American Health Information Community

Chronic Care Workgroup Meeting #13

Thursday, February 15, 2007

**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.*

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

Looks like we\'re ready to get started.

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

Great. Thank you and welcome everybody to the 13th meeting of the
Chronic Care Workgroup. Just a brief reminder that we\'re working under
the auspices of the Federal Advisory Committee Act, which means this is
being broadcast over the Web publicly and the public will have
opportunity at the end of the meeting to make comment.

Another reminder to speak clearly and distinctly and please identify
yourself as you speak because it is being transcribed and it\'s very
helpful for the transcribers to be able to identify who the speaker is.
Jennifer, why don\'t you introduce who is on phone and then we\'ll go
around the table here.

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

Sure. On the phone we have Terrence Kay from CMS. Jay Sanders from the
Global Telemedicine Group. Brian DeVore from Intel. Tony Trenkle, from
CMS. Colin Evans from Intel, as well as Jeff Rideout from Cisco, and
that\'s it for today.

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

Great. And at the table we have \--

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

Anand Parekh.

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

Karen Bell.

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

Cinyon Reed.

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

William Crawford from CMS.

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

Great. With that we can begin with Tony and opening remarks, please.

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

Okay, thank you. We have a number of things we wanted to discuss today,
and I guess one change that Karen asked me to make on the agenda was to
bring someone from CMS to talk about reimbursement policy. So I asked
Terry Kay if he could speak and he\'s graciously agreed to, so I guess,
Karen, once we finish the acceptance of the minutes, then we can let
Terry go ahead and speak for a few minutes?

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

Absolutely. And thank you, again, Terry.

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

Okay. I don\'t have any further remarks at this point. Is there any
comments on the minutes from the January 18th meeting? Colin, do you or
Brian have anything further you want to add?

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

Not at all. I think we should get into it.

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

Okay.

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

Tony, this is Karen. I do have two comments about the minutes before we
pass them and they're no longer drafts. One is, the third page, I think
we meant to say employee absenteeism as opposed to presenteeism. And on
the fourth page, I would like to completely eliminate, even though it's
in parentheses, the term "white papers" because they do have much more
of a formal connotation. So if we could just call those summary papers
of the recommendation discussion, if that's okay.

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

And this is Will Crawford from CMS. If I could just add one more
suggestion. Despite the fact I\'m continually promoted in some of these
things, I am not, in fact, a doctor.

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

That\'s a promotion?

\[laughter\]

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

This is Jay. I\'d like to move the acceptance of the minutes with those
modifications.

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

I second. This is Colin.

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

Thank you.

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

Karen, one other note, if Anand is an official member of the group, then
the Workgroup list needs to be updated to include his name because it\'s
not on the Website as him being a member of the group.

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

Yes. We will certainly do so. And I will also take this opportunity to
publicly state that as we move into the broader charge, we will be
asking members for recommitment and if they feel that they would like to
move on and be engaged in other areas, to let us know. So there may be
some changes in the listing of the Workgroup members over the course of
the next few meetings. So I just wanted to make sure everyone was aware
of that.

As I say, we\'re hoping that everyone will continue to provide the
incredible level of support that they have been able to do up to this
point. But we do recognize that people do have lives outside of the AHIC
and the Workgroup. So with much appreciation, we\'ll be offering people
options. Thank you very much.

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

Karen, is there any actions items you want to mention before we turn it
over to Terry?

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

The action items will be coming down line as we move forward with
recommendations. I would like to underline the fact, however, that the
March AHIC agenda is incredibly full. And we have been asked to postpone
our recommendations until the late March AHIC or possibly even into
June, because there is no May AHIC.

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

That\'s right.

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

I'm sorry, April, the April.

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

It\'s April the 27th.

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

The late April AHIC and possibly into June. So we do have time to really
craft a good set of recommendations, rather than feel that we need to
get something out the door in the next several weeks.

So I think that\'s worked to everyone\'s benefit on both sides.

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

And how many Workgroup meetings do we have now between now and the April
AHIC?

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

Let's see. Good question.

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

Judy is checking the schedule right now.

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

I'm checking the schedule. It will take me a minute.

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

I think when we get to that, Tony, I think we really, as we did before,
to try to back-schedule, to know precisely when we're reporting out, be
clear on what we're reporting out, and then back-schedule the workgroups
to make sure that we\'re working on the right things to get to the end
result.

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

I\'d agree, Colin.

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

March 22nd is the only one we have on the book between now and the April
24th AHIC meeting.

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

Okay, so the question to the group would be after today, then, I would
guess, as to whether we think we can accomplish everything we need to do
to put the recommendation letter together by the April meeting, or do we
need to schedule an additional Workgroup meeting to do that? Or do we
want to postpone it to June?

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

Yeah, good discussion.

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

The degree to which we can work off line to craft the recommendations as
we did actually on the first go-around.

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

Right.

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

So we could work them through \-- apologies here \-- with the intention
of having something to review and sign off on the 22nd.

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

Okay. That\'s fine.

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

With that, might I move forward into the item of the overview on
follow-up?

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

Did we approve the minutes? I had a proposal and a second. Any votes
against?

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

The changes, yeah. We\'ll make the changes.

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

Okay. Mohan, are you on the phone?

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

Yes, I am.

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

Thank you. Before we go into the larger overview and follow-up on the
action items and get into the recommendations discussion, I\'d like to
underline how important it is to understand how the largest payer of
healthcare in the world, i.e., the Federal Government, through Medicare
and CMS, makes some of its reimbursement decisions. I think all of us
have different ideas about how this could actually happen, but it turns
out to be a very complicated process, with oversight by Congress, with a
number of steps that need to occur within Medicare itself.

Terry Kay, and I know this is on extraordinarily short notice, so I will
take responsibility for that, but Terry Kay has most graciously stepped
up to the plate this afternoon and is willing to present us with the
approach and all of the processes necessary in order to get Medicare to
actually reimburse for a procedure or a process or something of that
nature. So with much appreciation, Terry, because this is such an
important topic, I\'m going to, if you could pick up the ball and move
from there. And I know that you\'ll also be addressing specifically some
issues around reimbursement for telemedicine.

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

Actually, Karen, before Terry starts, let me just ask Terry a question.
Are you going to strictly discuss fee for service, or are you going to
also discuss the plans, the Parts C and D?

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

I was planning on addressing, sir, the regular fee for service program
under Medicare.

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

Okay.

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

That may be part.

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

That\'s fine, I just want to make that clear to you, Karen, that\'s what
he\'s going to be addressing today.

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

I think that\'s what really is the part that most people are interested
in hearing about. So that\'s great. Thank you.

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

If there\'s additional discussion that needs to be held on Parts C and
D, we can bring in other people to speak on those regards.

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

Great.

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

Okay. I\'m sorry, go ahead, Terry.

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

Thank you. As background information, I\'m with the Center for Medicare
Management and I\'m deputy director of the Hospital and Ambulatory
Policy Group. Amy Bassano who is in the group, she\'s division director
for the division of practitioner services. That division handles payment
policy for physician payment. So in our discussions today we\'ll sort of
use physician payment as an example, but similar processes are followed
for other payments in the traditional Medicare fee for service program,
although as those of you familiar with Medicare, the payment systems and
codes and so forth tend to vary, but we follow a sort of similar
process. Essentially, under the traditional Medicare program, in
determining what to pay for and how much to pay for, we sort of follow a
four-step process. And so what I wanted to do today was just sort of
outline those four steps.

Whenever we look at a service, before we even start thinking about
payment or coding or anything like that, the first thing that we have to
do is determine whether the Medicare statute allows Medicare to pay for
the service. And we refer that \-- that process, we refer to it as the
benefit category determination. So that\'s step one. And as I said,
basically we look at the Medicare law, and the Medicare law in most
cases is reasonably specific about what we can pay for. Again, using
physician payment as the example for today\'s discussion, for physician
payment the first thing we do is look typically at section 1861-S, of
the Medicare statute. And if you happen to follow up and sort of go
through the Medicare law, you\'ll see there\'s quite a lengthy long list
of services that Medicare can pay for. But if the service of question is
not on that list, then typically Medicare cannot pay for it. But again,
that\'s sort of step one, is we look at a service and we determine
whether it seems to fit into one of the statutory categories that can be
paid.

The second step is that then there\'s an issue about coverage. And when
we discuss coverage, usually what we\'re talking about is a
determination of whether the service is medically necessary. Again, the
Medicare law says that we can only pay, under the traditional Medicare
fee for service program, we can only pay for services that are medically
necessary, unless the specific service is listed in the statute. So, for
example, we can pay for screening mammograms, and so forth because the
law lists them. But otherwise for physician services we can only pay
what is medically necessary. And to determine that, the second step sort
of has two processes. One, there\'s national coverage determinations.
CMS in Baltimore has an office, Office of Clinical Standards and
Quality, that has a coverage analysis group. They are lead for the
process of determining national coverage determinations, NCDs. And they
list their process on the Webpage, and the process involves getting
public input, reviewing research literature, and so forth. It turns out,
though, again those that are familiar with Medicare will recognize that
in most cases, Medicare does not have a national coverage determination.
And in those cases, Medicare delegates the authority to determine
coverage to the Medicare contractors. And the term used there is the
local coverage determination. And that really is the bulk of Medicare
services, is the coverage is determined at the contractor level, unless
Medicare has specifically established a national coverage decision.

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

Hello?

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

Yes.

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

Sorry to interrupt. This is Jeff Rideout, from Cisco. Are you referring
primarily to procedure and treatment coverage, or does that cover
service categories as well? E and M codes, and new service categories
don\'t go through a national coverage, or regional coverage review
process, to my understanding.

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

What I\'m referring to so far applies to any service that a physician
would do. Procedures, consultations, office visits, so forth. In
determining coverage payment and so forth, we follow this four-step
process.

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

Thank you.

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

So the coverage step is the second step. The third step is coding. And
in this case we would look at the service. Medicare through the HIPAA
process has adopted the CPT coding system for physician payment purposes
and for claims processing. So we would look at the service and we would
review the CPT codes to determine which codes would be most appropriate
for the service under discussion. And in most cases there\'s a code, but
if it\'s a new service, then CPT has sort of a expedited process to get
a new code established. Sometimes, for special purposes, Medicare will
establish its own code. In physician payments typically a so-called G
code and that\'s within the HCPCS system. Again, I\'d be happy to
discuss that further if you\'d like, but essentially that\'s the third
step, is review the service, try to figure out which is the most
appropriate code that exists in CPT that represents that service, and if
there is none, then Medicare considers whether to establish its own code
or follow up with CPT and request a new code. All those are
possibilities.

And then the fourth step of this four-step process is establishing the
payment amount. So we don\'t think about or talk about payment until we
sort of have established the benefit category, the coverage, and the
coding. For payment, physician payment is established pretty much
through the regulatory process. Every year we do a proposed and final
rule on physician payment. And typically the proposed rule is published
in July, August, sort of early August. There\'s always a 60-day comment
period and then we do a final rule which the law requires, a final rule
by December first and then the changes are effective, then, on January
1st of each calendar year.

So as I say, we follow the regulatory process. It has a lot of
advantages. Whenever we make a change in payment it gives the public an
opportunity to comment on it and it\'s part of establishing the payment
rates. We have a process where we work with the physician community,
specifically we work with the American Medical Association\'s relative
value update committee. It\'s a multi-specialty committee that reviews
physician services sort of one by one, in detail, looking at how long it
takes to do the service, what kind of resources are required to do the
service, and so forth. And then they make recommendations to CMS. We
consider that in our regulatory process. And that has worked out very
well. It\'s very helpful to get recommendations from a multi-specialty
group.

In any case, what I\'d like to do is sort of stop there and just give
you one example to sort of see how this would work. A lot of times folks
will say to us, well, why doesn\'t Medicare pay for telephone calls? And
basically our response to that is sort of following this four-step
process, for telephone calls, in short, depending upon the situation,
the law does allow us to pay for phone calls. And in fact, so we do pay
for phone calls, it\'s just we do not pay separately for phone calls.
And in establishing the payment rates for office visits, as an example,
we have factored in not only sort of the work involved in the
face-to-face interaction with the physician and the patient in the
office, but we also factored in pre- and post-time that's involved in
treating a typical patient for each of these office visits.

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

Can I ask \-- this is Jeff again. Can I ask another question? There is a
code for telephone consultation, so is it reasonable to maintain a code
if it\'s not being used by CMS, or is that so that private payers can
use it if they want?

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

Right, as I said, the CPT codes, that system is owned by the AMA. They
have a panel that establishes the codes. Those codes are free to be used
by other payers. Each payer makes their own policy determinations as to
whether they pay for those services or not. It\'s a standard coding
system that each can use. But each payer has their own policies
regarding payment for each of them.

And for phone calls, basically if Medicare was going to change its
policy for some reason, then the process would be that we would make a
proposal through our regulatory process, and also I would note that the
way the Medicare law was established for physician payment, if we sort
of make changes in our, the amount we pay for services, for example, the
law basically requires we do that in a budget-neutral way. So if we pay
more for one service then we have to reduce payments for other services
so that the total spending doesn\'t change.

And then the last thing I was just going to ask Amy to say a few words
about telemedicine. Again, it sort of gives you an understanding of how
it is that Medicare pays for telehealth in some situations and not
others.

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

Thanks, Terry. So we, the Medicare program does pay for telehealth
services. The services are mostly physician office visits,
consultations, and psychiatry services that are performed in a, what
they call the originating site has to be a certain type of location.
It's defined in the law, has to be in a rural health professional
shortage area, not in an MSA, and the sites themselves can be a
physician office, a critical access hospital, a rural health clinic, a
federally-qualified health center, or a hospital. And so if they\'re in
one of those types of locations, the beneficiary can be located there
and then the physician can be at a distant site and be, the connection
would be made and the physician can provide those particular services to
the beneficiary in the originating site.

We would pay the originating site what we call an originating site fee
that was established in, did not go through the process of establishing
the fee that Terry described. It was set in the law and has been updated
by an inflation factor every year. It\'s 20-something dollars, I don\'t
remember the exact amount offhand, and the physician then who is
performing the services is paid off of the physician schedule for those
particular services. We have a process that we go through if someone
would like to recommend adding additional services to the telehealth
list and that goes through the rule-making process as well. But
generally they are confined to these outpatient physician office visits
and the psychiatry services I think are the most common services
provided through the telehealth benefit. That\'s sort of in a nutshell.

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

So in summary, we\'ve, again, focused on the traditional Medicare fee
for service program, and sort of the four steps we follow to establish
coverage and payment. Other parts of the program, particularly for
demonstrations, the agency has a different statutory authority and
different flexibility for demonstrations. Again, this just applies to
the traditional program. With that, we\'ll stop and see if anyone has
any \--

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

This is Colin. I presume in terms of telehealth there's also sort of a
strict overlay of licensure issues in terms of where the tele part is
going from state to state. Is that a concern here?

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

Well, I\'m not sure I understand your question, but the provider, the
physician or practitioner, would have to be appropriately licensed and
then the facilities enrolled in the Medicare program and subject to all
the other sort of enrollment requirements.

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

Yeah, I can \--

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

But there's kind of a state overlay. If the doctor is in one state and
the patient is in another state. Is there some \-- I presume that\'s
also a limitation on the use of telehealth here?

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

But \-- this is Jay. But that\'s not a CMS issue. That\'s simply a
licensure issue, and from a regulatory standpoint what the states do is
define the practice of medicine as occurring at the physical location of
the patient, not the physician. So in essence, if you\'re doing a
telemedicine consultation across state lines, the physician needs to
have a license in the state in which the patient is physically located.
We argued early on, in the \'90s, that it should be defined as the
patient being electronically transported to the physician, because in
the absence of telemedicine, that patient would be physically going to
see that physician, so that the comparable situation, the patient
electronically transported to the doctor.

If that was taken as an acceptable regulation, then this whole issue of
state licensure would be a non-issue.

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

Yeah, okay. But right now it is an issue.

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

Right now it still remains an issue. Now, with respect to what CMS
covers in terms of rural-based, rural-defined locations, that\'s not
totally the case with respect to radiology. In fact, with teleradiology,
rural is not a component of the definition, which is always something
that has been of interest to me, that they will reimburse for
teleradiology regardless of location, but for other subspecialties,
including telepathology, that\'s not the case. Telepathology, which
ought to fit the same normative regulatory interpretation that CMS used
to justify payment for radiology, that\'s not the case. It\'s basically
on a region-by-region basis.

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

Terry, this is Karen Bell. Is that a decision that's made by the local
coverage groups, the local carriers? Or is the discussion that Jay just
presented something that is that is a central CMS decision, national
coverage decision?

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

Well, the rules on radiology are a bit different. We don\'t really think
of radiology as a telehealth service. Technically speaking, it\'s not
really part of the Medicare law as far as telehealth. But just to give
you an idea of our reasoning, it became our understanding of the way
radiology had evolved that basically when you\'re dealing with a digital
image, that it was the same image regardless of whether the physician
and the patient were in the same room or the patient and the physician
were at distant locations. That essentially the physician was
interpreting the same image. And that in a nutshell is why we have the
policy we do on radiology. That it just basically represented current
technology.

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

But if that were the case, then the same decision ought to hold true for
telepathology.

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

Well, I have to say I\'m not as familiar with pathology and sort of the
current state of technology and whether the digital images are thought
to be the same. It\'s something that we\'d be happy to look at.

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

Well, I would, you know, suggest that that actually be done because
you\'re dealing with the same type, if not a greater degree of digital
imagery in terms of bits and bytes, than you are with teleradiology.

I also have another question and I don\'t want the question to be
misunderstood in any way as a negative question. But in your relying
upon AMA\'s views and taking their views into consideration, if you were
talking about that being representative of the majority of physicians in
this country about decades ago, I would have said that\'s correct. But
in fact unless I\'m mistaken, the membership of the AMA has gone down
significantly and represents significantly less than a majority of the
physicians in the country.

Do you (inaudible) the information that you\'re getting from them truly
reflective of the majority of the physicians?

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

Well, in establishing the payment rates, we try to reflect what\'s
typical practice. The relative value update committee as I understand
the way it\'s formulated, it basically is represented by representatives
from each of the specialties on the panel.

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

Right.

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

And I frankly don\'t know whether they have to be AMA members or not.
I\'d say they\'re representing their knowledge of the services in each
of their respective specialties.

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

They don\'t have to be AMA members. But it is an AMA-dominated process,
for sure.

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

Thank you.

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

This is Karen. Terry, and I\'m not familiar with all of the things that
can be reimbursed by statute. And, but one of the things that I am
struck with is that with the exception of the types of telemedicine
coverage that you\'ve described, there is nothing that essentially would
cover care that could be rendered in a virtual setting. And I\'m saying
that because obviously we\'re very interested in health information
technology. This is the Secretary\'s significant interest as well. And
there is a belief that in the not too distant future a good part of what
occurs in a face-to-face encounter can easily occur, and perhaps more
effectively occur, in a virtual encounter.

Is there anything in current statute that precludes paying for virtual
care, or is that a decision that could be made by CMS independent of
statute? In other words, does a patient have to be in a physical
care-giving setting? And even when you describe telehealth, you\'re
describing that the patient has to be in either a hospital, a
physician\'s office, or something of that nature. So I\'m wondering if
you have an understanding of the extent of statute and law on whether or
not that is an absolute must right now.

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

Well, a couple of reactions. One, we basically have to look at the
details of the service you\'re talking about as part of this virtual
setting. But otherwise I would say the Medicare law is very specific
about what telehealth services can be provided and in what areas. So \--

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

But Karen \--

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

\-- having to learn a little more about what kind of services you would
be referring to in a virtual setting.

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

But Karen\'s asking a fundamentally different question. She\'s saying is
there any preclusion in statute for reimbursement using existing codes
for care rendered using technology-enabled telehealth. Is there any
preclusion or any restriction or requirement that a patient and a
physician have to be co-located in what is defined as a care delivery
setting. And I think that\'s \-- if we can\'t answer that question as a
Workgroup, we\'re \-- shame on us. That is a fundamental question.
Because if we can use existing codes to deliver care, using technology,
then let\'s figure that out first.

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

Well, it precludes it from a geographic standpoint right from the
beginning.

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

Why? If a doctor and patient are located in the same state?

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

No. Patient has to be in a rural setting.

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

No, you\'re asking what is telehealth. I\'m saying, can E and M visit
codes be applied to care that is rendered when the physician and the
patient are not in the same location? If you\'re saying that means it\'s
telehealth, and telehealth trumps every other statute. Okay, that
answers the question. If we don\'t define it as telehealth \--

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

Right.

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

\-- does the statute preclude physicians or other caregivers from using
existing codes, like the Department of Defense does?

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

Exactly.

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

A suggestion. If the Workgroup could sort of frame the specific question
that you would like us to look into, we can \--

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

Can I \-- can I use EM codes 99 203, 204, 205 if a patient of mine is at
home and I\'m working in my office and we\'re co-located in the same
state and I\'m licensed?

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

I don\'t think that\'s a fair question to be asking Terry at this time.
I think he\'s exactly right, if the Workgroup wanted \-- they need to
write something up and Terry is the not only one who would do a review
of that.

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

I don\'t disagree but that\'s the fundamental question whether it\'s
Terry or somebody else, but that\'s a fundamental question.

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

That's your fundamental question, Jeff, it\'s not the Workgroup\'s
fundamental question.

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

No, look, I\'m just raising the point. If we know or don\'t know whether
we can pay for services that are provided using technology, I think
that\'s a pretty important question for the Workgroup to decide under
existing statute.

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

Right.

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

So we do need to clarify that, and we\'ll follow-up on that and frame
the question and probably give it to you, Tony, and ask you to bring
back an answer later.

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

I would need to talk with Terry offline in terms of how he would want to
respond to that, either himself or someone from our legal OGC, or \--
but I think we need to frame the question for that.

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

Tony, this is Jay. Can I just underline something that Jeff brought out,
which I think is a very fundamentally important issue. If we get rid of
this silly term telehealth and just call, it you know, healthcare, maybe
we ought to re-look at it from that standpoint.

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

I have a \-- I don\'t mean to be creating problems here but I have
another question that may help us a little bit in this one. What is the
role of MEDPAC in determining how these decisions get made? I know
there\'s statute and I\'m not as familiar with the statute as I would
like to be on this so I\'ll go back and do some homework, but I also
know that MEDPAC as the payment advisory committee has a good deal of
influence on what's paid and what's not paid. So I\'m wondering if
that\'s an area that you could address, Terry, or whether that\'s
something we should look at another point in time?

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

In summary, MEDPAC is a Congressional advisory committee. So they, you
know, are sort of independent of the administration. They report to the
Congress, and they clearly put out a lot of very influential reports and
so forth. They do annual reports and special reports on various topics,
and in developing the reports they do their own sort of projects and
they have their own consultants. But in a nutshell, they basically
advise Congress and Congress then chooses to change the laws as they
recommend or not, as appropriate.

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

So just pushing this out a little bit further, if ultimately we believe
that the ability to provide care in the place that the patient needs it,
not necessarily the clinician\'s office, is an important element, and if
we discover in our work that there is something in local statute, in
Medicare statute that precludes it, the best way to perhaps deal with
that would be to go through MEDPAC? I know that there are a lot of
conditions on that, but I\'m wondering if in fact that is the case, if
MEDPAC is an appropriate step to take to change statute.

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

Right. I think the way the process would work, typically federal
employees really are not in a position to advocate for changes in law,
that changes in law are typically proposed through the President\'s
budget proposals. So \--

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

But do \-- would that go through MEDPAC? Because I\'m thinking that
obviously it's not a federal employee, I would not suggest that we do
that. But this particular FACA is a public-private partnership and there
could be private elements that could bring something to MEDPAC, if they
choose.

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

Sure.

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

That could be \-- if there\'s statute that is limiting here, we could,
there could be a private groundswell that could address it that way.

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

Yeah, I think, Karen, what Terry is saying is probably two ways of doing
it. One would be if ONC did a legislative proposal that got into the
budget, or to have private sector members approach MEDPAC separately, I
guess, that is what I\'m hearing.

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

Okay, that\'s very helpful, thanks to both of you.

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

This is Jeff again. I\'m sorry to be the problem child here again. But
if existing statute does not allow for reimbursement of services
rendered using technology for remote care, what\'s the process for
determining whether this goes to a national coverage decision or is
relegated to the regional carriers for approval? And having done some of
that in a prior life, I wasn\'t clear when national coverage decisions
were applied or not.

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

Well, the national coverage process has been developed and it\'s on the
CMS Webpage, in a fair amount of detail. The way it works, folks from
the outside can request a NCD on a national coverage decision for a
specific service. They can request a benefit category determination
also, for example. If there is no national coverage decision on a
specific service, then it automatically defaults to the contractors to
basically make a local decision on coverage.

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

Perhaps another way to think about this, Terry, and forgive me if I\'m
wrong, but if we\'re really talking about evidence-based decision, is
that what would go to the coverage and analysis group?

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

Right. Typically in developing a national coverage decision, they would
review all available evidence to support coverage for the service.

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

Whereas the local carriers may in fact cover based on standards of care
in the community, and that sort of thing?

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

They sort of have their own process that needs to be followed. They
establish their own (inaudible) advisory committees and so forth to
advise them on issues such as that. I\'m not as familiar with how the
local processes work. But clearly, you know, the more evidence that\'s
available, it makes it easier for national and local coverage
determinations to be made.

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

Karen, can I make a suggestion? We had gotten Terry at the last moment
and he graciously agreed to come. There seems to be a lot of interest in
this topic. Perhaps we can look at our next meeting and get some
specific questions that members might have and then see if I can get
back in touch with Terry and see if there\'s some others who might be
able to participate at the next Workgroup meeting. Because as I say, as
you know, we just got Terry about an hour or two before the meeting
started. So he hasn\'t had really a lot of time to do any kind of
preparation.

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

I don\'t (inaudible) him to volunteer.

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

Tony, I think that\'s a good idea. I want to put one overlay, or at
least ask a question on top of that, which gets back to my point earlier
that if we\'re looking at the specific areas that this Workgroup has
been asked to pontificate and recommend to AHIC on, I\'d like to make
sure that we specifically contain our discussion to that area. I mean,
those things that are helps or hindrances to the idea of chronic care
management, which is really what we\'re all about here. And I think this
is a bigger topic than just the one we\'re talking about. I think we
need to contain ourselves to the areas that are known barriers or known
opportunities when it comes to chronic care.

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

I\'d agree with you, Colin. I think that makes a lot of sense, otherwise
it could be a much bigger topic than what this Workgroup is really set
up to deal with.

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

Absolutely. I don\'t think we need to drain the Everglades on this one.
I don\'t think it is a subject that is containable. I know that Jeff is
asking a lot of relevant questions, the details required to get through
that but maybe we can try to filter the focus a bit.

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

Colin, I want to respond to that. Are you saying that reimbursement is
not an obstacle to \--

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

Sure it is. I\'m just saying \-- but \--

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

That\'s all I\'m asking. Can people get paid to do this?

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

Right.

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

That\'s all I\'m asking.

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

And I would just, before we move on, suggest that our broad charge
really is about providing virtual and remote care and all of the
barriers and enablers to assure that virtual remote care can have
widespread adoption in the future. So I think to that extent,
reimbursement issues are big and we just need to, I think, bring this
particular discussion to closure right now with a tremendous debt of
gratitude to Terry and to \-- I\'m sorry? And to Amy, so that we can
move on with the rest of our agenda.

But we will be pulling together the kinds of questions that I think
really probably do need to be answered as part of that bigger remote
virtual care discussion. So thank you again, so much.

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

And Jeff, I wasn\'t trying to be critical of the questions. I was just
trying to suggest, you know, this is a complicated topic and I think as
we look at what are the kind of recommendations \-- does this group need
to close in on specific recommendations as to how either current fee for
service could be tweaked in order to encourage development in this area,
or what more wide-ranging changes could be made to sort of enable us to
get to the point where the return on investment could be realized for
these kind of solutions. I sort of ask the group broadly, what level of
recommendation do we think we\'re being asked to construct here? I mean
just to say hey, this is a problem I think is probably \-- I mean,
that's undoubtedly true, I\'m not sure that\'s as far as we need to go
to satisfy the needs of AHIC for guidance from this Workgroup.

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

I do think Jeff is asking the right questions, Colin. I think that part
of what we need to understand as a Workgroup is the limits. But I agree
with you also that we do need to make sure we keep in mind that we\'re
dealing with the chronic care population.

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

So what level of recommendation \-- I know, Tony, you and I discussed
this before when Mark and I rolled out the last set of recommendations
and I think the most contentious area between the Workgroup as a whole
and CMS was sort of how to couch the recommendations about
reimbursement.

So I think we should be anticipating the difficulty of recommending
something that is considered to be feasible. And figure out if we can\'t
either restrict ourselves to things that are modest improvements that
are likely to get taken up and move forward, or \-- I\'m thinking aloud
here. I don\'t know what the right strategy is but I think we need to
think about it so we don\'t have the same issues that we had last time,
when we made recommendations that were hard to present to AHIC because
of other people\'s concerns about them.

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

Yeah. I think that\'s true.

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

I\'m not in disagreement. I just don\'t under how to do that if it
isn\'t clear what people can get paid for. Like when we need a
demonstration pilot, if physicians basically chose to submit bills to
CMS for secure messaging. We probably would want one, but it's a
fundamentally different question, and it limits or expands the range
what have we could recommend pretty dramatically and I\'m happy to kind
of keep having these discussions, but we\'ve been at it over a year. And
you know, that was like question number one from the start.

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

Jeff, I agree with you, and I think there\'s probably a set of things
that say within the current rules here's as far as you can go to move
this thing forward. And if you want to go further you have to change the
rules. At some point \-- that at least is one way of articulating it.
And maybe there\'s no way you can go within the current rules. I don\'t
know.

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

Well, for whatever it\'s worth, I think Jeff\'s question and the way he
framed it is totally on target, is exactly what we have been asking for
a year, and the whole issue of whether or not there will be
reimbursement for medical care, regardless of the setting, is really
central to this whole thing.

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

That doesn\'t even begin to get into the issue that you brought up,
Colin, which is how would we do that. I mean, there\'s fee for service,
there\'s capitation, there's lots of different ways you can pay for care
and that is actually a discussion we\'ll be having down the line.
Because this is a very difficult issue and we\'ve been around it a few
times, we decided that it probably would be best not to just bring in
one person at one point in time to talk about different types of
reimbursement. And because we have to spend quite a bit of time today on
moving the recommendations forward, we thought that we would work
together, the co-chairs and our office, to assure that we have a fairly
good representation about different reimbursement models from many
different payers down the line. So I think we will get into this issue
about how one can pay for care, not only referable to the Federal
Government but possibly even more referable to the private sector.

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

Right.

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

At another point in time and another Workgroup.

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

So this is Mohan. With respect to private sector, you know, given the
fact that I\'m accountable for at least one portion of that in the Blue
Cross Blue Shield network, reimbursement models associated with
telemedicine, shall we say, or telehealth, is something I\'m very, very
suspected in and would love to see models that I can experiment with
that allows for the economics of the healthcare system to lower its high
water mark to a level that at least is understandable and usable by the
general community. Is that the purview of this discussion or is this
another Workgroup?

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

I would suggest that because we are dealing with barriers and enablers
of remote care, that at least having a very open public discussion about
different types of reimbursement, what may be supportive of virtual
care, what may not be supportive of virtual care, I think is certainly a
direction that we need to go. Whether or not we come up with significant
recommendations at the end, or one that basically guides where the next
steps could be, I don\'t know. But I do think that we need to educate
ourselves and the public about various reimbursement models under
various circumstances related to virtual care or remote care. Because
that is such an important element of dealing with patients and improving
the health of those with chronic illness.

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

Thank you.

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

This is Eric Larson from Group Health. I was cut off for a minute and
I\'m not sure that this was said by somebody else, but I wanted to
comment that I thought the recommendation that, or the statement made by
\-- was it Tony? \-- that government employees cannot advocate for
policy change was worth noting, and then the subsequent statement that
well who can, and MEDPAC, maybe who can. And somebody said earlier about
our recommendations not being able to be acted on. We may want to be
very specific about who to direct our recommendations to, in addition to
the AHIC and HSS group.

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

Eric, this is Tony. I didn\'t say that. Actually, Terry said that. But
what he said was true. We can\'t advocate specifically. We can work them
through our budget process as legislative proposals, which is why I
suggested to Karen if ONC was interested in taking up something related
to this, they could make a legislative proposal in their budget request
or CMS to make it a budget proposal, if CMS leadership was agreeable to
that. But a specific employee can\'t advocate for it.

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

I see, okay, thank you.

[**\>\> Karen Bell:**\
]{.underline}But I think what you\'re saying, Eric, is you\'re pointing
out that there are two different ways, if there are some major issues
with statute, there are two different ways they can be addressed. One
through the private sector and then one through the federal sector.

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

Right. And I know that MEDPAC makes recommendations. They don\'t always
get acted on. I don\'t know where you consider MEDPAC, but they are
listened to.

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

Thank you. Thank you so much for, again, you're willing to step up to
the plate in the tight timeframe, Terry. And clearly I think we put our
finger on the fact that this is an area that we certainly do need to
learn more about, and you\'ve led us into this and we\'ll work very hard
to come up with some more focused questions and we may even get back to
you later, so thank you again, Terry.

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

You're welcome. We\'re going to sign off now. But again, I\'d sort of
encourage, when you develop the questions, as part of the background if
you could give us as much detail as to specific services you have in
mind, sort of like what is the clinical scenario. Because since we
haven\'t really been engaged in the issues you\'ve been dealing with
over the past year, we have to have a little better understanding of
what exactly kind of services you\'re talking about when you\'re
discussing virtual services. And anyway, with that, thank you very much,
and we look forward to speaking with you in the future.

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

Thank you.

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

Thanks again, Terry. Thanks, Amy.

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

Thank you, Terry and Amy.

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

Bye.

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

And colleagues on the Workgroup, a little homework. Terry just clarified
how we can best couch the questions so if you can send those over to us,
and we\'ll put them together and frame some questions and work with Tony
and Colin and see if we can get some answers.

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

Karen, I think Terry and the discussion that followed I thought was
excellent and I think it raised a number of key issues we need to think
about as we pull together a recommendation letter. And I think one issue
that Jeff raised was what can we and what can\'t we do today within the
current statute, whether it applies to CMS or other federal agencies.
And then secondly, what are some of the vehicles that can be used since
this letter is going to the Secretary, that the Secretary can use to
look at different ways to maybe create some more flexibility, whether
it\'s through demonstration projects or others. But I think Jeff was,
and Jay and others, are right. We have been dancing around this issue
for a year now, and I think it\'s time we kind of move on to the next
phase. But before we do, we need to address these in the recommendation
letter one way or the other.

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

Okay. We\'re actually going to be hearing quite a bit more about
telehealth and telemedicine at 3:00, when Dena Puskin calls in from
HRSA, because HRSA has had quite a few grants in this area and there\'s
very interesting information that will come through there as well. But
in the interim, we have about an hour to go over the overview and the
recommendation discussion. So if it\'s all right with Tony and Colin and
Brian, can we, it probably would be best to move ahead and may I start
the follow-up on the action items?

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

Sure.

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

Please proceed.

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

Okay. There were six action items and I just wanted to bring everybody
up to speed with where we were with a number of them. And I also will be
able to give you some updates on some of the information that was
requested.

Three weeks ago, and I will say it just seems like it was yesterday we
had the last Workgroup meeting and I guess we don\'t have another one
for about six weeks now, so it\'s \-- the timing is not always
consistent with what we would like to see accomplished.

But the very first two action items have to do with the, actually, the
first action item has to do with the Workgroup\'s scope and focus. And
the concept here was that we would talk a little more about this and
with the idea that we would have an action, a draft for this particular
meeting. Unfortunately, because of the short time frame, we\'ve not had
that discussion, so this action item will stay on the agenda for the
next meeting. And hopefully if we have time at the end of the day today,
perhaps we can talk a little bit more about that.

Secondly, the second action item in the same way was to rework some of
the issues related to the scope of work, including de-emphasizing the
financial return on investment. This is going to require, again, more
work and more discussion with a number of other entities, and given the
very short timeframe, we have, we are in the process of doing this work
but it is not yet completed. So this will be coming to completion at the
next meeting as well.

Now, with respect to the testimony, action item 3, on financial issues,
we clearly had some right now from CMS. John Linkous from the American
Telemedicine Association, was not available today, and so we have been
working with him for more testimony down the line. But what I would like
to request is that this action item be modified to include a more
robust, as I indicated a little bit earlier, a more robust and more
complete discussion on reimbursement methodologies in general as well as
methodologies with respect to telehealth and telemedicine. And that
would be not only John Linkous from the Telemedicine Association, and
the VA, but here we would also be able to bring in some of the other
telehealth/telemedicine programs that exist throughout the country and
get some input from them.

Item number 4 is about the draft recommendations for the Workgroup, and
we will be going into those in the next part of our meeting today. But
number 5 is where I\'d like to spend a little bit of time, because it
was to arrange for additional testimonies on key liability issues. There
are actually a number of liability issues, and I would like to bring you
up to speed with all of them. Rather than have external public
presenters on this, so much of this work has been done or is being done
either within other Workgroups or through our other contractors. So I
have this information available for you today and so I will be sharing
with you a couple of the critical items that were requested.

The first was on liability issues with the recognition that the EHR
Workgroup has been looking at, particularly, physician liability using
various forms of HIT. There has been a panel of lawyers that presented
information, answered questions, for that Workgroup. A number of other
questions were forwarded to them and they will be providing a document
to the EHR Workgroup for their meeting next Thursday. So I can\'t give
you the document today. But what I can tell you is that there are
essentially five or six major issues related to physician liability. One
is a concern about having a large quantity of unsolicited information
suddenly appearing on your desktop, as your clinician. The concern
obviously, how much of this am I going to be held accountable for, what
if I missed some of this, I didn\'t anticipate it. And the concerns go
on. The \-- a comment, the legal comment is that it is assumed that more
information leads to better decisions and better care. The remedy for
the concern that is generated is assuring that the information is
presented in a user-friendly and relevant format in the electronic
health record. So that is a remedy that is dependent on the technology
and how the information is presented in the EHR.

The second is perceived concern about liability as a result of receiving
and acting on inaccurate information. The comment here from the legal
team was that this is exactly the same as occurs in a paper environment.
One can clearly be receiving and acting on inaccurate information in the
paper environment as well as in the electronic environment. The risk may
be slightly increased because of the fact that there\'s a lot more
electronic information that will become available, but it is the same
liability that one has to begin with, and there has been certainly
enough case, enough cases that have been acted on to set precedent here.
So that is one that the legal team did not feel was of significant
concern.

There was a concern about disclosure of misdiagnoses or inappropriate
treatments. Here the possible remedy was the development and inclusion
of good decision support systems, and that is actually an area that the
Quality Workgroup is focusing on in its longer-term set of
recommendations.

The fourth is concern about clinical information in large data
aggregators being more readily available to litigious parties. The
interesting piece about this, and for anyone who is on the call that
would like to hear about this, please join the EHR Workgroup next week,
is that the very first malpractice insurer has gone public with the fact
that it has credits for physicians who are using some very specific
electronic health records. This is the Physician assurance \-- Insurance
Association of Massachusetts working with Connecticut Mutual. And they
have a significant credit that is applied to malpractice premiums, if,
if six very specific EHRs are used.

I spoke with them earlier in the week, pointed out that the six are in
fact certified EHRs, and discussed with them the possibility of perhaps
opening this to all certified EHRs. So that\'s something that we can
discuss in the future. But clearly they believe that the access to clear
documentation is a significant decrease in liability and therefore there
is now a credit towards premium, at least in the first big insurer that
moved forward with this. And again, for anyone who is interested, the
EHR Workgroup next Thursday will have a presentation from both the
Connecticut group and the Physician Association of Massachusetts.

The fifth concern is about privacy and security breaches that could lead
to litigation. And here again it\'s a big barrier to EHR adoption in
general. But that we clearly need, and perhaps through a different
method, either through changes in public policy or whatever, to address
those concerns. Because that is a current issue that remains very
important in physicians\' minds and clinicians\' minds, using any type
of HIT.

And the last one, number six, is, has to do with having information
available for uses other than direct patient care. Clearly there\'s
legislation around public health reporting, but there\'s also the need
to have good information available for research purposes, for reporting
purposes, quality improvement purposes, et cetera. So there\'s concern
about widespread use of data for purposes other than direct patient
care. So, and that is again an area that the Quality Workgroup will be
looking at.

So I\'m presenting this to you today and again, there will be a more
formal presentation next week in a formal letter that will be posted on
the Website on a number, on some of these issues. And again, the letter
will be presented at that EHR meeting next week, but giving you some
background information on some of the discussion that occurred at the
EHR Workgroup, because the same kinds of issues are relevant to
acquiring information from the remote devices and remote sources.

Does anyone have any questions or comments about that particular issue?

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

Karen, I just, maybe I\'m behind on my e-mail, but you were reading from
something that we should have received as an attachment, or were you \--

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

No. You will receive this after we formally receive a letter from the
\-- I was just reading you my notes.

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

Okay, because I think there\'s a couple things I\'d like to follow-up on
in that but I don\'t want to distract the meeting.

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

Some of this will be available when the summary from last EHR Workgroup
is posted on the Web, so you will be able to see the summary in the
summary document at that time. But this is not yet posted.

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

Karen, this is Eric Larson. Is it possible that some of that you, for
this particular topic, could you push that to us as members of this
Workgroup?

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

I can do that, for sure.

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

Thanks.

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

I will forward that one to you. And then we\'ll have more discussion, or
at least it\'s now in the public venue so I can send this to you now and
it will be, again, available on the Website in the future.

There was a second area that people had some questions about. And that
was around Stark and Anti-kickback. The ruling is that there will be a
safe harbor, and, for Anti-kickback, and Stark relief for hospitals and
other care entities, i.e., physician groups, that donate software and
services, not hardware, to physicians in the form of EHRs. The EHRs must
contain E-prescribing and E-prescribing alone can also be donated. But
the EHRs must be interoperable, and there is a ruling that also includes
that certification is a way of being deemed interoperable. We also have
a guidance, we have guidance that certification must be made by a
recognized certifying body, and the Certification Commission, CCHIT, has
applied for, and received, that status. So right \--

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

So they are, by definition, the only certified certifying authority. Is
that the way that works?

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

At the moment, yes. At the moment, yes. So that any hospital or
physician group that would like to donate can certainly do so, if they
are certified products. I will tell you right now that there are about
to be close to 70 products certified. And that the process also includes
some of the EHRs that have been developed by some of the larger systems.
So that a system such as Partners or Asheville Clinic or whatever can
have their product certified as well.

The concern that we have heard, particularly from hospitals around this
is not so much about having broken a law, or having problems with Stark
or Anti-kickback, but more from the concern of losing their tax-exempt
status if they were to make a donation. So the American Hospital
Association, just as recently as February first, met with the IRS to
resolve how that could move forward. And the IRS is coming forth with
its particular approach to remedy that solution. So once that is done, I
think that the doors will open and there will be much more opportunity
for support to physicians in that way. Before I go any further, are
there any questions or concerns about that? That was number 2 on my
list.

Number 3 on my list were concerns that the Workgroup registered about
fraud and the potential for increased fraud if one is practicing virtual
care. I can also address that one with you, and I can also point you to
our Website where you can find some information about our fraud and
abuse contract. But the bottom line here is that it is recognized that
there is the potential to enhance the possibility, opportunity for fraud
in systems where health information technology is used extensively.

To that end we have let a contract to develop, model, and test broad
requirements for electronic health records, with the idea that they
would be standardized by the HITSP standardization panel. That they
would be dovetailed with the work of the Certification Commission. And
that there would be essentially a product, the vendor product, whether
they\'re ambulatory or in-patient EHRs, would have essentially built
into them the assurance that proper payment would be made. And here I\'d
like to underline the fact that fraud doesn\'t occur unless it\'s
actually been proven. You\'re not, fraud doesn\'t exist unless you have
been proven to be guilty of fraud. So the real concept here isn\'t to
find fraud. The real concept here, particularly in the physician
environment, and I do want to underline this because if one looks at the
total numbers of dollars that perhaps can be regained through
eliminating fraud, then virtually a negligible amount are attributable
to physicians in the outpatient setting.

Right now, the emphasis on EHRs, or HIT, is around physician EHRs. So as
we move forward and other systems adopt electronic health records, it
may become more relevant. But the real advantage to physicians right now
is that if the appropriate processes and functionalities are in the
outpatient EHRs, then the physicians will be able to bill correctly on
the first go-around, and can be guaranteed prompt and accurate payment.
And I think as we all know, there are significant problems with
reimbursement that are related to not improper payment practices, but
erroneous billing and a number of other issues. So that\'s the approach
that we are moving forward with, with our fraud contractor. Any comments
there?

Lastly \--

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

I would just think that that\'s an important point to note, where the
fraud is actually occurring. And I don\'t think that\'s widely known.

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

I think that\'s true. CMS recently put out a report that outlined where
most of the fraud is occurring and where it\'s not. Do you remember the
date of that report, Tony, by any chance?

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

No, I don\'t, offhand, Karen.

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

I\'m sorry, I don\'t remember either. But it\'s been within the last few
months. I think it was right at the end of 2006. So what we will do as a
follow-up item is we will get the exact reference to that report and
share that with all of you.

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

Great.

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

And there was one more item that you had asked about. And I can give you
a update on that. And this is the NGA state-based licensure. Again, the
timing isn\'t great on this one. If we had just waited another week or
so, then the task force dealing with this would have met and we would be
able to report something significant out in terms of progress in this
area. However, I\'m going to ask that you let us hold this as an action
item for the next meeting, at which point in time we should be able to
have Bob Water (ph) present, because he will be actually engaged in this
in terms of what the results of that task force meeting will be. So
rather than jump the gun here, we\'ll wait until someone else does all
the work and we can benefit from it.

And that is, I believe, the \-- my report, the completion of my report
on the follow-up from the action items, with the exception obviously of
number 6, which are the draft recommendations, and we can go into those
next.

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

Great job, Karen.

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

Thank you. Any other questions or comments?

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

Thank you.

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

Thank you. And who would like to, Tony or Colin or Brian, would you like
to lead the discussion on the recommendations?

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

Colin, you want to go ahead?

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

Not really. You\'ve probably been closer than I have in our last three
meetings.

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

I believe everybody received the very succinct table on recommendations
where we listed the five critical areas on the right.

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

Right.

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

Talked a little about how we might want to do a recommendation. And
there are some areas where you will need additional testimony and we
talked some about that. And we\'ll move forward with it, but we can talk
more as we look at each particular area.

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

I guess, Karen, from a process standpoint in the areas where we say
there\'s no further testimony required at this time, do we want to go
ahead and craft recommendations, or do you want to have your shop go
ahead and craft draft recommendations, or do you want to just discuss
the areas and then based on our discussion come up with some draft
recommendations?

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

We will be more than happy to help craft the recommendations once you
all have discussed what it is that you would like us to do.

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

Right, that seemed to me to be the most logical way to do it. We discuss
the areas where require no further testimony, what are the
recommendation topics and decisions we\'d like to see in the
recommendations for those areas. And I guess part of that would be
building upon what we put in the original letter for the initial charge
since these are pretty much the same areas.

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

I think that\'s correct.

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

Yeah, I think the key there is to make sure that we kind of limit
ourselves to things we now need to talk about. If we\'ve made
recommendations once through, before, in certain areas, I mean we
probably don\'t need to re-recommend that stuff. We should probably
filter it and make sure we\'re adding something new from what was said
before.

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

Right, and I would just underline that the recommendations that went
forward before, last spring, were very specific to secure messaging.

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

Right.

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

And so now we are looking more towards the broader charge, and we will
we will be spending a lot more time looking at the broader charge but
given all the discussion we have had since the first batch, are there
recommendations that we can make now that begin to move us into that
broader charge?

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

But in some cases it may be just tweaking the ones that we had in the
initial charge to make them broader, rather than entirely new
recommendations. I think that might be one way of looking at it. For
example, some of the reimbursement discussions, I think some of that,
the recommendations might relate to broadening the charge to go just
beyond secure messaging, rather than just \--

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

Right.

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

\-- what was in the original one. So we might want to start from that
angle, look at what we had in the initial charge and see if there\'s
ones that just need to be broadened, or if there\'s additional
recommendations that we need to add with the broader charge letter.

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

I think that\'s a great idea. Would you like to start with the technical
and the confidentiality, privacy, and security because those two we
don\'t need any more testimony for?

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

Yes, as soon as I dig up my copy of the initial charge, I can speak, or
if someone else has a copy of the initial charge letter in front of
them, maybe they can start.

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

Would you like to us read the broad charge, or we have it right here.

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

If you could read the broad charge Karen, and then read what we put
under the initial charge in that specific area and see if it\'s
something we want to broaden or change for the broader charge.

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

Right. I\'m asking someone around the table to get us the original set
of recommendations that we made from that first go-around. The broad
charge is to make recommendations to the Community to deploy widely
available, secure technology solutions for remote monitoring and
assessment of patients, and for communication between clinicians about
patients. And I would like to underline the fact that the broad charge
does not limit us to patients with chronic care.

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

Right.

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

So I would actually like to put something on the table right now. I know
we talked about the scope of this Workgroup moving forward, and we might
have this discussion at the end, but maybe this is the time to do that.
Given the broad charge, just the way it\'s written, what, how do people
feel about widening the scope of this Workgroup? And I know we had a lot
of discussion last time but we didn\'t come to any agreement, any final
assessment.

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

When you say widening the scope, do you mean within the context of the
original charge?

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

Within the context of the charge. We are called the Chronic Care
Workgroup but the basic charge does not limit us to patients with
chronic illness.

**[\>\>\
]{.underline}**Yeah, I think our title, the Chronic Care Workgroup, sort
of constricts us relative to what the broad charge is. Maybe we ought to
change the name of the Workgroup.

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

That\'s entirely possible. I certainly will tell you that the
Biosurveillance Workgroup changed its name because as it moved forward
it became quite clear that it wasn\'t just about biosurveillance, it was
about population health in general. So that Workgroup is now called the
Population Health Workgroup.

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

Yeah, I would be very cautious about changing the Workgroup at this
point, Karen. I\'m just \-- and I know Colin and I have talked with you
before, our concern about scope creep and also making sure that the
recommendations get implemented, and I\'m concerned if we go too far off
and get into too much scope creep, we\'ll end up with an entirely
different mission for this group than what was originally anticipated in
the beginning. I don\'t know all the history \--

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

I mean, the title right now, it was 80 percent of U.S. healthcare
spending. I\'m not sure how you could expand the charge, quite frankly.

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

Yeah, but that\'s just the point. If we could switch to a more proactive
care delivery system, we wouldn\'t be having a lot of this chronic care.
And if you look at what the charge is, you know, it is not consistent
with the name of the Workgroup.

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

But I think the problem with, both the benefit and the problem with
having the 80 percent healthcare costs in chronic care is that if we\'re
talking about health technology and electronic health records and
connectivity, you wouldn\'t want to parse out a system to serve only the
80 percent. The system in its entirety should be available for acute and
preventive care, because those aren\'t separated, in most instances,
from chronic care.

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

That\'s right. Exactly. I can give you a specific example. The
tele-stroke initiatives. If you have tele-medicine into an emergency
room in a rural hospital and are able to assess that CT scan and tell
the physician at the remote hospital that this patient needs
thrombolitic therapy for their thrombotic stroke, you are avoiding the
chronic care of taking care of an individual with major paralysis.

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

This is Anand Parekh. One question I have, and Karen you might be the
best to answer it, when the specific and broad charge was first crafted
for this Chronic Care Workgroup what was the discussion in terms of I\'m
sure folks realized at that point that chronic care wasn\'t in either
charge, that phrase or that term, what was the history behind not
specifying, or not having that term in either of the charges?

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

I think, and this goes back to right when the AHIC was first forming,
the recognition that remote and virtual care is a very important piece
of getting patients the right care in the right place at the right time,
was the real driver behind this. So the real driver behind this whole
Workgroup is to deal with these issues of making virtual, i.e., remote
care, available. Now as we thought about how to do this, clearly from a
perception point of view, most people recognize, as you just
articulated, that most of our dollars are either going to chronic care
management and not enough are going to prevention of chronic care. The
whole concept of rolling this up into the rubric of chronic care gave it
the validity, so to speak, of being able to tie it to a group that we
believed would benefit very intensively from these types of systems.
However, I think there is also the recognition, and we have heard this
in some of our meetings, that cancer is now for all intents and purposes
a chronic illness. Many people have cancer. They are treated. They may
have ongoing medication or support to keep it in remission. So that
cancer has become a chronic illness. AIDS, as we know, has become a
chronic illness. It is no longer something that is immediately lethal.
Disability, for all intents and purposes can be considered a chronic
illness. So we have all of these conditions that roll into chronic care.
So we basically thought that if we called it the Chronic Care Workgroup,
it would deal with all of these very difficult and high cost areas where
we could really see the benefit of remote and virtual care.

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

Let me just throw out something, just as a target for everybody to shoot
at. What if we renamed it the Connected or the Connecting Care
Workgroup, or Connected for Care Workgroup. It\'s a name that Markle
Foundation has popularized. It\'s a name that IOM has popularized. It\'s
one that a lot of medical centers are now re-looking at naming their
centers that way. For instance, Partners HealthCare system is now
Connected for Care. The whole continual alliance initiative focus is
that way, and that really is the functional intent, connected care,
whether it\'s in person or whether it's virtual.

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

Karen, let me suggest this. Why don\'t we try to answer the issues
related to the broader charge and if that then results in what we feel
as a group needs to have a change of the group\'s name, then we go ahead
and do that. Otherwise we may get caught up in trying to rename the
group without really getting to the issues that we\'re trying to deal
with in the first place.

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

Okay. And then I would just, some of you have been engaged with the
Workgroup or even with the AHIC right from the beginning, so anyone who
is on the line who has a different or slightly different take on what
occurred, please jump forward. But what I just shared with you has
really been the driver. Really it\'s really the remote care, making care
virtually available that\'s been the driver for all of this. And that
includes monitoring devices and all of these other things.

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

Tony, I don\'t know how much time we have, this is Eric Larson, but I
just wanted to throw out a question that I flashed across my e-mail this
morning on this piece that Health Affairs published today, with David
Brailer\'s interview, and to what extent is the question of control of
clinical information relevant to this workgroup\'s charge? You know,
provider versus consumer.

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

That would seem to me, Eric, I don't know, Karen, you may be able to
answer this too, I think that\'s one of the areas the Consumer
Empowerment Workgroup would be looking at. Not that it wouldn\'t cross
over to our group to some extent, but it seems to me like, that strikes
me as something that they would be more tied up with more.

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

I can just give you an opinion on this, and it\'s strictly an opinion. I
think ultimately there will be electronic health information that will
be available about each one of us, that will be available about the
environment around us, available through research and science, that
different types of technology will tap into. If you\'re a clinician, you
will be using one particular type of technology. If you are a patient or
consumer, you\'ll use a different type of technology. Until we reach
that state, though, we need to deal with a lot of policy issues, as well
as technical issues, that exist at the provider level, at the patient
level, and at the level of other folks interested in accessing this
information. So the Consumer Empowerment Workgroup right now is dealing
with all of the barriers and enablers for patient access to that
information, whether it sits in a physician\'s office at the moment or
it\'s sitting in a big health bank somewhere or whether it's sitting in
a lab. How do patients access information? Our Workgroup is focusing on
how can we support the provision of remote care, so it's not so much
about access, patient access to information, it\'s about the provision
of care in remote and virtual settings. So there is a nuance between the
two. I don\'t know that that truly answered your question, but it does
distinguish our role versus Consumer Empowerment.

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

The reason I ask the question, and I appreciate your answer, is I wonder
to what extent achieving this goal of better access and better
communication, which I see as one of our sort of overgoals, if the
ownership issue is one that we have an opinion on as being a barrier or,
to making progress. I mean, we talked about the barrier of reimbursement
forever and ever, and I just don\'t know the answer to the question. So
I thought that you might have an opinion on whether they\'re related.

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

I think probably, and what I will tell you is that every time we are
asked the question about ownership, it\'s not \-- basically saying no
one really can own an electron. It\'s more about authorization, and use,
and that ultimately patients do have the right to determine how their
information is used and to whom it is \-- it becomes available. So it\'s
not so much ownership, it\'s about authorization and access.

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

Okay. So it\'s not really an issue, then.

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

I don\'t think so.

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

You know, Karen, but Eric\'s question does bring up a good point. If
we\'re going to think about the movement of this Workgroup beyond
chronic care, it seems like we\'re going to end up with more and more
intersection with the Consumer Empowerment Workgroup, and I guess the
question is, depending upon how we deal with the broad charge and decide
if the Workgroup\'s name or mandate does need to be changed, we have to
make sure we have a good intersection with them, because a lot of the
issues we are getting into and we\'ll continue to, do very closely
intersect with some of the discussions I\'ve seen and heard from the
Consumer Empowerment Workgroup.

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

Well, I think that\'s true. We certainly do need to \-- and I think one
of the things that we have talked about and we will be instituting soon
is to have all of the co-chairs of all of the Workgroups meet on a
regular basis. Now, that doesn\'t mean you spend two extra hours a week
doing this, but at least there would be even a monthly opportunity or
maybe even a quarterly opportunity for all of the Workgroup co-chairs to
meet together so that there\'s a good understanding of what\'s happening
amongst all of the Workgroups, so that we are very clear about the
directions we\'re going and we\'re not doing redundant work.

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

I think that makes a lot of sense because you had already mentioned
earlier the intersection with the EHR Workgroup on the licensure issue.
That\'s a very good example as well.

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

You see that one is easy because I sit on that one, too. But the others
\--

\[laughter\]

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

Get everyone else involved in.

Okay. Any more thoughts about where we think we should be going as a
Workgroup? I mean, is this something we want to make a recommendation
about? Or do we want to think about this and talk about it at the next
go-around?

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

I think maybe this is a redundant question, but I mean could you
summarize what you believe the, what you believe expectations are for
the next level of output from this Workgroup? Maybe that's redundant. Is
there a simple way of saying that, so we can \--

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

I think it would be understanding that as we move forward, we will be
looking at the vast array of telehealth services that can support better
care for virtually everyone.

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

Right.

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

And that recognizing that patients with chronic care constitute the
major proportion of the dollars spent in this country. But that
providing the kind of care that\'s necessary to prevent chronic illness
and the progression of chronic illness will be important for long-term
national health. Is that the general overall concept that would make
sense?

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

From my standpoint it is.

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

Yeah, I think it\'s fine.

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

This is Mohan. I feel the same way.

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

Then we\'ll craft something of that nature and we\'ll have a little
contest for renaming ourselves, maybe. With a prize.

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

I would \--

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

With any luck it will be chocolate.

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

Make the prize small enough that government employees can actually
benefit from it.

\[laughter\]

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

Chocolate.

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

This is Mohan. When you speak of chocolate, I have to chime in. You
know, I have an anxiety that maybe is not shared but one that I would
appreciate being addressed if possible. Is that, you know,
recommendations are fine, and making recommendations are fine, and I\'m
more than comfortable with the charter of recommendation. But I think
gratifying volunteerism with action is something I\'m also looking for,
and is there any way that the Workgroup can get feedback loops about
these recommendations turning into something concrete in terms of action
and next steps so that we feel a sense of momentum rather than we feel a
transactionally related to the groups or people we recommend to.

I would really appreciate that because I personally do not want to sit
in a committee making recommendations into the blue, and pardon the pun
on that, but making a recommendation into the sky without seeing some
acknowledgment. And the best acknowledgment for any volunteer is that
their recommendations are turning into something, even if the
recommendations are rejected, there is still an acknowledgment, and I
would ask for that to be part of this operating process.

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

Mohan, this is Karen. All I can tell you is you are right on and I agree
with you wholeheartedly and I\'m quite embarrassed that we haven\'t
gotten back to everyone with the follow-up to the recommendations we
already have. We have been working on them, many of them have been
implemented, many are in stages of implementation, and we absolutely owe
you that type of feedback. So that will be number one on our action
items for next go-around. We will bring you \-- I will send you a
document in advance. I am actually looking at something right now but it
has how many pages to it? Yeah, about 12 pages, and it\'s legal-sized.
So we will pare this down and get something to you before the next
Workgroup meeting and discuss at the next meeting and thank you so much
for your suggestion, Mohan.

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

Thank you for being so actively participatory on that. Because that
would make \-- personally, it would motivate me even more than I am now,
if I hear the echo.

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

Karen, this is Dena Puskin. I just want to let you know I joined you.

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

That\'s wonderful. Welcome aboard, Dena.

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

Thank you.

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

Perhaps I should ask the rest of the Workgroup, since Dena is on board
now, would you like to hear her testimony and then we can come back to
the recommendations?

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

Dena came on board when she heard about chocolate.

\[laughter\]

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

Jay, you know me too well.

\[laughter\]

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

Somehow I think putting it in the minutes that we like chocolate with
the chronic care committee was kind of \--

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

It treats all sorts of anxiety, Mohan.

\[laughter\]

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

Well, it is the day after Valentine\'s Day. Shall we move forward with
Dena and then come back to the recommendations?

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

Sounds good.

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

Okay. Let me just introduce you, Dena. Dr. Puskin is with HRSA, and has
been in charge of all of the efforts that HRSA has been making with
respect to telemedicine and telehealth, for how many years now?

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

Since 1988.

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

So it\'s been more than a few. She also has a very good understanding of
what is going on with respect to telehealth and telemedicine in the rest
of the Federal Government as well, and Dena, I will just tell you that
you are off the hook in terms of talking about Medicare reimbursement
because we did have a very nice presentation from Terry Kay on that a
little bit earlier.

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

Okay. I had actually prepared something very briefly, but that's great.

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

Okay.

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

I don\'t know what was presented but I will perhaps \-- did he \-- I
don\'t know if Terry is a he or she, actually. But was the, presented
the emerging issues with that? Or not?

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

Probably not, and I think that whatever you have to present you should
present, and then we\'ll go on. But I just wanted to give you a heads up
that we did have that discussion with Terry this, a little bit earlier
in the call and he was most gracious because he was just asked to do
this on a very short notice.

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

Right. So I don\'t have to do 101 about what\'s covered and what's not
covered.

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

You may, but we\'ll ask you questions.

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

I\'ll try to get through because you asked me to briefly cover the pilot
program. Is that still on the \--

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

Please do.

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

Okay. I\'m going to do some of this very quickly and I speak very
quickly so I\'m sure there will be lots of questions. Some of this is
sort of boilerplate, but it\'s important to get the perspective that we
have, at least that we have here in HRSA.

If you go to the first slide, we have, we use terms that are often used
differently in different parts of the, what I call the telehealth
community, and I just would like to make sure that everyone understands
how we use them.

When we talk about telemedicine, we talk about the use of information
and telecommunications technologies to provide clinical care when
distance separates the participants. It doesn\'t mean physicians
providing it, it doesn\'t mean, clinical care can be supportive care in
this context as a monitoring patients, et cetera. The difference really
is, with telehealth, is telehealth encompasses telemedicine from our
perspective. But includes health, use of information and
telecommunications technologies to support healthcare when distance
separates the participants. And supportive services in our mind include
health professions education, some of the administrative uses,
evaluation, research, in some instances it involves homeland security,
public health, consumer education and outreach, and regional health
information sharing. So telehealth is sort of the umbrella. And the
reason for that is because all our grants cover all of that. So we have
an umbrella term.

If you go to the next slide, just to give some perspective on where
we\'re located and where we are, our office is in the Office of Health
Information Technology here at HRSA, that reports directly to the
administrator. Our focus is on the use of these technologies to improve
healthcare for the underserved. And so the vision is no matter who you
are or where you are, you get the healthcare you need when you need it.

As you go to the next slide, a typical slide of distance education,
you\'ve all seen it. I think the important point here is that in all our
activities, whether we\'ve got a clinically focused program or an
Informatics program, what we find is almost all our programs do, have
used the technologies for educational and administrative uses. In part
because in some programs that was the loss leader. If any of you have a
retail background, you know that retail industries, basically you offer
goods at cost or below cost to get customers in. Often the educational
focus is a way for some of these programs to get practitioners to become
engaged in the use of these technologies, and then migrate to the more
clinical uses.

We divide the applications of telemedicine and the use of technology in
a couple of categories. The first is real-time telemedicine, in which
basically the patient is present at the time and there was a remote
practitioner who may be consulting these cases, it\'s a typical clinical
consult, or an ER. But the key here is it\'s occurring in real-time,
it\'s interactive, and the patient is present. There are two examples
there.

Another example on the next slide is in rehabilitation. The dichotomy in
some of the public policy issues we\'re facing now relate to store and
forward, where in fact an image is taken, information is taken and then
transferred electronically for essentially later interpretation or
review by a practitioner. You\'re storing the information and sending it
forward. Typical example is radiology. A lot of dermatology is done that
way. There\'s no real-time interaction between the patient and the
consultant or the remote practitioner. It\'s commonly as I said used for
dermatology and radiology. A lot of actually telemonitoring falls into
this category.

The next slide is actually a combined approach which relates to
ophthalmology. There\'s a real-time followed up essentially by later
interpretation by clinicians and this is in ophthalmology. What we\'re
seeing and this is where I\'m going to get into some remote monitoring.
Because of the aging of the population that you\'re all very familiar
with, and I certainly am as I\'m getting there, there\'s increasing
emphasis on low cost applications and improved quality of care, and
integration of information systems so that we can more effectively use
these technologies to provide healthcare.

As you go to the next slide, some of the emerging technologies which at
first may not look very inexpensive, are actually, compared to what
exists now, very much at the lower end of the cost spectrum. One of the
first one deals with pathology, dramatic changes in pathology where
we\'re using essentially store and forward technology, but instead of
using microscopes that essentially have to be moved remotely, these are
really computers in which you actually take an image of the slide and
just send the image. And this is used extensively in Japan. Another
emerging area is pharmacy, telepharmacy, E-prescribing, which we will
talk about a little bit later. But also E-dispensing, especially in
rural areas where it\'s harder to get a pharmacist than it is to get a
physician. And we\'re seeing the area of telepharmacy growing by leaps
and bounds.

Next slide is home health and that\'s getting into the area of I think a
lot of your focus in home monitoring. This is an older picture of a
patient, obviously using some equipment. This area is clearly one of the
areas of most, of great interest to many of the applicants we get for
our grant program. We consider this either you can have an interaction
as you\'re occurring here, and which in fact is a live, interactive
interaction between the patient or the client and the nurse remotely.
And they may be checking vital signs and medications, but there is a
live interaction and there's a picture, I hope you can see it, of
actually the quality sometimes of the images we can get. That\'s one
level.

But what we\'re finding is the most successful programs are ones that
match the level of technology to the patient\'s need. You don\'t always
need to visualize the patient. Certainly that\'s what the VA has shown.
And next image we have a congestive heart failure monitoring program in
which you\'re basically monitoring some vital signs. Sometimes you
don\'t even have to get that sophisticated with some patients. You can
use something like the health (inaudible) you\'ve preprogrammed it with
a series of indicator questions that are asked of the patient every day
to highlight whether in fact there are problems occurring. The next one
is essentially a mobile unit laptop used by a nurse going into a setting
to gather information and send it.

PDAs, increasingly we\'re seeing PDA devices are actually being used to
begin to monitor patients. And so that\'s sort of the emerging area. One
of the ideas is to basically, as I said, be able to handle the burden of
illness that is out there in chronic disease in the most cost-effective
manner and engaging patients and their families cost effectively in
doing so.

So the bottom line from our perspective is, in all the things we've
looked at, telehealth is a toolbox of diverse technologies applied to
diverse healthcare needs and it\'s a very dynamic field. When we\'re
looking at our own program, our own programs have been governed of late
by the Health Care Safety Net Amendments of 2002, Public Law 107-251
which basically created three programs for us to manage and in which we
fund grants and from these grants we learn a lot of lessons that help us
to inform policy.

The first one is the Telehealth Network Grant Program. The second one is
the Telehealth Resource Center Grant Program, and the third is Licensure
Portability Grant Program.

The last two programs have just been funded for the first time. The
other program has been around for quite a while in one guise or another.
What we are doing with our programs, and these are not the only programs
that HRSA has in telehealth, and I want to emphasize that, because we
have telehealth programs that come out of our Maternal and Child Health
Bureau, specifically dealing with genetics, and we have other programs
that are dealing with school health. We fund school health but so does
some of the programs that come out of Maternal and Child Health. We\'ve
had HIV-AIDS programs and our community health centers, we\'ve been
funding them with the Bureau of Primary Health Care to see how we can
advance primary care applications, and reaching out.

So what was the intent of establishing our office and basically its
programs? Well, first, to seed the field. And we think we\'ve done quite
a good job of that over the years, through pilot and demonstration
projects that show what is possible. To be a focal point for
coordinating telehealth activities, not only within HRSA, but we\'ve
worked over the years to coordinate across agencies. In large part
because we have so little money that the only way we can be successful
is to leverage other programs that are being funded by other parts of
the Federal Government. And to encourage our grantees and help them to
leverage those dollars. And the only way we can do that is to work with
groups, other groups, to provide technical assistance to basically
disseminate model principals and lessons learned, clearly to promote
collaboration and synergy. We don\'t want to duplicate but we sure as
heck, as I said, want to leverage the Dickens out of things. And to
identify options for addressing barriers to the effective use of
telehealth technologies and try to develop some solutions.

Some specifics on how we do our job. Well, we have a directory that\'s
on the web and that sounds sort of mundane, but it\'s not a directory.
It\'s really a very extensive tool we use internally to clearly identify
for folks what our grantees are doing. Specifically, what are they
doing, for example, in terms of payment. What kind of payments do they
get? An interesting factor, and we can talk a little about payment, we
find by querying our grantees that grantees are getting payment from
sources that when you call the sources they say they don\'t pay for
telemedicine. So it\'s an interesting way of getting a lot of
information, the extent to which they\'re involved in bioterrorism and
really providing profiles of the kinds of services they deliver, the
settings, and some specific areas that have relevance to policy.

We have a listserv which is an internal listserv for grantees current
and prior grantees. That basically allows them to provide technical
assistance to one another. The listserv allows no vendors on it, and it
provides an honest sort of broker role. What we find is people are very
\-- more willing to share their warts and concerns once they get to know
each other and feel part of a community. And the technical assistance
goes way up. We have provided technical assistance documents, we have
one that\'s a guide to getting started in telemedicine that came out,
was written by 50 individuals involved with our office, either they\'ve
been grantees or they\'re fellow federal agencies, on basically getting
started and a number of other TA documents that are on our Website but
we\'re about to also join with AHRQ, and use a portal that will be much
more available to folks than I think the current HRSA Website for
information, and will also include information from other parts of HRSA,
on telemedicine.

Our annual grantee meeting, Jay was just at and so was Karen, is a major
vehicle for technical assistance. We do one at the ATA, we\'re very
active with the ATA. Perhaps of greatest use to us over the years has
been the joint working group on telehealth and telemedicine which is a
Federal staff-level working group, in which basically staff of the
different agencies get together on a monthly basis to share lessons
learned, issues, and challenges. And through that group we\'ve written
two Congressional reports and whenever we get a request from Congress or
others, we really turn to our fellow agencies to help draft some of
those responses.

We serve as an ongoing resource to the public and hopefully provide some
policy support. Our partners are many, and they\'re listed in the next
slide. I think if we go to the following slide, it just gives you a
perspective, we\'ve awarded over 250 million grants since 1989. In 19
\-- in 2005, we awarded approximately 34 million that was competitive
and Congressionally-mandated and there were 159 programs in 47 states
and the District of Columbia. What you need to understand about that
figure, because it changes radically in 2006 and 2007, is that the vast
majority of those dollars were to Congressionally-mandated projects. For
those who do not know what a Congressionally-mandated project is, it\'s
an earmark, or some people call it pork. It\'s basically where Congress
tells us who to give the money and how much we should give them and for
what. What we find is often the projects are really in, shall we say,
very nascent stages of development and those are probably our hardest
projects to administer. However, our position is we don\'t care how you
get the money, once you\'re an OAT grantee you are subject to our
standards. And we expect that you, the taxpayers\' dollars will be well
used. So to the extent possible we try to treat them as if they were any
other program. And they have an application, they have progress reports,
they are treated pretty much the same except we have our hands a little
more tied in terms of some of the evaluation measures. And that\'s
unfortunate. We\'re going to try to change that in the future as we deal
with future earmarks.

Okay, so what are some of the programs currently managed by OAT? In
addition to the Congressional earmarks that are in the period of what we
call no-cost extension, we are managing a new set of grants that were
awarded in 2006 for the Telehealth Network Grant Program, the Resource
Center Grant Program, and the Licensure Portability. So Resource Center
Grant Program, we made six awards. Five regional resource centers have
been created to help communities, providers step off the curb and either
start or expand their telehealth programs. We have found over the years
that in order to really do this, you need to have technical assistance
closer to where the providers are. And you need to have the technical
assistance from people who have walked the talk. So these five centers
are essentially people who have had great success in doing telemedicine
and funding it over the years.

And they are \-- I\'m going to show you where they\'re listed. We also
have a national resource center, the Center for Telemedicine and
E-health Law, and it, it\'s job to actually support the other centers
and helping them with legal and regulatory issues that cut across the
different regions of the country. And to provide a national sort of
perspective on that. The way we\'re treating this resource centers is
basically they\'re part of a network, and you might think of them as
regional offices of this office, in the sense that they are going to
provide technical assistance locally but they are going to share
expertise because there\'s a limited amount of expertise to go around.
So if one center happens to be very good at technical assessment, that
center would be a resource to the other four in doing that. And we have
one center who happens to have great expertise in evaluation. It will
serve as sort of a center of excellence among them to help support them.
So we have sort of a matrix model on how this is going to work.

The Telehealth Network Grant Association, 16 awards were made for
networks, to essentially both expand telehealth services but there\'s a
greater focus on evaluation measurement and performance measurement and
three of those are focused totally on home care and home monitoring per
congressional directive. And their focus is absolutely on measuring
cost-effectiveness or at least costs and impacts of these services. And
finally, the Licensure Portability Grant Program is geared to trying to
promote essentially more effective cross-state practice and reduce the
cross-state practice barriers in telemedicine.

If you go not to the next slide but the following one, it actually
lists, you can see the folks who have gotten these awards, and you can
see that the Licensure Portability Grant went to the National Council of
State Boards of Nursing and the Federation of State Medical Boards, and
the reason for that is we needed groups that could basically work across
state boundaries and have had experience.

If you go to the next slide, characteristics of the grants, distance
learning, telemedicine, informatics, public health.

I\'m not going into the next slide much except to say these grants are
really about supporting operations. They\'re not about buying equipment.
You can use about 40 percent of the dollars for that, but basically
it\'s about organizational development, evaluation, and collaboration.
Because what we are asking our grants to do is leverage other dollars,
so they\'re required to participate in the universal service program to
essentially get reduced costs for their telecommunications costs.

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

So I\'m sorry, what \-- I\'m not familiar with that program. What are
the other dollars they\'re expected to leverage? Are there multiple
sources?

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

Yes, there are. And I can go into the universal service when I talk
about the FCC, I\'ll talk about that program. Okay? But that\'s a
discount, what it does is provides subsidies to telecommunication
services for providing distance education for healthcare providers, as
well as for clinical services. And there are some limitations on that
program, but we require our grantees to apply for those discounts
because, for example, we can have a grantee where without the discount
it might cost them 2,000 dollars a month for their telecommunications
line to do telemedicine, where with the discounts it may cost them 200
dollars. So with dollars saved there, they can use that to provide
services and develop \-- it\'s better use of the grant funds. Okay?

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

Okay.

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

I know I\'m going very quickly, but the earmarks, if you say the
earmarks are basically, they\'re very diverse. Typically, a Telehealth
Network Grant will be for 250,000 or less. The earmarks can be from
50,000 to over a million dollars a year. Some of you may be familiar
with the E-health Initiative. They have gotten 6.8 million dollars from
us over basically it was three years of award, to give you a sense of
the difference we funded the original nine RHIOs in this country under
that grant. And the scope of what these, an earmark may do is from
laying a fiber-optic line or establishing a brain imaging unit to
traditional telemedicine. They\'re all over the place compared to the
programs, which are quite focused on different services.

So what have been some of the accomplishments? Well, clearly, there\'s
been a dramatic growth since we\'ve begun this in telemedicine. In the
Telehealth Network Grant Program alone and the predecessor, Rural
Telemedicine Grant Program, we know there are over 700 communities that
have been supported. There are 700 sites, in over 239 communities that
have received funding from it for about 3.8 million dollars in the last
four years. We clearly have committed \-- created a community of
interest with the listserv and annual meeting. The folks have come and
been our grantees are now leaders in the American Telemedicine
Association and elsewhere, at their state level. So we really tried to
develop leadership, collaboration, which sounds so trite but it\'s the
only way we see moving things forward, especially, again, with very
limited dollars.

I think we\'ve become a trusted vehicle for knowledge exchange, and we
certainly promoted evaluation. The seed money that the grantees have
received, when they\'ve documented, they\'ve leveraged it ten to one,
and we\'ve had a significant, I think, impact on reimbursement and
evaluation activities moving forward in this area, particularly in
performance accountability. Performance measurement system that we\'re
putting in place is being looked at by the universal service
administrative company, and others, the military, for some of the
measurement and metrics and how to document performance in this area. In
terms of reimbursement, has been documented by the Department of
Commerce. It was studies that we did that actually led to changes,
changing perspective on the impact of telemedicine on the federal
budget. Originally, there was great reluctance to fund telemedicine as
part of the Medicare program because it was thought to be a
budget-buster. As a result of data we provided, I think Congress as well
as others realized it was not, and legislation changed. And I think that
is one of the values of having demonstration programs like this, is you
can provide critical information at the right time to influence decision
making, so it is not based on blind belief but based on actual
information.

A simple example of the kinds of things we look at is, for example, this
table looking at one point, the services available only through our
grants, to what extent have we influenced access as a result of having
the program? And looking at changes in that over time and there\'s lots
of reasons why things change over time but being able to track to what
extent are we essentially seeding the field by ensuring there are
services available that would otherwise not be there. And we have, as I
said, a whole system for evaluation.

So if we can get, go into reimbursement very quickly, and \-- if I can
just see what I did with that. One second \-- I would just want to
quickly talk about Medicare and Medicaid and private pay. Is that still
of interest? Karen?

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

Yes, it is.

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

Okay. Well the way I like to look at payment is, I like to ask five
questions. Who is being paid or covered in terms of patients and
professionals? What\'s being covered? And essentially where and how. And
I think what\'s very important to understand about the Medicare program,
if we start with that, is that really Medicare reimbursement for
telemedicine or telehealth services is divided into three areas. Remote
patient face-to-face services seen via live video conferencing. That\'s
that real-time video conferencing that I talked about earlier. Then you
have non-face-to-face services that can be conducted either through live
video conferencing or via store and forward telecommunications services.
And finally, we have issues relating to home telehealth, at least as
we\'re looking at them now.

So if we look at, start with the remote patient face-to-face services.
Let\'s talk about the who. Well, who are the patients? Well, basically
the services must be provided to an eligible Medicare beneficiary in an
eligible facility, which I\'m going to talk about a little later,
located outside of a metropolitan area. So the patient receiving the
services has to be basically rural, as defined under the statute, and
it's statutorily defined. There is no limitation on, or statement about,
where the provider has to be located. Okay? So that\'s where the patient
has to be. Well, who are the professionals? And the statute is very
specific. It\'s not like there\'s wiggle room in the statute. The
following practitioners are essentially eligible for payment under this
portion of the statute: physicians, nurse practitioners, physician
assistants, nurse midwives, clinical nurse specialists, clinical
psychologists, clinical social workers, and registered dietitians or
nutritional specialists. Professionals. Now, the clinical psychologist
and clinical social workers have some limitations in terms of what they
can bill for. They cannot bill for psychotherapy services that include
medical evaluation and management services under Medicare. And so there
are specific codes that they can bill for. So that\'s the who.

Now the what. What are the services that can be covered? And that, I
think, is that there\'s a specific set of codes of essentially what
services can be covered. So what services can be covered? Well,
consultations, and Medicare has a very specific definition of
consultations. It\'s not just any office visit. Office visits or other
outpatient visits, again, some very specific set of codes, individual
psychotherapy, pharmacological management. Psychiatric diagnostic
interview examinations. End-stage renal disease services and that\'s one
of the issues that I\'d like to address. And individual medical
nutrition therapy. So those are basically the services. And the way it,
basically, official CMS policy reads that the uses of telecommunications
systems may substitute for face-to-face hands-on encounters for
consultation, office visits, individual psychotherapy, and
pharmacological management. And then you get into the specific codes.

So that becomes sort of the what. Now, the mode of interaction here is,
again, interactive live video conferencing. That is where this, the
setting has to be essentially a rural setting. Now, there\'s another,
the where, is the setting. The law also specifies the specific site. In
other words, where the patient is can\'t be just anywhere. It can\'t be
a nursing home, for example. It has to be the office of a physician or a
practitioner that is certified under Medicare. A hospital, a critical
access hospital, a rural health clinic, or a federally-qualified health
center. For example a community mental health center wouldn\'t be
qualified. A nursing home wouldn\'t be qualified. And I\'m going to talk
a little about home care. So the settings are somewhat limited, the
geography is rural.

The how is essentially for these services, there\'s the \-- they get
paid, the consulting physician who is providing the telemedicine service
or consultation, is getting paid the same amount as he or she would have
been paid for a face-to-face encounter. The non-metropolitan facility
where the patient is located can get a facility fee. It\'s, I think, 22
dollars now. It\'s a limited fee that they get. And that\'s what they
get paid. And they submit a claim.

So that covers what Medicare narrowly defines as telemedicine, or
telehealth services. There is an exception, so store and forward \-- and
stop me if you\'ve been through this and this is getting too boring. Is
this \-- shall I go on?

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

This is good.

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

Okay. If I \-- what we then have to look at is okay, so now we\'ve
covered the live interactive. What about the store and forward? I\'m a
dermatologist, I get a slide from a colleague, I look at it, I tell them
whether it\'s cancer or simply a benign mole. How would I get paid?
Well, in fact, under the current system I wouldn\'t get paid for that
unless I was in Alaska or Hawaii where there are exceptions for what\'s
called store and forward for those kind of services. The thing about
store and forward is that store and forward can also be radiology,
pathology, interpretation of an EKG. In other words, services that never
really had a face-to-face contact.

So it\'s direct visualization, possible by X-rays, electronic
cardiogram, electroencephalogram, tissue samples. Those actually are
traditionally covered under interpretation provisions and they can be
covered now. What can\'t be covered is substituting a store and forward
visit for a face-to-face visit. And that\'s really the crux of some of
the issues with dermatology, where there\'s a feeling that we can do
things much more efficiently, for many, many indications, through store
and forward. And so there are significant issues there that have been
raised in terms of ultimate efficiency of the system.

Four. The remote services and I\'m going to define them, a service may
be considered to be a physician service where the physician either
examines the patient or person or is able to visualize some aspect of
the patient\'s condition without the interposition of a third person\'s
judgment. Direct visualization would be possible by means of X-rays,
electronic cardiogram, electroencephalogram, tissue samples. And an
interpretation of this kind would be covered. CMS does not consider
these telehealth services. They are considered the same services as an
on-site, and are to be coded the same way. Moreover, there\'s no
geographic or facility limitation on these services. So typically what
you\'re thinking of, I think, in this instance, would be radiology. So
that is store and forward of remote, covered.

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

All right.

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

But it is not the kind of store and forward that many people are talking
about now that, especially in the area of derm, that I think is of
concern.

The final area in reimbursement is home telehealth. And this gets
somewhat complicated and convoluted. Section 1895-E of the act that
essentially established telemedicine, telehealth services, states that
telehealth services are outside the scope of Medicare home health
benefit and home health PPS. So this provision does not provide coverage
or payment for Medicare home health services provided by a
telecommunication system. The law does not permit the substitution or
use of a telecommunications system to provide any covered home health
services paid under the home health PPS, or any covered home health
service paid outside of the home health PPS. Everyone familiar with the
home health PPS?

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

No.

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

No. All right. Shall I step back?

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

Yes, just explain PPS.

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

Okay. PPS is Prospective Payment System and under Medicare basically for
the home health benefit, it's sort of divided in half. If a patient
needs less than four visits, it\'s paid on a fee for service basis. But
if a patient needs four or more visits for a certain episode, the home
health agency gets a flat amount for that. Okay? And there are all sorts
of requirements and everything around this.

So the PPS is basically saying that you basically are not explicitly
covering telehealth under the services. What the provision clarifies,
however, is that there\'s nothing to preclude a home health agency from
adopting telemedicine or other technologies that they believe promote
efficiencies, but that those technologies will not be specifically
recognized or reimbursed by Medicare under the home health benefit. This
provision does not waive the current statutory requirement for physician
certification of a home health plan under the current statute.

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

Dena, this is Karen. Just to clarify on that. The first four visits, in
terms of home health, which are fee for service, have to be done
on-site.

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

Right.

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

However, if you are in the capitated piece of this, which is four or
more visits, you get a flat fee and you can manage those any way you
like.

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

No. Not any way you like.

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

Okay, I\'m just \--

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

I was going to get to it. But I\'m glad you clarified that. What it is
is you cannot in the capitated part, you cannot substitute a virtual
visit for an in-person visit as specified in the physician plan. The
virtual visit can be adjunctive, but it cannot substitute. So the plan
has to basically be set out where it says this patient needs four
in-person visits, and we are also suggesting, for stability and
everything else, that there be five virtual visits. But it must be clear
that the virtual visits do not substitute for what is minimally required
for essentially in-person.

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

Is the prospective payment or the capitation, dependent upon number of
visits you think you\'re going to have to make to the visit, or is it
just flat fee?

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

It\'s flat fee. So it\'s a flat fee, so if a home health agency has a
very vulnerable patient, but typically that patient has four or five
visits, and they believe that they can manage that patient better if
they also make daily virtual visits or twice a week virtual visits or
the, and that will actually improve the care of that patient and the
efficiency. It\'s a very odd provision, actually.

And perhaps \-- and this is where the real benefit comes. Let\'s assume
you\'re a home health agency and you are now taking care of a patient
that has been discharged from the hospital into your program, and your
home health agency is owned by the hospital or the hospital system,
which is very typical. What you\'re trying to do is avoid a re-admission
within 30 days. And you\'ve got a vulnerable patient, a fragile patient.
You may use those virtual visits because you think this patient is at
high risk of being re-admitted. And therefore you think if you monitor
them more closely you can avoid a re-admission because if that patient
is re-admitted within 30 days, your hospital system eats the
re-admission.

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

Karen?

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

Right here. Sorry, we were on mute.

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

I\'m just thinking about, this is a fascinating discussion, but I wonder
if we need to protect some time in this before the end of our meeting to
sort of think about next steps and that process, kinds of recommendation
stuff. I don\'t know the balance of, what's your judgment on the best
use of time for the next \--

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

I think you\'re right. And I would appreciate your jumping in at this
point. I think one of the things that we need to do, Dena, this is very,
very convoluted. And one \-- we will work with you to outline this in a
way that it can be easily seen visually, send that around to everyone so
that all of the issues around payment, which are very convoluted, can be
brought to the surface because I think if nothing else, there are ways
this could be made simpler, understanding that Congress is the one that
created the convolution. We may get Congress to straighten it out a
little bit.

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

If you give me five minutes I can finish this up.

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

Okay. What I would suggest you do is that you jump on ahead a little bit
just to point out that the FCC does have a pilot program, if that\'s
okay.

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

Yes, the only thing I want to mention is emerging issues for payment, or
a couple.

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

Okay.

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

Or emerging issues. Number one, I mentioned to you that ESRD there are
codes that allow for payment of dialysis. They have been approved.
However, there is a debate within CMS regarding whether in fact a
hospital-based ESRD unit is eligible to receive payment. And that\'s
because hospital-based ESRD units do not have a, have a separate
provider code \--

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

Hello?

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

Hello?

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

Did we lose everybody?

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

I\'m still here.

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

This is Mohan, I\'m here.

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

I think we lost Dena. Maybe what we'll do, as I say, we will get back
with Dena, get the salient points that she was making out in front of
everyone, and continue this discussion at another point in time. I will
just add in your presentation material, we did have a few slides related
to what the Federal Communications Commission is doing in terms of its
pilot, because it has 40 million dollars that it is using to build an
infrastructure so that there can be a broadband approach to providing
\--

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

Hi, Karen?

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

Yeah.

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

I was cut off.

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

I understand. That was not us. It was on your end. We need to come to
closure because we have to go into public testimony.

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

Let me just say that that\'s one issue. A second issue \--

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

Dena, we may need you to come back and finish up at another time because
we are running out of time and I\'m so sorry because this has been so
amazing.

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

Let me just say \-- give me two minutes on the FCC pilot program.

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

I think we\'ll come back and do that later, too, if we might.

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

Okay. You mean on another time.

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

Yes. And we will work with you to develop a document so that everything
you've presented about all of the convolutions around what\'s happening
with Medicare can be better understood by all and we\'ll work with Tony
and Terry and everyone to make sure that we get it absolutely correct.
Because I think there\'s some opportunities here to clarify and take
some of the convolutions out of the system, so to speak.

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

Right, they basically are, by and large, legislative.

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

Yeah, that we do understand. And I just want to thank you so much, Dena,
you\'ve done a fabulous job.

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

Great job.

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

And we will be asking you to come back and finish up, but we are very
strapped for time at the moment.

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

Okay, I\'m going to get off now and let you continue, although Cheryl
asked me to stay on for her, but if you don\'t mind, I\'ll just put it
on mute and just listen.

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

That\'s fine, and we can always pick up the pieces with you later, too.

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

Okay. All right. Let me let you go on.

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

Thank you very much.

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

You\'re welcome. Bye-bye.

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

Tony? Colin?

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

Yes, Karen.

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

How would you like to move forward at this point?

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

I think you actually \-- I\'m trying to track the various documents that
I got here, but there was sort of a table of how to structure, where the
areas were that we needed to have testimony and how we\'re going to sort
of deconstruct those steps going forward. This is a topic that could
absorb all human effort over the, for the rest of time. I think we need
to pick the one or two things that are the areas that we think could
have the highest leverage and effect from a set of recommendations
standpoint and put behind us those things that we recommended on and
don\'t need to talk about and then kind of focus on the areas that we do
and get a clearer idea of what \-- if there are a set of expectations as
to what we ought to be addressing in the AHIC report-out. Let\'s just
make sure we confirm that, and that whatever we spend our time in in the
next Workgroup is focused on getting us ready to create that, and figure
out who is going to do what, where, and how to create the
recommendations.

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

Karen, I\'m looking at the previous recommendations we made in the
initial charge and the two areas we don\'t need any further testimony
on. Under technical we had several recommendations. One was directing
HITSP to define standards for secure patient/clinician messaging
transactions.

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

Right.

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

Second was to direct CCHIT to establish certification criteria for
system interoperability for patient/clinician secure messaging. And it
seems to me that we could take those two recommendations and expand them
for the broader charge.

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

This is Karen. I think that would be very important, as you know, the
American Health Information Community had a lot of work to do on the
23rd of January, and it very, very quickly heard about the possible use
cases and the priorities. And decided that within \-- they were
presented three different areas for use cases, and then made a choice
within each area as to what the top priority was. And remote monitoring
was not one of the top priority use cases for this year. So if we think,
we need to think very carefully about when that, this needs to go on the
road map. Should HITSP be doing this in 2007 or should it being doing
this in 2008? Or 9?

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

I was very concerned about that conversation there, Karen, and I do
think that remote monitoring, it seemed like a number of the members of
the AHIC did support that. So I think if we came out a with a strong
recommendation in that area, it would, I think, be very helpful to the
AHIC.

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

I think that would be as well. And what I would ask is perhaps those of
you who are on the call and I\'m thinking primarily, frankly, of the two
chairs, who have a lot of the experience with this already in terms of
monitoring devices and interoperability, if there are priorities that
you think would be important to articulate, if you could share them with
all of us and then we can craft some language around that for discussion
for the next go-around.

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

You\'re saying priorities in terms of what we might want to advise HITSP
to do?

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

Right.

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

I think that makes a lot of sense. Colin?

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

Yeah, I agree.

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

Okay, how about the other one, about CCHIT?

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

There is a process that we have and this is a piece we need to discuss a
little more about internally as well as with you. But if the
certification, if the HITSP process comes forward with interoperability
standards and specifications, and there is an expectation that they will
then become part of the Certification Commission's roadmap for inclusion
into their EHR certification processes, both in-patient and outpatient
now. So at whatever point in time HITSP presents \-- and this is a
fairly long process here, and I\'m going to take a second just to
describe it. HITSP will present its harmonized standards to the AHIC and
the Secretary will accept them. At some point he will also recognize
them. If they are tested and ready to go, then he perhaps could
recognize them earlier in the process. But it can be up to a solid year.
It isn\'t until he officially recognizes them that they will be included
in the next certification cycle. So that would mean that they would not
appear in certified products until the following August, for instance,
July or August. So that there\'s a very long gap between the time HITSP
actually comes forward with its recommendations on interoperability
standards and specifications and the time you will see them in the
vendored environment.

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

Wow.

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

I think it\'s important to be very clear about when we want HITSP to do
this and what exactly it is we want them to do.

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

I don\'t see any value in, given the normal latency of how long these
things take, I don\'t see any particular value in waiting to \-- a lot
of these things, the sooner we get them in the hopper, the sooner
they\'ll come out the other end, and that's out of our control. To say,
don\'t worry about this until 2009, guarantees it won\'t happen until
2029.

\[laughter\]

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

The sooner we get the recommendation on the table, the sooner we\'ll see
it in the real world.

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

Exactly.

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

We\'ve already gone on the table with saying they should establish
certification criteria with system operability for secure messaging, why
not take it a step further and recommend a broader one to deal with
remote monitoring as well?

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

Just for historical purposes, I\'ve been dealing with this since Helen
Smith was the administrative of HCFA. It was then called HCFA.

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

But you couldn\'t possibly be that old, Jay.

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

Unfortunately, I am.

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

So you\'d recommend that we go ahead and get it on the table for CCHIT
then?

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

Absolutely.

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

And I think one of the things that would be most helpful if we are very
clear about what it is that we want the standards about, and we have
gone through that process and said we believe there are certain subsets
of monitoring information and data that would be important. We may want
to come back, pull that out and be very clear, this is what we need
HITSP standards on for remote monitoring.

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

Okay.

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

But I would like the folks that are really involved in this on a regular
basis to review that list and comment on it and make sure everyone is
comfortable with it. So we will send out to the Workgroup, after this
meeting, another set of that information, that list again just so you
have it fresh on your screen.

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

Okay.

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

Good idea.

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

Okay. The other area where we said we needed no testimony was the CPS
area, the confidentiality, privacy, and security area. And I believe on
the original recommendations, we punted a lot of that over to the
consumer \-- the CPS Workgroup. I\'m looking to see what we actually
said in the original \--

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

I would also just, you know, I may get kicked under the table at my end
here, but we aren\'t necessarily bound to asking CPS to do something. If
we really feel very strongly that we want to move ahead and make
recommendations in this arena on our own, we are welcome to do that and
I\'m seeing nods to the affirmative around the table, rather than kicks
under it. So I think if we choose to move in that direction, we can do
so. It doesn\'t have to be through CPS.

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

And that\'s basically one of the things I was getting to, Karen, is the
first question is if we come up with some additional recommendations, do
we want them to handle them? And then second I guess would be what are
these recommendations that we want to move ahead on? The first initial
charge we dealt pretty heavily with privacy protections, and things
related to that.

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

Privacy, authentication, authorization.

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

Right.

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

And linkage of patients with their data.

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

Right. Which were somewhat similar to some of the issues that the
Consumer Empowerment Workgroup had as well which is one of the reasons I
think we went ahead and decided to let the CPS Workgroup do that. But we
may want to take another look at that now from our perspective and just
have some specific recommendations on that.

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

I think also, and we had talked about this last time, when we\'re
dealing with remote care devices, we\'re not always dealing directly
with the patient. We\'re dealing very much with the care system around
the patient. You know, 60-year-old daughter taking care of her
90-year-old mother.

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

There\'s no way you can avoid the overlap. If it\'s \-- I mean, by
definition, you know, remote care, the data has to go somewhere, whether
it's to a personal healthcare environment or clinical environment. I
mean, there\'s overlaps.

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

Right, and I think the real critical issue here is what kind of privacy
and security recommendations do we want to make that encompasses this
broader perspective here.

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

Right. One of the questions might be is the ones we punted over to them
in the first place, which I\'m looking at the letter, was about seven of
them, and whether we want to take some of these back and make more
specific recommendations on this go-around. We just basically in the
letter laid out the areas that we felt should be developed by them.

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

Well, I think the only piece there is that it wasn\'t just us and the
Consumer Empowerment Workgroup but it was also the EHR Workgroup, all
came up with the need for these kinds of activities and recommendations
and so rather than have three Workgroups do the same work we thought we
would just create a new one and it would do that work. So I think that
group is moving along, and Tony you\'re on it. If you think it\'s not
moving along, \--

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

I think it\'s moving along, Karen. I\'m just saying there may be
additional granularity that we might want to address our Workgroup
perspective that they may not necessarily hit on from a broader
perspective.

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

Okay, that\'s a good point. Thank you. I misunderstood. So I\'m taking
away here that the follow-up item on this one is that \-- and here
we\'re going to have to be very proactive with all of you. And in terms
of either you\'ll hear from either myself, Cinyon, or someone who is
coming on board fairly shortly, whose last name is Harris, Yael (ph)
Harris, regarding follow-up and your input on what, how we should, what
should be considered here and the prioritization of that. So we can have
a fairly quick discussion about it at the next Workgroup meeting and
move on with crafting the recommendations.

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

Right.

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

Any other questions or concerns about these? And obviously we\'ll come
back and talk about the other areas more next time and we\'ll put
together some more of the testimony that we all talked about as being
important.

Are we moving along in a timely enough fashion for public comment?

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

Probably a good idea.

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

Any other comments or concerns from anyone on the call or everyone on
the call?

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

I\'m sorry.

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

No, go ahead.

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

This is Mohan. I would make a suggestion regarding the process of public
testimony, or testimony from the invited parties. I would recommend that
we have something to read ahead of time and not have a situation where
\-- I\'ve been watching the public testimony for quite some time, my
recommendation is that when we go through many slides, we may not be
able to capture the essence, and if you could force us to be more
prepared with questions and prior reading, we might be able to optimize
the short and valuable time we have together as a team. I don\'t know
whether that works or not but I\'d like to propose that.

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

I would second that. I think if we could limit people\'s testimony to a
certain period of time, and just address key issues. Kind of the way you
make us limit our time at the AHIC, Karen, when you have the Workgroups
come up and give presentations.

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

Okay, we will definitely do that. I think since we have a little bit
more time between now and the next Workgroup, it will be a little bit
easier to manage all of this, moving forward. And I do apologize, I was
out partially because of illness and partially because of vacation for
half of the time since the last time we met. So I was not as much on top
of things as I would have been otherwise. I think we can really move
forward in a much more prepared way next go-around, given the timeframe.
It's a good point, Mohan, thank you.

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

Karen, one minor issue. Under the medical/legal and the additional
testimony needed, not necessarily needed but resource available, and
that was the information that Dena gave in terms of her grants to the
Federation of State Medical Boards.

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

Yes. I\'m definitely going to follow-up with her on that.

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

Great.

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

Thank you.

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

Karen, before we get the public testimony, can we, or the public, can we
kind of go over what you want to accomplish at the next meeting, because
I think it\'s one of the questions you asked at the beginning of the
session, when we would be available, ready to present to the AHIC, and
you had mentioned the April meeting or the June meeting. And I guess we
need to kind of do kind of a reality check now, what we need to
accomplish between now and when we give the recommendation letter to the
AHIC.

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

Right. Well, I think between now and the next Workgroup meeting, we do
have some time here. We will be sending you information and we\'ll
probably just have almost like a little listserv internally and then
present the results of all of that at the next Workgroup meeting,
because, again, everything has to be in the public, in the public venue.

With the concept being that we will have done enough background work so
that we can actually discuss the first draft of recommendations, and
start some of the even wordsmithing around them. Particularly in these
two areas. The technical and the privacy and security areas. So that
would be the output. And then the final letter will get written after
that and will be reviewed and signed off by all of you before the actual
AHIC meeting.

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

What I\'m hearing from you is there\'s a possibility we may do it in
April, then in.

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

It would be optimal if we could do it in April, but if not, we will \--

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

Optimal for whom? Do we think it\'s optimal in April, or \-- just sort
of a general note. Would we prefer April because we think we can do
something by then, or do we prefer a later date in order to make more of
an impact in, having done more work?

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

I think if we can do something in April to sort of tie up these loose
ends, we can begin to get into some of these stickier issues, and the
bigger issues after that. And I do think that there is a \-- we talked a
little about really what is the scope, we need to clarify that, where
we\'re going to go. We do need to understand what we can do around a
reimbursement recommendation. I think that there are certain steps that
certainly can be taken. If nothing else, then to untie some of these
Gordian knots we've heard today. And I think we have no recommendations
at this time about the cultural concerns, but there is a lot of very
good material that\'s out there. Eric was kind enough to point out some
of the work that\'s being done with Group Health and I think we can hear
more information on that, the DOD, the VA, from some of the actual rural
hospitals who have done a lot of work in this area, the ATA. So I think
there are at least two areas, in the financial and the cultural area,
where we can really get into some very meaty discussions and then make
some subsequent recommendations down line on the broader scope. But I
think the sooner we move forward with the technical piece and the CPS
piece, the better it would be for us, so we don\'t get bogged down in
that. That\'s just my thought on the process.

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

Yeah, I would rather focus on an earlier date rather than a later date
because I think that would get us more focused on what we need to get
done.

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

I agree.

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

I agree.

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

Yeah, and if you do want any of this material to be presented that I
sent you, give me some advance notice because people have calendars and
so forth.

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

We will, and very frankly, it was just, we\'ve had a difficult time
getting people today because, again, the timing wasn\'t very good.
There\'s more information come from the NGA next week. So we really, we
have time now to really plan a little bit better for the next meeting
and absolutely, Eric, we\'ll definitely want to have some reporting from
your folks. Okay?

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

Good.

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

Do we have a plan?

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

Sounds like a plan.

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

Thank you, all \--

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

Should we bring in the public?

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

There\'s a slide up, it's been up for a couple of minutes, actually,
that has the phone number to call in. If anyone is already dialed in,
they just need to press star 1, and that will alert the operator.
There's also an e-mail address on the slide, if anyone wants to make
comments that way after the meeting.

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

Thank you.

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

We\'ll just wait for one more minute.

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

I\'ll certainly take this minute to thanks everybody who is on the call,
and you really are a wonderful group to work with, a lot of good input,
a lot of good discussion, and a lot of difficult material that we\'re
plowing through. So all of your effort is very much appreciated, and I
hope you will seriously consider staying with us for another while. A
little bit while. There\'s no one calling in?

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

There is no one calling in.

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

I think we can consider the meeting adjourned. Thank you all.

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

Thank you.

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

Thanks.

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

Bye.

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

Thank you, Karen.