######## [American Health Information Community]{.underline}

**Workgroup on Electronic Health Records**

**Summary of the Web Conference Held Wednesday, April 26, 2006**

######### (4^th^ Web Conference of This Workgroup)

+-----------------------------------------------------------------------+
| ##### Charges for the Electronic Health Record (EHR) Workgroup        |
|                                                                       |
| > **Broad Charge:** Make recommendations to the American Health       |
| > Information Community (the Community) on ways to achieve widespread |
| > adoption of certified EHRs, minimizing gaps in adoption among       |
| > providers.                                                          |
| >                                                                     |
| > **Specific Charge:** Make recommendations to the Community so that  |
| > within 1 year, standardized, widely available, and secure solutions |
| > for accessing current and historical laboratory results and         |
| > interpretations are deployed for clinical care by authorized        |
| > parties.                                                            |
+-----------------------------------------------------------------------+

# 1. Call to Order

Lillee Smith Gelinas welcomed everyone to the Web conference and noted
that the meeting would go from 10 a.m. to noon. She said that Dr. Robert
Kolodner would fill in for Dr. Jonathan Perlin for the first 30 minutes
of the meeting.

# [2.]{.smallcaps} Review of Call-in Procedures and FACA Guidelines -- Dr. Karen Bell, Office of the National Coordinator for Health Information Technology [(ONC)]{.smallcaps}

EHR Workgroup members were briefed on Web conference call-in procedures.
The EHR Workgroup is a committee subject to the requirements of the
Federal Advisory Committee Act (FACA), and Dr. Bell noted that input
from members of the public would be permitted at the end of the meeting.

# [3.]{.smallcaps} Introduction of Participants

Meeting participants were introduced. (See the list of participants at
end of this document.)

# [4.]{.smallcaps} Review and Acceptance of Minutes from March 21 Meeting -- Ms. Gelinas 

The minutes of March 21, 2006, Web conference of the EHR Workgroup,
which were mailed to Workgroup members on April 6, 2006, were accepted
as presented.

**\*New charge for the EHR Workgroup from the Department of Health and
Human Services (DHHS) Secretary**

Ms. Gelinas asked Dr. Bell to describe the additional task that DHHS
Secretary Leavitt had added to the EHR Workgroup's broad and specific
charges. Dr. Bell explained that Secretary Leavitt had requested that
the EHR Workgroup develop recommendations on how to ensure that first
responders responding to a disaster or emergency situation, such as
Hurricane Katrina, can obtain the critical health information they need
electronically. The EHR Workgroup should have recommendations on its
general approach and direction with respect to this charge at the May 16
meeting of he Community.

# 5. Review and Discussion of the EHR Workgroup's Draft Recommendations for the Workgroup's Specific Charge Related to Electronic Lab Results -- Dr. Bell

One of the most important goals of this Web conference, Ms. Gelinas
said, was for the EHR Workgroup to develop a consensus around the
content and wording of the Workgroup's recommendations related to the
Workgroup's specific charge -- the deployment within 1 year of
"standardized, widely available, and secure solutions for accessing
current and historical laboratory results and interpretations."

EHR Workgroup members were given a copy of a letter to Secretary Leavitt
with draft recommendations from the EHR Workgroup to review. Ms. Gelinas
noted that an effort should be made at this meeting to do the following:

-   Refine the EHR Workgroup's recommendations to be very clear and
    concise. Consider feasibility and inclusiveness.

-   Pay particular attention to "whom," both public and private
    entities, the recommendations are calling to action.

-   Ensure recommendation and responsible entity alignment. Merge
    similar/supporting recommendations to eliminate redundancy. (Ms.
    Gelinas suggested including a one-page executive summary.)

-   Prioritize recommendations for the Community's consideration.

Dr. Bell said she hoped that the discussion at this Web conference would
go fairly smoothly because of the many hours of work and effort to
develop the draft recommendations. She noted that the ONC staff would
modify the recommendations to incorporate the suggestions made at this
conference and would continue to revise and seek EHR Workgroup members'
comments over the next several days leading up to the EHR Workgroup's
next Web conference on May 2.

**ACTION:** The ONC staff will send the modified versions of the
recommendations to the Community with EHR Workgroup members for review
and comment and additional revisions prior to the EHR Workgroup's next
meeting on May 2, 2006.

## A. Recommendations for Reporting Lab Results: Central Focus

***Recommendation 1.0:*** The ultimate goal, "pure vision" is
patient-centered electronic laboratory results, with a recognition that
there is an evolutionary path from current business practices toward
that goal. ONC, in addressing the specific charge to the EHR/Lab
Workgroup, shall ensure that electronic laboratory data is transmissible
in a patient-centric environment, permitting all laboratory results on a
specific patient to be available to all authorized providers of care.

**Questions for discussion:**

1.  What other stakeholders in addition to ONC can ensure lab result
    data are available in a patient-centric manner?

2.  How can we broaden the "who" responsible for achieving the
    breakthrough?

##### Discussion

Mr.Houston said that Recommendation 1.0 seemed more like the charge of
the EHR Workgroup than a recommendation. Dr. Bell explained that the EHR
Workgroup's specific charge is to ensure that historical lab results and
interpretations are available and that, in order for ONC to ensure that
attention to the flow of historical lab information is a top priority
for contractors so the work can be done in the first year, there must be
a recommendation to he Community and then to the Secretary.

Mr. DuBois, although agreeing that the "pure vision" of patient-centric
electronic lab results is the end goal, stated that getting this
recommendation fully implemented as part of the EHR Workgroup's specific
charge in a year is unrealistic. Although a couple of commercial labs
might be able to get patient-centric results, provided the resources
were available, these labs are the exception. With no agreement on
standards, test names, descriptors, etc., it is going to be complex and
expensive to get to patient-centric electronic lab results.

Ms. Pure added that even if all the recommendations in the letter to the
Secretary Leavitt were implemented, nothing would change in a year.
Recommendation 1.0, as written, could be interpreted only as patient
centric. She thought the EHR Workgroup was going to try to chunk things
up within a year. She believes that the effort will have to begin with a
provider-centric focus and that it will take years to get to a
patient-centric focus. She does not want to focus so much on the end
state that opportunities for some short-term progress are missed.

Dr. Jim Sorace observed that Recommendation 1.0 as written did attempt
to recognize an evolutionary path. He believes it is important to state
the ultimate goal so that we know that incremental steps to foster
adoption and lower costs of interfaces will feed into something that is
patient centric.

Mr. Dubois recommended adding the following as stakeholders other than
ONC that can ensure that lab result data are available in a
patient-centric manner: ONC contractors, the [Healthcare Information
Technology Standards
Panel](http://www.ansi.org/standards_activities/standards_boards_panels/hisb/hitsp.aspx?menuid=3)
(HITSP), the Centers for Medicare and Medicaid Services (CMS), Congress,
and State governments. He noted that each of these has a role to play to
make this recommendation a reality, because of the barriers posed by the
Clinical Laboratory Improvement Amendments of 1988 (CLIA) and State
privacy laws and regulations that present a barrier to the exchange of
information by labs.

**DECISION/ACTION:** The ONC staff and EHR Workgroup members will
wordsmith Recommendation 1.0 to make it clearer that patient-centric
electronic laboratory results is a goal rather than something that can
be fully realized in a year. ONC contractors, HITSP, CMS, Congress, and
State governments will be identified as stakeholders in implementing the
recommendation.

## B. Recommendations for Reporting Lab Results: Standards

***Recommendation 2.0:*** HITSP should identify and endorse vocabulary,
messaging, and implementation standards for reporting the most commonly
used laboratory test results by September of 2006 so as to be included
in the Certification Commission for Healthcare Information Technology
(CCHIT) interoperability certification.

***Recommendation 2.1:*** ONC, in addressing the role of standards to
facilitate the exchange of electronic laboratory data, HITSP should
recognize and actively promote adoption of those standards endorsed by
HITSP as the basis for vocabulary, messaging, and implementation
guidance for electronic transmission of laboratory test results.

***Recommendation 2.2:*** In carrying out their work, HITSP must
consider CLIA options and Health Insurance Portability and
Accountability Act (HIPAA) regulatory requirements.

**Questions for discussion:**

1.  Can Recommendation 2.2 be included in 2.0?

2.  For Recommendation 2.1, which stakeholders would be targeted for the
    promoted standards use: laboratories, purchasers, CCHIT?

3.  Who are the responsible entities for achieving the breakthrough?

##### Discussion 

Dr. Kolodner made the following comments with respect to the questions
posed:

-   Recommendations 2.0 and 2.2, both of which address HITSP's selection
    of standards for electronic lab information could be combined.

-   In Recommendation 2.1, the following additional implementers should
    be added: payers, providers, patients, and commercial labs.

Ms. Laubenthal made the following comments with respect to the questions
posed:

-   Recommendations 2.0 and 2.2 could be combined.

-   In Recommendation 2.1, include EHR vendors as entities targeted for
    use of HITSP standards, because not just the senders of electronic
    lab results but also the receivers of such results will have to
    adopt the standards.

Mr. DuBois made the following comments:

-   Recommendations 2.0 and 2.2 could be combined.

-   In Recommendation 2.1, include hospital, commercial, and physician
    office laboratories as entities targeted for use of HITSP standards.

-   One question is how HISTP standards will be implemented. CCHIT,
    which certifies vendor products, is an important promoter, and once
    standards are recommended by HITSP, the two parties might marry
    their standards. The Federal Government might encourage the adoption
    of standards through the Consolidated Health Informatics initiative.
    Having the Department of Veterans Affairs (VA), the DHHS, etc. adopt
    the standards could encourage adoption within the private market.
    Howard Isenstein agreed that having a huge swath of the Federal
    Government adopt HITSP standards would encourage adoption and that
    this should be included in the recommendations. Dr. Bell suggested
    that perhaps the language about procurement powers and purchasing
    powers of the Federal Government in the introductory language for
    this set of recommendations could be moved into the recommendations
    themselves.

Mr. Isenstein asked whether the Workgroup's recommendations should say
that ONC needs to talk to State legislators or governors. Mr. Houston
suggested that perhaps Recommendation 2.2 could be deleted, because it
is already addressed in Sections 3 and 4. Dr. Bell noted that
Recommendation 4.1 addresses legal constraints in State and Federal
laws, so some combining might be possible. Ms. Laubenthal emphasized
that HITSP must consider currently existing laws and regulations when
approving standards. Dr. Sorace added that HITSP should also consider
CLIA and Federal standards when approving standards.

Dr. Scott Young reported that the Agency for Healthcare Research and
Quality (AHRQ) and ONC are doing some work to try to identify what State
laws, regulations, and practices are to inform the discussion. Right
now, there is little understanding of how State laws interact with each
other and Federal privacy law, CLIA, Patriot Act, etc. Ms. Gelinas asked
whether this lack of understanding would preclude action in terms of
implementing EHRs. Dr. Sorace said probably not, because even though
State laws are very diverse, there could be interstate compacts. He
added, though, that there might be specific State laws that would make
it difficult to implement lab EHRs in specific States.

Ms. Gelinas suggested the possibility of involving the Southern
Governors' Association in helping to address any issues related to State
laws. The governors of those States are eager to help, because they
recognize that the hurricane season is only 40 days away, and the issue
of not being able to exchange information across State lines is going to
arise once again if there is a bad hurricane season.

Dr. Bell brought the discussion back to the recommendations on technical
standards of vocabulary, messaging, and implementation standards. She
said what she had heard so far is that we need to ensure that HITSP is
aware of CLIA, HIPAA, and any State laws that affect the technology when
doing the standards work. Mr. DuBois agreed that the issue of Federal
and State laws would be addressed in the discussion of the next set of
recommendations.

Dr. Blackford Middleton suggested that the recommendations specify the
year that interoperability standards for patient health information
should be available, namely 2007. Dr. Bell concurred that it would be
good to add language referring to the interoperability certification
process for 2007, noting that a roadmap that includes laboratory
interoperability for 2007 had been agreed upon by HITSP in just the past
week. Mr. Dubois reported that the implementation guide for EHR-Lab
Interoperability and Connectivity Standards (ELINCS) approved, as part
of CCHIT, EHR ambulatory certification. Once HITSP gets up and says same
thing, the recommendation will come to fruition. Ms. Gelinas asked for
ONC to post the information about the roadmap mentioned by Dr. Bell.

**ACTION:** ONC will post the information about the HITSP roadmap that
includes laboratory interoperability for 2007 for EHR Workgroup members.

**DECISION:** ONC staff and Workgroup members will combine
Recommendations 2.0 and 2.2. In Recommendation 2.1, several additional
entities will be added as stakeholders targeted for promoted standards
use. Language regarding ways that the Federal Government can help
incentivize adoption of HITSP-endorsed standards in the private sector
will be moved from the introductory language preceding the
recommendations into the body of a recommendation**.**

## C. Recommendations for Reporting Lab Results: CLIA/HIPAA Options 

***Recommendation 3.0:*** ONC, in addressing the specific charge to the
EHR/Lab Workgroup, will seek to address barriers to the flow of
laboratory result information from laboratories to persons or entities
other than the clinician ordering the test, when access to laboratory
results is needed by such persons or entities for legitimate purposes
such as disease management or chronic care improvement. Specifically,
ONC should seek to resolve those hurdles currently created by CLIA,
HIPAA, and State laws.

***Recommendation 3.1:*** ONC should work with the National Governors
Association and other State-based organizations to resolve variations in
"authorized persons" under various State clinical laboratory laws, as a
resource for clinical laboratories seeking to define access rights to
electronic laboratory data.

***Recommendation 3.2:*** CMS should publish CLIA guidance that
clarifies the broad definition of authorized parties.

**Questions for discussion:**

1.  How is Recommendation 3.0 different from Recommendations 3.1 and
    3.2?

2.  Should we consider broadening/redefining the stakeholders
    responsible for carrying out these recommendations?

##### Discussion 

Dr. Perlin joined the Web conference and suggested that perhaps
Recommendations 3.0, 3.1, and 3.2 might be merged. Mr. Houston agreed.
Mr. DuBois, on the other hand, said thought the recommendations
addressed different issues.

Mr. DuBois also said he thought that Recommendation 3.2, in relation to
CLIA, was a short-term solution to a long-term problem and that it would
be unlikely to resolve the barrier. He recommended including a stronger
statement about the needs of Federal preemption of the various State
privacy laws. Mr. Houston disagreed, stating that preemption is a much
longer-term issue and not practical to think about at this juncture. Mr.
DuBois countered that including a statement about the need for Federal
preemption would be analogous to including a patient-centric focus in
the first set of recommendations to help set the direction for future
efforts. Mr. Houston stated that if we do what we can regarding
authorizations and dealing with authorized parties, we avoid even having
to go down the preemption road.

Dr. Bell asked whether there was enough difference between ONC working
with the National Governors Association and other State-based
organizations, and Federal law or guidance around Federal laws, that the
EHR Workgroup could at least break this set of recommendations down into
two separate recommendations -- one recommendation specific to CLIA
guidance and HIPAA, and a second recommendation more specific to State
law. Dr. Houston said that he would need to see the language. Dr. Bell
said that ONC could work on this internally and get back to EHR
Workgroup members that evening with some alternatives for them to
provide feedback.

**ACTION:** The ONC staff will reword this set of three recommendations
to two new draft recommendations -- one recommendation specific to CLIA
guidance and HIPAA, and a second recommendation more specific to State
law -- for the EHR Workgroup's review later in the day.

Dr. Houston, referring to Recommendation 3.0, asked whether "disease
management or chronic care improvement" activities were intended to be
specific for individual patients or more generally for population
health. He noted that there is substantial concern among patients'
rights advocates about the generalized uses of information absent
patient authorization, so if it is for individual patients, that should
be noted to defuse potential opposition from patient's rights advocates
that could impede implementation of this recommendation. Dr. Perlin said
that he would not want to preclude broader uses of data for public
health purposes such as detecting emerging pathogens. Mr. Isenstein
suggested putting a period after "for legitimate purposes" and omitting
the words "disease management or chronic care improvement." His
suggestion was accepted.

**DECISION:** In Recommendation 3.0, put a period after "for legitimate
purposes."

In Recommendation 3.1, Ms. Laubenthal suggested an editorial change of
"State clinical laboratory laws" to "State laws." This change is needed
because a number of authorized persons are actually defined in the
medical licensing laws.

**DECISION:** In Recommendation 3.1, change "State clinical laboratory
laws" to State laws."

## D. Recommendations for Reporting Lab Results: Privacy and Security 

***Recommendation 4.0:*** ONC shall support the development of a
national authorization and authentication infrastructure for both
patients and health information technology systems users. At a minimum,
this system should allow patients to opt in or out of data sharing and
to designate a surrogate who could authorize access to their data.

***Recommendation 4.1:*** The Workgroup has noted that legal constraints
in HIPAA and State laws specify that labs can release data on patients
only to the provider who has ordered the test. To address these
constraints, the Workgroup recommends that ONC review State and Federal
laws so that polices can be developed to make them more consistent and
compatible with sharing laboratory data in a patient-centric manner.

***Recommendation 4.2:*** ONC should include in its contract with HITSP
incentives to develop or endorse a methodology to match an individual
patient to his or her information across multiple systems.

**Questions for discussion:**

1.  For Recommendation 4.1, who should be the primary responsible party
    for carrying out this recommendation?

2.  Which groups should carry out Recommendation 4.2: HITSP, the Health
    Information Security and Privacy Collaboration, others?

##### Discussion

Dr. Bell began the discussion by introducing two people who had joined
the Web conference: Jodie Daniel, the Director of the Office oft Policy
and Research in ONC, with a strong background inHIPAA, and Katy
Barr**,** the new Executive Director of the American Health Information
Community.

Noting that all four Workgroups were focusing on the same issues of
privacy and security, Dr. Bell proposed establishing a short-term ad hoc
Workgroup made up of members of the four existing Workgroups and experts
in privacy and security to develop recommendations to take the place of
separate recommendations on these topics by the four Workgroups (EHR,
Consumer Empowerment, Chronic Care, and Biosurveillance). The purpose of
the ad hoc workgroup on Privacy and Security would be to ensure that the
approaches to privacy and security issues recommended to the Community
and ultimately to Secretary Leavitt are harmonized and unambiguous.

Dr. Houston said he thought establishing an ad hoc workgroup on Privacy
and Security such as that proposed by Dr. Bell would be beneficial. He
also agreed to serve on such a Workgroup. In addition, he noted that the
National Committee on Vital and Health Statistics (NCVHS) is about to
release a document related to privacy in the national health information
network that will be of value to this proposed workgroup.

Mr. Isenstein said he supported Dr. Bell's proposal and agreed to serve
on an ad hoc workgroup on Privacy and Security. He suggested coming up
with the language for the recommendation and then holding a conference
call with all the Workgroups to review that language. Dr. Bell said that
the ONC staff could work through the logistics.

Dr. Perlin indicated that he supported Dr. Bell's proposal because it
would help to cross-fertilize and coordinate some of the recommendations
of the four Workgroups, thereby accomplishing one of the metatasks of
the Workgroups.

**DECISION:** The EHR Workgroup supports the idea of establishing an ad
hoc workgroup on Privacy and Security, with members from all four
workgroups and experts in privacy and security, to harmonize and
coordinate privacy and security recommendations to the Community and to
Secretary Leavitt. Dr. Houston and Mr. Isenstein will represent the EHR
Workgroup on the new ad hoc workgroup.

**ACTION:** The ONC staff will work on the logistics of establishing the
ad hoc workgroup on privacy and security.

Mr. Dubois identified two issues, with associated liability concerns,
that he would like the ad hoc workgroup on Privacy and Security to
address. First is the potential, in the absence of a unique patient
identifier, for mismatching patients with misspelled names, maiden
names, etc. The other is the idea of allowing patients to opt-in or
opt-out of data sharing; the reality is that patients may need to be
able to opt-in and opt-out on a treatment-by-treatment basis to protect
their privacy. Dr. Bell said that by the end of the day, she would have
a list of all the privacy and security issues that have come out of all
four of the Workgroups. She would share that list with members of the
EHR Workgroup so that they could see whether it captured all of the
issues they wanted addressed.

**ACTION:** By the end of the day, the ONC staff will share a list of
privacy and security issues that have come out of all four Workgroups so
that they can review it for accuracy and completeness before it is given
to the Ad Hoc Workgroup on Privacy and Security.

## E. Recommendations for Reporting Lab Results: Assessment, Monitoring, and Research

***Recommendation 5.0:*** AHRQ should develop a proposed study
methodology to measure the extent and effectiveness of the adoption of
the first stage of HITSP standards, as well as the adoption and
utilization of aggregated patient-centric data as they become available.

***Recommendation 5.1:*** AHRQ should research best practices in the
implementation and utilization of patient-centric laboratory data stores
and how to disseminate this knowledge.

**Question for discussion:**

1.  Are there additional areas that need to be assessed, monitored, or
    studied to achieve the goal of patient-centered laboratory results
    data availability?

##### Discussion

Dr. Bell had noted that Dr. Young and Dr. Middleton had to leave the Web
conference early and suggested that the EHR Workgroup consider the fifth
set of recommendations related to assessment, monitoring, and research,
but by the time the Workgroup got to these items, Dr. Young and Dr.
Middleton already had left. Dr. Bell said she would work with them
offline and share the results with Workgroup members online in the next
few days.

**ACTION:** The ONC staff and EHR Workgroup members will consult with
Dr. Middleton and Dr. Young offline on the issues and recommendations
pertaining to assessment, monitoring, and research and share the results
with Workgroup members online prior to the next EHR Workgroup meeting.

# 6. Timeline Discussion

The timeline for the EHR Workgroup is as follows:

-   Today: Finalize recommendations

-   Week of April 24: Workgroup completes and reviews recommendation
    letter

-   No later than May 1: Finalized recommendations available for
    distribution.

# 7. Review and Discuss Outstanding Issues and the Workgroup's New Charge

Ms. Gelinas introduced this session by explaining that the EHR Workgroup
should consider three outstanding issues that came up in comments from
EHR Workgroup members during the process of vetting the draft letter and
recommendations to the DHHS Secretary pertaining to the Workgroup's
specific charge:

-   Whether standardization of laboratory test ordering is necessary

-   How to address physician office lab equipment

-   What, if any, incentives are needed

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-   The DHHS Secretary's new charge for the Workgroup to ensure that
    critical information needed by first responders to people in a
    disaster or emergency situation is electronically available.

**Need for standardization of laboratory test ordering?** Dr. Bell
explained that the question is whether the EHR Workgroup needs to craft
a separate recommendation on the standardization of lab test ordering
(as opposed to reporting). Mr. DuBois reported that for ELINCS, a
decision was made to focus on standardizing lab results information and
to get that done right before moving on to standardizing lab test
ordering information. Dr. Bell asked whether the lack of standards for
lab test ordering would be a barrier to realizing the EHR Workgroup's
specific charge. Mr. Dubois said this would not be a barrier for the
realization of the specific charge, although the standardization of lab
test ordering would be part of the overall evolutionary efforts toward
the EHR Workgroup's broader charge. Dr. Bell said that she would not
include the standardization of lab test ordering in the EHR Workgroup's
recommendations to the Secretary Leavitt in May but would mention this
issue as part of the overall evolutionary process in the draft letter to
the Secretary.

**DECISION/ACTION:** The ONC staff will characterize the standardization
of lab test ordering as being part of evolutionary process toward
broader goals within the context of the EHR Workgroup's letter to the
Secretary Leavitt. There will not be a specific recommendation on this
topic from the EHR Workgroup at this time.

**Need to address physician office laboratory equipment?** Ms.
Laubenthal explained that there is a wide variety of physician offices
-- from 160-physician group practices that have complex, hospital-like
labs to solo practitioners that do everything manually and use only test
"kits" or systems (like pregnancy or occult blood kits). The question is
whether this issue should be addressed in the EHR Workgroup's
recommendations. Dr. Perlin said that if we reflect on what is doable in
a year, this is a place to make inroads by coming to some degree of
standardization and then approaching people to offer them consistency.
Dr. Sorace stated that the first thing is to get standards for reporting
a test to an EHR at all; the second thing is to think about how to roll
out LOINC and other codes by working with manufacturers. These are
longer-term issues, not issues that can be addressed in a year. Mr.
DuBois concurred. Dr. Bell said she would address this issue as part of
the evolutionary process in the letter to the DHHS Secretary.

**DECISION/ACTION:** The ONC staff will characterize the issue of
physician lab equipment as being part of evolutionary process toward
broader goals within the context of the of the EHR Workgroup's letter to
the Secretary Leavitt. There will not be a specific recommendation on
this topic from the EHR Workgroup at this time.

**Need for incentives?** Dr. Bell noted that one of the suggestions that
arose in the vetting process was that incentives be provided for labs,
providers, and patients. She asked, "Do Workgroup members think that
incentives are absolutely necessary for the adoption process to be
successful?" Several Workgroup members answered that incentives are
necessary. Ms. Gelinas said that if the EHR Workgroup makes
recommendations without incentives and adoption strategies, they are not
going to go anywhere. Ms. Laubenthal and Mr. DuBois agreed.

Dr. Perlin suggested that incentives should be provided for labs,
providers, and payers (rather than patients, as originally had been
suggested). Other Workgroup members agreed that this change was
appropriate.

Mr. DuBois noted that he previously had commented that there should be
incentives to both physicians and labs related to lab test ordering
(e.g., an add-on payment for physicians whose health requisition is
transmitted using ambulatory EHRs that incorporate HITSP-identified
standards -- labs would benefit indirectly from more accurate test
requisition, reduced administrative burdens, etc.). He suggested that
incentives might be similarly offered for lab test results (e.g.,
reimbursement to labs for sending information electronically to Medicare
disease management projects).

Dr. Bell explained that one of the suggestions that arose in the vetting
process that was listed in the materials handed out to EHR Workgroup
members was the following: "CMS should charter a group to do a full
analysis of the capital expenditure mapped to the market segment that
will reap the financial benefits." She suggested changing this to a
recommendation that somewhere within the DHHS, a full analysis be done
of the business case associated with the proposal. Then the EHR
Workgroup could recommend that the incentives related to adoption be
based on what is learned in the business case analysis. Workgroup
members agreed that this was a good idea. Dr. Bell said that the ONC
staff would draft a preliminary recommendation from the EHR Workgroup on
incentives and circulate it for review.

**DECISION/ACTION:** The ONC staff will draft a preliminary
recommendation from the EHR Workgroup on incentives for labs, providers,
and payers and circulate it for review. The recommendation will suggest
that the DHHS do a full analysis of the business case associated with
the EHR Workgroup's proposal for realizing its specific charge and that
incentives related to adoption be based on what is learned in the
business case analysis.

Finally, Mr. DuBois made a comment about the draft letter to Secretary
Leavitt from the EHR Workgroup that had been circulated. Noting that
without physician authorization or a law, labs are not permitted to
provide results to other entities, Mr. DuBois recommended rephrasing the
sentence in the second paragraph on page 3 (in bold italics) that says,
"Labs will only provide results to the ordering clinician" to say "labs
are legally obligated to provide results to the ordering clinician." Dr.
Bell agreed to fix this sentence and asked anyone else with comments on
the basic text to let ONC know, please.

**ACTION:** The ONC staff will modify the second paragraph of page 3 of
the letter to the DHHS Secretary to say, "Labs are legally obligated to
provide results to the ordering clinician."

**How should the EHR Workgroup approach its new charge related to
electronic health information for first responders?** Finally, the EHR
Workgroup discussed the new charge for the Workgroup from the DHHS
Secretary to ensure that the necessary health information that first
responders need when attending to people in a disaster or emergency
situation can be made available electronically.

Dr. Bell explained that the goal for the EHR Workgroup at this meeting
was to agree on an approach for addressing the new charge. Addressing
the charge, she suggested, involves two steps: (1) defining elements of
information (e.g., medications) that are critical for first responders
with appropriate input from public and professionals societies, and (2)
addressing the issues necessary to make that critical information
electronically available to first responders. She noted that Alicia
Bradford from ONC had put together a set of slides to facilitate the EHR
Workgroup's discussion of the topic.

Ms. Gelinas said she is particularly interested in this charge as a
native New Orleanian. She emphasized that this issue is very big for the
Gulf States, and with the next hurricane season nearly upon us, it is
essential to act quickly.

Dr. Perlin agreed that the issue of preparedness for the upcoming
hurricane season is very important and that the presentation from the
Southern Governors' Association had driven that point home. He also
reported on the experience of the VA Medical Center and the Armed Forces
Retirement Home in Washington, DC, both of which received Katrina
evacuees from the Gulf Coast. Having electronic records of health
history, medications, etc., for VA patients was extremely helpful, but
some of the veterans in the Armed Forces Retirement Home never had been
to a VA medical center, so they did not have electronic records. He
noted that a patient's prescription history gives a fair amount of
insight into a patient's health needs.

Dr. Bell noted that the EHR Workgroup could devote quite a bit of time
to this issue at the next Workgroup meeting on May 2 and come up with
some recommendations for May 16 Community meeting. She suggested that
the EHR Workgroup might invite representatives of first responders both
within and external to the Federal Government (e.g., the American
College of Emergency Room Physicians, the American Ambulance
Association) to help specify what critical elements of information
should be available to first responders in the event of a catastrophe or
emergency. This would enable the Workgroup to present the critical
elements of information to the Community on May 16 and to present
recommendations on how to make them available to first responders at a
subsequent meeting of The Community.

Ms. Gelinas said that in discussions in the private sector, the three
critical elements that have been discussed are (1) medication history,
(2) allergy history, and (3) major diseases (e.g., diabetes).

Dr. Perlin said that the elements laid out by Ms. Gelinas are probably
the most salient, adding that he would hope that the EHR Workgroup would
be able to get greater insight into and agreement on what medications,
allergies, and diseases are really the most useful as core elements. The
other piece of the charge, Dr. Perlin noted, is how to make the critical
information available this summer in real time. Dr. Bell indicated that
both these tasks should be addressed at the EHR Workgroup meeting on May
2.

**ACTION:** At its May 2, 2006, meeting, the EHR Workgroup will develop
recommendations for the core elements of information that should be
available to first responders and a process for making the critical
information to first responders this summer.

# 8. Public Comments

There were no public comments. The following e-mail address was left up
for half an hour to enable members of the public to send in any comments
they might have: <ehlthrecrods-wkg@hsrnet.com>.

# 9. Conclusion

Dr. Perlin and Ms. Gelinas thanked EHR Workgroup members for their
insights, recommendations, and hard work. They noted that Dr. David
Brailer has resigned as the National Coordinator for Health Information
Technology.. They thanked him for his leadership and said it was hard to
imagine that anyone could have had better vision and focus in getting
Workgroups together. Dr. Bell added that Dr. Brailer wanted very much to
be part of the next EHR Workgroup's call on Tuesday, May 2, at which the
Workgroup would sign off on the letter and recommendations to the
Secretary Leavitt and focus on the Workgroup's new charge related to
making critical health information electronically available to first
responders in a disaster or emergency.

**[Workgroup on Electronic Health Records Members]{.underline}**

# [and Designees Participating in the Web Conference]{.underline} 

Dr. Jonathan B. Perlin VA

Co-chair

Lillee Smith Gelinas Veterans Health Administration, Inc.

Co-chair

Dr. Karen Bell ONC/DHHS

Staff Co-chair

**Members:**

Jason DuBois (for Alan Mertz) American Clinical Laboratory Association

Linda Fischetti (Dr. Jonathan B. Perlin) VA

John Houston

Howard Isenstein (for Chip Kahn) American Federation of Hospitals

Dr. Rob Kolodner (Dr. Jonathan B. Perlin) VA

Connie Laubenthal (for John Tooker) American College of Physicians

Dr. Blackford Middleton Health Information and Management Systems
Society

Pam Pure McKesson Provider Technologies

Dr. Jim Sorace (for Barry Straube) CMS

Dr. Scott Young (for Carolyn Clancy) AHRQ

**Others:**

Kathryn Barr ONC/DHHS

Alicia Bradford ONC/DHHS

Jodi Daniel ONC/DHHS

Judith Yost Centers for Medicare and Medicaid Services

**Disclaimer**

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