[This Transcript is Unedited]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Committee on Vital and Health Statistics
National Health Information Infrastructure (NHII) Workgroup
December 19, 2003
Hubert H. Humphrey Building
Room 705A
200 Independence Avenue, S.W.
Washington, DC 20201
Proceedings by:
CASET Associates, Ltd.
10201 Lee Highway, suite 160
Fairfax, Virginia 22030
(703) 352-0091
TABLE OF CONTENTS
Welcome and Introduction – Dr. Cohn
Status of ASPE NHII Activities – Dr. Yasnoff
VA Implementation of NHII Elements – Mr. Christopherson
Status of HIMSS NHII Survey – Dr. Steindel
Discussion of Workgroup Priorities and Plans – Workgroup
P R O C E E D I N G S [9:15 a.m.]
Agenda Item: Welcome and Introductions – Dr. Cohn
DR. COHN: I want to welcome everyone, this is a meeting of the National, the
Workgroup on the National Health Information Infrastructure of the National
Committee on Vital and Health Statistics. The national committee is as all of
you know the main public advisory body to the U.S. Department of Health and
Human Services on national health information policy. Now I am Simon Cohn, I am
not John Lumpkin who’s chair of this workgroup, John has asked me because he is
running a little late on his train to get the meeting started and to get
introductions going and such. I think we’ll be expecting him in the next ten or
15 minutes, so hopefully by the time we’re done with introductions and
hopefully before Dr. Yasnoff begins with his first presentation we’ll be seeing
him and he’ll be able to sort of move the meeting forward.
Obviously I want to welcome everyone, welcome staff and wish everybody happy
holidays. I obviously want to also remind everyone that we are on the internet
and to speak clearly and into the microphone.
Today we’ll be obviously talking about a variety of NHII issues starting off
with Dr. Yasnoff and a review of the status of the ASPE NHII activities. Then
we’ll move to Gary Christopherson talking about VA implementation of NHII
elements, and Gary thank you for joining us today. After a break Steve Steindel
will be talking about the HIMSS NHII survey and then we’ll be going into
discussions. I think our intent is to adjourn by 3:00 this afternoon to allow
people to get back home for their holidays.
Now with that let’s do introductions around the table and then around the
room. Obviously in the process of your introductions if there is anything for
which you need to recuse yourself you should publicly state in your
introduction, at least for those members of the full committee. I also
understand that there’s at least one subcommittee member or workgroup member
calling in so as we go around, after we’ve gone around the table we’ll ask you
to introduce yourself as well as any staff that are on the phone. Okay, with
that as I said I am Simon Cohn, I’m a member of the National Committee on Vital
and Health Statistics. I am the national director for health information policy
for Kaiser Permanente. While I don’t think that this issue will come before us
today if there are any issues related to CPT since I am on the editorial panel
I will be needing to recuse myself. Bill, would you like to continue the
introductions?
DR. YASNOFF: Bill Yasnoff, senior advisor for national health information
infrastructure at HHS and I’m HHS OS liaison to the workgroup.
MR. HUNGATE: Bob Hungate, Physician Patient Partnerships for Health, member
of the committee and the workgroup.
MR. BLAIR: Jeff Blair, MRI, member of the workgroup.
DR. STEINDEL: Steve Steindel, Centers for Disease Control and Prevention,
staff to the workgroup and liaison the full committee.
MR. CHRISTOPHERSON: Gary Christopherson, senior advisor to the under
secretary for health for the Veteran’s Health Administration and a supporter of
NHII.
DR. FERRER: Jorge Ferrer, CMS, staff to the NHII.
MS. WILLIAMSON: Michelle Williamson, National Center for Health Statistics,
CDC, and staff to the workgroup.
MR. KAMBIC: Bob Kambic, National Health Information Infrastructure, ASPE,
and staff to the workgroup.
DR. ZUBELDIA: Kepa Zubeldia with Claredi Corporation and a member of the
subcommittee.
MR. SCANLON: I’m Jim Scanlon, I’m the head of the ASPE Science and Data
Policy Office, I’m the executive staff director for the committee.
DR. DEERING: Mary Jo Deering in the Office of Disease Prevention and Health
Promotion where I’m the deputy director for health and I’m the lead staff to
the committee, the workgroup.
MS. GREENBERG: Marjorie Greenberg, National Center for Health Statistics,
CDC, and executive secretary to the committee.
DR. COHN: Okay, now why don’t we ask those who are on the phone to please
introduce yourselves. Do we have anybody —
DR. HARDING: Richard Harding, member of the committee, University of South
Carolina, I have no, what do you call, complications.
DR. HUFF: And this is Stan Huff with Intermountain Healthcare and University
of Utah in Salt Lake City. I would need to recuse myself if LOINC or HL7 become
topics of discussion.
DR. COHN: Anyone else on the phone? Okay, well Stan and Richard please make
sure that you can hear us and sort of let us know if you’re having any troubles
with the reception.
DR. HARDING: We will.
PARTICIPANT: — American Health Information Management Association.
MS. KLOSS(?): Linda Kloss, American Health Information Management
Association.
MS. WILLIAMS: Susan Williams, Otarum(?) Institute.
MR. WILDER: Tom Wilder, AAHP/HIAA.
MR. BLAKESLY(?): Bill Blakesley, independent consultant with Washington,
D.C. and on the board of HL7.
MS. MILGATE(?): Karen Milgate with the Medicare Payment Advisory Commission.
MS. BOWER(?): Cynthia Bower, Office of Disease Prevention Health Promotion
and staff to the workgroup.
MS. LEJONSON(?): Angela Lejonson, American Osteopathic Association.
DR. ORTIZ: Good morning, Eduardo Ortiz, Agency for Healthcare Research and
Quality, staff to the NHII Working Group.
DR. COHN: Well, thank you all. Well, Bill, do you want to get started with
your comments? As I said hopefully we’ll be seeing Dr. Lumpkin here
momentarily.
Agenda Item: Status of ASPE NHII Activities – Dr.
Yasnoff
DR. YASNOFF: Can the folks on the phone here me? Great. Well, good morning
everyone and I want to wish everyone happy holidays. Thank you for the
opportunity to report on the progress we’ve made in HHS on NHII, which as
you’ll see is extensive.
Let me start out by giving you an overview of what I’ll be talking about. We
have new staff, we’ve developed a strategy for NHII which I’ll share with you.
We’ve also finished the analysis of the recommendations from the NHII 03
meeting, which I will be presenting in some detail. We’ve prepared our initial
quarterly report, those of you who attended the NHII meeting will recall that
Secretary Thompson decided somewhat on the spur of the moment that there should
be quarterly reports in this activity and so we have done that. We’ve held two
additional stakeholder meetings, which I’ll describe, we’ve completed two
special projects. We’ve been involved extensively in additional standards
activity. I want to say a few words about the AHRQ’s RFAs for demonstration
projects for NHII. We’ve also established an NHII educational seminar series,
and then I’ll spend a few minutes talking about our plans for next year.
So I think most of you probably weren’t even able to hear Helga say hello
because I think the microphone was turned off, Helga, will you wave to
everybody please? Helga Rippen has joined our staff as deputy senior advisor
for NHII. Helga comes to us from RAND where she was director of the Science and
Technology Policy Institute. She was previously at Pfizer Health Solutions and
Mitretek and has expertise in bioterrorism preparedness and ethics in online
health information, and has been very active in the eHealth Initiative, in fact
is on the eHealth Initiative Foundation Board, which I think she’s going to
have to resign from unfortunately because that’s now a conflict, and HIMSS, the
NHII Workgroup there and IEEE-USA. So we’re very fortunate and I’m personally
very pleased to have Helga with us and I think that will enable us to
accomplish a great deal more.
We’ve developed a strategic outline, it’s the first step in a strategic plan
and I think part of this, this part I’ve shared with you before, the first
three points, inform, collaborate and convene, and so we’re working hard in the
inform area to disseminate the NHII vision, to catalogue NHII activities, not
just for us but on our website, and to disseminate lessons learned and you’ll
hear more about that. Collaborating with stakeholders, we’ve been doing quite a
bit of that, and we did convene the national meeting as you well know, and I’ll
be saying more about that.
But we’ve added these three additional points, which I believe I covered
last time, standardize, demonstrate, and evaluate, and so under the standardize
bullet the Secretary announced in March the adoption of HL7, DICOM, IEEE 1073,
NCPDP SCRIPT and LOINC for us by the federal government, although it is not
mandated for the private sector. And then at the NHII meeting the Secretary
announced the licensing of SNOMED not only for federal government use but also
to make it available at no charge to anyone in the U.S. We’ve also been
extensively involved in the ongoing continuing HL7 project to define the
standard functions of the electronic health record and I’ll be talking more
about that later.
Under demonstrate there is $50 million dollars in the FY ’04 budget for NHII
demonstration projects through AHRQ. As you know that budget has not yet passed
in Congress but in anticipation of that the RFAs for those grants have been
announced of course subject to availability of funds and I’ll be talking about
that.
In addition the eHealth Initiative Foundation received approximately $4
million dollars in an earmark from FY ’03 and that money is also for NHII
demonstration projects and we’re working with them. And the Markle Foundation
is moving towards phase two of their Connecting for Health Project and we’re
working closely with them in their efforts, so there are a number of
demonstration activities underway.
I should say as a footnote there’s also up to now the NHII activity has had
no budget at all and there is $3 million dollars in the budget for FY ’04 for
the NHII activities directly. My understanding is that the House bill that’s
already passed has the $3 million dollars in it and that there’s no opposition
to that so if and when the budget passes we will have some funds for our
activities as well.
And finally evaluate, I think this is a very important part of our
activities to develop increasingly rigorous assessments of NHII benefits and
I’ll talk to you about some of that today. And also to look very carefully at
policy options for aligning financial incentives, this financial incentives
alignment has emerged as a key issue, key obstacle in terms of progress.
Now before I continue you do have an additional folder in front of you, a
rather thick one with a set of documents that I will be referring to as I go
through this report and so I believe on the back of the cover page is a list of
all the documents, so if you turn the first page over there is a list of all
the documents that are in there. And for the folks on the phone we will get you
these as soon as possible.
So let me spend the next few minutes talking about the NHII ’03
recommendations, I’ll briefly review the background and goals of the meeting,
the breakout tracks, how the recommendations finally were organized and then
some of the details. You’ll recall that the NHII activities started in HHS in
September of ’02 and that we have been taking a voluntary approach as
recommended by the NCVHS NHII report from this workgroup issues in 2001. So
given that we were taking this voluntary approach it seemed reasonable to ask
the volunteers what they were willing to volunteer for on the theory that if we
try to move forward on things that the volunteers wished to volunteer for we
would be much more successful then if we tried other tactics. So this evolved
into a need for a consensus action agenda and so the national meeting was held
June 30th to July 2nd. We have over 580 people there
representing all the different stakeholders and as I mentioned Secretary
Thompson mentioned the federal licensing of SNOMED for no cost use in the U.S.
at that meeting.
There were eight breakout tracks at the meeting, privacy and
confidentiality, architecture, standards and vocabulary, safety and quality,
financial incentives, consumer health, homeland security, and research and
population health. And the names in parentheses are the folks who were track
chairs at the meeting who led the deliberations.
Now within each of these tracks there were a number of hours of breakout
groups and recommendations were produced that in theory were related to the
breakout track. However, it turned out as we analyzed the recommendations that
as you might expect there were a number, in fact a larger number, of
recommendations that were not related to the tracks that were assigned and in
fact were not related to any of these tracks. So when we had a chance to spend
some time with the recommendation we eventually organized them as I will
present them to you, basically into four major groups, management, enablers,
implementation strategy, and targeted domains. And under management we found
recommendations for governance, for education, for shared resources, and for
metrics. In the enablers category we found recommendations for financial
incentives, for standards, and for dealing with legal issues. Under
implementation we found recommendations for demonstration projects, for
architecture, and for identifiers, and there were two targeted domains
identified in consumer health and research. And as you can see I think we have
five of the recommendation areas here correspond to the original breakout
tracks, the others do not.
So let me start with the management recommendations. The first area was
governance and the folks at the meeting recommended that there be a
public/private NHII task force that included a number of subgroups, including a
steering group, an architecture task force, a privacy oversight group, and a
patient safety task force. They also recommended that there be regional,
non-profit public/private health IT corporations to coordinate investment in
local health information infrastructures in communities. There was also a
recommendation that NCVHS have a consumer representative. Does NCVHS have a
consumer representative identified as such?
MS. GREENBERG: No, we could.
DR. YASNOFF: How many members of the committee are consumers?
MR. HUNGATE: I have claimed to represent the consumer community but not
everybody acknowledges that as valid.
DR. YASNOFF: Well, that recommendation came out of the meeting so just
consider that as a recommendation. And there was also a recommendation that
there be a consumers union type public/private partnership to rate quality of
health care.
In the education and communication category recommendations included
informing the public about the NHII concept and its implementation and privacy
issues. Education senior executives in the public about health information
technology and the link between health IT and patient safety and quality.
Another recommendation was health IT education for consumers and it was also
felt that health IT education as well as hands on experience should be required
in the training regimens of all health care professionals. Finally, it was
recognized that if we are going to be successful in building a National Health
Information Infrastructure we need more clinical informatics training so that
we have health professionals who have a great understand of health IT, in
addition sufficient numbers of trained clinical informatics specialists to
actually build all the systems that need to be built.
Under shared resources there were to me a surprising number of
recommendations for shared repositories of information, including rules and
knowledge about health IT systems, nationally vetted clinical guidelines, which
in a sense we already have as put together by AHRQ. A repository of information
about biodefense preparedness, about data definitions, datasets, and metadata
for research, and also a national quality measurement database. Also in the
area of shared resources alliances in research and population health between
those communities and health promotion and prevention and treatment information
that’s available electronically to consumers.
And finally, the last area in management was this area of metrics, which
we’ve discussed here in this workgroup before, and it was recommended that
metrics be established to track NHII progress including specifically biodefense
preparedness, availability of the NHII to high risk populations, consumer
management of patient information, and the development and use of standardized
safety and quality measures. So there clearly was an endorsement at the meeting
of the concept of establishing and tracking metrics. It was felt that funding
should be tied to achievement of these goals as outlined in the metrics, and
also there should be specifically measurement of the credibility of health
information resources to help promote that.
So under enablers, the number one issue under enablers was this issue of
financial incentives, and for the most part these were divided into two major
areas, financial incentives for the acquisition of health IT and financial
incentives for sustaining health IT. And for acquiring health IT there was a
recommendation that there should immediately be available public/private
financing of $10 billion dollars to help acquire health IT. That loan should be
made available for IT that leads to quality, improved quality of care. And that
efforts should be made to stimulate private investment, although the specific
efforts were not specified.
In the area of sustaining health IT it was felt that all payers needed to
provide reimbursement for IT driven care, to provide continuing incentives for
the use of health IT, and in addition that all payers should reimburse for
improved quality and safety. It was also recommended that there be financial
incentives for the use of standards and that there be private and government
research funding to make standard data available. The idea here is to make
standard health care data de-identified available for research.
The second area of enabler is the area of standards, obviously there’s been
a tremendous amount of attention and activity in the area of standards, which
has not obviously, this workgroup and this committee has been a key part of
that. It was recommended that there be reliable and consistent funding for
standards, that in the area of adoption of standards we need to decrease the
barriers to adoption and increase the benefits. We need to improve our efforts
to dissemination, and it was recommended that standard actually be required in
two specific situations, one that there should be standards based labeling for
medication tests and devices, and that clinical data should be coded with
reference standards at its source, so that it is immediately available in
standardized form.
There were a number of recommendations with respect to standards
maintenance, it was felt that there needed to be a robust and nimble process
for maintenance standards, which included designation of core reference
terminologies, inter-vocabulary mapping, alignment of message and terminology
standards, and the continuation of the Consolidated Health Informatics
Initiative, which is identifying and adopting standards across the federal
government. It was also noted that in standards development consumer data
elements needed to be included and consideration related to privacy also needed
to be part of the overall picture.
And the final area under enablers is the area of legal issues and it was
noted at the meeting that there are a number of legal barriers for both health
IT investment and health information sharing, and I would mention that we in
the department are aware of these and are looking at these areas intensively.
Other barriers that were noted are related to collaboration, particularly with
respect to information sharing in a bioterrorism emergency and also barriers
with respect to liability related to safety and quality reporting. It was
recommended that there be a formal process to evaluate state and federal laws
that effect NHII with respect to architecture development and implementation.
The next major area of the recommendations had to do with implementation
strategy and the first sub-area was demonstration projects and there were a
number of recommendations for development of community health information
exchanges. It was recommended that there be 40 to 50 such projects, that they
support safety and quality, that they be led by regional steering committee
with aggressive sharing of lessons learned. That these local health information
infrastructures be coordinated with a national investment plan. That there be
an incremental approach to interoperability so as not to try to implement full
and complete interoperability all at once. That specifically consumers and
folks involved in biodefense preparedness should be included, clearly those are
the only folks to be included but those were mentioned because of concerns that
they might be left out. And of course that privacy issues should be clearly
addressed.
In the area of architecture there was a recommendation for an architecture
task force, I mentioned that earlier under governance, and it was felt that
this task force should follow what amounts to good practices for developing
architecture, privacy, confidentiality, and security should be prime
considerations. The architecture should be standards based, non-proprietary,
scalable, allowing for incremental growth. The technology should be simple and
easy to use and the overall architecture should have low barriers to entry. It
was also recommended that the CDC’s Public Health Information Network be
aligned with NHII. And finally it was noted that full implementation of NHII
will likely require affordable broadband internet access to people’s homes.
The last area of implementation strategy deals with identifiers and it
won’t surprise you that the folks at the meeting recommended that the patient
identification issue be resolved. And we did look for specific suggestions as
to how it could be resolved and actually this was alluded to indirectly, it was
felt that we should proceed with NHII without an identifier, without a unique
national identifier, recognizing that if it ever happens it’s certainly not
going to happen soon and so that there should be a review of the existing
mechanisms that are being used for patient matching in places like Indianapolis
and Santa Barbara and others. It was recommended that a new national unique
patient identifier be developed and established. It was also recommended that
there be a patient linkage algorithm developed for research and it was noted
that this algorithm did not need to be 100 percent accurate in order to support
the needs of the research community. Another recommendation was that there be a
new national unique provider identifier and I understand that efforts are
underway to make that happen.
So finally there were two targeted domains that were identified at the
meeting for special action, first was consumer health, it was recommended that
personal health records be established, that these records should be available
at no charge to consumers from a trusted authority using a well defined basic
platform so as to be as available to as many people as possible. That there be
specific promotion of eHealth tools, for example linking the personal health
record to relevant information resources and providing health alerts and
decision support to consumers. And that part of this process should be ongoing
evaluation of the role of individuals in the control and management of medical
information.
The other targeted domain related to research, in particular the research
on the impact of health IT, on safety and quality, and it was recommended that
a billion dollars a year be earmarked for such research, and that it be used
for projects such as evaluating existing systems, improving adverse event
detection algorithms, improving methods for maximizing effectiveness of
communicated information, and establishing an ethical, legal, and social issues
program for NHII that would among other things evaluate privacy policy options
and its work would be informed by public surveys.
So there were a lot of recommendations from the meeting and it took us
quite a while to reorganize those recommendations into a coherent framework,
which I think we’ve succeeded in doing. And if you take them as a whole they
really represent a pretty thoughtful and comprehensive program for moving NHII
forward and so I think they will be very helpful. There is going to be a
written report of the recommendations that hopefully will be published in a
well recognized journal.
Let me pause there and see, because I want to go through a whole series of
other things that we’ve been working on, just to see if people have any
specific questions about the recommendations from the meeting.
DR. LUMPKIN: Good morning, this is John Lumpkin, I am here thanks to
Amtrak, may not have come on the same train I started out on but I’ve made it
here. No, they just replaced the whole train. Jeff?
MR. BLAIR: Thank you. Thanks, Bill, that was a very helpful and informative
review of all of the recommendations that came out of the June/July meeting. I
noticed on the architecture recommendations it looked like they came up with a
very good set of principles to guide the development of an NHII architecture
but I didn’t hear that there was a recommendation for starting the development
of an architecture or forming a task force to do it or forming an entity to do
it. Was there any recommendation there that I just didn’t hear that indicated
we need to move forward and develop some type of either a conceptual
architecture or overall generic architecture so that we’re all targeted on the
same vision?
DR. YASNOFF: Yes. I think in the governance recommendations it was
recommendations that there be a public/private NHII task force and that one of
the subgroups be an architecture task force. And so I think the implication is
that that architecture task force would using these principles work toward
developing an architecture. I think it’s important to note that in the
implementation recommendations the beginnings of an architecture have already
been specified in terms of the consistent recommendations for developing local
health information infrastructures, so I think we have the beginnings of an
architecture but I do believe that the recommendations do, well, the
recommendations do specifically call for the establishment of an architecture
task force that using that principles would further specify what an
architecture for NHII would look like.
DR. LUMPKIN: Steve?
DR. STEINDEL: Yes, thank you. As Jeff noted, Bill, it’s a very thorough and
ambitious set of recommendations that came out of the meeting. I have two
specific questions in two areas, one is not really a question so much but a
little bit of a concern in the phrasing, and something I’m getting very
sensitive to as more and more groups as you noted, like this group in CHI and
others are working in the area of identifying standards to use for the
interchange of health care information. And what there appeared to be although
it is somewhat differentiated in the detailed section, but I would just like to
ask for some caution when the actual report comes out about stressing the
differences between standards and terminology and the use of terminology.
Because they are two different beasts in how they are handled and what needs to
be done in those areas and I would just ask for some caution in the wording in
those areas and how they’re developed and how they’re developed. There was a
little bit of ad mix in this brief summary, so that was just a comment and
seeing from you nodding your head I see you’re sensitive to what I was saying.
And the other was in the targeted domains and you just listed as two
targeted domains, consumer health and research, and of course one of the areas
was research and population health, of course CDC is very interested in public
health as being an area of domain. And what I’m asking is when you were listing
targeted domains were you listing specific targeted domains that might not have
been mentioned in the original NCVHS report on the NHII because these groups
were noted in that report? Or were these the only, and so therefore these are
additional domains and we should assume that the others are already included?
DR. YASNOFF: I think you should assume that the others are already
included, there’s no intention to exclude any other domains. The process of
organizing these recommendations basically was to take them all and sort them,
re-sort them, cluster them, reorganize them, until they fell into some
reasonable categories. And the recommendations that we had naturally fell into
those categories. This does not imply that there was no concern at the meeting
about other domains, these are the recommendations that came out of the meeting
and as they were organized these are the best logical categories we could put
them in and I think you’ll notice if you look through them again you’ll see
that some of the recommendations are a little bit, pushed a little bit to fit
into categories. So it’s of course difficult to, actually to me it’s remarkable
how after a sufficient amount of work we were able to get a relatively coherent
set of recommendations from what amounts to a set of working groups who never
talked to each other at the meeting. But I would take as the implication, I
wouldn’t take the absence of any categories or any recommendations as a lack of
endorsement, lack of interest, at all.
DR. STEINDEL: And I will assume that the final report will reflect that.
DR. YASNOFF: Of course.
DR. LUMPKIN: Marjorie.
MS. GREENBERG: Steve actually asked my question but I’ll push it a little
further I guess in that I heard a few references to bioterrorism and I didn’t
know whether that came out of the research in public health or perhaps the
homeland security group since they were I think separate groups but —
DR. YASNOFF: Can I say something about that before you ask your question?
The correlation of the subject of the recommendation with the subject of the
breakout group was weak, so there were recommendations about all kinds of
topics from totally unexpected sources.
MS. GREENBERG: I was in the standards group, I’m sure standards came out in
many other recommendations. But given that one of the groups was research and
population health I really did miss, and then the particular target domain is
now just research, I really did miss any recommendations specifically about
public health and I wondered if there really weren’t any or if they’ll end up
as subcategories or —
DR. YASNOFF: There were no major specific recommendations related to public
health that were really represented, except the one related to the Public
Health Information Network. And again, I think that certainly doesn’t, I would
not interpret that as meaning that the folks at the meeting have no interest in
public health or they don’t think public health is an important consideration
for NHII, but those were the recommendations that were produced.
MS. GREENBERG: What you saw is what you got.
DR. YASNOFF: Right, the task here was to organize and try to understand the
recommendations that actually came out of the meeting, but those
recommendations are the recommendations and so we had to start with that and
much as we would have liked to not embellish them.
DR. LUMPKIN: Kepa.
DR. ZUBELDIA: Bill, I have a comment, the second target domain, you call it
research but it sounds to me like it’s not research. It’s either IT research or
the impact of the NHII or the impact of IT. To call it research given that a
lot of people are thinking of health research or health care research, I think
it was a little bit confusing to me and it may be better to just rename it NHII
impact or impact of IT or research on the impact —
DR. YASNOFF: Or maybe NHII research —
DR. ZUBELDIA: I think that when Marjorie was thinking research and public
health she was thinking health care research and public health, and that’s not
what this is about.
DR. YASNOFF: No, I agree. Thank you.
DR. LUMPKIN: Simon.
DR. COHN: Bill, obviously thank you very much for the update on all of this
stuff. I’m trying to think in my own mind, I guess this is more of a question
as well as probably a comment. Obviously when recommendations come out after a
meeting like this on the one hand there’s obviously a desire to think about
them and organize them appropriate, on the other hand as the months go by the
world is moving rapidly. And I guess I’m just looking at a couple of these
recommendations, especially enablers around legal issues and removal of the
barriers to IT investment. And for example my reading of the Medicare Reform
legislation, if one looks at the whole ePrescribing section there is really a
breakthrough there in terms of further clarification of the STARK rules that
really to my view, I mean they don’t solve all of the problems but there’s like
a major breakthrough there about clarification that hospitals can help other
groups move forward with ePrescribing, etc. Are you going to be referencing
that in whatever it is you publish, think about, evolve? I mean it seems to me
like the recommendations, sort of life is moving quicker then these
recommendations.
DR. YASNOFF: And that’s a very good point and I think that’s a sign of
progress, and certainly to the extent that these recommendations are moving
forward we’ll certainly make every effort to reference that. I think it adds
not only to the informative nature of the report but it also to some extent
shows that the recommendations are perhaps being noticed, or at least the need
that is expressed in the recommendation has been noticed.
DR. LUMPKIN: Let me just, and I apologize again for being late, and so I
missed your preamble to these recommendations. I assume that they’re going to
come out as recommendations of the conference with some sort of disclaimer that
these don’t necessarily represent the views of the department.
DR. YASNOFF: That is absolutely correct. These are the recommendations from
the meeting, they do not represent the views of the government or the
department or even the organizations who may have sent representatives to the
meeting.
DR. LUMPKIN: Right. So as such do they have to go through department
clearance to be released?
DR. YASNOFF: No.
DR. LUMPKIN: But if you were to add an addendum or update such as was being
suggested that would —
DR. YASNOFF: I think, and I’ve done this before at consensus conferences,
the clearance process for written reports of consensus meetings is different
then the clearance process for other publications from the department. And so
the criteria is it has to be an accurate reflection of what was said at the
meeting and anything that goes beyond that has to be an accurate assessment or
factual and so on. But whatever publications arise from these recommendations
will be clearly labeled as not necessarily representing the views of the
department and that’s standard policy. Even if the views all did represent the
department it would still have that disclaimer.
DR. LUMPKIN: I think kind of just where I’m heading and it’s really just an
offer of assistance, to the extent that including nodi-bendi(?) at the bottom
of the report may constitute something that would delay the release. It may be
possible for us as a workgroup or so forth to add that sort of note that would
put that report within the context by a letter or something to the Secretary
congratulating him on the reports and thank you and by the way some of these
things have actually happened and occurred and the department’s main role. So
that’s really up to you but if that’s useful I think that may be a way that we
can deal with some of the, particularly with the comments that relate to the
fact that this was six months ago.
DR. YASNOFF: I think it would be helpful, obviously once this report is
produced I will share it with the workgroup and I think it would make sense to
me for the workgroup to look at these recommendations and evaluate those things
in terms of whether they are existing department policy and if they’re not
whether the workgroup feels that they should be policy, and it would be
appropriate to send a communication to the Secretary saying well we’ve noted in
these recommendations, we congratulate the department, you’re clearly working
on these 27 and we are happy to help with that, but we note these additional
things that we feel are important that the department should consider. I would
think that that would be a logical role for the workgroup.
DR. LUMPKIN: Steve?
DR. STEINDEL: John, Bill mentioned the possibility of submitting this paper
to an academic journal and having it published. Would it be appropriate for the
workgroup to offer to write an editorial for that journal?
DR. LUMPKIN: Sure, sure, we could do that.
MR. SCANLON: That was going to be my point as well, there’s no reason why a
preface or an editorial overview indicating the progress couldn’t be part of
the journal itself. We might even see if we could talk, well, we’ll have to
see, but we could talk one of the journals probably into, which actually has
special emphases, if they would include this plus a report from the group or
something like that.
DR. YASNOFF: The first step is to write it and find a journal that’s
willing to publish it at all, and then we can have further discussions after
that.
DR. LUMPKIN: And again, as you, Mary Jo?
DR. DEERING: Well, I had a congratulatory note and then, obviously as you
can imagine I’m particularly happy to see so many references to the consumer
domain and I know that having been on that they worked hard to make them very
meaningful and it’s nice to see them show through and also on the issue of
bringing comprehension from chaos except it wasn’t quite chaos. My question is
sort of a direct follow-up on the production of the report and absent any
formal requirement for an executive secretariat clearance, nevertheless how
will your draft report be reviewed externally and internally? Again, short of
an executive secretariat clearance, I mean there were a lot of participants
within the department who contributed, you’ve got external stakeholders who
participated, so will its publication be the first time that any of us see it?
DR. YASNOFF: I think the way the paper is being produced is jointly with
the leaders of the breakout tracks. And so all the drafts, actually there are a
number of drafts and they’ve been shared and the chairs of all the workgroups
have on been conference calls discussing how this ought to be framed. This is
not the first crack at organizing them and I don’t think I want to tell you
what iteration it is. There have been a number of iterations. So it’s being
produced essentially as a group project with the organizing committee. Other
then that I don’t think it will be reviewed because it’s essentially a report
of what the participants at the meeting said and I don’t think, there’s no
intention to essentially send it to all the participants to review and I don’t
think they’ll be any differentiation between the participants in the department
and outside participants in that regard.
DR. DEERING: I guess as someone who’s been stuck quite recently with any
time you want to submit something for publication that has to go through this
request for an outside activity, and then you do normally submit your
manuscripts through the department’s public affairs change, I mean that’s
happened to our office and the professionals that I’ve dealt with all the time.
So there is some internal review normally that goes on, so I guess I’m just
observing, I’m sure the committee also would love to be in the loop as early as
possible and those of us within the department who contributed to it would look
forward as it goes through that normal internal circulation to be able to see
it.
DR. YASNOFF: Well, clearly we will submit it through whatever departmental
clearance is required but these reports of consensus conferences, again which
I’ve been involved in before, that review is extremely minimal and I’ve been
through the discussions where you put something through a clearance process and
someone says well, that’s not department policy, that’s not agency policy, but
in this case it doesn’t matter, you can’t change what the people at the meeting
said regardless of what the policy is, you just have to leave it the way it is
and with the disclaimer people understand that this is just a report of what
people said and the department is not bound by it in any way.
MR. SCANLON: Let me emphasize again, this was a National Health Information
Infrastructure meeting, not a federal, and the recommendations are not federal
necessarily. They made some of them but we’ll work out the clearance process.
Peer review, journal publications are usually an office, the office really
reviews it, generating office, but we have many ways to do this. We’ll make
sure we meet all the requirements.
DR. LUMPKIN: Let me do just a quick logistics check. Are you going to be
here all day?
DR. YASNOFF: Yes.
DR. LUMPKIN: Gary, are you —
MR. CHRISTOPHERSON: Yes.
DR. LUMPKIN: I have a question that actually is more pertinent for later on
in our process, which I will save until then.
DR. YASNOFF: I will proceed and let me mention specifically John you have
along with everybody else a thick packet of documents related to the things I’m
going to present and I’m going to start referring to those. And the first one
of those I would direct your attention to is the initial quarterly report that
was produced. This is covering the quarter from July 1st through
September 30th, and that’s one of the things that’s in your packet.
And as I mentioned earlier Secretary Thompson at the NHII meeting requested
quarterly progress reports for NHII and so the first report has a rather
extensive background session since it is the first report. It has outlines of
key activities, many of which I will be saying something about, and then
there’s an appendix which has a list of meetings that we’ve attended and also
presentations that we’ve made. We’re going to be preparing very shortly another
quarterly report covering the period October 1 to December 31st,
we’ll be doing that in January, and as soon as that’s available of course I
will be happy to share that with the workgroup. And I should mention that this
quarterly report, although it covered the quarter ending September
30th, due to various logistics factors and staff time and so on
actually the report was not completed until recently so the workgroup should
not feel that this report has been sitting for two months and not available to
the group.
We also had two specific stakeholder meetings and we’re planning additional
stakeholder meetings. These meetings are to bring together specific groups of
stakeholders from a single category, or perhaps in some cases from two
categories to exchange views with each other. And our feeling about this was
that by bringing together a specific group of stakeholders we could get a
better sense of what the issues were related to NHII for that particular group
when they were unencumbered by concerns about what other groups might think if
they were talking in front of them. So on October 3rd we brought
together a group of providers and you have a report of that particular
stakeholder meeting in your packet which I would invite you to read, has much
more detail.
In general the providers were very supportive of the NHII concept and goals,
they expressed a strong desire not to have mandates imposed upon them. They are
very concerned about the return on investment for electronic health record
systems for physicians, and it’s their view that most of the benefits of those
systems accrue to the payers and he had additional information about that that
I’ll be sharing with you. And they also expressed a strong concern about how
electronic health record systems interfere with and slow down their workflow
and thus have a negative impact on revenue. I think there’s a less clear
perception of how electronic health record systems can save time that’s now
being spent so I think there’s an extreme sensitivity and awareness of how in
some areas it takes more time but particularly folks who haven’t had experience
with these systems don’t necessarily see the time that’s going to be saved. And
again I would invite you to read the report that we generated.
We also had in later October a stakeholders meeting involving payers and the
payers in general are quite a bit more skeptical about the NHII concept and
goals. I would say they’re a skeptical group in general. They are skeptical
about the benefits despite an example we presented to them from Maine and let
me just take a minute to digress and tell you about that. One of the things
that we became aware of is that in the state of Maine the Blue Cross plan
there, Anthem Blue Cross, which is the dominant commercial carrier having 70
percent of the market, is now in the third year of a three year experiment. And
this experiment consisted of providing funds to physicians to purchase IT
systems and then measurement of quality improvements related to those systems.
They also asked the practices involved to work harder to do things involving
care coordination as recommended for management of chronic disease. So the
funds invested were approximately $5,000 dollars per doc in a practice to
purchase IT systems and those checks if you will were written up front, so
these systems were then installed and they’ve been monitoring both the quality
and the financial results to them.
In terms of quality the markers they’ve been looking at are things like
hemoglobin A1C, cholesterol levels, blood pressure levels, and so on. And they
found remarkable and consistent improvements across the board.
With respect to financial results they found that the rate of increase of
their cost has dropped substantially and so from their perspective they’re
seeing a very substantial return on their investment. And so this experience of
the payer in Maine clearly supports this notion that most of the benefits of
these systems go to the payer.
The payers also are worried about the issue of coordination, particularly
coordination of various government activities, which they see as not
necessarily coordinated or communicating even with each other. They also have a
concern about what NHII is going to cost them. They also have a risk concern,
in particular if the NHII activities are likely to fail, like the CHINs, the
Community Health Information Networks, and I’ll be saying more about that in a
few minutes. And they also have what I call the interaction concern, what’s the
relationship of NHII to HIPAA and administration transactions. Now Simon, you
were at that meeting and so I would invite you to add to this if you feel it’s
appropriate.
DR. COHN: Well, if I could only just clarify the interaction concern, I
think I might almost express it a little differently. I think there was actual
concern that given that the country has made major investments in HIPAA and the
standardization of administrative and financial transactions that there wasn’t
an explicit linkage so that we could, in a sense of building off of that into
the NHII, be it privacy, security, the standards that already exist, and that
somehow in the NHII was being posited as sort of a different thing that was
unrelated. And so everybody was looking at each other having made million
dollar investments recently and sort of saying huh, this all ought to be
related, which is probably a reasonable comment to make.
DR. YASNOFF: And I think, as I think everybody in the workgroup knows, I’ve
worked very hard to disassociate NHII from HIPAA in the sense that I’m trying
very hard to get across the message that NHII is a voluntary process, it is not
regulatory, and so I think this feedback leads me to think that perhaps I went
too far in disassociating NHII from HIPAA and that people are now worried that
NHII is not even cognizant of HIPAA. So I think this is an important message in
terms of how this needs to be communicated and I’m hoping to strike a better
balance in that regard in the future.
I want to highlight a couple of special projects that we’ve completed, again
there are documents in your packet. The first one is a study of organizational
issues related to creating local health information infrastructures and this
was done on our behalf by Nancy Lorenzi(?) from Vanderbilt, I think most of you
know, Nancy is the leading authority on organizational issues in health
informatics, she literally wrote the book on this topic. And what we asked her
to do is to look at the CHINs, the Community Health Information Networks, and
the two most prominent LHIIs, Santa Barbara and Indianapolis, and for the CHINs
to identify those things that led to failure and for the LHIIs to identify
those things that led to success, and her report is in your packet.
And obviously there’s not sufficient time for me to summarize the entire
report but let me highlight that the key issues that she identified in terms of
making these efforts successful are the need for buy-in, the need to deal with
the issue of loss of control on the part of the organizations that are
participating in this, the need to deal with ownership of information, the need
to deal with financing, and finally the need to deal with technology. And I
think the important message of this is that while technology is important,
technology is not the biggest problem that has to be overcome in creating these
kinds of community health information exchanges. That report that you have will
soon be available on our website and our intent is to make it widely available,
particularly to support those folks who are going to be funded by AHRQ for NHII
demonstration projects.
We also commissioned a study of NHII costs and benefits from the Center for
Information Technology Leadership at Partners Health Care and Harvard, that’s
Blackford Middleton and his colleagues. Again, that report is in your packet.
I’m going to give you a very, very short capsule summary of it. Essentially
what they found is that based on the information that’s available, which
certainly is neither definitive nor complete, but based on the information
that’s available they divided the net benefit of NHII into three sectors,
inpatient, outpatient, and community health exchange. And what they found was
approximately $10 billion dollars a year of net benefit in the inpatient area,
about $20 billion dollars a year of net benefit in the outpatient area, and
about $90 billion dollars of net benefit from community health information
exchange.
This is a very interesting result and I think let me comment on this. If you
think about it the implementation of electronic health records in the inpatient
setting, while very important while producing key benefits, doesn’t really
radiate those benefits across the health care system because acute care
hospitals deal with episodic care. So the benefits are there but they do not
radiate. The outpatient environment, clearly much more care occurs in the
outpatient environment, so there are many more opportunities from savings from
electronic health records in the outpatient environment. But again,
implementing electronic health records in the outpatient environment does not
give you complete patient information at the site of care. It only gives you
better information that is within your sphere of operation.
You only get complete patient information at the site of care in two ways.
One is if you have a completely closed system and all patient encounters are
within your system. Or two, if you have community health information exchange
so that at each patient encounter you can get all the information about the
patient from all the different sources, integrate it and deliver it to the
point of care. And it’s clearly there where you start to get the big benefits
in terms of not repeating tests, not repeating radiology studies, in terms of
understanding the total list of medications for the patient and so on.
Now in each of these sectors there are different issues in terms of
penetration of technology. In the inpatient area in larger hospitals it seems
that the benefit of electronic health records has been perceived, many larger
hospitals have made investments in this area. On the other hand in smaller
hospitals and in rural hospitals investments in general have not been made. So
it appears that there may be a threshold of investment that needs to be made
that’s difficult for small and rural hospitals to overcome, it may have to do
with economies of scale, staff, but clearly there’s an issue there particularly
for small and rural hospitals.
The outpatient environment as emphasized by the stakeholder meetings and the
experiment in Maine, electronic health records in the outpatient environment do
not really benefit the folks we’re asking to invest. The payers are the ones
who benefit and so there needs to be a mechanism to align the financial
incentives so that the benefits can flow to those people who invest.
And then in the community health information exchange area we have a very
interesting situation where there’s a large amount of potential savings but the
savings as far as we know to any particular sector are not sufficiently large
to induce that particular sector to invest. So it’s everyone benefits once it
exists but the benefits to any one group are not sufficient for any one group
to throw money in to begin this. And so it seems that there’s going to be a
requirement to begin to create these community health information exchanges for
seed money to get them started. But that once the seed money gets them started
the savings should then drive their continued operation.
So the total net benefit that was identified in this study was about $120
billion dollars a year, and again that’s after the complete implementation.
There is a chart along with the spreadsheets that shows what a ten year
implementation cycle would look like in terms of costs and kind of ramp up of
benefits and so on.
And again, let me emphasize the data that support this study, not definitive
and not complete, and in particular there are whole areas of benefit that you
can identify that we are currently unable to quantify. So the expectation, at
least I think my expectation is that the actual benefits are likely to be
larger then this.
DR. LUMPKIN: Bill, this is very fascinating, unfortunately we need to pick
up the pace a little bit, we’re running a little bit behind schedule right now.
DR. YASNOFF: Okay. I want to move on to our standards activity. We’ve been
involved in this process that I think hopefully most of you are aware of, that
HL7 is engaged in to develop functional standards for the electronic record.
We’re expecting an international vote on this on about 250 functions for the
record in March of 2004. There is some contention about the need for defining
standard functions in specific care settings, for example, inpatient and
outpatient. This is within the U.S. only, the international community is not
going to be considering that. And HHS has taken the position that no standards
are needed for specific care settings because they are likely to stifle what is
a developing market and HHS has indicated that the department will be
determining its own requirements for EHR functions related to specific
projects.
As I mentioned AHRQ has issued a set of RFAs for NHII demonstrations falling
into three categories, planning, implementation, and assessment of value. There
are several million allocated for planning for 35 grants. Much of that may be
earmarked for small and rural communities. The implementation grants are up to
$500,000 dollars each. Matching funds, one to one matching funds are required,
and half of those funds are earmarked for small and rural hospitals. And
there’s also a request for research in assessment of value providing for 20
grants of up to $500,000 each. And I believe the letters of intent are due in
February and the awards are to be made in April, is that right, Eduardo?
DR. ORTIZ: Applications.
DR. YASNOFF: Applications received in April, pardon. Assuming the budget is
passed.
We’ve also implemented a set of NHII educational seminars, these are
internal to the department, the goal being to inform policy makers about NHII
issues. These are two hours every week. We’ve had a number of presentations in
different areas related to LHII, standards development, collaboration strategy
and so on. I believe there’s a list of the presentations that have been made in
your packet.
I want to say just a couple words about our plans for the coming year and
I’ve divided this according to our strategic plan. Under inform we’re going to
continue to give presentations externally and also invite people into the
department to do educational seminars. We’re going to be enhancing our website.
We have tentative plans for doing some communications work including developing
a written strategic plan, video briefings and a brochure.
In the collaborate area we’re going to be expanding our organizational
contacts and also working on facilitating collaboration among LHII developers
through conference calls and an electronic collaboration space.
Under convene we’re going to continue our special stakeholders meetings and
we have one scheduled for January with employers. We’re thinking about having a
subsequent one with the health IT vendors, perhaps one with payers and
providers together. We think this may lead to a constructive exchange of views.
We’re also planning for another NHII meeting in early July at which we will
review and refine the consensus agenda and also have presentations about NHII
projects.
In the standardize area we’re planning to continue our involvement in the
HL7 EHR activity and also begin the development by HL7 of EHR interoperability
standards so that EHRs can be moved arbitrarily from any one system to any
other system.
In the demonstrate area we’re planning to collaborate with AHRQ, or continue
our collaboration on the NHII grants, and in particular providing technical
assistance. We’re beginning a project to catalyze the development of the local
health information infrastructure in the national capital area. There have been
some, there’s been extensive interest expressed in this from folks in this area
and so we’re trying to work with them. And we also plan to work with the
eHealth Initiative and Markle Foundation demonstration projects.
And finally in the evaluation domain we’re continuing to look at policy
options for aligning incentives and improved estimates of NHII cost and
benefits.
And let me close with this statement from the recent IOM Report, it’s a
rather long report so I want to be sure to highlight this, this is from the
executive summary, that report stated more clearly then any previous report I
believe that NHII is an essential step if we’re going to have significant
improvements in safety and quality in health care and so the statement in the
report is that the committee believes that establishing NHII should be the
highest priority for all health care stakeholders.
And so let me stop there. Thank you.
DR. LUMPKIN: Okay, what I’m going to do is take a few questions, Bill’s
going to be here the rest of the day. We want to get through this portion of
the report so we can spend a significant amount of time discussion our future
directions. Steve.
DR. STEINDEL: Bill, since we want to move quickly, with regard to the HL7
EHR activity, again, I’m picking on terminology, use of the word standards, and
since I’m very directly involved with that both in the HL7 EHR sig and also
from the HHS point of view I’d just like to clarify a little bit. My
understanding is that HHS is really not taking a position on whether or not the
HL7 sig goes around and defines the care setting domains and what standards are
appropriate. What HHS is taking a position on is whether or not they become
ANSI approved standards and therefore the qualification for what an EHR is. We
would prefer that that be left as informative document that people can use and
not necessarily meet.
DR. YASNOFF: I think you’re very close. Let me state it a little bit
differently. The HHS position is that the application of specific functions,
functions EHR functions in specific care settings is very important as use
cases to inform but within the HL7 terminology, to inform as a reference
document the vote on the EHR functions. HHS sees no need for balloting of those
and does not intend, should they be balloted HHS does not intend to use that
information specifically.
DR. STEINDEL: Bill, that’s a very good clarification. Thank you.
DR. LUMPKIN: Jeff?
MR. BLAIR: I have a question about Bill’s answer.
DR. LUMPKIN: Go ahead, Jeff.
MR. BLAIR: Bill originally the HL7 effort was referred to as an EHR
functionality model, not a standard. It sounds to me as if what you just said
is that you are going back to that original concept, that the functions in
there are a model that are useful for use cases, a model that is useful for
other work as for reference points, but not to be used as a definitive standard
for interoperability or not to be used as a definitive standard for anybody to
specifically comply with. Is that correct?
DR. YASNOFF: No, not exactly. Let me again, let me restate it. I think
you’re very close. I think HHS sees the value of having a set, essentially a
universe of functions that relate to an EHR, and the value of that is that once
you have that universe of functions then that informs your efforts to develop
an interoperability standard for EHRs because clearly the interoperability
standard must support all of those functions. And the expectation would be that
some of those functions would represent things that perhaps had not even been
implemented yet but clearly are on the horizon.
But the department does not see any value in having a subset of functions
identified for specific care settings, particularly if those functions are
balloted and become even a draft standard because the care settings themselves
are changing rapidly, what’s inpatient today is outpatient tomorrow. The EHR is
evolving, and so what is an inpatient in the EHR today may have different
functions tomorrow.
Furthermore, the EHR in some care settings, for example in long term care
and in health in the community or home health, has really not been implemented
to a great extent and so we really don’t even have a good understanding of what
the functions of an EHR in those settings should be. So to talk about
standardizing the functions for things that are changing fast and that we don’t
understand just does not seem to be a productive activity.
However, it is important that use cases for the EHR functions that are to be
included in the balloted international standard of EHR functions be developed
so that balloters have a clear understanding of what the functions mean.
Without those use cases it’s often difficult to perceive what the statement of
a function in isolation really is trying to convey.
MR. BLAIR: Okay, but the idea is that you’re heading more towards a model
then a standard, is that right?
DR. YASNOFF: I guess that’s true.
DR. ORTIZ: My question is just if I could get a little in terms of, you know
a lot of these recommendations are out there, you could do a whole lot if you
had $10 billion dollars to do this and a billion dollars to do that, and $500
million dollars to wire up a community, but at least everybody I know thinks
that nobody’s expecting that type of money any time soon. So given the
realistic fiscal issues going on with the government I’m wondering if you could
comment in terms of what do you see in the next maybe year or two, maybe
thinking in terms of the FY 2005 budget in terms of what are some practical,
tangible, concrete things that you think you can do in terms of first of all
maybe getting some money, $3 million, $5 million, $10 million, $50 million, and
besides some of the conferences and things which I think are good, what is your
plans in terms of let’s say the next year or two or three in terms of trying to
take this concept of the NHII, which is still very conceptual, into something
more concrete and tangible?
DR. YASNOFF: Well, as you know I can’t comment on budget requests or needs
for funds except as reflected in the President’s budget. I think in terms of
the activities that can go forward, I think that there are basically three
sources of funding that are currently available for development of NHII
systems. The AHRQ grants, which I mentioned, there’s the funding from the
eHealth Initiative which comes through HRSA, and there’s the Markle Foundation
funding. I think we are hopeful that we can interest additional private
foundations in making seed money available for the development of local health
information infrastructures.
I think it’s interesting to note in that regard that for example Santa
Barbara, the Santa Barbara system was created with a $10 million dollar grant
from the California Health Care Foundation. But if you talk to the folks who
did Santa Barbara about what it would cost to do it again now that they’ve had
that experience, basically they say that you could create a system like this
for a tenth of that, for about a million dollars.
And so I think the major strategy is one of demonstrating the real benefits
of local health information infrastructures, in particular by continuing to
assess both costs and benefits of those systems that are operating and
continuing to build additional systems with whatever funds are available, and
again showing that there are costs and benefits. And also to make folks aware
of other activities that are going on such as the activity in Maine that really
show that you can incentivize physicians rather easily to adopt electronic
health records if the folks who benefit from those electronic health records
are willing to foot the bill to begin with.
DR. LUMPKIN: Thank you, you’re going to be here, I’ve got a couple other
questions to ask you that relate more specifically to our tasks the rest of
this meeting. So just to give you a clue what it’s going to be so you can think
about it, and you don’t have to write this one down either, what we’re going to
be spending the bulk of our time discussing is where should this workgroup go
and where can we add value to what’s going on, and so when we get to that
section I would like you to share with us your thoughts on that. Gary?
MR. CHRISTOPHERSON: My question is John do you want to proceed or do you
want a break? It’s your prerogative.
DR. LUMPKIN: I think we should take a ten minute break because we have to.
So why don’t we do that and then we’ll proceed.
[Brief break.]
Agenda Item: VA Implementation of NHII Elements
– Mr. Christopherson
MR. CHRISTOPHERSON: I want to thank the workgroup for inviting me, it’s good
to be here, I want to applaud your efforts to try and move forward the NHII. We
believe it’s important, we also applaud Bill’s efforts with what he’s trying to
do with the NHII office there and the good work that’s being done in terms of
the NHII overall effort. I think one thing I want to be very clear so there
isn’t going to be any confusion about it is we are very strong supporters of
NHII and will continue to be. In fact I think we may be some of the biggest
supporters and I think I’m going to try and indicate why we actually are in
that role here. We do proceed a little differently. We come the world of that
delivering health care, Simon and we do a lot of exchange back and forth of
having to both try to do larger things with out lives but also try to take care
of people as well. And whenever Simon gets confused I remind him that I’m one
of his enrollees in which he ought to pay attention to the greater scheme of
things.
DR. COHN: And we do.
MR. CHRISTOPHERSON: And he does, although I’m trying to get them to do a
little better EHR but we’re working on that part, we’ll get it there before
we’re done.
Let me walk through some things, I’m going to give you a little bit of
background on VHA in particular and then I’m going to give you a little
background as well as sort of beyond VHA in terms of the other relationships
that we have in that community there. The slide with the little oval at the top
there, I wouldn’t normally talk about it, I’m going to talk about it for a
couple seconds here because I’m going to tie it back to a later point. This is
about health care, it’s not about IT, and if anybody is confused about that the
difference between the house and screwdriver should be an important part of
that discussion. I’m going to come to that on a number of cases. And so the
world that I come from is really from the health care world. I often kid people
that I had the sort of strange fortune to have the first IT job in my life to
become the CIO for the Veterans Health Administration and it was a quirk in
that but actually that was by design by their part if not necessarily on my
part there. So I deal with health systems trying to get to where we really,
really want to go and how we improve health is the bottom line. Health
information systems we will argue to be an extremely important part of how we
get there.
Now how I’m going to drive this home is a couple ways, and again I’ll start
out with health care. Health care in the United States today is still basically
an episodic care based system, maybe a little chronic disease if you’re lucky,
but that’s really what we’re really good at and by the way VHA is much more in
that mode then we would like to be as well. The question of where we’re going
in VHA, you’ll hear me talk about that and I talked about what the Veteran’s
Administration is trying to do, is to get more person based, to coordinate care
across settings and to say I worry about you from the time that you first come
into my world, whether it’s an enrollee or being born depending upon which
system you’re talking about there, until you leave however you may end up
leaving us in terms of there. And I need to be worried about you across that, I
need to be worried about when you’re sick, I need to be worried about you when
you’re well, I need to be taking care of you throughout that process there in a
partnership mode.
Well, that’s not enough. You need the ability also to look across in a
population, groups of patients, whether it’s your diabetics, whether it’s your
spinal chord injury patients there, whether it’s your primary care panel, take
your favorite pick. We need to have a better content of looking at groups of
people and learning from that process of how to better care for people as well.
As you do that you start to build high action matrix to succeed, you need to
start to incorporate your best practices that are out there. None of us does a
good enough job of doing that as a matter of fact. We need to look beyond best
practices to what I heard referred to as ideal systems, you know the best
practice may still not be good enough and probably isn’t so you’ve got to be
thinking about creating the future best practice, which is much closer to what
the ideal setting would be. And oh yes as a matter of fact IT technology does
have a role to play here but you noticed about four layers down in what I’ve
talked about and again I think it’s important to keep on perspective, if you
really want to produce the outcomes of maximizing health and maximizing
people’s ability in this.
So let me sort of play forward, let me talk some about the VA system for a
few moments. This is my little bit of endorsement, the VISTA system has been
around for a long period of time. There are some people who say kind words
about us and what we’re trying to do there, and again IOM being one of those
who post that as being considered to be one of the best in the nation as a
system.
Important to a little bit of history, this is a system, health information
system called VISTA, it was created by the Veterans Health Administration, it
was a group of providers and IT folks who got together and literally wrote it
from scratch and created this whole systems in place. It’s the largest, one of
the largest systems in the world in terms of information systems, the most
comprehensive, I’ll talk about that. But the key thing about it also is it’s
publicly owned, everybody in this room and everybody outside this room owns a
piece of this action. And the intention to keep it in that public domain was a
very important decision made three years ago by VA.
Three years ago when I first came in there VA was on the point of deciding
to dismantle VISTA and go commercial off the shelf. Shortly after I got there
we reversed that decision and decided we would keep it here, even though we
were going to be using commercial products in certain key places, but that we
would keep it in the public domain and we would develop the future generation
as a public domain piece of software.
Obviously we’re a large system, one million veterans, a large integrated $23
billion dollar plus, 1300 sites of care, 180,000 personnel, train all kind of
clinicians, big systems doing lots and trying to do a lot of kind of things. If
we were to take you through one of our demonstrations there this would usually
get into the point of saying this is the wow factor, we showed you the clinical
parts, we showed you how nice it works, we get through all the physician order,
and then if haven’t fallen asleep by that time, unless you’re a person who’s
very interested, it’s like giving you the movies and we start showing you the
blood flowing, we start showing the signees, we show you all the wonderful
stuff, and by that time usually we’ve got you in our hold and you like what
we’re trying to do.
It’s not important that you like what we’re doing in terms of VISTA, like
what we’re doing because we’re a highly functional system that very honestly
everybody else ought to be having as well.
So bottom line says well gee, that’s wonderful, why are you changing, why
are you going to something in the next generation? And a few key points. VISTA
while it is very good is not yet sufficiently strong as a person based system.
Very facility oriented, if John Smith moves from one place to another the
system wasn’t designed to handle that. We actually now have steps in there that
we actually can track and provide clinical information among any of our
clinical sites across the country and we just put that in about a year and a
half ago. Standardizing data, right now we’re very standardized, we have 150
versions of that standards as a matter of fact and each one is very good in its
location. But the idea that we actually have one across the whole VHA system is
a very new vintage and that’s something that we also agreed to move on to the
new strategy. We had to modernize to replace it, it’s an older system, needs to
be upgraded, while it’s working very well it’s not as flexible as it need to
be, not as designed for sort of what the future health care might be as we know
it will be, low cost and maintenance, those kinds of things.
So bottom line, we’re going to a person centric approach, a data centric
approach, health data repositories, standardizing of data. A key point we were
doing, we’re not throwing away the old system, we’re actually building upon the
existing VISTA system, and migrating through the technologies, migrating
through into standardization, migrating through into the repository model. So
what you’d see if you were a clinician in our system, or people on the outside
who are going to use our system, you’ll see a migration path, you’ll see
improved functionality, some better performance in terms of there, some greater
flexibility to respond, but you will see a progression there, a very
comfortable transition to do that. It means the risk level is lower and the
comfort level it will provide is higher. Using modern technologies, relational
databases, JAVA, all those kinds of wonderful things, we take an enterprise
approach as opposed to a facility based approach there. Again, lots of work to
do that.
If you had to take a sort of very simplified picture of where we’re going,
this is the vision of what the future of VISTA will be, what we call Healthy
Vet VISTA. And Healthy Vet VISTA is really a much more modularized system, it’s
a standards based kind of system, it’s a system designed to exchange
information with the outside world. It’s a sort through My Healthy Vet to
provide a portal out to the person, to the veteran in our particular case,
provide services and information out there as well. So again, a system we’re
putting into place that will be the next generation. This system is being built
today.
In fact one of the first products of the new system is something that we
call care management. My earlier point about the fact that we need to move from
an episodic to a person ultimately to a population based system as well, this
is really our first foray into it and our first full capability. Previously if
you went and looked at a bunch of patients you’d pretty much had to go patient
by patient by patient by patient. Care Management is a new capability that’s
come in that allows you essentially to look at sort of any kind of cut of
patients you want to look at and manage across. Your diabetics, your primary
care panel, your spinal chord injuries, the patients in this hospital. Take
your favorite pick and the data is supported in the system now designed to
allow you to have that view in addition to the person view that we’ve talked
about earlier.
It is not a small project to say the least, it’s going to take us five or
six years to do all the things we need to do. The core thing which is the data
standardization, the repository, and the reengineering of our clinical front
end is 2005, which means we are literally now less then two years from that end
game in terms of producing that result. It’s not easy but we’re on track to do
that, they’ll be additional functionality with the new pharmacy system, new
scheduling system, that will be added to the system as well. But 2005 is really
the critical moment to try and do that.
Now I’ve heard some comments made in a couple places about funding and
support, let me give you two markers on this. The point was made by Bill about
one of the concerns that was out there was that because it took too much time,
clinicians would find it wasted time, they couldn’t get their workload through.
We don’t buy it, we don’t believe it’s true, we believe it’s actually quite the
opposite. We think it’s probably close to neutral on the front end, if you’re
going to do good documentation. If you’re not going to do good documentation
then the answer is any system of bad documentation will be fast. If you’re
doing good documentation we believe you about break even on the initial entry
of data.
Subsequently we think you start to save massive quantities of time from two
purposes. One is you have a lot of data there already used, and secondly the
ease of use. Instead of having to envision the chart of a patient that you’ve
been seeing for several years being like this, now go there in time to figure
out the history of the pharmaceuticals that you provide for this patient. And
the answer is watch how you thumb through it. Graphs of blood pressure over the
last three years, what kind of exercise for the, I think that’s usually where
the interns and residents have to get involved because they would be the ones
please chart the blood pressures and they would go off and spend some time in
this exercise. In our people it’s one click of the button and there it is and
you can have as far back, as defined as you want. Again, we don’t believe the
argument there.
Second part is the issue of investment. Should a provider organization make
the investment? Well, we’re kind of a provider and a plan so we’re kind of a
mixed bag, we’re not a purist in the sense of being either the payer or the
provider. I will give you the following marker. When we faced the decision of
doing the next generation I had the pleasure of going to the leadership of the
organization and saying is this what you want to do, to which they said yes
unanimously. And the second question I said to them is here’s what it’s going
to cost you, are you willing to pay for it? And the answer was yes. Now the
answer to the yes by the way, it was not a trivial answer, the answer to the
yes was an additional $125 million dollars a year out of hide, out of hide, not
a new appropriate, but out of hide.
NHII. Let me make a couple points here, and one is that you hear me use on a
number of occasions two terms, NHII and virtual health system. Now let me
clarify for everybody what the different meanings of these, there are different
meanings for different terms for different purposes. NHII as Bill has quite
well described is really the infrastructure that supports and enables a lot of
good things to happen out there. The virtual health system is hopefully one of
the results of all that effort coming together, in a sense what it allows to
occur in terms of the way we provide health care in the future. So one is
trying to talk about the end game of what we’d like to do with providing health
care, the other is essentially the key enabling capability to “make it
happen” in that world out there.
So what are we trying to do here? Clearly part of the strategy is of course
the EHRs, electronic health records, you can’t have any of this to work unless
you have those in place, they’re the foundational piece, what — said as
encouraging the private vendors out there to have better products, working with
the provider community out there to adopt these things, and again one of the
things that’s encouraged us to do is to make sure that Healthy People VISTA,
the public version of VISTA, is available out there.
The second part is personal health record systems, and again the idea being
here is you want to get the person more involved, where is the sort of the home
and the workplace, the connection out there, to allow them to become more
active participants in their own health and this is really the tool that allows
them to do it. It’s not just a record, though, it’s services, it’s information,
it’s the ability to link with other people and other folks to share
information, there’s a lot of things that goes inside that box if it’s going to
be successful.
The third thing is an exchange. Bill has talked about the community level
exchange. Terribly, terribly important, let no one be confused about the fact
that we will not succeed if we don’t figure out how to communicate and exchange
information at the local level. Health care is still primarily and will
continue to be primarily local, it needs to be built to that capability. At the
same time there’s learning experiences that we believe we can apply across the
board in terms of across communities and across providers. In the end game that
we’re trying to get to here is that any two providers who want to exchange
information at any point in time ought to be able to do it, and by the way so
should the person be able to do that. So how we bring that about is something
that’s a lot of work being worked on at both the community level as well as the
sort of broader capability kind of area as well. And as some of you are
familiar of the fact there’s a group that has gotten together, a public/private
collaboration being formed. Bill sat in for the first meeting there and gave us
some words of wisdom in terms of that, that group is now moving forward, in
fact we’re getting ready to have the second meeting on the 9th of
January to bring that into place.
The final thing is standards, standards, and standards. Key point here is
that we do not believe we can operate without them, Consolidated Health
Informatics is one of the key leadership groups that do that. We serve as a
co-lead in that effort as well, but again the key is for all of us to encourage
the strong development, NCVHS is a very, very key player obviously helping us
to all do that and we strongly encourage that work to continue. In fact as
Simon and I were talking about the break we’d like to even maybe nudge it along
a little further a little faster as a matter of fact.
How do we play our role? Where does VA fit into this equation? One is we
have sort of a larger public citizen kind of role that we play in terms of
pushing this whole movement, hopefully being strong supporters to all the
players that are here as well. We are clearly a strong supporter of the NHII as
a specific large broader piece to try and pull a lot of this stuff together.
EHR world we obviously talked about, we have our own electronic health record
system. We have our next generation Healthy Vet VISTA and we have the public
version which is Healthy People VISTA. Again, all the same VISTAs just
different generations and different uses of the same product.
In the PHRs we felt if we were going to talk about it we ought to go out and
actually do it ourselves, too, so we had in place something called My Healthy
Vet. My Healthy Vet first generation went live on Veteran’s Day this year,
that’s the information flow, the opening up of the portal. By the end of 2004
we’ll also have access to the medical record and the ability for people to put
their personal information in the system as well.
Federal health information exchange, information exchange, again we felt we
ought to show it if we’re going to be doing it. One is that we’re doing the
federal health information exchange with DOD, and I’ll come back to that for a
couple seconds, that was one of the requests I got to talk about. And again, as
we talked about the IHS as well in terms of being at that place.
The federal health information exchange to date is one way and important
because that’s the most primary reason which is having DOD data to flow to VA.
The future version of this is two way and so it really creates both for DOD is
one relationship in VA, a second relationship between VA and IHS to have
interoperability and have information flow and really create the partnership
between two large systems. And for those of you who complain about the
difficulty of information exchange, if DOD and VA can figure out how to make
exchange of data you have no reason to be complaining about your problems.
Standards as I indicated earlier, we’re adopting VHA wide standards, that’s
no small feat. VHA has been proud of its individuality at the facility level
there so for us as an organization to do this is a major move and a major
change in culture as an organization as well. We have gone through a number of
things to develop standards between VA and DOD and VA and IHS and it also made
the consolidation of all this is Consolidated Health Informatics. And I want to
emphasis why Consolidated Health Informatics is important in its progress,
first place is there are people now who really do listen to what both NCVHS and
CHI are doing because the adoption process is occurring, first five to six
depending on how you count them have been approved. I can also tell you that we
are now in the process of final balloting on the final six, not the final six
but the next six, VA has already approved them, DOD has just approved them as
well, and HHS I think is pretty close, at least three of the six if I’m not
mistaken. So again great progress and that means essentially we’re about to
come up with the next six, that will be a great piece of progress.
Just a few other tidbits from other things that we get involved with folks
trying to help advance this whole cause, obviously we’re doing work with a lot
of other parties like state veteran’s homes, where they’re going to be using
VISTA or VISTA tools to try and help them to use information there. Indian
Health Service, which is a long standing relationship, that’s getting much more
robust. We’re working with our affiliated medical schools and AAMC in terms of
partnerships about how to try and develop areas out there as well. We’re doing
a lot of work with local and state governments in lots of different
communities, D.C. Department of Public Health for example installed VISTA as a
system there, we helped them to do that sort of as a demonstration case to do
that and there are a number of other communities out there like Las Angeles
that are also working with us as well.
Personal health records, home tele-health, we have a whole effort going on
about care in the community to try and define some new ways to look at how we
actually can provide care outside the institutions and reach out to people
where they work, where they live, where they vacation, etc., and to do that as
well. We’re doing a joint effort with CDC on sharing data back and forth
between our two systems there, there’s a lot of competition going with the
private sector on whether it’s on collaboratives or individual institutions as
well. And then there’s a whole international aspect that’s now developing as
well where there are several countries we’re in conversations with who have an
interest in trying to move forward in the world of electronic health record
systems and are trying to get as much help as they can to try and figure out
how best to try and do that.
I said I was going to talk about DOD and VA for a couple seconds, when we
were looking at VA and DOD trying to figure out how we were going to solve the
age old bubble of sharing information it finally came down to two key points,
well actually three key points. One is that each of us had to have a good EHR,
familiar theme from what I said earlier in the presentation. A good EHR is the
foundation. Both of us are pursuing that path and producing those good EHRs.
The second part, we had to adopt standards and so the agreement amongst the two
organizations signed off by the leadership of our two departments is that we
will standardize data so we can exchange it at that level. Key case and one of
the first examples will be pharmacy data exchange, which has to be done at the
level where you can actually produce drug/drug and drug/allergy interactions
and that will be a key thing. The final thing is that we defined the idea of
having two repositories, so instead of for example in DOD having 104 mini
repositories as they do today, or VHA having 160 or 150 or 128 depending on how
you count them repositories we now have one and one and one to one is actually
a fairly easy relationship to communicate with. So commitment to the two EHRs,
commitment to standards, commitment to two repositories which have become the
enabling devices issue the two way exchange which is critical of the future.
So bottom line is you go back to the Institute of Medicine, at least the
most recent version of their decade long reports, where they said 2010 was the
target and we try to ignore some of the earlier words, which we’re obviously
not going to meet. The question was on the table was can we get there by 2010
and there was an interesting meeting October of 2001, Kaiser was one of the
participants along with us and a bunch of other folks and IOM, could we do it.
We said there’s certain conditions you’d have to meet. I will argue that as a
matter of fact those conditions are now falling into place, NHII, the EHR work,
all the other things you talked about, the standards work, all those things
coming together are producing essentially what we said we would do, instead we
have to get to standards, public/private sector kinds of collaborations and
convergence on standards. We have to get systems out there, EHRs and PHRs and
start to move that along pretty aggressively including things like financial
incentives, and the bottom line if you get that you get what essentially we
talked about for 2010, whether you call it paperless, whether you call it each
of these different pieces, some of us would like to call it improved health, we
get there.
Last slide, that’s what this in many ways is about, so as not to lose
confusion here, we’re talking about $1.8 trillion dollars in 2004, I’m going to
actually go back to a number that Bill put on the table there, Bill talked
about the benefits in a given year of potentially being $120 billion dollars.
Our best estimates, the estimates that we’ve talked about with some other folks
about how much would you spend in IT to produce that $120 billion dollars and
the best we can estimate right now is that you spend no more then $50 to $70
billion dollars a year to produce $120 billion dollars in benefits. You’re at
least getting probably a two to one ratio of benefits to cost, some will argue,
and I think Bill alluded to that as well, you probably can do better then that
at our back. And so we did it in the rural areas in the earlier part of this
century, probably time for health care to do the same thing.
Thank you.
DR. LUMPKIN: Questions?
DR. ORTIZ: Gary, thanks for that great presentation. The VA has been
wonderful in terms of implementing these IT systems nationally but one of the
criticisms that has occurred is that the VA has spent so much money
implementing and very little evaluating. In fact except if you can get
HSR&D research money where you have to apply for grants, I’ve heard, I
don’t know if this is true, that even if the VA is specifically prohibited from
spending their IT budget money for evaluating their research. And in a way
that’s one of the things that would be nice because first of all a lot of this
stuff that’s going on now in terms of driving IT implementation, Medicare,
ePrescribing things, it’s stuff that was able to occur because of the
evaluation of systems over the last 20 or 30 years at Brigham and Women’s and
LDS and that laid the foundation for saying wow, this is a good thing to do.
Well, here’s the VA that’s got this great system, they’ve got it all across the
board, they’re doing all these neat things, and if you did more evaluation I
think it would serve two purposes. One, it’s a good QI experiment because you
want to know if these things are working as intended, not just are people using
it but are they really improving quality. The second thing is I think it would
help drive the NHII agent because as you get this information out there that
shows that maybe you can counter, the VA can counter the concerns that Bill’s
doctors had and you could say well look, at the VA we’ve done this and this is
what we found in terms of quality, in terms of cost, in terms of effectiveness,
etc., etc., access to care, and so I wonder if you could just comment on what
you think about this, if that’s something that you think that the VA will at
some point start doing because there could be so much benefit. Because I just
think that that’s such an important component that’s just not really being
addressed by the VA.
MR. CHRISTOPHERSON: First of all I want to thank Eduardo for offering a
grant, obviously an AHRQ grant to VHA to help us to do this kind of work, so
deeply appreciative for that offer there. Let me go back, it’s an important
question. First of all there actually isn’t a prohibition against using IT
dollars for evaluation by the way. There is an issue of how many dollars we
have to spend and where we prioritize them, that’s actually much more what’s
been in play. But it actually goes back to an interesting question. You all or
a bunch of folks out there debating whether this is a good idea or not and we
have no understanding what you’re talking about. Of course it is, I mean how
can you possibly provide health care in the 21st century and not
have an electronic health record system. We don’t believe you can do it well
and I think that’s the key difference. Since we’re convinced going back to
John’s point about how we’re trying to restructure and revamp VA and what we’ve
done in the last five years to try to change outcomes and how we deliver care
there, we really say you can’t do it any other kind of way. That’s probably to
some extent why we haven’t done some of the evaluation because it’s never been
a question for us. It’s never become there. Part of us should have to go back
as I said in the original generation of the VISTA system, it was driven by
providers, they didn’t have a question about whether it was a good idea or not,
they said we’re going to build it, we think it’s such a good idea we’re going
to fight through all the walls that are normally around it and we’re going to
build this system. And that’s why the question really doesn’t come up in the
same kind of way.
But having said that, the answer is right, Eduardo, we need to sit down, I
think we actually have to sit down together and think about how we actually can
use the VHA experience to start to knock down a few more of these walls. And
there’s a few others, Kaiser’s got some stuff, some other folks have got some
stuff out there as well, as to how and try and do it. We’re a little tricky in
a sense that we don’t have a control, we have it everywhere so we don’t have a
place that well, here’s what it was like before, after, or what’s here with it
or without it, and by the way you’re not going to get any of our people to live
without it anymore this time here so I think we need to think about how to do
it.
But the answer is absolutely agree, more documentation, we do have to help
move the rest of the community along, those points are already on about the
skepticism about the wider community and the payer, we have to answer those
kinds of questions and I think we can play some role in helping to do that and
I think that is a nice potential partnership actually with AHRQ.
DR. LUMPKIN: Bill, you were just up there.
DR. YASNOFF: But I have more to say. I have a couple of brief comments and
then a question. First of all, on the $120 billion dollar benefit, that is a
net number, there’s actually $140 billion dollar benefit and there’s a $20
billion dollar estimated cost, and that’s after you’ve made the investment, so
that’s kind of a high point.
With respect to the time issue on EHR for docs, I certainly agree with you.
I think net it saves time and I think a good piece of evidence with respect to
that is if you talk to any doc who’s used an EHR, and knowing how many
complaints they have about it, if you ask them the question would you be
willing to give it up, I have yet to hear a single doc say oh yes, take it
back, they never say that. So the issue here is really more what docs believe
who do not have EHRs versus the reality.
I did want to ask a specific question, though, as you know one of the things
that I think would be very supportive from the VA in terms of NHII would be to
make the VA data available in local areas to exchange with developing local
health information infrastructures. In particular as you know I’m concerned
that the VA is one of the few health care organizations in Santa Barbara in a
successful LHII that’s not participating and so could you say some things about
what the issues are because that there are real issues that are in the way and
what kind of steps you’re planning to take to deal with those issues.
MR. CHRISTOPHERSON: First let me go back and reinforce, VHA is very
interested in sharing data at the local level so there’s not an issue about
that at all. I think there’s a couple things we go into, which is one is what
does it take to make that happen and we have some resource limitations like
everybody else has in terms of their, so obviously that’s somewhat of an issue
that comes into play, it’s not the Santa Barbara question by the way, it does
come up some other models we are working with as well. There are lots of
communities, lots of people are approaching us about trying to do the exchange
and we’re trying to figure out the best ways to try and do that, both at the
local level and at the national and it depends upon how it’s being done as to
whether we have to get into play at the national level because it requires
changes to the core VISTA system, or whether it’s really just a matter of work
out a business relationship between there.
The Santa Barbara case is an interesting case because we’ve been working
with them for quite a long period of time. The bump we’ve come up against is
that when Santa Barbara was put together the core of that was they struck one
set of legal agreements to sort of allow everybody to sign it and if one person
signed it it allowed the whole interaction to occur, sort of a one time signing
instead of having you sign a series of agreements. One of the things they built
into that was the issue of federal and state laws, and part of what that
required is it caused any of the people to follow state laws. Well, guess what,
we’re a federal agency and we don’t do those kinds of things, we can’t do that
by law. So what we’re trying to do, and there’s some discussion we’re having
with Santa Barbara now to see is there a way to get through that to where the
legal issue there. But that’s really the only issue I’ve seen us bump up
against that we figured we couldn’t get through, or haven’t been able to get
through as of yet there.
Other then that we think Santa Barbara has done some very interesting kinds
of things, some positive things, has worked through, in fact you and I have
talked about is what we’re learning from Santa Barbara, Indianapolis, and PSI
and some of the other efforts that are out there. Each of them has made a
significant contribution to what we’re going to try and do in the future of
community health kinds of exchange operations. But nobody’s quite got it all
together yet and it’s kind of like who’s the next model coming along, or
whether one of things can sort of pull even more of the pieces together to
produce some of those best case kinds of models. That’s by Santa Barbara.
DR. LUMPKIN: Okay, I’m going to take two more questions and then we’re going
to move to Steve and then I have a little exercise for us to do before we take
our lunch break. Jim.
MR. SCANLON: This is to follow-up on the questions that Eduardo raised. I
actually served on an advisory panel, Gary, to Nelda(?) Ray, who I guess is a
head of the research office, demonstration office at VA. On the other hand she
is leaving I understand so I’m not sure if it will help to have new
recommendations. But this was an interagency group as well as the VA
researchers and it was looking at exactly the question that Eduardo raised,
what are the research gaps and measurement gaps in quality measurement and
improvement at VA and what are the gaps and how could one move forward on this.
And to some extent there was a problem with, the research program apparently is
largely an extramural program, even though it’s VA scientists it’s often
through a kind of an RFA mechanism and so there are often gaps needed, research
needed, measurement needed in the quality area and others by VA but it’s hard
to get directed research. So we actually gave a number of recommendations to
VA, maybe I’ll share those with the committee if the VA is okay, and it turns
out that actually many of the quality improvement initiatives quite successful
that VA has been able to pull forward relied on the very information and the
infrastructure that we’re talking about here. So we recommended a number of
mechanisms, including directed research and contract research that again, if
it’s something that is consistent with the VA sort of legal structure it would
actually help in this area, including joint projects or use of mechanisms with
AHRQ and with VA, so hopefully the legal structure will permit the use of more
directed research as well to improve these areas.
MR. CHRISTOPHERSON: There is a vehicle in VHA to do direct research, we have
a health services research group who actually we’ve done some work in terms of
they can open that up. My sense would be by the way clearly we would do sort of
collaborative kind of venture that probably allows us to have a little more
latitude as well to try and do some things, so I think that’s where there is
some interesting possibility of doing that and I think that’s probably to the
benefit of everybody.
DR. DEERING: This will be real quick and it’s just to, since one of the
functions of these meetings is to sort of get onto the record as much of the
environmental scan as possible, you mentioned something in passing that I think
a lot of people may not know about and it would be good for you to just ever so
quickly describe, it’s the collaborative that you have, you mentioned a meeting
coming up in January and I wondered if you could just say a few words about
what that is, who’s involved, and where you’re going.
MR. CHRISTOPHERSON: What the, the question that was put on the table over
the last probably year was sort of the following, which is everybody is sort of
frustrated because they can’t figure out how to get two people talking to each
other. And it grew out of our experience very honestly because while we had a
designed a specific solution for VA/DOD, and we will do another one for IHS,
which will be much simpler because we’re much more similar systems then VA/DOD,
the question to us but wait a minute, from the VA perspective, we have 26
million veterans, 20 some million of them we don’t care for in a given year
basis there but we worry about them, at some point we’re probably going to care
for a fair amount of them, so we don’t have the vehicle to do it. So the
question that came out is we could go out and set up 100,000 of these sort of
exchange relationships that will die before they’ll ever happen.
So we started to look at the question and said is there a way to create a
way to do this that is not unique, not unique to VA/DOD, it’s not unique to VA
anybody, it’s a common mechanism that any two providers at any given point in
time can share information on. It’s sort of like a fax machine only better. I
think the question as we sort of looked at that said what would it take to pull
that off. And we asked a few people around the tables that said is it possible
to do that and the answer was yeah, do the tools pretty much exist, the answer
was yeah, we’re not talking about anything new, it rides on, I mean those
things were all kind of there, so it’s kind of like we just haven’t gotten
around to assembling the pieces and making sure that they work and that was
kind of the solution.
Then out of all those people we were sort of talking to we brought together
about 30 organizations, as I said Kaiser was there, Bill was there from NHII,
and others, we had people like Microsoft, we had people like Hewlett Packard,
we had CMS, we had Institute of Medicine, we had just lots of different kinds
of organizations. Probably a little lighter on the provider type then we’d
probably want to do for the long term there. And we asked the group very
simply, this was a 45 minute meeting, in a 45 minute meeting we said one, is
this a good idea, is this something we need and try to do and the answer was
yes. We asked them the second question is do we think we can do this and the
answer was yes. And the answer then to the final question was do you want to do
this, are you willing to proceed, and the answer was yes. So in about a 45
minute meeting we said yeah, there’s enough interest to go forward. Nobody made
commitments, nobody’s pocketbooks were picked, we said is there enough interest
for us to proceed forward, do we have a crucial mass.
The answer was yes and the second meeting as I indicated is scheduled for
January 9th and at that time we’ll begin to look at what the to be
model should be. There’s talk about peer to peer, there’s talk about some
variations on that, we’re going to look at the experience of Santa Barbara and
Indianapolis and PSI and others and the idea here is to bring the collective
wisdom hopefully together and together figure out a solution.
I will emphasize that the idea here is not to sort of talk about or create a
policy, it is to execute. That’s probably the one difference, when you get
involved with us we have a tendency to talk about executing things, we actually
want to say okay, we’re going to actually hook the wires together, negotiate
the agreements and make it happen, and I think that’s really what this group is
willing to come back to do.
DR. LUMPKIN: Great. How long are you going to be with us? You’re out of
here.
MR. CHRISTOPHERSON: I’m out of here.
DR. LUMPKIN: Okay, let me pose a question that I posed to Bill. Knowing
where this workgroup is, what we’re really needing today and your thoughts are
a helpful kick-off point is where should we next make our contribution in
trying to forward the agenda that we identified, I won’t say that we invented
the concept of trying to put all the pieces together but we certainly tried to
pull that together into a report —
But anyway, the point being from your perspective where do you think that
this workgroup can add to the effort to move forward the NHII agenda?
MR. CHRISTOPHERSON: Well, in the first place you’ve already made a
significant contribution by putting it on the table to help move the basic
concept forward and getting it there. So I think the first place is I want to
point out I think this group has already done a lot of good work, the NCVHS has
done a lot of good laying out the basic concept and laying out these other sort
of first marker down to get it going in terms of that, which led to a lot of
the efforts that we’re now doing altogether there.
In terms of the next steps I guess I keep going back to what are the
building blocks we have to make happen, so in the EHR world whatever you all
can do to nudge people toward financial incentives, standardization where it’s
appropriate, not to where it’s not appropriate in terms of the standardization
there, efforts there, we talked about the EHR functional model, by the way it’s
EHR functional model systems, EHR systems functional model and standards was
the original entitlement, I think put together going back to the IOM report
there.
So I think one is to push out the EHRs, standards, financial incentives. I
think whatever you can help us think through in terms of how we break through,
getting close to the people who are skeptical about using it, whether it’s
payoffs, whether it’s timeframe, whatever you can help us think through
together on that would obviously be to a great advantage.
One thing to keep in mind by the way as you go down that path is every year
tens of thousands of doctors come through our system and get trained on the
VISTA system, and then tend to walk out to the next place and they go and say
why don’t you have, and so something to keep in mind as we sort of go through
transition and growth there.
In the PHR space I think we really are at an infancy stage about where we
want to all go there, I think there’s actually some pretty good ideas on the
table about what it might begin to look like but I think there’s a lot of work
in that area and I think any work you can do to help us to define where the
consumer comes into play and how they’re involved and how we can enable that
involvement would clearly be important there. There’s some standards work in
that area as well but there’s just some basic issues around what functions do
we think are important, at least at a basic level for PHR.
On the exchange level the stuff’s that familiar right now, the community
exchange area obviously to help reinforce those efforts, reinforce the funding
that’s needed to try and get that work to be done both at the demonstration
phase but also the proliferation because at the end of the day we don’t figure
out some way to get to all the communities, all the communities in the United
States, we’re going to always be short, so how we make that happen. But
obviously the stuff we’re trying to do in some of the broader exchange is they
keep building these things, ideas you have there would be greatly appreciated
and some of you are involved as a matter of fact in that exchange effort and
obviously I assume you’ll do that as individuals if not as a workgroup there as
well.
The standards area I think is an area that we still have work to do in. For
example, one of the areas of CHI, and I think it’s very true that others have
done, have not put together, is what’s the model into which all these standards
fit, and we really have not done that. And whether we knew that that was the
case, we also knew we had to come back to it. And the reason was we had to get
some early hits, sort of get some momentum going, now it’s time to try and
build upon that.
I think it’s also quite clear in CHI there’s some areas of standards we
haven’t yet touched and I think you all need to help us think through what some
of those areas are which would make good sense for CHI and by the way NCVHS,
and begin to lay out, I guess what I’m relaying to work, what’s the sort of end
game roadmap we’re laying out for where we’re going with standards, what’s the
model, how does it fit together, what’s its potential scope, and then who’s
going to do it. And I emphasize getting the work done, this is not about
creating an interesting laundry list, it’s about creating, it’s an action
agenda for standards. And by the way the nice thing to keep in mind is we have
NCVHS, we have CHI sitting there, now there’s two viable mechanisms to help
execute.
A couple thoughts.
DR. LUMPKIN: Great, thank you. Thank you for coming. We’re going to go to
Steve and then let me just sort of share after Steve is done what I’m going to
ask us as a group is to spend about 15 minutes tossing out ideas of where we
want to go, mull those over in lunch, and then we’re going to dive into that
issue when we return from lunch. Steve.
Agenda Item: Status of HIMSS NHII Survey – Dr.
Steindel
DR. STEINDEL: Thank you John. I’m going to present some initial results from
the Health Information Management and Systems Society, HIMSS, NHII Task Force,
their initial survey on what people perceive of the NHII and I think the main
purpose of this is to provide some initial crude numbers to the group so they
can visualize what people are thinking about in the outside on the NHII.
There are a number of people in this room who participate in the HIMSS NHII
Task Force, it was established in October of 2002, it’s the first task group of
the HIMSS that reports directly to the board of directors, so this is a new
approach that also shows the importance that HIMSS puts on the importance of
the NHII. The membership fluctuates a little bit but there’s approximately 17
members on the group and it’s well split between providers, vendors, and
government representatives. Dr. Martin Harris, who’s the CIO of the Cleveland
Clinic Chairs, the NHII Task Group, and it’s charged with creating
demonstration projects and do a status survey of the NHII implementation for
the HIMSS membership. And what I will be reporting about is our initial survey.
I chaired the survey task group, as Bill knows I have an interest in surveys
in my previous life, so I kind of drifted into this, and this survey was
basically a target of opportunity that appeared in the HIMSS mechanism. They
have developed a quick survey mechanism that they use on the web that they call
the Advantage Point and it’s designed for HIMSS to get information from its
membership on issues of importance today. A month opened up that we could take
advantage of. It’s basically a web based survey, they have a limited question
set, they try to keep it at six plus or minus questions, and it tends to have
limited publicity. Given all that I think you can see that this is not the
mechanism if we wanted to capture realistic information of what’s going on but
it did represent a target of opportunity that we wanted to take advantage of.
We posted the Advantage Point survey in September with five questions and we
had 196 respondents, so you can see the results are not representative, I do
not think we can assume they are at that level of response rate, but it does
represent at least something from the outside world concerning NHII. We also,
and this has been a big criticism that we’ve had, we have no information on
what the respondents represent. And you will see, I will make the comment
showing the next slide about something that we have concerning these 196 people
who responded. I’ve given you the URL for the information from the HIMSS
website and we handed out to you the information that’s posted there, which
occurred immediately after the survey.
If we take a look at the next slide, which shows the familiarity with the
NHII, only one third of the people indicated they were not familiar at all with
the project. I think most of us would think that if we were sitting at that
situation we would feel very enthusiastic, so I think these people are a NHII
aware population. And when we look at this four percent are participating in
project developing and knowing the people in this room who participate, I’d
like the eight people that responded that way to raise their hands right now.
So I do believe that the people who did respond to this were a familiar
population.
The other thing is they are aware of the project but not participating in
developing, again that’s about 30 percent, I think these are high. I think if
we actually did do a representative population you would see this as much
lower. So given the statement of the number of people in this qualifying slide
I think what we are looking at is a biased survey.
But given that the information was still very telling. The most significant
barrier to forming a national, a local or a national health information
infrastructure was a question that was asked, and this goes back to some of the
comments that Bill made earlier and I was very struck between the familiarities
there. Basically they’re financial. If you look through it there are resource
constraints within the institutions, a financial course without defined return
on investment. Things that we considered to be barriers initially when the
workgroup was planning the NHII report, governmental intervention, was fairly
low at about four percent. Privacy and security issues from HIPAA was also
relatively low at around ten percent. The issues of standards, lack of
interoperability within a health care system was considered to be a barrier by
12 percent. And unwilling to exchange information with competitors was a
barrier at 14 percent and this was recognized within the conference that was
held in June and identified. So we do see even though this was what we would
consider to be a low and a non-representative survey, when we look at this it
tracks fairly well with what we’re seeing with other information for barriers.
We looked at functions that health care institutions process electronically
and what we see as the largest right now is laboratory results, at about 83
percent. Clinician access to patient results from outside the facility was also
just below 80 percent and I think those of us who are familiar with that would
also go along with the observations that I made that this is probably a very
aware population that answered this survey. Pharmacy orders and prescriptions
at just over 60 percent I think bodes well if we move into the ePrescribing
area and hopefully this transmits into that arena. Now I will point out that
the first demonstration project that the HIMSS Task Force is looking to do is
in the area of ePrescribing, so we’re hoping to get more information there.
Tele-health is just below 40 percent and patient access to results, which we
were talking about, which Gary talked about the importance of, is now being
done at about just over 15 percent. So the group that did respond to this is
doing a lot electronically, which bodes well at least from the subpopulation
that answered.
The national standards used for electronic communication was also tabulated,
now what I’d like to point out is we did not qualify whether this was internal
or external, so it’s a little bit misleading but it does show that the
penetration of the standards that were recommended by NCVHS for PMRI messaging
standards are being implemented in institutions and these are also some of the
standards that are being recommended by CHI and adopted by the federal
government. So this is also looking fairly well.
Now a question of interest to CDC and since I’m somewhat influential in the
task group I included this question in it, do you exchange information with
public health organizations, and 46 percent said not at this time. But what
struck me as very interesting was those that answered to full exchange of
information was 14 percent and sitting at CDC I would like to know those people
because we’re not aware of that high a number, but we were very encouraged by
it, I will have to say that. But we were encouraged about was 15 percent of
them did say they received alert information from public health agencies, which
we think might be more realistic then the 14 percent who do say they exchange
it.
What also what we were very struck with was would, if the other organization
could receive electronic information, the other organization of course is
public health, and that’s 25 percent said that they would do it if they could.
DR. LUMPKIN: If I could just interrupt, I’m actually not surprised about
that 14 percent because I guess they probably read the question as do you
exchange electronically the information you share with the public health
organizations, and they’re probably the four percent who don’t share anything.
But what they don’t share they do electronically.
DR. STEINDEL: I will accept that refinement. But I think what was just
pointed out was also a very good thing, we took advantage of a target of
opportunity and some of these questions needs refinement.
What we’re doing in the future, this is the HIMSS Task Group, HIMSS had
budgeted for a March 2004 survey, not a target of opportunity but this is a
planned budgeted survey, they are planning about 16 plus or minus questions,
and when I say plus or minus the survey mechanism, they will be using the web
based survey, allows branching, so we might be able to ask from a basis of
about 48 questions, 16 questions but they may differ depending on the groups
that are answering the survey. This will be well publicized, we intend to get a
fairly decent response rate, and we are going to identify the respondents so we
might be able to make some better inferences then we are now.
Long term, we’re planning to have periodic repeats of advantage type survey
to see what’s going on, a refined yearly survey, and we are working with those
who survey the E HR vendor community, and the EHR user community, to introduce
NHII like questions in those surveys. Bill kind of referred to that in his
statement where we now tend to ask EHR vendors how they do things internally.
For an NHII to work the EHR has to communicate externally and we’re going to
work with them to ask some questions about how they’re introducing external
type communications into their EHR systems.
We have some issues and that’s basically the target population from HIMSS.
It’s an institution and vendor based organization, so it’s inherently biased.
The link to ambulatory care are currently weak and HIMSS is investigating the
ways that they can increase their penetration into that community, it’s very
important for us to get it. The public health dimension is missing from the
HIMSS population entirely, so the surveys will be biased in that area. And the
personal health dimension is also something that is missing from the HIMSS
population. What the HIMSS population can answer is how their group provides
information to people, but it doesn’t necessarily provide any information on
how people can use it, and we’re looking at other ways to augment that.
And I believe this concludes my talk, I’ll be happy to answer any questions,
or if John wishes we can just go ahead and start our exercise. This was just to
provide a quick look at what’s going on outside.
DR. LUMPKIN: Great. Any questions? Bill?
DR. YASNOFF: The question about communicating with public health
electronically, I can’t tell from what you’ve handed out, could the people
answering this have thought that you included email or did you intend to
include email in that, categorizing email as electronic communication in public
health?
DR. STEINDEL: I think they may have and they may have considered facts. As I
noted we took advantage of a very quick target of opportunity and couldn’t
refine the questions clearly enough.
DR. LUMPKIN: But certainly it points out to future directions for questions.
Simon?
DR. COHN: Well I was just going to comment, I think we’re tending I think to
under appreciate that actually some public health data does go to public health
from private entities, things like immunization registries typically fed by
electronic data sources, many of the lab results, if Clem were here he would be
commenting that a lot of that goes electronically also. So we should not just
dismiss these numbers as being either inappropriate or grandiose —
DR. STEINDEL: And I will point out that for the March survey we took
advantage of this target of opportunity and refined the question according to
some of the comments that were just made.
DR. LUMPKIN: Because in fact a number of states have begun to implement
their net system and so there —
DR. STEINDEL: It’s starting.
DR. LUMPKIN: Mary Jo and then Jim.
DR. DEERING: Again in the interest of just making sure that information gets
put out to the people who may not be aware, you’ve done a significant amount of
work to come up with the questions that you will be asking, I know Bill you
have on your work plan to look specifically at metrics for the NHII. I know
John Hungate, Bob, you were very interested in the question of metrics, so I
just want to put on the table that we want to make sure that we don’t get into
dueling metrics here and I know that everybody does sort of talk to each other
but it might be very, I guess I’d ask you Steve, just since you’re on that side
of the microphone right now and then Bill can answer too, I mean how are these
efforts going to be integrated?
DR. STEINDEL: I don’t believe at this time there’s been discussion about
formal integration but there are members of Bill’s staff who do receive, don’t
formally participate in the task group but are on the task group distribution
list and are aware of all of this. They have a set of the 48 questions for
instance and I would hope that they would be looking at them and commenting
back.
DR. YASNOFF: In the future I think either I or someone on the staff will
participate directly in the work group but I think I’d like to defer the issue
on metrics until our discussion because I think clearly once there is an
established set of metrics having input on those metrics through HIMSS would be
very valuable. But at this point I’m not, it may be a little bit premature.
DR. STEINDEL: Commenting a little bit further, Mary Jo, I think there are
two different types of survey questions that we’re looking at and one is
penetration metrics, how many people have access to an NHII, how many
facilities are using the NHII, and the other is characteristics. And I think
right now we’re gearing the questions from the HIMSS survey point of view of
characteristics more so then penetration. It’s very difficult because of HIMSS,
that we’re just surveying the HIMSS membership, for us to look at any or make
any presumptions about saying what is the national penetration of whatever NHII
metric we want to talk about.
DR. LUMPKIN: Jim?
MR. SCANLON: A quick question, John. Steve, you mentioned that one of the
efforts planned by HIMSS in the year ahead was an ePrescribing demo. Could you
say a little bit more about that and the timeframe and what’s the nature of the
demo?
DR. STEINDEL: I can just talk very briefly about it, it’s still in the
formative stages. They are looking at using a ePrescribing RX hub, which is a
national clearinghouse for prescription information to participate in the demo.
I know Cleveland Clinic is going to be involved with it, I think the Cleveland
VA is going to be involved, and I think they’re recruiting one or two other
institutions and they are trying to introduce a full ePrescribing system
between those various institutions. Right now they are looking at some funding
from eHealth to help fund the demonstration project.
MR. SCANLON: The timeframe is to have —
DR. STEINDEL: I believe the timeframe, they are in the planning stages right
now pending funding and I believe they are looking at implementation sometime
starting in the spring and running the project for 12 to 18 months.
DR. LUMPKIN: Great. Thank you. Thinking about timeframes and where we are,
maybe I’m going to change a little bit and have us think about what we’re going
to do over lunch and then pull together. But let me just start you thinking
about this before we take our lunch break.
Yesterday the Commonwealth Fund released what they thought were the ten most
significant factors in health policy, for the year, for the year 2003. Now we
have to put this in context, despite the fact that I think one of the reasons
why we went to war with Iraq was related to weapons of mass destruction,
including bioterrorism, the outbreak of SARS, the public health system being
stretched to its limit, all those one could argue were significant events that
occurred in 2003. None of those did make it into their list of ten so they’re
really talking about health care policy events.
The number one major, first on their list was the major Medicare
prescription drug legislation is enacted, of which a number of provisions talk
about or give responsibility, one directly to the committee, in relationship to
that. Number eight was that clinical information technology standards gained
traction thanks to government effort. And number nine was that quality
improvement efforts are really starting to take strides, to make strides. So I
think that when you put it within that context there’s a lot of things going on
and information technology is playing a significant role.
It’s sort of a very interesting counterpoint, when we look at our document,
which is titled Information for Health, those of us who are on the committee at
the time, at the workgroup, remember that we didn’t think that the term
National Health Information Infrastructure would have any traction so we had to
come up with a different title that we thought would be catchy. Needless to say
that has not been proven to be true.
So what I would like to frame the context of how we think about where we go
from here is that our activities can go in three different directions, none of
those are necessarily mutually exclusive. The first direction is going back to
our diagram where we have three intersecting circles, we discussed that there
were other circles, actually there’s four directions, we discussed that there
were other circles that could be drawn but we didn’t feel that they really were
the focus of initial report. So one way that we could work as a committee would
be to move and trying to define other dimensions of the National Health
Information Infrastructure.
The second option is to go into depth on some of those circles that are
already there. We’ve already begun to look at some depth at the personal health
dimension, we’ve had some discussions, but there’s a fair bit of activity in
that arena, that is going to be the focus of the new Connecting for Health
Initiative funded by the Markle Foundation, the personal health dimension.
The second circle, which is the health care provider dimension, clearly with
the EHR activities and electronic, all the stuff that’s going on, the Standards
Committee, CHI, there’s just a lot of stuff going on in there.
The third dimension which is the population health dimension, we’ve already
had hearings on the Public Health Information Network, on NEDS, National
Electronic Disease Surveillance system, and there’s some work going on there.
But that would be again another alternative, that would be alternative two.
Alternative three would be rather then focusing at the circles we might
focus at the interfaces between those circles, the movement of data from the
personal health dimension back and forth between the health care provider
dimension, the interface between the population health dimension and the other
two dimensions. And how data moves from one to the other may be a third
alternative to look at.
And then the fourth would be to go back to a higher level and that is having
now been roughly two years since our last report are there higher level issues
that need to be accomplished. Have our recommendations been achieved, are there
other recommendations on a broader level that we would like to recommend, we
want to look at a strategy and a roadmap for moving forward.
So those are kind of four options that I see as kind of the scope and then
within those contexts we can look and pick and choose. We may choose to
continue to move forward on the personal health dimension and still take a
broad high level look but I think it gives us a context to come back.
What I’d like to suggest is that when we come back we’ll spend about the
first half hour putting up in sort of a brainstorming session. Let’s start
putting ideas on the table instead of trying to discuss each individual idea.
And then we’ll spend the rest of the time trying to weed, to pull the ones that
we think are going to be the most significant area for us to focus in on and
then use that as the basis of setting the agenda for the workgroup. Does that
seem like a reasonable approach? Everybody have their task for lunch? Which is
to eat? We’ll get back here at 1:00.
[Whereupon at 12:05 p.m. the meeting was recessed, to reconvene at 1:10 p.m.
the same afternoon, December 19, 2003.]
A F T E R N O O N S E S S I O N [1:10 p.m.]
Agenda Item: Discussion of Workgroup Priorities and
Plans – Workgroup
DR. LUMPKIN: Let’s get started. We’re going to use some high tech equipment
to keep track of all of these ideas. I have to tell you, you have these moments
in life where everything you do changes fundamentally. I’m a person who really
doesn’t trust technology and so I used to go do all my talks on transparencies.
Okay, tele-conference is on live, we’re getting back. And then I went to do
this conference, I think it was at CDC and maybe it was the conference, anyway,
some guy, some bald headed guy, haircut like me and wearing a beard said to me
you know, if you’re talking about information technology you really ought to be
using Power Point. Thank you, Bill, I’ve now completely converted except where
the technology doesn’t exactly work.
DR. YASNOFF: I didn’t say when you’re brainstorming and facilitating a
group that you should use Power Point.
MS. GREENBERG: You could do it on the computer. We were in a smaller room
and there were some white boards and people were writing on, but the thing was
that they ended and then the walls started and we didn’t notice so they were
writing on the wall.
DR. LUMPKIN: Okay. We’re going to start coming up with ideas for the
workgroup for ’04 and ’05, calendar year ’04 and ’05 for those of you who
operate on fiscal years other then January. Simon?
DR. COHN: What? I guess I’m not hearing you exactly. What were you asking?
DR. LUMPKIN: We’re going to start coming up with a list, looking really
over the next two years, what are we as a workgroup feel that is going to be
our contribution to moving forward the agenda that we started with our
Information for Health. And I think I see Jeff raise his hand but I did tell
Bill earlier I was going to ask him this question, and so we’re going to let
him start off. We do have a couple ideas we got from Gary, we’ll toss those
into the mix as we go along. Bill.
DR. YASNOFF: Well, I have a whole list of things but before I get to that I
want to kind of make an overall comment and that is I think that clearly in
this workgroup there’s a very clear understanding, at least I think there’s a
very clear understanding, of what NHII is and that it’s a good thing, and that
it has all these fabulous benefits as outlined in the report from a couple
years ago. In talking to folks, senior policy makers both in the Administration
and on the Hill about these issues, I can assure you that there is that
understanding of NHII is not at all common and the belief if you will that it
has all these benefits, particularly financial benefits, is not there really at
all.
And I’m relatively new to Washington still and what I’m often told is when
it comes to financial benefits there are only two groups that matter in terms
of convincing and that’s OMB and CBO. And I don’t know if that’s true or not,
obviously those groups are very important, but I can assure you that neither of
those groups is convinced that there’s any business case for this at all. So I
think that’s really an important issue.
DR. LUMPKIN: Okay, making the business case.
DR. YASNOFF: It was two things actually, making the business case but
communicating the vision of what NHII is, because before anyone’s even
interested in the business case they have to understand at least a little bit
what it is.
DR. LUMPKIN: Let me just probe a little bit on that. When you say
communicating the vision how do you mean that? Is this something we would do by
developing another report which sort of carries the vision forward? What do you
see under that?
DR. YASNOFF: There are a lot of different ways to do it, I’m just putting
it up there as an idea and if people think it’s important then we can flesh it
out.
DR. LUMPKIN: Jeff.
MR. BLAIR: Well, Bill, thank you, you were just perfect to lead into my
suggestions because it was really almost targeting the same type of thing but
maybe on a more broad basis, not just a government basis but on a national
basis. I think we have to put flesh on the bones of what the NHII is and I
think what it is in terms of what it will be, what we envision for seven for
ten years from now. And Bill, we had that architecture group but I think that
it has to be defined broader then architecture because that tends to imply
technology. And I want to jump on Gary Christopherson’s suggestion because he
virtually, he said it, he said we need an NHII model and I think that model
needs to be what we think it should be seven to ten years from now. And my
view, I think the word model is a good name because it would probably include a
functional model, a technology model, a standards model, a financial model, a
legal model, and probably an expansion of what we had in our report. We had a
values and ethical model, and I think that also needs to be part of it, it
might be called a policy model. So I think if that is, and I’m not sure how
much of that NCVHS workgroup should be working on or whether that would be Bill
in your domain, but I think there’s a sense of urgency for this because, and I
created something and Mary Jo, do you have those copies?
DR. DEERING: I do.
MR. BLAIR: Maybe if you pass it out it will illustrate kind of the concern
that I have because I did a rough and dirty ten minutes in just listing all of
the initiatives that are going on from legislative initiatives, to CHI
initiatives, to eHealth initiatives, to standards initiatives, and I came up
with I think more then 30 and I think that list is half of all the initiatives
and a lot of folks wind up thinking of these initiatives as this is part of the
NHII. But they’re coming at it from different perspectives and we need, and the
thing that I’m concerned about is that these initiatives will proceed forward
for another year or two or three and then the ability for us to be able to pull
them together into a cohesive single National Health Information Infrastructure
will wind up being that some folks are going to get hurt because they are
making their investments now.
So this is why I feel that this model of the NHII needs to be produced as
quickly as possible also because I think Bill, you and AHRQ and other HHS
agencies are about to wind up funding these demonstration projects but these
demonstration projects are an extension of what people are doing today and
they’re taking the next step and all of them vision from their perspective they
figure that they’re central to the NHII. But if you take a look at them how do
you prioritize them, which needs to come first? Do they really match that
national model of where we want to be ten years?
I feel you need this as from number one, to build consensus for the nation
as to what the NHII is ten years from now and number two to measure all those
demonstration projects against whether they’re getting us there, and then
here’s the third thing, is that, and Gary Christopherson mentioned this also, a
roadmap from where we are now with our initiatives and laws and demonstration
projects and standards stuff to that model that we want it to be seven to ten
years from now, what are the impediments, what are the gaps, what are the
milestones, so that we make sure that we’re converging on something we all
agree upon.
So you could almost tell by the intensity in my voice of the fact that I
feel like this is really, really important. So thank you.
DR. DEERING: May I just explain to Jeff, I inadvertently also did pass out
your stakeholder roles, I passed them both out at the same time.
MR. BLAIR: One of the aspects by the way that I feel is so important in
this national NHII model is that I’m a little concerned that folks like me who
are involved in technology and standards have too big a role in what the NHII
is and we’re driving forward and we kind of get a voice but there’s areas of
the NHII that I feel this model would begin to put an equal weight on, such as
the principles, the ethics, such as the support for wellness, such as the
support for personal health records, for example, the areas which don’t have as
much of a strong voice but when we go national really need to be central to the
privacy issues, the security issues, the idea of authentication, how are we
going to wind up authenticating everybody that’s here. That tends to not get as
strong a voice as interoperability and connectivity because we have those
capabilities, those are sort of clear to us, we can see how to do those a
little bit better. But this will surface these gaps that need more attention.
DR. LUMPKIN: Steve.
DR. STEINDEL: I think Jeff put it very eloquently. The point that I was
going to make and I think Jeff’s comments bring what I was going to say
together a lot was in comment to what Bill was noting about the two people
who’s attention you need to get are the budget people, CBO and OMB, and what
concerned me about that is of course the CHI Initiative is basically an OMB
initiative and OMB is very aware of the need for the interconnectivity of the
federal health systems. And if Bill is saying they’re not aware of the need for
the NHII that leads me, it would have prefaced what Jeff said but now it comes
from what Jeff said, is this roadmap is very important so that we can bring in
front of the budgetary people to show them that this is part of the roadmap and
this is the way to get to the end.
DR. LUMPKIN: Okay, other areas we want to think about. Yes, Stan. I’m
sorry, I didn’t see your hand up, my back was turned to you.
DR. HUFF: I’d just like to second Bill’s ideas, which I think to
communicate the vision and then put flesh on the bones and create a model as
Jeff and Bill have described I think are exactly the kinds of things I was
thinking. Just to put a slightly differently perspective on it is just if one
of the things that I think we need to do is sort of describe the vision state,
which I think is complementary to exactly the same things Jeff and others were
saying and that is, I mean what, if things were working the way that we hoped
they would work what would that look like to a patient/user, what would that
look like to a physician/user, I mean can I go, if I have symptoms would I be
able to go to a kiosk or just enter over the internet, and how does it look.
Does it change how I access health care, does it change the practice of
medicine? And if we could describe the vision state I think then that leads to
what would need to be in place in terms of privacy and confidentiality and
infrastructure and standards and business cases that would eventually get us to
that vision state. And maybe that’s been articulated someplace and I’ve missed
it and so if it’s already been described then I agree with the need to
communicate it, and if it hasn’t then I’m agreeing that we need to flesh it
out.
DR. LUMPKIN: Simon.
DR. COHN: Steve, did you want to follow-up on the —
DR. STEINDEL: I’d just like a clarification question for Stan. Stan, what
do you envision as the vision case that would extend beyond the first document
we produced? Because I’ve heard that did a very good job of articulating the
vision of what the NHII should be.
DR. HUFF: I’m ignorant, I have to plead ignorance, I need to go back and
read the first document. So it may be like I said, it may be that nothing is
needed, I just need to be educated and then a whole bunch of people like me
might need to be educated as well.
DR. LUMPKIN: Update, enhance, and re-communicate.
MS. GREENBERG: And then draw out from the vision, state what is required
more specifically.
DR. COHN: I actually am sort of agreeing with what everybody is saying so
far, I think Jeff actually was very eloquent, I also think —
DR. LUMPKIN: So you guys are trying to eliminate my process here —
DR. COHN: I listened to your four things and the last one you had mentioned
was high level strategy and roadmap for moving forward and I think that’s sort
of the area we seem to be glomming on. Now I actually was just going to take it
from a slightly different direction, though, which is I was reflecting that one
of the things that we keep talking about is metrics, to know sort of how far
we’re going, how close we’re getting to it or how much progress we’re making,
and of course that gets the question of net of to what or to where. And
obviously we have this vision which seems to have, I mean I think most of us
who know it find it very attractive, but it seems to be amorphous enough that I
have been observing recently that people with really diametrically opposite
views seem to be all embracing it and thinking it’s exactly their view, so
maybe there is a cause to maybe tighten it a little bit just because, I mean
it’s a wonderful vision but you don’t know really what it is so you can’t
develop metrics so you don’t know sort of where you’re going, etc., etc., and I
think all this begins to move us maybe in that direction.
Now the other piece that really wasn’t talked about here, obviously we
talked about the business case for the NHII but there’s also, how can I say it,
I guess I’m trying to think of something beyond, the business case I think Gary
was sort of saying this is the NHII is probably an enabler, and so it really is
not the business case for the NHII, you have standards, maybe they’d be in
NHII, NHII maybe is something else, probably more ideal health care. And so we
sort of need to draw that all together if we’re really talking about a business
case, and the business case obviously has to in some way reflect upon, I hate
to put it this way, but we actually probably do need to talk about financing
mechanisms at some point. I don’t mean financing for the NHII, I mean financing
for health care. I think that without reflecting on that we can’t really talk
about the business case very well.
DR. LUMPKIN: Let me sort of see if I can refine that a little bit so I
understand it. First, in your first comment I think we can boil it down to the
good news is there are a lot of people talking about the NHII. The bad news is
they all mean different things.
DR. COHN: Yes.
DR. LUMPKIN: So we need to clarify what it is that we meant. Second is that
in trying to move, look at the business case you’re really looking at the
finances, but there are other things that aren’t financial that the NHII will
add to it. We’ve talked about it within the context of quality. Now as a second
order of business case you can say by improving quality you save money. But I
was struck by the, what Bill talked about and I think it was the Blackford
Middleton Study —
PARTICIPANT: The $120 billion —
DR. LUMPKIN: No, not the $120 billion but the cost savings that were
yielded accrued to people other then the ones who implemented. That is a
significant one so if we’re going to really look at it we need to perhaps talk
about not the business case but financial models that lead to incentives for
implementation.
PARTICIPANT: Aligning financial incentives in essence.
MR. BLAIR: I had a presentation recently and the phrase that I wound up
putting up in there is we need to make sure that the providers share in the
benefits that result from the NHII, they have to share in the benefits.
DR. COHN: Well, actually I think a lot of people need to share in the
benefits, including —
MR. BLAIR: Providers have felt that it’s the payers that get the benefits,
the providers make the investment for the most part, the payers get the benefit
for the most part.
DR. LUMPKIN: And it might help if we were to have like an economist on our
workgroup.
DR. STEINDEL: John, what I was struck by in that cost/benefit analysis,
this was something you brought up just before we broke for lunch, was the large
amount that accrued to that community exchange portion and what that struck me
as I was looking at it is we had specifically identified benefits that we could
target to the large circles, like the provider circle would achieve this much
in benefits, $10 billion or $20 billion, whatever it is. But where the circles
overlapped was where the $90 billion accrued, and you mentioned the point of
maybe we should look more at the overlapped areas and that might be an area of
refining the vision.
DR. LUMPKIN: In the overlap areas.
DR. STEINDEL: In the overlap areas.
DR. LUMPKIN: Okay, so that really is tied into the model but we’re talking
about fleshing out particularly overlap areas. Kepa and then Bob.
DR. ZUBELDIA: In that overlap area I think there needs to be special
emphasis to see where the provider/payer view overlap, there’s something called
HIPAA that people are very anxious about and perhaps there needs to have a
specific discussion of how HIPAA overlaps with that overlap area.
DR. LUMPKIN: What I’m struggling is because it really is getting to saying
all of the above in my earlier dimensions but what this is beginning to argue
for, some of these items, is that in moving this forward we may need to
actually describe the financial dimension of the National Health Information
Infrastructure because that’s really the overlap that HIPAA is in there because
the payers and the purchasers weren’t really in our model.
DR. ZUBELDIA: — something that’s going on in Utah, I’m involved in a
project, the state of Utah is talking about building a repository for perhaps
lab information, radiology information, and prescription information. The
payers and the providers are involved in the project, the payers are saying if
the providers would look into the repository rather then ordering an extra
x-ray or an extra EKG or before prescribing, then the payer will increase the
reimbursement to that provider because they’re improving the quality. And use
the repository as a way to lower the cost and improve the quality and at the
same time improve the reimbursement to the provider. So that’s where everything
overlaps and you have the financial incentive for the provider to use the
repository.
DR. LUMPKIN: Okay, let me just sort of, okay, refinements on this, Simon.
DR. COHN: Well, I was actually just going to support your purchaser
dimension a little bit, I wasn’t actually going to use Kepa’s example because I
think it’s a small piece of what we’re talking about, but I had a pre-meeting,
I sat on the payer panel that Bill put together and had a pre-meeting with all
the various payers and I found myself having to apologize to them that, that I
said well gee, we really do have the payer in here somewhere, even though it’s
very hard to see, and the money really was thought about in all of this. And
sort of said yes, well we just decided not to put in another circle. But
certainly one would recognize and I think Bill started off the conversation by
talking about trying to persuade the OMB and the CBO and all of this stuff,
here now we’re coming back to sort of another version of that. There’s a lot of
obviously questions about how this actually shows financial value. There may be
quality value but certainly there’s a financial case, I mean the reason that
the OMB and others are somewhat cynical about this one is not that it’s going
to cost payers or providers more money, they’re afraid it’s going to cost the
government more money if they do all of this. And I think we need to probably
look into some of that in the payer/purchase dimension.
DR. LUMPKIN: Steve.
DR. STEINDEL: Those of us who are showing our age and have been on this
workgroup for a long time probably can recall as we were developing the model
several sessions where we talked about putting in an administrative or
payer/provider dimension. And we actually deliberately left it out because in
part we couldn’t figure out how to put it in because we didn’t know enough
information. But now it’s several years after the NHII model is out and several
years after HIPAA has been out, and we now have a clearer picture of the way
the finances are interacting with the care area. And I think it is appropriate
to reinvestigate it and put that dimension in and talk about it more precisely.
DR. LUMPKIN: Jeff.
MR. BLAIR: It is possible that the financial dimension really is a circle
that overlays all of the three other circles, just the same way privacy may
overlay all three —
DR. STEINDEL: That was why we sat back and said we’re having trouble
putting it in because we though it did overlay —
DR. LUMPKIN: See we ran out of circles, we already had three, you can’t
have more then three circles.
MS. GREENBERG: As a topic it overlays but not necessarily as a stakeholder
group.
DR. YASNOFF: I think the depiction of how you put those things together is
something that we could discuss and I think there are different aspects that I
think you can inform that discussion in part from the recommendations from the
NHII meeting where we have implementation strategies and enablers and
management and so on, so I think there’s a way to do that. But I did want to I
guess make a confession to the group, and that is that the presentations that I
give now I added a fourth circle, not financial, the fourth circle is called
research/public policy, and so, and I think that while those areas are
certainly not going to drive the NHII I personally believe that in the long run
those are areas that are going to be incredibly valuable. For example, imagine
what you could do in medical research if you could take a 100 percent sample of
every patient in a certain age range with two vessel cardiovascular disease and
look at how they’re doing with the treatments they’re being given. Obviously
tremendously important implications for research. So I did want to mention
that.
DR. LUMPKIN: We have it up there. Marjorie.
MS. GREENBERG: I was just thinking, and thinking what a strength of the
committee is, if you decided to do another dimension or to see if you could
define this payer/purchaser dimension, which I think by saying payer/purchaser
definitely makes it, and maybe plan, I don’t know, but broader, that would be a
way to engage those communities, you could hold hearings as opposed to this
sort of sitting around trying to figure it out, it could possibly serve a
useful purpose in engaging them in the vision.
DR. LUMPKIN: Eduardo.
DR. ORTIZ: I guess this goes back to the brainstorming session, when I
looked at that think like the fleshing out the bones, I think that’s great, but
I kind of go back to pushing as I always do is the whole outcomes oriented,
what do we actually have that’s tangible. And I like the couple, that piece
with how do you achieve these things and what are some real substantial
tangible achievements that can occur. And also, kind of in line with what Jeff
put out here I thought was very interesting, was the fact that all these other
entities are doing a lot of similar activities, and so for example the AHRQ
activity, in a way I should clarify. People need to understand the AHRQ $50
million dollar portfolio is not an NHII portfolio, it is a patient safety
portfolio, it’s a Congressionally mandated patient safety portfolio on how to
use information technology to improve patient safety/quality of care. But we’re
doing this and we’ve got the money and we’d like to try in doing this to
facilitate as much as possible interconnectivity, the use of standards,
improving quality through IT, and to the extent that we can help support the
vision of an NHII that’s a piece of it. But at the end of the day it’s not an
NHII project, it is a patient safety project and that’s what it was judged on.
But there are opportunities and that’s why I like in our planning, in our
implementation, what we did is we said you have to use interoperable standards,
look at the CHI things, we want consortiums of three or more entities. In the
value of we said we want to demonstrate the value of information technology,
why, because to the extent that you can demonstrate that value that’s things
that can push policy makers and funders and payers, etc., to supporting the
vision of an NHII. So all this fits but my point is that there’s a lot of
activities out there like AAFP, Open Source EHR, there’s stuff like the VA
trying to roll out their stuff, that all kind of lead to and facilitate or may
enable the future of an NHII but they’re not specifically NHII project. So I
think it is an interesting thing to look at who’s doing what, how do these
things fit together, where should these things reside, etc., etc., because
there are a lot of activities as Jeff has shown us and there are more then
this, but we don’t know how they all fit together although they are all leading
to the same goal to a certain extent.
DR. YASNOFF: Can I please correct something? I’m sorry but I need to
correct what you’re saying on the record, I know that it’s the AHRQ view that
that $50 million dollars is patient safety, but the history of that $50 million
dollars is that it was written specifically by ASPE as an NHII Initiative and
the Congressional language says it should be used to show NHII. So I think that
that is actually illustrative of this issue that Jeff has showed us with all
these different organizations participating in this and I think the point that
you make, which I agree with, which is how are these things going to be
coordinated and how are they going to work together, and how are different
views of the same thing going to be reconciled.
DR. LUMPKIN: And those two positions are not mutually exclusive, they’re
complementary.
DR. ORTIZ: Exactly.
DR. YASNOFF: No, we’re in favor of patient safety and quality as well, I
just want to make that clear.
MR. HUNGATE: I’m going to come from a little different cut at this. Two
specific ideas, I want to make the ePrescribing Initiative a demonstration of
NHII. Now I don’t know whether I can do that or not, but here’s something
that’s on the blocks, it’s a piece that’s important, can we make it, overtly
think about how to make it a demonstration project of NHII. So that’s one idea.
The other idea is to try to do something that cuts across the local health
information infrastructures that are creating and do something that is common
across more then one, which ties to patients beneficiaries, so that we can pull
out a few vignettes of how somebody’s results were better because of sharing of
information. I think it’s great to have a goal that we can articulate and
describe but I think we’re going to have a hard time staying ahead of the
momentum of the crowd if it’s going the way it looks like it might be, and that
we might be better off trying to put more logs in the fires that burn fast.
And so I’m trying to think of ways to make demonstrations in two years of
the benefits that you see in ten in small areas. If I focus on a disease group,
a condition, a narrow view sooner, which incorporated the ideas we expect to
have more complete later. I don’t know whether I’ve said that all or not —
MR. BLAIR: I’m assuming, are you aware that the Medicare Prescription Drug
Improvement Modernization Act does include demonstration projects for
ePrescribing that follow the selection of the standards? It’s in there.
MR. HUNGATE: Yes, but does it have this same motivation?
MR. BLAIR: The point that we were making is that you just picked another
example and I think if we go around the table we could probably come up with
ten or 12 more examples, all of which are initiatives that are all underway,
which somehow have to be pulled into this vision of where do we want to be
seven to ten years from now.
DR. LUMPKIN: So the question is, which I hear being played back and forth
and we’ll come back to it, is are we far enough along with enough
demonstrations that we need to pull it together, or do we need to have more
smaller demonstrations. Is that a fair? Well, I think both, counter posing —
MR. BLAIR: I think it’s both, we need the demonstration projects but we
need to have that vision of where we want to be seven to ten years from now
because at some point I think we have to give guidance to the funding that’s
given to the demonstration projects to make sure that they’re converging on
that vision for seven to ten years from now.
DR. LUMPKIN: Well, but what I’m trying to counter pose is the work of the
committee, we could work in trying to encourage more demonstration projects, or
we could work in trying to pull them together and say this is how they fit
within the context. Or we could do both. Mary Jo.
DR. DEERING: Well, I was going to say something different so if Steve had a
comment that was direct to that point then let him go.
DR. STEINDEL: My sense is John I agree with what you’re saying is we have a
lot of demonstration projects out there, I think it’s time to put some
articulation on how to bring them together into an NHII vision. Because like
Bob was alluding to we’re just told to do ePrescribing and we can suggest
standards to the Secretary and a demonstration project can be put out for
ePrescribing, and it could have nothing to do with patient safety or the NHII,
it could just stand totally on its own, even though someplace else in the
Medicare Act there’s something concerning patient safety. There’s nothing
really linking the two and we need to provide a vision that links the two of
those.
One thing that I was just struck by in all this conversation, I looked at
the stakeholder list, I was just made aware of the other day of a massive
stealth program that’s going on in NCI about bringing together all their
researchers into common data exchange for both clinical trial data and normal
cancer data from laboratories, etc., that needs to be brought into this picture
in some way. So I agree with you, John, I think we need to start articulating
how these demonstration projects can be brought together. How can the LHIIs,
how can they be brought together because to my knowledge Santa Barbara is not
and may not be able to exchange data with Indianapolis, and that needs to be
demonstrated. If we’re going to create and link together LHII.
DR. LUMPKIN: That’s just West Coast elitism. The important thing is can
they exchange data with LA.
DR. DEERING: I wanted to get to a little bit of a process question here
that both draws on something that Marjorie said about how the committee, or how
the workgroup is able to work and I think getting back to some of Jeff’s
original points, namely about not only the multiplicity of efforts out there
that need to be drawn together, but the multiplicity of people who can actually
make things happen, who have the power and the initiative and the influence in
one sector or another to influence things. And I had a couple of sort of
process observations, the first is that however we come down eventually with
this new vision it does sound like that’s going to come out at the end of the
wash that there’s some new vision articulation, refinement, etc., that that we
a collaborative effort. In the past the staff worked with Susan Canaan and the
workgroup members and we put this together and then it only went out for review
a little bit toward the end. But it could well be depending on the parameters
of our next vision product that it could be appropriate to envision some way
that some of these outside groups could play a more direct role other then just
coming to hearings and talking to us in the creation of that statement.
And then the second piece was that some of the problems and issues that
have been put on the table, I mean clearly they’re different levels. Some
things that have to do with perhaps financing might lend themselves more to a
targeted study and it seems to me we do have some funds, or we can lean on
people with funds, because it might not involve a whole lot of money, but if
there’s in depth issues that we need to bring forward that maybe those could be
pulled aside and said let’s see if we can commission a really good paper on
that that could then feed into what we’re doing.
DR. LUMPKIN: And just to feed off of that, I think that we might also want
to consider the world of philanthropy, which I’ve gotten a little bit of an
insight to, not necessarily the one I work for but there are other foundations
who are interested in different pieces of the health care picture who might be
willing also to fund similar but connected kinds of studies. Let’s see, let me
sort of say what I see coming through.
My impression overarching is there’s sort of a consensus that we need to
flesh out the bones of what we did in the first report, to develop a roadmap of
how we get from where we are now to where we want to be in seven to ten years.
That includes a model that has multiple dimensions, which maybe legal, policy,
which includes values and ethics, standards, architecture, and financial, not
only the business case but looking at financial models. That we want to look at
as two candidates both the payer/purchaser dimension as well as the
research/public policy dimension, looking at expanding the scope of those who
ought to have a stake in the National Health Information Infrastructure. That
part of that is to encourage the development of metrics so that we can begin to
be a little bit more concrete about how we measure the steps going forward then
we were in our initial report. And that we need to as developing that model
think about how all these little pieces that are going together are going on, a
lot of activity to talk about how all those fit together, the inability of
Indianapolis to talk to Santa Barbara and so forth. Simon.
DR. COHN: I actually agree with everything you’re saying, I think the only
thing that I was sort of going to add to this was just a recognition, I think
if Clem McDonald were here he probably would mention that this is after all
America and probably we need an early education in chaos theory, just
recognizing is what’s happening is is that there’s a lot of people that, and a
lot of different entities, that are empowered to help create this in the same
way many other things have been created in America, and we just need to make
sure as we go through all of this that we aren’t too restrictive, that we
identify wherever possible the ability for people to do things different ways
and figure out how all this can somehow fit together into somehow this sort of
grand vision that we’re talking about.
MR. BLAIR: I think you’re right, we really need to have consensus,
especially on that NHII model with all of its multiple facets for where we’re
going because we have to have everybody buy in. I think we also, that there is
a sense of urgency and we need to try and get that in place quickly, so if
that, if we feel like both of those objectives somehow need to be obtained
maybe there is an initial group that could move quickly to create a straw
person or straw man of what those models are and then we then start reviewing
it with broader and broader sectors for buy in. And one of the thoughts that I
would have and I’m really just throwing this out kind of for discussion, my
thought is that Bill’s group may be able to put together that initial set of an
NHII model and all of the pieces and bring it like to our next NHII Workgroup
meeting where we then look at them and when we feel comfortable with it then we
start to bring it out to broader sets. That’s just one possible piece, you
could it a lot of different ways but just an idea.
DR. LUMPKIN: If I could just sort of jump in and I’ll get Marjorie and
Steve, I heard an interesting analogy that’s very appropriate for the time that
we’re in, which is the 100th anniversary of the Wright brothers.
After they had their flight there was one thing that everybody could agree on,
if you’re going to build an airplane if needed to have a wing. And that was
about it. I think we’re at that stage, where there are certain things that we
can agree on are the wing and then the whole rest of the development of this
thing that will be a flying machine is still going to be developed and that’s
sort of the interface between the chaos and the order in that we don’t want to
shut down into too many places and to essentially destroy the entrepreneurial
zeal that is America. But we do want to use those sort of standards so that it
may not be that the ultimate model will allow Santa Barbara to talk to
Indianapolis as long as they both can talk to a neutral third party. So I think
that there are a lot of options but what we want to do is try to put together
this overall vision and to nail down those things that we think we can agree
upon are the wing of this flying vehicle. Marjorie.
MS. GREENBERG: Just one thought I had had and it’s a little different timing
then what Jeff suggested but again it was a kind of a coordinated effort with
Bill Yasnoff’s activity and particularly the meeting that is being tentatively
planned for, the NHII meeting in I don’t know, late June, early July, whatever,
of 2004, that there might be some piece of this work that the committee could
do between now and then that could then get broader feedback and input at that
meeting, if that meeting could, one aspect of the meeting could be a vehicle
for that because I know a lot of, had a lot of people who came in for that
meeting last year and I would assume they would come again.
DR. LUMPKIN: And if I could just feed off of that and I’ll go to Mary Jo,
what we saw this morning was one approach to those kinds of meetings, which you
have a meeting, the meeting is what it is. And what I think I hear Marjorie
suggesting is that you have a meeting but under both the auspices of ASPE and
the committee, and then those recommendations can be further crafted into a
vision that’s put forward by the committee as our vision, which we then hand to
the department and the department can adopt those pieces that are there. So it
allows there to be a report from the conference and then an aftermath, and then
a couple of aftermaths.
DR. DEERING: I’m going to pile on to sort of that same direction and was
going to suggest that among people who have given entrepreneurial conferences
and you know that the next time around it’s always you know your first one is a
hard act to follow and given the fact that there is I think a lot of clamor out
in the field for tangible follow-up I would simply say that instead of, and
maybe this is exactly what you just said, instead of just having some small
component of the conference be built around accomplishing something, help Bill
build into his overall conference that this is really a working conference just
like the first one was, and that its agenda is very specific and it doesn’t
just derive from its first conference but it is part of an overall broader
thoughtful effort. And maybe that’s exactly what you just said.
DR. LUMPKIN: For instance, one of the workshop groups could be to try and
flesh out and define the research/policy dimension. Another could flesh out the
payer/purchaser dimension. Another could begin to look at what is the
overarching pieces of the model, what are the gaps, what are the metrics.
DR. YASNOFF: I think from my perspective using the conference to further
discussion and input about not only the model but more importantly the path we
need to take to get to the model is certainly, I’m certainly open to that and
actually, or reviewing and advising on the NHII ’04 conference is on my list of
things I would like the workgroup to do already, so even before this came up I
think that that’s a wonderful thing to do. But if the committee is going to do
that it has to be on a timeline that is consistent with having this conference,
probably last week in June, so I just want to caution the workgroup that there
is a timeline that must be followed and so that mean I think some intensive
work in the first couple of months of next year.
DR. LUMPKIN: But in a sense we would see this conference as kind of a mega
hearing.
DR. YASNOFF: Let me also say that I think that we’re prepared to write down
and present the model of how we think this NHII can be built and bring that to
the workgroup in short order because I think we’ve outlined a pretty clear
vision of that and we are supporting and pushing forward that vision. So we
would be happy to do that and would welcome the committee’s input and ideas and
also the committee’s efforts to solicit additional input and ideas from other
folks.
DR. LUMPKIN: And just one other thing, financial models I think again, we
need to think about that and we actually do have help on the committee now to
start working in that area.
DR. STEINDEL: This is exactly the direction I was going to suggest and when
Marjorie spoke I said well, I don’t have anything more to say because I agreed
totally with what she was saying. But as the rest of the comments came around
I’m agreeing with Bill in the sense that what I would like to see is to use the
conference for this purpose but I think we do need straw person documents for
each one of the groups, that Bill’s group can start taking a first draft at and
then the workgroup can refine in time for the conference so they have something
to react to.
DR. LUMPKIN: Eduardo and then Mary Jo.
DR. ORTIZ: I just wanted to push back a little bit though on this
conference, for example, is to really push that Bill and whoever is working on
this to really try and think of some unique contributions that can occur when
you have this conference in June 2004 because the first one was very good and
very successful but at the end of the day if a lot of the output is we need
more financial incentives, we need standards, it’s the stuff that we already
heard the first time. And so I don’t know how much that’s going to contribute
in terms of moving the agenda forward. So I know that may be a piece of it
because it has to be but I’m going to at least push, I don’t have the solutions
but I’m going to push to think of beyond that what can be some unique
contributions and some new things that can come out of this conference that
will really push the field forward.
DR. STEINDEL: Eduardo, I think that’s why we need the straw person documents
because those are the mechanism that we would use to push the conference
towards unique results.
MR. BLAIR: Let them critique a roadmap, let them say whether we’ve
identified the proper gaps or whether we’ve left some out.
DR. LUMPKIN: Jorge, you’re from CMS right?
DR. FERRER: I am.
DR. LUMPKIN: So I think it’s going to be important particularly since we’re
looking at this dimension and the financial models that CMS play a fairly big
role in that piece of that, in trying to think through and helping develop the
straw person document.
DR. FERRER: I would add that in lieu of the fact that we’re not just working
abstractly, but we actually have a Medicare reform bill, because the best I can
tell, the ink dried and the President signed it, that since we’re already
beginning to look, and Stu Gutterman who’s an economist and the head of RDI had
those financial models that will stimulate the clinical effectiveness of care,
that we do need to start getting this involved sort of now because the
demonstrations and the Medicare reform bill, the language from OMB that Dr.
Yasnoff is speaking about, this is already beginning to gel and to shape so
it’s not like Eduardo says a year from now let’s have a conference and come up
with the same very good ideas, but we actually now have an opportunity where a
bill allows us to probably for the first time look at the financial impact of
clinical modifications of IT. If we do it correctly it sets the stage for the
program to move forward. If it’s done incorrectly then we lose maybe ten, 15
years of progress. So I think we really need to get a lot of folks involved,
and Stu Gutterman, the head of RDI, is beginning to think about these financial
models and however I or anybody can help in having NCVHS sort of
co-participate, collaborate, whatever the correct terminology is, to really
begin to shape what is that financial model because those are very, very
complicated Medicare questions that are actually already in discussion. Because
these are new, these are new policies that we haven’t really done this if you
will so it’s a lot of work to be done.
DR. LUMPKIN: And I would suggest that there are some conceptual pieces that
are behind those financial models and that CMS is one player, one purchaser,
that’s thinking about those. So we can test out those financial pieces in six
months when this conference is there, get input from a broad spectrum without
CMS necessarily being committed to any of the issues but by your input we can
at least make sure that the models that you’re, you’re now looking at say of a
menu on that straw number 15 different approaches or 15 different pieces that
may be put into one approach. We can test out those 15 and maybe another ten
through the vehicle of the model, so I think that that’s, it sounds like that
may be worthwhile. Jim.
MR. SCANLON: Just two things, as we’re planning the conference, I think
again, the Secretary is probably, and the departmental leadership is going to
have some ideas as well as what other facets they want to pursue, so we just
have to leave open a fair amount of flexibility but this sounds certainly very
positive.
The other thing is, again financial incentives don’t just mean the federal
government. There are all sorts of market incentives, there are incentives to
others, so again we have to keep an open, we’re going to get far, a certain
distance but not the whole way and maybe nowhere at all if we only rely,
nothing is going to happen unless the federal government pays for this, and
that’s just not the way others are really viewing this.
DR. LUMPKIN: Mary Jo.
DR. DEERING: Actually in a way Jim’s comment tees this up very well when you
said after all this is the Secretary’s conference, but in fact Bill just told
us that last year it’s not the Secretary’s conference, it’s the conference and
it’s the conference’s recommendations that are being put forward, so I think
that being reminded of that sort of fine line is very helpful because the point
I was going to make is that depending on how many straw documents, straw person
documents, how many sectors we’ve mapped out or eventually get suggested to be
considered at the conference, isn’t it, aren’t we losing a great opportunity if
they are all drawn up internally? I mean granted they’re all just straw person
documents and they’re going to go out and they’re going to be looked at, but
isn’t this an opportunity, I mean you had steering groups before that included
many outsiders but they were still sort of collections of people and maybe this
is an opportunity to at least think about assigning to certain stakeholders the
responsibility to take a lead in the initial drafting and seeing it through.
And you could view it from two different ways, just as you’ve identified CMS as
an important player in mapping out what that’s straw document looks like so
that it serves your purposes. I think the same would be for other people who
are in positions to do really important things, to make sure that not only are
you getting their buy in from the beginning but you’re actually giving them
useful feedback to influence their actions. So again, it’s just a way of
considering to open up the planning and development process.
Let me just not lose the mic without suggesting an entirely different minor
point, Bill you put together research and public policy, I know something about
for example the NCI effort and I think we need to split those apart because to
influence the people who are working on like the bioinformatics grid and the
research grid, they won’t see themselves as caught up. I mean clearly we see
the linkages between them and the value of the research findings getting into
public policy but those two people speak more rarely to each other then
providers and other people so I just think it’s helpful.
DR. LUMPKIN: Let me just sort of feed off of what I heard you say Mary Jo
and suggest that I think that given the timeframes and the process it may be
very difficult to look at a single straw document, straw person document, but
we could look at opening up the process to have the opening presentation in an
arena may be two or three documents that are prepared. And then our committee
would then take the input, working with our federal partners, take the input
from the conference and out of that craft into our single document input that
may come from various straw documents. So it’s sort of almost like a call for
papers although not quite that broad. Jeff.
MR. BLAIR: I’m a little confused and maybe Mary Jo, what you said, is
consistent with what I was thinking, what I thought Bill and Steve were saying,
the thoughts that I was having was that there needed to be work during these
next three or four months with those folks that really could intensively pull
together like a straw person and I think Bill was saying that he could, his
staff could pull together something, could review it with NCVHS, we could
refine it, if there is time to review it with the broader pieces that would be
fine and then the opportunity to really get broad input is the June meeting
where we run these straw models and roadmaps by the broad group of people, all
of the different stakeholders, and then gather all their critiques and
suggestions at that point. At least that’s what I was thinking of. My thought
is that if we tried to do it with a broad group during the next three months we
won’t get, it will just be very hard to really make that much progress. Am I
missing something?
DR. LUMPKIN: I think what I was trying to get the merger of those two. Let’s
suppose we’re talking now about the financial model, we would look for ASPE to
take the lead as they’re taking the lead for the conference, working with CMS,
to develop a straw document about financial modeling, what are the
alternatives. Then we may go to the American Association of Health Plans or
whatever its new name is now that they’ve merged and say we would like you to
think about putting together a similar type of document from your perspective.
We may go to two or three other groups that would then at this conference we
would have a number of positions that will be presented. And then the attendees
and then that subgroup would really start looking and comparing the soundness
of the various approaches. That would enable us as a committee to try to put
together a synthesis document that would give to the Secretary some alternative
choices to reaching this end.
DR. YASNOFF: Just a couple of comments. Let me just say that there’s nothing
that’s preventing the committee from taking the output of last years meeting
and digesting it and putting out additional recommendations, and whether you
want to do that or not is up to you. It may in fact be more important to plan
what needs to be done for the next meeting. I think that one of the big
contributions of the last meeting and a lot of the work that’s been done by
many, many different people in many, many settings is to clarify those areas
that need discussion in a meeting like that. Those initial eight areas were,
they were not simply my own creation, there were a number of discussions about
those, but they were at best an approximation to what the real issues are and I
think certainly I have a better sense of what the issues are, I think the
committee does as ell. What I would ask is this, that I would welcome input as
to which areas we ought to work on and would be happy to work with the
committee on developing position papers and soliciting those with two caveats.
One, the process that’s defined has to work within the timeline that doesn’t
necessarily provide flexibility in certain ways. And second as Jim said that
ultimately this is a department meeting and there are certain things we’re
going to have to do. But other then that I think the committee’s interest,
involvement, assistance in soliciting greater participation and so on would be
very positive and is very welcome and I think is a great idea.
DR. LUMPKIN: Steve.
DR. STEINDEL: The thing that was brought up several times, and my feeling at
the actual meeting itself last June was basically mentioned a couple of times
today in the reports as sort of an aside was stove piping at the meeting. We
had Marjorie saying earlier well she attended the standards section and can’t
comment on what was brought out in the other sections, Bill commented that when
they were reviewing the reports they found the same thing mentioned in multiple
sections, and while I was facilitating the standards section and I felt very
stove piped. And what I would like to see is I think a meeting like this we
bring in experts who have both specific talents and broad talents and I would
like to see the tracks set up so that they’re not stove piped. I would like to
see groups talking about the same thing but different groups and trying to
synthesize the ideas at the end from all the groups instead of just focusing
one group on looking at financial, and another group looking at added
dimensions. I think we can do that at more targeted meetings, we can even do
that at hearings around this table, and that if we’re going to bring all these
experts together I think we need to take advantage of the experts collectively,
not in small sections.
DR. LUMPKIN: I think we have to be careful that we don’t get too much into
this, we’re just kind of playing around with this meeting as being a vehicle to
allow us at some timeframe to put together a follow-up report on the NHII that
talks about a model, a roadmap, and begins to really delve into financial
models and fleshes out right now three other dimensions, and metrics.
MS. GREENBERG: I just need to understand whether that research dimension is
research on IT or biomedical, okay, because somebody mentioned that the way
they saw it kind of laid out here —
DR. YASNOFF: The last set of recommendations were more oriented towards
research about the relationship of IT to safety and quality as opposed to
medical research.
MS. GREENBERG: But here we’re talking about more medical research.
DR. LUMPKIN: No.
MS. GREENBERG: What are we talking about, I don’t know what we’re talking
about.
DR. LUMPKIN: Health research, broader then medical.
MS. GREENBERG: Okay, but we’re not talking about research to show the impact
of the NHII, we’re talking about a field of research, the dimension of
research.
DR. LUMPKIN: All that stuff that’s funded by NIH and CDC and private
foundations and all that other stuff.
MR. HUNGATE: Before we go create another dimension called the research
dimension it seems to me that it can be argued that research is part of each of
the dimensions, it’s not a separate domain.
DR. LUMPKIN: Mary Jo.
DR. DEERING: Well, I think that if you think of why we did the dimensions in
the first place and I would disagree with Steve a little bit about why we
didn’t add administrative, for example, is that probably it was a psychological
marketing reason as well and we wanted to focus on core users, and we want to
be able to speak to them. Researchers see themselves as a universe and NCI and
NIH are pouring billions into a research informatics grid that isn’t thinking
at all, or at least its thinking only secondarily about how to plug into our
concerns so I think from that point of view it’s important that they see
themselves in it and that’s why we would want to tease it out.
MR. HUNGATE: But I would like to argue that discussion, too, and rather just
cede a point, I think there’s another viewpoint, that’s all I’m trying to say.
DR. LUMPKIN: Let me jump in there and sort of take you back a little bit of
how we got to where we did in the report. One of the earlier terms that we
wanted to described these were views of health info space. We didn’t, we were
going to call them, I can’t remember the other term, but we wanted to get away
from the concept that this was a thing or a program, but it was if you were a
patient, if the NHII was going to work then it had to work for how you looked
at health information systems, the health care system, and health data. Within
that context as we start now getting into more granularity of different views
of the health info space, even though research and finances, and I would argue
even population health, goes through all the other dimensions. There is a
certain view that researchers have of the health info space that may be of
value, and I’m just right now putting in a placeholder, may be of value, to
explore.
MR. HUNGATE: All I’m kind of arguing is let’s not overly complicate the
model because there’s some real benefit in simplicity and easy to identify
structures that work and when you get more detailed you lose people, they
wander off. If in fact we’re dealing with a chaotic situation I think it is
that keeping the model fairly simple helps.
DR. LUMPKIN: And let me push back on that a little bit and say that we kind
of have picked in this list interestingly enough the three areas where we think
we have the most trouble with penetration. And so by describing to them through
their lens what the NHII is and what it can do may be of benefit and that in
that description we need to maintain our core model, which are patients, health
care providers, and population health.
MR. HUNGATE: And I would agree with that. But the thing that’s start to it
seems to me say is that part of our task is to say where are we lagging on the
acceptance of the model, it’s not further detailing of this model as much as it
is gaining acceptance for a fairly straightforward nebulous model but probably
if you get it more complicated it’s not going to help the argument, is part of
what I’m, vignette sells better then more detail.
DR. LUMPKIN: And I think what I’d like to suggest is to hold onto that and
as we start, I mean there are certain things when you start writing and
starting putting together you need to come back to that point. Because we
should play around with your reservation, which I think I’m sure more then just
you and I share, but if we play around with this, come back to what that
reservation is and say does that go too far, if not we need to look at how we
can disperse that back into the overall discussion. But the first draft, the
first straw model of this, we may just want to flesh it out to make sure we
have adequate coverage.
DR. YASNOFF: Let me suggest one of organizing these various topics and that
is I think clearly the vision of NHII is of an information space that supports
all the different stakeholders but a single information space to do that. And
so given that I would suggest it might be helpful to think about these various
ideas in two categories, one is the category of what I loosely term management,
how do you manage getting this thing to exist. So what’s the vision of what it
looks like at the end, what’s the roadmap to get there, how do we pay for it,
and how do we as we’re on the road measure whether we’re going forward,
backward or sideways. So that’s kind of the management piece for building the
central, unified, information space that serves the needs of all the
stakeholders.
Then there’s the issue of what are the specific issues, concerns, views, of
the various stakeholder groups, and I think much more is known I think about
the provider clinical stakeholders, I think less is known about the consumer
stakeholders. I’m not sure how much is known about the community stakeholders,
we’ve identified the payer/purchaser stakeholders, there’s the medical research
stakeholders, the public policy stakeholders, so there are these various
stakeholders who first of all need to understand what this central thing is and
realize that it’s advantageous to them to work with these other stakeholders to
build a single information space rather then staying in their own world and
building their own. And so I think if you think about it in these two ways that
may be informative as to how to construct not just this meeting but to how to
organize the activities of the committee to help to promote the vision and move
it forward.
DR. LUMPKIN: And that the vehicles, the tools that we will use potentially
would be the conference, maybe selected hearings, there may need to be selected
hearings on financial models. We may need to do hearings on each one of these
dimensions —
DR. YASNOFF: Well, just as an example, I mean as I mentioned we’re having
these specific stakeholder groups, I mean there’s an issue with how many people
you can have at one of these groups but if there are specific committee members
who are interested in attending, we’d be happy to have committee members
present, we’re learning a tremendous amount about the views of individual
stakeholders groups by bringing the groups together and essentially mostly
listening, so that’s one venue. There’s of course the venue of hearings that
the committee can have and there’s this meeting. I think my bias is that the
highest value of the meeting is to deal with these management issues of you
define and get to the single information space so as to increase the commonalty
of views of the various stakeholders rather then trying to use one national
forum, to bring people together in one national forum and then necessarily
split them. But if you have those stakeholders there there’s certainly for
logistical reasons maybe good reason to have several of these separate
meetings.
But I guess one of the things I’m specifically concerned about is I I’m
concerned about having a different set of recommendations for how we get to
NHII from each stakeholder group rather then a unified vision of one system
that benefits all.
DR. LUMPKIN: And I would say that that sounds like the theme for Information
for Health part two.
DR. YASNOFF: But not a central database.
DR. LUMPKIN: But not a central database.
DR. YASNOFF: One system but not a central database.
DR. LUMPKIN: One approach, not necessarily one system. I would like to point
out that I had described a methodology for us to get to where we wanted to go
and all of you completely ignored it.
DR. YASNOFF: We never agreed to it.
DR. LUMPKIN: But clearly it was a super saturated solution, we dropped in
that seed crystal and then we adhered in that way around this idea. I’m going
to sort of describe it one more time and then let’s finish up and then I think
we can finish up with next steps and then our work here is done.
That the central theme is a central info space to which many stakeholders
have needs and views but all build the same central info space, which is not a
single system nor is it a single database. Part of our approach to that as a
committee is working to flesh out the bones of the first report, focusing on a
model, a roadmap of what to do between now and seven to ten years down the
road. That model will be what it should look like in seven to ten years, the
roadmap to get there, the metrics for measuring progress towards getting there.
The financial models and incentives that need to be in place in order to get us
and continue the direction. And then looking at some particular, going back to
the old term, views of this info space of certain interest groups that we think
we need to bring into the fold.
DR. FERRER: And I just wanted to add, with regards to the financial model,
just a plea perhaps to the committee, but it would be advisable at least for
the financial model to not just be from a financial and clinical model, the
financing of health care drives physician behavior, they’re well documented, we
need to not just abstractly look at that financial model in and of itself but
think of how that financial and clinical model will actually facilitate the
behavior of incentivizing the use of information technology. And information
technology for me, at the end of the day I want to be able to have a system
that evaluates the clinical and the financial effectiveness of the care that we
pay for. We oftentimes either have too information from one system and way too
little for others, but then we’re making policy decisions about the clinical
effectiveness of care on information that at best is clinically very poor.
DR. LUMPKIN: Yes. Because what you’re saying, and that was really part of my
concept of a financial model, and I basically start off in the fact that money
will do very perverse things to clinical systems if you don’t model them out
far enough to think about the unintended effects, and so the goal here is to
how do we achieve the goal of the system by looking at the models because right
now it is our belief that the current models, financial models, impede
progress, both towards quality because the people who do the quality
interventions aren’t the ones who necessarily benefit from quality occurring,
and impede the development of the NHII for similar reasons.
MR. HUNGATE: I don’t know exactly how this fits in the model that we’re
talking about but it seems to me that there are interfaces between the
perspectives, like between the payer or the purchaser and the provider, that
each of these domains, there are some defined interfaces in between them,
transactions in favor of what I just said. If anyone can manage a chaotic
system it’s probably here and so it seems to me that those interfaces are part
of what must be managed in the system design if there is one. And so
enumerating them is part of this task it seems to me. If you’re going to
solicit individual perceptions, payer/purchaser dimension, the researcher
dimension, then you have to pay attention to what the communication methods and
interfaces between each of those dimensions are it seems to me as a piece of
the system. I don’t know how to articulate it but I think it’s important.
DR. LUMPKIN: Well, I think what you’re doing is putting an addendum to what
I described by saying that one of the things that we need to pay attention to
is the interfaces between the way this info space facilitates the interaction
between the different stakeholders in this health care enterprise that we’re
talking about, the national health care enterprise which includes about 280
million people.
DR. YASNOFF: I want to add a note of realism here, and that is that I think
given that agenda you’ve outlined, despite the tremendous productivity and
energy of the committee, and the expected tremendous participation in the
meeting, I don’t think that this will all be defined and laid out, for example,
in a 12 month period, in great detail.
DR. LUMPKIN: I was thinking 18 months.
DR. YASNOFF: So I would like to suggest, but I would welcome your efforts to
try to accomplish that but I would suggest perhaps a common informatics
approach to this problem which is the idea of iterative prototyping or
essentially gradually specifying more details and approaching where we’re
trying to go. So for example in looking at this roadmap there’s certain things
that I think we could easily define and then there are certain things we can
point to and say we just don’t know how that’s going to work yet. In other
words there are going to be holes in the vision that we have when we start to
define it and another example is in the area of metrics, I think there are some
metrics that you can point to at the end state that make sense to measure
because we know certain things that we want to happen at the end state, but
there are many metrics of progress, since we don’t know exactly how they’re
going to be moving we can’t define all the metrics of progress. So I guess what
I’m suggesting is to in trying to put together a realistic work plan for the
committee that we try to encompass, I mean there are two ways to split it, you
can either say okay, well this is more then we can do so we’re just going to do
this one thing, or we can we’re going to touch all these areas and we’re going
to outline them to the level at which we understand them and we know about them
and we’re going to explicitly allow spaces where we just don’t know yet, and
then after the meeting maybe we’ll fill in more and over the next maybe couple
of years we will get to the point where it becomes more clear in a lot of
detail.
DR. LUMPKIN: Which is what my little cryptic notes after that said is that
we may be looking early in ’05 or mid-way in ’05 to come out with our first
report, that report may identify gaps but we are defining a plan that will
extend into ’05 and ’06 in an iterative fashion, that we will have the initial
draft of what we’re going to do or interim product and then we will have
subsequent updates and refinements as time goes on.
DR. YASNOFF: I would also take note of the fact that there’s an implicit
recommendation in the discussion, which is that there definitely should be an
NHII ’04 meeting. In other words this group clearly agrees with that so I’m
just pointing that out.
DR. LUMPKIN: Oh, okay.
MS. GREENBERG: Not only agree, they’re trying to take it over.
DR. LUMPKIN: Michelle?
MS. WILLIAMSON: Just a question on the models that we’ve identified, is this
list comprehensive or are we planning to flesh it out further? I had a couple
of others that I thought needed to be added based on the information that we’ve
heard already from Gary and just some of the discussion, that there should be
at least a model for education, something that could address how the NHII works
and how education needs to be a component for different levels, for hospitals,
what they need to be doing, what needs to be done in health departments, what
needs to be done within medical training, there’s a lot there that I think
needs to be developed in a model. Also for consumers. Gary mentioned that one
of the questions where consumers come into play so that in itself I see as even
a separate model.
DR. LUMPKIN: I don’t think it’s a separate model, but I think it would be a
metric of sorts of the model that we develop. Does it address consumers, does
it address how we convince providers, hospitals, and so forth to engage in
that. Part of that may be tied up in here because my argument, the financial
models, basically my experience with hospitals, hospitals will do it because
they have, when you’re dealing with a one or two percent margin its got to make
business sense. As much as their hearts may be in doing other stuff if it
doesn’t make business sense it’s not going to get done.
MS. WILLIAMSON: Well, as long as it is a component of financial, as long as
we’re addressing the consumers, but what about education? Do you see that as
being a component that we could really look at in detail? I think it’s often
missed and I think it’s actually the grassroots of what’s going to happen for
the future. If we’re not providing the proper training in informatics and in
other areas —
DR. LUMPKIN: I think that’s an implementation strategy, is where I would see
that, a recommendation and an implementation strategy.
MS. GREENBERG: Part of the roadmap.
DR. LUMPKIN: Okay. Eduardo.
DR. ORTIZ: Just one quick question on the financial issues you’re talking
about. When you’re talking about the hospital example one is trying to
demonstrate the business case or the value based on the current reimbursement
system incentives, which people would argue are screwed up, they’re pretty
perverse because we pay for acute episodic care and for procedures and we don’t
do things that we should be doing. My question is kind of are we thinking in
terms of we’re stuck with this system and let’s see what we can do in terms of
demonstrating value and benefits and ROI and financial models based on our
current system, or are we also trying to be a little idealistic in saying our
system’s screwed up, we want to demonstrate quality in other things hoping to
drive changes in some of these reimbursement policies, etc., which may or may
not occur. I’m just trying to get a sense for where we’re at philosophically
from that perspective.
DR. LUMPKIN: Let me do what I learned I was supposed to do in media
training, is that if you’re given two alternatives always pick the one that
really makes the most sense to you, which may not be one of those two
alternatives. And I would argue that we need to sort of —
PARTICIPANT: I didn’t hear the punch line. What did you learn?
DR. LUMPKIN: That you always answer the question that you wished they had
asked, not necessarily the one that they did ask. And that is that these models
should be designed in such a way that they are fairly resistant to change, or
maybe even drive change in the health care system. So that it may not be an
actual reimbursement model but it may be principles for which a model needs to
be designed. So if we do fee for service like we do, if we do managed care, if
we even go to a single payer system, there are certain principles in that that
would need to be in place in order for this model to drive the kind of change
that we want to see. So the answer is yes and no.
Okay, next steps. I would propose, now this is a really radical idea and
approach, that we would support a conference in June on NHII.
DR. YASNOFF: How about July?
DR. LUMPKIN: That what we would do between now and then are three things. We
would assist in the planning of that. We would begin to work on our strategy
and as we’re working on our strategy look at what the conference will
accomplish for us and what it won’t. And then based upon that assessment we
would then map out a series of hearings for the remainder of the year after the
conference that we would shoot to try to finish up with the hearings by this
time next year, and then proceed to start writing in January, shooting for it
to take about six months to write. That the synthesis would take from the
conference, from conference number one, conference number two, and the
hearings. Jeff.
MR. BLAIR: Does the next steps include the preparation of straw models to
bring to the conference?
DR. LUMPKIN: Yes. I think that we’ve already had an offer from ASPE to take
the lead on that.
DR. YASNOFF: Is the intent that this next report would then be, essentially
could be presented at conference number three?
MR. BLAIR: Say that again —
DR. YASNOFF: In other words what you’re saying is that this next conference
will inform writing a report, in early 2005 you’ll start writing and so
presumably mid-2005 they’ll be another conference, so it would be nice if at
least a synopsis or something related to this report would then be available
for that conference.
DR. LUMPKIN: Okay, let me just sort of extend the timeline a little bit
further and suggest that we would have the pretty well cooked draft that would
be presented to that conference, that we would let people who had the
involvement in this have a whack at it, and then the final version would then
be submitted to the committee for approval in September.
DR. YASNOFF: I think that would be very good in terms of getting additional
buy-in and feedback.
DR. DEERING: Just a point of clarification, so that Bill knows what he’s
going to go home and do and we understand what he’s going to go home and do. In
terms of mapping the actual structure of the conference, who takes the lead in
really identifying what these components are exactly, is it just the model
components that we’ve fleshed out there that are going to be worked on? Is this
the opportunity while we’re all here to hear whether he already has some plans
or can we set a timetable for sort of hearing how the shape of the conference
is coming out?
DR. LUMPKIN: Well, there’s a third party that we need to coordinate with
down on the sixth floor. So I think what we do from here is we kind of take
what we’ve got, Bill has what he’s been thinking, hopefully we’ll get some
input from the sixth floor, what perhaps they were thinking about in the
conference. I’m going to delude myself that our meeting in January will not go
until 4:00 or 5:00 —
MS. GREENBERG: The 29th?
DR. LUMPKIN: On the 29th.
MS. GREENBERG: I think it’s supposed to go until about 3:00.
DR. LUMPKIN: To about 3:00. What I’m thinking of is maybe from 3:00 to 4:00
we would try to meet and try to go over that, the plan and sort of try and
finalize it right after our meeting on the 29th. We have a short
meeting focused just on where we are with the conference and then we would
work, our next full meeting is in March —
MS. GREENBERG: March 4th, 5th.
DR. LUMPKIN: And that will set, pretty much our meeting will set our
involvement and what we need to get done, which we’ll have to do by either
coming in, we may have to have a special meeting in February to flesh out and
finalize the conference, and then at our March meeting we spend more time in
looking at our timeline of what we need to do besides the conference.
DR. STEINDEL: John, is everybody involved with the workgroup going to be in
on Thursday? For the January meeting?
DR. LUMPKIN: The thing is there’s a Quality Subcommittee meeting, there is a
Privacy Subcommittee meeting —
MS. GREENBERG: No, no, Populations, Standards is the 27th and
28th, Populations is the morning of the 28th, Quality is
the afternoon of the 28th, late afternoon on the 28th is
the orientation for the new members. There’s a dinner that evening and meeting
on the 29th.
DR. STEINDEL: I was just wondering off hand if we could carve the hour out
on Thursday.
DR. LUMPKIN: I don’t think we can carve it out on Thursday but we could
carve it out from 8:00 to 9:00 on Friday.
DR. STEINDEL: I would prefer it from 8:00 to 9:00.
MS. GREENBERG: Friday is the 30th.
DR. LUMPKIN: I’m sorry, from 8:00 to 9:00 on the 29th.
DR. STEINDEL: I would prefer to have it at the beginning of the day then the
end of the day because there’s going to be a couple of us here who that will be
our third day in Washington.
DR. LUMPKIN: Let’s shoot from 8:00 to 9:00 on the 29th.
MS. GREENBERG: I’m trying to think if that meeting is actually starting at
9:00 or is it starting at 10:00.
DR. LUMPKIN: We’ll start at 8:00 and if we have one hour we’ll do an hours
worth of work and if we have two we’ll do two.
MS. GREENBERG: That’s on the 29th, 8:00.
DR. LUMPKIN: Bill?
DR. YASNOFF: I would like to hear a clear message as to what you expect from
me. I haven’t quite heard that yet.
DR. LUMPKIN: We would like all of the straw man papers done by then, we
would like, I think at a minimum we should look, use that meeting to gel what
it is the meeting in July will be.
DR. YASNOFF: So at a minimum you would like to see a draft plan for the
meeting.
DR. LUMPKIN: Consistent with trying to position us to accomplish this
direction, or as much of as seems reasonable to do within the context of that.
DR. YASNOFF: And if the committee is going to have any, the committee wants
to have, the workgroup rather wants to have input into the draft roadmap, draft
metrics, draft of the financial incentive situation, when is the committee
meeting, or when is the workgroup meeting in March?
DR. LUMPKIN: Well, no, I’m thinking based upon our descriptions that we’re
probably talking about a committee meeting in February.
DR. YASNOFF: So you would want —
DR. LUMPKIN: Bill, you need to tell us when in February.
DR. YASNOFF: Yeah, I understand, but let me just make the following
assumptions. Let me assume that there will be a meeting in February and that at
least a week before that meeting you will want some documents to work on that
will then be discussed at that meeting.
DR. LUMPKIN: Right.
DR. YASNOFF: And I think that again, I’m very supportive of this but the
committee, the workgroup has to be willing to meet particularly in the
timeframe really everything, all the major planning for the meeting has to be
totally completed by the end of April essentially for this meeting.
DR. LUMPKIN: And so we’re talking about meeting in January, meeting in
February, and meeting in March.
DR. YASNOFF: Conference calls are a possibility, too, but I just, what I’m
saying is that I’m happy to do this from my perspective but the workgroup has
to be willing to put in the time also.
DR. LUMPKIN: I think that’s what we’re saying.
DR. STEINDEL: If we’re talking about a meeting in February, the HIMSS
meeting is rising in more importance on people’s schedules and that’s the last
week in February, so we just want to avoid a conflict with that.
DR. LUMPKIN: So let’s do some balloting for the end of the third week of
February.
DR. YASNOFF: No, can we do it sooner? The week before hand?
DR. LUMPKIN: The second week of February? I’m thinking the week before
HIMSS.
DR. YASNOFF: Yeah, the week before HIMSS, which is actually the third week
of February, the 17th or the 18th.
DR. STEINDEL: The 18th and 19th are Privacy, they’re
having hearings. So the 17th would work out well. Or the
18th would work.
DR. LUMPKIN: I don’t have my calendar so we’re going to have to —
MS. GREENBERG: The 16th is a federal holiday.
DR. LUMPKIN: Is that a problem?
DR. YASNOFF: That is a problem.
MS. GREENBERG: Well, we couldn’t meet on the 16th.
DR. LUMPKIN: Well, we could meet outside here couldn’t we?
DR. YASNOFF: You could meet on the sidewalk in front of the building. If
there are too many people the security folks won’t appreciate it.
DR. LUMPKIN: See I used to come to these meetings when they were on state
holidays. I don’t think we can work out a date here but let’s ballot for a few
days, let’s look at the second and third week of February, let’s pick a couple
of days that we think might work and go from there.
Okay, we’ve got a plan, we’ve got a concept, we’re working on dates, we’ve
got meetings scheduled in January, February, and March, we’ll have to start
working on an April meeting, and then we’ll talk about hearings in the latter
part of the year.
MR. BLAIR: As my daughter would say looks like a plan to me.
DR. LUMPKIN: It’s a plan, great. I hope everyone has a wonderful set of
holidays, starting with tonight and moving on into next week and then the
1st. Be safe, be healthy and we’ll see you next year.
[Whereupon at 3:00 p.m. the meeting was adjourned.]