AMERICAN HEALTH INFORMATION COMMUNITY

WORKGROUPS:

CHRONIC CARE #1

February 1, 2006

1 p.m. EST

\>\> Matt McCoy: Okay. Thank you, Cindy. We\'re going to get this
meeting started in just a minute here. We\'re waiting for Secretary
Leavitt to come on and make some opening comments. And as soon as he
does that, we are going to take roll of the workgroup members and start
into the agenda. And Craig, if you would like to say something before
the Secretary joins us, your line is always open.

\>\> Craig Barrett: I\'d like to compliment the President on his State
of the Union message last night. I thought it was very interesting. But
if I\'m the only one who is open, I\'m going to be talking to myself.

\>\> Matt McCoy: We\'re all listening to you. We\'re just not talking
back yet.

\>\> Craig: I can see your head shaking up and down. I think I\'ll give
the Secretary 50 seconds to show up. If it doesn\'t happen at that time,
we\'ll talk about a few things in anticipation.

\>\> Matt McCoy: That works. I\'ll jump in and let you know when he does
join. We\'ll give him another minute, and then we\'ll get this thing
rolling.

[\>\>]{.mark} Matt, Karen is sitting in for Tony today, and her line
should be open.

\>\> Matt McCoy: Karen Bell?

[\>\>]{.mark} No, Karen Trudel.

\>\> Matt McCoy: Okay. Cindy, would you please open Karen Trudel\'s
line? And that needs to be open for the entirety of the call.

\>\> Denise: This is Denise in Secretary Leavitt\'s office. I\'m going
to put him in on the line.

\>\> Matt McCoy: Mr. Secretary, are you with us?

\>\> Secretary Leavitt: This is Mike Leavitt.

\>\> Matt McCoy: Mr. Secretary, we\'re all listening. You can go ahead
with your comment.

\>\> Secretary Leavitt: I wanted to, first of all, note that you were
meeting and thank you for your service and, second, to make certain that
you know the level of my aspiration for this to move forward and to tell
you I\'m looking forward to the deliverables that you\'ll bring to the
March 7^th^ meeting. I\'m seeing this as one of the great opportunities
for breakthrough, and I just wanted to convey my appreciation and
interest in your progress. And I\'ll look forward to hearing a report on
your meeting. That\'s all I had.

\>\> Craig: This is Craig Barrett. I\'m the meeting coordinator today.
We\'ll do our best to have a good meeting today, good meeting in a
couple of weeks, and then at the AHIC meeting in early March.

[\>\>]{.mark} I know, with your leadership and the others participating,
that we\'ll not be short on vision, nor aspiration. I\'m appreciative of
the way you keep us focused on delivering to millions.

\>\> Craig: I try to do my job.

\>\> Secretary Leavitt: Thanks. Goodbye.

\>\> Matt McCoy: Craig, if it sounds good to you, I\'ll go over the
comment procedures for the workgroup members. We\'ll take roll, and then
you can start into the agenda.

For the workgroup members who are listening in right now, we sent you an
e‑mail describing the process for making a comment during these
meetings, and I\'ll just go over that again very quickly. Your lines are
all set to Listen Only, which means that you can hear what\'s going on
but you can\'t make a comment. If you\'re interested in making comment
or asking a question at any time, you need to press star 1 on your
phone, and that will put you into a comment queue. From there, we can
recognize you and open up your line and allow you to speak to the group.
The only other piece of that -- if you\'re waiting in the queue to make
your comment and you feel like whatever you were going to ask has
already been addressed, press star 2 to take yourself out of the queue
to keep us moving along. And the only other piece of technical advice
I\'d pass on: to work group members who are looking at the Web
interface, please don\'t click through any of the slides when you\'re
looking at it. We\'re all on a live interface. Any changes you make on
your computer are going to be seen by everybody who is watching the
streaming over the Web. And that\'s it for the technical part. I think,
Dana, we\'ll start calling roll right now. Probably what works best is
if we ask everybody to introduce themselves and say a little piece,
maybe 30 seconds, that will allow us to get the lines queued up for the
next people and make it move as quickly as possible. And Dana, if you
want to begin with the workgroup members you have with you live right
now, I will queue up the workgroup members on the phone.

\>\> Dana: Great. Thank you. Do we have Ed Cameron on the line?

\>\> Matt McCoy: Dana, if there\'s some people live with you in the
Humphrey Building, why don\'t you go through the two of them, and I have
a list of everybody who is dialed in on the phone.

\>\> Dana: Okay. Great.

\>\> Jay Sanders: Good afternoon. I\'m Jay Sanders, CEO of the Global
Telemedicine Group, and President Emeritus of the American Telemedicine
Association, and Adjunct Professor of Medicine at Johns Hopkins.

[\>\>]{.mark} (Inaudible) I\'m sitting in for Shaygan Kheradpir, who is
Verizon\'s Chief Information Officer, and wanted to be part of this
group as sort of a follow-on to our CEO\'s participation last year for
the Commission on Systemic Interoperability.

\>\> Dana: That\'s all we have from here, Matt.

\>\> Joan Kaiser: Joan Kaiser calling from the United States Department
of Agriculture. I\'m substituting for Ed Cameron. Ed runs our advanced
services division here in the telecommunications program. We are
essentially an infrastructure granting and lending agency and we
actually do grants and loans for telemedicine purposes. So we\'re
pleased to be here this afternoon.

\>\> John Rother: Good afternoon. This is John Rother. I\'m the Policy
Director at AARP. We obviously have a very strong interest in the issue
of chronic care, and we\'re looking for ways to be even more supportive
of innovation and applications of health information technology. So I
look forward to the call.

\>\> Matt McCoy: Thank you. And Mohan Nair, go ahead.

\>\> Mohan Nair: I\'m the Executive Vice President and Chief Marketing
Officer for the Regence Group, an affiliate of the Blue Cross/Blue
Shield group of companies. I\'m also Adjunct Professor at (inaudible),
focusing on cost and finance management. Glad to be here.

\>\> Matt McCoy: That\'s all the workgroup members we have on the phone
right now, Dana.

\>\> Dana: Okay, fantastic. And then for our Co‑chairs, we have Craig
Barrett and Karen Trudel. And I\'ll defer to you all in just a moment to
make your opening remarks. The one thing I want to make sure of: all the
workgroup members should have been sent an agenda, a content list, a
milestones document, and a briefing document. For the Office of the
National Coordinator, your point of contact is Karen Bell. And so for
all coordination of all the outputs from this group, that will be
handled by Karen. At the conclusion of the call, we will have a time for
public input. The folks that can comment during this call are only
workgroup members. Now, if you are a designee of a workgroup member, you
can talk. But if you are a workgroup member and then have to step out of
the call, then let us know that, and let us know who your designee is in
the course of the call. And with that, if there are no other questions,
I will now defer to Craig and to Karen.

\>\> Craig: This is Craig Barrett from Intel Corporation. I\'m the
General Technology Rep on AHIC and Co‑chair of this workgroup on chronic
care. What I\'d like to do -- and by the way, I suspect that this
meeting will last only an hour or so, if things go well; it will not
take the entire time frame that\'s been allotted ­-- what I would like to
do is to start from the top. I\'m a strong proponent of problem-solving
methodologies. And one of the bigger issues typically is to figure out
what problem you\'re trying to solve. So what I would like to do is
start off with the charters for the workgroup, both the broad charge and
then the specific charge. I would like to get workgroup agreement on
what we\'re trying to do and then take it to the next level down. So I
would like to make a specific comment, if you would go to the chronic
care briefing document that Dana had mentioned that we all received and
look at page 1, which is under the charges for the chronic care
workgroup. The broad charge for the work group reads, "Make
recommendations to the Community to deploy widely available secure
technology solutions." A little bit of English there, I think, for
remote monitoring and assessment of patients and for communication
between clinicians about patients. I would like to suggest a slight
modification to that as far as the communications portion is concerned,
and I would like your input on this modification. I think it ought to be
basically for communications between clinicians, patients, and
caregivers. My definition of "caregiver" is a third‑party family member
or caregiver who may be responsible for remote caregiving to the
patient. So I\'m looking at -- the broad charter is one of looking for
widely available, secure technologies for remote monitoring and
assessment and for communication between clinicians, patients, and
caregivers. I\'d like to throw that open for discussion, as that\'s the
widest scope of charter that we have to consider.

\>\> Karen: While other people are queuing up to comment, I absolutely
agree about that, that expansion.

\>\> Matt McCoy: If any of the workgroup members want to make a comment
on this, press star 1, and I can recognize you from the queue at that
point. And Dana, I will let you run it from your end if members in the
room live with you want to comment.

\>\> Dana. We have members that want to comment.

\>\> Jay: Craig, I totally agree with that. The other issue: I would
hope that we are viewing the term "clinician" very broadly, also, and
not simply meaning "physician," that we are including all the
practitioners that may be involved in the patient\'s care.

\>\> John Rother: Actually, I was going to make exactly that same point,
so let me just say I strongly support both the inclusion of caregivers
and a broad definition of clinicians.

\>\> Craig: Any other comments?

\>\> Joan Kaiser: Hi. I would just like to back up, Mr. Sanders and
Mr. Rother, that the same thoughts occurred to me probably
simultaneously.

\>\> Matt McCoy: The queue is empty, Craig.

\>\> Craig: Sounds like we have somewhat unanimous agreement, then, to
reword this slightly to include caregivers and also a broad definition
of clinicians. And if I hear no further comments, we\'ll assume that
that will be the broad charge in the workgroup.

If you look at the specific charge for the workgroup -- and I\'d like to
get a little bit of discussion on this as well -- it says, "Make
recommendations to the community so that within 1 year, widespread use
of secure messaging as appropriate is fostered as a means of
communications between clinicians and patients about care delivery." We
go back to the broader charge; we should probably include caregivers
into the three‑party communication systems as well. I would like to get
the feeling of the group, though, in terms of should our short‑term
charge be just the widespread use of secure messaging, which in its
simplest form perhaps is just what it says, messaging or e‑mail
communication. It really doesn\'t imply anything about remote monitoring
or assessment. I would like feedback from the workgroup in that area.

\>\> Andy: If I could comment, I agree with your idea of trying to
broaden a little bit. You know, in fact, in the broad charge when you
talk about the word "communications," I\'m assuming a broad definition
of both voice and data and video, and I think you\'re right that you
should try to expand that through your specific, instead of just
messaging and talk about the secured transmission of communications or
voice data and video. That way, you\'re opening it up to remote
monitoring or videoconferencing, telemedicine, those types of things.

\>\> Craig: If we make the leap in the short term to video, it has some
obvious ramifications about bandwidth. I\'m wondering if, in the short
term, I was just trying to get to the point of messaging to me implies
basically text messaging back and forth. It doesn\'t apply data
communication. Really trying to see if we ought to get that into here to
be a little bit more general.

\>\> Matt McCoy: The queue is empty. Sorry, Joan Kaiser just jumped in;
please open her line.

\>\> Joan: Trying to get to, "Are we talking about just text messaging
or something a bit broader?", but perhaps not full-motion to interactive
video. I can speak to some of our grant and loan applicants. A lot of
them run visiting practitioner-type operations, where they\'re very
interested in using various telemonitoring devices that are left either
in a hospital or hospice room or a patient\'s room for a period of time.
And while that may not strictly be text messaging, it\'s certainly a
vital transfer of health‑related information that helps the clinicians
and does help the patients. I don\'t know if that adds anything to your
discussion or not.

\>\> Craig: That\'s the direction that was leaning into to make sure we
include effectively data transmission data monitoring here as well as
simple messaging. I just want to make sure we\'re focusing on the right
topic, and the right topic seems to be a combination of remote
monitoring and communication, communication being used directly as
really a person-to-person communication style of remote monitoring,
being more data access and data transmission.

\>\> Mohan: I agree with what was discussed, and I would just articulate
that maybe we ought to consider the word "secure messaging" as the
infrastructure, but the nature of the dialog being monitoring and
communication from the perspective of language dialog, text dialog as
well as video dialogue between parties. So if you can hear what I\'m
saying, if we can just adjust the language not to talk about just secure
messaging based on Craig\'s point. Some degree of analytics as well as
dialog.

\>\> Craig: I\'m only hesitant here if we assume we\'re going to target
a broadband versus a narrowband solution. Long term this would go toward
a broadband direction, and as broadband becomes more ubiquitous in the
U.S., that inures in our favor. But for the 6- to 12-month time frame,
I\'m wondering if we should limit ourselves more to a narrowband
solution which any dial-up capability would give as opposed to a richer
broadband type solution. So data and text communication is pretty
simple, I think, over a dial-up capability. As soon as you start putting
video in this, you\'re probably leap into the broadband area. This is 
something we need to resolve up front before we get into the next level
of detail.

\>\> Matt McCoy: While we\'re waiting for other comments, I want to make
a note to everybody. I\'m getting a message from the operator that some
people are coming through a little low on volume. So everybody please
try to speak up as much as possible.

\>\> Jay: You know, in terms of all the discussion that\'s been going
on, I think we need to look at it obviously not as an either/or type of
situation. If you actually drill down to the specific disease states
that we would be prioritizing, like congestive heart failure,
fundamental reality as a physician -- the only thing I really want, the
most important data I want, is what that person\'s weight is. So how we
input that, you know, it could be either done through a text message, or
it could be done through a data stream. I suspect, by the wording of the
specific charge, it\'s probably addressing, Craig, as you pointed out,
probably simply text messaging. But I think within the general framework
of what we address relative to text messaging, we need to make sure that
the standards we adopt are both capable of dealing with the specific
types of bandwidth that we have available as well as the type of
electronic information we want to transmit. So if we\'re looking at a
patient with diabetes, a simple transmission of what my glucose level at
4 a.m. in the morning in a text message is good, although it might even
be better if it could be done more automatically in terms of it being
wirelessly transmitted from my glucometer into a cyber file that is
specific for my particular parameters. So I think all of the discussion
is appropriate. I think maybe we ought to just find out from AMCHP as to
whether or not their particular definition here was strictly to focus at
text messaging.

\>\> Karen: I would just like to make a few comments about this very
robust discussion that clearly is pointing out the need for us to move
forward in this broader direction. However, one of the things that you
have as a task for March 7^th^ is to outline all of the critical issues
that surround any type of communication that\'s occurring in this remote
fashion right now. And clearly, there are a number of them. But they
focus around issues of privacy, security, authentication, State laws,
reimbursement, and that\'s just to start off. I\'m sure you\'ll go into
many, many more. And the intent of this particular workgroup is to focus
on something that can be implemented within 1 year to basically address
or point out how we can address all of these larger issues. And so I
would just underline the fact that, again, on March 7^th^, you will be
-- to be very clear about the specifics of the type of communication
that will be occurring, the particular parties that will be involved,
the major issues that will need to be addressed, and also recognize that
whatever you present at March 7^th^ is one piece of this very much
broader picture but that it should be specific enough and focused enough
so that it can be implemented and evaluated over a 12‑month period. So
thank you very much. And I\'ll turn this back over to the chairs.

\>\> Craig: I\'m not sure, Karen, exactly what you said. I totally
understand that there are other factors which are going to play in here,
which we\'ll talk about in a few minutes. I\'m just trying to get a
basic infrastructure issue settled up front, which this is either going
to be a broadband or narrowband approach.

\>\> Dana: The thing that we have to be sensitive to at this point is
that this is a charge that was agreed by consensus of the community. And
the workgroup doesn\'t really have the authority to alter the charge.
Now, the workgroup does have the ability to determine how they want to
pursue the need for that charge, but the ability to just change what the
charge is is not within the authority of the workgroup. Does that
provide clarity, Craig?

\>\> Craig: No, you just muddied the water from my perspective. We have
to do something; we have to understand what we\'re doing, and I\'m
trying to clarify that. Telling me that we have to keep a obscure phrase
in the charge doesn\'t help a whole lot.

\>\> Andy: I think you\'re actually on the right track, Craig, the
discussion of narrowband versus broadband. I would probably be
supportive of the narrowband. And I think you\'re also right about the
word messaging, and maybe it\'s just an agreement among us what
messaging really means. And I think, you know, I was talking to Jay a
little about it on the side here. Maybe the word messaging to us -- and
I don\'t know how you encapsulate it -- would talk about data
interchange. And we can have it among ourselves, because I think we\'re
saying it has to be more than just sending text messages on a cell phone
or something like that if you exchange data. And you\'re probably right
to focus on narrowband; don\'t get into the bandwidth issues.

\>\> Craig: If we start off with narrowband, it\'s obviously expandable
to broadband later on. But my concern is with the time frame that we
have here to do something. We probably ought to take the lowest common
denominator and determine the connectivity and the ability to do simple
text messaging and also data transmission. So let me try again here for
an understanding within the subgroup that we\'re talking about
widespread use of secure data and communications, with parentheses
narrowband as appropriate, fostered as a means of communication between
clinicians, patients, and caregivers. So Dana, I fully understand that
you may hold the specific charges somewhat sacrosanct until we get back
to the full AHIC, but we need to decide what the charge is that we\'re
going to work on in the meantime. So I would propose that we adopt, as
we said on the broad charge, a broad definition of clinicians, include
caregivers, and then in the specific charge, we focus on effectively
secure narrowband communications data and text, if you will, and include
caregivers into the clinician patient\'s communication channel. Is that
okay with the rest of the group?

\>\> Mohan: I agree. I think that does not -- in my opinion, does not
change the charge. It just defines it more effectively in narrowband to
include data communications.

\>\> Karen: I agree also.

\>\> Matt McCoy: No additional comments in the queue, Craig.

\>\> Craig: Let\'s consider that done. And what we\'ll do, we\'ll try to
kind of have our subgroup recasting of the broad charge and the specific
charge and get that out to you for our next meeting. I would then like
to engage in a discussion, not so much of the exact milestones, but how
we might go about attacking this problem. And from my perspective, I\'m
an IT person. I\'m not a medical person, and I am not fully cognizant of
all of the baseline capability that exists or the baseline demands
associated with various chronic illnesses. And if I were to attack this
problem, the first thing that I would do would be to build upon some of
the briefing material that went out. And if you look at page 2 under
tools and plans in the briefing document that went out, it lists a few
examples of Connect To Care and some of the Blue stuff that\'s going on
and Kaiser Permanente stuff. But I always attack problems by trying to
figure out what the customer wants or what problem we\'re trying to
solve, what\'s available in the specific area that they\'re focusing on,
and then what might be available in adjacent industries. So let me
propose something, which would be some background gathering, which might
be useful to us.

If we were, for example, to go out and look at the demands of the top
five chronic illnesses -- and we could discuss what those might be in a
minute, but just to inquire from either HHS or the appropriate groups
that are involved in these top five chronic illnesses exactly what would
be the most useful information data or communications which would make
this remote monitoring -- remote communications capability useful, and
you could start to see what the demands are and what sort of a solution
you should put in place. So that would be the first thing that I would
do, and I would then just throw this out for discussion, and as an
example, you might pick that the top five chronic illnesses in terms of
depth and cost in the U.S. are heart, cancer, stroke, pulmonary, and
diabetes. You might put mental issues and arthritis in the sixth or
seventh place, but recognizing that we can\'t be all things to all
people. If we at least looked at the top five and quickly surveyed the
needs of those top five to see if any particular system you put in place
was acceptable. Would that be a good starting point? I throw this out
for discussion.

\>\> Joan: Yeah, actually, that\'s probably not a tremendously bad idea.
I might suggest a couple of background tasks as well in addition to the
illness side, which I can\'t really deal with. But in terms of another
immediate task this brings to mind is, you mentioned sort of what\'s
available now and what\'s available in adjacent arenas. You know, my
sense in reading the materials this morning in prepping is that to some
degree, this is not so much "Develop a technology" or "Develop a
protocol" as it is "Deploy what already exists," especially since we\'re
going to be focusing on a short‑term narrowband focus. There\'s an awful
lot of stuff that runs over the wire.

\>\> Craig: What I\'m suggesting here is the first of three parallel
steps. Just what are the requirements in terms of chronic care
communications, chronic care data for these top five chronic care
categories?

\>\> Mohan: May I offer a suggestion as well? I think that what you
suggested is a very good framework. I know you\'re speaking one of
three, so I may be jumping the gun here, but from the experience I\'ve
had, both in the IT side as well as the health care side from the
insurer\'s perspective, I\'ve noticed that there is a difference in
communications or dialog between physician and physicians, physician and
patient, and the infrastructure demands and the expectation are slightly
different. So I would add to this, besides just the nature of the
illness, also if you could frame who the customer is and who are we
satisfying in this activity.

\>\> Karen: Could I ask another question for clarification? The briefing
document definitely is focused on a physician‑to‑patient two‑way
communication, and I\'m wondering whether the disease management
organizations that do a certain amount of the chronic care disease
monitoring -- for instance, diabetes, etc. -- are also going to be part
of our charge and whether we\'re just talking about this bilateral
communication between, for instance, primary care physician and patient.

\>\> Craig: I\'m perfectly open to input from the customer, whoever we
decide the customer is, from disease management in associations who are
presumably expert in this topic. I\'m not proposing we do a 6‑month
study of the issue, but basically query disease management associations
or similar situated people as to, "All right, if you want to use
technology for remote monitoring and communication data gathering on
heart disease, what are the top five issues as far as you\'re concerned?
What are the top five things you\'d like to do?" Do the same thing for
cancer, stroke, diabetes, etc. At least we get a simple framework where
we can understand what the general needs are. You may not satisfy
everybody\'s need, but at least what the general needs are, so you\'re
sure what you\'ve put in place and what you worry about from a
regulatory and technology standpoint. You\'re attacking the right
problem.

\>\> Jay: Craig, let me address this from the medical standpoint.
Because fortunately, or unfortunately, we really don\'t need to have a
whole heck of a lot of data that is specific for each of the disease
processes. If you want to look at the literature in this, you will find
that a \$100-billion-a-year problem in all of these disease processes is
a simple one. It\'s called compliance. So simply knowing and reminding
the patient what medications they\'re supposed to be taking, making sure
they\'re taking it in an appropriate way, ensuring that they\'re not
only taking your medication but they\'re not taking a physician\'s
medication that I know nothing about that they saw 6 months ago -- that
seems to be a very, very critical issue.

So a simple generic comment that overrides any of the diseases that we
want to put on the list is, very simply, compliance and education as to
what the disease process is. When we study how much a patient retains
after they see us in the office, and even assuming we have the time to
talk to them, number two, that we actually talk in patient‑speak as
opposed to doctor‑speak, by the time they get home, they only retain
about one‑third of the information. It\'s not because they\'re not
paying attention. It\'s not premeditated. It\'s just the fact that
they\'re nervous. They\'re anxious. They\'re sick, and they need
repetition. So we find, many of the times, the revolving-door nature of
the patient with congestive heart failure or with diabetes is not
because their diseases become more severe; it\'s just that they
haven\'t, for one reason or another, complied with the particular
prescriptions and advice that the doctor has provided. So I see e‑mail
secure messaging as -- the major importance of it being education and
reminding the patient or, when the patient has a question, to be there
to respond to the patient. I know that was a long response, but I want
to add a second thing. Second thing is, I\'ve decided just out of fun --
I\'ll use the new verb -- to Google-secure health messaging. I did that
yesterday. Luckily, it only came up with 2,100,000 hits. So we\'re
not --

[\>\>]{.mark} Wait until we\'re done.

[\>\>]{.mark} Absolutely. We\'re really addressing a problem that both
the government and industry has addressed for quite a while. There are a
whole bunch of good solutions that are out there. And I think, really,
one of the things that we should look at in our charge is not
necessarily to identify a specific technology but to identify one
functionality that is required regardless of how many different
companies can provide it and, most importantly, to address the issue of
interoperability and that it be a HIPAA‑compliant secure messaging.

\>\> Craig: You just leaped a little bit ahead of where I was, Jay, in
that. I\'m quite sure that compliance is going to be on everybody\'s
list, if you went out to, say, the top five folks or the top five
chronic diseases I mentioned. I\'m just proposing that we simply go out
and pulse either the disease management associations or equivalent
bodies and say, "Okay, what are the top five?" And if it\'s compliance,
weight, blood glucose, whatever it might be, you get those five bits of
information very quickly, and then you can use that as a background as
we go forward. I\'m just trying not to leap to the conclusion
instantaneously.

\>\> Matt McCoy: Craig, we have a few more comments in the queue.

\>\> Mohan: I don\'t want to rush to agree to what you said as a good
format. I mean, it\'s okay to pulse and find out what the top five are
and what the nature of the dialog is necessary for us to improve this
communication. I think that\'s okay. I also want to endorse the point
that the doctor made specific to the area of compliance, because we\'ve
got the same experience. I\'ve got a significant number of nurses who
are telling nurses they\'re almost hysteric calling chronic care
patients in our health plan. We\'ve seen significant transformation in
their behavior based on just being bugged all the time and assessed all
the time with respect to phone calls. They\'re like telemarketers. The
only thing: they have highly educated capability to converse with
individuals who are in chronic care, and I\'ve actually experienced it
on the phone and watched how they do it. They gain the trust, and then
they gain the counsel, and then the next thing you know, we see
significant improvement. So both those factors are there. I want to just
rush to the fact that I think if you want to find out what those are,
those are very quick answers that can be delivered to you.

[\>\>]{.mark} That\'s exactly what I was hoping. And as I said, I would
like to be able to have those data back by our next meeting to use as a
format.

\>\> John: As usual, I\'m finding myself agreeing with some previous
points. But just to make it more clear, perhaps, I believe that our
focus ought to be on functionality, not necessarily on the technology.
So for compliance, for example, e‑mail followup is one way, but so is
hard paper, and so are other kinds of reminders, especially important
that caregivers have access to that. Oftentimes, it\'s the spouse that
becomes the de facto compliance officer. So it\'s -- I think it would be
a mistake to focus solely on the technology. What we\'re really after
here is behavior change.

\>\> Matt McCoy: The queue is empty, Craig.

\>\> Craig: Let me inquire, Karen, or anyone from HHS who is on: you
guys have access to the information that I was talking about?

\>\> Karen: I think we could get some good contacts and make a few quick
phone calls; we\'d be happy to do that.

\>\> Craig: It would be great if we could get it in the next 10 days and
prior to our meeting next month.

\>\> Karen: We can check with the disease management associations and
also with some of the major groups like the College of Cardiology.

\>\> Craig: That would be perfect.

\>\> Karen: Will do.

\>\> Craig: Okay. So we\'ll call that an action required. Karen, you\'ll
drive that.

By the way, the comments vis‑à‑vis behavior changes and however you
achieve behavior changes, whether it\'s with a nagging e‑mail or a
nagging spouse or a nagging whatever it might be, I won\'t put -- I
won\'t suggest we put nagging into our specific charge. But I would
assume that whatever technology works is appropriate. The second
question I had is, again, baselining or background would be an extension
if there is an extension of who is doing what in health care today?
Again, page 2 has tools and plans defined. But I\'m interested in the
workgroup\'s thought of, "Is this an inclusive study of who is doing
what today? Or is there an opportunity to in fact see how many
reasonable-size chronic care trials are in existence today which include
the capability that we\'re talking about; that is, communication between
clinicians, patients, and caregivers and the secure transmission of
messaging and data?" If we are looking to, in fact, have rapid
implementation within a year, it seems we will probably build off
existing capabilities as opposed to reinventing something. So having a
firm backlog or baseline of existing capability seems to be important.

\>\> Karen: This list was essentially designed to highlight some
examples of what\'s available and what\'s out there. It was no means
intended to be something completely inclusive. So I just wanted to make
sure you were aware of that.

\>\> Craig: I\'m not critiquing it from that standpoint, Karen. I assume
that it was just a sampler of what\'s available. And the question is if
we looked at the top 10 or so examples today of trials that are under
way or people that have a commercial model, or whether it\'s a bunch of
-- a clinician‑driven model or a payer‑driven model or whatever it might
be, would seem to be useful to have the top 10 models which are in
existence at our disposal.

[\>\>]{.mark} Craig, are you at all interested in and looking at data
internationally?

\>\> Craig: Yeah, as soon as I would say who is doing what in health
care, I would not differentiate necessarily between a U.S. trial, the
National Health Service in the UK and what might be going on in Germany.
I think we ought to be not very proud, steal or borrow from whoever is
doing it right.

[\>\>]{.mark} I think there are a lot of piles we could step into.

\>\> Matt McCoy: The queue is empty, Craig.

\>\> Craig: I need to see your faces. Is this a reasonable baseline data
collection issue as well as the one we just agreed upon a minute ago
that Karen agreed to follow up on?

\>\> Matt McCoy: Please open Joan Kaiser\'s line.

\>\> Joan: Hi Craig. I think perhaps the reason the silence may be
deafening is we may all need a moment to think this one through. You
know, from my perspective alone, just looking down the list of the
people that are on the call, I can see a lot of different perspectives
coming into play in "We\'re doing this, we\'re doing that, and we\'re
doing the other thing," and it may get fragmented very quickly. I don\'t
know. I think it\'s one possible way to look at this is to go look at
what\'s deployed in the field today and, say, see if we can quickly,
roughly categorize at least some types of the technologies that service
the messaging that we were talking about a moment ago, whether it be
data or text messaging, interaction between provider, caregiver,
patient, because there\'s a lot of stuff that\'s actually happening
right now. You\'ve just heard a couple of people talk about the nurses
doing a lot of followup phone calling, or text messaging or e‑mail
messaging. I think perhaps a little time on a search engine might
actually just turn up some broad classes of what\'s already happening as
opposed to a lot of, you know -- I mean I think it\'s already there. I
think it\'s just a matter of perhaps just gathering it all in one spot.

\>\> Craig: And any time in my business when we engage on something, we
try to baseline where the marketplace is and where the technology is or
where the capability is. And that\'s all I\'m suggesting we do here.
Again, it\'s not an extensive summary of everything that\'s going on.
But it at least is a quick market overview of what\'s happening, what
the capability is and what people are doing and you build off of that.

[\>\>]{.mark} I think you\'ll actually find I wasn\'t kidding when I
said there were 2,100,000 hits on Google. You will see a very rich list
of secure messaging capabilities that are being done in a variety of
ways, also with reimbursement that occurs for this with all of the
factors that you might think about in initially addressing this, that\'s
already been addressed. So once again, I don\'t think it\'s a technology
issue and also not so concerned about the functionality issue other than
ensuring that the functionality from one system to another is totally
interoperable in a secure, private fashion with appropriate
authentication. I think we can get from -- draw from the experiences of
some of the companies as well as health plans that are doing this to
find out the strengths and weaknesses. I think that would be very
helpful for us. But I do want to put in a little bit of a footnote that
we need to just keep in the back of our mind, and that is we make, at
times -- I certainly do at times -- make a naive assumption; that is,
gee, if I\'m sending information electronically, I make the assumption
that it\'s information. And a lot of times, I go back to reminding
myself that my ignorance now, in the absence of an electronic medical
record, luckily just stays in my office. My ignorance about a patient\'s
care is not necessarily now transmitted into an electronic format that
can be sent all over the world to display my ignorance. So I just want
to make sure that when we think about this that we\'re also thinking
about ensuring that any information exchanged is done in an environment
in which the patient has access to all the information that they need
and, most importantly, the physician has access to all the information
he or she needs.

[\>\>]{.mark} Also, to help frame out what you want to do, maybe it\'s a
simple matrix where you have Step 1 of these, "Identify the top five
diseases." You identify the top five functionalities that they need.
I\'m sure there are projects and trials for each one of those. So maybe
you list a couple of these examples of what\'s happening. I think you
might be able to get to that pretty quickly, because you don\'t want to
say "This is the best one" versus "this one." You want to have a couple
of examples where it\'s working.

\>\> Craig: That\'s a very clear statement of what I was trying to lead
the discussion to. "Here are the top five chronic diseases; here are
trials that are going on in these areas, kind of pluses and minuses of
challenge associated with those." Just have that as common background
information for all this to go forward, to get the conversation going
ahead.

\>\> Mohan: I endorse almost all the conversation discussed. I would add
a perspective that came to me only from being around in the health plan
for a while. Just by background, I was a former (inaudible) years ago. I
came into a health plan and became a marketing guy and a health plan --
I\'m paying penance when all the vendors call me and want to demo all
the technologies and I\'m unable to say no because I feel so bad about
my past. In that learning, I\'ve discovered the only way I could frame
these technologies coming at me and these functionalities coming at me
is through a perspective. And I do want to urge a perspective to be
taken. So I add a column to your two‑by‑two matrix so that as we look
through the lens, we consider the perspective of who they\'re serving.
If they\'re serving a member focus or if they\'re serving a clinician\'s
focus, the nature of the technologies may shift. We have taken in the
arena, at least in this region, a consumer focus where we\'ve said
we\'re trying to enable consumerism and enable the individual patients
to take charge of their own health, and through that, even though the
word "nagging" comes into play, it\'s really about educating and
reminding that allows the consumer to take hold of their health in a
more effective way. So if there\'s some way we could frame all of these
technologies as well as all of these functionalities in the perspective
of the consumer or the clinician communicating with other clinicians, it
might help me get a frame more effectively. I don\'t know whether that
helps others in the team. If it doesn\'t, we can reject it. But that\'s
my suggestion.

[\>\>]{.mark} We like that perspective here in Washington.

[\>\>]{.mark} As a matter of fact, I would underline it and say one of
the things that I tell my patients is they have to be the physician.
I\'ll be their coach.

\>\> Matt McCoy: Just a note to the members of the workgroup who are
speaking live from the Humphrey Building: please identify yourself
before you start speaking so everybody on the phone knows who\'s
talking. Please open Joan Kaiser\'s line.

\>\> Joan: I\'d just like to back up what Mohan just had to say,
especially from the standpoint of somebody who works on a program that
is focused on specifically rural residents. I mean, we actually have a
charge directly from Congress in our enabling statute that says get this
technology out to improve in this particular case and improve the
quality of the delivery of healthcare to rural residents. So yet
defining who we\'re talking about here, who is the audience and who the
customer is, is going to be really, really key, you know, because I look
at it this way from running these programs. I essentially have a couple
of different sets of customers. One is those patients whose lives will
be improved by the money that we grant or that we loan for these
projects. But also, we do have sort of larger kind of more broad-based
constituency in terms of attempting to answer some of the overarching
health care needs, things like the critical shortage of nurses and
specialists in rural communities, and a lot of this technology, even
with the narrowband level, can go a long way to stretching the economics
of a regional health care system a little further. And so I definitely
agree with adding that third column to the matrix in terms of who the
customer is. I\'m just kind of struggling with how we define all of that
right now.

[\>\>]{.mark} Can I ask a question? What would be the role as an
information source as well as an (inaudible) of the RHIOs? Will our
recommendations, you know, be utilized by the RHIOs, or can we use some
of the RHIOs that have already been established as resources to see what
kind of secure messaging systems they have established?

\>\> Craig: I would hope it would be bilateral in the sense that, as the
RHIOs are engaged in some of this activity already, that we would draw
off of their experience, but presumably we would have a little bit of
intelligence of the overall recommendation which they might take back.

Karen, let me lean on you in terms of a data-gathering exercise. We\'ve
really kind of talked about who is doing what to whom and what the
various trials look like and who they\'re targeted at, what they\'re
doing. Is this -- I\'m not suggesting that you leaf through the
2,100,000 Google entries. Maybe go to Yahoo Search; it might go down a
little bit.

[\>\>]{.mark} I\'m so relieved.

\>\> Craig: But if we could figure out, you know, one of the -- somehow,
the 10 top trials or systems that are under way and then just do a quick
snapshot, you know, kind of much less than one page on each one. You
know, what are they targeting? Who are they targeting? How are they
targeting? What technology are they using? Do they have any results?
Something like that. Is that information your team can gather?

\>\> Karen Trudel: Craig, I think that\'s something that I would want to
work with Karen Bell and her folks on, because I think I\'m going to
need some support on that one. But we can certainly start that dialog.
Is that all right with you, Karen?

\>\> Karen Bell: Absolutely. Sometimes I think that when I hear the name
Karen, I\'m not quite sure who it\'s being addressed to. But I suspect
we\'ll have to work as a team on this one.

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

\>\> Karen Bell: So what I think is that CMS will do that original leg
work to come up with the top five and any corollary information we can
come up with, share that with the group, and then perhaps pass that
along to Karen to see if she can -- if she can help us work out some
additional research after that.

[\>\>]{.mark} Okay. All right. We\'ll lean on the two Karens, in that
case, and I\'ll try to get you straight going forward.

[\>\>]{.mark} The third generic area here was this whole area of secure
communications and what\'s going on in the rural. And obviously there\'s
a lot of secure communication that goes on effectively over the
Internet. And the finance community comes to mind. And my thought here
is, would it be useful for the group to basically have a quick
categorization of secure technology or secure communications capability?
Again, who is doing what to whom, where, and how? And this is a more
broad topic out of the health care industry. I might volunteer my
technology friends to come back with a briefing of this type, kind of a
two‑page summary of what the capabilities are, pluses and minuses, and
where they\'re being used. Is that useful information?

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

\>\> Jay: I would just add that we might also want to hold hands with
the military health care system. If there\'s any system that\'s secured
enough about security, they are, and Carl Hendricks, who is the new CIO
of the military health system could be a good resource for us.

\>\> Craig: The group agrees. We\'ll take the charter to come back at
our next meeting with kind of a couple-page summary of what\'s going on
that we\'re aware of in the capability of secure communications and all
of the authentication stuff that goes with that and then kind of have
that as a baseline as well for the organization. I don\'t hear any
objections. We, Intel, will take that and come back with it.

\>\> Craig: I think we\'re making progress, actually. If I look at the
document, which is entitled, I think, *Breakthrough Workgroup Activities
and Community Milestones*, which kind of has a summary of the meetings
for the year and some of the suggested milestones, it basically has the
meeting that we\'re supposed to identify existing tools and solutions;
identify local, State, Federal agencies; blah, blah, blah, that are
needed to support the tools and solutions and present a detailed
timeline for the realization of the specific charge of the community. I
think we\'re addressing the first milestone in the three actions that
we\'ve already put forward. I\'m wondering if anyone has a good idea or
thought process in terms of identifying local, State, and Federal NGOs
and private entities that are needed to support the tools and solutions.
Let me just throw that out for thoughts of the subgroup.

\>\> Andy: I\'ve been duly reprimanded to identify myself. You know,
just one thought on that, and sort of going back to your Step 1 about
the chart of identifying the diseases and the trials. I think it\'s
probably going to be important to identify the roadblocks and the
problems encountered by those trials or what needs to be changed to
further spread those trials or something. And once you can identify the
roadblocks and problems, then you can start identifying the organization
who you work with to solve those problems. End of comments.

\>\> Craig: I think that\'s valuable insight, because again, what we\'re
trying to do with the three actions we listed above are to baseline what
is happening, and part of that baseline includes pros and cons or pluses
and minuses and challenges that they face. So I guess going back, Karen,
if we can include that as a query into the trials that are existing --
they come up with, that would be very useful.

\>\> Karen: Just to clarify, I\'m assuming those roadblocks could be
technological, legal, or they could be behavioral.

\>\> Craig: I think it\'s useful for us to know the entire gamut of
roadblocks.

[\>\>]{.mark} That\'s what I thought. Okay.

\>\> Craig: Okay. So perhaps as a first step in anticipation to our next
discussion, we don\'t go out and try to look at roadblocks
independently, but we look at roadblocks and problems consistent with
our analysis, what trials are under way, and what people are
experiencing at this time. And we can come back and visit this obviously
at a later date as we zero in on some exact recommendations.

\>\> Matt McCoy: There\'s nobody waiting to comment in the queue.

\>\> Craig: Okay. I would propose, then, that what we do is take the
three action items that we have, which are really baseline action items,
and combine those with the slight changes we\'ve internally made to the
broad and specific charges of the workgroup, so we understand as we\'re
going forward, and structure our next meeting to look in detail at the
baseline and then have a discussion on those baselines as how we might
zero in on some further scope recommendations and come up with a
detailed summary for the March 7^th^ AHIC meeting. I\'m perfectly open
to comments at this stage about what other background material we might
need to collect or what other thoughts the group members have in
anticipation of our next subgroup meeting.

\>\> John: I\'m calling to apologize. My board is calling me out of the
room, and I\'m going to have to leave the discussion for a while. And I
certainly support the direction that we\'re taking, but I will not be
able to be on the call for a period of time now.

\>\> Craig: I would not propose at this time that we try to clarify or
make detailed comments on the specific milestones for the rest of the
year. I think it\'s incumbent that we try to gather the background
material and then digest that with the exact charge that we have and
then see how we can integrate those two topics into creating a series of
milestones going forward, to try to have a good set of milestones at
our -- when is our next meeting, Karen? February --

\>\> Karen: February 22^nd^ -- 23^rd^.

\>\> Craig: One of those February dates. That we try to clarify at that
meeting what are our findings and recommendations going into the AHIC
meeting on 7 March.

Does anyone in the subgroup have any further comments they\'d like to
make at this time? Hearing none, I think it\'s appropriate that we open
the meeting to public input and --

\>\> Matt McCoy: I\'ll just jump in there and explain how the public
input part will work. For everyone who is following along looking at
this Webcast on a computer, we\'re going to put up a slide in one second
with a call‑in number and pass code that you can dial to be connected to
the meeting and make a comment. It should be up on your screen now if
you\'re following along. In addition to the call‑in number, there\'s an
e‑mail on there, and you can send in e‑mail comments to that address,
and we\'ll get them that way as well. I\'ll let Craig and the rest of
the group know. It usually takes 5 or 6 minutes for the members of the
public to call in and work their way through the operators and connect
to the call. So Dana, if there\'s anybody live in the room who would
like to make a comment, we can go to them first. Otherwise, I suggest we
just hang on a second here and see if we get some members of the public
queuing up.

\>\> Dana: That sounds great. And to reiterate, the next meeting is
going to be the 23^rd^. It\'s here in Washington. We encourage folks to
come to the HHS building. We do have a room reserved, and we do have a
room with some folks in it. It\'s always nice to see smiling faces.
Again, if you have any comments, provide those to Karen Bell, and we\'ll
be delighted to work together as a team to (inaudible) all of this.
We\'ll have minutes of this meeting publicly posted within 5 days. With
that, there\'s no one who has public comments. So Matt, I turn it back
to you.

\>\> Matt McCoy: Craig, we still probably need to give the public a few
more minutes to call in. So I\'ll defer to you if you want to fill the
silence until we get some calls, or we can just wait in anticipation,
and I\'ll jump in as soon as we get some people on the line.

\>\> Craig: You don\'t want to hear me sing; that\'s for certain. Just
to review then, we have the three action items that we\'ll review at the
next meeting. Two of them will be basically (inaudible) out of HHS, and
that\'s going to be the summary of the top five chronic illnesses and
the required functionalities and communications messaging capability
required. And the second is a summary of who is doing what in this
general area pros, cons, and roadblocks. And then the third one will be
kind of a summary of secure messaging capability, not only in the "being
here today in the health industry" pros and cons, but also what I would
call in adjacent industries, where there\'s secure transmission of
confidential information going on on an ongoing basis.

Having said that, I think we will wait until the public can get in
either through the phone number --

\>\> Matt McCoy: Let\'s just give it maybe 3 more minutes, Craig. And
I\'ll do a final check with the operators just to see if anybody is
working their way through the switchboard. If they tell us no, then we
can go ahead and adjourn this thing. Looks like we have a comment.
Operator, would you open the first name in the queue?

\>\> Lynn Adamvac: Thank you. My name is Lynn Adamvac. I noticed, during
the conference, you referred to a briefing document. I may have missed
it in the beginning, but I\'m wondering if that is available for the
public or if somebody could comment on that.

\>\> Dana: That document is available on the Web site.

\>\> Lynn Adamvac: Thank you.

\>\> Matt McCoy: Looks like we\'re getting another lull. We\'ll keep the
clock running from what I initially said, 3 minutes, and then we can
wrap it up. I just checked with the operators, and they\'re not getting
anybody else. So Craig, I\'ll defer to you on the final call. But looks
like we\'re good to adjourn it from our end whenever you\'re ready to do
so.

\>\> Craig: I think we\'ve given people satisfactory amount of time to
call in. So I would move that the meeting be adjourned and we\'ll try to
get -- Karen, I guess we\'ll try to get minutes out of this, and exactly
how is that going to work?

\>\> Karen Bell: There will be minutes posted on the Web within 5 days.
That will be available to everyone. And again, we\'ll be working with
you and Karen Trudeau and Tony Trenkle in the interim.

\>\> Craig: Thank you all for attending.