American Health Information Community

Quality Workgroup Meeting #5

January 9, 2007

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

Good afternoon everybody, and welcome to the fifth meeting of the
Quality Workgroup, and happy new year to you all. Just a reminder that
this meeting is being conducted publicly and has been notified in the
Federal Register and there will be a period at the end of the meeting
where the public, if you so desire, you can make a comment at the end of
the meeting.

Also to advise the Workgroup members, if you would speak clearly and
distinctly and state your name before you comment since the meeting is
being transcribed for putting up on the Website after the meeting. So I
think I'll turn it over to Matt, if you would let us know who is on
phone and then we can go around the table here and let you know who the
members are present at the ONC offices.

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

Okay. Jane Metzger, First Consulting Group. Susan Postal, HCA. Margaret
van Amringe, Joint Commission. Pam French from Boeing. Jonathan Teich
from Brigham & Women\'s Hospital. Anne Easton, OPM, Michael Kaszynski,
also from OPM. Michael Rapp from CMS. Jerry Osheroff from Thomson Health
Care. Helen Burstin from National Quality Forum. Carol Ostrowski from
NQF. Sunil Sinha from CMS. Reed Tuckson from UnitedHealth Group. And
Josie Williams from RCHI.

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

Yes, here.

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

Is there anybody who I did not call? Okay, Judy.

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

And in the room we have Carolyn Clancy, co-chair.

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

Nancy Foster from the AHA.

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

Phyllis Torda from NCQA.

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

Kelly Cronin from ONC.

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

Okay, I think I can turn it over to Carolyn.

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

Good afternoon, everyone, welcome and happy new year. Our fifth meeting.
Wow.

Pam French, I\'m delighted that you could be with us by phone today.
Rick Stephens could not be with us but we did have a chance to chat with
both him and Pam yesterday.

Our first order of business is acceptance of the minutes, the meeting
summary from our last meeting. And any discussion about that as well.
Would someone like to move that we accept these minutes?

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

So moved.

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

Second?

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

Second.

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

Okay. Any comments or discussion about the minutes? Great, then we will
accept the minutes and we\'ll move on to description of the use case
process and what our next steps are.

Let me just state by way of high-level comments of what we're going to
be discussing today, most of our discussion today is going to be
focusing on our recommendations to the American Health Information
Community. We had originally anticipated that this would be at the next
Community meeting, which is scheduled for January 23rd. It turns out
that actually because of competing demands and schedule requirements,
and you can only do so many things in one day, we actually are going to
be doing it, I think it\'s March 7th? March 6th. So we have some more
time. But I actually think, and I think any of you who have had a chance
to go over them in detail will recognize that I think that will be time
fruitfully invested as we all collectively get our heads around what
precisely we\'re asking the Community to do. What is it that the
Community has unique jurisdiction over, where their actions need to be
aligned and integrated with the actions of others and so forth.

So without further ado, I\'ll turn it over to Kelly.

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

Thanks. There\'s been a lot of discussion over the last couple of years
about use cases, and sort of what their purpose is in our overall
agenda, and I think it\'s really a fairly technical term that outside of
the health IT community doesn\'t resonate very well. But certainly
within HHS it\'s become a little more mainstream and as AHIC has
discussed so many times I think people are starting to understand what
this concept is.

But just to make sure that everyone is clear on this, what we\'ve been
considering it really is sort of a high-level description that\'s not
necessarily applicable to the development of one software system, but
that it articulates the needs of many systems or stakeholders or
individuals, and it strives to provide enough detail and context for
standards harmonization, architecture specification, certification
considerations or criteria or processes around that. And then also gives
some context for policy discussions to be advanced.

So we\'ve been trying to take sort of what we think is important from a
system perspective or a functionality perspective and identifying
priorities, and Carolyn has already presented that to the Community
previously in the way of how it\'s sort of translates at least initially
from our specific charge to what needs to be articulated to automate the
reporting and measurement of a core set of measures.

And from those priorities that we\'ve already advanced, there will be a
discussion across all of the outputs of the Workgroup at the next AHIC
meeting, so they can go from sort of a superset of all the
considerations across seven \-- well, six to seven subcommittees, some
of the newer ones will not be considered for this round, but essentially
a much larger set of potential priorities to something that will be
manageable in the next say, 9 to 12 months, given that the Health IT
Standards Panel, Certification Commission, and the NHIN process won\'t
really allow for all of the priorities that we\'d like to advance in the
near term.

So given the limitations we have both from a process perspective and a
resource perspective, over the next several weeks we\'ll be trying to
get some input from the AHIC members and get their specific feedback on
how we might be going from a much larger set to a more narrow set to
really see some tangible progress in the next year. So for us that means
out of all our priorities we would like to advance what will be most
critical in the context of other population health needs, of other needs
for clinical care, and other needs for consumers around various aspects
of personal health records.

So I think over the next few weeks we\'ll be getting a little more
direction from the community on what that will look like, and then that
will really feed into a drafting process of a much more detailed use
case.

So what we have now really is just a description of the priorities that
are being vetted again with the co-chairs to make sure we have all those
specified at the right level of detail. That will then go into more of a
narrative description of what might this look like at a high level for a
use case, and then we\'ll be going into a much more detailed description
of the actual use case over the next six weeks or so. And we plan to get
some public input on that. So we\'ll have an opportunity as a Workgroup
to look at that more detailed document to make sure that all the aspects
of capturing data, data requirements, the way the data might flow, how
it would be aggregated potentially, and publicly reported, or fed back
to clinical care, all of that will be described and we\'ll have a chance
to review that and make comment and to make sure that it\'s in alignment
with what we discussed or we think as a group.

So that\'s it for now. But John Loonsk is likely going to join us later
and we might want to invite him to expand on it since he's really going
to be leading that whole process in ONC.

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

Let me just ask if there are questions or comments? Yes.

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

Nancy Foster. One of the things, Kelly. This is my first experience with
use cases. So new thing for me. But it seems to me that we have some
organizations that are in the forefront of using health IT for quality
improvement, some of the systems we know VA, and so forth,
InterMountain. Others are really moving into that framework and have
recently come aboard. The Trinity Health System comes to mind in that
regard. They, I think, will have important insights for us about what\'s
there and what's not there, and how we might improve the document. So to
the extent I could be useful in sharing it with that group, I would be
happy to do so, but may ask if you can spend some time talking with them
to get their input as well.

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

Yeah, that would be great. I think similar to what we just did with the
emergency responder EHR, we had hundreds of comments coming in from
people who had some really knowledgeable firsthand experience in dealing
with the issues. And it would be great to do that for both inpatient and
outpatient, for the measures. But I think we also need to keep in mind
that we don\'t have a one size fits all and what happens within one
institution or within one system might not have a lot of external
validity and we\'re trying to think about how this might work from one
organization to another. It's always that balance of how much detail do
you drill into that may work in one situation but is not going to be,
you know, helpful, in the larger context.

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

\-- could wave our magic wand and know exactly how to balance that.

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

Right.

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

Let me just say that, given extra time, since we\'re not going to be
presenting on January 23rd, I\'m still getting my head around this
actual new opportunity of more time, I think it would be helpful and
would welcome your sharing with them what we\'ve made available in the
public domain for folks, both the letter, in particular, because
there\'s nothing like being in the weeds of an implementation to
understand all these things you wish someone would have thought of. I
think that would be great.

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

Be glad to.

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

Any other comments or questions? Great, then we\'re going to dive right
into the meat of the letter to the American Health Information
Community.

Those of you who got the documents from today will see that this is
framed as always, as a letter to Secretary Leavitt who serves as the
chair of the American Health Information Community. It starts off with a
description of our broad charge and our specific charge which I don\'t
think will come as news to either one of you. I mentioned earlier that
we had an opportunity to have a conversation with Rick Stephens and with
Pam French yesterday, and I thought that their suggestions were
incredibly helpful, so Pam I\'m going to tell you what I heard and you
can tell me if I overlook anything.

What I heard was that they were recommending that we have a little bit
more of a preamble. I\'m not talking many pages, at the front end of
this. This letter, as currently framed, gets down to business instantly.
And on one level that\'s a very easy way to deal with things. On the
other hand, several points that they made were the critical importance
of alignment and integration and that that is central to the work that
we\'re trying to do here.

The second point that they made very, very clearly was that we needed to
speak to use of the information, both for the purposes of informing
consumers' decisions, as well as giving providers feedback in near or
real time and this letter might actually be better read or could be read
by a cold reader, if you will, someone who hasn\'t been intimately
involved with the intersection of quality and IT, if we had that kind of
preamble there.

So let me ask Pam, first, did I overlook anything from the sense \-- I
didn\'t want to be too succinct in summarizing \--

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

I think you did a good job of summarizing it. I think what we\'re
looking for when we \-- we think about this as such a major opportunity
that we recognize that there are a number of groups working on these
issues. And we also recognize that this may need to go out kind of in an
iterative kind of process. So that we build upon, you know, a baseline,
but that we think about the scalability of the scope of what we\'re
working on. And I think the other point you made is really again about
making sure we\'re also consumer friendly in how this information
eventually gets disseminated, and allows for meaningful information for
consumers, for providers, so that there can be good discussions about
health care, and the right kinds of health care decisions.

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

Thank you. So consistent with how a Federal Advisory Commission \--
Committee Act group works, all of our information and documents that
we\'ve been discussing are in the public domain, but I think this letter
becomes particularly important because it is a clear, integrated
synthesis of what we have been doing and where we think we need to go
next.

So I would invite comments first on whether we should have that sort of
initial preamble, relatively brief one or two paragraphs.

**[\>\> Margaret van Amringe:]{.underline}**

This is Margaret van Amringe. I think it would be very helpful to have
something like that because it sort of sets the stage as to how, why all
of the things that we\'re doing here is actually going to benefit
patients in the long-term. And I think it\'s true that it\'s not just
consumer choice, that what we\'re looking at also is the ability to
really forge ahead very quickly with quality improvement because that
helps everyone, even those consumers who don\'t have an opportunity to
choose among providers for whatever reason. So I think if we can put
something in there, it would be, I think, important to set that stage.

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

So I guess what I\'m hearing you say, just to be clear, is that it\'s
not just to say consumer use of information to make good choices, but
also to be really concrete about what types of choices that would be
informing.

**[\>\> Margaret van Amringe:]{.underline}**

Well, I think, sort of, but I think the point I was also trying to make
is that there are times when people don\'t have choice, or they have
limited choice, or the kind of performance data will not be, will not be
as robust as we want in all areas for choice.

But to the extent that performance measurement is feeding back
information to clinicians to help them improve what they\'re doing and
to bring patients more into their care, then that\'s benefiting all
patients regardless of whether or not the measures are available or
useful at the moment for choice purposes.

So I wanted to try to \-- to make sure that when we set the stage, that
we give equal weighting to the quality improvement side as we do to the
consumer choice side.

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

Thank you. Any other comments? Phyllis?

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

This is Phyllis Torda, from NCQA. I would support that as well. Because
even exercising \-- I mean, the goal I think of measuring is to improve
quality. Exercising choice is one way of improving quality. But there\'s
other ways. And occasionally it sounds like we\'re sort of measuring for
the sake of measuring, as opposed to \--

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

Absolutely.

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

\-- improving quality. If I can introduce just one other theme maybe for
this preamble, and it will carry on later on. You mentioned Carolyn, I
think, scalability. I think there\'s also an evolutionary aspect of
this, which is different than scalability. That what will be needed will
change over time, as people adopt technology.

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

Thank you. I think that\'s a terrific point, and it was another point
that I heard very clearly from Pam yesterday, that we needed to give
people a sense that this was likely and invariably going to be an
iterative process but that we were going to get some momentum going now.
And absent that, it can sound incredibly abstract about what we will do
some day when we have a perfect architecture which many people can hear
as never. To be concrete in terms of how it affects what they\'re doing
today. Nancy?

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

I want to also second what Margaret has said and the suggestion that
there be a preamble that Pam and Rick had made. I think that would be
very helpful and if I could add one other theme because I think this
document does need to be read more broadly than in the rarified air of
these conference rooms where every one of us gather to meet so
frequently. We probably need to articulate in just a couple of sentences
the fact that this effort is in fact one of many things under way to
stimulate quality improvement both by choice and by real, stick in your
fingers and do quality improvement in the hospital, or in other health
care settings.

And that, as such, it plays an important role within the context of all
of these broad efforts under way, so that people can see that we\'re
focused on one part of it, and that\'s because we know others are taking
care of the other important pieces. Hopefully they are. And I say \-- I
ask that, recognizing that Christine and her colleagues, Booz Allen had
tried to lay that out for a group of us and it took several pages to do
that. So I know I\'m asking a lot to just try and keep it short.

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

Thank you. Other comments?

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

Helen Darling here, Carolyn.

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

Welcome, Helen, I didn\'t realize you were with us. Thank you.

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

I would just suggest, you twice, I think wisely, used the word concrete,
and my suggestion would be certainly that I think a few more sentences
here explaining it as everyone has said, is really important. But if you
even just keep that sentence that says will be judged and to inform
consumers\' health care decisions and to improve care, and just gave two
concrete examples. The reader would get it. And a lay group could easily
understand it if the examples \-- and that\'s really all you need, I
think at that point.

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

Thank you. Anyone else?

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

Carolyn, this is Jane Metzger.

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

Hello, Jane.

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

Hello. I totally agree with everything that\'s been said. There\'s a
theme in the vision matrix that we\'ve been working on that I wonder if
it doesn\'t belong in here. And that is this need for a unified national
agenda and a clear, agreed upon set of metrics for judging progress
against that agenda, because one of the \-- you mentioned alignment, and
that\'s one part of it. But I think this focus on, you know, which
measures and why, is something that we might want to allude to in this
preamble as well.

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

Other comments? Phyllis.

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

I just want to react to that little. I think it\'s always important to
recognize that different specialties will need different measures. So
there\'s not one set of measures that\'s going to be the answer for
everyone. I mean, there should definitely be national goals and all
that. But I think it\'s also important to recognize that there really
need to be different sets for different specialties and we're not saying
that one size fits all and everybody has to \--

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

Yes. And I think the other point again, giving equal weight as Margaret
suggested earlier, to the choice agenda and we discussed this quite a
bit last time and the improvement agenda means that you\'re going to
need a lot more granular information, by definition, for improvements.
And there\'s going to be information and data collection that would be
enormously helpful to some subspecialists and almost nobody else. And so
Jane, that prompts a question for me, which is \-- and one that we got
into a conversation about at the annual meeting of the National Quality
Forum, and Helen Burstin you may want to chime in as well. Is a national
agenda about choice, is it about improvement or is it about both or do
we just stay silent on that.

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

Well, this is Jane again. My comment is not that you have cardiologists
working toward the same performance metrics as primary care physicians,
but I still think we\'re in a world where it\'s not clear what the
primary care improvement goals and metrics are. So I wasn\'t trying to
imply what I guess one reading of what I said, and I think it should be
very clear where everyone should be headed on general med search
hospital performance.

So I'd just like to clarify that. And I do think unless there\'s a way
that for each specialty, or for each practice area, there is a process
for coming up with a high priority focus and a single set of metrics
that we will not have removed one of the significant barriers that we
have today.

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

Thank you. The really good news is that CMS will be pushing, by virtue
of legislation, a lot of that activity. Or that there\'s certainly a new
kind of incentive to be thinking about that.

I thought someone else wanted to jump in. No?

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

Carolyn?

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

Yeah.

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

I couldn't tell if I was on mute or not. This is Helen. Hello. I agree
with what Jane just said, and I think the whole prioritization piece
will be really interesting to see how this progresses with the different
specialties, groups, coming forward over time. So, very much agree with
what Jane just said.

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

Great. Well, I think we have strong enthusiasm for a preamble and we
will work to get you something to react to.

Let me also just comment and thank again Jane Metzger and many other
folks who have been incredibly helpful and as recently as this week
additional comments coming in, thanks to Pam French and others, in
expanding this vision matrix.

In addition to that, Christine Anderson made what I thought was just a
brilliant suggestion, like why didn\'t we think of that? That what would
be really helpful for the Community would be a summary. So we have a
first draft of that. I don\'t think we shared it this time or did we?

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

It probably needs a little massaging, but we\'ll get it out soon.

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

And we very much welcome your comments on that. So we won\'t be touching
on that today, but it turns out none of the other Workgroups have done
this. But I think actually the four or five-page summary, I think
that\'s about how long it is now, but whatever the length, begins to be
a place to tell a coherent story without getting trapped in the what\'s
midterm and what\'s longer term, recognizing that a lot of that is
pretty unpredictable.

So please be watching your e-mails because this is an opportunity that
we\'re going to actively take advantage of.

So moving throughout this letter, you can see that the next phase of it
talks about very specific ways that our deliberations have highlighted a
number of key needs, automated data capture reporting to support core
sets of measures derived from AQA and HQA quality measures, providing
feedback to providers in real- or near real-time, enabling data
aggregation to allow public reporting based on comprehensive clinical
data pooled across providers, and so forth. And then last, aligning
performance measurement with the capabilities and limitations of health
IT.

Now, of all of the near-term issues, I would say that number 4 may end
up being the most challenging because, as we discussed last time, by and
large many measure developers, not all, but many, particularly I would
say from the physician community with which I\'m more familiar, are not
thinking about data needs when they\'re developing measures. They\'re
thinking about what evidence do I have, they\'re often thinking about
what guidelines have we developed based on evidence that we have. And
they\'re not thinking about well, there\'s an idea, now how would I
measure that?

On the other hand, we may have an opportunity working with them to
encourage that kind of synergy in the future. But I just wanted to make
that point that this is not something that we\'re going to say to the
Community on March 7th, here\'s our, you know, high level area and
we\'ll be back to you July 1st with the whole enterprise changed.
Because clearly that\'s going to be definitely an evolutionary process.

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

Carolyn, this is Reed. A small point here, consistent with the earlier
discussion about preamble and making sure that the so-called average
reader would understand what we\'re getting at here.

I don\'t think we set up anywhere the idea that performance measurement
occurs, measures and/or data occur from two different sources, one being
claims data and one being the office record or hospital clinical
real-time data.

I think we might want to think about putting in something either here or
in the very next section in the background, where we sort of at least
give people an understanding as to what that issue is about.

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

I think that\'s a terrific suggestion, Reed.

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

This is Phyllis. That sort of begins to get into some of my thoughts
about the evolutionary nature of this. Because now, you know, we\'re
very limited by claims data and we\'re using claims data, I think it\'s
the hope for the future that more data will emanate directly from the
provider which (indiscernible). But that laying that out is probably
useful.

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

If I might suggest, Carolyn, it\'s Nancy, in the "enable data
aggregation" bullet, if we could capture in there this thought that we
talked about previously, in the preamble, that the comparisons really
\-- or the data aggregation is also for quality improvement at the
clinician level, and that may not be publicly reported but it\'s
critically important we be able to look across organizations or across
providers even if the data never rises to the level of public reporting.

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

Sure.

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

Carolyn, before we move on to the next subject, I\'d like to \-- this is
Helen, I\'m sorry. Helen Darling.

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

Yes.

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

I\'d like to raise an issue on this "enable data aggregation". I know
that the charge of the committee is really to be looking at a little bit
more at the future and what we need to do to enable certain things to
happen. But as you know, we right now, we have data aggregated at the
national level that is the CMS Medicare claims data, that are not
available to people because of multiple reasons, and I\'m wondering if
somewhere in here \-- it\'s almost as if we\'re sitting here and
designing the plane for the 22nd century, where something right now
which is aggregated data actually fits what we\'re talking about in
terms of its potential usefulness, is actually available, but there are
barriers to our getting our hands on it.

And I\'m just wondering if somehow we couldn\'t tuck that in here and
maybe even use it as an example of something, a step that we could take
now that would get us farther down the road than we\'ve been in years,
quickly, and we\'d also learn from that what we need to be doing with
the other enablers to make progress for the future.

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

Yeah, Helen, let me assure you with every fiber of my being that this
area is getting the highest attention from many folks very senior in the
Department. So I would expect that you will be hearing about some very
specific issues related to access to the benefits of use of Medicare
data in the relatively near future. That\'s about as precise as I could
possibly be whether in a public conversation or in a private one.

As you know, there are a lot of issues to this.

What I am taking away from this, though, is that most people that we
would meet on the street probably would not have an awful lot of
connectivity with the phrase data aggregation unless you actually
spelled out what that meant. So you\'re making it very clear that A, we
need to spell out what it means, I\'m going to leave the 22nd century
airplane to the good folks from Boeing, actually. And \-- that doesn\'t
have to be part of the minutes, whoever is writing this down.

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

Thank you.

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

Because I know they\'re on it already.

And probably allude to the challenges inherent in aggregating data from
multiple sources. And to say that the Secretary and many people in the
Community have heard very, very clearly the very strong interest of
folks who are interested in access to the Medicare data is an
understatement.

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

That sounds good to me.

\[Laughter\]

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

So continued progress on that front.

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

Thank you.

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

Any other comments before we move on?

**[\>\> Margaret van Amringe:]{.underline}**

Carolyn, this is Margaret van Amringe. I\'m not clear when you say move
on, move off the letter or go through the letter?

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

I was just going to move to the next discussion.

[**\>\> Margaret van Amringe:**]{.underline}

Okay, because I did have comments on other parts of the letter.

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

The next part here that I have actually is a bulleted discussion about
our vision for the future. And also after six bullets and some very
brief paragraphs, much of which I\'m thinking now will be folded into
preamble, we then actually come to the emerging principles that we\'ve
discussed I think from almost the first meeting.

One, that we would not be prescribing specific solutions in areas where
market experimentation is currently helping to inform emerging
consensus. That we're likely to take a requirement approach to this
work. Third, that we were going to acknowledge that electronic health
records would not be the only form of data capture in the foreseeable
future. So for example or to be very specific, it\'s far more likely
that in the foreseeable future much of what we\'re going to be measuring
is going to require to be scalable aggregation of claims potentially
enriched by electronic data elements. Such as lab results, potentially
pharmacy data. Notice how that rolled right off my tongue.

We don\'t know how to do that and we certainly don\'t know what the
business processes for that look like, but I think clarifying that and
putting a sharp focus on what needs to happen would be an important
contribution. And then these other principles, I think the fourth one,
in particular, reiterates that quality reporting is just one example of
many of secondary uses of clinical data and that we need to make sure
that we\'re aligned with what the other Workgroups are doing in this
area. And then finally, that particularly on the EHR side, developing an
efficient and effective quality measurement and recording solution is
going to require a pretty broad skill set. I don\'t mean in one person,
but a group of people from EHR vendors, coders, quality experts, and
clinicians and really can\'t be developed in a vacuum.

Another way to say this would be, I guess, we believe that the important
and painful lessons that many health care organizations are learning as
they\'re trying to implement electronic health records and finding out
that no one has really thought about some of these issues that there is
not an off-the-shelf solution, or something that we could anticipate as
we move ahead in our work.

We\'ve gone over these principles a number of times, so I\'m not sure
that we need to have a discussion, but let me just ask if there are any
comments here or editing suggestions.

[**\>\> Margaret van Amringe:**]{.underline}

This is Margaret van Amringe. I didn\'t have any editing suggestions on
the particular emerging principles because I think they\'ve captured
very well what we\'ve talked about. I had a few editorial, but I can
give these to staff later, on the vision. Unless you want to hear those.

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

No, I think that would be fine, and I actually think our discussion
today has been very helpful, built on and adding to our prior
discussions, you know, fleshing out the matrix and debating what\'s the
best way to organize and array these issues. But we would appreciate
either specific edits or comments on the vision and you can send those
to Michelle and Kelly. That would be terrific.

**[\>\> Margaret van Amringe:]{.underline}**

Then I had one question on the priorities, which come after the
principles when we get there.

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

Okay. Any other comments on principles?

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

I just \-- this is Phyllis. I wondered if on number 3, to give one
example \-- might be controversial, I don\'t know. If we want to make
reference to the use of CPT II codes, or something. Code sets that are a
short-term solution that are designed to support quality reporting.

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

Yeah, I think the, I think the question is whether that goes into sort
of a preamble where Reed had mentioned we basically need, it would be
really helpful to a cold reader to tell what we\'re improving on, as one
potential solution. I have no problem with lumping CPT II codes in here.
Obviously something that\'s \-- people have been working on that for a
number of years.

Any other comments? Good, okay. So then the next phase of this letter
talks about critical barriers and enablers for near-term priorities. The
first being that the business case for automating quality measurement
must be developed in concert with the incentives for electronic health
record adoption and the sharing of clinical data. The second being that
data aggregation strategies are needed to support public reporting of
clinical care at a regional, state, or national level.

The third very importantly saying that business process and work flow
changes will likely be required to ensure uniform capture of data.

Fourth, obviously security and privacy concerns must be addressed.

The fifth saying that consensus is required on a patient identification
system that will support quality measurement reporting.

And last, that translating quality measurement and reporting into
improved results for patients requires rapid development and evolution
of market competition and collaboration across multiple stakeholder
groups.

So let me just ask for any comments on these barriers and enablers.
Again, these are focused on our near-term priorities.

**[\>\> Margaret van Amringe:]{.underline}**

Well, this is Margaret. And this may be considered editorial, but
because it comes up later as well, on number 5, when we talk about the
patient identification system, since for patient identification can be
such a red flag for many, kind of a hot button issue when we talk about
identifying patients, I think even though we have 4, which talks about
general security and privacy concerns, that it\'s always maybe politic
and advisable to, when we talk about patient identification systems, to
say that it will support quality measurement reporting while protecting
patient confidentiality, or something to always make it clear that
we\'re balancing patient identification with public trust, and concerns
about privacy and confidentiality.

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

I don\'t know if it\'s editorial or not either, but it\'s really
important. So thank you.

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

It\'s Helen. I would support that clarity as well. Certainly our data
show, as I\'m sure everybody\'s do, that if we don\'t solve the problem
of trust and confidence and information is going to be protected, then
we won\'t be able to get anything done because there will be such a
public reaction.

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

Nancy?

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

I thought Margaret was going to say that patient identification means
something else to most people in hospitals, and that is like a wristband
with a name on it.

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

That, too, Nancy.

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

I think we need a different term here, or at least clarity. Actually
identify in the document about what we mean by patient identification.

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

It comes up later, and I thought later we could also add some clarity
there to that terminology as well.

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

It\'s a really good point because nothing here was intended to suggest
that the wrist bracelet was going to be the key factor here that put us
on the right path. Phyllis?

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

This list does not include provider identification, which I think is
also a big barrier, to physicians, there may be other providers.

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

We haven\'t really talked much about MPI or others yet.

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

Probably the biggest barrier (indiscernible).

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

Well, there\'s no question that we won\'t get into data aggregation, any
kind of discussion without getting into this issue in a really deep and
personal way.

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

Carolyn, this is Jane Metzger. I wanted to comment on number 1. I feel a
bit like a broken record but it seems to me that the business case
becomes very clear once we have a single set of metrics for an area like
primary care, and we have the various groups in the country who are
requesting that information for public reporting and using it in some
sort of a pay for performance schema, agreeing to use that same set. I
mean, it seems to me then there\'s a very clear business. \-- So again,
it seems to me it harks back to some sort of a unified set of measures
and wide agreement by all those who use measures to use that same
information.

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

I mostly want to agree with you, Jane, and we may follow up with you
offline just for clarity of wording. On the other hand, just to be a
little bit provocative for the moment, the Congressional Research
Service right before the holidays put out a little synthesis, I think
intended for a Congressional audience since that\'s their job, sort of
making it clear that at the current amount of resources allocated to pay
for performance programs for a physician, I think they were labeling a
GP, in this case, whose gross revenues are 250,000, if you were able to
capture 1 percent of that, that\'s actually relatively modest dollars.
Now, it\'s nontrivial, I don\'t want to say that 2,500 dollars is not
something that means nothing.

On the other hand, if you think about the disruption to a practice in
terms of adopting electronic health records, having to change like every
single thing you do, I think there\'s a reasonable debate about that. So
the spirit of what you\'re saying I agree with. On the other hand, I
think reasonable folks might disagree, so we may need some help in
wording that.

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

It\'s Nancy again. Was this also intended to bring clarity to the
business case for those developing electronic health records that they
come into conformance with the standards, and reference that? Or was
this just about the providers\' business case?

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

I think our past discussion has been more provider-oriented.

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

I think it\'s been more provider in the past. I guess we\'ve been making
the assumption without being explicit enough and maybe we need to be
explicit, that to the extent that this functionality becomes part of the
Certification Commission\'s requirements, if you will, in order to have
a certified product, that will be the business case for vendors. Now
that may also be a contestable premise.

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

Again, it depends sort of on how things line up. If providers then will
only purchase those things that are certified, which may mean somebody
has to suggest to them that that\'s the appropriate thing to do, then it
becomes a business case. But otherwise it\'s \-- it just becomes a Good
Housekeeping seal.

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

Right.

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

Carolyn, this is Jerry Osheroff. Can I comment?

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

Yes.

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

You emphasize that these are barriers and enablers that deal with the
near-term priorities, but in the first, the third, and the sixth item we
talk about business cases, work flow changes, and the need for
collaboration, and each of those things are obviously clearly critical
for the near-term priorities. They\'re also going to become essential
when the group turns its attention to the broader charge and the
performance improvement side of things. So I just throw out for
consideration the possibility of mentioning the fact that not only are
these things critical for the near-term priorities, but in some ways a
performance improvement face will be the other side of the same coin
around the business case and the workflow changes and the collaboration,
so it might be worth pointing that out up front because when we make
recommendations about the longer term things, that those will come to
play in important ways, as well.

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

Incredibly important point. Thank you.

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

Carolyn, this is Jonathan. I have sort of another slant on the same kind
of thing. Number 6, I interpret to be a \-- something which has a little
bit of masking to it but is saying that if \-- once quality measurement
has been done, then there are things that need to make people either
vote with their feet. This is sort of where turning this into improved
results means that we want systems that are reporting better or even
reporting better quality are able to have either some kind of incentive,
some kind of pay for performance, some kind of publication for consumer
direction, seems like that\'s a bunch of different things. And that\'s
not explicitly said here but that\'s how I interpret it, so I\'m happy
with the level of language written here as long as I\'ve actually got it
right.

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

Say again your interpretation.

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

My interpretation is that, when it says translating quality improvement
reporting into improved results, presumably means that as we get more
measurement we are able then to understand things that make these
measurements turn out to be better, make people have higher quality,
higher performance and so on, and that presumably the translation is
that measurements that show better attention to measurements or better
attention to quality get some sort of reward, whether it\'s pay for
performance or whether it's some sort of better listing or better
enrollment or something along that line.

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

Yeah, no, I think you do have that right. I don\'t think we were
focusing quite so much on the volume of measures as much as saying if
there\'s not a demand for people to do this, it ain\'t going to happen.
Or it certainly isn\'t going to happen at the pace we would like.

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

Yeah, I think that\'s fair. I think it\'s making a great statement, and
saying the reason we\'re measuring quality is so we can get people to
eventually bring themselves up.

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

Yeah. And clearly we\'ve heard a lot of comments today saying we need to
be much more articulate about that, right at the beginning of the letter
and we will do that.

Any other comments before we move to specific recommendations?

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

Carolyn, just one other thought, which is this moves for me \-- there
was a little disconnect here. It moves from this broad vision to
recommendations to the AHIC Community. It would be helpful to me if
there was in fact a paragraph that suggests what the key opportunities
are for AHIC, to move things forward, recognizing they\'re not taking on
this world. That they\'re part of what\'s transforming health care, but
they\'re not the only thing.

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

No, I think that\'s exactly right. And I mean, it\'s certainly an issue
we\'ve had lively discussions about, even pulling this letter together,
as well as specific recommendations and why I think Rick Stephens kept
insisting yesterday on the words "align" and "integrate", rather than
we\'re not reinventing the world. But actually figuring out where the
AHIC fits in. So I think that\'s terrific. And I like the subhead.

So moving to recommendations. First recommendation \-- actually, the
first. recommendations 1 and 2 speak to \-- recommendation, 1, rather, I
take this back, now merged, I\'m reflecting a earlier version, refer to
automating data and capture and reporting to support a core set, first
of AQA measures, and then of HQA measures.

So we\'ve already discussed that part of it. I don\'t think there\'s any
discussion about that. There\'s a little bit of background on what are
AQA and HQA. But then the recommendations get very specific and here I
think we need your attention focused both on the what as well as the
who.

So recommendation 1.1 says that this workgroup should create an expert
panel \-- let me just tell you that term is used in the most generic way
possible \-- to actually get extremely specific in detail about
analyzing the data elements, standards, and workflow changes required
for these core sets of measures.

Now, recommendation 1.1.1 actually says the expert panel should
consolidate current efforts to analyze data elements and should present
detailed findings with a recommended priority list of measures to be
targeted for automation, and we\'re suggesting a target date here of the
end of July.

Now, we\'re kind of making that up. At the same time, I think \-- I mean
the date, that is. What\'s very, very clear, particularly from touching
base with the effort being led now by NCQA, CMS, and the AMA consortium
is that even mapping this out for one measure is not something you do
lightly. And it\'s the kind of thing that many people might do for one
measure and then say I think I\'m done and I don't need to do this
again, but actually to have a coherent sense about how and where we can
build momentum, I think we do need to take the core measures and begin
to map that out and look across and see which data elements and
standards are relevant for multiple measures and so forth.

And then there are similar specific measures for the HQA measures. So
let me stop there and ask if there are specific questions about that.

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

This is Kelly. I just wanted to add that one of the concerns we heard
about in doing some background research and talking to many of you was
that there\'s a real risk of volunteer burnout, and I mean our suffering
from that in a variety of things we\'re working on now. But if this
really is a heavy lifting exercise over the next six to however many
months, we really need expert-based input and probably people who are
actually being paid to do this, to support this process. So that was
sort of one of our premises in trying to draft this, and we heard from a
couple of you that this particular idea would probably work if it really
did build on what's already being done, and include a lot of the people
that are already working on this.

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

This is Helen. I think that\'s excellent. I would add, I think having
the date specific is more inspired than is \-- oftentimes reports say
these things should be done, but without a timetable and specific dates
that people have to respond to and act on, and that also sort of in a
sense feeds the burnout problem. Because you don\'t know when something
is going to end if you meet the deadline. I think it\'s very good.

[**\>\> Margaret van Amringe:**]{.underline}

And I agree. This is Margaret. I agree with what you said, Kelly. One of
the things that I was wondering about is \-- and this is kind of talking
out loud, I suppose, in one way. But as one is looking at the priority
list of measures, and we certainly know what measures we can start with
in terms of the AQA, and the HQA ones that are available now. But it
seems to me that part of the focus should be going below the measure
level and looking to see if we can come up with a core set of data
elements that may cut across the majority of measures. It may not \--
they may not be in all measures but they may cut across the majority and
they will also end up being, because of what they are, sort of the
infrastructure for other measurement activities that come later because
they will tend to always be ones that people will need, you know, and
may be some of the demographic measures, and so forth. So this group
ought to, I think, as they're looking at prioritizing measures, I think
they really ought to be looking at prioritizing or coming up with a list
of data elements and then, with that in mind, considering what those
data elements, what are the acceptable values, what are the \-- what is
the data dictionary to go with those data elements. If we can do that,
the halo effect of coming up with this core set of data elements may be
even greater than the set of measures that we currently have between the
AQA and the HQA. Does that make sense? I probably didn\'t say it very
well, but \--

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

I was trying to say that before and you said it far, far more clearly. I
think it\'s incredibly important and it also, I think, underscores the
importance of getting at the workflow changes. It\'s one thing to say
that we need X data element for four measures, I\'m making that one up.
But it\'s much harder to figure out what is the process by which we can
get access to that data at the time that it\'s needed and so forth. And
that\'s certainly a point I\'ve heard from you and your colleagues on
many occasions.

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

This is Josie. I have to weigh in on this, because as you know, we\'ve
been working with 66 small rural hospitals just to get very specific
standard data elements out of their systems. And so the more specific we
can be with a standardized data dictionary in the beginning, the easier
it\'s going to be. Because we even today are still having to bring the
data in-house and clean it for many of the very small rural hospitals,
and so this is going to be critically important going forward with the
infrastructure.

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

Thank you. Other comments?

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

This is Phyllis. I mean, I would just pile on and say I think it\'s
foundational, and you can\'t collect \-- you know, unless do you, this
you can\'t have a standardized way of collecting measures and
accomplishing what we want to accomplish.

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

And I think that\'s true, but I also think that looking at this whole
thing, as we were talking about the barriers, our infrastructure, I
started to weigh then in but I know you guys are tired of me talking
about it. But I\'m not even sure we've got the infrastructure in
anything besides the primary hospitals, those are over 100 beds, any of
the hospitals less than 100 beds in this country, unless they\'re
affiliated with the system, just getting the data out is a major issue.

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

I would agree with that, Josie, and it\'s a nice moment for a public
service announcement, basically to recognize the importance of the work
that you are doing with rural hospitals. So I intend to keep bragging
about it early and often.

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

Well, I appreciate it, but boy, it has been sluggish.

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

Carolyn, this is Jane Metzger. I assume in this process we\'d be testing
out another one of our recommendations, which is that both developers of
EHRs as well as users of EHRs would be at this table to comment on, you
know, any down the road implications for will providers be able to, or
willing to provide this information and what will the particular
EHR-related challenges be.

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

Absolutely. I mean, one of the biggest challenges that I\'ve come to
appreciate is answering the question, do you want to hard code this into
electronic health records, or did you want to just specify where the
data are going to come from. And that becomes entirely important when
you think about updating measures as science gets better, because
otherwise you\'re hard coding in last year\'s measures and that\'s not
where we want to be.

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

Certainly to be able to have at least the certified, the certified
products, to have a basic data dictionary and core set of demographics
and ways of pointing that data are going to be extraordinarily
important.

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

Well, I am certainly hearing a lot of enthusiasm for this. Let me just
say that I think we will be consulting with a couple of you just around
some concrete mechanical steps on this. I said the term "expert panel"
was a generic term, not because it\'s a bad one but just because if you
think about most expert panels, the people doing the heavy lifting are
the staff. So trying to figure out the right sequence of steps. But
I\'ve heard very clearly from Helen that having an end date here is
going to be incredibly important. So we\'ll follow up on that.

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

This is Helen. Just to add a little information on the date. I think we
may be obligated to get something finished before this, before July
31st, if we want it to be feeding into the certification process, or
into some of the other things we have going on with the Health IT
Standards Panel this year. So we\'ll work on that internally, figure out
what would be our latest possible date.

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

That would be fine. So then recommendations 1.2 and 1.3 speak to the
alignment with what the Health IT Standards Panel would be doing, as
well as the Certification Commission. You should all be very
appreciative that you didn\'t get earlier drafts of this letter that had
XXX for dates. But again we appreciate the importance of goals and
specific dates.

So the second recommendation gets to the issue of providing feedback to
providers in real or near real-time. And at this point I\'m going to
thanks Margaret van Amringe for taking over chairing this Workgroup. I
have to step out for a conference call because my electronic calendar
took care of a conflict by just erasing it, but that didn\'t really
address the conflict problem. So I will be back in a little bit.

**[\>\> Margaret van Amringe:]{.underline}**

Thanks, Carolyn. I may not \-- fortunately, there are other people in
the room from the Joint Commission like Laura, because my calendar did
the same kind of thing. I may have to step out, too, in a minute. But on
this one, I think the issue here is that it\'s really important to
figure out ways in which we can identify where information is about
patients in order to ensure that it can be useful. So while there may be
some suggestions for wording, does anybody have an issue on this
particular area? Provide feedback to providers in real- or near
real-time?

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

This is Jerry Osheroff. Can I make a comment? It says in here that in
in-patient \-- it talks about the in-patient environment and the
outpatient environment it sort of proposes specific times when the
intervention should be given and it seemed like that was unnecessarily
narrow. And just from a conceptual perspective, we talked a little bit
in the last call about mapping out the care processes and where the
opportunities are for either providing decision support or gathering the
core measures and it would seem like the \-- beyond the wording changes,
that that may be appropriate. Making a comment about the fact that
knowledge can be delivered all throughout the care process or data can
be gathered all throughout the care process and there might not
necessarily be one specific point to focus on.

**[\>\> Margaret van Amringe:]{.underline}**

That\'s a good point. Let me \-- let\'s see here. I mean, I do think
that it\'s important that we be able to figure out ways to provide the
data more quickly and not have to wait because then one can\'t take
advantage of the data in order to improve care while the patient is
still under scrutiny or under the watchful eye in many of the episodes
of care.

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

Right. Absolutely. But I think the point is even within that episode
there\'s different components of that interaction, and I think different
kinds of information will be most usefully acted upon if it\'s delivered
right at the most opportune time and I think that\'s the point that this
should make.

**[\>\> Margaret van Amringe:]{.underline}**

Any more on that? If not, I'd like to go to number 3, only because I'm
going to have to actually, unfortunately I just got an urgent call so
I\'d like to make a comment on number 3, but I feel badly that I\'m not
going to be able \-- I\'ll have to come back after I take this call in a
couple of minutes. But this is the one to talk about enabling data
aggregation and I\'d actually like to make a comment of the chair at the
moment to say that I think we may want to reword the statement
underneath 3, because here we\'re talking really about the fact that we
may need to merge and pool data for various reasons to ensure that we
have an accurate and credible reading on the particular measures that we
have. And I think the first paragraph where it says there is a wide
agreement that there should be only one quality score might be better
enhanced if we said that, instead that there are many times, or let me
put it this way, there are many measures that require that data be
collected from multiple sources in order to actually, to accurately
portray performance. And if we can\'t link across those databases to
provide that accurate picture, we will have two problems. One is that we
may have different measures then, based upon which database one goes to.
But secondly, we won\'t have the really true picture of performance. So
I\'d like to see maybe a little bit of wordsmithing on that particular
area.

Does anybody else have any questions or issues there on number 3?

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

Margaret, this is Helen. My understanding on that was that it\'s sort of
missed the comments, a mismatch to the bullet as you\'ve noted. But the
mismatch for us becomes the following. We have employers, especially who
have employees all over the country, and they\'ve been concerned that a
set of measures, sometimes the same measures, sometimes not, could lead
a provider to be categorized as preferred, meeting certain criteria for
high performance, and from another say, plan, or in the case of, could
be federal data, they somehow don\'t look preferred, or are not
preferred.

And so I thought that that was, part of what this was trying to get at,
and all of those are important parts but they just don\'t belong
together, among other things.

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

Margaret, this is Phyllis. First of all, I totally agree with what you
said, and I think, as Helen said, the point is data aggregation solves
many problems, and I think we need to probably be clear about that. And
one problem is the problem that Helen pointed out. And another problem
might have to do with looking at care across episodes, you know, from
different providers. So I think that addresses what both of you were
saying and I wholeheartedly agree with that.

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

Margaret, this is Kelly Cronin. If you would like, I\'m here and
Christine Martin Anderson who has also worked a lot on drafting this
letter is here, too, so we can cover in your absence.

[**\>\> Margaret van Amringe:**]{.underline}

Oh, that would be perfect, and I will be back in about five to ten
minutes.

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

Okay, great. So I think we could easily expand that paragraph to include
the different problems and issues associated with data aggregation to
make it more clear up front about what needs to be solved, and the
different issues that would be addressed in doing so.

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

Kelly, could you go back to number 2.

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

Since we jumped ahead pretty quickly and there was a lot of ambiguity in
our early conversation around patient identification algorithms, and I
think even in our last Workgroup meeting we had a brief but a little bit
of a confusing conversation around this and it\'s perhaps maybe one of
several issues we probably need to be thinking about over the long haul
about provider feedback in real- or near real-time.

So perhaps we should just get some more feedback from the group about
the overall issue and whether or not we do need to be describing in the
introductory paragraphs any additional considerations.

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

Kelly, this is Mike Rapp calling, or on the phone here.

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

Great. Hi, Mike.

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

Sorry I\'m not there in person. But if we\'re on paragraph 2, I just
have a question about the basic goal here, or recommendation where it
says "automate data capture and reporting". I guess I\'m on \-- excuse
me, I\'m really on 1, when we talk both about AQA and HQA, "automate
data capture and reporting to represent a core set of AQA
clinician-focused quality measures".

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

Mike, we just had a conversation about that and that\'s really been that
sort of the core \-- it\'s in the essential part of our specific charge,
which is really trying to get some short-term progress in the near-term
to make sure that through certification and standards harmonization and
the other activities under way that we can start to automate the
reporting of a core set of measures that are applicable both to the
in-patient and ambulatory care environment. And recognizing all the work
that\'s been done by HQA and AQA, in doing that kind of work. And we\'ve
also in the last few months been talking both in our public meetings and
offline about how best to do that given there is some work already under
way. We just a little bit ago referred to the NCQA, AMA, CMS, work that
I think has already taken on one or two measures in trying to really
define the data elements. But we recognize then how time-intensive, how
labor-intensive that whole process is and how we risk volunteer burnout
and probably need some real, paid experts to drive this process in the
near-term, and get a lot done so that we can start feeding it into the
standards harmonization process and certification process and NHIN this
calendar year.

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

I was on \-- I\'ve been on the call today. When you say "automate the
data capture", though, does that mean from an electronic health record?
Is that what the automation refers to? Because if we\'re talking about
AQA measures, most of those are claims data, or at least administrative
data, since they\'re essentially HEDIS measures. When we talk about
"automate the data capture", it just sort of implies to me that we\'re
talking about electronic health records, and so information that comes
from it. I\'m just trying to see whether that\'s really what we\'re
talking about, or we\'re talking about something else.

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

Yeah, I think that doesn\'t necessarily suggest that we\'re talking
about the hybrid approach but automate would essentially mean, at least
down the road, from electronic health records. That\'s not saying
that\'s the only mechanism. We\'ve had a fair amount of discussion to
recognize the Web-based or ways of capturing and aggregating data, in
the near- to midterm. But for the purposes of trying to make sure
electronic health records as they get adopted, really do facilitate this
process and automate the process, we want to make sure that the criteria
is developed to ensure that.

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

Yeah, if that is the focus, the electronic health record, I just wonder
whether that should be made clearer in these recommendations.

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

Yeah, I think \-- that sounds reasonable. Either in the preamble or at
some point we\'re going to have to also be clear we as a Workgroup have
recognized the need for a hybrid approach for the foreseeable future and
the data sources are potentially numerous. It\'s not going to be solely
reliant on EHRs or health information networks.

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

Okay, thank you.

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

Kelly, it would be helpful, I think, to understand why there is one very
specific recommendation in Section 2 in that others \-- or other
candidates might be.

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

Again, I think we probably have time today to really have more of a
thorough discussion around this. I think in our last Workgroup meeting
we didn\'t really have the time to fully flesh out potential ideas. We
only had presented a couple of ideas that have been surfaced in previous
conversations. But really we have an opportunity to more carefully think
about what is at least some of the short-term things we could be
thinking about that are relevant to our specific charge.

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

One of the reasons this particular one is here is because it became
evident that it\'s not possible to even consider real-time or near
real-time as opposed to retrospective, which clearly falls into, as
well, chart review or claims, if you don\'t know \-- if the electronic
health records can\'t recognize at the time the patient is in front of
the provider, that they fall into the denominator. And so trying to
address this issue of how do you know who's in the denominator. And
that\'s where this patient identification algorithm is a really poor
label for that, but the concept is who is in the denominator and to whom
does this measure apply. If you\'re going to automate the data capture
there has to be a trigger for that. That\'s been a struggle both within
hospitals working diagnoses and other ways of documenting, also been a
struggle in physician data because when you look at the claims data it
doesn\'t tell you at what point you knew what. It only tells you what
you did after the fact. There may be other barriers.

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

I actually read it as who is identifying what patients go with what
doctors. Which is also \--

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

That\'s a great conversation we had with Margaret as well that made it
obvious there are really two here. The other was how do you link across
providers which is obviously a big \-- linking across providers but
provider identification and linking across time for patients, if there
were \-- for instance, so within a setting, knowing it\'s the same
patient is really not quite the issue.

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

Right.

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

Across settings is the big issue.

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

One of Margaret\'s \-- that the balancing of patient confidentiality
needs to be brought into this recommendation as well. When you\'re
trying to figure out where the different settings are and how to use the
patient \-- confidentiality incorporated, perhaps language in that
recommendation.

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

Right, if we \-- the original intent was how do you know the patient\'s
within the denominator and they\'re within the system as to whether or
not the data ever leaves. Around data aggregation I agree that
confidentiality is a really huge issue, but even within a system it\'s
not so easy to get real-time feedback.

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

I also know Mike Rapp might know more about the current thinking but
there has been discussion about how the Privacy Act applies to giving
providers feedback that may represent care that goes beyond what they
have ordered or delivered. To the extent that it reflects sort of
comprehensive care delivery across a variety of providers, there might
be some considerations there.

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

Kelly, this is Mike again. Can I go back again to the physician \-- can
I hit just sort of the broader issue of going back to EHRs and data
aggregation and so forth, just to clarify something?

So if we\'re talking about data aggregation, the reason one does data
aggregation is because one is looking at the world from the perspective
of a payor. So the payor \-- multiple payors, the data of multiple
payors has to be aggregated in order to measure the performance of an
individual physician or other provider.

So that\'s why I want to again go back to the distinction between an EHR
and a data aggregation process for queuing the world. If you\'re doing
it from an EHR perspective, you don\'t have to aggregate any data
because you\'ve got it from the perspective of the provider of care and
all the patients in that particular practice.

In the context of the hospital, that\'s what we do, the hospital data is
collected at the provider level. There\'s no data aggregation that has
to take place. It\'s submitted directly, it's all payor data, it\'s all
patient data.

But from physicians, that\'s different. And so there\'s just a kind of
fundamental distinction, and insofar as one gets a Workgroup together
and one has them tackle a particular challenge, it seems to me that one
has to again make that distinction. Are you using claims data
supplemented by additional administrative data that\'s collected at the
payor level that you then aggregate? Or are you going directly to the
provider who is \-- where perhaps the lab data goes to the EHR and you
get it directly from the provider? Again, once you do that, the data
aggregation becomes a moot point.

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

Yeah, Mike, I think if your comments are applying mostly to the Section
1 of the recommendations, that I think we are really more oriented
towards what do we need to do to make sure the electronic health records
are going to be able to report out the data that\'s needed for a core
set of measures.

So that really is more geared towards data elements that will be
electronically available in an EHR. And not necessarily, you know,
particular code sets or data fields that would be applicable to
administrative data sets.

So I think we\'ll be trying to, obviously, refine recommendations 1.1
and 1.2 and 1.3 and really try to make it clear as to what needs to get
done by some type of expert panel, to make sure that their scope and
deliverables are clear to a broader audience. Would that address your
concerns?

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

Yes, it would. That\'s \-- I just am trying to make sure that insofar as
the letter makes a recommendation, set up an expert panel to tackle a
particular challenge that it\'s pretty clear what that challenge and
what we\'re trying to make sure they do.

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

Okay.

So getting back to number 2, providing feedback to providers in
real-time or near real-time, I think we probably could look into perhaps
some of the issues surrounding confidentiality or privacy in the context
of the Privacy Act or HIPAA. We haven\'t really had much of a discussion
around that yet.

But I do know that there are some folks internally at CMS who work on
the Privacy Act who could potentially give us some technical assistance
with that.

Are there any other broader considerations beyond the need for clearly
having mechanisms or algorithms to identify who is in the denominator or
how to link across providers and getting the numerator and denominator
right?

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

This is Jonathan. Two things. One just about the comment you just made
and the discussion we've had about the Privacy Act. I\'m all for making
sure that we\'ve cleared those hurdles but it\'s important for us to
make a clear statement that feedback to providers is a good thing and
that we want to make sure that that can go forward within the bounds but
that it can go forward nonetheless.

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

I think that\'s really helpful. I think particularly in the right
context, I think when it comes to CMS, for example, using their data, if
it\'s going to be used outside of research and demonstrations and for
operations or treatment, then there just needs to be probably a clearer
legal framework for them to, for example, offer data to a potential
health information exchange, or some kind of network operation that
would use both clinical and claims data that would end up going back to
clinicians that participate in that network.

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

Right, right, absolutely. Some way, whether it\'s to the care giver, the
gatekeeper or to everyone, there needs to be a way to get that across.

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

Right.

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

The other point is that we sort of have an impression here that all
people that get EHRs are kind of the same. That we\'re going to get data
standards that bring them together so that what I get from system vendor
1 is similar to system vendor 2. But there are some variations to
consider. There\'s \-- a small practice will continue to have some
distinctions in what they can do from a large practice. A practice that
is a highly specialized practice will have some distinctions. So
somewhere in the expert panel, this may be under the surface, but I
think we need to say that we are going to try and make something that
does the best for each provider subdivision.

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

I think that\'s critical, too. This is Josie.

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

Does that make sense?

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

Yeah, it does. Thank you.

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

This is Nancy, and I\'m not going to find the right words to express
this because it\'s something I\'m still struggling to figure out exactly
how to say. But as I was listening to the discussion about number 2
here, it seems to me that we\'re missing a \-- we're missing something.
I don\'t know if it\'s another bullet or goal or what have you, but if
we\'re really focused on whether we capture the data and put it into a
measure correctly, what we\'ve missed is the opportunity the patient
gets the right care at the right time. So that somewhere in here we
should really be talking about how this has to be integrated not only
into the data capture, but into the decision support so that the
clinician gets the right reminder at the right time.

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

Right, that\'s a good point because it was supposed to be a bridge
between the short-term, which is how do we get these measures done, and
the longer term, which is how do we enable quality improvement. One of
the threads that has to carry all the way through is that you know who
is in the population. It's really population identification, you know.
And so I think that\'s right. That the real reason you do that is not
the end game of measurement.

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

Right.

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

It\'s the end game of improvement.

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

Thank you, you said it much better.

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

This is Phyllis. I had a nitpicky reaction to the term "feedback" which
to me does sound retrospective, as opposed to "decision support". To
provide an example that might make us think about it a little
differently. More than one system that uses the practice management
system, looks at the practice management system, the night before,
figures out who is coming in, and then provides decision support to the
physician in their office that day. I mean, that's kind of clunky, but
it\'s just another way of thinking about decision support happening that
might think about it a little differently.

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

And that's another good point. That\'s what we\'re trying to get at with
the definition of real- or near real-time, the part that I think Jerry
commented on. We\'re trying to translate that in the in-patient
environment in order for it to be considered real- or near real time. It
could be next morning, subject to the measures, could be the next hour
for some measures, but for ambulatory environment that that really
varies. The patient can leave and come and go and it doesn\'t
necessarily mean that you\'ve lost your sort of real-time ability to
impact them. It really is condition- and evidence-specific in terms of
how quickly you need to interact with them. We\'re trying to define that
but I think we need to find a way to define it that\'s not constraining,
to say you never have to do it more frequently than before they leave.

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

This is Jane Metzger. I think when you\'re talking about the decision
support as opposed to performance feedback about a population, I think
it would help if we used "assistance" or something else besides
"feedback". Because I think to most people that connotes retrospective.

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

This is Helen Burstin, I would concur and also just say I think in
general the concept of feedback doesn't really fit very well the model
of decision support. (indiscernible).

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

Helen, could you speak up a little bit.

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

Sure, I\'ll see if I can get off the speaker phone. Is that better?

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

That\'s great.

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

I was saying I was going to say something similar to Jane, that the way
it\'s titled it may just be we\'re trying to lump a lot of concepts into
saving words, but providing feedback to providers sounds more like
feedback around quality as opposed to decision support. I know we\'re
trying to push the decision support peg into this hole but in some ways
we are sort of mixing, a bit, the concepts of decision support and
quality measurement feedback and there might be some way to nuance that
in a few more words.

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

Right. I guess the other consideration is that this is going to be our
first letter that really is supposed to be reflecting recommendations on
our specific charge, and it\'s really our broad charge that takes on
clinical decision support. We\'re going to have a lot more time to
deliberate and figure out what really need to get done. So if there\'s
something in the near-term that we think we can advance that would
result in something meaningful this year, then, you know, it would be
great to articulate that over the next couple months. But I think we do
\-- we are going to have a lot more time to take on the broader issues
with CDS.

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

I think the CDS issues are longer term and I think in some ways if you
look at the specific charge it\'s really about quality measurement
reporting. And the CDS stuff may be an outflow of that. But it is kind
of a bigger nut to crack than simply providing feedback in real- or near
real-time.

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

It\'s Nancy. I just don\'t want to let go of this one. If you programmed
your electronic health record by identifying somebody who is in the
relevant population and who should be getting whatever therapy you\'re
measuring, you know, it doesn\'t seem to me that we should lose the
opportunity to say that right to the clinician. If they\'ve got an
electronic health record they should have the capacity to say it to the
clinician at that time. And allow the clinician to say, no, because of
X, Y, or Z.

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

It\'s hard to separate concurrent coding from decision support. They
really are one continuum except for there\'s a lot more logic that has
to go behind the decision support that we\'re not trying to tackle right
now. But I think if you\'re going to do either you need to
foundationally know who the person is.

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

It might be helpful to explain some of that here.

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

Exactly.

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

It\'s not clear here now.

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

I think maybe starting with what you just said which is both for
reporting and for the broader goal of quality improvement you have to
know who the patient is. And so for the near-term activity that\'s the
focus, but it will eventually benefit both quality reporting as well as
a real-time decision support. So just kind of reverse the order of the
logic as it\'s presented here.

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

Yeah.

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

And the other thing, this is Jonathan and certainly I want to get the
CDS side of things and I know that comes later on. As far as the
feedback goes, I think that there\'s a lot of benefit, and this has been
demonstrated, in knowing where you stand. There\'s no question that
feedback that says among your peers you are in the upper 60th
percentile, the upper third percentile, some people take it and
immediately break whatever sent that to them, but other people use it as
a fair amount of \-- there is feedback that says here\'s where you \--
you have a goal and here is how you are doing and that has an advantage
to itself. So that\'s another kind of feedback that seems to fit this
and the quality measurement rubric more closely.

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

This is Jerry. To sort of keep building on this theme, that a lot of
what the specific recommendation deals with is the issue of who. But
this overall point 2, I think there\'s an issue of when that comes in as
well. So it talks about real-time or near real-time. So the first
recommendation 2.1 is about narrowing down exactly who we\'re talking
about, but a lot of the comments that relate to both clinical decision
support and performance measurement tie very critically to this issue of
when. When exactly are you going to either get that information that
you\'re looking for, or provide the input into the process that\'s going
to lead to performance improvement. So I guess a question is, should
there be the consideration of an additional recommendation to start
teasing out the when issues both in terms of the performance measurement
stuff that needs to happen, augmenting the stuff in the section 1 and
setting the stage for some of the additional things that are going to
happen in the dealing with the broader charge.

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

This is Jonathan. Just to elaborate on that. Yes, the recommendation
doesn\'t quite match up to the paragraph, and if there are
recommendations that says we recommend that HHS establish standard
timeframes and standard sets of feedback that come back to the
physician, and these are things therefore that people have to develop
to, that seems like that would more closely fit what we\'re saying here.

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

Yeah, do others feel like it would be worthwhile to add a recommendation
that would address the timeliness needs and perhaps mechanisms or ways
that could be done?

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

It may just be a way of getting at the multiplicity of needs, was what I
was hearing, so you could talk about in that real-time, while the
patient is in front of you, decision support, and the need for aggregate
depth of data-level feedback and I don\'t know what the right time is
but some short time after your patients have been in front of you, a
group of patients have been in front of you. And talk about both of
those as being of value and intimately related to the work we\'re doing
here.

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

Interesting, Kelly, because in the inpatient market, this is Christine
Anderson, competition has evolved that to the point where some are
getting near real- \-- are doing concurrent coding and are getting
resonant feedback. And so the competitive element of what the providers
are demanding has driven that down to a very constrained period of time,
that is actually near real-time. Whereas, in the physician environment
where it hasn\'t \-- it\'s still reliant on claims that are forced to be
a certain period retrospective, we haven\'t quite had the ability \--
the competition only drove it to when claims are adjudicated. It
couldn\'t really get much closer. So I think it\'s useful to have a
dialog, I\'m just wondering what more can AHIC do than what the
competition market is doing on its own in that regard.

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

Right.

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

Is it just the more sophisticated facilities that have \-- wise or
experienced CIOs that are demanding this and could there perhaps be
better communication of what the need should be? Expressed and maybe
there is a communication or education role.

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

Or all vendors tend to follow. One vendor goes and slowly the vendors
have to move there in order to stay sort of competitive.

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

I think there is a thing where the most sophisticated places do that.
But a substantial majority and particularly smaller and particularly
ambulatory do not. I think AHIC\'s role can be to bring everyone up,
essentially. We don\'t have to change the more sophisticated sites but
we want to have some kind of norms that other people are expected to
have this kind of feedback.

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

This is Josie and I couldn\'t agree more with that. And even now with
some of our hospitals where we do have the, we do have the least \--
where we\'re getting the data in, getting it out and making available
for them in real-time, almost real-time data evaluation and use, they
don\'t know how to use it or even that they really want to use it. So I
think it\'s very critical.

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

Then are we thinking this is mostly an outreach and education role,
then? With rural provider associations or other physician organizations
to ensure that demands are understood and articulated?

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

Actually, I think it\'s both but I could be persuaded that many of the
larger facilities are doing it and that maybe you don\'t want to go to
more than just education, but also comprehension of that. But I actually
think that it\'s not as widespread as the large facilities think it is.

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

I don\'t think it\'s very widespread at all. I mean, concurrent coding
is something that\'s a cultural, institutional change that\'s much
larger than the ability to report out real-time. The big changes they
make is their internal workflow and processes and then they demand that
their vendor keep up. It\'s really not that their vendor just because
they have the functionality could help them concurrently code.

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

I agree with that.

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

So is there a role for AHA, and other like organizations to be educating
their members? If it is about workflow, business process, and needs
around that. That would drive the market.

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

(indiscernible) expectation. There could be incentives.

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

Right.

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

And well, AHA is perfectly willing to take that on, in fact we\'re
moving in that direction already. That\'s a small piece of the market
we\'re talking about here.

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

Your membership.

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

Yeah.

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

I mean, by some of the larger systems, but \--

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

I agree. It is a very small piece of the market.

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

I\'m just wondering, you can\'t mandate cultural change.

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

Right. What \--

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

I'm just struggling with how far AHIC can go with this.

\[multiple speakers\]

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

Now, for the vendors themselves, the ability to \-- an EHR. If you\'re
implementing an EHR, and you want to concurrently code, we can help
influence that they should be able to, right? Because we\'re \-- that's
where the first recommendations were getting at that. Here\'s the data
elements and here's what the standards would be and that would allow the
data capture.

Whether or not someone chooses to fill it in I think would be harder to
mandate, right?

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

I\'d love to.

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

But even having the capacity to outline and help people envision \--

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

Let\'s get back to the document, we talked before about another benefit
might be a \-- some kind of a guidebook around implementing the EHR that
playbook of sorts that would help them \-- I think some kind of playbook
or something would be useful.

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

This is Pam. I think that\'s a really good idea, because one of the
issues with the EHRs, is it interoperable and if there was sort of a
guideline set around that, that might help facilitate the
transferability or the interoperability of the information.

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

Well, you know, with the certified products, and somebody that more
knowledgeable than I could speak to this, but certainly there are
several of the QIOs that have developed some of those. It\'s getting
people to use the information that's there but collecting the
information or putting it in a succinct form might be helpful.

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

Mike Rapp, do you have any insights as to what the QIO programs have
already done that might be relevant?

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

You mean \-- well, in terms of collecting the measures?

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

And in particular any guidance or guidelines around EHR implementation
or sort of the processes that would support the quality measurement
process.

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

The main thing is DOQ-IT, and that the measures and the standards for
collecting them have been developed. For a certain number of measures
that have overlap with the AQA starter set. And so the standards are
there. Or the vocabulary is there to collect the measures. But the fact
is that although that vehicle is there, the physicians are not reporting
it.

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

Yeah, the TMF also has a program in which they will help physicians
analyze what EHR is best for them and how to implement it. And I\'ve
seen others of those as well so my question is, is the data out there
and we just need to collate it better, or do we really need a guidebook?

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

There\'s a substantial amount from DOQ-IT on this. They\'ve done a lot
in terms of EHR implementation guidance and several states, at least,
are using this pretty actively. And I think as you know, Kelly, there\'s
a CMS contract out now to apply that same guidance to clinical care
management and disease management and such.

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

Yeah, that was my sense.

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

It's out there, the question is the level of implementation and can we
sort of espouse that.

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

Well, one way, we have the physician voluntary reporting program, and
now we have the new legislation that encourages physician reporting,
gives an incentive to do that, and the methods \-- potentially one of
the methods would be through the electronic health record. And so
insofar as that were available, and it is for a certain number of
measures, then the incentive might encourage it in a way that hasn\'t
happened so far.

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

Okay, well, I think there might be, you know, a little bit more
background work we could do to find out what exactly would be relevant
from the QIO program in the way of guidance that would be more broadly
applicable to, for both hospitals and ambulatory care, specific to
supporting quality measurement. And perhaps we could come back to you
all with a little more information in the next meeting. But I think that
the idea of trying to have a recommendation on timeliness and sort of
the when factor, as Jerry articulated, we could, you know, do a little
more work on that in between meetings as well and talk with you to get
some more concrete ideas on what kind of mechanisms we could consider
that would be appropriate for a FACA committee to suggest to the
Secretary. Recognizing that this is really going to probably be an
institutional effort and, you know, beyond having some maybe case
studies or sites that would be representative of the ideal. I don\'t
know, you know , we\'d have to probably think a little bit more about
how to make this really meaningful and relevant to a wide set of
providers.

So are there any other comments about Section 2?

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

This is maybe largely editorial, but the discussion made me realize that
I think there\'s an assumption in here that's implicit that we might
want to make a little more explicit. And that is, the same evidence
underlies measures. There\'s one evidence base. That evidence base
underlies decision support as well as quality measurement. And you
really are working from one evidence base and then that\'s what allows
you to try to do both of these things at the same time.

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

Is there anything else from the original list of ideas we had for this
section that would be worth talking about?

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

I think most of them, Kelly, ended up going further down the decision
support road and we decided to fall back to the specific charge for this
year. So they were sort of advancing how we make decision support
possible.

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

Okay, great, so are there any other comments on Section 2? Let\'s go
back to section 3, then, and pick up on some of the comments around data
aggregation that I think we already made and one thing I think was
particularly helpful before that we can work on over the next week is to
articulate all the problems that need to be resolved in data
aggregation, and perhaps make sure that whatever recommendations we
craft are at least recognizing those problems.

So in both the preceding paragraph and in the recommendation we have to
make sure that we\'re not just referring to the issue of having a clear,
reliable quality score for each clinician for the purposes of
stratifying them as a preferred provider or in a certain percentile. But
that we recognize all the different reasons why data aggregation is
important and what needs to be resolved in doing so.

So are there any specific comments about the recommendation 3.1?

I think that the one thing that has been recognized and probably already
being addressed, Nancy Wilson is also in the room from AHRQ, who has
been working on the AQA, HQA \-- or AQA pilots. That are addressing this
issue of merging claims data and one set in particular is focusing on
\-- we\'ve heard from Marc Overhage on this, who's focusing on merging
both the clinical data coming from their regional network with claims
data. So there are obviously a lot of issues to work through in that
process, which is being articulated at a high level in this
recommendation. But is there anything else that we need to be specifying
or considering?

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

Kelly, do you want to address the specific \-- (indiscernible) embedded
here or \--

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

Yeah, one of the questions here that we welcome any of your input on is
should there be a recommendation about how to make sure quality
information is usable by consumers, possibly through Web-based
interfaces. This is not directly applicable, I think, to the
recommendation 3.1 or 3.2, but it did come up on a conversation with our
other co-chair Rick Stephens yesterday who thought that it was
particularly important that whatever we do aggregate gets reported out
in a way that\'s going to be usable and meaningful. So it\'s sort of the
next step in the process. But it speaks to the fact that you need to
have the right combination of data sources to at least have that
reliable measure you can report out.

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

And this is Helen, I do think it\'s important to stress that, at this
stage, for a couple of reasons, including the fact that at the very
beginning we say the way essentially we\'re going to be judged a success
is what a difference we make in terms of consumers as well as improving
care.

So that\'s a nice symmetry. But also it seems to me that organizations
like NCQA and Consumers Union, in particular, and others who have been
working with researchers about how to communicate more effectively and
social marketing and behavioral change, there\'s a lot of information
about what will affect consumers. I think building it in here, at least
recognizing its importance and adding to the value of what the work
they\'re doing with the fact that more information will be available,
and that we could develop along parallel paths would be very helpful.

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

But I think \-- Helen, it\'s Nancy. I think this is well beyond the
scope of this particular group. So I\'d love to be careful in the
language here, recognizing the importance of having data that is easily
understood by consumers, and that is in fact the job of some of the
groups you mentioned and others who are working on this, so that AHIC
has to be integrated with and be cognizant of the fact that its efforts
will end up feeding into their efforts to create useful, understandable
information. But that\'s not \--

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

I know there\'s another Workgroup, too. So it\'s just referencing it and
therefore highlighting its importance. It\'s very easy for us to go down
paths in our own little world and forget that at least a lot of this
information is going to make a difference or be valuable and therefore
worth spending some money and time on, is when \-- is able to reach
consumers. There may have to be translation, I\'m not suggesting there
wouldn\'t be, but Consumers Union, for example, really does a very good
job with that and they use basically hospital discharge data.

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

And this \--

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

This is Jonathan. I could see us recognizing the issue, I agree that if
we were much more farther advanced in the science of how to do this,
then we would put it in here but right now it\'s pretty experimental and
would take quite some time to figure out how to put this out. So I
wonder if we could do something like recognize it in one of our
paragraphs without attaching a specific, timed recommendation to it. You
know, just as we\'re saying we\'re going provide feedback to providers.
Well, we also recognize there\'s a desire to provide cogent feedback to
consumers.

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

Right.

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

This is Phyllis. I think I agree with the drift of the conversation. If
we\'re going to set it up as a goal, then we need to say something about
it, and I think we need to acknowledge it, we don\'t know how to do this
yet. Certainly haven\'t \-- I think something like the reference to
possibly through Web-based interface is way too narrow at this point.

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

Uh-huh.

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

Okay, so perhaps what we could do in expanding that preliminary
paragraph before recommendation 3.1 is recognizing the importance of
consumers\' needs in determining how to go about setting this up so that
in the end they\'re going to have output that will be meaningful to
them. But it\'s a little bit premature now to be specifying exactly what
type of technologies would be needed or what type of aggregation would
be needed that would be specific or that would be advancing consumers\'
use of this information.

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

And this is Pam. That was really the intent of Rick\'s comment on this
section. It was again just the recognition that we\'re not just
gathering data for the sake of the exercise or the technology of doing
it, but keeping in mind always the intended purpose and I think the
other comment was what somebody brought up just a minute ago, was on the
integration that recognizing that we need to be able to utilize other
approaches and integrate with them in order to get this information out
in a useful manner and then something that Helen mentioned earlier, I
think we covered in one of the other sections as well but it\'s regional
and national ability to have data aggregation.

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

The concept that we could make clear building off of our previous
conversations is the fact that the benefit of aggregating this data is
ultimately going to result in not only quality improvement but
empowering the consumer with this information to help them make better
decisions. So if that\'s sort of \-- if that benefit is driving this
activity, then it can be put in the context of any risks that are
associated with data aggregation or the use of a repository.

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

Right.

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

Are there any other comments on 3.1, or recommendation 3.2?

Okay, well, then, let\'s move on to \-- John Loonsk has joined us and
would like to make some comments although he\'s just getting over a bad
cold.

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

Thank you, Kelly. I\'m sorry. And I apologize for sort of entering into
the conversation late. But as heavily involved in the Nationwide Health
Information Network activities I'm looking at these recommendations and
thinking about them in the context of what they imply from an
architecture standpoint and what they specifically say from an
architecture standpoint relative to data aggregation. So number 2
specifically identifies data aggregation, and number, recommendation 3.1
seems to suggest that data aggregation needs are one of the things that
should be fully teased out and described. And I just wonder about the
ordering of those two and I\'m not sure if that\'s a coherent question
relative to the status of you. I\'m just worried about charging the NHIN
with doing something with the specific objectives or it may still have
some ambiguity.

More concretely, some would articulate aggregation in this context as a
conclusion rather than a functional need. And I\'m just wondering where,
whether 3.1 is in that regard. Are you specifically identifying \-- it
seems like you\'re building to the identification of what appropriate
levels of need are there but then you\'re jumping to the next step.

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

Yeah, I think there\'s been a lot of discussion just recognizing the
need for this hybrid approach. And knowing that there\'s going to be a
lot more federal dollars going out the door to support regional- or
state-level implementations of health information exchange through this
NHIN process, that there\'s an opportunity probably driven through the
use case, as it\'s developed, to specify what would need to be done to
try to get the right data sources together.

So I don\'t think there is \-- I think we need to work on the wording,
but there\'s no intention on trying to sort of create expectations or
something that\'s not feasible to implement in the next year. Yet there
is this real opportunity to start figuring out more than in Indianapolis
how we might be able to demonstrate how some data, namely meds and labs,
could be integrated with claims. And it might even have to be something
that's broader than the NHIN effort. It could be complementary process
that AHRQ and CMS would be involved with.

So maybe we need to do more background on that and figure out how we
might be able to work on it.

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

Kelly, one of the core questions here is whether or not exchange and
aggregation have to go together. I know that for quality measurement and
reporting we need aggregation. But there are many other functions that
are supported by data exchange that don\'t require aggregation. And so
to what extent do we want to tie together that, you know, they have
other things that are synergistic, right? If you\'re going to have to
identify a patient's care over time, across providers, and the process
you go through in data exchange allows you to do that, could you
leverage that for quality, for the quality aggregation. So I\'m not sure
they have to occur in the same process but they ought to be able, if
there\'s a patient identification process that occurs it ought to be
able to be leveraged across both efforts so you\'re not doing the same
thing twice.

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

Uh-huh.

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

I don\'t know how best to articulate that. But we want to make sure
they\'re in alignment but not be prescriptive about how any one data
exchange product would have to implement.

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

Or you could test a variety of approaches. Not necessarily be dependent
solely on the NHIN contracting process. It would be perhaps in
collaboration with what CMS and AHRQ are planning to support and to a
certain extent already are supporting.

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

So there are several levels of questions. One is just specifically in
terms of the NHIN, and not attesting to the \-- the language may need be
refined around the NHIN contracting process simply from a FACA
standpoint, the NHIN process but \-- but it seems like you\'re on the
nomenclature one would want to talk about the functional need of having
data associated, in association so that you could perform quality
activities, and that that could speak to several different levels.

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

So then one of the aspects of this that may or may not be related to 3.1
is understanding and identifying the functional requirements associated
with \--

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

\-- with making data usable for \--

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

\-- for quality measurements.

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

Yes.

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

Yeah. That could then feed into or be the basis for considering
certification criteria.

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

And other processes.

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

Right.

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

It could be \-- the NHIN process is valuable in that regard as well as
other things.

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

As well as EHRs, yeah. We haven\'t had to chance about as a Workgroup
very much, but in 2008 there will be a process started to identify
criteria for certifying what will become the NHIN service providers, as
we have been calling them. So network providers that are enabling health
information exchange will be going through certification process down
the road just like electronic health record vendors are doing now for
ambulatory care and what we expect in the near future for in-patient. So
that the idea of, early on in thinking through this is that if all these
systems are going to connect with each other, they\'re all going to go
through a certification process.

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

And if you can work to identify what the specific needs are for health
information exchange, health information networks, to support quality
accomplishments, that would be a long \-- go a long way to setting up
that contextually for that activity and others.

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

Kelly, I think it goes back a thing, one of the different problems that
data aggregation solves. We sort of disentangle these different problems
then we can go back, in order to do this we need the functionality to do
that.

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

Get a framework for it, essentially.

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

Are there any other comments on section 3? Okay, so for section 4, I
think that we have a very high-level recommendation to consider and a
brief explanation preceding that that articulates sort of the need to
more formally integrate these communities so that they can actually
figure out how to align quality measurement and health IT specifications
and while being mindful of what\'s feasible and not feasible. And I
think admittedly this recommendation is relatively high level and needs
more specificity. So I think we\'re hoping in part to get your input on
how to refine this and make it meaningful so that it will result in
something that will be tangible coordination among various organizations
that are really critical to making both quality measurement and health
IT interoperability possible.

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

Kelly, this is Jerry. There was a handout that came along with the
meeting information on the public/private measure automation efforts and
it sounds like those things that were described there are making some
significant headway into this kind of thing, if I read that right.

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

Summary of efforts that we sent to them.

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

I think that the critical issue here is just \-- is really the how. So
we know that the processes are not well-aligned and it\'s not like
there\'s only one process, standard process for measure development to
begin with. And only one standard process for \-- or one standard around
what kind of data is available. So the question was, where is the best
place for measure developers to intersect with data needs, and first
we\'re very specific in the last version and said at least in the
testing process, we ought to make sure that in the, on the testing
process, that you at least know the relative benefit versus burden of
any one data element when you\'re testing your final measures. And then
some folks reacted and said that\'s much too specific. Someone could do
it other than in the testing process, which is accurate.

Then the question is how do you advance this dialog or at least identify
some other areas of opportunity for how they could come together, and
understand one another\'s worlds.

[**\>\> Margaret van Amringe:**]{.underline}

Well, this is Margaret. I think this is where to the extent that there
is \-- that there\'s sort of a cadre of data elements, this core set of
data elements, what you want to encourage measure developers to do is to
the extent possible utilize the values of those data elements without
having to create new ones. Now in some cases you may have to create new
ones, but I think if we can accomplish our first recommendation, then
this will sort of flow because you want to then encourage developers to
attend to what comes out of that first recommendation when they put
together new measures, consumption. I\'m not sure there\'s a place today
that they can go. Until we have that first recommendation completed.

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

This is Phyllis. My inclination was actually similar to Margaret\'s.
This isn\'t going to be informed by what the expert panel does and maybe
it is premature to anticipate what we\'re going to learn from them.

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

I think partially I agree with that and I think partially \-- but I also
think at a higher level, if you just think about the measure development
process and all the places that you intersect with the guidelines and
think about where you\'re going to get data, irrespective of what the
data is, I think there\'s some questions around what would be the most
logical places to really think about the data. Not that you\'d be
further informed by knowledge what data is available which will get into
Section 1, I think they are complementary. I\'m not sure though if there
isn\'t \-- maybe that\'s only one avenue. Should we identify \-- there
is a list \-- maybe another avenue is the NQF approval process that has
some sense of \--

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

That's tangible.

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

\-- burden, or \--

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

And I\'m sorry, it\'s Nancy. Janet has already started down this path
with the NQF and has reached out to measure developers to begin to talk
about elements that ought to be in common unless there\'s a substantial
clinical reason that they ought not be and a whole variety of things
that would make automation \--

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

Go with that.

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

\-- more practical. And it seems to me that is the right place for this
conversation, not CMS or AHRQ, with all due respect to my colleagues
from there. But it really is a function of whether a measure gets to
that point of being good enough, and well enough developed that it ought
to be considered for a national standard.

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

This is Helen. Sorry.

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

I might have a slightly different \-- I think these are really big
issues, and no one knows the answers and I think NQF is struggling with
what to measure, but I think there\'s a lot that\'s dependent on
implementation and how a measure is going to be used. And so it\'s
really hard to come up with a process that will take into account all
the various ways. So I think there\'s a question of what needs to be
standardized and what can be standardized and I don\'t think anybody
knows the answer to that right now.

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

Helen, were you going to jump in? This is Carolyn. I'm back.

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

I was going to say the role of being the body that could help bring
focus together to do this is one that we would be very comfortable
doing. Not so much leading it, but really being the convener and trying
to see how to make this work.

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

I guess the issue that I have struggled with in terms of who and what,
is thinking about a supply chain of quality measures. There\'s certainly
a lot of folks who haven\'t tuned in to this issue at all who are
developing measures today. Some of them are actually going to be
reporting on them starting in July. So there\'s almost like a whole
trajectory of issues that has to do that. I think ultimately there\'s no
question that this is institutionalized at NQF, because they are the
people who are having to tell people no, I\'m sorry, your package looks
really nice, but you wouldn\'t get to step 1 of our process because you
haven\'t thought through the following issues. And it\'s very easy for
me to imagine, particularly having had some terrific conversations with
Janet about this that at some point that becomes part of the standard
instructions.

I think the real challenge is figuring out where are we now and who
needs to be part of this and frankly who's been funding some of the
measure development. Janet's been clear they\'re not above developing
measures. Very critical role in terms of convening and giving that
feedback. But they\'re also at a fairly sensitive position where, if the
feedback is if you don\'t meet my thresholds and my criteria, the
response might be okay, I\'m not going there. Which I don\'t think is in
our best interest either. So that was a little bit of the sense behind
the who and the what in terms of getting the ball rolling.

Phyllis, can you say more about how they\'re used?

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

Well, I actually spoke to the NQF implementation conference and just one
example I used was blood pressure and it gets to what is the measure. So
NQF has endorsed, I think, 130 over 80, I'm not sure. The blood pressure
measure. And just to give you an example in our recognition program, we
wanted to measure a good blood pressure control and a bad blood pressure
control. And so 130 over 80 was kind of the happy medium if you were
going to do one measure, you were going to report it out as a granular
measure, and it was for, you know, comparative purposes. But if you
wanted to measure \-- have a measure that sort of looked at sort of like
A1c, a good level, are you getting somewhere? And are you getting to
perfect control and you wanted to go to different values. Sometimes
measures are used as a stat and they\'re not used for granular
reporting. You're not going to report out one value, you're going to
look at it as a set. You're not going to look at whether everybody
passes them or not. I mean, I think all of those kinds of
implementations details can affect specifications for a measure, so it
gets really, really hard to say this is the measure that should be used
for all purposes and all settings regardless.

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

Kelly, this Josie and I\'ll have to weigh in, I guess. This is
exceedingly complex, and the more we\'ve dealt with this at PC I, and
trying to, one, gather measures both not only for reporting but also for
improvement, get measures that you can actually measure the data, and
that is get access to the data at this point. And doing that in a way in
which it clearly delineates the standards of care is extraordinarily
difficult, as this group knows. And I truly believe what someone earlier
had said, but I think we just don\'t have the state of the art to go
much further than where we are at the present time. Certainly
specifications around the way to collect the data, where to get the
data, how to collect that data, must be a part, I think, of what we
discuss and how we put out that criteria. And I do think we\'re going to
have to have the criteria. But I think that we\'ve got to be content
with the state of the science as it is today, as we begin to develop
that. And I think the continuation of the development of those measures
and the development of the ability to collect that data, specifically to
collect it in real-time that way, and collect it in a way where both
those folks looking at the measures and those people from whom we are
collecting the measures, will not get a lot further until we have that
point of care measure. If we have a point of care measure that now we
can look at from a number of directions, for a plan, for a payor, for a
patient, for performance improvement, but still it\'s a single point of
measure, which I think NQF's measurement sets, as they've been approved,
are getting us much closer to that standard, but until we get to that
point, I don\'t think we\'ll see a lot of improvement in the science of
measurement.

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

To build on that, and to respond to your point, Carolyn, do you have \--
and I think Josie just said it, does a measure have to specify what data
sources should be used? There\'s a whole bunch of characteristics that
need to be specified in order for something to be useful as a measure.
Without going to say that the characteristic has to be A, and B, and C.

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

Or should the specifications be flexible given how, what environment it
might be implemented in. So where this is electronic data more readily
available it could follow a certain specification but when its dependent
upon claims data it would need a different set of specifications.

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

I think that\'s where we are today.

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

Right.

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

I think the difficult part here is that the recommendation was meant to
be about how to increase alignment, really not about knowing the answer.
You know, so it could be different by a different measure, it could be
different by use, it could be different under a lot of different
scenarios, but how do we increase that dialog and alignment?

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

I think that\'s exactly right. And to that extent I think if we don\'t
have people or entities that are funding measure developments, we\'re
not going to get that kind of alignment, which again gets back to sort
of who is the subject of this sentence?

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

Right.

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

So on one level I think we see the end state and where this might reside
in terms of measures being approved and endorsed.

Backing up from that, and trying to figure out how much of this do we
take on and how much of it is kind of uniquely related to our work here
and how much of it is about where our work here has to align with what
others are doing and how to do that, is, I think, what we\'re struggling
with.

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

Let me just try a slightly different formulation. Is this about saying
what measures need to specify in order to be useful for the purposes of
the (indiscernible). Again, data sources would be an example. Measure
developers don\'t know that they need to think about data sources, or
data elements. I think there\'s certainly room to promote better
understanding of that.

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

I mean, even to have just a clear articulation of what the ideal would
be in the measure development process, so that you could give some
guidance out to measurement developers to say, well, moving forward this
is really what we\'re going to need to make this relevant and
implementable.

**[\>\> Margaret van Amringe:]{.underline}**

I think that\'s a good idea. This is Margaret, Kelly. Because I think
with all this said, we\'re just not at the point yet so what we need to
say maybe what the ideal state is and again, as I said before, I think
if we\'re successful with the first set of recommendations, then we\'ll
have something to provide as some kind of fodder for measure developers
to look at and try to align their work with. In terms of the data
element.

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

Maybe that\'s the best we can do at the moment.

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

I do think having heard Janet Corrigan present on this a couple of times
now that she\'s keenly aware of this issue, and I would strongly urge
that there be a conversation with her and others at the NQF, Helen, as
she comes up to speed on her very new job there, and others that will
help us figure out and describe perhaps in text what that transition
from current state to the longer-term is. Because my fear is that if we
describe what we can do right now without acknowledging the longer-term
goal of having it be housed at the NQF, that we\'ll never get there.

[**\>\> Margaret van Amringe:**]{.underline}

Yeah, and this is Margaret again. I was certainly not suggesting we were
going to describe just what we have now. Just to clarify that this is
kind of like the \-- we\'re describing the ideal state. As part of that
state, it seems to me that one aspect of it is that just as you said,
Nancy, when NQF provides guidance and perhaps criteria, to the field, as
to what makes an acceptable measure, that part of that includes this
very thing. The idea that the data can be automated and that it\'s
consistent with the data values that have been agreed on for other
measures.

But that\'s just one piece of it, I think. Because I don\'t think \-- I
mean, it would be great if everything that everyone did went through the
NQF. But we\'re certainly not there yet.

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

But I agree, we want to put that ideal state out there.

**[\>\> Margaret van Amringe:]{.underline}**

Exactly. And so I definitely think that the NQF should be part of that
conceptualization.

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

Right now measure developers have the luxury of not worrying about
whether things are easily coded, and therefore captured electronically.

**[\>\> Margaret van Amringe:]{.underline}**

Exactly.

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

And if we want to move to an electronic data capture state, that luxury
disappears.

**[\>\> Margaret van Amringe:]{.underline}**

Right.

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

Along with it, some of the richness of our quality measurement
activities. But that\'s a tradeoff.

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

I guess the issue I\'m struggling with is this. I have no doubt that
entrepreneurs will figure out how to solve this problem. Now, whether
they figure out how to solve it in a way that reflects the interests of
multiple stakeholders and that comes up with a transparent methodology,
I think, is an open question. So we could simply say we\'re going to
make a bland statement that data specifications are important and the
NQF\'s working on it and we think that\'s great. Or we could be more
concrete. And maybe this is not the right venue to do that. Because I
recognize that\'s also sensitive because lots of people have a very
strong interest and a track record here.

But I am a little worried that if we don\'t say much more than data
specs are important, that' the NQF's great, go Janet \-- I\'m being
hyperbolic just to be provocative here. We\'re not going to get very
far. And there are people right now who actually do this. They do it
more with claims data. But basically they say, okay, I want a robust set
of measures and I\'m going to go to HEDIS, I'm going to go to AQA, I'm
going to go to any place I can find them. And I\'m going to write them
off claims specs and if you have them, Phyllis, great. I\'m not paying
you for your algorithms, by the way, but I\'ll use whatever is in the
public domain and if I don\'t have it, I\'m going to make it up. And
what\'s driving it is the synergy of being able to collect the data. So
technically, this can be done. That\'s not a problem. What they come out
with is a black box on the other end and I don\'t think we get to
improvement if that\'s what we\'re doing because the problem with the
black box is you don\'t know what to fix.

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

The other thing, too, that this \-- this is Helen \-- that it reinforces
is this sort of individual action which then people turn around and say
either I don\'t want to move ahead because we have no certainty and it
could be a waste, or I\'ve got to move ahead and sort of get ahead of
the game and therefore I\'m going to win, and it in fact creates a group
of people who have already spent a lot of money and time and are
frustrated because it may be wasted.

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

Carolyn, to respond to your point, I think the suggestion of the group,
or the thrust of the conversation, was actually, in some way building on
the work in recommendation 1, that we could use the work in
recommendation 1, which is the expert panel, to then try to accomplish
recommendation 4, and to actually, ultimately be more specific in
recommendation 4.

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

(indiscernible)

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

As I look at it, I think Margaret said this first, in recommendation 1
we're sort of going to be going back and trying to look at current
measures and flushing them out, and to what degree can we identify, come
up with, tease out the information that is really needed to make them
collectable in electronic form, in an ongoing basis. And if we do that,
we can then specify that process, and say that's the process that should
be going forward on these measures.

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

I don't know that we can tell measure developers what process they need
to use, right? To what degree does the \--

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

To the extent that they're funded by HHS or other entities, they could
be encouraged.

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

Well, it seems to me our statement is to say in order to be collected in
a standardized way, using, making maximum use of electronic data, here's
what's necessary. We could then recommend to the NQF and, \-- that that
be incorporated potentially into their endorsement process.

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

Might there be a certification process for measure developers coming
down the pike? Because that's what we need, right? Something to feed
into.

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

There sure are a lot of issues. Thank you for that clarification,
because I recognize that I just stepped out of the room for an hour and
dove right in as if I hadn't missed even a minute. When indeed I had. I
think the way you framed that makes sense. What I'm not sure is, what's
the output? I am a little bit worried that if we don't have all the
right people in the room, including people funding measure developments,
today, we've got, actually, short-term needs to respond to legislation
and so forth, and I don't think anyone from CMS was able to join us
today, and if I'm wrong, people on the phone \-- Mike, you are on the
phone. Thank you. Thank you. That we're going to continue to have
multiple trails here, and I don't think we will have accomplished a
whole lot. I've heard Peggy speak before about shared leadership here,
and this feels like a real opportunity for that, and clearly this would
be of incredible importance, I think, to the AMA consortium, which has
to deal with a lot of physician organizations who are getting their feet
wet for the first time. Is that diplomatic enough, Josie?

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

Yeah, maybe.

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

You know, for whom this is new stuff. Boy, it would be nice to imagine
that at some point in the future not only has the NQF specified it,
because I am completely confident, and I should have said go Janet and
Helen, earlier \-- that they can specify that by next week, if they
haven't done it \-- it's in their heads already, that's not an issue.
That the issue is actually getting all the right folks involved, on whom
we now rely on for their legitimacy, right? Because after all, if a
measure comes to your committee and it looks good and I've got an
article, but there's not a guideline, or some physicians group who's
made a statement, an authoritative statement that says, yeah, we think
this is important, my guess is that it still isn't going to go terribly
far. So that's the kind of stuff I'm trying to float in the air. So
yeah, I think a lot of this can be folded into this expert panel and by
February 7th we're going to have a whole lot to tell you about what that
looks like, and options for you to consider. But I wonder what the
output is by that date, which Kelly told us is probably not July 31st,
but earlier than that. And we may not come up with an answer today. I'm
posing as many questions as actual solutions.

Mike, do you have anything to add? Or anyone else, I should say.

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

One way to think about output might be a template for what needs to
accompany a measure in order to accomplish the purposes that we've set.
And so that's what I think \--

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

If you keep it within the scope, if you were to say this is a template
of what would be required for a measure that could be automated.

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

Exactly. And perhaps make that template sensitive to different
environments, say we have three different hybrid models, under three
different scenarios of EHR adoption, versus network availability of labs
and meds, or claims only, or \--

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

That would actually be very reasonable. And not at the back end, which
is, oh, I didn't think about this, I thought about what was important.

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

Right.

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

But a template at the front end might actually be very useful.

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

If you're going to develop a measure, here's what you have to do.

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

Or at least also clearly delineate, separate out, put the onus on them
to at least separate out, when they know that they're using a data
element that either has no standard, and/or has no clear data collection
method, to call that out. Because a lot of times those don't emerge
until well past testing and into implementation, and then thousands of
people find out at once that there's no easy way to do that.

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

Right. And certainly some of the reorganization that's being done of the
measure development process at NQF, would actually support that template
work as well.

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

Oh, yes.

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

I mean, it fits in really beautifully to the way this is going to get
redesigned. So if there's a way to somehow make it such that there's a
role there, obviously not solo, but a role for NQF in helping to develop
that up front template, I think that would be really useful.

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

Oh, no, I think that is a given.

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

So would we want to have a physician organization sponsoring measure
development, along with other entities, other categories of measure
developers, weigh in on that? Along with people who would really
understand the technical requirements?

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

Yeah. And I'm not quite as clear, and Margaret or Nancy might want to
speak to this, or others, I know Margaret said some of her colleagues
are on the phone, Laura's here. I'm a little less clear about how this
works exactly, in the hospital world. But I do know from having sat on a
couple of NCQA panels that this legitimacy issue becomes very, very
important. At one point one of my panels thought we were going to do
something really groundbreaking, and the lack of a guideline really kind
of stopped it all in its tracks, and I don't think that's uncommon. But
I don't know what the counterpart is, on the hospital side, exactly.

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

All of the measures we have considered thus far have had to have a
substantive clinical literature backing up their impact on quality and
if not a guideline, at least some sort of tangible clinical consensus
that they are \--

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

They've all come from expert consensus panels of some sort. Which have
spent a great deal of time synthesizing the literature.

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

The heart measures and so forth do come from guidelines as well.

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

Yeah, but those guidelines also come from the work of expert panels as
well, so there's a lot behind them.

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

Right. And I would anticipate that that would continue.

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

Right. Okay. That's the point where you would love for these consensus
panels to have the thought ticking in the back of their brains, okay, we
think X is important, and the implications of our saying X is important
are that someone is going to want to measure X, so how would I do that?
Is this measurable? Because as Helen knows very well, actually, in real
life, the process is actually sometimes even more elementary than that
because a lot of the guidelines aren't operationalizable at all.

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

Right.

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

Doctor X should consider. That kind of stuff.

\[laughter\]

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

So, where are we on our agenda here? We're going to turn to the
visioning matrix, and I guess the question is how much of this
conversation is useful in sort of real-time, and how much would be
better to ask people for their comments, since we've had some additional
comments coming in last night, and we're going to be sharing a summary?

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

Yeah, I think that'd be great. Yeah. We will aim to get a summary out to
you all, I think over the next couple of days, and allow for you, for
some input. I think it's really going to reflect what we've already
agreed on in the matrix, so we don't expect any new ideas, or concepts
to be in that summary, but we just thought from a dissemination
perspective, it's going to be a lot easier for various people to read
it, and get the message.

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

Great, so we would very much look forward to your comments, and you can
count on e-mails from us and seriously we would very, very much welcome
them. They can either be embedded in documents that we send to you, they
can be rough little e-mails. However you are most comfortable works for
us. Which brings us to the last agenda item, an overview of
public/private measure automation efforts.

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

Yeah, I think \-- I'm sorry, I don't have that.

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

I think that's just what we attached, right?

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

Yeah, that was just the attachment.

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

Oh, I'm sorry. Never mind. I just made up a new agenda item.

\[laughter\]

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

Matt, I think we're ready for the public comments.

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

Okay. Folks following along on the Webcast will see a phone number up on
the screen now, and directions about what to do once you get through,
and if anyone's on the phone right now, press star 1 to get in the
queue. We'll wait about a minute for people to get through and after
that we will close the lines.

Nobody is calling in today.

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

We\'ve worn them all out.

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

Let me thank all of you for the comments and participation today. I
thought this was really a terrific discussion and in fact I actually
think it\'s a very good point that we didn\'t settle all of our issues,
and so we\'ll be bringing that back at our next meeting, which I do
believe is February 7th. And next time I will be following the right
agenda and not announcing a new agenda item. So we\'ll look forward to
seeing you then. But in the meantime we\'ll be looking for your comments
on the visioning matrix as well as the vision summary that you will
receive shortly, soon.

So again let me wish you a happy new year and thank you for the time
you\'ve invested with us. Take care.

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

Thank you.

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

Thank you.

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

Thank you, Carolyn.