.

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

Yeah, and the question is, is it appropriate just reflected in the
recommendations, or is it appropriate \-- I\'m thinking out loud,
here \-- is it appropriate to elevate it to a larger issue of consumer
empowerment? And understanding value across all subgroups or
subcommittees.

Or it specific that this arena where we understand value to be really
for physician-clinician interaction for chronic care management? And
that\'s the question I think the committee has been struggling with, and
so have I.

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

This is Eric Larson again. I thought that was just sort of understood as
one of the reasons why we would do this, anyway. And I\'m wondering if
we actually need to say it. And that\'s \-- I\'ve not had enough
experience to know if we need to state the obvious, or if it will be
just common knowledge.

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

I would contend that it\'s not common knowledge, that there is a
significant amount of misconceptions on value in this arena. It may be
common knowledge to you and I, but I\'m not sure if you ask a physician
why would you communicate \-- what is valuable to you in communicating
this, you may find different physicians having different approaches.

If you talk to patients, you may have a different view, as well. I would
contend that, and I\'m subject to being challenged by the committee.

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

This is Paul Nichol. I think it\'s fair to state the obvious, because I
found that what\'s obvious to me isn\'t obvious to everybody else. And
then not always right. So it\'s important \-- I think it\'s important to
state that in some way. I don\'t think it hurts to be redundant, if
people already understand it.

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

If value was so obvious, then why is this not widespread today?

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

That\'s because we\'re not paying for it.

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

And if we\'re \-- if we go back to the original discussion, which I will
challenge the committee on and myself, if we are to pay for it, then
where is the value coming from? In other words, we have to pay for it to
see value. But people don\'t see value enough to pay for it themselves.

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

Mohan, I\'m looking at my notes on the previous meeting, it said that
you were going to write something up on value, and \--

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

I did.

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

\-- was going to take back a draft that was going to harmonize it across
the workgroups.

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

I did, and I don\'t know where it went.

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

So I guess we need to put this as something we have to follow up with
Karen on.

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

This is Kelly. I haven\'t talked to Karen at length about this issue,
but I know in theory Recommendation 1.0 tried to capture the concept of
trying to \-- you know, monitor and report on patient-caregiver
satisfaction, so that implies that the concept of \-- you know,
satisfaction or value to the patient would be measured. But it\'s not
sort of an overarching issue in the preamble.

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

Right, and I did do some work with this prior to this meeting and did
make the recommendations in communication with I think Richard Singerman
on the workflow, as well as the Patient-clinician Value section. And it
was supposed to be placed in the Consumer Access section, which is not
reflected here, that\'s why I was confused.

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

Well, you know, there was a discussion that Craig asked to put the value
into Recommendation 1, which gets into the patient \--

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

Reimbursement, right?

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

Patient and caregiver satisfaction.

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

Oh, I see.

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

But I think you had argued that it needs to go beyond that, because it
wasn\'t strictly limited to reimbursement, it got to a larger issue that
gets into some intangible issues.

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

I think Mohan\'s point, you know, the perceived value also drives \--

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

Usage.

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

Well, the need for people to tackle medical liability, licensure,
standards, all the recommendations \-- there\'s value in slaying those
dragons, right?

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

Previous discussion I subdued my ideas to place those ideas under the
concept of consumer access, which was I think it was subordinated by
Section 4 as is currently spaced, and it\'s not reflected there. So I
may have failed the committee, or maybe we just missed, but that could
be \--

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

It does sound like it\'s a higher-level conceptual issue that perhaps
could be captured in your future deliberations, but what I\'m hearing is
you\'re saying that sort of recognized consumer value might end up
driving or inducing demand, access and utilization?

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

Yes.

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

That\'s something that could be in a preamble, because it would end up
sort of informing reimbursement policy.

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

Mohan, this is Jay. I\'m a little confused. Are you asking the question,
is this a value? And therefore, it puts it into the framework of there
should be an ongoing evaluative process that is dynamic as the system
goes forward, and that there are time frames within which the program is
relooked at?

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

No, I\'m sorry, Jay. And again, I failed the committee by keeping this
longer than it should. The trail of this discussion was we had talked
about value and workflow, and Tony and \-- especially, had articulately
divided workflow separately from value. Put workflow into reimbursement,
because that\'s really what the change in behavior was. Then the value
component, which was the arguments we all had about peace of mind versus
what is concrete about this patient-clinician relationship, was lost,
and was not placed anywhere.

It was then argued that it be placed in the Consumer Access section. And
I had written I think one paragraph, and adjusted one paragraph, for
that section. That is not reflected in this document.

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

Yeah, Mohan, I recall the discussion very clearly, and I think what
Kelly was saying is probably right. It probably should be put into the
preamble for this entire letter, up in the beginning there should be
some discussion on value. Because I think what you were referring to was
really a change in cultural behavior created by this, and the idea that
it needs to capture things such as you mentioned, peace of mind, and
other types of thought process that this creates that go beyond just
reimbursement or other types of quantitative results.

So I think, you know, this may be something that needs to be put into
the initial part of the letter, and then it drives a lot of the other
discussion that gets into specific recommendations.

I don\'t know if that\'s \--

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

I\'m okay with that.

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

I just wanted to also point out that I think Richard has worked on
trying to make sure that there\'s a lot of background materials that are
either going to be in appendices or \-- concepts are captured in some of
the materials, right?

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

Yeah, we had appendices for each of the recommendations, and we were
just asked to move those into a separate background document. And we\'ve
captured some of the \-- these issues of consumer value in that
background document that\'s going to accompany this. So that\'s where
some of this got moved.

But if appropriate, we can move some of \-- a couple of those sentences
back in the main letter, but we\'re still going to have the supporting
document is going to be submitted in the packet for May 16.

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

This is David, if I could just maybe give some advice about how to
pursue this. Separate and apart from whatever you do with respect to the
letter and the other materials that will go forward, I hope that this
group will hold this topic over as it begins looking at the broader
charge. Now, there\'s nothing that is more disruptive to the history of
medicine than technologies that allow care to be delivered while the
doctor and the physician are separate and apart, and then obviously in
the future even asynchronous with remote sensing technologies.

This question of how to engage the consumer and their value in this is
something that I think has gotten too little attention. So at some point
I hope that you\'ll be able to revisit this and think about
recommendations about beginning to frame and educate and measure some of
the value either from a consumer-operant perspective or clinician, maybe
now in the short time is not the time to do that, but this is probably
one of the major issues in the transformation towards remote
technologies.

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

This is Jay, David. I totally agree with you, and I think we sometimes
take for granted a lot of things that have never been actually measured
and evaluated, and I think it has to be a dynamic process.

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

This is Eric. I think David has said it very nicely, and that would be
my preference for our working group, would be to close the book on the
letter, but keep this as an area where we would really start to develop
some group thought about it. I\'m at a meeting in Cambridge right now
and just heard a number of presentations about secure messaging and
systems, and people are starting to think about \-- you know, how you
project value, and to whom.

And most of it is to, I hope, the consumer. And it creates a different
kind of consumer than we ever had before, and \-- but I just don\'t
think we have the time to develop those ideas in a three- or four-page
letter to the Secretary right now. It\'s \-- it sort of warps my brain
too much to think of a way to say that in three or four sentences.

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

So should we put a hook to that in the preamble \-- to try to suggest a
way to close this between now and Friday, should we put a sentence or
two in the preamble that talks about the importance of
consumer-clinician perceived value from changes in the way care gets
delivered that needs further development, and then leave it at that in
the preamble, and then in the presentation at AHIC on May 16 we have the
details in the document, but then we wrap that around with some of these
broader issues that David has suggested we tee up for future
development. We\'ve mentioned some, the broadband is one, other ones. Is
that the way we\'re closing this to go forward?

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

David, could I comment on one word you used in this \-- in your comment,
and that was the word "perceived." And I think that\'s a very critical
word. Because is our intent to be concerned about the perception, or the
reality? The fundamental point is that many patients will determine
value based upon their perception of what happens. So they will \-- the
mother will be very happy that the doctor, the pediatrician, gave their
child an antibiotic for their otitis media, and the otitis media went
away within 7 to 10 days. Or the antibiotic for the common cold. The
perception on the part of the patient is they got value out of that,
when we know scientifically that it was ridiculous.

So perception is important, but I think factual evaluation is going to
be as important.

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

This is Eric Larson. Would it be possible in the \-- at the end of the
first paragraph, under reimbursement, where we talk about as technology
continues to find new and better ways, we could put a sentence in there
that indicates that we see that the definition of value will obviously
change. But clearly, this is an area where there\'s already proved
value, and transformative kind of value to improve patient outcomes, or
something like that.

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

So that was a suggestion for how we might word \--

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

It will register without having to get into the recommendations, and \--

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

I guess what I\'m trying to suggest here from a mechanical
perspective \-- because obviously we\'re not going to explore this
subject in enough detail soon enough to make this letter for the 16th.
So we\'re in agreement \-- but this is a big topic for the future. I\'m
just trying to figure out \-- see if we can close on a mechanism for
that, which sounds like \--

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

I think we should put it in Category 2, which is the big issues you\'d
like for the AHIC to be aware of, and perhaps discuss and refer back to
you.

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

I agree with that, David, so I think the suggestion is do we put a
paragraph or sentence or two in the preamble of this letter just to
provide a hook to that saying we believe this is an important issue
going forward, but don\'t bother with it in the recommendations area. Or
do we leave it out of this completely and merely put it in the
PowerPoint on the 16th? I\'m just trying to get a sense of the group as
to what the right sort of satisfaction mechanism, so people didn\'t
think the issue is being overlooked.

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

My proposal to the committee is that we should put it in the letter as a
highlighted large issue that we will frame, and that it is a fulcrum
issue for further discussion.

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

And we put that in the preamble?

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

Yes.

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

Do you believe you have a paragraph that we can insert and do that,
Mohan? Here we are on the 2nd, we have to do this by Friday.

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

Yes, the paragraph has already been written. If you want me to rewrite
it I\'d be glad to do that, but anybody can \-- Karen or whoever wants
to connect with me, we can do that.

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

Yes, this is Kelly. If you could just resend your e-mail to Richard
Singerman we\'ll make sure it gets addressed.

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

Okay, and you can carve it into the letter, right?

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

Yes.

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

Okay, great.

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

Okay, so is that topic \-- I\'m not trying to hustle people. Are we sort
of clear, if there\'s path forward then are we okay with that? I think
the remaining of this Workgroup meeting, Tony, is probably to sort of
then make sure we\'re all clear on steps between now and the 16th \-- or
now and Friday.

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

Now and Friday, I was going to say. So Kelly, are you going to then take
what we have said today, is Richard or you or somebody from ONC going to
redraft the letter, then, based on the input and send it out one final
time to the Workgroup, or how are you going to do that?

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

Yes, we\'ll go ahead and make changes probably immediately, and try to
get something out. Again, as soon as possible, tomorrow, for a final
review, and then make \-- you know, any final minor edits in preparation
to sort of lock everything down on Friday.

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

Okay, I think that sounds good.

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

Yeah, that\'s perfect. We should all understand that the scope for
editing after that is \-- you know, major grammatical and spelling
errors only, right? I don\'t think we\'re likely to get anything
substantive done on e-mail between now and the end of the week, I don\'t
think.

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

Right, I think we\'re pretty close to closure here. There shouldn\'t be
anything else other than possible changes in a few words that people may
have been \-- have written down wrong or whatever, but I think we\'re
pretty much in agreement here, and just have a quick turnaround with the
next draft, and bring it to closure on Friday.

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

I agree. So between Friday and the 16th, Kelly, was your assumption that
someone at ONC would take the recommendations and turn this into \-- you
know, sort of a summarized PowerPoint sort of slides, or what\'s the
mechanism you believe \-- what\'s the presentation mechanism on the
16th? You said that the Co-chairs present.

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

Right, we are going to have PowerPoint slides. As soon as we have the
final language on the recommendations we\'re going to make sure there is
selected one recommendation per slide. And then we\'ll have sort of
high-level summary points that will be sort of the preamble to the
cluster of recommendations. So one to explain the reimbursement
recommendations, one to explain medical liability and licensure, another
for standards, another for consumer-clinician access, and privacy and
security. And then with each slide that describes the recommendation,
we\'ll have \-- you know, an area where the community can sort of show
what their definitive determination is, whether they\'re accepting,
whether they want to table the recommendation, or whether they want to
reject, and then we\'ll try to also document action items in real time.

So we\'ll go ahead and do the preparation work on that, and share it
with the Co-chairs for your approval. And hopefully, we\'ll be able to
do that by Friday.

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

Okay, that would be wonderful. And the presentation, you\'re assuming
that \-- I\'m representing Craig at that meeting, so are you assuming
the Co-chairs present, or Karen will present the actual \--

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

No, Colin, it would be you and Mark McClellan, or if Mark is not there I
imagine it will be Tony.

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

Mark will probably be there, I\'ll have to check with the scheduler.

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

Craig has a conflict with the Intel Board of Directors meeting, so I\'m
representing him.

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

Karen and I will be available for any explanation or any \-- you know,
details needed on, you know, what was \-- what the variations included,
so you can rely on us if you need us, but you\'ll be the primary
presenters.

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

So I would assume Mark and I would have to do a little quick offline \--
figure out \-- double team, figure out how we carve up the presentation,
then, we can do that when we\'re there, I expect.

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

Yeah, we did that last time with Craig and Mark, we had a little
premeeting before the meeting. So let me go back to Mark and find out,
#1, if he\'s going to be there. And secondly, how he wants to
approach \-- whether it be a phone call or just get together a few
minutes before the meeting.

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

If I need to get on the phone and do a rehearsal at the time, I\'ll be
happy to make the time to do that.

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

That\'s fine.

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

The only other question I have, Kelly, the other issues we have sort of
put in the bigger issues for further consideration category, there are
two I heard. The value question, the broadband connection. Two
questions. One is how do they get captured in the overall presentation;
secondly, are there any other categories that the working group thinks
are issues that they think ought to be on that list for the 16th
meeting.

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

Yeah, I think it sounds like you do have those two sort of major
evolving issue areas, so we can first make sure that the presentation
reflects all of the specific recommendations, and then move into that
second category of these evolving issues that you\'d like to have some
discussion or guidance on. And we\'ll describe sort of the \-- in high
level what we heard today from you all, and get your reaction to that
before the end of the week.

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

Okay, yeah, if you draft that I\'d be happy to respond to that.

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

Okay, great.

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

So are there any other issues that the Workgroup members feel that ought
to be added to the second and third categories that David brought up,
which are kind of the larger issues, the larger evolving
recommendations, or have we captured those two? Privacy is the one that
spanned workgroups, but then we had broadband and value, as well.

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

I don\'t know when our next Workgroup meeting is, Colin, I didn\'t see
it listed on our \--

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

Yeah, I don\'t have it.

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

I think it\'s actually later in June, so we have a bit of a break, after
all the hard work.

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

Do you have that? Just remind us on that date, could we just check on
that date right now? Do you know the date, Kelly?

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

Hold on. Yeah, somebody in the room has it, just hold on a second. We
think it\'s the 16th.

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

June 16? Okay, and then council, if there\'s no further discussion, we
need to open it up to the public.

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

Yeah.

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

Yeah, we\'ll send out an e-mail and follow up. We don\'t have a
definitive date handy right now.

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

All right. Any other comments from the Workgroup before we open it up
for public comment?

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

Colin, I just wanted \-- I was asked to send a letter, send an e-mail to
Richard, I believe, and Karen Bell. I\'m sending it right now.

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

Thank you.

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

Can you copy us as the Co-chairs reps as well, Mohan?

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

Okay, sir. I don\'t have the Colin\'s e-mail address.

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

Colin.evans@intel.com.

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

Mohan, just to confirm, this is what now is \-- what was the
recommendation is now going to be part of the preamble?

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

Yes, sir.

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

Colin, I would recommend you spell your first name for your e-mail.

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

Only with one L, I don\'t know why people in this country seem to have
to have two Ls, but it\'s only got one.

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

Thank you for that request, by the way, because I had 2 L's on mine.

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

I thought I could have counted on someone from the commonwealth to get
it right.

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

Well, you know. Some of us escaped.

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

Are there any other comments from the Workgroup before I turn it back to
Matt to solicit public input? Okay, Matt?

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

Okay, thanks, Tony. As always, if there\'s members of the public who are
listening along on the phone right now, you can press star one to make a
comment. If you\'re following along on the Webpage you\'ll see there are
now instructions now up on the screen for calling in and making a
comment. And we\'ll give a few minutes for people to get through. And if
not, we will leave up the e-mail address for people to submit comments
and questions that way.

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

Matt, we do have someone here in person that would like to give
comments.

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

Why don\'t you go ahead.

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

Thank you. My name is Tracy Moorehead, and I\'m the executive director
of the Disease Management Association of America. I have one broad and
two specific comments to make, thank you for the opportunity to do so.
First of all, I want to commend the Workgroup again for the incredible
amount of work. Dr. Brailer referenced earlier how far he\'s been
driving the Workgroup, all of the workgroups and the staff, and it\'s
very clear from the recommendations and evolution of these
recommendations from the previous meeting how hard you all have been
working. And as a member of the public, I appreciate that.

My specific comments are first, on Recommendation 2.0, I understand this
is a recommendation to HHS, but I would like to go on record to inform
the Workgroup and AHIC that DMAA is currently undertaking a project to
identify various States' licensing requirements and regulations that
govern the provision of disease management and chronic care services
across State lines, for nurses and call centers and other practitioners
and clinicians. We would be pleased to serve as a resource to HHS,
particularly on this recommendation. And we\'re working on that through
our compliance committee.

The second recommendation \-- or the second comment that I have is about
the whole document, but also specifically Recommendation Section 1 on
reimbursement. At the previous meeting of the workgroup, there was
discussion on the use of the term "clinician," versus "physician." And
the comment was made that "clinician" would be a more appropriate word
to use because of recognition that licensed nurse practitioner can also
be reimbursed. And I would note that in Recommendation 1.1 and elsewhere
in the document, there is specific use of the word "physician" that I
would urge staff and Workgroup to consider changing to use the word
"clinician" as discussed at the previous meeting. Thank you, very much.

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

Thank you, Tracy.

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

Doesn\'t look like anyone else is calling in with comments at this
point. So if nobody else in the room at ONC wants to make a comment, I
think we\'re done with public comments.

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

Okay, thank you, Matt. Well, Colin, should we call for adjournment,
then?

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

I think we should.

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

Okay.

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

Hearing no objections?

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

Thank you very much, nice meeting.

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

Thank you, Colin. Thank you, Tony.

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

We\'ll see you.

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

Thanks, guys. Bye.