American Health Information Community

Quality Workgroup Meeting #3

November 1, 2006

**Disclaimer**

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

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

Good afternoon to everyone and welcome to the third meeting of the
Quality Workgroup of the American Health Information Community. It\'s a
beautiful morning, or afternoon, in Washington, D.C. This is Judy
Sparrow and I want to remind you that all of these meetings are designed
to meet the requirements of the Federal Advisory Committee Act.
Therefore, they are broadcast over the Internet, recorded and
transcribed for anybody that misses the meeting live, they can go back
and see what has occurred. So therefore, as you speak, please speak
clearly and identify yourself as you\'re speaking so the transcribers
will know who to give the credit to.

One other note, no one except Workgroup members are allowed to talk
unless they\'re invited to do so. And at the end, the public will be
invited to chime in for any public comment they may have.

With that, you\'ll turn it over to you, Matt, to introduce people on the
phone and then I\'ll have the Workgroup members here in the room go
around and introduce themselves.

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

Okay, thanks, Judy. Calling in today, members of the Workgroup, we have
Jane Metzger from First Consulting Group. Susan Postal, from Hospital
Corporation of America. Chantal from American Hospital Association, I
believe here representing Nancy Foster here, is that correct?

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

That\'s correct.

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

Okay. Reed Tuckson from UnitedHealth Group. Jonathan Teich from Harvard
University. Mike Kazynski from Personnel Management is, I believe, here
representing Anne Easton, is that correct?

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

Correct.

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

Janet Corrigan, from the National Quality Forum. And Abby Block from
CMS. Are there members or designees for members who called in whose
names I did not just mention?

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

George Isham, HealthPartners.

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

(indiscernible), CMS.

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

Okay. And Judy already explained most of the procedures for today. Just
to repeat it one time for the members who are calling in on the phone,
please keep your phone muted when you\'re not speaking. And then when
you do make a comment, introduce yourself first so everybody following
along remotely can know who is speaking.

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

Thank you, Matt. And let me invite the members in the room to introduce
themselves.

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

Margaret, I\'m with the Joint Commission.

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

Ann Carson, from NCQA.

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

Charlene Underwood, Siemens Medical Solutions and HIMSS EHR Vendor
Association.

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

Okay. Kelly \--

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

Kelly Cronin with ONC. And I have here with me Dr. Mark Overhage.

**[\>\>\
]{.underline}**A second time for us now.

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

And Carolyn Clancy will be late joining us. And is Rick Stephens on the
phone yet?

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

No, we actually have Pam French from \-- is she going to be on as a
designee for Rick today?

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

Pam, did you want to make any opening remarks for Rick?

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

Not at this time. I think why don\'t we go ahead with the agenda?

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

All right. This is Kelly Cronin; I\'ll get us started today. I think
Carolyn will be joining us momentarily and I imagine Rick will be on the
call soon. But I think we have a great agenda today. As we mentioned in
previous meetings, we wanted to quickly progress into a visioning
exercise, realizing that we have a pretty significant broad charge ahead
of us, and even challenging specific charge. Yet we want to really sort
of lay out the total landscape, and try to understand our end goals of
the vision that we\'d like to realize based on this broad charge so that
we can start to organize a lot of our thinking in a way that will help
us reach some tangible progress over the next few years. In an effort to
get to that realization of our broad charge.

So in preparation for that, the one area that we really haven\'t covered
in our last few public meetings was data aggregation and data
stewardship, and I think there\'s been a lot of discussion on these
issues and AQA, and other organizations, who have been working
diligently in this space for a while.

So we thought before we embark on the visioning exercise, that it would
be particularly helpful to hear from George Isham who has been leading a
lot of the work on data aggregation and some of the initial conceptual
thinking on data stewardship, so if we could hear a presentation from
him on the AQA proposal, we\'ll get some good context to then take with
us as we hear from Mark Overhage, and Lynette Nilan, from the VA. On
their efforts on data aggregation.

But before we move on to the presenters, we plan to make note of the
fact that we did share the meeting summary in the last meeting and if no
one objects, we\'ll go ahead and approve those minutes.

Okay, we\'ll consider them approved, then. And with that, I\'ll turn it
over to Mark Overhage \-- I\'m sorry, George Isham.

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

Thanks a lot Kelly. Can you all hear me well?

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

Yes.

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

I am going to talk a little bit about the national health data
stewardship entity work that we\'ve been doing as part of the data
aggregation (indiscernible) of the AQA. If you go to the second slide
there, I\'ve got to cue the slides. There we go. Just a couple slides of
context, then I\'ll get right to the entity that we think needs to work
toward creating uniform rules and standards for the collection of
information.

So for reasons that the AQA was founded was because of multiple
measurement systems, (indiscernible) authorities, burdening physicians,
creating confusion (audio cutting out).

Next slide. Some of our goals \-- also uniform set of measures for
physician performance. Develop a union formed set of efficiency
measures; develop a model (indiscernible) data, which is the work that
our subgroup has been working on. Developing principles for reporting
information to providers and consumers. And then the second item that
(indiscernible) (audio garbled). That support performance measurement
and reporting. Next slide.

We\'ve endorsed data sharing and aggregation principles as a workgroup.
We\'ve recommended and designed for and questions to be answered by the
data aggregation pilots that have been established and we\'ve already
talked about that previously.

We\'ve endorsed the need for a national data stewardship entity, and we
have produced a document that describes that, which I will focus on in
the balance of my remarks. We\'ve endorsed a HIT subcommittee mission
and scope and principles for HIT, aggregation and endorsed
characteristics of an organization that could fulfill the
(indiscernible) of national data stewardship entity and I will also talk
about in the balance of my remarks.

Next slide. From now, there are two other handouts in addition to the
PowerPoint slide. One is a document titled the National Health Data
Steward, and that is a document that I will be talking about
(indiscernible) at this point and then there\'s a second called
Characteristics of the National Health Data Stewardship Entity and I\'ll
talk about that in a little bit.

But now focusing on the national data health steward, we recognize as a
group that there\'s a need for common standards and rules for health
data sharing and aggregation to support a national strategy for quality
measurement. And secondly, we very clearly recommend that a
public-private entity have primary responsibility for setting uniform
operating rules and standards for the sharing and aggregation of quality
and efficiency data used in both the public as well as the private
sectors, for the purpose of performance measurement and reporting.
Further, we think that rules and standards are essential for enabling
stakeholders to continuously improve quality and efficiency across the
country and to bring consistency to many regional and private and public
efforts.

Next slide. We think that the entity that would be created should
operate as a voluntary consensus for purposes of Section 12-D, of the
national technology and transfer and advancement act of 1995. We do,
however, feel that this particular entity, while setting rules and
standards for data aggregation, would by itself assume a direct role or
responsibility in data aggregation, and this is a pretty critical
recommendation, part of our recommendation.

So to step back from this series of slides, and this recommendation, we
think \-- we\'re recommending there be in a sense a nervous center, a
nervous system center to the system of collecting and aggregating data
across the country that would set these uniform rules and standards that
would reach across both the public and private sectors and would be a
major force in reducing the confusion, the unnecessarily duplicative
efforts, fragmented efforts that are going on, and create a consistency
to the national data and aggregation effort.

Next slide. The mission of this entity, this public-private entity,
would be to set uniform operating rules and standards for sharing and
aggregating public and private sector data on quality and efficiency,
offer guidance on implementation of such national operating rules and
standards, and provide a framework for collecting and aggregating \--
collecting, aggregating and analyzing data to afford a means of more
effective oversight of health for data analyses and reporting in the
United States.

Next slide. We, in terms of thinking through this, we actually came to
our conclusions and our recommendations, and then the Institute of
Medicine released its report on data reporting in just about this time
last year. And within that report, the Institute of Medicine suggested
the creation of an entity that is similar to what we\'re recommending.
So we actually paused, examined carefully that report, and in our
opinion, our proposal, while not as extensive and as highly developed as
the vision that the Institute of Medicine laid out for an entity
performing similar functions, we felt that our recommendations were
actually largely consistent with what the Institute of Medicine was
recommending. But a much more practical, direct and (indiscernible) kind
of recommendation in terms of creating this national data \-- national
health data stewardship entity. So I wanted to make sure that the folks
here were aware that we have taken a look at it, we actually created a
grid, which cross walked our recommendations with those of the IOM and
we think it\'s largely consistent with that.

The Institute of Medicine vision is much more fully developed and much
broader than our own. Ours is more of a next direct step that could be
taken in order to get to that vision that the Institute of Medicine laid
out.

Next step. Some of the proposed steps of the recommended National Health
Institute are to be objective in its decision making, to weigh carefully
the views of its constituents in developing concepts and operating rules
and standards. To bring about needed changes. In a way that \-- ways
that minimizes disruption to current aggregation efforts. To review the
effects of past decisions and interpret, amend or replace operating
rules, standards and processes in a timely fashion, when such action is
indicated. And to follow an open, orderly process for setting policies,
rules, standards, that precludes placing any particular interest above
the interests of the many stakeholders that would rely upon health care
information.

Next slide. I realized when I created this slide that it might be not
playing to the strengths of PowerPoint, because what I\'ve done here is
in one slide cover the section of our document that talks about the
scope of work. Just look at it, it would look like number one, data
aggregation is suggesting that this entity be involved in that. But
that\'s not the case. As I indicated before, we don\'t believe the
entity should have a direct role or responsibility for actually
collecting the data itself. But rather set the rules and procedures and
so forth that relate to data aggregation. These nine scope items that
talk about scope of work are more fully detailed in the document that I
\-- that accompanies these materials and I won\'t go through them in any
further detail here.

Next slide. Now, shifting gears a little bit, to the characteristics of
the entity or the particular organization that ought to be created, or
that exists, that might fulfill this role that we\'ve laid out, we
recently, just as recently as I think last week, brought to the full AQA
alliance, recommendations on characteristics of an entity that might
serve that purpose, with the idea that we ought to begin to identify
candidate organizations and make a recommendation as to an entity that
might fulfill this role so we can move this idea forward.

So beginning on this slide, are some of the characteristics that we
thought might apply to selecting that entity. Should be objective,
independent, knowledgeable, and responsive \-- next slide.

Trustworthy. Adaptable. Transparent. Timely. Collaborative, and it
should be a sustainable organization.

Next slide. In terms of a process for determining which \-- which
organization might fulfill this role, we initially actually started some
preliminary interviews of nominated organizations to ascertain how each
might exemplify the characteristics that we\'ve just gone through. We
realized, as we were going through this process, that that wasn\'t as
robust or as open a process as we felt was necessary in terms of making
an appropriate recommendation. So therefore we recommended to the AQA
last week, and they agreed, that we use a broader more formal method
that will allow any interested entity to respond to a RFI or RFP, with
respect to fulfilling the role of national data stewardship entity.

So we believe this RFP or RFI process which we have yet to design would
help gather the necessary information about funding, and contract
requirements needed to serve and fulfill this important role.

Next slide, please. So that\'s about where we are in the process. Our
goals for 2007 include determining what entities could serve in this
role through a formal application process, which we need to design. And
some other things on this slide that relate to other aspects of our
program in data aggregation and strategy.

Next slide. And this is my concluding slide. And this slide indicates in
our document, in our data entity document, that we recognize there\'s a
workgroup, the wide range and large number of activities that are
currently being undertaken in this and related area, including when we
wrote the document, the AHIC, and that the public-private entity to be
considered would need to be considered as an integral component of a
broad quality strategy to advance health data exchange and use. So we
are recognizing that our recommendations need to fit into actually the
main purpose for this Workgroup, this Quality Workgroup of the AHIC.
This is to discuss the relationship of this to the standards for HIT,
and to further advance the right kind of infrastructure to enable
quality to develop across the country.

So I hope this discussion, this overview and these documents, give you
some idea at least of the thinking that we\'ve put into this issue over
the past year. And I hope it serves as a good base for conversation
about this role as we look toward the visioning process. With that,
I\'ll turn it back to Kelly.

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

Thanks, George. That was an excellent overview. I think we have some
questions in the room here. So Margaret has one to start off with.

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

Thank you, George. It was a very good overview. I was just wondering, I
was unable to make your last Workgroup meeting and I was wondering, has
there been any discussion that perhaps such a group does not exist today
and that it might have to be formed de novo so the process might not
even identify any? I\'m curious about that.

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

Over the course of our conversation, that certainly has been a
possibility. In former presentations of this, I\'ve always talked about
this as being the creation of or the \-- or the selection of an existing
entity. So that certainly is a possibility. I think as we begin to think
through what process we\'ll actually go through to find an existing such
entity, we thought that why \-- a process to inform us as to whether or
not there is an entity that could serve the role. If we can select that
or make that judgment, but if there isn\'t, obviously then the
recommendation would be that one would have to be created.

We\'re also quite cognizant of the fact there are already a plethora of
quality organizations with related functions, and it would be nice if we
didn\'t have to create a new entity. So I think that probably reflects
the conversation the Workgroup had.

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

And George, this is Kelly. When I was involved in the Data Aggregation
Workgroup last year, I remember us talking about a proposal to have this
be federally authorized and to perhaps model the Federal accounting
standard board, and I know the thinking has evolved since then, so I
just wondered if you have a comment on whether or not those are still
relevant.

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

Well, we\'ve certainly had discussions about that. We do think that it
needs to be a public process, needs to have that consistency with that
Federal law that I mentioned earlier. But we\'ve made no firm decisions
about the implications. I\'m probably not the right person in terms of
the legal implications of these various structures to make further
comment upon the appropriateness of it.

But we\'ve really not had further conversation about how consistent it
needs to be with that act. I mean, I don\'t know if I can say much more
than that at this point.

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

Go ahead.

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

Hi, this is Jonathan Teich. George, just to clarify, and thank you for
the presentation. Is it at the current status that there is
consideration of going forward with an RFP, or there actually is one
going to come out? And if so, when is that? Like to know sort of what
the next step timetable is.

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

Now that we have approval of the general direction that I\'ve indicated,
as a Workgroup, we need to meet and figure out what we need to take in
order to design that and get it \-- (indiscernible) approval of what it
should look like, and then get it issued and get it out. So we don\'t
have a firm timetable at this point. That\'s actually the next thing we
need to do as a Workgroup at our next meeting, is to establish that work
plan for the coming year in order to get this done.

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

Thanks very much.

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

Charlene Underwood. Appreciate the presentation, George. I have two
questions, actually a question and a comment. What is your thinking in
terms of who makes up the constituency of public and private? Have you
done any thinking on that?

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

Other than it needs to be broadly instituted. Not specifically, we
haven\'t done any thinking about that. On the public side, it definitely
needs to be represented \-- representative of all the public entities
that might have an interest in these standards. And on the private side,
it needs to be, as well, very broadly constituted. But specifically, no,
we haven\'t taken it to that next step.

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

George, I\'m sure you\'ve done some thinking \-- this is Josie, I\'m
sorry. You\'ve done some thinking how you\'re going to organize that and
how it would come out. Can you give any more insight into that?

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

What I\'ve presented here is where we are. You know, there\'s nothing up
my sleeve, nothing under the covers.

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

I\'m just thinking about all the logistics and how that would play, and
it seems to me that it\'s a massive undertaking. And I just wondered
what your thoughts are about that, and if the RFP is coming out --

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

I think, we have, Josie, when I think about potential (indiscernible) of
the organizations, we have a number of them that handle this process in
a different kind \-- in different kinds of ways.

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

I think that was the issue I was thinking about I can think of a number
of entities that handle it, but all of them in somewhat different ways,
and how you would reconcile those is one of the things that was coming
to my mind and one of the questions I had.

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

Looking at the RFI process as being a process that will educate us as
members of the Workgroup as to the strengths and weaknesses of meeting
that characteristic, would be representative. And I suggest it will
educate us on this point as well as a number of other points.

Then actually with that education, inform how we put together the
details of how we feel about the strengths and weaknesses of existing
programs as part of existing entities, or if we get to the point where
we had to create a new entity, how we might \-- the part of that that
would address that issue.

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

This is Chantal at the American Hospital Association. Thank you, this is
interesting stuff. Just had a couple of questions. The RFP implies that
there\'s a business model that you all have thought about. Wonder if you
can shed some light on that. And also, in a national health data, is
pretty broad. Are you thinking this covers everything from health plans
through hospitals to physicians, or public health? What scope of health
data are you thinking?

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

Health data is the scope of health data that would be applicable to the
AQA alliance, the AQA and HQA alliance and so forth. This is meant as
the data aggregation model that would support the standard that have
been determined by the HQA, and AQA, you know, alliance, in a sense.

It also is a \-- as far as the data and the data types and so forth, it
includes all those data that might be necessary in order to support that
program as defined by the larger AQA/HQA alliance. So it\'s not meant to
be either limiting or expansive beyond that. The point of this, to set
standards and uniform rules and procedures, that carry out that agenda,
and so that would be \-- that would be how I would respond at least to
the second part of your question.

You want to repeat the first part of your question?

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

I was wondering about the business model.

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

The business model, again, is a challenge. And again, we want to make
sure that through the RFI part of the process that we begin to generate
conversation about that model might be created. We do not at this point
of developing the concept; have any specific business model in mind. But
we need to have one in order to make this happen eventually. So we need
to be informed about what the issues are in terms of business models for
creating and supporting this entity.

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

Great, thanks.

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

George, this is Helen Darling. Your presentation on the business model,
it seems to me we\'re spending certainly tens of millions if not
hundreds of millions of dollars right now on all of these measures. So
the business challenge is going to be how do we substitute the, if you
will, new entity for activities that already now being paid for one way
or another? And we ought to be able to resolve that.

**[\>\>\
]{.underline}**That\'s true, Helen. But, as you know as well as I, money
\-- existing money in one category \-- of that category (indiscernible).

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

Maybe the transparency will help us in that regard.

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

I would hope in looking at that comment, Helen, we would not be afraid
to invest a little in order to pry a little money out of some of those
other buckets and result in a total net lower cost for the existing
quality system in the country. But you know, the \-- one of the real
problems that we have finding a business model and funding model, is
that many of the existing models that are focused on supporting the
existing quality activities may not be compatible with this larger
vision of a coordinated focus activity that covers private and public
sectors and operates parsimoniously against a defined set of standards.
So how do we get the money to move from those pockets to this purpose is
of course maybe what the wisdom of this group had contribute to solving.

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

Well-said.

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

Charlene Underwood. Your last slide where you advocate working with
other entities and workgroups that are working on health data and
standardizing it, I support one of the pieces you may want to look at is
the new HITSP organization is standard and policy that harmonizes
standards, so that may be a model you would want to get some input from
as you\'re putting your RFI together.

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

That\'s a very good suggestion, I appreciate it.

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

This is Kelly Cronin. I wanted to offer a point of clarification too,
because I think that when we\'re all talking about standards, that can
mean many different things, and I think in the context of your
presentation, George, you talked about clinical standard meaning the
measures, but a lot of the standards that this entity could be setting
would be in fact policy, business, and maybe in some ways enabling the
clinical standards. But they\'re not actually the technical standards
that would enable the transmission of the data.

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

That\'s correct, and at some point we\'ve got to figure out how those
pieces come together, which I think is also one of the points of this
Workgroup, as I understand it, Kelly.

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

Right, yeah, I think that\'s right.

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

This is Margaret. Just a comment. I think \-- I really like the work
that your group has done. But however we move forward on this, I think
it\'s a critical area, because until we have the rules of the road
decided, and trust in the system of how data will be aggregated and who
has access, under what circumstances, et cetera, et cetera, it\'s a real
barrier to moving forward.

So these kinds of issues just need to be settled, you know, sooner than
later on the public policy agenda, I think.

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

Certainly there are more questions that are raised by our work than
answers that I can give you. But we need to catalog them carefully and
work our way through.

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

Yeah, I think also when we get into our vision discussion in a little
while; one of the aspects that\'s been raised by other workgroups and
talked about yesterday in the American Health Information Community is
the need for clear and practical policies around secondary uses. And
obviously that\'s front and center for us right now. Of but it also is
part of the scope of the stewardship entity and I guess one of the
things that might come out of your RFI process is whether or not this
stewardship entity would be interpreting current law, or would you be
sort of setting up some policies (indiscernible) taking it a step
further? Not that it wouldn\'t be compliant with current law, but it
might be perhaps offering the (indiscernible) that doesn\'t exist now.

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

That\'s a good point. And obviously, in terms of being consistent with
and offering clarity, interpretation of law and so forth, are areas in
which this entity could certainly be operating. On the other hand, on
the private side of, it it\'s going to be one of the operating in the
areas which encourage the private-sector (indiscernible) procedures to
be engaged in this work as well. So it\'s got to navigate that delegate
territory between being truly public and private. In my opinion, if
we\'re to gain the advantage of pooling these data sets according to
uniform standards for the purpose of getting real meaningful information
at the level of \-- at the granular level of practice where it occurs on
the ground and in many communities across the country.

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

I think that\'s critical. I really appreciate your bringing that up. I
just think that\'s one of the things that we have to pay attention to as
we go forward. And just the magnitude of it, I guess; a little mind
boggling.

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

Are there any other comments or questions? For George? Okay, great. Why
don\'t we move on and ask Mark Overhage to present on his experience
with the Indiana Health Information Exchange.

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

Good afternoon, everybody and thank you for the opportunity to be here.
I think that my goal anyway, or I think why I\'m here is to maybe share
a little bit about what we\'ve been learning as we\'ve been trying to
operationalize some of the things that Dr. Isham was just talking about.
And if you can go to the next slide, please.

The Indiana Health Information Exchange created about 3 years ago to
really focus on the vision that\'s shown here. And I just want to
highlight that the very first bullet, if you will, is to improve the
quality of care for a whole host of reasons that you all know well,
that\'s the place to start.

Next slide, please. The Health Information Exchange was created to
support these processes primarily within the State of Indiana. And in
this diagram you see, H. is representing hospitals, physician practices,
laboratory, and radiology centers, buried underneath the other dots. And
the point of that is just that we tend to think about this from the data
sources, not just coming from the providers of care the physician\'s
office but the pharmacies and where the data comes.

Next slide, please. The project I\'m going to describe this afternoon,
though, quality health first of Indiana is being launched first in the
Indianapolis metropolitan statistical area which is about 1.7 million
people, about 3,800 physicians right in the middle of the State,
including Indianapolis, IN.

On the slide that you\'re looking at now, if you could go forward again,
please, perfect. On the slide that the bar chart, what I was trying to
illustrate, each of these bars represents a kind of data that\'s
important for us to know about the first bar represents inpatient stays,
the second bar representing laboratory results. And the total height of
the bar representing all of the data that are out there. The different
bands, or different colored band in these help you see how many
different places that data comes from. It gets worse as you go to the
right, and you look at claims data on the far right, for example, from
payers and even after you get Medicare and Medicaid and Well Point, the
largest commercial payer in the world, I\'m still only up to 70 percent
of the claims data for the market. In part because there\'s a chunk of
uninsured, because there\'s nobody to send a claim to. And secondly,
because they\'re self-insured and all these other arrangements that make
it very challenging. Physician practices likewise, if you think the
hospitals and laboratories are bad, the physician practice bar goes down
to practices of 10. So 40 percent of the practices in the market, and
this is typical of the country, are less than 10 physicians. They don\'t
have infrastructure, they don\'t have time, and they don\'t have people.
And trying to do things in those practices directly is extremely
challenging.

So the take-away message from this slide is really just that the data
that \-- number one, that the data that exists out there is very
fragmented, in lots of different places. No surprise to most of the
people in this room, but it\'s important to note that because it takes
so much work to pull that together, that we believe you have to do that
once and then use it for many purposes.

The second take-away that I think is very important is that the fact
that so many physician practices are so small and they have so little
access to capital and so little access to infrastructure, that adoption
of electronic medical records is going to continue to be a tremendous
uphill battle, even with all the great work that the Federal Government
and others are doing to try to move that down the road.

And in fact I think one of the major barriers to making progress in this
area if we rely on that as the only way to get it done.

Next slide, please. So what we\'ve been doing is building a Health
Information Exchange. This is replacing the operator plugging together
people on telephone with wires where the Unix computer that switches
automatically. And the important principle for us is data reuse. Every
bit of data that we capture need to be used for every purpose we can
imagine, within constraints, I\'ll talk about in a moment, because it
costs so much to get it standardize it in a usable format. So services
for hospitals and physicians and public health and payers and so on.

Next slide. The important principle \-- oops. Got lost \-- on the
previous slide there\'s a lovely picture of a lock and key in the
middle. There we go. And we call this process negotiated access. But we
have all these different sources of data and we absolutely, absolutely
have to be sure that every source of data understands how their data
will be used, when, where, and by whom.

Now, that\'s an interesting undertaking when you have many uses of the
data and we\'ve been evolving a process for keeping them informed,
having a collaborative decision making process, but not one that gets
bogged down in the process, because you want to take advantage of that
data.

Next slide. Many of you have probably seen this next diagram, which is
from the Markle Foundation. Which is a model for how to do health
information exchange, one that we think works very well, where their
data sources on the right, like laboratories and so on. The patients\'
identity, the fact they have data, particular source is registered, if
you will, with the patient index on the top with the purple band. And
then when a patient presents at the left, care provider and needs care,
they can query that directory of patients and say where does the patient
have data? And then using clinical information standards such as those
being identified and, I don\'t know what the right word is, sanctioned
by HITSP can query and obtain that data.

And drill down on the data source bubble on the next slide, please. The
challenge of how to do this with without breaking the bank. How to keep
the barrier to entry low enough. The way we approach it, we captured
data directly from source systems and let\'s think of a hospital, for
example. They have a laboratory system, they have a pharmacy system,
they have an admission transfer system, transcription system, and
actually many, many others.

And so what we do is capture data directly from those sources, using as
close as we can to clinical information standards. Now, the reality are
despite the best efforts of everybody and vendors\' best intentions and
you don\'t always end up with pretty information come out of those for a
whole variety of reasons.

So what we do is we capture that, and I\'ve labeled here it here as
standardization and interface, we capture that and standardize the data
at that point as it\'s generated from those source systems. Laboratory
results, depend rate the message, it\'s close to standardized and
certainly in the format of the message, for example, but then the
standardization interface engine, how the data are reported hemoglobin
or stool culture and you know the (indiscernible) was isolated on that
particular assay, for example. And we store that in something we call
\-- an edge proxy. It\'s database that represents that institution or
that participants especially data. You do the same thing for physician
practices, commercial laboratories and so on.

Next slide. As you do that over and over, what you start to see is there
are on the right-hand side, those five boxes are intended to represent
different data sources like different hospitals or physician groups, for
example, and there are certain institutional, if you will,
interoperability components. Certain works that happens inside the
institution to make them interoperable, and then the edge proxies and
there\'s a very few things you need that are shared interoperability
components. Those things in the middle of the Markle cartoon to allow me
to find the right patient and then the standards and transport and so on
that let us move data in between them.

Next slide. The next slide primarily is to emphasize how important these
clinical data standards are. We\'ve been doing this about 13 years now
and without these standards for messaging and con at the present time;
we would be dead in the water. So we have tried to monitor and look
ahead to where the Federal Government and other groups are going and
anticipate what things they might end up adopting as national standard.
So that we wouldn\'t have to change too much. But we didn\'t want to
wait. I\'m sure all of you have heard the secretary talk about the
employer\'s hair being on fire and it\'s true. If you wait until you
know all the answers, you\'ll never get there.

Next slide. What this looks like from a \-- any data use standpoint, is
this. And the various contributors of data be those laboratories,
radiology centers, hospitals, public health, pharmacy benefits managers
and so on, or payers, like WellPoint, like Medicaid. Their data is
stored and represented in an edge proxy, linked together by these common
interoperability elements, the patient locator service or record locator
service, which we call the global patient index, common sets of
terminologies or concepts, and common ways to understand who providers
are, because providers, too, are identified in different ways and in all
these different data sources.

Next slide. So I\'m going to turn to \-- you can go to the next slide.
Quality health first, which we just launched this year actually and this
is probably the most exciting thing I\'ve been involved with in ten
years. I am just really psyched about this. And basically, the goal is
to bring information and financial resources to providers, starting with
primary care providers, so they can improve the quality of care they
deliver.

Next slide, please. And just rapidly move on to that because folks have
the other slide in front of them. This is based on the usual set of
principles and there\'s a very nice article, for example in the annals
of internal medicine, November 7 issue that describes principles for
these kind of pay per value programs and we subscribe to I think
essentially all of those is nicely laid out.

Next slide. Key to it, though, is bringing uniformity to the measures.
So the physicians aren\'t getting a report from eight different payers,
all with different measures and timings and so on. They all go in the
trash, I put them all there. And so by bringing together a large enough
bases of payers with a consistent set of measures and infrastructure, we
think we can succeed. And today we have payer participants including a
large Medicaid managed care organization that serves that market. We
also have Medicaid fee for service but that will be nonexistent in our
State after January. So \-- and plan provider HMO, Medicare through and
Dr. Isham mentioned the AQA pilot promise, the name changes daily, best
quality information for Medicare beneficiaries was the last one I heard
although I understand they\'ve evolved. And we also have a demonstration
project under the MMA section 646, that\'s going through MB clearance
now.

Well Point and a participant and a couple other national payers expect
this month. These represent an aggregate of 900,000 lives. So we\'re
over half of the lives in the market who we have serve active
participants from the payer side for.

Next slide. And we focus on, not just the claims data. I mentioned all
these payers because they\'re paying the bill, writing the checks for
the operating the infrastructure and delivering information as described
to clinicians. But the focus is on outcome. Not on \-- hemoglobin get
done but quality and also as was mentioned on the principles, on
incensing improvement, not just high achievement for a whole variety of
reasons.

If you go forward two slides, please, actually. So the way this works
mechanically, is that we have this \-- perfect. The shared information
instruction. There\'s a lovely animation you\'re all missing, but
that\'s okay. And what we do is we essentially identify a cohort of
patients who are eligible for particular criteria and we just ran, for
example, five of the AQA measures last month for the first time. All the
way through soups to nuts. And it first identifies cohort. For example,
all women who are below the age of 75 or whatever the metric is, and
that may be the cohort. For mammography.

We then use, it\'s a sort of a query language called care, which
essentially for each patient in that cohort says tell me about their
mammograms, tell me about the surgical procedures that they\'ve had,
either from claims data, hospital data, physician practice data,
whatever it might be, have they had a mastectomy, contraindications, for
example. That goes out to the global index and says where does this
patient have data. From there the query goes out to each of the places
where that patient has data, that edge proxy, that data is aggregated
that thing called the DA, called disperser aggregator, a lovely name and
aggregates that data back together and then the clinical decision logic
in the care query, yes, they got an appropriate mammogram, no, they did
or they\'re due next month. That is delivered into a quality reporting
database.

If you go to the next slide. That database is used in a variety of ways
and is updated on a \-- where our current process is a monthly process.
First of all, clinicians have access to their own data in real time and
this is the web-based access that they have to that. Where they can view
the sort of where they are in a global basis, so the left hand pie
chart, for example, shows the distribution of hemoglobin levels
including those folks who didn\'t have one that they can look at and
doesn\'t show up real well. But the boxes, they can drill down and see
the list of patients who fell into each of those criteria. And if you go
to the next slide, please.

Another way that we deliver the data to them is in the comparative
reporting reports time trending and these are done on a quarterly basis.
We\'re just doing this year so they don\'t have a lot of trend yet. But
the notion is on the left hand panel for a particular measure like
children with laryngitis, where are you in the community on this
measure? And where is the community on this measure? And so in the
second query, the community may have improved and you in fact may have
improved but not as much as the community did, so you\'re sort of
falling behind. Of this is just the where am I in the world kind of
view.

Next slide, please. On the next figure, is an example of how we try to
make this as actionable as possible for the clinicians. So turning those
reminders, the quality metrics into something actionable. Says for this
particular patient, here\'s some stuff you ought to think about, either
that\'s past due, coming due, might have been neglect. We always assume
we don\'t know all the answers and there\'s a mechanism for them to
feedback \-- we don\'t want to do that because X, Y, Z. But trying to
turn it into very actionable information, they can say I didn\'t realize
X. Or wow, it\'s been 8 months and I haven\'t rye assessed the
patient\'s cholesterol, those sorts of things.

So three tiers, if you will, on line get it whenever you want, but then
on a quarterly basis push to you, where are you in the community and on
a monthly basis, push to you, here\'s the list of patients who have
issues that maybe get some attention.

The data coming back to that is all the same data we use for all of
these other functions for clinical messaging to deliver results, for
public health reporting, and things of that nature. But in this
particular view of it, is using that same data, clinical and
administrative data to fill in the holes, to deliver even to physicians
who don\'t have EMR, clinical reminders, sort of registry type functions
about where they are in the world and we hope and the payers are putting
up money because they hope as we improve the quality or the 3- to 5-year
horizon they will see decreased out-year costs. And so are willing to
support this common infrastructure and by doing it in common, drive the
cost down and again reusing the data to a point where that\'s a
tolerable thing for them to do and the risk benefit ratio making that
investment today. Makes sense for them.

So that\'s all I had to contribute this afternoon. And I look forward to
the chance of this group, you heard from before, evolves their thinking
and so on, to sort of test what we\'re doing against that and make
improvements, adjustments and understand how to leverage that.

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

Thank you, Mark. That was an excellent presentation, and I think it
gives so much food for thought to how this could work. Not to be too
heavily dependent on claims data as we are now, but in the near term I
think we could be looking to more and more regions in the country as
they become more operational as Health Information Exchange and their
efforts mature. We could expect to see more merging of claims data with
clinical data. Even over probably the next 18 months. Give that\'s a
Nationwide Health Information Network, activities will be tending and
expanding into 2007. And since we\'re going to have a quality
measurement \'and reporting, but use case to direct a lot of the
efforts, I think we\'re hopefully going to be seeing efforts not as
mature as yours, but that it will really be good progress to start
combining various different data sources and using all this emerging
technology to really advance this whole area.

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

If I may add one note, Kelly \-- thank you. One of the things that we
have discovered even in the short year or so we\'ve been working on
this, and it won\'t be any surprise to the quality folks, but the
evolving data needs, it\'s he ongoing and if you try to proscribe day
one, here\'s the list of 22 things you need to answer the questions,
it\'s been hard to do that. And the fact you have all the data available
makes it easier to say let\'s adjust a little bit our measure and then
go forward. So this unpredictability of what data you will need makes
\-- has been really mitigated a lot by having the core data available
and just poll what you need. Never have it all, but \--

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

Right. I also thought just want to make one note before \-- I\'m sure a
lot of people have questions. Since the AQA has done so much good work
on conceptualizing what might need to be doing, there\'s a lot of new
challenges and new dynamics introduced in the world of Health
Information Exchange, where data sharing arrangements have already been
worked out contractually among partners and a Health Information
Exchange or RIO that\'s acting as a business associate. And to the
extent I think it was stewardship entity might be talking about how data
would be captured aggregated or analyzed and that\'s already been worked
out in some regions of the country, I just think that through the RFI
process, it would be helpful to understand that more fully. So that
whatever entity would be eventually funded to do that, they could build
off of the understanding of what\'s currently happening.

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

That\'s a very good point, Kelly.

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

I also wanted to recognize that I think Rick Stephens has joined us.

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

I have joined the call, yes, thanks. Apologize for being late.

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

We\'re still waiting on Carolyn, but we expect her any moment.

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

You guys are doing great. Let\'s just press on.

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

Okay. And I think Helen Darling has a question.

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

I actually have two. I want to be sure I remember them. You mention that
you might not have some data for self-insured claims. And I know that
since many times claims are paid for by an insurance company for
self-insured basis, I wondered, did you all try to get those claims and
they just balked, or have you not gone down that path?

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

It\'s a complicated world and for some payers, their business, we get
those claims but there are just hundreds and hundreds of little TPAs and
things like that even around our small market and it\'s been very
difficult to reach them all. And we\'ll keep working at it. But we\'re
down in the \-- the next largest payer in our market has 5 percent
market share Helen: That\'s a good lessen, because I think many of us
don\'t think about those thousands of the little ones that much. So we
need to put that on \-- another thing on the to-do list.

My second question would be, for anthem or any of the other payers, have
they thought about or begun to talk about or do any tier-ing based on
your data?

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

A very interesting question, about high performance networks or tiered
networks, the principle has been the model is to raise all boats and
partly we\'re starting with primary. In most markets there aren\'t
enough primary care doctors and that\'s only going to get worse. If you
look at it on a population basis and try to tier, it doesn\'t work
because there\'s no place to push the volume to. The high performance
docs can\'t accommodate any more patients than they have today. That has
not been a core part. Although the slippery slope and something that the
physicians are very anxious about.

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

And so maybe in \-- but as I recall, and correct me if I\'m wrong, in
the Indianapolis actually has a fair number of hospitals, and a lot of
capacity, so maybe they have not nearly enough primary care physicians,
but they may have plenty of hospitals. And I wonder if tier-ing on the
hospital would be a little more possible.

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

We\'ll have to see.

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

Not to put you on the spot.

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

No, no, I wouldn\'t anticipate it related to the market but who knows.

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

Good, thank you.

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

This is George. To your question. And I know that the Minnesota Data
Exchange, which operates a little differently than what we\'ve just
heard described, but collects and pools data in roughly the same way.
Some of the measures are similar to what we as an individual payer use,
to construct our tier-ing on quality as well as cost products. I believe
other payers as well use some of that kind of information, if not the
same information, to tier their own products. So I think that\'s a
possibility.

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

This is Margaret. I wanted to ask you, because I\'m very excited about
this (indiscernible) of your presentation. About the care query process,
if you could elaborate a little bit more on that. Is that coming from,
for example, a clinical practice guideline, or are you embedding some
kind of intelligent design with this system? Come out with the fact that
Charles Smith did not have a data blocker?

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

The care, it\'s a very old software system; registry institute developed
essentially a query language like SQL, that\'s designed and crafted for
clinical decision support. And so it embeds the reminder logic, the
guidelines and quality metrics, as logic or knowledge into that query.
So it says, if\' the last cholesterol was more than X months old, then
remind \-- that provides that.

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

Okay. One of the things I seem to \-- this with the model, maybe with
coming out with just that. It could get an issue that I think is going
to become increasingly important. And that is, as we start to aggregate
more and more data from different sources, including the data when we
get the personal health records, (indiscernible) as well. The amount of
information is going to be so vast that the clinician is going to have
to support through and it may be a task that\'s almost ominous. And so
\-- oh, my goodness, it\'s Halloween time again.

To the extent we can embed in these models some kind of intelligent
design that can summarize even the data and say, well, you\'re asking
for information that the patient, we\'re going to look at the last ten
blood pressures taken and put it into a chart and here\'s either
histogram or a normal chart so that pops right up at the time of care
because it\'s actually sorted through all the information intelligently
underneath. I can see this system having the infrastructure to do that
at some point.

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

It does at some level, and there are some challenges in doing that doing
around knowing when patients are getting care and so on, and we could
spend more time on that. You reminded me of a point very important to
make, and this is a process point and architecture point. But we live on
a monthly basis these reminders to clinicians and in January they hear
Mrs. Jones is overdue for a mammogram and February and March. Only in
April that the payer gets a measure that they generate a payment based
on so they\'ve had two or three shots at addressing it. If they want to,
so it\'s not a surprise. It\'s not a retrospective flap on the knuckles
you bad doctor. It\'s proactive, we\'re trying to help you here, you
know, you\'ve had a couple chances, if you have questions, ask them.
Okay. Still didn\'t do it.

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

Right, right.

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

Can I get a question?

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

Sure.

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

Mark, Jonathan Teich. How are you?

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

Jonathan who?

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

Great presentation. I think your next photograph will be sitting in
front of a server and not a bunch of books.

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

Good point.

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

The question I\'m sort of trying to tie together what you\'ve done and
some of the things George talked about. I spent a fair amount of hours
in the last year sort of looking at national data aggregation. And the
question really is how does one put together different types of
information? You\'ve had some work, you\'ve undoubtedly worked with a
variety of different systems trying to get them, in although there\'s in
some ways some homogeneity there as well on a national case when it\'s
not sort of locally driven, how does one take different source systems,
different EHRs and so on, and not only bring their data in, but have
some sort of semantic equivalency to it? I think the different
electronic records think of a smoking question in different ways, and
perhaps the way that you\'re going to do your quality measures are going
to be different based on things. So it seems like when you get these
systems and each system has to have some kind of translator to turn into
quality language, just without getting into too much detail, can you
comment and how this would expand to a wide variety of systems.

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

As usual, you\'re absolutely right, Jonathan about the challenges there
and just to make your example concrete, one system might say smoking,
yes/no and the other system say how many packs per day they smoke. Zero,
one, two, and the third say health behaviors, smoking, drinking,
whatever it is. And so how do you bring those together in a way and
there\'s a couple of answers. The first is, I am not willing to let
prosecution get in the way of moving forward. And so on certain of those
you say I\'m not going to get it today but I\'m going to forge ahead.
And smoking is a great example where that\'s a challenge. The other 80
percent I can move ahead on so I\'m not going to wait until I get that
all sorted out.

Because many, many things like medications and laboratories and things
like that, are much easier to deal with.

The second thing, as you describe, as you identify those that are
important and important driven not just by the quality improvement
efforts, but by clinical care issues and other uses of the data, you go
after those individual items and you do in that, like you say, in that
hand crafted, if you will, way, at the interoperability engine, fix
those, if you will, so that they\'re usable. You always drive from day
one to get as close to that as you can, but it is a very challenging
area, and is one that will dog us for many, many decades, I think.

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

Yeah, it seems like we may have to, this group or (indiscernible) will
have to define kind of a quality medical language we can ask vendors to
make their systems fit into that context in some way.

I think that\'s exactly our near term specific charge, starting with a
core set of measures. But they\'re really good points. And I do want to
emphasize your point as well, Mark. I think we have to live in a hybrid
or imperfect world. Without losing \-- without losing sight of the
importance of getting some momentum. But also not losing sight of the
fact we can do better than this in the long run.

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

Absolutely.

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

This is Reed. A question, just in terms of the economics. What does it
\-- what do you know, is your budget and what are you asking for, what
are the relevant contribution of issues today and where do you see it
going forward? Supposed to talk about data aggregation, but get into
other things always. The model we\'re using, again, IHEA is a not for
profit organization and we still have to pay our bills. But the model
that we\'re using is a per-member, per month, per fee, through the
payers, for this service. So the payers pay two things, per member, per
month fee to us and pay incentives to the physicians based on their
performance.

The per member per month fee to us, we started out and we made some
guesses, hopefully educated guesses, about our operational costs and we
pegged that at 30 cents to start out with. And we\'ll adjust it from
there, and there\'s a steering committee of the payers, of the
administrative committee that reviews the budgets and will help us
ensure that we keep that figure as low as possible.

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

So basically, I think I got, it let me make sure. A per member, per
month, all the financing is from the insurance companies?

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

Correct. And the rationale behind that is \-- and this is frankly a
grand experiment, a bet on their part, is betting on if we can drive the
quality sufficiently in the right direction, that over the three to
5-year time frame, they will see reduced utilization in things like
hospital admissions, and testing, they will see increased utilization of
certain things like medications, certain kinds of testing and so on.

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

And finally, do you know that the amount of money that you now are
budgeting now, per member per month, do you have a sense of whether that
number goes up or down based on more data coming in and the need to
manage the data and so forth, or do you think this is pretty level set?

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

It will go down some. The reason it doesn\'t go down a lot. There isn\'t
as big a scale factor as you might expect because of the bar chart I
showed. And every time you go to a different market, you have a whole
host of new data sources that you have to work through. So it goes down
on a \-- as you grow, but it doesn\'t go down on an exponential scale.
It goes down on more of a geometric scale.

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

Thank you. What does the aggregate come out to be per member, per month?
How much money does it

actually represent?

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

For the infrastructure costs?

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

Uh-huh.

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

You mean, so, well, you can do the math. 900,000 people, at 360 a year.

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

Thank you.

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

Yeah, can I clarify. Because you said just the insurers or does it
include Medicare and Medicaid?

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

Medicare, and Medicaid are insurers in my book.

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

I just wanted to make sure.

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

Absolutely.

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

Some people wouldn\'t \--

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

That\'s a very good point. Medicare is participating in the different
way through the 646 demonstration project and not by paying the \-- so
\--

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

But they\'re paying.

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

This gets into the nuance of the private payers are essentially front
loading and paying the up front expenses but Medicare is providing
larger incentives to the physicians, so the physicians are more
incentivized?

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

But they\'re paying, it\'s not just the insurance companies are paying.

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

Medicare is not contributing any operational support.

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

They\'re not paying today, Helen, but they need to pay in the future.

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

What about Medicaid?

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

Medicaid does (indiscernible).

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

This is Kelly Cronin. I also wanted to share some conversations that
were happening early last week that are relevant to what Mark presented.
The American Health Information Management Association, group in the
last 8 months or so, and these are nine States probably the most far
along in terms of getting some kind of statewide health information
exchange work together, either they\'re coordinating regional efforts or
trying to get some kind of infrastructure across their State, and they
produce some guiding principles to help these efforts along, but most
recently, actually a colleague of Mark\'s has been working on trying to
understand out of all these types of activities across the country, how
many of them are actually making money? And of those making money, what
are the most financially viable services to start off? And the early
results are showing that quality reporting, or quality measurement
reporting and the aggregation necessary for that is not a first out of
the box service.

While they think it\'s absolutely instrumental to drive their long-term
business plan, so their financial sustainability will be absolutely
dependable on making this work, it\'s complex and involves a fair amount
of ability to not only locate all of the data that\'s needed and
aggregate it, but then the sophistication with dealing with all the
analysis. So what has been a more common starting point is clinical
messaging where they\'re just reporting some results out to clinicians,
and that in that instance, the payers are not paying for that up front.
So there\'s a different type of business model that is developing based
upon the service that they\'re offering. But I think the two most
important things that we\'ve been hearing are that the quality part of
what they\'re doing is going to be absolutely instrumental to their
financial sustainability. And that it\'s going it take them probably a
couple years to be up and going to further able to offer that kind of
service.

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

I have a question as well, Carolyn. This is George. Follow up on who is
paying questions. Mark, how do the self-funded employers contribute to
the funding of this effort?

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

Again, this is the first year of this effort. Way it has worked this
year is essentially they\'ve gotten a tax on their fees. The TPA or
whatever tacks on their 2/10 of a percent or whatever it is.

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

On the administrative fee for the self-funded?

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

Correct.

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

So there is an explicit mechanism to bring them into the funding of this
as well?

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

Oh, yes.

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

I wanted that also \--

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

That\'s a good point.

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

I have two questions. Or Carolyn, I guess. One is, DHRs. To what extent
do you have people participating, providers participating who have the
DHRs? And to what extent do they have the capability for the kind of
decisions support type \-- which you\'ve shown us? And so where do you
see that going, are you going to be at a certain point on that end? Out
of business? In that regard?

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

I hope so because decision point at the point of care is the most
effective way to do it. I\'m just not willing to wait to get started
until then. Our market is pretty typical of the national market. Large
groups, larger than 40 or 50, have or are in the middle of deploying
EHRs that for primary care represents less than half of the market. The
second challenge, though, is even those that have deployed, only about
20 percent of those, and those are frankly all affiliated with a
particular practice, affiliated with regulatory institute has years of
doing this has any kind of clinical support I think that is going to be
years even behind deployment of EHRs. So I don\'t know whose numbers you
like, but some people say 50 percent EHR penetration by 2010, I don\'t
know if that\'s right or wrong. I think clinical decision support; this
level of sophistication will lag three to five years behind that.

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

I think that\'s a critical point, and I agree with it, George. This is
George.

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

Yeah, and I would also agree, Mark, this is Josie. And just what we have
found over the last two and a half years, just trying to get hospitals
and just get their claims data claim not it begin to mention all the
other data that we\'re trying to get them to get to, it will take at
least that long.

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

This is Jonathan and bear in mind that\'s a second function of this
committee at some point to try to work on how we can accelerate that.

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

Let me ask my second related question, which is \-- and you mentioned
the other potentially accountable entity which (indiscernible) a group,
IPA, some type of arrangement like that. To what extent do those exist?
And to what extent are they able to help with improving on the
information that you\'re giving? in respect \-- in respect that if
you\'re just looking at a physician to say order a test and giving
information back saying you haven\'t ordered a test for a while, maybe
you want to order a test. That\'s pretty straightforward for a physician
to follow up on.

If you\'re trying to achieve better control in a certain area,
particularly given the patient self-management component, which is not
at all straightforward, to what extent does an infrastructure exist to
help support that?

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

If what I hear, Bill, is the \-- so we brought the horse to water,
we\'ve brought information, data, and we\'ve brought some resources
dollars to the physician\'s doorstep and now how do we make sure they do
something worthwhile with that. And I\'ll give you a couple of level of
answers and we don\'t have a great answer, to be honest.

The first is physicians by and large are smart people that work hard and
have really \-- really want to deliver quality care. Of so I think
they\'re going to try their best to do so. That having been said, as you
say, many just don\'t have the resources, the knowledge and so on.

So we do not have a great structure to support that. The things that we
do have in place are one is obviously the QIOs in the community are
those part of the stated scope of work and they have been develop some
expertise in that. So there\'s one resource. The second is we have sort
of a community collaborative that is designed to help on a communitywide
basis implementing, so for example, in (indiscernible) inpatient to
date. But we have a common way to manage post-op hyperglycemia across
the entire community. The every doctor does at a time same way and doing
similar things in the ambulatory setting to try to say, okay, this big
group a Medical Director, they bring in consultants and figure something
out. They share with the other groups. And so we need some better
answers. So if you have any, we\'d be glad to learn.

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

I think the only thing I would say, to the extent that you\'ve got an
IPA medical group type infrastructure that has medical leadership in
some way, and possibly that includes a physician and nurse support.

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

Right.

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

Or some type of clinical support.

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

Certainly the medical groups, we see in the organized groups, we see
that. But again, that\'s half of the physicians.

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

And I think as Secretary Leavitt moves ahead with his vision to more of
these pilot sequences that we are going to be seeing more variation and
be able to learn empirically how people are handling this issue. And I
think there will be a nice map between where the QAs go for the scope of
work and what are come out of some of these communities. Indiana looks
different from California where you have a lot more folks \-- I\'m just
getting a little worried about time and using our time as efficiently as
possible. I\'d like to move to Lynn.

One quick comment in passing, one was to reinforce what Jonathan said a
few minutes ago that trying to balance or keep in our sight the split
screen, full, being able to automate the reporting but also be an able
to give some kind of feedback which we\'re loosely is calling clinical
support, which I don\'t think should be equated with some of the most
sophisticated support capacities. I think we can at least get to a
preliminary kind of feedback in something like a team-ly fashion so that
people can make improvements while we\'re on route to what Jonathan and
others can envision and the rest of us can only see in small glimpses.

With that, I\'d like to turn to Lynnette, am I saying that correctly?
You\'re not Lynnette.

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

It\'s NILAN. That\'s pretty close.

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

Okay, great. And you\'re going to tell us about VA.

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

Actually, I think the request to talk to this group got kind of passed
from person to person here as we all kind of dropped by the wayside,
we\'ve got several emergencies. So I probably have not got the level of
detail that you may want to hear about, but given the time restrictions,
I think we can probably just kind of do a high level, from based on what
I\'ve heard the other speakers talk about. I think the VA has the \--
I\'m going to say because I\'ve been here and it\'s my system, probably
the ultimate electronic record at this time. That has enabled us to
build aggregate databases that are quite advanced. It has been able to
provide our physicians with clinical reminders, roll-ups, decision
points, and what I\'d like to do is kind of give you an example of how
we build that.

So one of the things that we do in addition to just the general everyday
medical care at the facility, the medical record, the package itself,
the electronic medical record captures all of the data except what is
\-- well, it also collects the written, the handwritten progress notes
that as everybody knows you can\'t reallying a gate and pull those up at
this point without some pretty expensive software that really isn\'t
working very well yet anyway.

So but as far as vital signs, dates, allergies, medications, labs,
radiology, we are able to capture the vast majority of that in data
fields that we can aggregate and roll up.

So as a physician in a clinic, these are a number of ways that I could
use, or the nurse practitioner or any provider in had one of the
clinics, or in the inpatient. These are some of the things I could do
with medical record there. I can look back and graph and chart in a
matter of about 10 seconds on the front page of my medical record, the
patient\'s last ten blood pressures, his last 15 hemoglobin A1C's. I can
pull up his actual radiology imaging and look at that. And what some of
this does and what this leads me to tell you about as far as aggregate,
that we are just now getting to the point, we probably initially when we
started out with our electronic medical records, we pretty much said to
each and every facility and there are about 150 of them out there and
about 800 clinics, 880 clinics to be exact, we pretty much told them,
you design it the way you want to use it at your facility because you
need to get your physicians and your medical \-- your team to use it as
a buy-in to it and to have it be valuable to them and a good tool that
they would want to use.

So in a way that was excellent because then all of the providers got to
get involved in it, they designed it, but on this end now, 10 years
later, we are now having some difficulty aggregating that data across
facilities and clinics. So what was called \-- how a hemoglobin A1C was
put into the computer and filed in one facility may not have been
standard across all of them. When we tried to roll that aggregate data
up to make decisions for performance purposes, we found that we had a
lot of trouble making sense out of that data.

We have over the last couple of years managed to standardize several of
our packages and we are rolling that up into a national health data
repository, which will be used for performance improvement, performance
management, research and any other number of things, also for
evaluations, in fact. But what has currently been standardized
nationally for that purpose are our vital signs, which includes all five
vital signs, pain, blood pressure, temp, all of those. Those do roll up
and we can aggregate those nationally. We can currently aggregate and
roll up our pharmacy, our laboratory, pretty much our radiology, and
I\'m thinking there\'s one other area. I\'m not pulling \-- oh, surgical
procedures, and that kind of thing.

So what we are able to do right now is to pull at least those kinds of
things. And one of the ways we\'ve been able to aggregate that in a
performance arena is that we built this last year, we built the \-- a
measure to look at (indiscernible) use in hypertensive, FY decides and
diuretics. We are now able to use that system to identify our patient,
identify our cohorts, and exclude patients with complications or risk
factors which we wish to exclude. Look for their medication, and then
also track back through however many years we want to, to find out if
the patients been on it, continuously, if he has second meds or multiple
therapy as opposed to single therapy. I think we\'re moving in it a
direction where we can do an enormous amount of information and an
enormous amount of data aggregation at the national level.

I think where we\'re still having problems is of course in those fields
such as the doctors\' notes and things that have to do with exceptions
and variations and those kinds of things. That you almost have to get
down into the nitty-gritty, the notes themselves, so delve into.

I think that\'s kinds of basically what I could give you as an overview.
I think probably if you want more detail into our actual system, some of
the detail that I\'ve heard from the other two speakers, I\'m sure at
one of your future meetings you could probably invite Tammy Z. or Kathy
F. or some of the effects who work on the real \-- the actual technical
aspects of this and they can probably give you manager information about
how it rolls up. But having said what I, did I think maybe we could just
go on for questions and what I could do is keep track of things that
you\'d like to know more about, and make sure I get someone in contact
with you for that kind of information.

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

That would be great. Questions for Lynnette?

(Captioner break)

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

There is actually a very standardized reporting system that we provide
them data every quarter and additional data that rolls up every month.
It depends upon the level of the measure. We have the VSSC, Veterans
Service Center, I can\'t remember what the other 'S', stands for, which
rolls up continuously, data every month and that is more the workload
kind of data and the clinic wait times and those kinds of things. More
the process sorts of things.

But every three months, every quarter, we roll up the clinical
aggregated data and report that back to the field.

At the current time we have about 101 performance measures that are all
clinically related and those go out every quarter at the (indiscernible)
and facility and at some cases the clinical level. And then we have also
another 300, what we call supporting indicators which give the
facilities and the providers additional level of information. So for
instance, we might have a measure that asks how many of their patients
have blood pressure that is greater than 160/100, or was not done, we
couldn\'t capture anywhere and we assume if we couldn\'t find it, it was
out of control. Supporting indicators would be how many were out of
control, how many were in fact not documented and how many of those were
systolic as opposed to diastolic they get that other level of
granularity if they want dig into it.

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

Do you give information back to the facility and it\'s up to the
facility to give it back to the providers the individuals in.

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

Actually, it\'s all posted on website so they can actually get it, but
as a general rule, I would bet the quality departments in certain
departments within each facility are the ones that are actually pulling
the data and providing it to them so they don\'t have to go looking for
it.

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

Thanks, that\'s helpful. I was curious, I heard about some facilities in
Cleveland that have a unique or certainly sounds unique and kind of
innovative approach to giving physicians monthly feedback.

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

A lot of people are giving monthly feedback on different levels of data.
And we in fact with the executive order are just now launches, the last
2 months have launched a massive effort to roll the data up, get the
national health data repository ready to go and focus on provider level
feedback.

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

That is terrific. Thank you. Are there questions from folks on the
phone? Notwithstanding the temperature in this room, how can you
complain if it\'s 70 degrees outside?

\[Laughter\]

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

It is a little bit warm in here.

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

Thank you for doing that Lynnette.

**[\>\>\
]{.underline}**Please invite someone back who can give you more
technical detail if you need more detail.

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

This was very helpful. Thank you. I\'m thrilled to hear you\'re marching
along executive exported anticipating what\'s coming next there.

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

That\'s a huge effort on that right now.

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

Thank you for inviting me.

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

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

A pleasure.

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

I guess we\'re ready to move on to visioning. Kelly, do you want to give
us a little context to this? I\'m going to put you on the spot with some
questions later on. So not entirely passive exercise. People on the
phone can heave a few sighs of relief.

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

As we talked about previous meetings, the four other original workgroups
under AHIC have gone through this visioning exercise and it was intended
to be helpful to them as they got into their broad charges, many of them
which are fairly daunting, trying to predict what a future might hold
when there\'s a lot of uncertainty. But because there are so many
uncertainties, and many different paths you could take, I think it ended
up being a very helpful process in particular for the groups that were
taking on very new innovative areas, like widespread adoption of
longitudinal consumer-centric personal health record. Or how to be
linking public health and clinical care to enable real-time response
suspect public health surveillance. Those are areas there\'s an awful
lot to brainstorm around to figure out what the world could look like in
an ideal situation. And since we also have a really challenging broad
charge, the hope is this exercise could be helpful to us to have a group
make around what the world could look like if we had the kind of
clinical physician support at the point of care that will really enable
evidence-based medicine that we could also have completely streamlined
process for a capturing data at the point of care and then enabling it
to be exported or aggregated and analyzed and then reported back to
clinicians and the public as appropriate, without being burdensome to
anyone in that process.

And then also as a part of the broad charge, trying to figure out how we
might be able to have that information then inform how future measures
could be developed so that the quality community can be really in touch
with what HIT will enable for them. So when it comes down to figuring
out whether we can advance new measures or develops new measures that
may be more patient centric and perhaps move away from process. That we
\-- the IT requirements can be built in to enable that as well.

So all of that is very forward looking, but since Carolyn and many
others have noted that there\'s a long way to go, and a lot of ambition
to get there as fast as we can and real urgency from the purchaser and
payer perspective in particular, the hope is that we can first start on
trying to agree on what we think an ideal world would look like,
according to our broad charge. And then work back from that. The sort of
reality-based and remind ourselves where we are right now. What we\'re
missing, what we don\'t have. And then really think through what are the
sets of enablers and barriers in the way of policies and the way of
resources, and the way of speaker immediataries. Technology development,
whatever it might be, really think through all those issues in a
critical way so that we can be realistically be saying how far can we
get in the next few years to reach a mid-stage. Recognizing there
probably won\'t be one clear path, there lab lot of parallel efforts
given we\'re living in a world based on claims. But we will have an
emerging market for Health Information Exchange.

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

A little bit of background on what we tried to do over the last 2 weeks,
we took all the testimony we\'ve heard to date and a lot of the work
that AQA has already done in the way of data aggregation and data
stewardship, we also looked at IOM reports over the last year and a half
and tried to take from what we\'ve heard and what has already been
widely considered, to describe what that end state might look like and
we\'ve shared it with a few members and including Carolyn and
unfortunately did not get a chance to take into account the EHR Vendor
Association input that we just got yesterday, but we\'ll absolutely be
talking about that as we go forward.

But I wanted to let you know we did try to just provide a starting
place. This is not anywhere close to where we need to end up in a common
understanding, but it gives us some food for thought.

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

Great. So in terms of process, I think it might make sense to go through
what we have here and ask people in particular what\'s missing. Now, on
one level, I did make an executive strategic decision on your behalf, so
I can be honest about that right now. The question was whether we should
do this today or should it proceed right down the path with our specific
charge where we have to very quickly identify barriers and strategies to
move forward on automating this core set of measures. Now, on one level
that\'s straightforward, at least state something straightforward. The
devil will be in the details, of course.

I thought it would give us more context to imagine and to envision where
our efforts are helping us to get. You know, to imagine that end state,
otherwise it will be like that old joke, I think there might be \-- a
Yogi Berra, if this is a fork in the road, take it. If you don\'t know
where you\'re going, any route is going to get there. So I thought it
was actually worth our collective time together to be thinking about
this.

You will see draft stamped across every page of this document, because
that\'s exactly what it is. A first pass, and I\'m hoping that each of
you can give us some good input. I must say, as I was reviewing, it I
had altitude problems. You know, in terms of how much to roll it up, how
granular or detailed to get and I imagine we could have some discussion
about that as well.

And there are also some timing issues. It could be, well, we\'ve
selected 2014 as the end state. I know some went out to 2020. Let\'s be
honest and say we\'re all guessing around time frames. These people who
pick time frames, we say with great enthusiasm are kind of guessing
because there\'s a whole lot of missing parts. This is not designed to
be a completely linear process. With that as caveats and a backdrop,
just starting with a brief description, I think the current state is
fairly straightforward. Our care delivery system for the most part is
pretty fragmented unless you are a member of Kaiser VA, or a couple of
other places like that, where they\'re sort of responsible from end to
end for all the care you get.

Even where we have electronic health records, and the mass general group
says that\'s about 25 percent of physicians have adapted some kind of
health record, we see variations in how much of the functionalities of
the records is being used. And the records themselves are designed to
support care delivery, kind of in the way we\'ve all been trained to do
it. One patient at a time, do your best and move on. They really have
not been designed to give us an aerial view, if you will, or to be able
to look at patterns of care across population groups. If I\'m wrong,
tell me, it sounds like VA is on path to fixing this.

Clinicians and provider organizations rarely receive their performance
reports in a timely fashion. To make it very focused and concrete, from
the time the hospitals hit the button on submitting their electronic
data \-- mind you, this is data they\'ve gathered by sending people out
to find the charts and extract it but they put it in an electronic file
and send to CMS. It\'s 9 months until that information is posted on the
website.

Clearly that is not the information that\'s helping you make internal
changes. Now, some hospitals will actually say what that means is their
energy is going into public reporting because there\'s a lot on the
table and incentive for them to move forward. But the point is, I don\'t
think we could agree that 9 months was timely for anything except
perhaps for creating life.

The use of clinical physician support where that exists is generally not
specifically linked to quality objectives. And if you read the work of
Brent James and others, and even what they\'re doing in the U.K. with
their pay for performance scheme where they have a huge array of
measures, they allow the docs the opportunity to opt out to say this
doesn\'t fit for this patient. And you hear a lot of this from docs on
the ground, who say, "Oh, great, I need to get type control for my
patient with terminal cancer. Who also has diabetes" And that makes a
whole lot of sense. Of course it doesn\'t make sense. But what we don\'t
have in our systems unless you were (indiscernible) very select
institutions is any capacity to learn from those exceptions. I don\'t
mean this in an external audit kind of way. I mean actually trying to
figure out if a really good clinician with great judgment says this
doesn\'t apply here. We could actually be learning from that as we move
forward. Then the end state looks different. We have wide diffusion of
interoperable health and personal health records which of course blurs
all our distinctions about what is the silo in which people get care.
What actually is an encounter, and we\'ve now moved to assessing
episodes of care, and so forth. And now enhancing physician support base
on exceptions and people get very timely feedback and don\'t just get
feedback, they get prompted at the time they\'re making the decisions; a
vision Kristine Anderson helped us see on the hospital side. And in
addition to that, just to make this really a glorious vision, we\'re not
just incorporating what happens in those walls where we define health
care to happen, but we\'re including what happens at patient\' homes and
so forth. I think to some extent some of this is possible within VA
right now. Will even in VA, I think the different fusion is somewhat
selective. This makes sense. This is a huge enchilada.

Let me ask you, are we missing anything from the end or the beginning
here?

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

A couple minor points. Like the whole document, really. One thing we
talk about in current and end stage across the sites of care, but even
in the current state, we can\'t necessarily do it within a site of care.
It\'s not all about getting across the different continuum of care
sites.

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

Just to be specific, a patient\'s information doesn\'t necessarily flow
very well from the ICU \--

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

Exactly.

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

On the end state, it seems to me one of the things \-- and this gets to
a point I made earlier, especially as we get to the end of this
discussion, we talk about now capturing information separate of
electronic communication, for example, and other information. We want to
be able to capture that information but present it at the point of care
in a way that\'s intelligent. Otherwise we\'re going to have volume of
data but no information at the clinical time. Because you\'ll see a
thousand blood pressure read that came from home care. All sorts of
information, and since we know that we can create systems that can
present, summarize and present the data in a way that\'s meaningful, I
think we should aim for that. But we also should aim for information
that\'s presented in a way that sort of hones in on where the
communication issues may be when you\'re going across the sites of care.
For example, if you always have a problem with, that pops up on the
screen that has eked out all of the problem issues from all the
different sites of care then you\'re going to force a little more
coordination of the services. Because you\'ve got that information like
right in front of you. I\'m just thinking we might want to put the words
in here about \-- it\'s not just collecting and capturing, it\'s how we
present the information so it\'s useful, meaningful, at the point of
care so that the clinician is not sorting through hunks of information
and therefore still may miss a lot of the issues for coordination
communication because they\'re just buried in reams of data. I don\'t
know if I said it very \--

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

That\'s very helpful and last week I visited a very sophisticated cancer
center that I won\'t mention, but they\'ve got a fancy IT system and I
was talking to one of the physicians later in the day, told me while I
was giving my talk she was busy with her Blackberry e-mailing three of
her physician colleagues, patient who was having a clinical near
emergency and they were making decisions, I mean very much on line. Now,
ultimately you see some of that captured because one of these people is
entering orders. On site or remotely. But I said this is great. We\'ve
now \-- you\'ve now \-- we\'ve created electronically what we do on
paper. Which is that messages from home for care givers or whatever, at
best are paste interested a paper chart. But if we don\'t begin to think
about \-- either that or you are relying on some clinicians who kind of
think back about how they present it, we don\'t have any way to think
about how \-- and it\'s more and more stuff gets done off site, that
seems very important.

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

As recently at a meeting, sort of trying to think about this, too. And
someone brought up the fact that if a patient goes to an emergency
department there\'s a certain list of information that the emergency
clinicians want to have. You know, the allergies, the medication list,
certain \-- certain things they always want to have and if there is a
way that we constantly keep in our minds that we have to synthesize the
information, so that we are constantly considering how we don\'t drop
off important information, we keep the communication going across the
site center, I think it will be easier for the quality of care and
safety of care in the long run.

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

Carolyn?

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

Carolyn? Hello?

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

Wait a minute.

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

George, can you hear any of us?

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

Yeah, Carolyn, I have a point to make here. Can I go ahead?

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

Yes.

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

On your question about the exceptions, how do you account for the
exceptions and how do you learn from them. In the totally different
conceptual bucket, we know a great deal about that from the work of the
institute for clinical systems improvement up from Minnesota, along the
work we don\'t think about it in terms of performance measurement or IT
for that matter. And how you set up the system so that you have a
learning system that learns from the actual deployment of rules and
standards against real populations of people, I think is a critical
aspect of describing the future state. And I would put that under having
a system, a future state that incorporates a system of locally engaging
providers in terms of using the data and the information in their own
electronic record systems. To continuously learn and improve.

And so I think that\'s an aspect of that that I think is missing from
the document as we see it.

The other aspect that I think is missing is the aspect of priority for
focus around the effort. Some of the \-- some of the emphasis that Janet
Corrigan is talking about in the context of the NQF, that we need
priority or focus that drive our system to improve. And I\'m
increasingly thinking myself as that we need a sense what have the clear
priorities or clinical issue or quality problems are and by specialty
and by segment of clinical practice that drives the effort overall. And
I don\'t see that reflected yet in this grid that I \-- which we have. A
couple suggestions.

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

That\'s great. Thank you.

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

Carolyn, this is Jane Metzger.

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

This is a followup to your comment about many of the current data
feedback loops take too long. I totally agree, but I wonder if in our
end state vision we don\'t want to include the electronic health record
is \-- can provide at any time feedback on any measures and any patients
that seem to fall outside the measured parameters of care. Rather than
expecting that actionable feedback and even measurement has to wait
being returned by the data stewardship entity.

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

I think that\'s a very, very good point. In fact, you would expect,
I\'ll test this premise. In any future state, no matter what the state
of stewardship entity looks like, what is being reported up, if you
will, or to that entity, is a subset or rolled up measurement strategy
where what you need on the ground is actually going to be much more
granular. and the idea that that is not dependent upon some period like
every month or whatever your time frame is, but can be given every time,
I think is a very important point.

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

It also fits with the prior comment about giving the practice not just
point of care decision support. But other ways too fuel their internal
improvement efforts.

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

That\'s great.

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

I have a question. Do we want to be envisioning or describing a data
stewardship entity to actually be receiving and doing some type of QA on
data that would be publicly reported? Or is this completely a sort of a
standard setting or policy setting organization that is only sort of
saying how it should be for the rest of the world but not ever being
hand on and in a QA, or oversight way.

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

QA, information reporting.

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

I guess the way George was describing it earlier, they will be saying
how data would be \-- or it would set the appropriate rules and
procedures and policies for how data would be captured. Aggregated and
analyzed and reported. But not actually receiving any data and doing any
oversight or quality assurance to make sure people are actually doing it
in an appropriate way.

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

Yeah, let me just, if \-- how do I know this is on mute or working?

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

It\'s red if it\'s on mute. You\'re okay.

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

Okay, cool. What I would say right now is that there\'s no consensus
about what this looks like. That \-- which doesn\'t mean we couldn\'t
have a view collectively about what it could look like. And I guess I
would look at Margaret or Bill in terms of thinking about in the current
world, it feels like the regulator and the enforcer are standards in
some fashion, is it necessarily the technical assistance function, but I
don\'t know that we won\'t be thinking differently in those terms. So do
either of you have a view on that in.

\>\>\> I do think that certainly a workable \-- for the entity that does
the oversight to also do the technical assistance and there\'s clearly
some advantage to that. I think some of them are perceptual because the
perception then by those being overseen is that this is really at least
in part an attempt to improve quality of data. Rather than simply to
wield the stick and help people if they\'re doing a bad job.

So at least in our experience up to this point, I would say that\'s a
good approach to take. And that is distinct from the other function of
setting the standards in that sort of thing in it seems to me that as
it\'s evolving, it probably is, and again you could make an argument
that it doesn\'t necessarily have to be that way. At a minimum, I think
you want very significant coordination between those two entities. So
that they do speak with one voice at some level.

But I think that aspect of it probably could go either way.

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

I know this is an issue of the joint commission.

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

I think for a long time we felt there needs to be some setting of
national priorities and was going to bring that up under public
reporting, there has to be a body of some sort that says these are the
most important areas to focus on. Not going to be everything that we
want to focus on, but these are things that we think are important
because they\'re major quality or safety concerns, we can measure them
and then the metrics design flows from that, and your stewardship, I
think, embodies in terms of the rules of the road for aggregation and so
forth in my mind is probably a separate body. That does that. They\'re
not necessarily the ones that have the same expertise to say these are
the quality issues.

So it\'s that the other body that\'s going to have to say, well, are we
making the progress that we want to in the performance measurement that
we think is important, do we need to change the measures, are they \--
you know, so that kind of a separate thing. I also agree with Bill that
certainly that whoever is doing \-- setting some types of the rules and
can give sec tall assistance. Technical assistance. I don\'t think
there\'s necessarily dissonance there. But I don\'t think the decision
body and priority setting body are the same.

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

I\'m inclined to agree. The stewardship body will have plenty to do in
terms of trying to control the actual data come in and trying to help
support the goodness of quality of the actual data. And it could be both
the servant and the partner to many different organization that is are
trying to set what quality is. The stewardship bodies, responsibilities
are to make sure we have adequate aggregated data of sufficient quality
to support a whole variety of different kinds of initiatives.

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

Carolyn, where are we going with the visioning? I\'ve been penciling
various kinds of place where is I would make comments. Is this an
online, offline, where do we want to go from with this document? -Which
is very good.

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

What I thought would make sense is to have a preliminary discussion and
I expect that would mean some folks would say oh, I forgot to say \-- or
would continue to think about this. Certainly that\'s the process I had
to kind of get my head around it for a bit.

But I think it does begun refine how we\'re thinking about the future
state, and also frankly what are contributions we can make as a
Workgroup that aren\'t the specific concrete steps that we\'ve agreed
are the specific charge that we\'ve gotten from the community. Does that
help, John?

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

That works fine, thanks.

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

This is Rick Stephens, how are you doing?

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

I\'m great, how are you?

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

Good. I guess a couple comments on the draft from a visioning
standpoint. One is, I see the current state and I seat end state, and
I\'m concerned about us heading towards what I call the big bang theory.
And the big bang theory are that you set your goals and objectives for
the future and given this is clearly 8 years away and in terms of an end
state and since we don\'t know the predictability of when that end state
could be achieved, we don\'t know all the opportunities or risks
associated with that, I think we need some midterm milestones along the
way, otherwise this thing will tend to wander and being one who is in if
a business that does large-scale integration all the time, get something
greater specificity about midterm elements I think will be important.

The second comment that I would make is this is 14 pages, which in my
experience is a lot of information, but I get genuinely concerned about
how to balance all of these requirements in some form of order. And I
think there was an attempt to try under the brief description that says
here\'s the top level items but the realities are they are going to be
limited resources, they\'ll be limited time, and unless there is some
sense of priority ordering, there will be lots going off in different
directions and we will end up with some conflicts along the way. And so
I think some priority ordering is going to be important.

The third comment I would make, this appears, while maybe not intended
to be, very largely focused on the clinicians and the care providers and
I have difficulty really understanding how this is going to benefit the
end care provider if they \-- or the end \-- I\'m sorry, the end
customer, consumer, if we expect the consumer to pay \-- play a fair
role in making sure that ultimately they\'re the check and the process,
the outcome of the process they\'re getting. And so while I understand
the need for collecting data on the part of the physicians, on the part
of the payers and the part of the hospitals, when I go between the
document that was dated September 6, which frankly I thought was the
better of the two documents, I lose an awful lot about this whole notion
of this amount of accountability amongst the consumer, the provider, the
purchaser and the policy maker.

While I think there are lots of good thoughts here, I\'m concerned,
again, too much information here, I would like to see it move towards a
higher level and frankly, I happen to like the September document a
whole lot better when we think about vision.

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

Let me say, I think those are great points. Thank you. I need a point of
clarification. Which September document are you referring to?

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

It was in the documents we got, it says joint commission, round table on
September 6 draft. Potential principles for national performance
measurement data strategy.

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

That\'s \-- that came from a separate round table, was not part of the
visioning.

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

Okay.

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

Not having been part of the vision, I happen to like that document
better about where we\'re trying to go.

\[Laughter\]

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

We like it, too. Thank you.

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

This is Reed. I\'m wondering. How did we set the outside date, by the
way? Was that just given to you to (indiscernible) with?

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

This is Kelly. We are in no way stuck to that date. I think as Carolyn
mentioned there are a lot of different end dates we could set for
ourselves. The other workgroups initially thought 2014 would be in line
with what the President initially charged us all with in terms of trying
to reach a goal for most Americans to have electronic health records.
But you know, many of the other groups thought we may just be at a
mid-state at 2014. So I don\'t think we need to be restricted by those
exact dates.

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

And then the issue, I think, that we\'re just heard a moment ago, I
think where I think there\'s going to be some need for healthy input is
on where do we really think we\'re going to get in the middle versus
that far out. Some of the things put that far out are things that may
need to migrate to the middle and maybe that\'s kind of the things we
should give you as suggestions offline.

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

That makes a lot of sense, thanks, Reed. Helen?

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

A couple things. I want to reinforce the things about the personal. I
hadn\'t figured out how to say it but in the immediate state, it isn\'t
clear that the role of the individual either patient or patient
caretaker, if the patient can\'t take care of themselves. How they \--
when they will get information, what it will be, how it ties, we just
sort of say personal health records. And I think especially for the
intermediate state, we need to think about are we talking about at a
minimum everybody having a handwritten something? Because actually that
would be a pretty important step forward. Even if the aim is to do it
all electronically, people still walking into drug stores right now
getting prescriptions filled and not knowing what their other drugs are
and things like that. So somewhere between current and in the next
couple of years, how are we going to get from here, where we have next
to nothing, to the wonderful state, and how are we going to take care of
millions of people in the interim because there are millions and
millions of people right now getting prescriptions filled and seeing
doctors. And they don\'t have anything. It would also help build up
people\'s confidence if they begin to think about things like that about
the electronic system. Because one of the big \-- I\'m sure we\'ve
talked about it a lot but one of the big threats of everything we\'re
doing is about the fear of privacy. And if people can get used to the
idea that every American would have a personal health record, and there
would be information in there and doctors could check it and somebody
could fill it out, a lot of simple things, it would help us get to where
we are to where we\'re headed, that the average American could relate
to. So that\'s one point.

Second is I think in terms \-- I thought the comments about priorities
were so important, too. And one thing that jumps out at me, if you look
at a lot of sections like the pay for performance, there are some things
that the Federal Government, just as the President has done in his
executive order, can in fact almost overnight make a huge difference.
And all these other things that will take \-- I mean, if VA still
struggles with some of it, it will take us many years and many billions
of dollars to accomplish. If we\'re going to prioritize, obviously we
would go with the ones that would have the biggest effect immediately
but also the ones where the Federal Government, can do things after and
move them along, setting standards. And this document which looks so
daunting can be prioritized according to those things which we have some
more control. Not \-- not dropping the dream and the hopes that we\'ll
have all these things connected. These things that really can be done
would be objecting the top of the list.

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

That\'s incredibly helpful.

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

I have \--

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

Ought to be things that really matter. That are prioritized and really
matter in terms of changing quality and improving carry in the country.

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

So the title of the document relates to quality measurement, that\'s
actually \-- is that the focus rather than the quality?

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

We\'ve been sort of \-- this is a broad charge of the Workgroup. So we
didn\'t actually repeat the broad charge in the title of the document.
So it\'s clinical physician support and automation of comprehensive set
of quality measures.

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

At least some of what I \-- caught my attention and I think similar to
the last two sets of comments, which is there\'s still a quality
measurement focus to the description, and with that in mind, I think the
consumer end of it isn\'t very well articulate. If you think about it,
and I thought perhaps that\'s because really it\'s aiming to focus more
on the quality measurement aspect. If you really are aiming more broadly
than that, I think the consumer part of it needs (indiscernible).

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

The other thing I might say is just on the business case, I don\'t know
how broadly you were trying to think in terms of your description of end
state, but certainly the issues of the potential need for a more
substantial restructuring of payments mechanisms. Don\'t at least seem
to come through to me as much as they might. And in that regard, I guess
I\'m thinking of two things. One is a lot of the Lindberg stuff that
relates to the impact of supply, first of all, secondly, so far as a lot
of focus here is on for P-for-P, as a sort of next version but what it
would look like, I think that\'s entirely appropriate.

But when you\'re talking about an end state, you might want to go even
beyond what "P-for-P" usually connotes to people at this point. I think
a lot of respects it is more of a mid-state than an end state.

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

And intermediate technology.

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

Yes, exactly right. Hopefully \--

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

And can you suggest what you would \-- what we should be including in
the way of more along \-- end assist for payment reform?

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

Well, you know, in a sense from CMS\'s point of view, to some degree
what 646 is about. So I think a lot of these things have to be really
worked out. But just in terms of the descriptive, I think if you think
about that, we ought to clinically be able to come one language that
captures something that brought in what you\'ve got.

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

On that very note, I had thought of some language for that little
section here. And I think gets to your second point here. I felt the
second bullet where it said financial incentive to promote higher level
of quality process that we needed to say something like that this would
be on top of a reimbursement system designed support quality and safe
care on a consistent basis. Because you ultimately, even if you want to
pay for performance incentives forever, you might say there are always
some things we want to get quick behavior change on, and you want to
have the underlying system be transformed in a way that it consistently
facilitates quality and safe care on a consistent basis. So that it\'s
paying for the things appropriately that should be paying for.

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

He and not paying for things it shouldn\'t be.

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

These are great comments. I had a suggestion actually as I looked
throughout implications for key stakeholders rules and issues, and that
looks mighty thin. I must say, I was getting fatigued as a clinician
getting caught down in the stuff I\'d like to see down there.

When I think about the Lindberg issues and I think about the fact that
historically this country has not displayed sustainable enthusiasm for
health planning, and if health supply drives a lot \-- or the supply of
providers actually drives a lot of our spending, then you now,
potentially the only route out of that besides payment reform, is
informed consumers. So it seemed that might be a logical place to go
next. and I must say, we have an open slate. So before we get to sort of
priorities and thinking about what are the midterm gels and whether
we\'ve got stuff in the right box, maybe some things should be in 2010
or more proximate than that. Every time I\'m with the secretary, he
reminds me of the urgency that payers are feeling right now. I\'m very
fluid in my own thinking about where these boxes should go and frankly,
the Everest of my ambitions with as to give you something to react to.
So we could begin to make some progress.

Can we think about consumers for a moment and just maybe I might go
around the room. We can start with just voluntary comments about what
can we say with the current state what we think should be some end state
without getting too theological about what that end state should be.

Comments on the current state? I think there\'s like one state \-- one
sentence fragment there.

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

One thing that\'s not there is the fact that there may be disinterest,
but we have a huge problem in this country with basic health literacy
and second of all, not everyone has access to \-- computer technology or
technology. So we have I think an access issue and an education issue
that are confronting us. As well as an issue that I think probably goes
somewhere else. But there\'s also a trust issue. That has, to I think,
maybe not necessarily in this column but I think for people not to want
to opt out or people to want to opt into things, they need to feel
there\'s \-- the system is trustworthy in handling their information. So
\-- but there\'s definitely a knowledge issue, a health literacy issue
and a computer access issue.

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

Great. Other comments?

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

Yeah, actually, to get back to something I already said but I want to
repeat. I was just trying to think. Consumers don\'t have information at
all on how to use the health system or even themselves. For example, if
you go to a doctor\'s office, you have a bunch of tests. You may or may
not today ever see the results of those tests. You may not know that you
should. You might be told about them, or sent a report saying you\'re
fine. You may or may not understand. How basic, how far off we are on
just the basic information.

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

And understanding what that test is and why it should be done to take
that step.

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

And given information in a written form that you could understand and
then take home and read later or someone could read with you, that you
could explain. I mean there\'s this whole, so the interest in
information, and then the additional step of quality information.
That\'s just how I know what to take and when to take it and why I\'m
doing this or why I shouldn\'t do this. And that\'s the starting point.
The second would be then do I know anything about what all of this is
quality care and how I do know that? And stepping back and segmenting
all these different steps and then figuring out what could we do between
the current state, which is unfortunately much worse than this, and the
intermediate state which would be a way for bridging the consumer
through understanding and information some quite basic, to the future
state.

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

We\'re actually working with the ad council this year trying to
encourage consumers to ask questions. Most of them don\'t. One point
four questions on average per encounter. And that\'s about parking.

\[Laughter\]

A lot of "don\'t ask, don\'t tell."

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

But I think the point you\'re raise something a culture piece because
today like the whole issue in terms of coordination care, you know, we
\-- on coordinator care, there\'s no tools to do that. But we don\'t
even know we\'re supposed to coordinate care, take accountability. So
the end state has to look like we\'re accountable and we know these
things and can facilitate these things. The current state is the whole
culture we need to change of how public testimony need to be engaged and
accountable for their health. So that\'s huge.

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

Well, \--

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

Carolyn, the list that someone put forward that included health
literacy, I\'d like to add to that. I think parallel with the concept
that we think of as measurement techies, you know, is the concept for
consumers of an affordability. And expressing in terms that consumers
can understand and work with. The affordability of services that go
along with the other concepts that were mentioned earlier. And I just
would like to put that into the mix.

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

Great. Other comments?

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

Going back to your comment about the people who ask 1.4 questions per
visit, I mean I don\'t even think people know what the list of questions
is to ask. And I can tell you one of the things we\'re looking at in
Boeing is giving our employees a sheet of paper that says here\'s the
norm alleys of questions you ought to ask your doctor when you have a
visit. And without that, again, people aren\'t going to ask the
questions because many of them are intimidated. The other is they may
not want to know, but as I \-- saying it\'s okay to ask and here\'s the
list I think goes a long ways and that\'s really simple. That\'s a
cultural discussion as opposed to a technological discussion.

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

Right.

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

I think they can\'t get a word in edge wise because the people are so
rushed.

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

They get a lot of signals that their seven minutes are up.

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

Stand up, \--

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

When I work with people that ask me, because they know me, about fee for
conversation, the choices they\'re facing in terms of chronic disease or
therapy choices, particularly if they\'ve been recently diagnosed, for
example, with cancer. But one, is an opportunity to really explore that
issue with somebody who is knowledgeable that can feed them back
information. In a way that is a service that really isn\'t provided in
the typical ambulatory encounter. And I think that is where the clinical
need, the consumer need fuses itself with the ability of technology and
availability for clinicians for a different purpose other than getting
through a short visit. Might be part of the final vision.

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

This is Bill. I would just echo, then weigh said before about
potentially the need for payment mechanisms which are consistent. That I
think are probably significantly different from what in the near term
will happen in a P-for-P.

On the consumer side of things, I guess I would want to add one thing on
the information side, which is just essentially people need to own their
own personal health information. So having information that helps them
make decision is one thing but having the information available to them
is such a fundamental piece of what\'s missing.

The other I would say is it\'s not just a matter of information. It\'s a
matter of people also having technology that can help them self-manage
and do so in an efficient way. Interact with their providers and in an
efficient and effective way. And manage their own care in a efficient
and effective way. And that\'s not just information. Technology can do
much more beyond information than just that.

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

Like?

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

Like help somebody keep track of their food intake. Or their exercise.
Or on the interactive side help them have communications with their
provider that don\'t require that the intrusiveness of trying to speak
through somebody else who is doing triage and wait for a phone call back
in order for that exchange to occur, those kinds of things, are the
kinds of things I had in mind.

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

This is Anne Carson. I think there\'s a very early intermediate state
which isn\'t technologically driven, education driven and it\'s getting
the consumer to the point for patients to the point all of us, we\'re
pretty educated and probably don\'t use \-- they acknowledge their own
personal vested interest in this. And want to do. This because even the
current statement of interesting quality and information is increasing,
I feel like I can acknowledge that statement if I think about the people
I work with every day who are in had this. But if I take this, my
75-year-old parents, I\'m not sure they\'re \-- if I take it for the
average American, I\'m not sure we can say interest \-- lack of personal
ownership.

We have a survey, still a minority of people, though. Some of the
results would make me wonder what do they think of this information on
inches and quality going on. For example, there\'s a whole lot \-- there
are a few items where they say, I\'ve seen stuff on doctors, and I\'m
thinking what in God\'s name have they seen besides opinions?
Washingtonian Magazine, or stick to your local (indiscernible) magazine
that says \-- now maybe that reflects tremendous interest, and this
survey didn\'t allow that kind of fall-back, but I don\'t want to
overstate that. There\'s a lot of surveys that I\'ve been hearing about
if you ask people where they get their information, the numbers about 70
percent say they get it from their doc. Going to rush out and get out
the door and move on to the next person. It would be hard to say
consumers are very much interactive.

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

And only asking .4 of the second question.

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

Exactly. That\'s where the .4 comes in.

So I\'ve heard a lot that says people don\'t actually do very much about
information, that they don\'t know what questions to ask. They don\'t
even know that it might be their job to ask questions. But engagement is
limited and very few tools to help people manage their own health care.
The concept that they are co producers in this production. Hasn\'t quite
caught on, to put it mildly.

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

They may also be capable in the sense they\'re not health literate.

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

Yes.

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

I think that\'s important from the \-- that standpoint, but I also think
that it\'s also something that we still don\'t see in practice in most
of our facilities, to support our facilitate it.

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

Oh, I would agree with that.

So if we get it right at some end state, and we\'re going to call it
2014 for now but we could call it any year you want. But what does that
look like?

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

This is Susan Postal. One of the key things we talked about that we
don\'t have in the current state is the current coordination of care. I
think that coordination of care is critical with the patient being
engaged in coordinating their care, and being knowledgeable on how all
the pieces come together to the end state of better health.

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

Say more about coordination. I agree with you a thousand percent. I just
think it would be great if we

could deconstruct that a little bit.

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

Okay.

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

Beyond having a wife. Who keeps track of things. That\'s one way to
think about coordination, right?

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

I think one of the issues we have right now is just the fragmentation,
so is it leveraging technology to be able to have data and information
about a patient aggregated across the different delivery systems and
with the patient\'s input on their participation in that, too. So I
think the comments that were made earlier about intake, blood pressure
checks on a routine basis, as an example.

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

Interesting. I just had a flash thought. So any time a patient goes in
to see a doctor, consumer, right, a note is produced. Can you imagine
what it would be like if there were a consumer version of that note?
That actually the patient went home with. As opposed to simply the
prescriptions and all that kind of stuff. Now, it would actually be
nontrivial to figure out how to do that in a way that was accessible to
a variety of audiences of different education levels and so forth. But
it would actually be pretty cool.

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

We have heard a little bit about this. In the integrated EHR/PHRs where
a lot of follow-up notes about following your diet therapy, whatever
specific helpful information would allow the patient to become more
engaged in active management or self-care. That it tends to be a
subsequent \-- or something that would be immediately following a visit.

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

I wrote that as available in our system today, where the patient can
access that on line or have a printout as they leave the office.

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

That\'s cool. So can they actually get the progress note, George, or do
they get something customized for them in.

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

At this point it\'s more \-- looks more like the progress note. But the
intent is to have it more customized going forward.

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

That would be great. Helen?

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

So I \--

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

Health literacy issues that we\'ve raised earlier in terms of putting a
form that people can really understand and access. But I think that\'s a
future challenge for that kind of functionality.

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

So we could \-- a week ago I was a meeting of the medical directors for
American college of cardiology and I saw a form, it could be electronic
or it could be hard copy, and it blew me away. First of all, it had on
it the information about the individual patient, this is for the
patient, this is filled out by the doctor, and handed to the patient. It
had \-- and you negotiation it talked about conditions like congestive
heart failure. Obviously these are cardiologists so they had a subset of
conditions. And they had down \-- they had a matrix that had on it what
your medications might be and your treatments, with \-- written down the
amount and the frequency that you were supposed to take them. And then,
and Carolyn, you would love this. This is evidence-based practice at its
best. It then had a column to the right that listed what were the
possible contra indications, and then you actually had to check that.
For example, it would say, beta blocker, and then you fill it in and
then over to the right you could explain by checking the boxes why you
didn\'t give them a beta blocker. So they would understand the thought
process. It went on. It had in multiple places underlined bolded to
every visit bring all of your prescriptions. Weigh yourself every day. A
bolded, bolded. So it had all. This you turned it over and it was more
of that. It had everything that the doctor would obviously tell the
patient, show the patient, and then the patient would walk out with it.
It was fabulous looking, and obviously if you could do that
electronically, that would be even better because you could build in
continuation things.

But in the meantime, if you had forms like, that and obviously it\'s
harder for like primary care because you have many more conditions but
you could probably figure that out with an electronic system.

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

I think there are some physician that\'s have done that. It\'s created
these forms so it embeds the prescriptions that they\'re on in the form,
the patient takes the form home, and then can check off if there\'s been
a change or anything, or add other medication. But then they bring that
back to their primary care physician, they bring it to the hospital,
wherever they\'re going for some site of care and consistent form
throughout the health system. And it tells you to take it everywhere.

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

I want to go back to the coordinated care. One of the things I see as
you\'re going across settings, a tool to help you facilitate that, but
again where I see confusion is why am I even going to the next setting?
What is the outcome that\'s going \-- why am I going for the test? When
I\'m going to the nursing home, what am I doing there. How does that
prepare me for next step? So that need for the carefully, that
facilitates, which I think what you talked about was the start of that.
But that care plan that helps you once you step, guides you through the
process. And helps facilitate. That\'s focus on outcome of the care
delivery system which is broken now much because even if we could start
with when you\'re discharged to the nursing home that information of
what happened, even at the VA could be sent over automatically. And some
objectives could be written. Not 5 days into the stay or 2 weeks, but
immediately. And those things are still broken.

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

I think there\'s a lot of opportunity to facilitate that coordination
which will help drive improvement of quality. That\'s where it gets a
lot of breakage.

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

Also I wanted to mention \-- this is Kelly Cronin again. The Consumer
Empowerment Workgroup has talked a fair amount about the issues that
relate to consumers and their need to be participating in the
decision-making process, and to have tailored reminders to comply with
come back for their mammography or the colonoscopy or their annual
screening checkup. So I think that \-- and some of that will be
prioritized in terms of infrastructure development in the next year.

But there hasn\'t been as much discussion on how do you make sure that
information on quality is readily available to them in a user-friendly
format? As we proceed with our specific charge, it\'s not beyond the
bounds of my imagination to imagine we could have a parallel path and
might want to have an interface with the Consumer Empowerment Workgroup
on. This to say when you click on a website why are we measuring this,
why does it matter and what\'s your role here? Or something along those
lines. I don\'t pretend to be an expert in this domain. But what I know
is there\'s no Web site I\'ve seen that gets anywhere near. This in fact
I\'ve taken to asking audiences, most of who are interested or they
wouldn\'t be there, right? How many of you have looked on line for
quality information for yourself or family member. Well, half to 2/3 of
the hands \-- well, keep your hands up. If what you found was meaningful
and helpful. And then a lot of hands go down. Not all of them. But I
mean, because very knowledgeable cognoscenti know what they\'re looking
for and they learned what they needed to know. But if you could imagine
trying to present this or at least teeing up that need. Because there\'s
no way you\'re going to make it part of the personal record until you
can articulate what it means.

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

I\'ve got another suggestion on the coordination of care and the
interface with this Workgroup and the consumers. We\'re just rolling out
a tool within our medical records that allows physicians to have
information upon referral sources and physicians. And obviously the idea
of facilitating information about where one should refer for what kind
of clinical situation, not just a specialty, but where you get a
particular kind of thing addressed like a particular disease or
particular problem, this tool is designed to answer that question. Now,
obviously the interface between this and performance information and
access information, cost information, in an environment where patients
may not be aware of that information and sees decisions are being made
would obviously be a point of opportunity for this Workgroup and a
Consumer Focus Workgroup.

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

Thank you, that\'s very helpful. Other comments on consumers? You can
choose current state or end state. And I didn\'t mean to push too hard
on the coordination, but from the measurement side, I know no one has
figured out how to measure this. Some part of it is about information
flowing and some about understanding and some about frankly getting
stuck in the radiology department and having a problem and suddenly
you\'re on your own.

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

This is \-- one of the things and I\'m sorry that Bill had to leave,
that as you look at the financial incentive, they likewise need to \--
you know, to look not episodic, but they\'ve got to look continuum. For
instance, when you\'re at one of the access of cares, you\'re focused on
meeting the quality of care objectives of that institution. But the goal
to serve the longer term problem because you\'re being paid for that
particular encounter, if you will. Tends to be focused on achieving the
quality there. Rather than balancing looking at the quality of whatever
the problem is, if I\'m going to \-- discharge someone with beta
blockers and you know, make sure they eat what they need to, but who
pays for the disease management process that keeps them coming back, the
whole debate, back to the hospital. You know, and back to the emergency
room. That whole debate, that\'s where the incentive. Who pays for the
nursing home, when they get home, you make sure they\'re not going to
end up there again? Because they don\'t take proper precautions for
those. So it\'s that kind of stuff that I think as we start to change
the focus to quality, and we look at coordinating the care, we don\'t
need \-- (indiscernible) and the financial incentive helps change that.

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

I will say that there was \-- there were earlier address that is had
more details on payments, which as an editor here, I simply said true
but not our issue. But we may need to keep looping back to that to get a
little bit more specific because when we\'re thinking about specific
enablers, it\'s going to be very important. I think we should rename
ourselves the payment group, then we can \-- (indiscernible) we
wouldn\'t have enough phone lines to get people on the call. That was a
little joke for the official record.

And Rick, you have certainly sensitized me that a lot of things about
the detail which I think we are going to need to get very concrete and
down and dirty about, but is probably more relevant to the next steps
and getting to the specific charge than it is a visioning process.

Let me open it up, then, and ask, we\'ve started to peel away a little
bit and certainly feedback to more of a summary about what it would look
like for consumers if we were getting this right or what are some early
steps we could take. Frankly, I think we\'re so far away from any end
state it\'s hard for us to imagine. In recognizing the consumers don\'t
all come at a single size. Are there other priority areas that are not
here? In terms of what\'s missing? And I would frame this broadly as
improving quality of care, not just measuring it.

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

I think the areas that we might move, be able to move faster on that
combine the electronic infrastructure, with improved quality, and I\'ll
give one example. Pharmacies benefit management, and drugs. First of
all, almost everybody in the pharmacy benefit world is already has had
some kind ever infrastructure. This is an area that we know that lots of
patients are confusing bid or don\'t fill or refill. There are a lot of
things that go wrong for a whole bunch reasons and it\'s an area where
the hospital or ambulatory care center or any number of provider
locations might have electronic communication, at least with pharmacy.
So it may be we could take that on as a way to, one, it has a high
priority; and two, it involves a lot of money and lives, adverse events,
a lot of confusion, et cetera, et cetera. And for things like moving
people to generics or over-the-counter drugs or brand formulary kinds of
things, there\'s a lot of opportunity for improved quality and
affordability, by focusing on that. And it\'s a he a subset of the
health care system but it\'s a big one and it\'s probably one of the
irritants in the private practice office because if you have a pharmacy
benefit manager which most people do, then if you get a new drug, they
have to give you a retail prescription and a mail order, et cetera. It
goes on and on. And people lose them. All sorts of things happen. So if
we could focus on, or at least put that on sort of the top of the list,
and I\'ll give you one example of how I got so excited about this. I was
at my own doctor\'s recently, and she is a private practice physician, I
think there are only four physicians in the building, she practices in
Silver Spring, Maryland and this last time I was there, I was there for
my usual visit and I have some maintenance drugs. So she whips out her
actually fairly old looking blackberry, and for the first time I\'ve
been going to for five years, for the first time she said, you know,
which drugstore do you use? Which PBM do you use in and she, while I\'m
sitting there, keys it in, she sends to my PBM, my refill prescription
for the next 12 months. In seconds, she does the same, there was a new
drug that I was being given, so she said I\'m going send one to CBS, and
I told her who it was. And by the way, I didn\'t have to know the phone
number of CBS, because she said what street is it on?

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

I want one of these.

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

This is not a particularly high-tech office in any other way. But all
right, so then literally everything happened. I don\'t have to have
slips of paper. It all happened; I even had already gotten a call to my
home from the PBM there was some question about one of them. It was a
simple question, not one of these stupid, you got to go back to the
doctor and get another piece of paper kind of question. And never seen
anything that works as smoothly as this did. And this is a very kind of
low margin office, et cetera. So maybe if we took some of these, surely
must be quick hit and focused on some of those that tied all together
and make the messages right and the early part. This is intermediate.
This doesn\'t have to be end state. It may be end state for the whole
country, but it could be intermediate for an awful lot of clinicians.

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

And a lot of these measures do overlap with use of the pharmacy and the
good news is the additional standard that would support some of the
sophisticated set of functionality around electronic prescribing will be
ready in early 2007, you heard it here, and they're being piloted now.
So I should think that\'s very good idea.

Other priorities?

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

This is Anne Carson. I\'m not sure if this falls in to priority.
Prioritization as much as shifting to more near term and that\'s the one
about coordination of quality organizations and how they relate to
vendors and measure development. And the \-- I think this is very well
articulated here about measure developers and EHR vendors working
collaboratively to ensure that data capture (indiscernible) I think
that\'s beginning to happen. I know at NCQA, we are trying to begin to
do that. And to see that one as an end state, I actually think it\'s an
enabler to get us to the end state.

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

Great.

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

Very reasonable.

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

Even as you water those impacts and some level of a roadmap in terms of
what order are we going to put those in. So as we think about the goals
and start to work backwards, then there\'s \-- getting them as well as
what\'s impactful in that combination.

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

Well, and this also ties to the business case, because the business case
is going to come from the changed processes and the elimination of
things so we can pay for the new functionality. And I think \-- I
don\'t, with all due respect to my different George Isham, I don\'t
think there\'s going to be extra money out there from employers, at
least to do some of these things. They\'re going to be looking for
improved processes, I mean they don\'t, friends from Boeing doesn\'t get
paid extra to do something. He has to sell the plains within the prices
that the market will sustain. And I think we\'re going to have to deal
with that.

The government is not going to be spending a lot of extra money either.
They\'ll be taking it away from someplace else. So we have to focus on
those examples as quickly as possible that demonstrate reduced cost to
change processes.

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

This is Rick. You\'re right on the mark. And I can tell you next, so
this year I pay \$1.9 billion in health care costs. Next year that
number is going to go up \$150 million. And we know, from running our
business, we have to take 4 percent costs out year over year. So we\'re
looking for some real optimization that would take that 150 million
going up, to start being able to at least flatten it out or start
driving it down.

**[\>\>\
]{.underline}**Anything else that we\'re missing here? The theme of
impactful and short-term focus areas that could make a big difference
seems \-- fertile to me.

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

To that end and I\'ll provide input in terms of the current state. The
interest in working with many customers today to try to go after quality
of stuff of the give them order sets which have beta blockers and those
kinds of things. Been looking at the measures on the docket side and
many measures have been working to include those measures as parts of
their system. Adoption is still an issue. But I don\'t know if we survey
the work that\'s been done to help you know at least from what\'s there
so we can start doing that stuff sooner. Clearly like we can\'t automate
every single measure. But the standardization measures is crucial but
those for CMS stuff, that\'s stuff then vendors work on embedding be a
clinical documentation or order set today because we have the
technology. You know, so that\'s \-- you\'ve got some low hanging fruit
that\'s enable clinical \-- it\'s not where we want to go. Not going to
give you the knowledge and we still have gaps in the aggregation stuff.
But I don\'t know if that would be helpful in terms of impactful stuff
you could say at least as a standard, you know, order sets that have
these pieces in them. And again, our customers do, that but they still
to compete on quality. So I don\'t know to what extent you can share
knowledge. But truly some small things, not small, but things you could
do in the near term, in terms of adoption.

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

Carolyn, Josie. Just to expand on that a little bit. One of the things
that I am concerned about is those facilities and those physicians that
are affiliated with the larger systems and are affiliated with the
left-armor groups, tend to be able to have the expertise to even
implement, understand and to develop those processes that will give them
the kind of economy of scale, if you will to be using the information
and move forward. I see huge hosts of our guys and the people
specifically I work with, that do not have the tools, implementation
skills, and once I\'m concerned, even as we\'re feeding them back now,
early data around our HIT grant, I don\'t even see the expertise in
understanding how to utilize it and we\'re literally having to
(indiscernible) I\'m afraid in those 50 percent of practices in groups
of five or less, they\'re going to have to have that kind of support. So
anything we can do to make it easier to implement, make it easier to
improve their process, tools, et cetera, we can beg, borrow and steal
from what is already there, will make it much easier to implement in
those practices.

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

Yeah. I think one of the challenges that we\'re confronting,
particularly with the specific charge that we have been given by the
community is trying separate out rhetoric from reality. So I hear lots
of people talking about embedding measures in EHRs. We have some case
studies that suggest that it\'s easier to say than to actually
accomplish. Charlene, I would love to take you up on your offer,
recognizing that some people may not feel safe to do this. Because what
I worry with is that many vendors are \-- and a physician because the
measures have not been specified to date, they\'re coming up with some
customized solution. This is really a great for Practice or Organization
A. What it doesn\'t do is get anywhere near consumers helping them to
figure out if A is better than B. or if they\'re using different
approaches to measuring it.

So I don\'t want us to get too, too bogged down in that detail, but I
think at some mid-level understanding what is possible now, what are the
challenges that people are confronting, so that as we\'re preparing a
view of what needs to happen, we have some sense that we\'re bringing
along people we\'re going to need to actually implement that. I think
Rick said on a prior conversation was I build systems and we can\'t
build a system that no one is going to want to buy or help us produce.
And that made a whole lot of sense to me. I think about patients one at
a time. That\'s not how I\'m hard wired here.

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

This is Jane Metzger. I think one of the things that where this group
could have some near term impact, is definitely on certification because
there is a roadmap. It does include things focused on a lot of topics
we\'ve been talking, clinical decisions support, and feedback reporting
from the EHR. But there are also some barriers to CCHIT actually
incorporating the full set of what will eventually be needed. I know
that one is that at least if you look at it from the CCHIT side, there
really isn\'t agreement or sanction or any sort of blessing of one set
of measures.

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

I would \--

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

For instance, you know, so I wonder if that shouldn\'t be one of our
near term tasks, what is \-- what has CCHIT been able to incorporate in
the roadmap. And where are there barriers to incorporating more of
what\'s going to be needed?

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

Right, so I think some immediate pieces, Jane, are going to be figuring
out realistically when do we actually get this on their radar screen.
That\'s clearly within our sights. I think we have to get on their
screen now, Kelly, you\'re right. But the question is when can they get
it on theirs, our screen?

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

We\'re going to be drafting use case that is this group will get a
chance to review that will be based on a core set of measures.

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

Great.

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

So as we advance recommendations s in the near term, we need to think
about that, because it\'s going to be \-- the use cases will be drafted
as we\'re drafting our recommendations. The in our public meetings
we\'ll probably want to have some ongoing communication there.

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

I think that would be fabulous. And knowing realistically what the right
expectation here is. Is that something they get to in \'07 or not? Or in
our lifetime? I don\'t mean in our lifetime but very low probability in
\'07. I don\'t know.

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

I think it\'s already been talked about, they\'ve been thinking about
Year 2, Year 3, conditional, criteria, and what we probably need to be
thinking about is in that sort of 3-year context, what gets sort of
phased in. And there\'s still to be determined what out of the 2007,
these initial use cases we\'re working on now, the second round, not the
first three, how will they be worked into a May, June, or July
certification, yet to be determined.

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

That\'s great. Fundamental level, what I see coming back to us, we have
an executive order that there\'s an enormous amount of support from the
private sector for, which I think just has been a game changer in making
us think about how do we get to more value in health care. But we\'ve
got a huge disconnect. On the one hand, the executive order says at some
point in the near future, as a condition of doing \-- with the feds
which is big, you\'ve got to adopt these standards that are come up
through the AHIC. But the problem is today if I make an investment in
electronic health record or health care organization that isn\'t helping
me with the demands for transparency about quality.

So that\'s the gap that we\'re trying to close. So your comments and
feedback on this preliminary document have been incredibly helpful. We
will be make something radical changes. And bringing it back to you for
your feedback and I really do want to push on this consumer piece
because I am very, very worried that it gets very comfortable keep
putting this off to the side. I recognize we have a Consumer Empowerment
Workgroup, but I think this whole space is so undefined at the moment,
or amorphous, that we can be extremely focused on what it is about
quality of care that would help people understand more about their
active engagement, and make the information more meaningful to them.
Both in terms of what it is we\'re telling them and what it is they can
do with the information. Because I think it\'s unlimited opportunities
in that sphere. So thank you all very much for your participation. Do we
have \-- I know we have a date. I\'m blocking on it. The 13th?

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

December 13.

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

And we do need to open up the line for public comment.

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

Thank you.

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

Matt, if you want to go ahead and do that while we talk about the next
date. That would be great.

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

Thanks, Judy. For members of the public who are looking at the Webcast
right now, you\'ll see a phone number on your screen to call in and make
a comment. And if we have some people from the public who were already
called in ask listening to the meeting over their phone, you can press
Star-1 on your touchtone, and that will put you into the queue to make a
comment. And we\'ll give people about a minute to get through.

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

I just would like to make a process comment. This is Kelly again. I
think we\'ll definitely be sending you an updated matrix and I wanted to
thank Michelle, the policy analyst at ONC, and Kristine Anderson, our
subject matter expert supporting the Workgroup. They did great work
getting us ready for today. And we\'ll certainly want to incorporate all
of your updates. We\'ll do our best to capture what you said today. But
to the extent we mischaracterize any of it, please correct it. But also
as you give us input, if you could keep in mind Rick\'s comments about
what\'s particularly important. What\'s really going to matter and drive
us forward. When you get to describing enablers and barriers, because I
think that \-- in our next meeting we\'ll have much more time to focus
on the near future and what we really can accomplish. And the enablers
and barriers are going to help us get a lot more focused and will
probably help us as we get down the road to crafting recommendations.

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

Looks like we have one person on phone to make a comment. I believe the
name is Jennifer Eames. Can you open up the line?

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

This is Jennifer Eames from the Consumer Purchaser Disclosure project.

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

Hi, Jennifer.

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

Hi. I just wanted to say I really appreciate the conversation that
you\'re having on consumers and really trying to hone in and focus what
the intermediate and end state is. So I\'ll keep my comment very brief
and just say for the project that I\'m working on, the consumer
purchaser disclosure project, we have a set of guiding principles of
presenting information to consumers that I think would be really helpful
and I think some of those principles were articulated in the
conversation, but some of them were not. And I\'m happy to send that to
you and you can use that information if you want in terms of using \--
you know, filtering the document.

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

Thank you.

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

Is that it for public comment, Matt?

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

That\'s everyone on the line, yes.

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

Okay.

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

Thank you.

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

The meeting is adjourned.

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

Yes, meeting is adjourned. I didn\'t bring my little gavel.

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

Adjourned.