American Health Information Community

Chronic Care Workgroup Meeting

June 28, 2006

1 p.m. EDT

**Disclaimer**

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

**[\>\> MATT McCOY:]{.underline}**

Okay, we\'re live. Would the Co-Chairs like to begin with some remarks,
or do you want to go straight into a roll call?

**[\>\> CRAIG BARRETT:]{.underline}**

Let\'s just welcome everyone to the meeting. This is Craig Barrett, and
Tony Trenkle was on there for a half a microsecond.

I think the best thing to do is to start off, perhaps. Karen, are you
going to do just a brief review of the call-in procedures, and the FACA
guidelines?

**[\>\> KAREN BELL:]{.underline}**

Absolutely, thank you, Craig. I just want to remind everyone that the
only people who will be speaking at this meeting will be the bona fide
Workgroup members. However, the entire conversation is clearly open to
the public, in terms of listening, and we will have a period at the end
of the session which will be open to the public in terms of comment. I
apologize.

Let me just quickly finish, and then I will go on mute while we change
equipment, here. In addition to that, because this is a free and open
discussion, everyone is clearly entreated to state their representation
openly and clearly. And I am now going to go on mute, because apparently
we\'re having problems, here, with the system.

And I\'ll turn this back to you, Craig.

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

Are you guys going offline or are you going to stay online?

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

Stay online, but I\'m going to be on mute until the echo goes away.

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

All right. I think we should go down and do a formal introduction of the
participants. And let me start, I\'m Craig Barrett, Co-Chair.

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

You know, Karen, I think that\'s probably you guys feeding back. But in
the meantime while you\'re working on your situation, make sure you have
your computer speakers muted, because that will cause the feedback if
you have that loop going.

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

Yeah, I think we finally took care of the situation. We switched from
the \-- whatever the ceiling apparatus is to the star phone.

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

Sounds better. Craig, if you\'d like, I can just continue with a quick
roll call.

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

If you could go down the list slowly so everybody can get it in their
notepads.

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

Sure. In addition to our Co-Chairs, Craig Barrett and Tony Trenkle today
on the call we have Francis Dare, who is sitting in for Jeff Rideout
from Cisco Systems; Jay Sanders from Global Telemedicine Group.

**[\>\> JAY SANDERS:]{.underline}**

Aye.

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

Joyce Dubow from AARP, she\'s sitting in for John Rother today. Don
Horton is sitting in for Mike Krist from Lab Corporation of America.

Eric Larson from Group Health of Puget Sound, and Paul Nichol from the
Department of Veterans Affairs. Are there any member workers on the
phone whose name I did not call?

**[\>\> JOE GIFFORD:]{.underline}**

Hi, this is Joe Gifford from Regence, sitting in for Mohan Nair.

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

What was your last name, Joe?

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

Gifford, G-i-f-f-o-r-d.

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

Thank you.

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

Just to reiterate a few points that might have gotten lost in the
feedback, when the Workgroup members are speaking, please identify
yourself before you make a comment so we get it \-- all the attributions
correct on the transcript. And when you\'re not speaking, please keep
your phone line muted. And if you\'re following along with the Webcast,
please don\'t touch any of the controls to advance the slides while
we\'re going along with the meeting. And I believe that\'s it for the
roll call.

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

Good. Karen, could you just tell us again who is with you from HHS?

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

Thank you, Craig. I\'m Karen Bell, I\'m here in the room as a
facilitator for this meeting from ONC. And with me today are Richard
Singerman, who has been support staff to this Workgroup for some time.
And in addition, we have a new member to our ONC team, Judy Sparrow, who
has a background in telemedicine with HRSA actually, and is here now on
detail from HRSA as executive director for the AHIC until such time as
her appointment can be made permanent.

In addition to that, Dr. Anand Park is joining us. He\'s an \--
emergency room physician, Anand?

**[\>\> ANAND PARK:]{.underline}**

Internal medicine.

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

Internal medicine, thank you. Who has been working closely with the
Secretary and the Secretary\'s offices primarily on emergency
preparedness, pandemic, and surveillance, but has a strong interest, as
you can imagine with a background in IM, in chronic care. So he is
joining our group, as well. Thank you.

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

Okay. We sent out a ton of background information. Which as I noted
earlier, if you are connected at low bandwidth it takes a very long time
to download. But I think two of the items that we sent out were the
minutes of our previous meetings of 24 April, and 3 May. And we have not
formally approved those minutes. And I don\'t intend to allow you to
read them right now, but if you have read them, and have any comments,
now is the time to offer corrections, additions, subtractions. And if
there are none, then I would entertain a motion for approval of those
meeting minutes.

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

This is Jay Sanders. So move.

**[\>\> ERIC LARSON:]{.underline}**

Eric Larson, second, I read them.

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

All in favor?

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

Aye.

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

So approved. The next item was the review and discussion of the
implementation of the specific charge recommendations. Did we send out a
list of those, you guys?

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

I do not believe that we sent those \-- perhaps sent them out again.
They were included in previous handouts and they are available on the
Web. But we did not send them out as a separate packet or handout for
this meeting.

**[\>\> FRANCIS DARE:]{.underline}**

So minutes from the previous meeting did highlight where some of the
draft recommendations might change. Do we need to go to the Web to find
the most current version of those, is that what you\'re saying?

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

Probably the most current version is on the web, but what I can do is we
can go through some of the followup items, and give everyone an update
of where these \-- where they are found, if that would be helpful.

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

If you would do so, please proceed.

**[\>\> TONY TRENKLE:]{.underline}**

I\'d recommend, also, Karen, that we discuss the one recommendation that
you and I talked about yesterday. In more detail.

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

Yes. Yes, I think that\'s going to be important, as well.

The \-- I\'ll just run through some of the others fairly quickly, then.
There was one piece of work in particular that the Blue Cross Blue
Shield Association had volunteered to do with respect to gathering
information from various health plans on what they were doing with
secure messaging and their reimbursement of secure messaging.

Justine Handelman was able to in a very short time frame distribute a
survey to not only Blue Cross Blue Shield Association members, but some
members from AHIP as well, the American Health Insurance Plan
association. And unfortunately had a relatively low response rate,
possibly because of the short time frame. So in discussing with the
Co-Chairs yesterday about how to proceed, we reached agreement that
rather than present a small piece of information, or a \-- not very
robust piece of information at this point in time, we would pursue
gathering more information directly from other plans, and through the
three major vendors that are involved in secure messaging.

So we will have a full and more robust report ready for you at the July
AHIC \-- July, I\'m sorry, Chronic Care Workgroup meeting.

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

That Justine is going to present in July as well, right, Karen?

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

Yes, absolutely.

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

Okay.

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

Secondly, as you are aware, all of the recommendations regarding privacy
and security are moving forward as part of the cost-cutting
recommendations. We are in the process of developing a subgroup to the
Consumer Empowerment Workgroup that will be looking at privacy and
security. That has not yet been completely codified yet, so that I
don\'t have any names to announce at this point, but that will be moving
forward fairly quickly.

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

Is that going to be a subgroup or a separate operating group?

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

It has to be a subgroup to an existing workgroup. One of the reasons
there\'s been some delay in moving this along is that we had to work
very \-- we\'ve been having to work very closely with our legal guidance
to assure that we are FACA compliant in everything we do. So this is
going to be a FACA-compliant subgroup to the Consumer Empowerment
Workgroup.

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

It just seems that that is such an important topic, that is the
foundation for just about everything else.

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

Yeah, we absolutely agree with you, and I couldn\'t enforce that more.

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

Karen, this is Joyce. You said that the recommendations \-- I want to be
sure I understood what you said. The recommendations from all of the
subgroups have been combined, and will be forwarded to a subgroup, is
that what you said?

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

No, only the recommendations on privacy and security.

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

I\'m sorry, that\'s what I meant. Have you gathered those
recommendations into one document so they\'re available for us to see?

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

The recommendations that went to the American Health Information
Community were essentially identical from every single workgroup. So
that set of recommendations that came from this work was exactly the
same as the other three, so those are the recommendations that are being
followed.

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

So those are the recommendations submitted at the last community
meeting?

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

Yes.

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

Okay, thank you.

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

The May meeting, I apologize, the May one. In addition to that,
recommendations have gone to HITSP with respect to their use cases and
what the standards harmonization panel needs to do to assure there can
be interoperability, and that any secure messaging that occurs can be
incorporated into an electronic health record. So that process is
underway, as well.

There are \-- there was a recommendation regarding a demonstration
project, and I\'d like to turn to Tony for this discussion, as well.
Because I think that this is an opportunity for this Workgroup to
provide input into exact \-- into the types of questions a demonstration
project should be answering with respect to moving forward, and any
other recommendations that could be made with respect to the
demonstration project. So Tony, would you like to pick up there a little
bit?

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

Yes, Karen. Unfortunately I don\'t have the actual recommendation in
front of me, but I was going to dig it up in a second. But I believe it
talks about both CMS and others using demonstration products, projects,
and other types of activities to kind of help build the evidence base
for secure messaging reimbursement, or words to that effect. Do you have
the exact recommendation in front of you? I don\'t at this point.

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

I believe that we do. It is Recommendation 1.0.

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

I\'m thinking of 1.2.

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

I\'m sorry, 1.2?

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

1.0 was the one that Blue Cross and Blue Shield was involved in, I\'m
talking about 1.2.

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

Public and private payers, including the centers for Medicare and
Medicaid services should contribute to the evidence for and information
base on reimbursement strategies through direct reimbursement, pilots,
or demonstration studies for coverage analysis for internet based
patient-clinician encounters in accordance with guidelines developed by
the American Medical Informatic Association, the American Medical
Association. That\'s just a health data consortium for structured secure
messaging, including but not limited to encounters that could qualify
under CPT Code 074T.

I think the discussion is if CMS were to move forward with a
demonstration project, what are the critical elements, the critical
questions that should be addressed. And critical elements of that type
of a demonstration project. And so I think we can approach this one of
two ways. We can certainly have some discussion on that right now, we
don\'t need to come to a decision right now, we can begin the discussion
and we can complete it at the July 25 meeting.

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

Are you guys bringing that recommendation up on line now?

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

Yes, we are.

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

It\'s available for viewing.

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

One of the things that Karen and I talked about is we want to make sure
there was consistency in the questions that would be asked across
different types of activities. Not only the ones being done by CMS but
by others as well. One of the things Mark wanted us to do is to see if
\-- easiest to us would be to integrate that into some of our existing
demonstration projects, if possible.

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

This is Jay Sanders. With respect to CMS developing evaluative criteria,
I assume they\'ll be looking at what type of evaluative criteria
companies like Aetna and the Blues and Cigna looked at to make their
positive decision in deciding to reimburse for secure messaging.

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

Francis Dare from Cisco. I\'d add to that perhaps these seminal studies
around all this was actually done by a team at Stanford, and it dates
back a couple years now, but I think that was very much a factor in Blue
Shield of California\'s decision to reimburse. So that might provide
some reference in terms of survey structure or key criteria.

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

Are there any other \-- is there any other guidance or direction that we
could take in terms of pursuing more information, on how we might think
about some recommendations or we might think about providing some
guidance to CMS on the demonstration?

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

It\'s not just CMS, once again, it\'s public and private payers
including CMS.

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

Absolutely, thank you.

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

Is it fair to say that the demonstration studies right now that were
implemented under MMA, like 721, Chronic Care Improvement Program, that
they bundle things like secure messaging as part of their program? Are
there any ongoing demonstration studies that only look at secure
messaging, or that we can really analyze what the costs and quality
impact is of secure messaging?

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

Yeah, I think that\'s fair to say, that the existing ones for the most
part do bundle it with other types of activities. The ones we\'ve found
that would probably be the closest would be the physician group practice
ones. And we need to sit down and talk with them more, because they\'re
the ones that work specifically with providers.

Some of the other ones work more through the plans.

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

Can someone tell me specifically again what the issue is here? We\'re
trying to get consistent input from public and private payers, is that
the issue?

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

Yeah, I think the issue, Craig, as I understand it, is that we want to
develop a list of standard questions that could be answered across
various activities, so that we could get information on potential
reimbursement strategies for secure messaging. And of course, you know,
we\'ve obviously continued to raise the mantra that anything needs to be
tied to outcomes, it can\'t just be tied to the use of it.

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

Agreed. So basically we\'re looking for are these the 10 key questions
to ask of any demonstration project, program, implementation, et cetera?

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

Right, because that way we can look across these different types of
activities consistently without having varying degrees of input.

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

Just as an example, we had a lot of discussion on multiple meetings ago,
about various approaches to secure messaging. Should it be based on a
population, should it be based on examining what high use providers
might perhaps be doing? There are a number of different ways that secure
messaging that could be rolled out. But in essence, if once we go back
and look at those discussions, they would generate a number of questions
that perhaps might need to be answered, or could be answered, across
various demos in both the public and private sector.

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

And the next step is \--

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

The next step would be for this group to come to agreement on what those
questions would be.

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

I think one aspect is coming to agreement on what the next \-- what the
series of questions would be, Karen, but I think the other one is to
agree on \-- and maybe it\'s not the purpose of this group, but we have
to agree on what the demonstrations would be used to \-- I mean, within
CMS we\'re looking internally to see what the demonstration projects
might be appropriate for this, or if we have to do, you know, a separate
demonstration project. But we need to have agreement at some point on
that. And I guess some of that may be based on the questions, but I know
we\'re looking at it separately from that. I think the point you brought
out about the types of groups involved in this is certainly one issue,
and the geographical issue that we brought up months ago, but I think
it\'s got to be a combination of things. I think we have to have the
questions, but also, what are the different projects we\'re going to be
using to test the questions on.

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

Let me \-- in the interest of time, let me make a proposal, if I may, to
both of you as chairs.

Would it be helpful if we went back, pulled those questions and issues
out? Also, went back and looked at the methodology for the initial
projects that were done? Stanford was mentioned. And again, if anyone is
aware of any other projects that have looked at this issue, that we
could then go back and looked at the methodology, find out what
questions were being asked, we will then synthesize all of this
together, and get it to you prior to \-- well in advance of the next
meeting, so that we can have a more specific discussion or perhaps
prioritize certain questions or issues, and come to clarity about where
we need to go.

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

Yeah, that\'s perfect. I was trying to get to that point where \-- how
do we move ahead rapidly with the next step to get a draft of the issues
we would like information on. And you will ensure, as we discussed
earlier, that it does include outcomes and quality, et cetera?

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

Does anyone else have any other guidance about where we might go to \--
to learn more about how to set up such a study? Before we move on to the
next topic?

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

This is Eric Larson. It\'s possible that somebody like Michael Barr at
the ACP in Washington, DC, that office, there, may have some ideas. I
know they\'ve done some work on this.

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

Great idea, thank you, Eric.

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

Francis from Cisco. As you were pulling this together for the next
meeting, it occurs there are at least two fairly different use cases,
potentially. One where the secure messaging is more directed towards a
disease management, nurse care manager sort of person, and then the
instance where it\'s more direct from consumer or patient, directly to
the physician. And there may be others as well. And the questions to be
considered could be different, based on those use cases.

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

Thank you, that\'s a very good point. I believe that the intent of the
specific charge was for secure messaging to occur between patients and
their direct caregiving clinicians.

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

Right.

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

So we are focusing on that particular use case.

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

But Karen, weren\'t we using the descriptor clinician as an umbrella to
include not only physician, but also nurse?

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

Yes, we were. From the perspective of nurse practitioner?

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

Right.

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

Someone who has assumed responsibilities for the patient\'s care.

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

Right.

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

Gesundheit.

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

Thank you. And will the \-- will there be a bias towards chronic illness
in this whole exercise?

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

I think that\'s one of the questions that we need to address. Yes.

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

With our Chronic Care Workgroup?

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

That would certainly be from our perspective I think, because obviously
most of the ones we look at are the chronic care population.

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

I just want to make sure that we kind of adhere to the AD 20 rule. We
had lots of discussion that a great majority of the health care costs
are in chronic disease management, et cetera. So rather than figuring
out how to monitor and see how people prescribe aspirins for headaches,
we focus more on the care and management of chronic disease in this
whole exercise. So if we could bias it in that direction it would be
appreciated.

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

And if I could add to that, if we could even go one step further and
focus it on multiple chronic conditions. It\'s the same 20-80 rule that
applies, you know, 20-some percentage of Medicare beneficiaries with
five or more chronic conditions, and ultimately, you know, they account
for 70 percent of the costs, as well as low-quality indicators and poor
coordination. So specifically, individuals with multiple chronic
conditions could probably benefit the most from all these things.

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

Thank you, I think that gives us a little \-- you know, enough guidance
where we can move forward now and pull this information together, and
distribute it to you.

The next Workgroup meeting is July 26, I believe. So that\'s just about
a month away. I think we can get this to you within the next couple of
weeks, so that should give us plenty of time to review it beforehand. So
thank you very much.

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

Karen, this is Joyce, just one question about the survey that the plans
are doing. Does it have a focus on chronic care, or is it just all
secure messaging used by the plans?

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

We\'ve asked them to tell us what populations they\'re applying this
for. So we\'re gathering as much information on their decisions as
possible.

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

Okay, thank you.

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

Do we have other issues on our specific recommendations?

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

This is Jay Sanders, I just have a question as to the status of the
licensure recommendation.

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

Thank you very much, Jay, I was actually just thinking about reviewing
and realized I hadn\'t addressed that one. We are pulling together a
list of issues that we are hoping that the Secretary may be able to
address when he meets with the National Governors Association in August.
And again, he is on the agenda, it\'s unclear yet the degree to which
we\'ll be able to use that as a vehicle. But very clearly that may be an
opportunity for him to underline the fact that some form of reciprocity
across State lines is going to be important for interoperable health
care. Particularly in pandemic and disaster situations.

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

Yeah, exactly.

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

And related to that, we are also looking at other vehicles where we can
address State variance in this particular arena.

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

If we do go with the NGA with a request or recommendation, are we going
to do any advance work with them?

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

That would be dependent on the folks in the Secretary\'s office. We hope
to be getting information to them by the first of July, actually, in
terms of what options could be discussed, and they\'ll determine whether
or not it\'s the appropriate venue. But we recognize that is an
opportunity, and would like to assure that it at least gets considered.

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

If I\'m not mistaken, Karen, and you\'ll probably have to ask the
Secretary. When the Secretary was head of the NGA, he authored a
proposal with respect to this issue. That he might want to \-- you know,
refresh.

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

Yes. Yes, and that\'s what we\'re hoping will happen.

Again, I certainly can\'t speak for either the NGA or the Secretary
right now, but I am committed to assuring that he has all the necessary
information. And he is aware of the importance of it, and how it will
actually develop is unclear at this point.

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

Should we be pushing on Governor Napolitano, who is head of the NGA
right now, or anyone on the staff to promote this as a viable topic?
I\'d hate to see it brushed off just in the standard form of
administrative procedure.

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

I don\'t think we need to do anything just yet, but I will certainly let
you know prior to the next meeting if it appears that there needs to be
some action in that direction.

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

Yeah, okay. Well, Napolitano is governor of Arizona, and some of us are
Arizona residents, so we might have some input with her, if that\'s
appropriate. So don\'t hesitate to call us, all right?

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

Thank you so much, I won\'t.

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

As a matter of fact, Arizona is part of a four-corners statewide
initiative that addresses the issue of reciprocity of licensure.

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

That\'s correct, and I know that that\'s one of the things that the
Secretary is very interested in, as well, because of that four corners
situation. So it is front and center on our plate.

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

Right.

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

Just so \-- it\'s one of those key issues that I think we ought to just
exercise every avenue to get it on the agenda, and then get some
progress made.

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

Will do, thank you, I will take that as support to move forward.

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

Do we have other recommendation issues?

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

We don\'t have any further followup here, but certainly would be happy
to entertain any other questions that you may have among the Workgroup
members.

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

Anyone have issues?

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

This is Eric Larson. I guess this has sort of been hinted at. We put
some timelines on some of our recommendations, are you pretty confident
that we could meet those timelines?

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

I believe so. There is a 1,000 day initiative focusing on health
information technology that the Secretary has announced, as you know,
early part of May. And the recommendations that have come forth to the
AHIC and from the AHIC to the Secretary, as they are being accepted by
the Secretary in a formal way, are being added to a workplan with the
intent that they will definitely meet their timeline for both milestones
and deliverables.

So right now, we\'re on a course that appears to be meeting its
deliverables.

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

I guess the reason I asked is because when we were going out to do these
surveys and data collections it would probably be worthwhile letting the
people that you\'re trying to get responses from know that this is a
speak now or forever hold your peace because we\'re on a timeline.

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

Right. Good point, Eric, we\'ll certainly do that.

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

All right, if we have no other issues on the specific recommendations,
let\'s move to the next agenda item. Which looks to be the discussion of
the Workgroup road map and timelines. And is there a presentation for
this?

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

There is no presentation for this, this is the road map as it was
presented at the American Health Information Community. And it outlines
for you on your agenda the seven steps of the road map, and the
timetables of what we\'ll need to accomplish every month between now and
December, in order to begin to address meeting the broader charge.

As you all recall, a tremendous amount of energy and effort has gone
into the specific charge, and we\'ve just had some discussion about
that, but now is the time to begin to look at the broader charge, so
that today, you\'re being asked to \-- when I say develop a workplan,
it\'s very, very high level. But essentially, being asked to lay out the
critical components in terms of what needs to be done, or the high level
strategies or tactics of what needs to be done in order to begin to
address the broad charge. And we will then have some discussion on how
to address them.

And in subsequent months we will have the opportunity to move that
agenda further, as is described here.

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

If I look at the outline that just came up online, critical components
today, testimony, background research, analysis, et cetera. During July.

Stakeholder issues in August. And then consider \-- continuing on with
the more background, barriers, et cetera. Throughout the third quarter
or \-- fourth quarter of the year.

The critical components of today\'s agenda item, I presume, are
effectively the summary of the recommendations we were just discussing,
the specific action items of research, analysis, questions, et cetera.
Correct?

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

I think that\'s correct, it might be helpful \-- this is Karen \-- if I
were to read the broad charge again for the Workgroup, so that everyone
could focus on where we\'re hoping to go. Is that all right?

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

Yeah, please.

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

It\'s to make recommendations to the community \-- and this is what
we\'re talking about for December \-- to deploy widely available, secure
technology solutions for remote monitoring and assessment of patients,
and for communication between clinicians about patients. Which is, as
I\'m sure you\'re well aware, is much broader than the secure messaging
between the patients and their responsible clinicians that we have no
specific charge. So this is really an opportunity to really start
thinking about how we can provide care using the appropriate
technologies, in multiple settings. Remote settings.

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

Yeah, I\'m trying to rationalize that to some degree with the charter
that we have, which is to be specific, chase after the low hanging
fruit, have specific actionable items, et cetera, et cetera?

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

Francis from Cisco. So in some essence this perhaps stages the
Workgroup\'s work for Phase 2, is that the intent here?

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

That\'s correct.

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

That seems clear. Thoughts come to mind the potential for a survey of
what are the common, widely available chronic disease information
technologies that are available. Is that the kind of thing you\'re
looking for here?

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

Karen, several months ago when we first got this group underway I know
Karen Trudell had some work as well as Brian De Boer who works for
Craig, and I believe Richard also did some research in this area. Is it
possible that we could get some of that material and take a look at it
and see what applicability it has to what we\'re going after here?
Because some of that material I think was applicable.

Remember we had deferred some of it until the broader charge?

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

Absolutely.

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

Another resource, Karen, this is Jay, would be the American Telemedicine
Association, and its special interest group in telehome care. Which has
a vast amount of information regarding these types of technologies.

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

Is there a particular person we might contact there, as a first step?

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

Yeah, I would contact John, John Linkus.

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

Okay, that would be great.

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

This is Eric Larson. Craig, you would know more about this than I do,
but I think Eric Dishman in your shop has done a lot of work in this
area, and I would like to recommend James Ralston from Group Health who
has presented to I think some of the community off and on about some
ongoing work we\'re doing here in Seattle.

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

All right, I think both of those are good recommendations.

**[\>\> JOYCE DUBOW:]{.underline}**

From the consumer perspective you may want to talk to the folks at ARC,
who are beginning to consider how patients experience the use of
technology in the course of their getting health care services. They\'re
just beginning to think about this. But you may want to talk to Chuck
Darby on the CAPS team.

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

Okay. And obviously when we have our public input, there may be members
of the public who would like to contribute, as well. So if there are,
please let us know at the end of this call.

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

Yeah, there\'s a rich literature in this area, Karen.

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

Well, I will work with the folks that have been recommended or our staff
here will work with folks that have been recommended. And again, we\'ll
take input from the public on this, as well, and review the literature.
And essentially do very high level \-- we\'re not staffed to do a very
deep environmental scan, but what information we can gather between now
and the next chronic care meeting, we\'ll bring back, and then plan
testimony accordingly.

There\'s another approach that we\'ve been using with the other
workgroups as well, and that\'s to think about what we could do amongst
our strategies, so we can have that discussion a little later on, in
addition to this one.

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

Karen, and the two chairs, when I hear about the broader charge which
you just read, is the issue of some kind of a national or unique
personal identifier going to come up in this whole conversation at some
point?

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

I thought that was one of the issues for the privacy and security group,
is that correct, Karen?

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

Yes, it is, they are addressing how a patient can be identified with a
very high degree of certainty, and linked to his or her information.

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

So in other words, we don\'t need to sort of make a statement or come
down with any kind of a deliberation that says you can or cannot do this
without a unique identifier?

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

I thought we basically had made that statement, didn\'t we?

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

We made a very similar statement with respect to the recommendations
regarding the secure messaging.

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

Okay.

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

And again, it wasn\'t a unique patient identifier, it was a methodology
for uniquely identifying a patient.

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

Okay. Okay.

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

The identification issue \-- this is Jay Sanders \-- not only relates to
patients, but apropos the obvious concern about both natural and man
made disasters, having unique identifiers for clinicians is very
critical, also.

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

Thank you, Jay. And also I think the authorization process that goes
with it.

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

Exactly.

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

It\'s kind of interesting from a more global perspective that if you
look at the debates going on in this area, and you look at debates going
on in immigration and guest worker programs, et cetera, unique
identifiers are kind of the key enabler in all of those discussions.
Wouldn\'t surprise me to see the mood of the U.S. move away from its
historic position to more of a national identity system. You know,
we\'re kind of at odds with the current framework of not wanting Big
Brother to watch over you, but wanting all the benefits of Big Brother
watching over you.

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

One of the things I might add to the conversation is while we\'re on
this meeting, the National Health Information Network folks are meeting
at NIH, it\'s a conference of about 600 people right now, and they\'re
really talking about what are the critical functionalities necessary for
this type of an architecture. And this issue of how one identifies the
patient is front and center. So I expect that as the results from the
NHIN prototypes are completed and brought forth clearly by the end of
this year, they will also have some input into how this might happen.

So that\'s another place to watch the process.

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

This is Eric Larson, again. I have to leave a little early but I wanted
to ask another question of Karen on the charge. And this relates to the
meeting that\'s at NIH. Are we going to address anything related to the
use of the information systems for research and chronic disease
monitoring and quality improvement?

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

When you ask that question, Eric, are you looking specifically around
one particular area, around research, or clinical decision support, or
is there \--

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

No, no, no, I just want to know what\'s the scope of this workplan here,
what\'s the boundary that we\'re drawing around ourselves? Because I
know there are other people who are interested in chronic care who see
the development of NHIN as being kind of critical for achieving sort of
global health goals for populations, not just in private pursuit of good
health.

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

I hesitate to be proscriptive, but I think the concept that we\'re
really looking at here is assuring that these populations of chronically
ill patients, or patients with chronic conditions, they may not be
specifically ill but have a condition, are able to receive care when
they need it. And that can be guidance, again, in a home setting, it can
be the ability to gather information in a work or a school setting and
be able to transmit that to someone who can help them or work with them
to assess and evaluate that information, so that they can then make the
right decisions, or the best decisions for them, moving forward.

So I think that if we move in that direction, it may ultimately support
the larger goals that you\'ve described. But I think we are trying to
look at what needs to happen, and what are the critical components of
taking care of individuals \-- an individual right now.

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

Okay, thank you.

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

I really think what \-- this is Jay Sanders \-- I really think what Eric
has brought up is critical. Because in making the statement, we want to
make sure that the patient gets good care. At this point in time we
don\'t know what good care is. And gathering and utilizing the data that
is collected, so that it does not on one hand provide a unique
identifier of the individual, but can be used from a collective database
analytical standpoint, is very critical.

Was that what you were \--

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

Well, yeah, and it gets us up against this whole issue of unique
identifiers, and privacy, and it\'s \-- you know, I just need to know
how much we\'re biting off in terms of coming up with a document at the
end of the day.

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

Yeah, there are some examples which I\'m sure you\'re aware of, like
Mayo Clinic and IBM, University of Pittsburgh and IBM and the
Massachusetts General Partners, where they\'ve collected this data and
feel fairly confident that they have in essence hidden any possibility
of identifying individual patients, and are using that data. Using the
collective data from medical records.

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

Right. Right.

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

So one of the things that strikes me is that, you know, the next thing
on the agenda was to go through some of our goals and strategies. And as
we\'ve worked through other workgroups this week and last week, it
becomes an exercise which helps us to really focus on those strategies
that might lead us to addressing the critical components of the broad
charge.

And we may have missed something here, and so I think it would be very
helpful for us to review some of this, determine what is appropriate to
the broad charge, and then if there are gaps, try to identify them so
that again, on the next \-- at the next meeting we can be a little bit
more specific about options in these critical arenas.

And that comes up because one of our strategies is to find ways to
gather information in a way that it can be used in a much more
patient-specific way. Similar to what you\'ve just been discussing.

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

Well, I guess \-- this is Eric Larson again \-- what we could \-- I
think I\'m addressing what you\'re saying, but as we go forward with
some of this research and data gathering, my recollection was that we,
in our recommendation, said we want to define something like best
practices around \-- around secure messaging and reimbursement.

We may also want to keep our tentacles open to look for best practices
that relate to the way people have collected or used this capacity to
exchange information and monitor and promote communication as or for
secondary gain, if you will, in terms of either research or monitoring
the health of a population or looking for population needs that are
unmet because we\'re collecting this kind of information in a routine
way, or this information is out there to be collected in a routine way.

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

This is Francis. As you\'re speaking about that, it comes to mind that a
number of the Medicaid programs around the country have disease
management programs in place, and have had for awhile, obviously through
contracts to do that, but there\'s potentially a rich source of data and
lessons learned and insight to be mined, and we haven\'t spoken of
Medicaid as a payer much in the conversation today.

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

This is Joyce. It also sounds as though, you know, back to the unique
identifier, that the RTI contract is going to address some of this stuff
because it touches so \-- so obviously on the privacy issues.

They\'re supposed to be collecting best practices among the States,
aren\'t they?

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

They are, that is correct. And we should be getting information from
them, as well as from the NHINs. Is there any interest in moving forward
with the goals, strategies and objectives, then?

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

Yes.

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

Let\'s do so.

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

Okay, I\'ll jump right in. These were presented very, very quickly at
the AHIC, at the last AHIC meeting at the end of the time frame. We had
a very active and robust discussion on clinical decision support just
beforehand, and so the discussion around the goals, objectives and
strategies will be \-- was essentially tabled until the next American
Health Information Community meeting.

But I would like to call your attention to the document which is labeled
Office of the National Coordinator goals, objectives and strategies,
June 6, 2006, and has \"draft\" printed on literally every page.

Because it is a draft document. It is set up in such way that we have
four goals, and when you think about it, those four goals are not
inconsistent with our four workgroups. The first goal of informing
health care professionals is really all about EHR adoption. So the EHR
Workgroup spent a lot of time with those possible strategies yesterday.

Interconnecting health care is actually the foundation for being able to
manage patients with chronic conditions across a broad array of
settings. And so in many ways there are a number of strategies here that
we might want to focus on.

But recognizing that a good deal of chronic care management falls in the
realm of personal health, and personal responsibility.

The third goal, personal health management, which is very consistent
with the work of the Consumer Empowerment Workgroup, also has within its
strategies that would likely be critical for this group to realize its
broad goals.

And the discussion that we\'ve just had about improving population
health has a number of strategies in it that really do relate to
research as well, and collecting information, and that venue.

So I think that if we were to go through this document and identify
within each goal \-- and actually, within each objective, those
strategies that may be critical to reaching this broad goal that we now
have to address, we might then have some focus on where we might go, in
terms of really thinking through the next steps, what tactics, what
actions, what recommendations might be necessary in order for that
broader goal to be reached.

Having said that, it may be that we miss some strategies. This is a
draft document because it has not yet had the value of full feedback
from folks like you who really understand these areas better than us
collectively here.

So again, it\'s your feedback that\'s important here, and if we\'ve
missed something, that\'s important, but I think at the end of today
we\'d like to have at least several strategies that we think are
critical and high priority that we can then start fleshing out and
working on with you, in order to help support you in reaching your
broader goal.

Any comments on this, at this point? Has everyone seen the document and
everyone has got it in front of them?

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

Yes.

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

Yes.

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

Yes.

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

The only thing I was trying to rationalize, Karen, this is Craig, is if
you read through this document, it\'s very difficult to argue with any
of the goals, obviously. Or any of the next level strategies. Trying to
rationalize that to the charter of doing something in the near term, and
not getting confused about \-- getting bogged down in the global
long-term vision, as opposed to \-- as Secretary Leavitt mentioned and
Brailer mentioned, kind of grabbing the low hanging fruit and getting on
with life, and quite often there\'s a conflict between those two. You
can get stalled in the overview phase because your goals are so
far-reaching and so esoteric in a certain sense as opposed to what can I
do today and tomorrow to get started.

And so I\'m trying to decide what is our role, our charter here. I
thought we were chartered in the very near term, specific phase, what do
we need to do. And when I read through this set of goals, it\'s nirvana,
it\'s motherhood, it\'s apple pie, it\'s all those good things. Which
direction do you want to us move in?

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

I think \-- and I\'m glad you brought that issue up, Craig, and thank
you for doing so. I think that the specific charge, you know, ours was
pretty clear-cut, secure messaging between patients and their
responsible clinicians, was the place where we were looking for
something to happen relatively quickly, and the low-hanging fruit. Or at
least clear definitions on the barriers and enablers that need to be
addressed.

So those \-- you know, there was a huge amount of work everyone has
done, and I can\'t underline enough \-- I think the Secretary\'s
appreciation and the appreciation of everyone here at ONC on the work
that was done to get us to the point where we are now. We are now taking
those recommendations and making sure that they happen in the time
frames that are necessary to realize that the breakthrough itself can
exist in at least several places by the end of the Secretary\'s term.

So we\'re moving ahead with that, in terms of a shorter term
deliverable.

I think the transition to the broader charge gives us a little bit more
space. In order to move forward to the broad charge, clearly some of the
things that were identified in the specific charge need to be addressed,
and we\'re doing that. But there are other things, as well, that may be
important. And so if there are remaining big barriers, or there are
remaining things that we can do to enable achieving the broader charge
of not just secure messaging but the use of remote monitoring devices,
and the use of IT that supports remote care, then we need to look at
that straight-on.

It may not be resolved in the next year, but that\'s okay. We need to at
least understand what needs to be done in order to go in that direction.

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

Yeah, not to be argumentative, I\'m just trying to rationalize in my
mind the unanswered questions we have on specifically what to do in this
particular area or that particular area, to do our short-term charge. At
the same time of looking at cleaning up the waterfront, with the
longer-term charge.

So I guess I\'m questioning where do we put our energies. And I know
you\'re asking, golly, let\'s just look and see \-- do this document, if
there\'s anything missing or if there\'s any specific things we want to
add to that, you know, that\'s a great exercise. How much time do we
spend looking at the blue sky as opposing to the immediate task ahead of
us?

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

I think the real concept here is \-- this is the broad charge time. So
we really are thinking what do we need to do to get to the broad charge.
And you\'re absolutely right, at a very high level it is apple pie and
motherhood, no one would argue with having better informed clinicians.
But as we start getting deeper into it, and as we start thinking about
various strategies, we then can define more tactics, more actions that
you could use as recommendations to the AHIC.

I do need to underline perhaps for all of us, including myself, that the
function of this Workgroup is to make recommendations to the AHIC, and
then the AHIC will make recommendations to the Secretary, and the
Secretary will determine which of those recommendations will be carried
forth.

So the real \-- the real piece here is if \-- there are some critical
recommendations that need to be made, then we might use this as a
framework to think about them, and then further develop them.

And that\'s really \-- that\'s really all this is, this is a framework
to get that kind of discussion going. This isn\'t feedback, we\'re not
looking for feedback to basically say yes, this is a good document or
not a bad document, this is a mechanism which should and hopefully will
engender the kind of discussion that will get us that specificity.

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

Okay, well, I\'ll shut up for a minute and let others talk.

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

Karen, this Workgroup also I see many strategies here, who actually then
goes and tries to operationalize the strategies, or try to figure out
what are the actual \-- what are the actual steps, or projects or plans
that would make this strategy viable?

Are you looking for this Workgroup to \-- if there are particular
strategies that involve chronic care or the broad charge here, could
this or should this Workgroup try to think of specific ways to
operationalize some of the strategies?

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

The operationalization is not within the purview of the Workgroup. It is
a recommendation in terms of what needs to be operationalized. And so I
think that may be the best way I can say of differentiating it.

And I\'ll go back to the specific charge, again, as an example. We have,
out of the specific charge, a number of recommendations that will be
carried through. The actual breakthrough itself will be operationalized
in a number of sites, but it is not the Workgroup\'s purview to
determine the sites, or how that gets operationalized. We will do that
through our own prophecies on track, et cetera, throughout all of HHS in
order to really operationalized the breakthrough itself. So we\'re
really looking here what are those critical recommendations that need to
happen in order for remote care, remote monitoring, to come to fruition.
In a widespread way.

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

Francis from Cisco, a question for the folks on the Workgroup on an
ongoing basis. Has the Workgroup discussed the aspect of consumer
readiness? I see goals around informing clinicians and others, but to
some extent it\'s a challenge of consumer readiness and willingness to
use these technologies or to participate in this sort of care delivery.

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

The discussions have been on two aspects of that, perhaps. One is just
the availability of the capability to the consumer. Also the value to
the consumer. Those, in my mind, drive the consumer readiness.

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

Perhaps paired with an advocacy or educational sort of initiative as
well?

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

Yeah, we talked a bit about the cultural impact on the consumer of doing
this. And I think, as Craig said, one of the things coming out of it was
the value proposition, and part of that would be include an outreach
effort to the consumer just to make them aware these capabilities exist,
but also realized value. One of the things, you know, that HHS is doing
is this whole transparency initiative to provide \-- you know, more
information to consumers on the quality and costs of their health care.

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

Right. Right.

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

One of the things that I think could be tied into this.

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

This is Joyce. The followup on the issue of readiness, we talked very,
very early on about the fact that different population groups,
particularly when you talk about people with multiple chronic conditions
who are extremely vulnerable, may not have the same readiness by virtue
of a whole bunch of characteristics that other people will have. And so
I think beyond recognition of value, and simply having access to the
technology, there is another dimension, in terms of readiness. And I
think there\'s a real question about whether everyone is going to be
ready.

**[\>\> PAUL NICHOL:]{.underline}**

This is Paul Nichol. I think the experience is not everyone will be
ready at the beginning, and there are things we can do to facilitate
adoption.

I think it is an important question. We built it based on the value
provided, I do think it will be important to get that information out,
and you\'ll see a gradual increase in adoption. I\'m not sure exactly
sure what the tipping point will be, but I think the focus on value and
getting the word out is important.

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

I think \-- this is Jay Sanders. I think there is once again a rich
literature base looking at receptivity in the chronic disease patient
population with much more complex technology than simply secure
messaging, and the overwhelming result has been very, very positive.
That\'s not to say that we shouldn\'t have an ongoing evaluation of
this, but the literature has been quite positive.

And I would also turn to a very large project that CMS has been funding
for years now, that\'s the one at Columbia, the idea-tel experience, and
it would be of interest to look at some of their data in terms of
patient receptivity.

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

Does that address a vulnerable population?

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

Very much so.

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

It will be interesting to see those data.

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

This is Cathy Voles. Catherine Dansky and I published an article on
patient reactions to telehome care that you might also want to take a
look at.

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

Hi, this is Joe Gifford from Regence. Let me just try framing how I
think I\'m seeing it now. We laid out well in our first set of
recommendations the #1 deal was reimbursement. And indeed we believe
that the real basic issue here is the business model right now is all
wrong for adoption of electronic technology; that is, the current
visit-based reimbursement model makes adoption really risky here of just
something that drives up costs and creates more speed and confusion, in
an existing tangled mess. So really the primary \-- I guess \-- and this
committee has said that.

The primary deal: Work on the business model. Now, that said, you know,
we could all just go home and say it\'s not time yet. But we don\'t want
to do that. So the question for us now is, you know, having said that,
waiting for a business model where there are competing accountable
entities that are rewarded appropriately for good chronic care, and so
on, who will then adopt in an intelligent way without driving up costs.
You know, waiting for that world to come, what can we do to make sense
right now, what can we promote technology wise that makes sense right
now, that isn\'t just speeding up a broken process or laying wires to
nowhere.

And I don\'t have an answer to that, but that seems like the right
question for this group right now. Other than just pilots, it\'s easy to
say let\'s do a pilot or lets do a study of this or that. Maybe that\'s
the answer. But is there something in the technology sphere that we
could say lets do this anyway, even though the reimbursement business
model thing isn\'t fixed? That seems like some kind of frame we could
use.

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

Well, if you look at the issue, what we\'re proposing are a series of
kind of fundamental infrastructure changes which allow IT to be used
effectively. If I hearken back to the banks of 20 years ago, when you
had to go to the bank to get money and carry out a transaction, there
were fundamental technology and infrastructure issues you had to resolve
before you could use the ATM cards or bank online.

Not everybody adopted the technology initially. However, over a period
of time, the value and convenience to the end user ruled the day. It
seems to me we\'re in an exactly parallel course here, where we need to
put the infrastructure in place to allow the capability, allow the
process to take place, and that is secure messaging, its identifiers,
its reimbursement, its \-- all of those things that financial industry
went through in their example.

And I would hesitate to assume that you have to turn everybody on at
once, because everybody won\'t turn on at once. You just have to make
the capability and the value available. And then we let nature run its
course.

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

Yeah, I think that\'s such a critical issue. I mean, we\'re looking at
this like this is cutting edge stuff that we\'re doing, and it\'s not.
All these other service industries have used these for the consumer for
years, and looking at some of the hurdles they addressed early on, and
how they resolved them, could be very, very helpful for us.

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

But again, the problem here is that the analogies to other industries
don\'t hold up because health care has this unique problem of third
party stuff. And that we\'ve all addressed, you know, already, but
that\'s such a huge barrier. On the infrastructure and technology side
of course, like you say, that\'s not really the issue. The internet
exists and software aps exist. So the question is how do you promote an
environment which this stuff just takes off on its own, and we recognize
that\'s fixing the business model. It seems like that\'s the answer, so
let\'s all go home.

But no, let\'s not go home. What still can be done, that said, right?

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

Well, I guess there\'s no debate that you have to fix the business model
and fix the infrastructure, and it\'s then how the major players promote
the use of the technology, you know. And whether you promote the use of
the technology as the banks did, by, you know, having ridiculous banking
hours, and making it so inconvenient that you had to use the technology,
or charging you a transaction if you had a face-to-face interaction as
opposed to an electronic interaction. And so we can address the
situation by what do the major suppliers or payers do to promote the use
of the technology, what do the employers do who are paying the bills,
what does CMS do that\'s paying the bills to promote the use of the
technology, once the infrastructure is put in place? Once the business
model is put in place.

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

I think the business model was looked at by the likes of Aetna, Cigna
and the Blues in making their decision to pay for secure messaging.
Because they saw how much it reduced rehospitalization rates, which was
a big cost to them.

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

Yeah. No, absolutely.

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

Well, but let\'s not say absolutely. I mean, with respect, I don\'t
think that\'s a given. That\'s given. I mean, Mark McClellan doesn\'t
believe that, and CMS isn\'t paying, and most Blues are not paying
because of the strong suspicion that just paying for E messaging in the
existing business environment will drive up costs without really
effecting quality. And there\'s pretty strong conviction about that in
most circles I look into, despite what you just said about Aetna and
Cigna. So I don\'t think that\'s clear.

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

Right. You couldn\'t have said it better than I could say it for Mark.

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

Do we know exactly what they pay for and under circumstances?

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

Come on, guys, effectively all of the information we\'re seeking and all
of the case studies we want to look at and all the best known practices
we want to look at are supposed to specifically answer the questions of
how you use the technology, and what is the resultant cost, quality, and
service implications, right?

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

Okay.

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

I mean, this is the issue we keep talking about, and so this is the
issue we say let\'s go out and specifically address and collect the
information. And it\'s always has as its basis cost, quality, and level
of service. Level of care. Improvement of care.

I don\'t think anybody has a different opinion, do you?

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

No. This is Karen. I\'m wondering if what I\'m hearing, and just to
level set myself, here, is that in order to really move forward with the
broader charge around multiple remote devices and other approaches, we
really need to address the barriers and the issues that were defined
with the specific charge before we can really get into more work on the
broad charge. Is that what I\'m hearing?

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

Well, I just \-- I mean, that\'s sort of the point I made. Is that our
Recommendation #1, on the narrow charge, I think says it all. But having
said that, we\'re not just going to go home. But it is true, in my view,
and I believe Dr. McClellan\'s view, that until you figure it out at
that level, the rest is all just \-- you know, academic pilots and
studies and stuff.

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

What I\'m wondering, is there a difference between secure messaging as
we know it now, with there\'s information that the patient is gathering,
and putting in him or herself, versus information that\'s being gathered
from, for instance, monitoring devices? That can be hooked into the
internet, and sent to a physician or clinician\'s office. The
remote halter monitoring that can appear on a cardiologists screen. Or
the insulin pump, for insulin readings that occur. Is that essentially
the same, the same issues as secure messaging, or is that a whole other
level that we need to be thinking about?

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

It\'s part of the continuum of data that would be required in order to
assess the condition of the patient. It\'s not an either/or, it\'s just
part of the continuum of information.

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

It\'s the variety of tools that can be used to help monitor the patient,
and hopefully improve outcomes.

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

I think secure messaging is a communication between the patient and the
physician that although it\'s asynchronous, it\'s bidirectional. The
information that comes in from monitoring is \-- is data that is
somewhat different. It has the same security issues, but I think that
the secure messaging is a more direct communication and somewhat
different.

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

You\'re still tying it back to various outcomes, Paul.

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

Yes, I would agree with that.

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

All right, Karen, you now raise this issue of the global strategy
relative to our incremental, shorter term infrastructural strategies and
recommendations. I, for one, am getting the sense that we\'ve got a set
of infrastructure issues to overcome before you can even start to get
improvement in the delivery, quality, cost-effectiveness of health care.
And until we solve those basic infrastructural issues, the global issue
is going to be \-- is somewhat of an academic discussion.

If your question to us was look at these big strategies, and are we
missing something, I haven\'t heard anything new that affects our
specific recommendations for secure messaging, reimbursement, best known
methods and practices of this nascent health IT capability. And I stand
to be corrected if anybody has a different opinion.

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

I don\'t disagree at all, I\'m just wondering a little bit apropos the
earlier discussion around patient receptivity. Would patient receptivity
about having information being transmitted from a device be different
than patient receptivity vis-à-vis more active engagement, i.e., through
having to log on to a computer, authenticate, and then do secure
message?

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

You get \-- you know, if you polled 100 different people you\'d get at
least 110 different answers.

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

Is this an area we might want to spend more time doing some either
research on or think through with AHRQ, where they\'re going?

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

I think you certainly should talk with AHRQ, Karen, because they are
doing a lot of work in this area. Looking at the whole patient response,
and whether it does improve outcomes, and things of that sort. Helen
Burstin I think is very involved in that, it probably would be worth
discussing this with her a little bit.

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

I actually had a fairly robust conversation with John White on it and
will be following up and getting more in the detail, so I actually agree
that\'s a very important direction to go in.

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

I\'m sorry, what would the intent of the research you\'re talking about
be?

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

This is to understand better patient acceptance, patients finding value
from devices that transmit information directly, essentially without
very much effort on their part. Versus their acceptance of communication
through a secure messaging or portal of something of that nature which
requires them to be much more actively involved. Is there a difference
between the two, in terms of patient acceptance.

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

You know, I think it\'s such a rapidly evolving area that the
information you get at one point in time may not \-- may be outdated by
the time you analyze it.

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

Yeah, I\'m not sure I understand how that advances our work, here.
Understanding that answer.

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

Yeah, I think there needs to be research looked into, but I would agree
with Joyce and Craig that it almost gets to become an academic exercise,
it really doesn\'t fully address where we\'re trying to go, here.

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

There are a tremendous number of other factors that affect acceptability
from how the providers use it, so I think it would be difficult to do. I
think what we\'re looking at is being sure that there are safe,
effective, standardized means for that communication to occur. And I\'m
not \-- I\'m not sure that we \-- that we need to try to do research to
figure out if patients want it at this point. I think that\'s already
clear, it\'s just a question of how rapidly it gets adopted.

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

And I think what AHRQ is trying to understand is how patients perceive
the \-- the use of technology in the course of an encounter with a
clinician, whether it\'s intrusive, whether things are more convenient,
whether information is more accessible. I think they\'re looking at
those kinds of responses.

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

I hate to say it, but it\'s reinventing the wheel. It\'s all been done.

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

That\'s kind of what I feel.

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

Maybe what we could do, then, and I certainly want to be very respectful
of everybody\'s time, but maybe what I\'m hearing, then, is that we need
to find some way to essentially do an environmental scan or a meta
analysis or research \-- essentially pull together a research project,
and pull this information together in a way where it can be presented to
the public through this Workgroup. This Workgroup would review it, and
then to the AHIC, and could be presented in such a way that could then
help guide more of the research that needs to be done. If there is more
that needs to be done, such as the demonstration project we were talking
about earlier, then let\'s get on with that. And if the research is
already there, and we can take away good, clear recommendations from
that research, then tee those up.

But I think it sounds to me as if we need to pull together existing
information, existing research right now, in a way that is comfortable
for everyone, and that from which we can derive recommendations. Is that
fair?

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

You know, that\'s fair. I guess the thing that some of us are struggling
with is, is there any question or doubt, in anybody\'s mind, that this
is where we\'re going?

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

Right. So \-- I\'m sorry, Joe Gifford again. To be a broken record, if
our mandate is to promote adoption of this stuff, then there\'s two ways
to do it. One is through a strong Soviet style command and control deal,
in which we mandate that all this stuff happen and we\'re willing to pay
for it on an atomized basis. Not to attractive, right?

Number two is that we encourage a sort of free market adoption mode in
which quality is improved and costs are decreased through value
competition among free market entities who figure it out themselves. The
technology is already there, we don\'t need to invent that. The value
proposition we all intuit that it\'s in there. But just let the market
go to work and figure it all out, and they will. That\'s option two. I
can\'t imagine there will be a lot of dispute that #2 is better than #1.
And if #2 is the case, we don\'t have a structure to do that now. So
let\'s all go home.

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

Well, #2 is the action, but remember that the free market doesn\'t have
the incentives or reimbursement in place to promote this use. So that\'s
part of what we\'re trying to do is identify those barriers and make
recommendations to remove them.

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

That\'s the one thing inhibiting the free market.

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

Right, which is my point. Until that gets figured out, which plenty of
people are working on, of course, there is just not a lot for this
committee to say, other than to try to say, well, if it were a command
and control thing we think this would be a good idea. Which is all kind
of academic, but we could do that.

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

I\'m coming back to, Karen, the charter for our committee, I thought,
was to make recommendations specifically to define the barriers, make
recommendations around the barriers, for the implementation of health
IT, for chronic care, et cetera, et cetera. Why don\'t we use 110
percent of our energies to do that, and to drive that part of the issue,
as opposed to battling the Soviet style versus the capitalist style of
implementation.

Is that a fair direction?

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

I think that\'s fair. I think, though, that \-- I absolutely agree with
you, I think that the real \-- you know, the real question is how do we
foster HIT use in these endeavors. Recognizing, as I\'ve said before,
that so much of this care is external to the clinician\'s office. I\'m
looking at Anand right now, both of us have practiced internal medicine
for years, and we\'re lucky if we see a patient for a total of about 1
hour and 15 minutes over the course of a year. Where there\'s a lot of
care that gets rendered in other settings.

So I think the real question is how do we meet that objective that
you\'ve just articulated, Craig, with using HIT, and what are the
barriers to allow that to happen.

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

And I keep coming back to we\'ve got a list of recommendations. We want
to gather data, we want to get best known methods, we want to get case
studies, we want to make sure that the studies are there to show that
outcomes result in better care at lower cost, as opposed to higher cost.
You know, I think that\'s the CMS issue, and other people\'s issues, as
well.

But it seems to me we have a solid list of recommendations, without
getting into solving global warming.

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

Well, I think you\'re absolutely right, we need to come to the
recommendations. The recommendations we can put into whatever strategies
appropriate for them, and that\'s what we\'ve done before. We have this
larger picture, and all of our recommendations and tactics and actions
can hang in it someplace in this framework. So we\'re not using the
framework, again, to solve global warming, just to give a home to
whatever recommendations come forth.

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

I apologize for the comment.

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

Actually, I\'d like to point out that an effective secure messaging will
decrease the use of the automobile to go back and forth to the office,
and will in fact decrease global warming.

\[Laughter\]

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

Thank you.

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

Good point. Good point. But no, as I\'m saying, if we have good, solid
recommendations, that we could \-- in addition to what we already have,
then we can articulate them, and essentially save a lot of work over the
course of the next 6 months.

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

I just would like to put our energies, as a group, into making the best
specific set of recommendations, collecting the best information
associated with those recommendations, to clarify, direct, change,
alter, modify, et cetera, such that we can help HHS, help everyone, to
get \-- use information technology to get better health care.

And to me, the answer of using IT is so obvious. It\'s happened
everywhere else, it\'s going to happen here. So what are the barriers,
what are the recommendations we make to overcome those barriers, whether
they be technical, business model, et cetera. And then to get on with
it.

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

I would agree with Craig, particularly in the chronic care area, as you
said earlier, is such a big percentage of the health care costs.

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

You know, it seems like we\'re rehashing old ground in many ways. I
think that the free market approach hasn\'t worked very well for health
information technology. It\'s given us a large number of systems that
don\'t speak to each other very well. And so I thought what we were
trying to do is learn from the previous problems of electronic medical
records, and at least begin to talk about some standards for secure
messaging in terms of how information gets transmitted, and the
procedures for security, patient identification, those things that
should be common no matter what the specific application is.

And to support those as a means of moving forward in a more standardized
and consistent way than has been our free market example in the past.

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

Well, it may be a chicken and egg situation. If you have nothing driving
you from a reimbursement standpoint, you really don\'t have a \-- you
really don\'t have a huge market driver. If there is reimbursement, you
watch all the players get together and say look, we now have a big
market opportunity, let\'s make sure that all of our systems interrelate
and talk to each other.

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

Right, and we just hope it happens a little bit more quickly than it has
with the electronic medical record.

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

Exactly.

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

Karen, have you got all the help you need?

\[Laughter\]

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

Maybe after a good night\'s sleep I\'ll figure it all out. Well, you
know, I think we probably can table this discussion, at least for now,
and come back to it again in July with maybe a slightly different focus.
I think clearly we have plenty of work we need to do between now and
July to address the specific charge more. So that\'s the most important
takeaway that I think I\'m hearing from today\'s discussion.

I think that we may be able to think a little bit more about barriers,
did we capture all of them, as you say before, are there other things
that we can or should be doing other than what was defined on the first
go-around? Between now and July. But I do think that continued
discussion in this vein probably isn\'t going to be as helpful as coming
back to you next July with more information on the specific charge.

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

Is the addition of remote monitoring one of the main differences between
the specific and broad charges? And if it is, if it\'s just a remote
monitoring, and then we talked about how that\'s different from data
that\'s collected, from secure messaging, and it\'s more automatic,
potentially more objective, and potentially physicians could utilize
that data in more real time to make changes in their treatment policies.
I guess other than these five reimbursement liability systems, consumer
access and patient ID, are there any other big ticket items
specifically \-- specific to remote monitoring as opposed to secure
messaging that would be a hurdle, or that we would need to address to
get remote monitoring, to move that forward, as well?

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

Am I incorrect in my assumption that remote monitoring is kind of a
subset of the whole secure communication between clinician and patient,
and caregiver? I\'ve always kind of assumed that it was just a subset of
what we\'re doing. And that as we looked at the examples of how Kaiser
does it, how the VA does it, how the Blues do it, et cetera, that it
will pop out where the value comes from.

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

Yeah, I agree with that, Craig, I view messaging here as secure
information flow.

**[\>\> DON HORTON:]{.underline}**

This is Don Horton at Lab Corp. I think there\'s another difference
between the broad charge and the specific charge that we haven\'t I
don\'t think specifically talked about, and that is, the broad charge
talks about communication between clinicians about patients, whereas the
specific charge talks about communication between clinicians and
patients.

I think most of the focus has been on the latter, and I don\'t know if
that means that communication between clinicians about patients is being
downgraded as a component of the broad charge or not.

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

Do you mean clinicians or clinician?

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

Yes.

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

Yeah, I think you\'re right, we really haven\'t focused a lot on that,
although I don\'t think there was any intention to exclude it. And
clearly, it\'s very important from the standpoint of how our health care
delivery system, how it works in the care of a patient.

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

I agree.

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

This is Joe Gifford at Regence again. Just want to focus my comments
into something that might \-- you know, something concrete we might
think about. The Recommendation #1, about reimbursement, had the flavor
of, you know, we have to figure out how to pay for this stuff. But I
would \-- I would focus that and maybe propose a different \-- or a
nuance to that, that what really should happen here is a system of
accountable \-- a system of accountable provider groups who are \-- who
have level playing field competition to take care of chronically ill
people. And that it would be our opinion or my opinion that in that
situation, you know, they would figure it out. That the tools are out
there, the \-- and the promise is huge.

So if you let \-- you know, let\'s say Group Health compete with Kaiser
and compete with \-- I don\'t know, Mayo Clinic, give them each \$1,000
and 50 patients, and you let them just figure it out, where they were
totally accountable and responsible both for outcomes and for the
dollars, that, you know, at the end of the day, or the end of a decade,
they\'d figure it out. And all this very complicated stuff would make
sense. Because they all have lots of smart people, and the tools are
already there. And that is \-- that\'s what I would say is the nuance to
our Recommendation #1, that is where you would have to get to, to really
promote adoption.

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

So in terms of where we need to go next, that probably is the direction
we should be pursuing? Joe?

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

I would just say in terms of articulating the barriers, which as I think
somebody said, is really the right next step here, that\'s just a good
nuance to put to our Recommendation #1. That the barrier is that the
current \-- you know, the free market can\'t work in this environment,
and there need to be some accountable, clearly boundaried, a nice
competitive environment, in which all the smart people can take all the
existing tools and can figure it out.

So it\'s kind of a meta, you know, way of saying here is how adoption is
going to happen. It\'s just an addendum to our Recommendation #1, which
is that the recommendation or the business model issues are primary,
here.

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

So what I\'m taking away is that we need to incorporate that in that
particular recommendation in a way that would perhaps allow a \--
perhaps public comment, or some way of eliciting recommendations on how
we could make that happen, how we could change the environment?

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

I would like that, yeah. I think the word competition should be in
there, so that the public can comment on that, because it\'s a hot
button. And it also modifies the existing flavor of recommendation one,
which I think that flavor is kind of, you know, can\'t we all please
just pay for this stuff. Which I think isn\'t quite the right flavor, I
think the right flavor is to put that word competition in there, and
that would be my vote. And then yeah, let the public comment, let the
debate begin on that.

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

You know, Karen, I may have mentioned this before, but just as a
reference point, there is a large health care delivery system that has
embraced this technology for a number of years. Initially based upon
multiple evaluative research sites, and based upon the results of that,
now have basically, as you would say, gone public with it, is no longer
in a research environment. That\'s the VA.

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

Yes, I know. I understand, and we\'ve been talking very closely with
them about a number of these issues, as well. I think we \-- I think
this gets back down to, again, the two things we\'ve talked about.
Number one, I certainly appreciate and like the approach that\'s just
been described about having to rethink a little bit more about how we
would frame the market \-- the competitive market around this issue.

But I do think there\'s also the opportunity to pull together a lot of
the research that\'s already been done, and create essentially some
public testimony around that, that can be aired to this Workgroup that
can better inform where we need to go forward. So those are the two
pieces that I think I\'m taking away from today\'s discussion.

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

Yeah, I think that would be a grade idea, Karen.

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

I\'ve just created a lot of work for our internal staff. Thank you very
much.

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

You\'re very welcome.

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

Considering we only have about 10 minutes left, and I think we\'ve kind
of finished the agenda, is it appropriate to open this to public
comment?

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

Very much so, thank you all.

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

There\'s instructions up on the screen for calling in and making a
comment for any members of the public who are following along. And if
you\'re already dialed in on the phone line just press star 1 to queue
up to make a comment.

And I\'ll give us our standard 2 or 3 minutes, I\'ll jump in and let you
know if anybody is dialing in. Otherwise I\'ll let you know when that
time is over, and we can adjourn.

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

While we\'re waiting, Karen and HHS gang, I think the real issue is
getting the information of ongoing case studies, applications, of what
is happening, what are the results, and how do those results translate
into quality care, efficiency, for the system.

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

Really, the environmental study that needs to get done, Craig, is that I
think what you\'re describing?

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

Well, environment from the standpoint of \-- I would divide environment
into two categories. One is what are the fundamental limiters of using
technology, and whether that\'s reimbursement or secure messaging and
the technology aspect of it. The other part of the environment is what
has been done, what experienced people have, what demonstration proofs
do we have that we can replicate. And so gathering that information as
quickly as possible, and then being able to use that to clarify and
crisp-up our recommendations to AHIC I think is what\'s important.

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

I think you\'re right about that.

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

So, you know, that\'s why I keep coming back, we have finite of staff
energy, finite amount of everybody\'s energy, let\'s focus on those
specific issues which allow us to fulfill our immediate charter, and
then we can worry about the more global issues at a later time. I will
never use global warming again, although \--

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

I would like to solve global warming, it\'s okay.

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

Well, the clarifying comment that if we use less gasoline, we partially
solve it, is appropriate.

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

We\'ve got one public comment. Operator, can you please open Jim
Acklund\'s line?

**[\>\> JIM ACKLUND:]{.underline}**

Hello?

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

Go ahead.

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

Yes, hi. This is Jim Acklund with System Health Enterprise. I just
wanted to offer the suggestion that comments concerning some of the
difficulties on establishing standards, and interfacing and so on, can
be addressed by taking an enterprise level, system level approach to the
system definition, and ask whether or not it\'s possible in the current
environment, that is, given the charter that\'s on the table, is it
possible to have maybe a splinter group or a side effort that would take
that enterprise look at the problem?

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

Are you suggesting beyond the standard issues of common basis or common
protocols, common standardization of terms and ways to communicate?

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

Well, some of those will get done in the process of defining the system
at the enterprise level, and some of the issues associated with some of
those factors disappear because interfaces are no longer an issue.
Because they inherently occur because they\'re part of the system.

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

Yeah, if I look at the finance analogy, the finance world is comprised
of a number of different enterprises without standardization, but the
finance world communicates to each other through common interfaces and
protocols. That\'s why I asked the question.

I think it\'s a bit of a challenge to assume that you will have an
enterprise level definition where everybody follows that, when you have
a wide variety of different enterprises involved in the institution.

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

Yeah, that\'s why it would be very helpful if the government, HHS, would
step up to helping with that. Because as was suggested at a recent Mayo
Clinic symposium, the notion was that if we adopted an oversight
management level that was analogous to the SEC System, the Federal
Reserve System, that we would be better off than the kind of system that
we currently have. And I think there\'s a lot of merit to that.

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

Well, Tony, I don\'t know if you or any \-- Karen want to make a comment
about what\'s going on in the standards side of the business.

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

Yeah, I really don\'t. I think, Karen, on \-- with this type of
committee, we can hear public testimony, but I don\'t believe we\'re \--
we need to get into a discussion with the public, is that correct? I
think the purpose of this is to just get testimony out there.

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

That\'s absolutely correct, Tony, thank you.

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

My apologies.

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

Thank you.

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

That\'s it for public comments.

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

Do I hear a motion for adjournment?

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

So move.

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

Move.

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

Second?

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

Second.

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

Second.

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

Thank you, all.

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

Take care, everyone. Bye bye now.

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

Happy Fourth of July.