All official NCVHS documents including meeting transcripts are posted on the NCVHS Website (http://ncvhs.roseliassociates.com).

Department of Health and Human Services

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

Subcommittee on Standards

E-Health Vision and Standards Roadmap Roundtable

September 18, 2013

National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782
Auditorium A & B


The National Committee on Vital and Health Statistics Subcommittee on Standards convened a roundtable discussion on September 18, 2013. The meeting was open to the public and was broadcast live on the internet. A link to the live broadcast is available on the NCVHS homepage.

Present:

Committee Members

  • Walter G. Suarez, M.D., M.P.H., Co-Chair
  • W. Ob Soonthornsima, Co-Chair
  • Raj Chanderraj, M.D., F.A.C.C.
  • Alexandra Goss
  • Linda L. Kloss, M.A., RHIA, CAE, FAHIMA

Absent:

  • William J. Scanlon, Ph.D.

Staff and Liaisons

  • Kamahanahokulani Farrar, Lead Staff, CMS
  • Suzie Burke-Bebee, ASPE
  • Nicole Cooper, CDC/NCVHS staff
  • Debbie Jackson, CDC/NCVHS staff
  • Eric Jamoom, Ph.D., NCHS (discussion facilitator)
  • Marjorie Greenberg, NCHS/CDC, Executive Secretary
  • Katherine Jones, CDC/NCVHS staff
  • Jim Sorace, M.D., ASPE (via phone)
  • Robert Tagalicod, CMS
  • Michelle Williamson, R.N., MSIS, CPHIT, NCHS

Absent:

  • J. Michael Fitzmaurice, Ph.D., AHRQ
  • Donna Pickett, RHIA, MPH, NCHS
  • James Scanlon, ASPE
  • Nicole Wilson, VA

Roundtable Participants

  • Matthew Albright, CMS
  • Bill Alfano, BCBSA
  • Georges Arges, AHA
  • Meryl Bloomrosen, AHIMA
  • Denise Buenning, CMS
  • Deborah Brown, ASC, X12 (via phone)
  • Rich Cullen, BCBS
  • Jim Daley, WEDI
  • Terry Deutsch, CMS
  • Lorraine Doo, CMS
  • Joyce Dubow, AARP
  • Bill Finderfrock, HBMA (via phone)
  • Rachel Forester, CAQH
  • Doug Fridsma, ONC for HIT
  • Lynn Gilbertson, NCPDP (via phone)
  • Michael Glickman, HIMSS
  • Denesecia Green, CMS
  • Shane Hickey, NACHC
  • Diane Jones, AHA
  • Steve Lazarus, CAQH
  • Gwen Lohse, CAQH
  • Tim McMullen, CE
  • Rebecca Moore, PAHCOM
  • Amy Mullins, AAFP
  • Jean Narcisi, ADA
  • Dan Rode, AHIMA
  • Rob Saunders, IOM Study Group
  • Lucia Savage, United Health
  • Mari Savickis, AMA
  • Cathy Sheppard, X12
  • Robert Tennant, MGMA
  • Margaret Weiker, X12 (via phone)
  • Tom Wilder, AHIP

EXECUTIVE SUMMARY

WEDNESDAY, SEPTEMBER 18, 2013

(Please refer to Detailed Summary below or transcript for further information)

ACTIONS

  • The Subcommittee will discuss the possible formation of a Standards Review Committee to determine how standards should be tested and vetted (amongst themselves and with CMS) in order to make a formal recommendation to the full Committee at the November 2013 meeting.
  • The Subcommittee will prepare a draft vision statement that prioritizes, emphasizes commonalities and defines the elements of a roadmap. The draft would be refined by Subcommittee members and then distributed for review to other involved parties such as Roundtable participants before the November 2013 meeting. At that time, the full Committee will receive the Subcommittee’s vision statement draft; further delineation of roadmap elements; and possible recommendations and/or guiding principles.

Call to Order, Welcome, Introductions and Agenda Review

Walter G. Suarez, M.D., M.P.H. and W. Ob Soonthornsima, Co-Chairs

Roundtable Purpose, Goals and Outcomes Co-chairs

Transformative healthcare changes in the United States were described. NCVHS must clarify how such changes will alter data/information exchange and the use of standards.

The overarching goal of the Roundtable Discussion was to define the core elements that will help the National Committee to frame a vision for e-health standards into the future and to create an industry roadmap for current and future standards requirements. The National Committee will advise the Secretary about adoption of new standards, taking sequencing, timing, pace and size into consideration. Another goal was to identify interdependencies of existing requirements in order to establish ways to monitor how health reform is shaping the new relationship between providers, payers and other system elements. (Refer to written document of September 18, 2013 outlining the purpose of the Health Vision and Standards Roadmap Roundtable for further information)

Other considerations included questions about new initiatives relative to cost and payback; convergence opportunities; and how to make good use of data (“big data for the greater good”). Major changes in health care as required by law impact physicians, Rx/lab/health services, employers, health care services, government programs (Medicare and Medicaid), commercial payers and hospitals. Mandates and initiatives being worked on include the HITECH Act, ICD-10 (as of October 2014) and HIPAA standards. Providers will be significantly impacted by the health insurance exchanges (October 1, 2013 enrollment; January 1, 2014 start date; risk adjustment begins in January 2015). The next operating rules will come out in 2014 and attachments standards are also forthcoming. (Refer to “Roadmap” Outline PowerPoint for further details)

E-Health Vision, Roadmap and Goals Roundtable Discussion

Dr. Eric Jamoom, Facilitator

Participants briefly stated their visions for e-health. See complete list of responses in Detailed Summary below. (Note: some participants represented their own point of view while others represented their organizations).

Summary Discussion of E-health Vision Common e-health definitions must be developed. Noting the importance of consumer choice/patient preference, patients must be able to use personalized data to improve their health care. Data must be reusable for providers and researchers as well as secure. A short-term and a long-term vision are needed for the creation of a flexible e-health roadmap. A functional regulatory process and policy development are greatly needed to drive the change, accompanied by communication and engagement between stakeholders. A broad perspective is needed for the vision that covers a public health through patient care continuum, including community and population health.

Resources must be balanced with priorities and a baseline framework is necessary. Different stakeholder data needs require options and an ability to shift priorities. Common denominators include data integrity, quality and definitions. Focus should be on data capture, collection, documentation practices and principles.

ROI

ROI was discussed at length relative to: its evolutionary nature; end users; different perspectives about data value; difficulties of quantifying ROI with governance, stewardship, privacy and security; impact on access to care; increased provider requirements with no reimbursement; the need for measurable value beyond economic (e.g., better patient outcomes; better recruitment and retention of physicians in medical practices); the need for a rational consensus process upfront to avoid push-back at every state; and an ability to make midcourse corrections. ROI must advance the entire healthcare system. A forum to discuss priorities would lay the groundwork for developing a feasible system and new governance model with a practical timeline that improves quality of care. Seamless interaction within the system should identify existing and potential common capabilities and agreements that, in turn, help frame guiding principles for short- and long-term ROI.

Vendors

As uncovered entities under HIPAA, vendors are outside of the system. Vendor approaches may not be interoperable with competitors. How can they become part of the process? The only leverage the government has with vendors is meaningful use certification.

Provider Concerns

A pending imbalance was noted: as more people need primary care, more practitioners are leaving the field because they cannot afford to or may not have time to fulfill the regulations. The process must become simpler for providers.

Meaningful Use and Interoperability

The ACA and the National Quality Forum have reached consensus about a meaningful reuse process that illustrates how quality is measured. Interoperability is achievable when goals are clear (DICA example given).

Roadmap

The roadmap is a tool that allows regulators and the industry to build upon existing requirements. Timing, sequencing and overlap of existing regulations are important considerations. A new data paradigm will drive the roadmap, replacing the traditional notion of gathering data to treat patients or seeking payment (i.e., a “seismic” shift from encounter-based payment mechanism to outcomes-based reimbursement). Better and more granular data are needed. The new paradigm will drive purpose and change the way quality measures and electronic standards are established. A recommendation was made to ensure asset synchronization and to consider technology disparities. Information must be shared with other government departments (e.g., Department of Education) and information must be shared with community resources outside of the medical arena.

E-Health Vision for 2020

Participant statements about a 2020 e-health vision can be found in the Detailed Summary below.

Discussion Some infrastructure goals are probably achievable before 2020. Common themes include a need for patient access to pertinent information; and increased consumer engagement and accountability, noting the usefulness of new consumer education and incentive models. Physicians sometimes doubt data accuracy on insurance claims, indicating the importance of trustworthy and relevant data. Legal liability provider concerns were raised. There are ways that the private sector can help (e.g., financially support employee participation in PHRs).

Encryption must be addressed within compliance requirements. As we become more digitalized, physicians must be better educated about patient information protection (CMS and ONC can help). Privacy concerns were raised (example given). There must be freedom to present standardized content in different syntaxes for different users that is still recognized as the standards. The WEDI report documents barriers to movement forward.

The overall workload was raised as an additional concern. People have so much to do to comply with laws and regulations that they don’t have time for what they deem important. Unique individual identifiers or an identifying process are critical. Why not think outside of the healthcare box (e.g., Amazon addresses customers in a seamless, easy, customized way). Some believe that health care should not be overly regulated but at a minimum, the right regulations must ensure data quality and trust. Patients must track their own health and whether their providers are making mistakes. Technology should document outcomes.

The role of organizational culture can pose barriers (examples given). With a less than 100% e-health adoption rate, where and why is the system not being used? Regulations can work as long as they don’t ask too much of users. Examining simpler systems (e.g., PatientsLikeMe) that ask simpler questions across a more diverse set of diseases can open communication channels for people with similar issues. Timing, scope and resources are three variables to consider, with a recommended focus on scope (using an iterative, incremental approach to provide the most value to patients and providers). Infrastructure additions and changes must be accommodated. New businesses need flexibility.

What are feasible priorities that allow for incremental movement from Point A to Point B? Guardrails (wiggle room) for meaningful use timeframe are desperately needed. A request was made for NCVHS to recommend more flexibility and meaningful use for Stage Two “as soon as possible”. Meaningful use gaps were noted on an NCHS physician survey. Current system gaps also include long-term care, property, casualty and some practice management systems. Should regulations be changed or are there more innovative approaches to address ongoing concerns? More case studies are needed.

Providers face challenges from their non-HIPAA covered vendors in that they don’t have to adopt the regulations. Certain products are not covered under HIPAA. Vendor systems not covered under meaningful use or HIPAA and even some covered lives with certain insurance are not in the framework. How can they be engaged? There are expected ICD-10 contingencies a year in advance because certain trading partners (e.g., EHR vendors; clearinghouses; health plans) will not be ready. The 20% of providers still using 4010 are in dire straits. With the upcoming implementation, it is critical to test providers internally and externally with trading partners. Medicare’s decision not to test is irresponsible.

The potential for claims processing disruptions and consumers calling for help is high as the mid-October ICD-10 implementation date draws near. Meaningful use challenges continue and NGS testing presents an additional challenge. Standards development was defined as an iterative and incremental process involving development, conformance criteria, testing, pilots and maintenance. Tools that don’t work must be fixed and testing must become “use”. Data must be reliably anonymous for use in public health (“anonymized” data).

Knowledge exchange and sharing ensures that everyone has a stake in implementation. How to achieve a shared vision was further discussed. More resources will be available when certain state variations and regulations are addressed and certain implementation requirements are removed. A suggestion was made to examine other efforts to articulate an e-health vision (e.g., Health People 2020; Health IT Strategic Plan; Health Disparities Report; examination of life sciences). Will implementation of new or updated processes be evaluated for lessons learned?

A belief was expressed that the majority of relevant players are already at the table. From a historical point of view, it was noted that each new implementation to date has been cast as an upcoming “train wreck”. Ten years of remarkable progress was also noted. It was reiterated that an integrated structure is needed for public/private dialogue about implementation; and a suggestion was made to bring together core working groups. Further questions arose about meaningful use relative to purpose and goal. Those who fail may refuse to go through a standards process again. Users must be equipped for success in order to further health IT in the country

Reusable building blocks (i.e., vocabularies, structures, transports, security and services) can solve many problems; and what doesn’t work can be replaced. What goes into clinical documents (changes in an understanding of health care) must be separated from what goes into transport and security (changes in technology). Interoperability must be tested in the real world to make sure that it works.

To date, stakeholders do not have the ability to influence timing, scope and resources to deliver on what Congress and others have laid out or to introduce other important pieces of the process. Providers should not be disincentivized with penalties because this might translate into fewer Medicare patient slots in medical practices. The ICD-10 “train wreck” is a frightening but very real possibility (example given). A message must be sent to groups still working on 4010 (e.g., small rural clinics; community health centers) about the importance of shifting to ICD-10 and 5010.

Next Steps The Subcommittee will develop a document that illustrates elements of today’s conversation and a draft e-health vision statement that identifies roadmap elements. The summary will reviewed by the Subcommittee and then by Roundtable participants and other relevant parties before being presented to the full Committee in November 2013. The intent is to finalize the vision and roadmap prior to a third Roundtable Discussion (date unknown).

Participants were asked to put forth one word to describe a vision of what must happen next:

Words included: out of the box; open-minded; prioritize; seamless; process; efficacy; resources/vision; pilots; collaboration; dialogue; alignment; transformation; multidimensional; shared goals; patient-centered; streamlined; pragmatic; defining the destination; certification; money; partnerships; convergence; ever-evolving.

Subcommittee Discussion

The National Committee is a good vehicle to establish a visionary statement about achieving a functional e-health system. Common themes include patient-centeredness; seamlessness; interoperability; alignment and convergence. The expectation is that e-health goals will be realized by 2020. Concerns about immediate issues (i.e., meeting requirements of ICD-10; health reform; and Meaningful Use, Stage Two) were a significant part of the discussion. Identifying, documenting and creating a roadmap or a picture of the different e-health elements and their connections is important (noting that work has already been done by many organizations in this area). Addressing disparate visions and obstacles and prioritizing (identifying the next set of low-hanging fruit) allows for staging and progressive movement towards goals. Flexibility in the progression is valuable.

It would be useful to identify a common set of visions and themes that capitalize on operative words such as actionactionable and deliberate in order to develop a set of guiding principles. This type of roadmap could be used by the entire Committee to address a range of crosscutting themes.

It was suggested that the Roundtable transcript be part of the record. Development of a one-half page “straw man” vision capturing concepts that resonate with the Committee’s work would be useful. Recommendations could be organized into categories. Process deficits must be addressed and mechanisms developed that allow for ongoing dialogue (noting that some perspectives such as those of employers have been missing). A dynamic process that moves things forward is needed.

The ICD-10 implementation deadline is not going to change so why not collaborate and move toward a shared vision? A stewardship framework is fairly well defined but needs updating to include common elements of a shared vision and those with potential. Guiding principles developed in the August 2012 Executive Subcommittee Retreat should be reexamined. Although much of what is being discussed is overdue, some feel that the process is moving too fast. More consumer and public health voices are needed. A problem exists if meaningful use, EHRs and the SNOMED CT implementation aren’t helping people move to ICD-10. What can be done by CMS to improve the process; and is there a way to make the system less punitive? It was noted that CMS is offering technical assistance and training to rural community health centers, behavioral health communities and specialties. It was also noted that specialties such as optometrists and mental health practitioners also do not have “a seat at the table”, which makes integration of patient care in those areas a challenge.

Moving forward (notably from 2017-2020), changes in reimbursement from fee-for-service to value-based care and cultural cohesiveness must be taken into consideration early on in order to engage hard-to-reach small groups (e.g., AAFP). Incentives for using meaningful use must cross the whole spectrum of providers, including dentists. Developing partnerships and collaborations will be a “tough nut to crack,” requiring out-of-the-box thinking, breaking down turfs and modernizing healthcare systems. A suggestion was made to solicit input from state leaders and to leverage innovation efforts within CMS. Better data are produced through incentives rather than enforcement.

Further discussion of the e-health testing component and vendor interaction was suggested. How are standards evaluated with respect to maturity and adoptability? When should regulations adopt national standards and how can the challenges of balancing regulations be met (example given)? Standards should include tools to develop business functions such as a registration process. A disconnect exists between regulations, standards, transport protocol and payload content with end users who must make these processes work for patients.

Existing documents about regulatory reform, principles that define good standards and a series of evaluation criteria about adoptability and maturity were identified as resources (see Detailed Summary below). How to incentivize patient involvement was again raised. Rather than standards, consumers care about access to needed information in a crisis as well as the capacity to understand options and payment processes.

Public CommentSteve Lazarus, Boundary Information Group

Private sector innovation will lessen the cost of applications and testing time (examples given). While there will be application, provider and health plan failures, one failure does not signify complete failure. Infrastructure pillars must be created within the next three years in order to function by 2020. The standards become the data, the way data are defined and what datasets are used. Other models exist that accommodate small business (i.e., resource sharing). Ideas and case studies should be disseminated.


DETAILED SUMMARY

Call to Order, Welcome, Introductions and Agenda Review

Walter G. Suarez, M.D., M.P.H. and W. Ob Soonthornsima, Co-Chairs

Roundtable Purpose, Goals and Outcomes Co-chairs

Transformative changes are occurring in the United States in the way that health care is structured, delivered and financed. Public health and population health management have changed significantly since the November 2012 Roundtable Discussion relative to health reform; updates to the National HHS Health Strategy across all health domains; the development of strategies for international quality, national IT and national patient safety; and the progression of meaningful use of HIPAA. NCVHS must clarify how these changes will transform data/information exchange and the use of standards.

The overarching goal of the Roundtable Discussion was to define the core elements that will help the National Committee to frame a vision for e-health standards into the future and to create an industry roadmap for current and future standards requirements. The National Committee will then advise the Secretary about adoption of new standards, taking sequencing, timing, pace and size into consideration. Another goal was to identify interdependencies of existing requirements in order to establish ways to monitor how health reform is shaping the new relationship between providers, payers and other system elements. It will be useful to reference existing roadmaps such as CMS’s e-health strategy or ONC’s work. (Refer to written document of September 18, 2013 outlining the purpose of the Health Vision and Standards Roadmap Roundtable for further information)

Other considerations included questions about new initiatives relative to cost and payback; convergence opportunities; and how to make good use of data (“big data for the greater good”). Major changes in health care as required by law impact physicians, Rx/lab/health services, employers, health care services, government programs (Medicare and Medicaid), commercial payers and hospitals. Mandates and initiatives being worked on include the HITECH Act, ICD-10 (as of October 2014) and HIPAA standards. Providers will be significantly impacted by the health insurance exchanges (October 1, 2013 enrollment; January 1, 2014 start date; risk adjustment begins in January 2015). The next operating rules will come out in 2014 and attachments standards are also forthcoming. A roadmap will clarify key mandates, purpose, goals, milestones and timelines as many changes occur simultaneously. It will identify challenges and opportunities for HHS units and the private sector. What upcoming industry activities will shape future direction?

(Refer to “Roadmap” Outline PowerPoint for further details)

E-Health Vision, Roadmap and Goals Roundtable Discussion

Dr. Eric Jamoom, Facilitator

Dr. Jamoom asked participants to briefly state their vision for e-health (noting that participants may represent their own point of view or that of their organization). Points and questions included:

  • Patients and consumers have been forgotten amidst so much focus on providers and plans. It is time to “renormalize” patient-centered care, which includes self-reported data. E-health must assure better health for individuals and populations at lower cost without compromising quality or safety. Administratively, e-health is about transformation of health care relative to delivery and payment. How do claims and payment data get shared? How can EHRs and PHRs be standardized for dissemination purposes? Health care encompasses more than primary care, including, for example, labs, ancillary care, mental health and aftercare. Tele-medicine is also transforming care but questions remain about how to account for and pay for such services.CMS recognizes the importance of partnerships (in-house; with other federal partners [e.g., FDC; FCC]; and with industry) in order to achieve integrated health care. Alignment of quality measures is important across CMS programs as is a focus on Meaningful Use Two or interoperability. The four big data sets to be considered include: claims and payment; clinical data; patient behavior; and patient sentiment data. CMS is developing a plan to “normalize” data, whether socioeconomic or clinical. What are the codes, clinical metrics, payments and payment adjustments that matter? Health equity – how to address disparities – is another priority.

    All providers must move from strategy to tactics to ensure success with ICD-10. Interoperability and national regulation are necessary to compare data. What authorities and leverage already exist that might curtail the need for further regulation? What essential standards need agreement?

  • It is important to remember what a day in the life of a family physician looks like. It is important for the patient and provider to have a relationship. E-health is a good extension of that as well as a way to offer increased access.
  • There must be agreement about core words that define e-health. For example, it is the appropriate availability and access to high quality health care and health care data for multiple purposes across the care continuum. Preventive health care is essential. AHIMA believes it important to be mindful of consumer-mediated data. How can consumers make their data more accurate? The vision must be futuristic.
  • E-health is a seamless and secure flow of information among stakeholders (including consumers) such that the right information is in the right place at the right time. Standards are tools rather than goals. Underlying business objectives must be examined in order to determine whether standards can help reach the goals. Standards must remain flexible enough to evolve as new business models, consumer requirements, healthcare methods and new technology are developed. In a 2013 update of its 1993 report, WEDI examines four basic areas critical to the future: patient enablement; payment models; data harmonization and exchange; and innovative encounter models (e.g., EKG using an I-phone).
  • The ADA has concerns about meaningful use. Only a small percentage of dentists are participating in that program because of the benefits (example given). While there is support for implementing SNOMED – CT in EHRs, it won’t infiltrate into many dental offices without some benefit coverage. There is also a big problem with adult coverage. Mouth diseases are systemic, not just dental. Medicare has no dental coverage. Adult benefit coverage is decreasing and there is an access problem due to lack of benefits. ADA is very supportive of all standards being proposed by HHS.
  • E-health is the seamless exchange of information of electronic data specifically among all stakeholders (patients; providers; payers; clearinghouses). It is important to consider non-covered entities (e.g., property and casualty is still in the ICD-9 world so when ICD-10 is implemented, there will be dual coding). “Seamless” means normalized, semantic interoperability that allows a consumer to easily access data on a home computer.
  • A roadmap must be broken into manageable pieces in order to produce meaningful information (rather than “big data”). Meaningful reuse of data is the real reason to have e-health information. Clinical, financial, population-based and research data use should be separated from EHRs and PHRs due to different reliability, granularity and terminologies. There are also standards that revolve around transport, payload and vocabulary. When all the elements are put together, it is possible to achieve semantic or commutative interoperability. The key is testing and tools to simplify that testing.
  • The basic mission of the healthcare system is prevention or diagnosing patients before symptoms emerge. More thought must go into diagnostic work flows early in the process. When patients present, they go through a process that hopefully leads to coding but more detailed work is needed to determine how the process should work.The goal of data is to support true discovery. When more data are gathered, other patterns may reemerge that are false discoveries. Issues of data stewardship (including how data are studied) should be examined. Standards complexity should be made easier for stakeholders.
  • It is important to address three essential components of e-health early in the process: reuse of information, partnerships and education. Reuse of information is complex, noting challenges of obtaining information from EHRs for reuse in vital records. Partnerships must include consideration of vendors. Good data can only be gathered when those putting information into the system understand the lack of semantic interoperability.
  • From a historical perspective, NCVHS made convergence a main theme in 2011. Convergence also includes population health and public health data (noting their roles in meaningful use and health reform). Health care and public health use data differently. “Roadmap” might not be the right term because what is really being discussed is transformation. This is not a linear process.
  • New stewardship models are needed for data that fall outside of the HIPAA framework (e.g., community uses of data that are “deidentified” but run the risk of “reidentification”). The Subcommittee has developed such a framework although it is still in the beginning stages.
  • One prevalent theme is a societal shift in how partnerships are viewed, how human interactions are leveraged and how data are acquired from a variety of care settings.
  • As a consumer with chronic conditions (and with family members with chronic conditions), there is concern about how to keep up with the cultural and technological shifts. Leadership is needed from this group and the industry to ensure a seamless and efficient system of care.
  • It is important to think about capturing consumer care preferences within electronic records.
  • The AHA would like a new and transparent framework for the e-health process that corrals the different ways of setting priorities and work plans. Provider, health plan, patient and public policy data needs are different. Data must be normalized because incorrect data at the implementation stage are harder to undo.
  • PAHCOM’s goal is to keep small medical practices informed and involved with e-health.
  • When thinking about implementation fatigue, consider how a patient with no access to data feels. HIT and e-health represent enabling tools to improve quality; and should be considered the cost of doing business (which consumers pay for in their premiums). Policy goals must drive the standards. The public is wary about use of their data. They need to feel confident that their information will be respectfully addressed, handled and shared in accordance with their wishes. Cultural competency, cognitive issues, decision-making, literary skills and family caregivers must be taken into account relative to data access.
  • E-health enables a safer, higher quality, more equitable and sustainable health system for all. A short-term vision is needed for the next few years that balances the industry’s strategic priorities with the tactical. This would involve identifying a comprehensive roadmap with the appropriate sequencing and timing of mandates and non-mandates. The increased complexity of today’s regulatory mandate landscape makes it harder to determine that roadmap and sequencing. Non-mandates must be examined for interdependencies (example given).
  • There is a macro-roadmap that includes all industry standards and requirements that must take into account the operational impact on end users (e.g., federal quality reporting requirements are an example of reporting redundancy). Another frustration occurs when specialists are asked to do tasks designed for primary care. Ongoing delays must be addressed as in the case of transaction standards. There is also a micro-roadmap: each standard should have its own roadmap, which must be different from what exists today. Sometimes, standards are created that address no current need (e.g., accounting of disclosures access report). A distinct ROI must be established. Providers must have direct input before, during and after the development of standards. Pilots have been avoided. While the HIPAA standard pilot, showing ROI for providers and health plans, was a resounding success, the final regulation was never released. A comparison study between ICD-9 and ICD-10 would have saved the industry a lot of angst.
  • E-health is a trusted system with the same data definitions for all participants, whether consumers, home health and public agencies, non-profit or for-profit health plans, large or small hospitals. Governance of e-health includes sustainability. What will drive the ROI and how will components be evaluated? How will funding decisions get made; how will the public and private sectors work together; and how will quality assurance work? Relative to timeframe, what are the goals for each phase of development?
  • The Committee will be judged by its ability to support the triple aim: to improve the healthcare system (quality and outcomes); the health of its citizens (in particular, engaging consumers outside of the healthcare system); and systems efficiencies (quality improvement and reduction of extra tests). The focus here is on how to use health information technology to achieve this triple aim. A definition of interoperability was proposed (based on the IEEE, the world’s largest professional organization for advancement of technology). Interoperability has two components: 1) the ability of two systems to exchange information; and 2) an ability to use information that has been exchanged. It is important to move beyond what is built to what is enabled. Discussions about use will lead to interoperability.What is the definition of “big data”? What about “lazy data” (collected data that never gets reused)? Small data analytics must be supported for PCPs as well as big data. Small practices must be able to see the value of the work they put into the system. Lazy data must be applied, measured, learned from and improved. In order to have a self-sustaining system, healthcare practitioners must use the data to learn such that they can be applied to real-time decisions. Data must be measured for quality and outcomes. Clinical decision support, process reengineering and change management must then improve the process. Interoperability should be driven by business to use the information to improve health care and accomplish the triple aim. It must improve quality and cost. When information is exchanged and used, interoperability becomes an emerging property of the system. Finally, a roadmap can be useful if it gets agencies and organizations to work collectively toward common goals.
  • E-health requires a viable response to the following question: what are you making AHIP members do; in how much time; and how will they benefit? E-health means having the right information in the right place at the right time with the right cost and value to the end user. Stakeholders should decide what is in their best interest rather than having structures imposed upon them by government agencies. More important than laying out a specific set of goals and deliverables is getting people together to share perspectives and information.
  • AMA’s moniker is ‘helping doctors help patients’. To improve health outcomes, AMA’s current foci include pre-diabetes; cardiovascular disease; and graduate medical education (GME). E-health must be thoughtfully implemented with better communication and coordination between CMS, ONC and OCR. Other considerations include clinical and administrative health IT deadlines (e.g., HITECH; ACA): federal HHS mandates (e.g., Medicare contracting reform changes); non-e-health changes; a meaningful use program that is more flexible and less punitive. ROI should be maximized for better care and outcomes but also weighted against mandate costs (example given of mandates and meaningful use when combined that represent costs exceeding maximum physician incentives).CMS should do a comprehensive assessment of each e-health mandate including ROI and financial impact on the industry. Changes that can be made without regulation that offset identified pain points should be prioritized. An additional assessment of information workflow from the provider to the payer and back would be beneficial. Simply put, interoperability is one EHR talking to another in plain English. Using analogies, the healthcare system is more like an (annoying) frequent flyer system than an ATM, which delivers cash conveniently. Concerns include privacy, security mobile devices, payment delivery forms and a system that does not fluidly but safely exchange information or support consumers. Physicians are not technophobes but they want to use well-developed tools that drive care outcomes and assist them in helping their patients.
  • E-health requires a seamless system with demonstrable ROI. It is frustrating to see negligible improvements in interoperability despite an investment of billions of dollars.
  • Definitions are needed for short- and long-term goals and visions. Resources must be included in any ROI calculation. Resources for X12 include a limited set of volunteers who do the bulk of the work. It is imperative to always consider the patient point of view.
  • Implementation fatigue has set in relative to efforts to make processes consistent across different kinds of standards and regulations. There are different process requirements based on interpretations as well as different timelines and modification requests. The process must be nimble and consistent to allow activities to move forward.
  • It is important to roll out a well-conceived and coordinated plan in order to dismantle a huge precedence of incomplete attempts. The plan must be flexible, adaptive and doable. Resources of people money and time are finite. Standards and policies should only be set for things that matter.
  • An individual’s healthcare can be difficult to categorize or code for reimbursement – at times, it is like putting a square peg into a round hole. The business part of data collection assumes that clear coding and claims bring reimbursement. But the clinical side poses categorization challenges for clinicians and end users. As physicians do a great deal of uncompensated work when responding to mandates, a compensation model is needed.
  • What is the best way to represent the various entities, address the challenges and complete goals that fit with the clinical and administrative work of health care? Many caregivers do not agree with the goals and objectives laid out for electronic data exchange. The current regulatory system is ‘start and go’. A recommendation was made for government departments involved with these issues to meet with constituent representatives to determine how to address specific systems problems and to clearly define organizational roles.
  • We must focus on the vision and how to achieve it. We must break down the obstacles in order to achieve the goals.
  • Technology, data and consumer demand for information is changing as are insurance-like and health plan products in the market. The system must keep up with the changes (note a BIG report commissioned by Citibank about changes on their website). A big shift is underway from a health plan payment/provider reimbursement process to a consumer-responsible-for-payment process. Consideration must be given to what workflows and tools are needed to successfully affect this shift.

Summary Discussion of E-health Vision Common definitions for e-health must be developed. At the center of e-health, patients must be able to use personalized data to improve their health care. Consumer choice or patient preference is key. Data usefulness includes reusability for providers and researchers. Data must be secure. A short-term and a long-term vision are needed for a flexible e-health roadmap. How can the regulatory process work to further e-health and lead to sound policies? A sense of urgency exists to develop policies that drive the change. There must also be communication and engagement between stakeholders.

Because multiple and potentially conflicting expectations exist, resources must be balanced with priorities. With such healthcare system complexity, an underlying agreement with a baseline framework is necessary. Due to different stakeholder data needs, options and an ability to shift priorities are needed. Common denominators include data integrity, quality and definitions. The perception that automated data are accurate and timely is not necessarily so. Focus should be placed on data capture, collection, documentation practices and principles.

Attention must be paid to ROI and the end user (patient and physician), noting different perspectives in terms of data value. It was noted that data must be normalized and combined with experience to become knowledge. Discussion ensued about the difficulties of quantifying ROI when taking governance, stewardship, privacy and security into account. ROI, which directly impacts access to care, is about and for the patient. It is not a business proposition. More provider requirements for investment and time are being imposed with no reimbursement. This can lead to bankruptcy in smaller medical practices. Data must be standardized from a regulatory point of view.

Process is important and governance is a key part of a process moving forward (roadmap). Measurable value and outcome that improves patient care must be evident. A forum to discuss priorities lays the groundwork for developing a feasible system and a new governance model with a practical timeline that improves quality of care. ROI must have measurable value that goes beyond economic (e.g., better patient outcomes; better recruitment and retention of physicians in medical practices). ROI should have a rational consensus process upfront to avoid push-back at every stage (no do-overs) although there should be room for midcourse corrections. It was noted that the ACA uses a mechanism with specific criteria to achieve measurement consensus. There must be a mental map that allows for transformation rather than the status quo. ROI must mean advancement of the entire healthcare system (an assets assessment would be useful). What are sustainability models for different stakeholders?

Vendors, which are not covered entities under HIPAA, are outside of the system. The only lever the government has with vendors is meaningful use certification. A vendor’s approach may not be interoperable with competitors. How, then, can vendors be part of the process? There was mention of how to use the regulatory process and a question about how to avoid it. A pending imbalance was noted: as more people need primary care, more practitioners are leaving the field because they cannot afford to or may not have time to fulfill the regulations. The process for providers must be simpler to allow them more time to provide care.

Consensus has been reached for a meaningful reuse process by the ACA and the National Quality Forum. This meta-process illustrates how quality is measured. A suggestion was made to use existing agreement to avoid reinventing the wheel. Interoperability is achievable when goals are clear (DICA example given). It involves an ability to act on as well as disseminate and transmit data. A broad perspective is needed for the vision that covers a public health through patient care continuum, including community and population health. However, some measures have a broader purpose than others. Seamless interaction within the system that identifies existing and potential common capabilities and agreements is needed. Such identification will help frame guiding principles for ROI (short- and long-term). The evolutionary nature of ROIs was mentioned, noting that results must accommodate rapid cycle time evolution. ROI includes quality as well as financial returns.

The roadmap is a tool that allows regulators and the industry to build upon existing requirements. Use of existing mechanisms lessens duplication and the need to create another round of requirements. Timing, sequencing and overlap of existing regulations are important considerations. A new data paradigm will drive the roadmap, replacing the traditional notion of gathering data to treat patients or seeking payment (i.e., from encounter-based payment mechanism to outcomes-based reimbursement). Better and more granular data are needed. The new paradigm will drive purpose and change the way quality measures and electronic standards are established. A recommendation was made to ensure asset synchronization and to consider technology disparities. Thinking “at the higher level” means thinking more broadly. Information must be shared with other government departments (e.g., Department of Education) and information must be shared with community resources outside of the medical arena.

E-Health Vision for 2020

Participant statements about a 2020 e-health vision included the following:

  • Healthcare professionals are trying to help patients determine what they want from an e-health system. Fear is no longer an excuse not to make e-health as easy as on-line banking. Patients who want to maintain records without technology are free to do so without reduced quality or higher prices.
  • 2020 e-health is a seamless system that allows clinical and business data to flow efficiently between all system parties that is nimble enough to embrace emerging technology.
  • All stakeholders have the right information at the right time in order to make informed healthcare decisions. Reimbursement methods account for that and regulatory processes are modified to allow more fluidity with the standards.
  • 2020 e-health is seamless; intuitive; ubiquitous; and indispensable.
  • 2020 e-health has an informed and streamlined information exchange between the patient and provider. It gives providers an accurate, timely and efficient healthcare data flow that is meaningful, accurate and actionable.
  • Base information is “standard plus” with the amount of “plus” driven by users of healthcare functionality with no regulatory mandates. Such information is available to everyone on multiple platforms without degradation. Sharable and non-shareable data can exist within each instance.
  • 2020 e-health has a framework that enables seamless exchange of accurate, reliable and consistent health and healthcare data for multiple purposes across the care continuum, including population health and research. The framework is supported by underlying practices and principles of data integrity, data and information governance and data stewardship.
  • Physicians and other stakeholders can collect, consolidate and use all pertinent information (which must be correct), as needed. Consumers have access to care 24/7 anywhere. Consumers are 100% satisfied with their healthcare experiences, feel better and are healthier as a result.
  • 2020 e-health has seamless, granular data sharing with privacy and security between all healthcare providers. Patient identification is seamless, whether through biometrics or individual identifiers. All access to healthcare data and providers occurs through secured devices.
  • 2020 e-health is the seamless and secure exchange of standardized electronic data to promote efficiency, accessibility and quality of care.
  • 2020 e-health is a mechanism for improved quality of care. Patient health involves clinical, financial, public health and research data in acute ambulatory and home settings on multiple platforms 24/7.
  • Medicine is personalized due to the integration of genomic research domains. It employs a continuous feedback loop of healthcare standards, development, conformance criteria measures, testing, feedback use and maintenance.
  • 2020 e-health is an interoperable diagnostic medicine system that unifies pathology, radiology and imaging. An established method of query locates patients with similar health concerns nationally to promote ideas exchange between providers. Statistical methods have been developed to differentiate true discovery from false discovery as well as random data patterns.
  • 2020 e-health eases the legal framework of reform for providers delivering care with guideline management and mandate performance. It facilitates accurate clinical data entry by increasing provider reimbursement for extra time that is currently uncompensated; and its payment reform is transparent. Regulations must be enforced after due time for processes to work.
  • 2020 e-health addresses the needs of the full healthcare spectrum (i.e., referrals; care coordination; and population health improvement), including the development of patient-centric EHR and HIT systems that from initial planning, take population health and other program needs into consideration. Advances in technology and design help health care evolve.
  • Consumers, communities, healthcare providers and plans function in a learning health system with a timely, accurate and secure exchange of standards-based information needed to improve and manage population health, one’s own health and that of one’s family. That information takes into account a person’s health conditions, functional status, test results, recommended interventions, preferences, goals and the environment in which s/he lives. A focus on individual and population health outcomes is rewarded.
  • The United States will have demonstrated the value of an integrated approach to population health improvement that is guided by evidence-based research and ongoing quality management. Interoperable standards-based IT and analytics are deployed by providers and public health, and used by patients. Provider incentives and payments are aligned and patient and community incentives are also in place.
  • 2020 e-health provides a significantly improved patient and consumer healthcare experience that is easy to navigate, with specificity around care scenarios; informed decisions about care options, cost and quality; and an understanding of financial impact. There is specificity about how new and existing administrative, clinical and other non-traditional data are used to facilitate care coordination, inform patients and measure specific sets of care quality. Effective and efficient administrative processes are measured and tracked for incremental improvement, keeping in mind specific and prioritized business processes.
  • 2020 e-health is a seamless, interoperable, secure, efficient and sustainable system of technology infrastructure with application tools and devices that support access to and delivery of high quality patient-centered healthcare services anytime and anywhere at the lowest possible cost. The goal is to achieve better health and wellness for individuals and populations.
  • Consumers experience a healthcare delivery system that is swift, transparent, accurate, accessible, patient-centric and secure. Providers have the electronic, administrative and clinical tools and information necessary to render comprehensive care across all settings with information exchanges seamlessly working with patient, provider, plan, lab and public health entities.
  • All healthcare consumers in the United States will be empowered by meaningful, actionable knowledge via standardized electronically-enabled media that ensures access to the right care at the right time and place at the right cost in a safe, secure and seamless manner.
  • NCVHS can play a pivotal role in creating a framework that is inclusive; that establishes a process of ensuring the participation of relevant stakeholders; and that clearly defines key components, common vocabulary, standardized data content, messaging structures and secure data exchange routines.
  • 2020 e-health provides interoperability and patient information exchange in a timely manner. Physicians are provided with a means of practicing medicine that is financially viable. Patient access to care is refined.
  • By 2020, there will probably be two versions of X12 standards. An interoperable system of health care and health information allows patients, advocates, physicians, researchers and public health agencies to share appropriate access to information. Data exchange is managed by a set of appropriate standards that are updated and adopted in a flexible schedule that accommodates industry needs based upon technology advances.
  • 2020 e-health enables a safer, higher quality, more efficient and sustainable health system for all. Pertinent information is available when needed that easily engages consumers and empowers providers to holistically manage patient care and enable population health.
  • 2020 e-health is an interconnected healthcare ecosystem that is proactive, transparent and patient-centered. High quality care is delivered to patients where, when and how they need it at an affordable price. Medical records follow patients as they navigate the healthcare system irrespective of what healthcare facilities, vendors or providers are used.
  • 2020 e-health will have enhanced consumer engagement through deployment of tools such as Smart Chip and web-based technology. Standards development and the implementation process are business-driven and operationally actionable, fully engaging providers and other stakeholders. All claims and data quality are directly abstracted from EHRs.
  • 2020 e-health is an impactful, clinical and administrative interoperable system that is trusted by multiple and aligned users. A shared public-private governance structure manages the system, assuring training needs, quality, security and privacy. Its sustainable model is designed to evolve the system and target resources and incentives based upon tracked impact.
  • 2020 e-health has a structure that enables the right information at the right time and place for the right cost and value.
  • 2020 e-health gives providers access to the information they need to treat patients – where they need it and in a manner that helps them to improve patient care. It takes patient preferences into account and helps providers become more efficient. This reduces red tape, screen work and paperwork for providers, allowing them to focus on treating patients while keeping up with the cost of delivering good care.

Discussion Given the commonalities, some infrastructure elements and goals are probably achievable before 2020. One common theme is access to pertinent information for the patient. Physicians are “a little afraid” of data (e.g., from insurance claims) and sometimes doubt their accuracy (in some cases, with good reason). Information that is received and used must be trustworthy and relevant. Legal liability provider concerns were raised. Another theme was the need to increase consumer engagement and accountability. New consumer education and incentives models are needed. The private sector can help by financially supporting employee participation in PHRs, for example.

Encryption must be addressed within compliance requirements. As we become more digitalized, physicians must become better educated about patient information protection. CMS and ONC can help with this. Privacy concerns were raised (University of PA health assessment example given). There must be freedom to present standardized content in different syntaxes for different users that can still be recognized as the standards. The WEDI report documents barriers to movement forward.

The overall workload was raised as an additional concern. People have so much to do to comply with laws and regulations that they don’t have time for what they deem important. Unique individual identifiers or an identifying process are critical. Why not think outside of the healthcare box? Amazon addresses customers in a seamless, easy, customized way. Some believe that health care should not be overly regulated but at a minimum, the right regulations are needed to ensure data quality and trust. Patients must track their own health and whether their providers are making mistakes. Technology should be used to document outcomes.

The seismic shift of moving the healthcare delivery system away from fee-for-service was again raised as was the issue of consumer engagement (especially with younger generations). New businesses need flexibility and the role of organizational culture can pose barriers (examples given). With a less than 100% e-health adoption rate, a question must be posed about where and why the system is not being used. Regulations can work as long as they don’t ask too much of users. Examining simpler systems (e.g., PatientsLikeMe) that ask simpler questions across a more diverse set of diseases can open communication channels for people with similar issues. Timing, scope and resources are three variables to consider, with a recommended focus on scope (using an iterative, incremental approach to provide the most value to patients and providers). Infrastructure additions and changes must be accommodated.

What are the feasible priorities that allow for movement from Point A to Point B in an incremental way? Meaningful use timeframe guardrails (wiggle room) are desperately needed. A request was made for NCVHS to recommend more flexibility and meaningful use for Stage Two “as soon as possible”. A gap was noted on an NCHS survey of physicians who claimed to meet meaningful use but did not have capabilities associated with Stage One CORE meaningful use. Some providers will decide that it is less expensive to take a penalty than to invest in a costly lab interface or a patient portal; while others think they are compliant but miss the mark for one or two measures, for which they are penalized. Current system gaps include long-term care, property, casualty and some practice management systems. How can those not under the regulatory framework be engaged? Should regulations be changed or are there more innovative approaches to address these ongoing concerns? More case studies are needed.

Providers face challenges from their non-HIPAA covered vendors, who don’t have to adopt the regulations. Certain products are not covered under HIPAA. Vendor systems not covered under meaningful use or HIPAA and even some covered lives with certain insurance are not in the framework. How can they be engaged? With regard to ICD-10, there are expected contingencies a year in advance because certain trading partners (e.g., EHR vendors; clearinghouses; health plans) will not be ready. The 20% of providers still using 4010 are in dire straits. With the upcoming implementation, it is critical to test providers internally and externally with trading partners. Medicare’s decision not to test is irresponsible because they are in a position to help lead policy and innovation to help bridge the gap.

The potential for claims processing disruptions and consumers calling for help is high as the mid-October ICD-10 implementation date draws near. Meaningful use challenges continue and NGS testing, in need of a platform, presents an additional challenge. The need to empower patients was reiterated, particularly as populations become older and sicker. Standards development was defined as an iterative and incremental process involving development, conformance criteria, testing, pilots and maintenance. Tools that don’t work must be fixed and testing must become “use”. Data must be reliably anonymous (“anonymized” data) for use in public health.

Knowledge exchange and sharing ensures that everyone has a stake in implementation. How can existing programs (required regulations, activities and mandates) be shaped to coincide with a shared vision? How can practical and pragmatic steps yield measurable results? What looks tactical is actually more of a strategic plan. When certain state variations and regulations are addressed, some implementation requirements can be removed, which would free up resources. Consideration must be given to what goes on at the federal level and within each state as well as with small versus large providers (e.g., free and public health clinics versus large academic medical centers). There is no good sense of the current scope, given the many unknowns. A suggestion was made to examine other efforts to articulate an e-health vision (e.g., Health People 2020; Health IT Strategic Plan; Health Disparities Report). What is happening in the ecosystem, including life sciences? Will implementation of new or updated processes be evaluated for lessons learned?

A belief was expressed that the majority of relevant players are already at the table. From a historical point of view, it was noted that each new implementation to date has been cast as an upcoming “train wreck”. Ten years of remarkable progress was also noted. It was reiterated that an integrated structure is needed for public/private dialogue about implementation. A short-term need to increase alignment of those working on e-health was identified with a suggestion to bring together core working groups. Resources are especially needed to support providers. Further questions arose about meaningful use relative to its purpose and goal. Those who fail may refuse to go through a standards process again. Users must be equipped for success in order to further health IT in the country. A path of least regret must be taken and risk management should be taken into account.

Reusable building blocks (i.e., vocabularies, structures, transports, security and services) can solve many problems and what doesn’t work can be replaced. What goes into clinical documents (changes in an understanding of health care) must be separated from what goes into transport and security (changes in technology). Interoperability is not created in committee: it must be tested in the real world to make sure that it works. Systems must allow for iterative and incremental improvement.

To date, no process allows a stakeholder to say, “I may miss the mark but I understand and am striving to meet the intent of meaningful use. I would like recognition for this effort.” Stakeholders do not have the ability to influence the timing, scope and resources to deliver on what Congress and others have laid out or to introduce other important pieces of the process. Providers should not be disincentivized with penalties from moving ahead with HIT. Penalties might translate into fewer Medicare patient slots in medical practices. The ICD-10 “train wreck” is a frightening but very real possibility (example given). A message must be sent to groups still working on 4010 (e.g., small rural clinics; community health centers) about the importance of shifting to ICD-10 and 5010.

Next Steps The Subcommittee will develop a document that illustrates elements of today’s conversation and a draft e-health vision statement that identifies roadmap elements. The summary will reviewed by the Subcommittee and then by Roundtable participants and other relevant parties before being presented to the full Committee in November 2013. The intent is to finalize the vision and roadmap prior to a third Roundtable Discussion (date unknown).

Participants were asked to put forth one word to describe a vision of what must happen next:

Words included: out of the box; open-minded; prioritize; seamless; process; efficacy; resources/vision; pilots; collaboration; dialogue; alignment; transformation; multidimensional; shared goals; patient-centered; streamlined; pragmatic; defining the destination; certification; money; partnerships; convergence; ever-evolving.

Subcommittee Discussion

The National Committee is a good vehicle to establish a visionary statement about achieving a functional e-health system. Common themes include patient-centeredness; seamlessness; interoperability; alignment and convergence. The expectation is that e-health goals will be realized by 2020. Concerns about immediate issues (i.e., meeting requirements of ICD-10; health reform; and Meaningful Use, Stage Two) were a significant part of the discussion. Identifying, documenting and creating a roadmap or a picture of the different e-health elements and their connections is important (noting that work has already been done by many organizations in this area). Addressing disparate visions and obstacles and prioritizing (identifying the next set of low-hanging fruit) allows for staging and progressive movement towards goals. Flexibility in the progression is valuable.

It would be useful to identify a common set of visions and themes that capitalize on operative words such as action, actionable and deliberate in order to develop a set of guiding principles. This type of roadmap could be used by the entire Committee to address a range of crosscutting themes.

It was suggested that the Roundtable transcript be part of the record. Development of a one-half page “straw man” vision capturing concepts that resonate with the Committee’s work would be helpful. Recommendations could be organized into categories. Process deficits must be addressed and mechanisms developed that allow for ongoing dialogue (noting that some perspectives such as those of employers have been missing). How can the vision for a dynamic process be refreshed, particularly when roundtable discussions of the past have repeated the process rather than moved it forward? The cycle must be broken in order to create a new, healthy route although participants in this Roundtable seem to better understand the need for collaboration.

The ICD-10 implementation deadline is not going to change so why not help each other and move toward a shared vision? A stewardship framework is fairly well defined but needs updating to include common elements of a shared vision and those that have potential. Guiding principles developed in the August 2012 Executive Subcommittee Retreat should be reexamined. Although much of what is being discussed is overdue, some feel that the process is moving too fast. More consumer and public health voices are needed. A problem exists if meaningful use, EHRs and the SNOMED CT implementation aren’t helping people move to ICD-10. What can be done by CMS to improve the process; and is there a way to make the system less punitive? It was noted that CMS is offering technical assistance and training to rural community health centers, behavioral health communities and specialties. It was also noted that specialties such as optometrists and mental health practitioners do not have “a seat at the table”, which makes integration of patient care in those areas a challenge. In addition, long-term care is not included in e-health (although representatives of the above-named groups were invited to this Roundtable Discussion).

Moving forward (notably from 2017-2020), changes in reimbursement from fee-for-service to value-based care and cultural cohesiveness must be taken into consideration as themes early on in order to engage hard-to-reach small groups (e.g., AAFP). This means moving beyond a physician-centric approach to include other advance practice providers (e.g., dentists). Incentives for using meaningful use must cross the whole spectrum of providers. Some providers adjust better than others to the transformative process that takes them from small, simple systems to certified EHRs. Case studies might enlighten the field.

Developing partnerships and collaborations will be a “tough nut to crack,” requiring out-of-the-box thinking, breaking down turfs and modernizing healthcare systems. A suggestion was made to solicit input from state leaders and to leverage innovation efforts within CMS. The obstacles must be overcome and the vision must be streamlined. Better data are produced through incentives rather than enforcement. Greater inclusion of ineligible providers (e.g., long-term care) was again recommended.

A suggestion was made to further discuss the testing component of e-health and vendor interaction. How are standards evaluated with respect to maturity and adoptability? It was evident from the start that improvements were needed with 4010 and to some extent, with 5010. Some national standards are risky to adjust. When should regulations adopt national standards and how can the challenges of balancing regulations be met (example given)? Do the standards include tools to develop business functions such as a registration process? A disconnect exists between regulations, standards, transport protocol and payload content with end users who have to make these processes work for patients. Over time, organizations will hopefully develop competencies for how to implement standards. Everyone must move toward a common principle framework.

In 2009, the Committee presented a paper on regulatory reform with contributors from X12, NCPDP and HL7 (copy will be sent to Subcommittee chairs). Principles that define a good standard can be found in the 2003 regulation that established the HIPAA standards of 4010; and a series of evaluation criteria about adoptability and maturity of standards has been developed by the HIT Standards Committee (adoptability, maturity and marketability challenges noted).

Is there a way to incentivize patient involvement? Consumers don’t care about standards; they care about having the information they need in a crisis, understanding their options and payment processes. Because there is so much diversity, what will an engagement model look like?

The possible formation of a Standards Review Committee (to determine how standards should be tested and vetted) was mentioned although further discussion is warranted. The Subcommittee will discuss what is possible (amongst themselves and with CMS) in order to make a formal recommendation to the full Committee at the November 2013 meeting.

The Roundtable Discussion has yielded enough information to draft a vision statement that might be entitled, “Elements of a Vision”. This draft document will be a single statement or a statement with several supportive bullets that establishes priorities and emphasizes commonalities. The Subcommittee will also define the elements of a roadmap. In practical terms, Subcommittee members would refine the draft and then distribute it for review to all who participated in today’s Roundtable and others before sending it to the full Committee. The Committee would receive a draft vision statement; further delineation of roadmap elements; and possible recommendations and/or guiding principles. After this, the next Subcommittee deliverable is a set of operating rules.

Public CommentSteve Lazarus, Boundary Information Group

Private sector innovation will lessen the cost of applications and testing time (examples given). While there will be application, provider and health plan failures, one failure does not signify complete failure. Infrastructure pillars must be created within the next three years in order to function by 2020. The standards become the data, the way data are defined and what datasets are used. There are other models to accommodate small business (i.e., resource sharing). Ideas and case studies should be disseminated.

Adjournment4:45 p.m.


To the best of my knowledge, the foregoing summary of minutes is accurate and complete.

/s/

Walter G. Suarez, M.D., M.P.H. DATE January 14, 2014
Co-Chairman

/s/

W. Ob Soonthornsima DATE January 14, 2014
Co-Chairman