[This Transcript is Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Standards Subcommittee

Workshop on the Predictability Roadmap for Updating and Adopting Standards and Operating Rules

August 21, 2017

Hubert H. Humphrey Building
Washington, D.C.

Proceedings by:
CASET Associates, Ltd.


P R O C E E D I N G S (9:08 a.m.)

Agenda Item: Welcome and Introduction to Appreciative Inquiry

MS. DOO: Good morning, friends, colleagues, Spockians, and whatever else. We are thrilled to have such an amazing group of people here today. First thing I wanted to ask is for the folks who are sitting in chairs, not at tables, would you like to sit at a table? We have an extra table, and it has playdough on it already. It is about to have some Lego people, and pens and some workbooks. So please, if you would like to be at a table, please join one. This one — and it will have goldfish and gummi bears and other things shortly. So do not feel left out. It will also have a couple of other things.

So first things first, I assume you’re a little bit curious about how the day is going to work, what you’re going to do with the toys, when you can eat the treats, who is in the room with us, and maybe why on Earth you agreed to come.

So if you’re thinking about those questions, that’s good, because today is all about questions and asking good questions and hopefully finding some answers to them. So we’ll get to all of that.

First, just a couple of housekeeping things. Phones, like you’re in the movies. Mute, por favor, and if you do need to take a call, obviously we understand that. You’re supremely busy, but just take it outside. I think there’s pretty decent reception here, maybe until the solar eclipse.

I did, as promised, bake, and I made these black and white cookies, but I made solar eclipse cookies. So those are in the back. You have to have a theme, right, and they’re super sweet, and as I call them, they’re cookies that make you want to bite somebody. So probably you can have one or two. But anyway, those are in the back. It’s a good thing.

I will be your facilitator for the day, if you could not already tell that, and I’m Lorraine Doo. I think that I do know everybody, but just in case, I should have introduced myself. That would have been helpful.

Before we do get started, we obviously are the NCVHS federal advisory committee. I would like to ask Alix, the co-chair of the committee, to come up and do the honors for getting us kicked off properly.

MS. GOSS: Thank you, Lorraine. Good morning, and welcome to those attending in person and those virtually attending today’s workshop of the National Committee for Vital and Health Statistics. This is a standard subcommittee meeting. We do have some formality that we need to undertake.

The first thing we are going to do before we jump into some setup for today is ask all of the committee members to please stand up. We do need to complete our announcing ourselves and whether we have any conflicts. So for those who are official NCVHS Standards Subcommittee members, I’m going to start. I’m Alix Goss, member of the full committee, co-chair of the standards subcommittee, and I have no conflicts.


MS. KLOSS: Linda Kloss. Member of the Full Committee, member of the Standards Subcommittee, co-chair of the Privacy, Confidentiality, and Security subcommittee, and no conflicts.

MR. LANDEN: Rich Landen, member of the Full Committee, member of the Standards Subcommittee, no conflicts.

DR. STEAD: Bill Stead, chair of the Full Committee, no conflicts.

MR. COUSSOULE: Nick Coussoule, co-chair of the Standards Subcommittee, member of the Privacy and Security Subcommittee, and no conflicts.

MS. STRICKLAND: Deb Strickland, member of the Full Committee and the Standards Subcommittee, no conflicts.

MS. GOSS: Now I would like to move into staff. Everybody here stand up who’s staff.

(Introduction of staff and attendees.)

MS. GOSS: I think that rounds us out. Thank you everybody for supporting us in our federal advisory committee procedural steps.

So as you know, I’m Alix Goss. I’m from Imprado Consulting, and along with Nick Coussoule from Blue Cross Blue Shield of Tennessee, we are the co-chairs of the Standards Subcommittee of NCVHS. It is truly an honor to be here today with such a talented and knowledgeable group of individuals, representing organizations named in regulation along with our federal rulemaking partners.

It is the partnership of standard setting organizations operating rule authoring entities, designated standards maintenance organizations, national standards group in CMS, and industry participants such as private sector businesses and WEDI that enable us to design and steward healthcare improvements that achieve increased value in the United States healthcare system.

So I thank you for attending today’s workshop and for the advanced work that many of you have supported to discuss and better understand how standards and operating rules are developed and maintained and how federal processes work to adopt and orchestrate implementation of national standards and operating rules. This workshop is one activity within a larger process being held in response to numerous calls for greater predictability.

Today’s objective is to identify specific opportunities for change that will enable covered entities and their trading partners to more effectively plan for implementation of new versions of standards and operating rules. We plan to broadly disseminate the results of today’s efforts and to seek formal feedback to guide NCVHS’s work to produce a set of recommendations for Secretary Price and the standards development community and operating rule authoring entities.

In preparation for this session, it seemed very ironic to me that today HIPAA turns 21. It’s now the legal limit.


And there’s a solar eclipse occurring. I don’t know what’s going on, but there’s a lot of interesting stars aligning.

So a few other factoids for August 21, in 1888, American inventor William Seward Burroughs patented the adding machine. In 1959, Hawaii became the 50th state. Since we are in the Hubert Humphrey building, it seemed fitting to include that today in 1968, the Democratic convention opened in Chicago and went on to nominate Hubert Humphrey.

Let’s get back to the HIPAA history. Just over 17 years ago on August 17, 2000, the final rule was issued adopting the first set of HIPAA administrative data standards and related requirements. The first full upgrade of the HIPAA standards was proposed 9 years ago on August 22, 2008, leading to a final rule issuance in January 16, 2009, with a compliance date of January 1, 2012. Seems like yesterday, but that was a while ago.

So these interesting factoids aside, we are all very well aware that our lives and our resources are finite. Many of us have spent substantial portions of our professional careers advancing administrative simplification and many more hours working to solve related issues within and beyond our organizations. When we set out on the journey to bring the HIPAA law of 1996 to fruition, principles were designed to aid the effort. The 10th principle is quite germane to our workshop, and it states: incorporate flexibility to adapt more easily to changes in healthcare infrastructure such as new services, organizations, and provider types, and also information technology.

The federal government’s health information technology strategic plan and interoperability roadmap call for the use of electronic health records by all providers and electronic exchange of patient information between all users of the data. The convergence of clinical and administrative data has been an important topic of discussion between health plans, providers, vendors, policymakers, and federal advisory committee members for the past decade. Standards again are at the heart of efficiency and interoperability.

This is our day to use the depth of our experiences and creativity to create ideas to support the next generation of HIPAA standards. As we apply what we have learned and think creatively, we will have the opportunity to embrace our healthcare efficiency dreams and through our collaboration design a more predictable lifespan for HIPAA standards and operating rules. This will increase the value of administrative simplification and support the best use of our precious resources in delivering and administering healthcare in the United States.

This is a very long time coming conversation, and we hope that today’s framework is one that’s positive and really enables us to think a little bit outside our own box and come up with some solutions that we can then engage our partners in vetting and really take the next level of foundation for HIPAA that will give us the next hopefully 10 or 20 years of success.

So with that, I’m going to turn it over to Lorraine who is going to be, as you know, our MC for the day.

MS. DOO: Thank you, Alix. I think that we have gotten a good introduction from Alix about what we are here to do today and what the roadmap is about, and really what we are looking for from you all today is — and I know that some of the things on the table look a little silly, but it’s also to get us out of our regular way we think day-to-day. What we are looking for from you is engagement, your ideas, and support about the long term.

I’m going to talk a little bit about what this whole visioning exercise is all about. But the first thing that I want to ask everybody to tell us a little bit about is what’s the best thing that happened to you today so far.

I am more than happy to start. We just want to get a couple of ideas, because that is what appreciative inquiry and the whole thing that we are going to be talking about today or the way we are framing everything today is about.

So the best thing that happened to me today is I left the house and had to get up super early, as you can imagine, because I live in Baltimore. So I had to leave the house at about 4:30. But I had no traffic coming from Baltimore to D.C. That is a pretty darned great thing. Then I had parking in the building, another thing that never happens to you, and I had my pick of every single spot near the elevator, and I did not have to go through security with my six bags and boxes. I got right from the parking lot up to the penthouse. So that was a pretty great set of things that happened to me today, and I am still smiling about all of that.

And I’m here with a bunch of people who I really respect and admire. So I have had a pretty great day so far, and it’s 9:24.

So does anybody else want to share anything, the best thing that has happened to them so far?

MR. STELLAR: I live in D.C. Took the subway in this morning, and the red line did not break down.


These are major accomplishments in life. So I’m very happy, and I was here 40 minutes before I expected to be here.

MS. SPECTOR: I had a nice walk from the Hyatt across Capitol Hill over to here, and I just stopped and enjoyed the beautiful view of the Capitol and then the Washington monument on the mall, and I just — whenever I’m in D.C., as many times I’ve been here, I still just find that to be such a beautiful sight. So that was my good part of the morning.

MS. LOHSE: (Off mic.)

MS. DOO: Her neighbors’ flowers. That’s great.

Anybody else? Priscilla?

MS. HOLLAND: I managed to get here from Springfield on the Metro, changing trains three times, and didn’t get lost. So I’m thrilled.

MS. STINE: My favorite thing this morning is a really good cup of coffee, because that always gets me started in the morning.

MS. PHELPS: I live in D.C., and I am able to walk to work when the meetings are here, and that for me is a thrill.

MS. DOO: Take one more? Okay, Alix.

MS. GOSS: So the good thing that happened to me this morning was that when I stepped on Deb’s shoe, she did not trip.


MS. DOO: Well, I think we are off to a pretty great start. One of the things that you are going to do, so you all have, well, a lot of things on your table, admittedly. So you have a workbook, and I don’t know probably some of you have flipped through it already, but the way the day is going to work is you’re going to have a series of conversations, and you’re going to have some individual conversations with people at your table. I’ll have to do some counting off. So most of them will be in pairs when you do individual ones, and then others will be with your group, and you’re going to take notes in the workbook. Does anyone not have a workbook?

(Discussion of workbooks.)

And you are going to do some initial discovery review, so you’ll take notes in it, and then you’ll have some table conversations and you’ll talk about major ideas and documenting your table views, and then we actually have some big sheets. There’s easels where all of that will be documented, and then there’s going to be group sharing out to the wider group. So very typical of other visioning sessions.

The big sheets that we have are actually — they did them on beautiful paper. So we will be able to preserve them for time immemorial. This is like supremely nice. So actually the person who writes, figure out over the day who has the most gorgeous writing. This is really nice, surprisingly beautiful paper. At the end of the day, we will come out with something that’s really for the good of the order.

So that’s how those conversations are going to work. Each phase will be like that, sort of individual and group conversations.

But let’s talk a little bit about — so what is this thing called appreciative inquiry? How can it be any different than any other exercise, and why did I start with asking people to have something positive to say? So appreciative inquiry, you’re going to see this sort of cycle of just a couple of times, and it’s a framework of change for most change management.

What’s unique about appreciative inquiry, it was developed at Case Western University by David Cooperrider, and it’s based in a theory of psychology. It looks at change from the perspective of possibilities waiting to happen. So it’s looking at it from the discovery of what have been the high points in your life, which is why I started with what’s happened good today.

But it’s understanding all of the good things that have happened, not just in your personal life but also your professional life, what’s good about what we already do. What is our foundation of good, best practices, successes? Starting there, and looking at what’s good and what we do in the standards world, but also the foundation of what we are doing right.

And then taking that to the next level of dreaming and imagining. So what it could be, based on our past successes. What do we think we want it to be, and how do we articulate that and dreaming about what that could be, and then designing what’s the ideal. So if we really could have this dream, what does that look like? And brainstorming big picture. It may not feel like it’s completely realistic if we got everything we possibly could want, but what does that real ideal look like if we could design it with all of this brainpower that we have working together?

And then the destiny of at the end of the day, what can we commit to? What’s the smallest change we could make that would actually begin to see that change transform what we have? And appreciative inquiry continues to look at, so what are all the things we know we’re doing well, what could we borrow from someone else that they’re doing well, that we could take in our own organizations or our own selves and begin to see if we can make that transformation happen.

Appreciative inquiry has been used in national companies, international companies, banks, production companies, manufacturing companies. So it’s not just used in a university. It’s not just used for leadership training. It’s used broadly and has been used very successfully.

So something else that I really like about appreciative inquiry is this concept of the two words, where “appreciate” is that which we value ourselves, we value other people, but appreciate is also to grow in what we perceive and what we value. Then inquiry is to ask questions, and that’s why we started out with a question today.

So how do we ask questions about the way we do things and how we can explore what we are going to be doing in the future? So AI solves problems or challenges by looking at what’s going right already and how we can use some of that to consider how we might change what we are doing going forward. So it’s a pretty complicated field. If you wanted to look it up, you’d be able to explore more about the concepts that are embedded in it. But they are all based in this foundation of strengths, peak successes, best practices, and other elements that are based in that foundation. I would encourage you to look into it a little bit more.

Now we talked about the roles. We don’t have facilitators the way appreciative inquiry typically has facilitators, but everybody does have an NCVHS member at the table, correct? Except the back table perhaps, right?

So for the most part, the NCVHS committee members are going to be participating actively, and then we’ll help out at the back table, but in terms of facilitating, you won’t have someone kind of guiding you through the questions. What I did for the first exercise, you see you have little chat cards on your table, and when — they are little teeny square things. So I’ll tell you how you’re going to use those. But that will help facilitate some of the conversation. So I’ll show you how to use it.

One other differential I wanted to walk you through in terms of change management, in case you didn’t sort of understand the difference in the concept, typically when we look at change, we see issues and organizations as problems to be solved. So we identify a problem, oh woe is me; okay, what are the reasons, what are the causes? Let’s figure out some ways that we’re going to fix them. Let’s figure out a couple of those, and let’s implement the ones that we think are best.

We get into this cycle and we do that. Oftentimes, it’s pretty demoralizing, because we have — I targeted something as a problem, and we end up doing the same thing, and then we end up with a couple of problems again that we have to problem solve. So it’s like you’re the problem, the individual or the issue or the organization is the problem.

AI chooses to look at change management differently. They are possibilities waiting to happen. So it’s in sort of a more uplifting way of looking at things, and that’s what we are trying to bring to this exercise today. So what’s working? What do we do well? How can we have that cross-pollination, and then imagining how it could be.

To Alix’s point, we have been at this for 21 years. We know some things work really well. We have done it. What can that be now, when we seem to have a lot of opportunity at our fingertips? How good could it be if we all worked at it together and shared all of those concepts and ideas, and then what kind of commitments can we make? What’s reasonable, and what’s the smallest thing that we can do and build on that?

So I told you about your workbook. You have space to write. You can draw pictures. You can take notes. There’s even one whole page for you to take notes on. Super generous, because I don’t like to print paper. So you really got away with a whole big white space there.

Now we are going to begin. Let’s see. So you have candy. That should keep you energized. We are going to take a break, but we are going to be sort of fluid about the breaks, too, because you are going to be moving around a lot.

So first, before we sort of begin, does anybody have any questions about the concept or anything?

(No response.)

Excellent. So the first exercise, so this in your workbook, we gave you a lot of background, and at the back of your book, if you have not yet discovered it, are all of the standards and operating rules we have adopted thus far. Alix alluded to them. So if anybody had any questions like they’re not memorized and etched in your brains already, they’re in the back of your book should you need them for reference, like if you’re going to build a Lego or something like that of the NCPDP standards.

Agenda Item: Discover

But the first thing you are going to do is you think you know each other very well, is you are going to get to know each other a little better, and if there’s not an even number at your tables, then you could do like just have three people talk to each other, and I want you to find another person at the table, and it could be somebody — would be nice if there’s someone you don’t think you know that well, but just partner up, and ask them a question about what they felt really good about, either in their career or something personal in their life, and if you want to you can use those little chat cards also as an opportunity to talk to someone about something.

But ask them to tell a story about themselves, something that was successful in their life, what they feel proud of, what was really great, and this is just going to be two minutes each person, and then take notes about that story, because you’re going to tell that story to the other people at your table, and then we are going to talk about what was successful about the work you have done on standards.

So the first thing is to break down who are you as human beings, because at the end of the day, we are all just human beings, and then we are going to talk about what was really successful in the work you did in standards.

So first either take a card or just talk about each other from the standpoint of one thing that you have done that you have been really successful at that you feel really proud about, tell the other person, take notes, and then I’m going to call time, switch the role, and the other person take notes.

This is just about discovery and what it’s like to get to know another person sort of at a more fundamental level. You can also use the questions that are in your notebook. There’s a whole bunch of questions in your notebook, and there was another question that I actually had last night that I wanted to throw out.

You can move around the tables. You are not stuck there.

So this question, so some of the questions, describe an experience when you felt you were contributing to a successful improvement in your organization or large healthcare system.

Discuss what attracted you to the healthcare profession. What were your early aspirations?

Pick a partner.

(Table discussion.)

MS. DOO: All right, everybody. Time is up. Where’s my mic? Thank you, I appreciate that. Nobody is listening. All right, time’s up. I can probably get an app for that. Maybe that will be part of my dream sequence, an app for silencing NCVHS meetings. What a great idea.

Thank you for doing that first exercise so willingly. Any immediate comments before we ask people to provide us with input about their groups?

PARTICIPANT: We’re awesome.

MS. DOO: Excellent, that’s good. I guess we have colors so we don’t have to worry about numbers, but I would like to take some notes on what you discovered about this esteemed group here. So I am going to do that up front. I’m hoping I’ll be able to write enough. I’m going to have to probably borrow paper from people and hopefully people are willing to share, but could we have a volunteer color-coded group to give us some ideas about what folks discovered about their group individually and as units for personal successes and professional successes that we might put on this sheet and have as a guidepost for the day?

So we’re going with — is that Yellow? Am I colorblind today?

MS. STINE: Yeah, we’re Yellow.

PARTICIPANT: It’s Lime Green.

MS. STINE: We are Neon Yellow.

MS. DOO: Okay Neon Yellow, yes, ma’am. We’re just going to do like a minute.

MS. STINE: I think for our group we have perseverance and we have leadership. Nick, what would you say about yours, or are you good?

MS. DOO: We know he’s good.

PARTICIPANT: Anybody else?

MS. STRICKLAND: I think strategizing.

MS. DOO: Yeah, I think it’s strategery, right?


MS. DOO: Wait, now I can’t spell at all. I’ve messed myself up. Okay, how about strategy. There’s no spellcheck with regular hands. Okay, thank you very much, Yellow.


MS. GOSS: The first thing I would like to add from the Orange team is that it is a group of dedicated and committed individuals who are about the people, the heartfelt mission of the work that we do.

MS. DOO: So are those three things dedication, commitment, commitment to people?

MS. GOSS: It’s, for instance, the work to implement the CHIP program that one of our participants, Chris, was involved in. It was the mission behind that because it was involving kids and a number of the work in infectious disease, the mentoring, the leadership within a commonwealth, the commitment to being a nurse really came through as it’s not only about being committed to making a difference but it’s committed to the people.

We’ve got big hearts. And the last thing that I want to do that I think is very apropos of today’s discussion is that we have a classical archaeologist who is now an EDI operating rule expert and it’s all about the data, and it’s so true. No matter what you’re doing, it’s all about the data and the process.

MS. DOO: Should I put data focused and process on there?


MS. DOO: Okay, thank you. Who’s next? Sure, Gary, Lime Green, your color is Lime Green?

MR. BEATTY: I think a couple of the words that came up in our group were certainly passionate, diversity, and volunteerism.

MS. DOO: Good, thank you.


MR. LANDEN: The Blue line here. Gary stole our word. Volunteerism, I think, was a common theme, and specifically in the area that all of us came up through projects that involved professional people working together in more of a voluntary than a compulsory mode to achieve some sort of success across different components of the healthcare system, whether it was pharmacy, or operating rules, or standard transactions or provider identification.

So it’s the balance of what skills and knowledge the volunteers brought with the opportunity to organize them and to seek value across — so I think that would be the theme, value across organizations.

MS. DOO: Okay, value across organizations.

MR. ANNADATA: Also being not only data-focused but also information-oriented.

MS. DOO: Is it okay to put them together like that?

MR. ANNADATA: That is fine, because from our perspective, data, you can collect all the data you want, but unless you glean some meaningful information that’s going to move your project, program, or business forward, it doesn’t make much sense to collect the data.

MS. DOO: Okay. Fuchsia? Are you Fuchsia, Pink?

MS. MEISNER: Fuchsia is good. So on the leadership, we had that one as well, but leadership toward success was more what we were — leading to success. So bringing it to completion. And then for what Rick was talking about, the value across organizations, we had similar, but we called it collaboration.

We felt that this group really had a lot of collaboration going on, and what we found among all of us is not only were we prone to be in leadership roles but also people that when we start things, we bring it to completion and try to finish what we’re doing. So that was kind of a common theme that we were all proud of things that we had completed.

MS. DOO: Okay. So it is not just doing something for doing something, it’s really going towards the end. Okay, thank you.


MS. BANKS: I’m trying to see what’s different.

MS. DOO: It’s fine if there is consistency.

MS. BANKS: I think one of the big things was being able to create the vision to drive organization compliance. So being able to tell that story to get the funding in order to ensure compliance with the standards. Also the need to — said the same way in a different way, being able to create the ROI or the value to the organization or the stakeholders versus what the cost and complexity is, to be able to measure that and determine and sell the value.

Administrative and clinical quality controls as we — administrative and clinical data are beginning to — travel together for different administrative or clinical purposes, how do we ensure that the data is passed as accurate in order to protect additional diagnoses that we never had, right? That could really be a problem.

MS. DOO: What’s the word? Can you put that in a word? Like, what’s from the success perspective, what word can we use as a theme? Or is that a quality theme?

MS. BANKS: It’s quality control, how is that? Both administrative and clinical. And then the alignment of incentives across stakeholders in order to achieve whatever objective. Again, the data in process, the data is key.

MS. DOO: So those were your success themes? Is that right? Okay.

PARTICIPANT: This is the transparent table.

MS. DOO: Okay, excellent. Superpowers.

MR. CHRIST: What else? We can share — we talked about the role of technology in improving processes, that technology is not something you do just for the sake of itself, but it’s a tool that’s used as part of improving the workflow, improving process, and sometimes, when deploying technology, the most important thing to be considering is not the technology itself but how it affects the organization and how to deal with the change management issue ranging from medical billing software that I work with or Dan who helped get email started at the Strategic Air Command hospital system, for those, long before some of the folks in the room were even born, but not me.

What else did we talk about? I think collaboration was another key theme. And then quality assurance, we have a couple folks at the table with direct experience in auditing QA rules.

MS. DOO: Okay, great. Thank you. So there was a fair number on collaboration, volunteerism, which I think actually, I don’t know if people would agree, that dedication and commitment and commitment both to program and people would also align there. Data and process, would I think align and also go along with the ROI and quality controls and the technology, so there seems to be a fair amount of consistency in the group. Rich?

MR. LANDEN: Lorraine, I would add another word from the last table. The SAC email did it for me — innovation.

MS. DOO: Okay. Would you all agree or would there be any dissension that there’s a lot of commonality in terms of the things that have driven your successes to date, that these things have been a foundation for all of you, and that it’s what has driven your desire, your passion and what’s gotten you where you are, and that’s kind of foundational for everything that you’ve been doing thus far?

So it’s kind of got to be foundational for what’s going to drive, for the rest of the day, and what’s going to continue to drive what we can do with the standards and operating rules and how we move forward. Thank you very much. Now do people need a break, or can we move on to dreaming?

It’s not nap time, no. You can dream of a break, okay. That’s why I plied you with sustenance. Okay, and again, you are welcome to get up and move around, which some of you have been doing, which is fine.

Agenda Item: Dreaming

MS. DOO: All right. So can’t wait until dreaming about the future. So we’ve talked about our past, and again, thank you for doing that. So now, thinking about — I actually had a dream myself. We’re going to — this is where we’re going to get a real chance to dream about the future.

This is where you have a chance to think really big and bold and visionary, in a way, and it’s thinking about, what would be the perfect achievement if we updated or developed standards and operating rules for the future or just technology for healthcare. Things are moving so fast.

And I want you to be big and bold. I used to think some of my ideas were big and bold, except things keep catching up so fast. So I’ll give you one of my big and bold ideas, and maybe it’s not so big and bold anymore, but everybody knows who Watson is, right?

Watson — my dad used to work for IBM, and I remember when he brought home the first computer with his keyboard, which of course, the only reason I liked it was because it had a lot of buttons on it that I could push, and I said, but whoever is going to use one of these things, right? What’s the practicality of it?

But of course, now I love Watson, and my vision for the future is that there would be — and Watson is, of course, ubiquitous now — that every physician would just be able to have access to a Watson at any point in time, and put in some diagnostic information for any patient, and it would immediately come up with all of the probabilities and possibilities, what the illness was, what the appropriate protocol was, and what the medication was that would be the most effective, promising, and of course, least expensive.

But it would be available to every physician. It would be simply part and parcel of whatever the system was that he was using. It wouldn’t matter who created it. It wouldn’t matter what system it was. So that’s a vision that I have, that that should just be available, and it should be just through Watson or whatever the competitor is, but it doesn’t matter what the system is.

So that’s just a vision I have, because it’s possible. Because all of the data is already there. So that’s my dream. That’s the kind of dream that I want you guys to have. It doesn’t mean it’s something you could have tomorrow, but think like that in this portion. So you can imagine it from the I perspective. So sort of selfishly, if you ran the zoo, what do you want for the healthcare system, for the standards system?

What would you love to see? And just think about it and write down some ideas for a few minutes. And then come back in your table and talk about your ideas, and then as a group, come up with some ideas for how you could gather those ideas together. What, as a group, could a group dream be?

So the instructions on page –I’m sorry, I’ll start telling you the page. So on page ten, I provided a scenario in the workbook. 2025 — which actually is not far enough away. It’s not really far enough away at all. It’s kind of around the corner, isn’t it?

But I painted this scenario, what image comes to mind when you think of providers, plans, standards, development organizations, operating rules, operating entities, and all the rest of our family, what does that look like? You have a new generation of workers, new generation of systems, a new generation of electronic health records; what’s happening in technology and industry?

We can create standards to do what? Create standards by doing what, leveraging what? But don’t think of it as 2025 because that’s probably too close. You have to dream bigger than that, like if we really solved the problems by really being all of these things you just talked about, what would it look like? Get out of your comfort zone. What would it really look like?

And I, I mean I can’t even finish the rest of that sentence. But that’s why I said, take a minute, think about your future, standards, development organizations, operating rule, authoring entity, and there’s a page here for you to scribble your notes on. So on page 11, there’s a page to scribble your notes on. So what would it look like? What does it have? What does it do and why is it possible? That’s just a recording.

So first, you’re going to just write down, give yourself some time to think. Write down your own ideas just for a couple of minutes. When you’re ready, you can start the conversation with the table. This is just for a couple of minutes, just think for yourself. What are your own ideas?

Because you need some time to think and then start the conversation. When people start looking up from their sheets, you’ll know when it’s time to start having the discussion. And then we’ll give you — this says 30 minutes, but we’ll give you about 20 minutes to do this and you will each get one of these very fancy sheets. That’s why I said pick a really great writer.

Because I don’t think — I don’t know that these are erasable but they are super nice. Aren’t they?

(Table discussion.)

MS. DOO: Time’s up for this part of the session. Can we come back together for a couple minutes? You’ll have time to continue, but we want to do some sharing now. It’s sharing time, circle time, show and tell. I won’t say pens down.

Did people in general have a good time doing that? I’m hearing sort of mixed I’m-not-sure-whats. Have another chocolate. Have a cookie.


So we would like to hear, it sounded like to me as I was walking around, it actually sounded like there was an amazing amount of not only sharing and positive information but really great information and the start of some incredible ideas that could be the start of something quite beautiful.

So I’m just wondering, I know, it sounds like a song, but I’m not singing. I just started banjo lessons and you don’t want to hear that either. Not yet, but pretty soon. Who would like to go first to share?

Whoever speaks for the White table will have to use the microphone, because we want to have it transcribed forever in history.

MS. PHELPS: Okay, how do you want to do it, Lorraine?

MS. DOO: Well, somebody could hold up your beautiful translucent sheet, would be great. Can everybody at least hear? The colors are gorgeous.

MS. PHELPS: How do you want me to do it? Do you want me to go through the idea and then these for each idea, or how do you want to do it, Lorraine? All right, we came up with three big ideas. The first is automatic identification of noncompliant transactions or partners and it should operate in near real-time and eliminate interpretation.

What it would do is eliminate the dependence on a provider having to detect and report noncompliant payers or other entities in the industry. It’s possible because, we put because it’s necessary.


And it’s being done, it’s already being done. It’s just a human process. Humans identify noncompliant payers and when they dig their heels in and won’t get with it, humans report them to CMS. So the foundation for the process is already there, but it isn’t automated and it depends on individuals who are brave enough to out somebody else, and it shouldn’t. So we’d like to eliminate the human part of that.

The second idea is industry-wide real-time adjudications, and it will need to have, once that’s done, it will have semantic compliance industrywide. In other words, every alphanumeric character will be in the right segment on the flat file. What it does, it achieves administrative simplification for all stakeholders across the industry. It’s possible because NCPDP already does this. Yay, NCPDP.


And I guess we could say that for NACHA as well. The banking industry does that very well. The third one is voice-activated standards, operating rules and protocols, running simultaneously with the workflow. This would harmonize the clinical and administrative workflows. It would increase efficiency and replace manual workflows through automation. It’s possible because, we already have some examples, Alexa, Watson, natural language processing are already pieces in place.

Administrative and clinical protocols are also expanding across the industry. So there are pieces of all of these in place already.

MS. DOO: Very good. First of all, thank you very much. That was great.


Will duct tape work on that wall? Oh, we found a pin. All right, thank you so much. Who is next?

MS. GOSS: From the Orange table, we liked what we heard from the White table. We believe in seamless data capture exchange and use that is timely along with the ubiquity of the data for easy capture.

So think of, at one point I think we said Siri on steroids, so you can just sort of talk and it captures it and it really enables people to be focused on the patient and also the patient accomplishing their outcomes that drives the process and produces the value at each step.

Clear roles and responsibilities with robust collaboration, this is covering all the various industry partners, SDOs, operating rules, industry providers, in that robust collaboration, but also we tried to focus on positive statements so it was sort of eliminating any redundancy aspects there.

Access and use to affordable quality healthcare exists and is no longer debated. Citizens are health literate and applying it to their decision making. We are tech-neutral and focus on our programs or our use cases.

We did not get far, we did not put it on our little chart. Sorry about that, Lorraine. So then it has all the money it needs to fund the activities to build and implement the infrastructure.


We have plenty of expertise and smart people to do the work. We have clarity on the lead of who’s lead in each one of the process steps. So whether it’s clinical or pharmacy or administrative financial, who’s point person in the SDO operating rule entity structure?

We have a singularity of data definitions. We’re very pretested and validated before we roll anything out. We are focused on patient care, not the operations or the back office is automated is another way to look at that. It’s possible because we all want quality care for ourselves and those we love.

MS. DOO: Okay, thank you.


All right, thank you. George?

MR. ARGUS: Unlike the Orange group here, we used the standard form.


What it looks like, we believe that is has to have semantic interoperability as part of that process. It has to have the ability to kind of constantly move towards reducing costs. It provides a level of affordability and it meets market needs. I think that was another piece that we identified because it’s the market that determines what they will bear as part of this process.

It has uniformity. It has an ontology that helps users understand what to have as part of it. It has universality as part of that process and it has a consumer focus that is an integral part of that activity.

What it does, it does provide a level of adaptability, innovation. Stays current, has continuous process improvements, stays with medical knowledge as it changes, and it’s very agile. It’s intuitive and it also employs a process that safeguards the information. It’s possible, actually, because we said so.


But they didn’t want me to put that down. It provides a visionary framework, both in terms of the predictable path forward, urgency in terms of the business case, it has to be understood so you can get buy-in, and you have to have a knowledge of the resources that it will take and be sensitive to those resources. So that’s fundamentally what we identified.


MS. DOO: Okay. All right, sir, Blue?

MR. LANDEN: The Blue line continues to roll. We had an interesting kickoff to the conversation, trying to figure out at what level are we dreaming and we eventually came down with, by 2025, we want to look at the U.S. healthcare system as an innovation network. That means data and systems to support patient outcomes.

So primary focus is on the patient. That means it’s not the primary focus. We’re not saying ignore the other, but it’s not the primary focus when we talk about the payment systems, which are obviously essential, accreditation in provider networks and health plans, or various measurements that we all need to do. So all those are necessary, but not primary.

Payments would be based on outcomes. That’s one of our assumptions. So what are the qualities that our vision has? It’s data and information to support provider and patient, standards and data stay in lockstep, the standards and systems are user-friendly, easy to update, not cumbersome, and the data and information are accurate, available, they evolve, they’re agile, and they’re flexible.

As a couple of the other groups have indicated, I think Alix is going to pay for this, solid funding and dedicated resources throughout the system, everything real-time, and the approach of the system needs to be a multidimensional model. It’s not just point A to point B, but it’s A, B, C, D. Some of the stakeholders that are components or axes of these models include the covered entities, providers, payers, clearinghouses, plus the interrelationships of the stakeholders. Also, patients, SDOs, ORAEs, and public health, to name a few, not limited to.

Now, what the system does. It’s innovative, it’s iterative, I think Gwen phrased it as trial, error, reduce. So it’s a cyclical process of analyzing either errors or glitches or identifying opportunities to improve, going back to the next cycle and adding value at each cycle and multiple cycles.

Focus always stays on the patient. Regulations, federal, state, what have you, and contracts, which are the private sector equivalent of regulations, must support a culture of innovation and process improvement. Data is used for feedback for that process improvement process. Ensure safety throughout the innovation cycle. So that’s a paramount feature. Everything has to be tested enough to be safe.

All right, it’s possible because we know banking and telecom have both successfully implemented this type of vision worldwide, and because we believe that vendors will innovate systems as long as it’s clear what those systems need to accomplish for the clients.


MS. STRICKLAND: We can continue with the Yellow group. Okay, what our sticky notes look like, we didn’t commit. We were noncommittal.


We kept floating from one to the other. So we have innovative, nonintrusive. So part of the everyday, more frequent pushes to change, so say every six months, all participants in the process, so anyone who is impacted by it is a participant of all the changes, no hidden agendas and transparency, and adaptability.

In ours, we have speed, again, it speaks to getting to changes quickly. Change to payment models being more interoperative, real-time payments, all understanding what the return on investment is and the cost investment in the process. Simplifying, having everybody have that ability to participate in the process, having flexibility, aligned incentives, and real-time knowledge of the changes and increased flexibility.

What this does is it integrates the health record, it serves the patients’ needs, it brings care to those who need it quickly. It fulfills the industry’s needs. It creates a seamless, quick, and reactive process, and it provides care. So it separates the care process into two different categories, providing care, which would be your preauthorization, your eligibility, and it separates claim and payment information.

And this is possible because everyone’s at the table. It is funded. Boy, that’s a common theme.


Everyone is aware of all the changes. The data is available to everyone, there is consistency in the delivery, and the service providers help to deliver the changes. There’s a single process for all standards to follow. The changes happen quickly and they are predictable, and there is simplification across all SDOs.


MS. MEISNER: We talked about funding going external, from the healthcare industry completely, you know, let Microsoft work it out. Our big dream was having a Microsoft Office for healthcare. So that was a big dream.

What we said it would look like would be very simple end-to-end with only the minimum necessary to get the job done. One of our big conversations was we have this 900,000 data element claim transaction that meets the needs of everybody rather than focusing on the small physician that only needs a certain part of that information.

What it has is version agnostic. So you’re accepting the software without worrying about the version. That would just get pushed automatically, and that makes it very flexible. So this is a real pipedream here, guys. What this first part does is it takes away the antitrust thing that goes on today where the physicians don’t trust the health plans and the health plans don’t trust, so these administrative transactions are jam packed full of things that are justifying why I’m doing what I’m doing. We would like to see that kind of disappear in 2025.

What this does is provides rapid transformation of the practice and payment models so that you could actually meet the needs as quickly as possible. Then the reason this is possible is that we have data analytics now. So we should be able to be able to identify these outliers. Instead of making me justify it upfront, punish me in the backend, and stop making everybody give huge justification for what they’re doing, when every time I do it I get approved anyway.

So we’re saying push it toward the backend of the process. Don’t pay it if you think I shouldn’t get paid, but also, pay me if I should. So that was our vision, a very simple, with parentheses around it, Microsoft Office for healthcare.


MS. DOO: Yeah, transparency. We know you’ve got yours on Post-it notes.

MS. BHUTTO: So we didn’t fill out this big chart because our discussion went on a little bit too long, but overall the general theme we had was we think that standards should be updated much more frequently, so incremental and more frequent, rather than waiting years and years. So some things should be done sooner and vendors should be involved in that planning process.

Another thing we discussed was it would be good to have that semantic interoperability across different EHRs, billing claims, so everything is automated in that dream, ideal world.

Harmonization with other SDOs is important as well. So standardize as well as harmonization is important. I don’t know if you wanted to add anything to that. So that’s all we had.

MS. DOO: Okay, thank you.


Agenda Item: Design

MS. DOO: Okay, so now, before lunch, you are going to start doing some design. Now, I think that 2025 wasn’t far enough away to get your guys’ juices going about the standards and the operating rules. We didn’t put anything else on our list, right, Alix? Just standards and operating rules, we weren’t going to conquer everything. But of really making a change in how we develop, update, and adopt, and I barely heard anything about the federal government, a couple little ones in there. I heard a little bit, Margaret, I got it.

Now is your opportunity to take what you thought about in your dreams, put them on steroids, like you had Siri on steroids or I had Watson on steroids, put more of them more on steroids, and really think about, we’re talking what we loved about the way we do things today, what we really admire about each other, about the way when we really have a great success, what is it that makes it great?

When it really works like, oh, I’ve got to do that every time, what is it that if you were going to redo this process and there were really no barriers, what would that look like? That’s part of what you were dreaming about, and there are a lot of really, really solid ideas in here.

So from the simplified Microsoft Office, we all talked about innovative speed, flexibility, doing it more often, I mean, all this stuff is in there, talking about automation, real automation, best practices from NCPDP and NACHA, being tech-neutral, and I’m not sure I captured everything because I couldn’t get it all, funding, funding, funding, funding, got that, real-time, this iterative nature and that we do get the regulations to support innovation. What does that mean when you say that? What does that look like?

So at your tables, and this is where you’ve got some little dolls to use, they can be your little tech people. I added a tree. I have more dolls if you want to use them. You have Legos. You may need to collaborate on the Legos if you use them. If you haven’t played with Legos in a long time, there are instruction books.

I had to use an instruction book to make my little guy. So you might have to share some of the Lego pieces and some of the books if you want to make something. You don’t have to make him, but he was super cute, so I had to. I know he’s cute.

But it’s not as easy as it looks, actually, but you can make like tables and chairs if you need to, if that’s something that you want to make. So there are instruction books around, there are packages of Lego pieces around. Try to use them, but do try and share. It’ll tell you how many pieces you need for each thing if you want to make it, but it’s actually just good therapy to do that every once in a while. Then you’ve got little Lego people if you need them, and the playdough if you just want to make something out of that.

Here’s where you’re going to do. Take what you’ve got, and if you want to expand on what your design is. but the focus, remember, for today, is we really want to give the NCVHS folks what they need, and you guys what you need. So if we’re going to make improvements in how we get more predictable about the way we develop and adopt standards and operating rules, how do you take what you’ve done now, and design something? What does that look like physically?

You can also draw it. You can also make a song, you can also do a headline. You don’t have to use the stuff at your table. It’s just sometimes nice, personally, it’s nice to use your hands, but you can also do something else with that.

So before lunch, we’re going to start the first part of this design so you can enhance what you’ve got, focusing it in on the standards and operating rules in terms of what’s the best about what you discovered this morning, what’s the best about the sort of dreaming that you started, but honing it in on the standards and operating rules of how can we be more nimble in terms of the way we propose going forward to all of us, that we update them and get them ready for adoption on some more predictable way. That’s why we all agreed to come together today, or that’s why I think most people came together today.

So this is your opportunity, really for visioning. It’s turning your dream into reality. You’re not making a commitment yet. Every idea is a good one. What are the tools that you need to bridge it?

Here are some of the rules. Defer judgement. No idea is a bad idea. Stay focused on this topic of updating, developing, and adoption. Try to have one conversation at a time in your groups. I know it’s easy to have sidebars. Be visual if you can, if you like to, and the more ideas, the better, because this is your design part.

So you’re going to be able to show your work. Remember that from math class? Show your work so I can see that you didn’t get it out of some book. So I think those are my guidelines. Now, this is on page 12 of your workbook. This is part three, thinking about all the ideas. So it’s beginning to develop some prototype.

I’m not going to give you these sheets yet, but in your book on page 13 is the beginning of conceptualizing your ideas of what the change will be and what the impact would be for this first part of the ideas. So you can use that to help you actually figure out what you want your design to be before you actually develop it.

So take the time before lunch to look at your ideas, figure out what they might be, and how you might use the tools. You don’t have to do anything with it yet, just think about it and look at page 13 of what your idea might be and what the change might be to hone in on what you’ve just been talking about. Then at 12 we’ll break for lunch.

(Table Discussion.)

(Luncheon recess.)


MS. DOO: Can I have your attention for five minutes or less? That would be great. So we will let you know when it’s a good time to go outside-ish, and I did have the livestreaming on, but right now you have the opportunity to be super creative. You’ll start to see it kind of get a little dark. So everyone will be able to run for the doors.

But right now, you have the time to be creative. Can you hold up that spider? Some people have already been using their supplies. There’s a little spider there. She made a radish. There’s a kinetic sculpture already. We have a little doctor’s office with a patient. Wow.

Okay, and there were some playdough things going on down at that table. They were bracelets or something like that, right? Danny, I saw you. I know. You cannot get away. So we have already had some things going on. I need you to open up your fidgets. I don’t know what the purpose of those things are, but I could not resist getting them.

Let’s go back to some basics. Debbie is already writing. People, your task is to focus on mission critical. There’s a million things we could fix in healthcare today, and I know you want to fix them all, as do we all, but the mission for today’s appreciative inquiry exercise is updating, developing, updating, and adopting standards and operating rules. So we can’t fix the entire system. As my sister used to tell me, you can’t live your whole life this week.

So we can’t fix the whole healthcare system today. So our focus is on standards and operating rules. So when you’re finishing, working on your design, and your ideas, and building a prototype now, that’s what you are focused on. So from everything that you have been developing up to now and in terms of all of your ideas that you were beginning to think about, now is a time to really hone in when you’re building your prototype and you still have wild ideas, that’s still okay, but your design is really focusing on those aspects that were improving or enhancing or enabling something related to standards and operating rules.

So you have about 30 minutes or so, to build a prototype of how we can improve standards, development and adoption of standards and operating rules. So all the things that you have been talking about all morning and the afternoon is really focused on those kinds of design elements.

Now I’ll be quiet.

(Table Discussion.)

Agenda Item: Design Presentation

MS. MEISNER: We talked about decoupling some of the functions that we have in place that are huge, and carry many, many functions. So, I’ll use the claim as our example, just so that you understand where we were going.

Right now, the claim — for the professional — handles everything from durable medical equipment, to ambulance, to lab and X-ray, to bla-bla-bla. So we felt if we could identify a base, this is the information regardless of what type of provider you are, you always have to send this, and then do some add-ons, and allow those versions of content to be changed without impacting everything else.

So if I am a physician, a pediatrician doing office visits, I don’t care that you just added some more information for the labs to collect. Not my business. So why should I have to move to a new version?

So we felt, if the regulation could be focused on the data content and the rules around the data, rather than the syntax and the capturing of that data — as long as we had rules around the data for each function, whether it’s COB, one of us were talking about, we’ve got COB in this claim as well, why do we need that in the initial bill?

And then allow the transport to be flexible. Name a primary syntax, but allow trading partners to agree if they want to move forward to the great new tomorrow, as long as they stick to the content and the rules around the content. As long as we, as trading partners, agree to take XML or FHIR or the next great new tomorrow, as long as we are following the content rules, then we should be able to do that.

And then we said the regulation could point to multiple versions of things, with a floor but not a ceiling.

So that’s how we thought we could work toward meeting our dream. Questions?


DR. STEAD: One other thing we talked about a fair amount is that the floor of the syntax and the floor of the content could be moved along — they could move and you could say, this version on content require this version on syntax. So they could advance in an iterative fashion off the floor.

MS. BURKE-BEBEE: Thinking the old-fashioned way, what happens when all the different flexibility creates roadblocks for transmitting things?

MS. MEISNER: We’re dreaming. These are our dreams.

MS. DOO: Right. These are just, right now, remember, these are all of the concepts and ideas, this is the brainstorming,that says anything is possible.

MS. MEISNER: And the one-offs, the flexibility part of this, think of this kind of — we hesitate to use the word because it has certain connotations — but the safe harbor, where if I’m a provider and I want to send you the 837(5010) transaction, and that’s the minimum requirement, then the receiver has to receive it.

But if I agree as a trading partner to start sending you the FHIR transaction, or I want to do a direct data entry into your portal, or I want to upload something, or I want to use a voice-transmitted file, then if we agree to it, that’s okay. You’re not in violation of the regulation, as long as you stay with the content.

MS. BURKE-BEBEE: I was just thinking, what is the common denominator? What’s the floor —

MS. MEISNER: We would want one — that’s what the floor is, the primary syntax.

MS. DOO: So don’t get into the how not, these are — we’re trying to think, one, positive, best practices, opportunities, possibilities. You don’t want to be today, you’re trying to think of tomorrow. So keep elevating yourselves. I know it’s really hard, because all we know is today. We need to be thinking of tomorrow.

So fair questions, but think about how could we get there, because that’s what these guys have done. Very nice. And Deb, I just wanted to ask: so the regulation would point to the floor and not the ceiling, and then, is it content and rules, or was it content rules?

MS. MEISNER: The content and the rules around that content, without getting into this loop, this segment, this data element. It would — not the operating rules. This would be strictly the content, and the rules around the content, not the operating rules.

MS. GOSS: Could we clarify semantic versus syntactic, sort of approaches?

MS. SHEPPARD: We can, but let me say first, we talked about the fact that we think operating rules have these same kind of constraints that can be unconnected and reconnected and flexible, so even though we talked mostly about the SDO, we don’t think it’s different. It’s the same concept with a different application. Syntax versus semantic?

MS. GOSS: Because when you talk about content rules to me — I’m trying to figure out whether you are focused on the data or you’re — only?

MS. SHEPPARD: We’re focused on the data set that you need to send to send this message so that someone can understand it, not the look and feel of that data.

MS. GOSS: Not the structure.

MS. SHEPPARD:: Right — well, kind of. No, not that clean.

DR. STEAD: Truth be known, we couldn’t wrestle that to the ground.

MS. GOSS: I get that feeling.

MS. SHEPPARD: What we finished with, I think, is that we finished with is that there would be a defined order and defined relationships and defined usage instructions, but not, that said, you send me these seven characters and then a semicolon, or you send this in XJK3f — whatever comes after the syntaxes that we know now — just the vocabulary of the message, being. It’s an hour, so it’s not the whole thing, but in theory that would be the what you send, not the how you send it.

MS. DOO: Let us get back to the future. I think the Blue team had agreed to go next, and then we’re going to do the Yellow, yellow-lime.

MR. LANDEN: The Blue team has come down many tens of thousands of feet from its 2025 vision, but we are still many tens of thousands of feet above the street level. We do have a vision that we were getting pretty excited about, so I’m happy to share it with you, and let me introduce you to Ted. This is healthcare’s future, this is Ted. And I will explain Ted in a few lines.

So our goal was for the industry to have a trusted platform by which to drive down, to shorten the time period between development, NPRM, final rule and deployment. Want to ensure usability, understanding — I can’t read the next there — action-focused, quality, and testing. Pilot testing is a critical component that needs to be built into every update, every transaction, that is approved.

So, shorten the timeframe and development cycle. And there would be shared timelines and shared strategic plans, across all the industry actors.

All right. So Ted. Ted is our trusted group that brings together the different industry stakeholders, the SDOs, the operating rule authoring entities, business, the government programs, Medicare, Medicare Advantage, Medicaid, Indian Health Service, VA-DoD, and so on, all of the above, and what happens is our basic concept is, right now, under HIPAA and then extended by the ACA, we’ve got the SDO development process which is triggered by a request for change, goes through DISMO, development by the SDO, and when that process is finished, then from our friends the feds — we get an NPRM, public comment, final rule, and then some lead time before everybody has to go live and enforcement starts.

What we have done is shifted — we’ve essentially eliminated — or not eliminated, we were withdrawing the current regulation, moving the primary regulation to the front of this process so that the regulation in place would designate our friends at TED — trusted industry stakeholders — to go through a process whereby each proposed change or new transaction to be adopted, would be thoroughly tested, and tires kicked, evaluated for quality.

There’d be a concomitant industry panel that would talk about scalability and how much of a lead time — based on the content, the complexity, and the volume of the change — how much lead time before implementation would occur, and TED would go through a kind of a process whereby the SDOs, either individually if it’s an independent transaction, or collaboratively, if it involves — our favorite example was claim attachment — so it’s HL7/X12, possibly a core for the operating rule around that.

So either independently or collaboratively, go through pilot testing based on one or more defined user scenarios, and once it then — once TED agreed that the pilots were successful, there’d be a yes/no decision point. If the pilot were successful, and TED’s decision is a yes, then the implementation would be scheduled with the lead time that had been advised by the industry group, and at this point we get a little bit fuzzy about whether, is there another final rule, an interim final rule, an NPRM? We’re hoping not, but we can’t see our way around that now. Such that then the industry would adopt this new transaction, this updated transaction according to some scheduled cycle. So there’d be predictability.

And to take a half a step back, each organization, each SDO, each ORAE, would have its own schedule for its releases. So there would be a calendar with a published schedule. So every three months, every four months, every six months, every 12 months, whatever the SDO says.

So they could make changes to their transactions going through the TED process, independent of each other where independence is appropriate; where, like claims attachments, it’s a joint collaborative project, that would be coordinated, as we pointed out earlier, there’s a shared timeline and a shared vision and strategy.

So as we go through that, then, implementation would occur hopefully on a much more rational basis, transactions that didn’t need changes would not have to change, there wouldn’t be a giant all-transactions-updated. Transactions that had minimal changes to it could go through the system in a much more accelerated process, so there wouldn’t be the delays we’re seeing now. And then the more major changes would get a more thorough review — and as I, let me say this again: pilot testing, pilot testing, pilot testing, based on use case scenarios.

And that, we think, would increase the flexibility, the agility of this system. It would vastly shorten most timelines. It would reduce the uncertainty that we have from having an NPRM final rule at the tail end of the process, move that to the front end of the process, and generally enhance our ability to do things more rationally.

Now, there’s a lot of assumptions here. As I said, we’re still tens of thousands of feet above street level. A lot of stuff to be worked out. It assumes that TED can be put together. As we talked about earlier, one of the key assumptions underlying this is a reliable source of funding.

So our concept, as we talked about it, we could pilot that concept itself, and a voluntary effort, kick the tires, see if it worked. If it does work, then we would have a case to argue for more permanent funding and resource stability.

So let me ask the table mates if you want to add something?

MS. DOO: Rich, just could you tell, I’m sorry, what does TED stand for? Trusted —

MR. LANDEN: Well, that really doesn’t matter.


We called him TED.

MS. DOO: I thought it stood for something.

MR. LANDEN: Testing, education, and deployment. But — not germane.

MS. DOO: I thought it was like trusted external developers or something like that.

MR. LANDEN: We could use Bob or Sue or Francine.

MS. DOO: That was brilliant.


Thank you. Yeah, we should probably hold questions till the end. I broke a rule by allowing them last time.

MS. BURKHARDT: So, as a reminder, one of the things that we looked at was that we wanted to have basically all the SDOs be brought together under one umbrella, and so that we’re all operating under the same work. And I’m going to skip to this page first, because I think that will help set up the scenario.

One of the things is, our barriers and constraints, is that we’re out of our silos from an SDO’s perspective. We wanted to all come under the same regulatory requirements, but, not naming a version, we wanted to align regulation with assumptions in our timing. We wanted to remove personal attachments to specific SDOs.

We really wanted to be an industry-agnostic division, so that — the reason why that kind of came into play is that most — the current issue we are is — a sex code. Okay, gender code. Male, female, and it’s bigger than that. So if we all operated, so if HL7 used the same values, and we all worked on the same way, we could go moving forward. So anyway, that was just an example. You use that three-letter S word, and it’s like, oh.

So part of our assumptions to keep in mind going forward — and I’ll get more into this — everyone has to support two versions, remember that. There’s no further back than two versions. We’re all on the same schedules and vendors are covered entities.

So what would this look like? So today we would be in a production version, and we would have a development. And so what would happen is you would have a production version, plus two versions back. And then the SDOs, a single SDO, you would be in development on one. We couldn’t come up with a timeline, but we’re looking at, like, every year you would have an update. So that would require you to have your change requests prioritized and reprioritized. We talked about how would that happen. But that would be the picture.

So part of the common content — so that kind of comes back down to that gender code that I was talking about — is you all work under the same underlying data dictionaries. And we didn’t — toolbox — I think that was a new word. We didn’t know — because we have probably a stronger X12 background, we really wanted to be agnostic, again, to the SDO.

We’re all pulling out of the same toolbox, using the same tools. So we also wanted to use the same definitions. That was the other thing, is trying to use the same definitions instead of everybody having their own definition, and then getting the mix-up. Because, again — now, although some of the SDOs don’t cross — maybe, I think all the SDOs cross at some point, there’s always cross-secting, so it’s not like there’s any SDO that, they’re off on their own. We’re all already kind of working together. It’s just working on bringing those more together.

Some of the central — so we came up with centralized standard organization, CSO. So, sorry, no Ted. There’s centralized organizations, we would have resources. This would be where our implementation guides, our standards, publisher publication things. We have a shared volunteer list, or a shared volunteer pool with an expertise pool, across all of the standards. Not just pulling from our own individual ones, it would be more of a shared across the board.

We would have — so some of the other things, they would also deal with the funding, government issues. We would have a process that we would all work under the same process and procedures. So, coming back to what we talked about earlier, is that we would take the best — I think everyone does something well. We don’t do everything well, as individuals, but maybe as a collaboration we bring all those best practices together and build one process and procedure. And this would really help the industry that’s not at the table.

One of the big things is that they would also be in charge of making sure there’s cooperation, coordination, and communication. They would do the prioritization of the current releases. They would be schedule-driven. So it’s you do what you can do in six months, and that’s it. You do what you can do in a year, whatever that timeline is, it’s all schedule-driven. I mean, every other — Nick, you brought up Microsoft. They push it out. They don’t care if you’re ready for it or not. It’s a done deal.

So maybe not so much that strict of a model, but that type of model seems to be where I think there’s some parts of that work well. I mean, if you know that you can only do a change every six months, it really makes sure that you put the right things first. And then they would also be in charge of the education.

So our storyboard — I don’t remember the storyboard anymore. So we have Chip — they didn’t like it, I thought we’d all have chips in our arms, you know, or our fingers, have all of our information. So anyway, Chip is, he’s on the road. He’s a road construction guy. He’s ill. He’s a little bloated, and stopped — he has a problem. Jim’s going to an unknown doctor, and we have Jim’s health care data out in the cloud — oh, excuse me, Chip. We have Chip’s data out in the cloud, see our cloud? That’s a cloud. That was Nick’s contribution.

It’s a cloud. Use your imagination. He’s going to the doctor, the doctor knows right away that when he does all his healthcare information, his payer information, all of that is out there, and all the information that they need to know about Chip is there, available, so they know what his past is, all that data’s immediately available. They know who to bill to. Because, you know, Chip’s wife, she’s out of town, too, she can’t be reached, he doesn’t know his insurance. He doesn’t know the number. He doesn’t know anything. His wife takes care of all that for him. At least that’s my world. My husband wouldn’t know.

And the payer’s all involved. So Chip can really get all the services that he needs, and that’s ultimately who we’re concerned about, right? Because all of us, or one of us, are going to be Chips, at one point or another.

So anyway. The payer’s a rainbow, by the way, if you can’t see that. I had the lime green, the pink and the blue.

MS. DOO: Very nice. Thank you, that was excellent.


Okay, Lime green.

MR. BEATTY: I’m going to sit through this. Our theme kind of went along sort of the lines — one of the thigs we were looking at was agility. So here are some common themes: reducing the cycle time. So some of the things that we were looking at is establishing firm cutoff dates, you know, how do we shorten things down so that we’re not in the same model we are today where we have such a huge span between versions, and have a volume, a high volume of changes.

How can we make it smaller, more frequent changes that are more consumable by the industry? Which kind of goes along with predictable cycle, having the shorter, frequent updates, use — go from using the full regulatory process to using the interim final rules, by having the shorter, smaller volume of changes. Can we have interim final rule with comment rather than going through the full comment process?

And looking to have vendor investment, I think one of the other groups had mentioned having vendors be covered, which would be an interesting concept. Increasing industry engagement, look for innovative approaches to data management, and how we use the data, which kind of ties a little bit I think into some of the concepts that we heard at the table over here. And then looking at the differentiation of the timelines involved in the process.

MS. KLOSS: (Off mic.)

MR. ARGES: Primarily, I think — other people have touched on this — I think the idea is that you build the ontology, in terms of the content, and the content really drives everything. And whether you use JSON down the road, but the idea is it’s all about data, and it doesn’t matter where the data resides within the providers’ operations — the key data is always identified, and the key data has got a corresponding ontology crosswalk, and it moves a little bit quicker, moves a little bit better. It can be used for provider-to-provider, provider-to-payer, provider-to-patient, as part of that process.

So the idea is, it becomes kind of agnostic a little bit towards whether it’s a current EDI transaction, or it’s an XML or the JSON, but the idea is data drives everything moving forward.


MS. DOO: Okay, White.

MS. BANKS: Ruth-Ann and I, we just had a really nice conversation, because we both come at it two different ways. So we get to that intersection, and Ruth-Ann made a really good point: if you’re going to strive to eat the elephant, you’re never going to get it done. And of course, I want to eat the elephant.

So we came back to the point that George that was just coming off of. Data is key. So how do we make whatever changes we do today relevant for the future, where we know that administrative and clinical processes are emerging. It’s the same underlying data that’s going through.

So how do we set up the standard setting, organization operating rules, and terminologies, in order to get to where we were going is, a real-time adjudication, doing it right the first time. How do we get the information where it needs to be, which may not just be between the payer and provider, it could be between the caregiver, the provider, the payer, the patient, right? Because then we got talking into billing, right? We have one patient-visit billing versus episode patient billing, and the patient wants a coordinated bill.

So we stepped back, moved again back to the data, and we’re like, okay, what are the actionable steps to get to coordinating this, all of us together, in order to make that data usable? So no matter how that data is transported, whether it be in a standard, whether it be through FHIR, whether it be through whatever type of mechanisms, how do we get the information in a way that’s understandable for whatever purpose or use case that you’re testing through your pilots.

So the suggestions we had was to form a committee to develop a data dictionary, and when we mean data dictionary, we know there’s a lot of different terms, is: common terms and their uses across all the standards. Across all the operating rules — I think they’re based on the standards — as well as the terminologies. You know, like CPT can be used in a lot of different ways, even though there’s an industry-standard way to use it, it’s still used inconsistently. How do we harmonize all those?

Second, form a committee to identify the best practices for — because, not just doing it, right? — we’ve got NCPDP, shout out Margaret, and also across the world. Ruth-Ann had mentioned some other countries that are doing real-time adjudication. Why are they doing it, and what can we learn from them?

The third, develop crosswalk of data fields to standardize the data exchange. So, when the data fields have different names, that’s fine, but how do we know if we’re going to be pulling data out of different standards or out of different vendor systems, that we’re actually pulling the data that means the same thing that we’re intending it to be? So how do we attack that animal?

The fourth, develop industry-wide semantic compliance and standardization. Again, the field, if it’s alphanumeric, it doesn’t really help us, does it? But it has to meet the purpose of the use case that that information is needed.

Which drives us down to five, which I think is mentioned by someone else as well. And we didn’t know if it should be a mandated minimum or max set, so we were kind of going back and forth, and there needs some better minds thinking about the use cases and what it should be, but develop a mandated minimum or maximum data set for auto-adjudication and stages to pilot incrementally to support emerging payment models.

So the professional or institutional or does it need to be by specialist? However that incremental approach needs to be, but the point is, how do we get the information up front to the right parties — again we’re not just talking payer-provider anymore. Coordinated care, patient, get them involved, simultaneously in a way that the data is meaningful, and it’s meant as it’s intended and the receiver understands what that information is.

Do it right the first time.


MS. DOO: Thank you. We have left transparent — is that right? And then Alix. Orange. I’m sorry. Transparent and orange.

MR. SAWYER: Our plan is, let’s get small. Let’s get small. As Blue was saying, as Yellow was saying, and others, we need to go through our plan-do-check-act cycle, right, Deming model of management and process improvement, plan-do-check-act. We need to do that a lot faster.

Now, if you’ve got a large process rolling over a distance, you’ve got a larger process, kind of smaller revolutions per minute per inch, but we need to get that down to a much smaller, rapid process, where we’re cycling through possibly even the same process that we have right now. Don’t have to change the legislative process, don’t even have to change some of the other processes. But what we do need to do is do this more rapidly with a smaller increment or smaller amount of changes per increment in the transactions.

So as people were saying, it’s along the same lines, but this gives us predictability in terms of budget, in terms of everything else. If we’re able to say, let’s get the magnitude down, not do a large magnitude every five to seven years, but a much smaller magnitude, agile development, smaller increments more often. Let’s get the magnitude down; let’s get the frequency up.

And even still, as I was saying, so the existing process where it goes through, and the standards bodies develop and increment, and it goes through, comes to NCVHS, NCVHS to CMS, and CMS for final rule. As long as we’ve got these things in overlapping development, and it think it was Yellow was talking about that as well, having these preplanned and prearranged where you already know what’s going to be in that cycle, you already know what’s going to be in that cycle, and as you’re working this one for development and implementation, these are already in the works almost ready to hit.

So you’ve got that continuous process, smaller increments more often. Basically I think everybody knows that’s where we need to get to. I don’t think it’s going to be even that resource intensive, as long as we can take our current processes and move it into a more frequent overlapping cycle.


MS. DOO: Thank you. All right. Orange, may we have your presentation.

MS. GOSS: Thank you. Because we are going to take our time traveling machine and we are going to go to a land where we’re all connected and we have an enforcer at the top that helps us move along to ensure that we all play ball, so that we have lots of carrots and sticks and eat well and are healthy, and have plenty of chocolate along the way. I hope I didn’t forget anything there.

I’m going to just talk to it, because I get to mostly say, ditto, to what all of those great other thoughts that you guys have presented so far from the other teams. Orange is clearly focused on the blending of clinical and administrative financial data. Our focus is data. And nothing else. So you might want to call us DANE — data and nothing else.

And we’re about the scope of the data not being a governance body that creates necessarily standards that enable the data to go between organizations, but more about being technology neutral; and structure neutral, so that — using the pieces of the puzzle that we already have today, but we’re focused on data and their attributes and resolving redundancies, but in order for that to be done effectively, they’re going to have to be federally recognized.

They’re going to have to get funded somehow, and they’re going to have to be empowered to wrangle the kittens. Also to ensure that semantic alignment really happens around the data and its attributes, that they ensure the testing and the piloting occurs. We strongly believe it needs to set a floor, not a ceiling, because there is a dynamic with states having their ability to promulgate or to adopt their own rules, but we really like the set the floor.

As I noted before that the current players, the HIPAA and the high-tech world of players, would all be a part of this new organization that we envision for governing how the predictability is achieved and to garner more value, but that you could be voted off the island and your standards could be retired if they need to be.

We started to talk a little bit but didn’t finalize our design of this creating a new organization by rulemaking. And to decree — like almost having the feds be able to decree the charter for this organization, and possibly have an RFP to award it. One of the things that we were trying to deal with was also a way so that it wasn’t — we’ve been through this process of creating governing bodies in the past, and we sort of rearrange the deck chairs, but we don’t necessarily get to anywhere better.

Or let me put it more bluntly — we don’t establish the trust in the level of collaboration that truly needs to be there to effectively govern, to get the value for the U.S. healthcare system, as opposed to the various agendas that go on. So we did not get as far in our discussions as we would like, because we found that those aspects of the trust, how they got created and how they got funded, to generate a lot of ideas but we didn’t have enough time.

MS. DOO: Thank you.

MS. GOSS: You guys want to add anything else to that?

(No response.)

MS. DOO: All right, thank you.


Agenda Item: Destiny

MS. DOO: We are coming around the bend, as is the sun, interestingly enough. We are on the last phase. Isn’t that interesting? How kismetic? Is that a word? But that’s good, that’s a good thing. I make up a lot of words.

You did an amazing job with the supplies. I had no idea and you really — don’t take that apart. You can take it home. We can auction it off, actually, and donate to a charity. New governance model, something like that.

So this next part is, if the rest wasn’t difficult, the last part should be. How will these ideas be implemented, and again, I will continue to challenge you to, one, be positive about where you’ve come from, but also be a little bit hard on where you’re trying to get to. Because I think the reason — we’re not here because things are going 100 percent how everybody wants them to, because we’re adopting standards every year.

The last rule we wrote was 2009. And maybe we don’t need new versions of standards every year, but something — something is leading to the reason that we’re here. So we’re trying to look at how we do things well. But there’s also something else that’s causing this charge for, we’d like it to be a little more predictable. You have 50 really interesting ideas, but you can tell that there’s a lot bubbling under the surface that’s not being said. It’s the proverbial elephant in the room that somebody doesn’t want to eat all of today.

So you still have an opportunity to get at some of those things, and as the destiny slide says, what are the smallest things that can be done that people here are willing to commit to or not to commit to, that you have to decide to do them, because you have to go back to your organizations and have a conversation about today and say guess what I did? I played with Legos and playdough for a day.

But while we were thinking about doing something. Ruth-Ann?

MS. PHELPS: There is one — maybe it’s a small piece, at least I’m hoping it would be a small piece, but there’s one idea that has been mentioned in more than one group, I think at least three groups, and again, this is borrowing something from NCPDP. Typically, the new standards and requirements are huge, and require a lot of time, a lot of money. Why can’t the industry send it out in small pieces, just like NCPDP does? There are quarterly updates for that. I mean, it’s doable. It’s something you can comply with. It isn’t huge.

I mean, the standards for 6020 were already agreed upon, but they weren’t released, because we are waiting for 7030.

MS. GOSS: Are you talking about external code lists, or are you talking about structural transaction modifications? Two different things, and I’m —

MS. PHELPS: I am talking about all of it. I’m just saying instead of bundling it up into something huge, putting 6020 and 7030 all in one package that we all have to comply with, why not try to do it incrementally like NCPDP does? Small bites at a time. I mean, that to me is doable.

MS. DOO: That could be something that could go on one of, on your team’s —

MS. GOSS: I am sorry. I am really confused. I’m not an NCPDP expert, as you can tell, and Margaret and Patsy, are you guys actually rolling out structural changes on a quarterly basis, or are you rolling — I thought it was just external codes.

MS. WEIKER: No, no, it’s not just external codes. It’s everything. We used to ballot — if there was a change, we didn’t ballot if there was no change, obviously. But we used to ballot on a quarterly basis the telecommunication standard, the standard, plus any changes to data elements, code values, anything associated with that.

We did that on a quarterly basis, and what was happening though is we would get one or two little changes with rewording the definition. Well, that’s a new release. So we said, you know, we’re popping out versions that aren’t really needed. We’re running, burning through versions.

So what we did was we went then to balloting structural changes to the standard twice a year, but external code list four times a year. But if need be, we could always go back to four times a year, if we had to, but that’s how we — that was the model until about, what, how many years ago did we change that, Patsy? Three or four years ago.

MS. LOHSE: Ruth-Ann, to your comment, and I guess back to Margaret’s, one of the lessons learned, I think, as I look at this and I think about these incremental changes, within the operating rules between version 1, 2, to 3, what was integrated — and I’m not saying that the operating rules are the solution — was that maintenance on an ongoing basis was built into the actually passed regulation. So CORE can go in and actually update and change pieces of the operating rules without needing to go through the entire regulatory process.

There is a consensus-building process. It’s business case driven. It’s transparent. It’s open. It meets the other needs. But it allows that continuous evolution and involvement from the industry to speak to the business needs and evolve more quickly.

There’s probably many places, and you know a lot more I think the people that are at the SDOs, whether it’s the language, the data content, the transport, there’s things throughout the requirements where you could actually bake in a frequent maintenance that has an established process and allows for ongoing updates.

So I don’t think it’s just one particular, whether it’s the code sets, it’s the data — it’s probably throughout the entire process we could do that.

MS. DOO: This is a great discussion, but we sort of got ahead of ourselves in a group discussion. So I apologize. But we’re going to do the last part of this, just so we can get through your workbook.

So we’ll do the last one, and then we’ll be able to go outside, for those who want to. But let’s at least do this last exercise. We’ll just take the 15 minutes, because it’s sort of a culmination, but we don’t want to lose out on this opportunity to hone in on — so everything you have been thinking about, much of what you have heard from the groups, because this will enable you to take all of this and, sadly a little bit, even though you’ll go back and talk to your groups, you do need to pick something from everything you have talked about in your own groups.

So if you had to choose, what’s the one thing that you would like to put in your sheet that you would want to work on? So now on page — Alix, would you please tell me what page? Page 15. You will pick an idea that you have that you would suggest that we all — what’s the one thing that you think we should work on and what does success look like if we worked on it?

What are the actions? You don’t have to say all of them, but what’s important here is who else needs to be involved? Who is not at the table that needs to be at the table?

So what did we say at the beginning, one of the rules? No sidebars. Just give me one more minute. So if you’ll just fill in this for yourselves, and I’ll actually give you big sheets for this one also. But just to develop as a whole group with your groups for this, because then I’m going to give you sticky dots, and you’re going to go around and as a group, you’re going to put dots on what you think is possible for our industry.

So this is the big moment. So I’ll give you 15.

(Table discussion.)

MS. DOO: I know it’s late in the day and you may not have been able to finish and you’re still talking over me but that’s okay. I’ll talk over you. Thank you. You will have plenty of times to have other chats.

This last piece is our destiny phase and some of these have been written and are available for viewing, yes? No? Alix, is your destiny available for viewing? Yours is available for viewing. Debbie? Gary, if you turn yours around, is it available for viewing? Okay. Transparent group, is yours available for viewing?

So I think that, again, the point of this was to see if you could consolidate all of your ideas into something that you would be able to have a goal and that you’d really be able to identify what success looked like, and then have what actions needed to be taken, who should be involved, who’s not at the table, and what you could commit to.

What NCVHS really brought you here together is what would be the next steps in terms of harnessing all of this information together, pulling it together, creating some kind of a summary set of actions that could then be talked about at a potential hearing? So looking at this document, saying, okay, what did we learn from today, and where do we go from here? Because obviously the intent of it was to help you find ways to have more predictability and help industry have more predictability in both the updating and the adoption of standards and operating rules?

So I don’t know if there is enough that we can really vote on anything today or if it’s better to have a discussion, and so I’m really going to leave it up to the chairs of what we do with, now, all of the information that we have. Is it better to have a discussion about all of the ideas and see where that will leave us from a framing standpoint of how we synthesize it, take everything, all the hard work that you’ve done today to get to these sort of consolidated destiny statements, and where we go next. In the next 30 minutes, we want to have a discussion about all of the sort of consolidated effort.

MS. GOSS: I think Nick and I agree with the discussion. So quickly run through what you want to say and then leaving time so we can enable people to comment.

MS. DOO: Okay. Which group would like to report their final consolidated idea? Let me take notes on the sheet.

MS. MEISNER: We didn’t redo our board; we prioritized into what we thought could be done and we think our number one thing that we think we can do is split into two. We think that the regulation, the next set of standards, is going to happen before most of this other stuff can happen because this isn’t going to happen overnight, but we felt that the regulation for the next version could be that flexible, allow for a primary. This is the bottom line, but also allow for trading partners to move forward with new technology, as long as the regulation specifically says the content has to be the same.

So we think that could happen. That would include the regulatory folks and the standards, people getting their next versions ready.

MR. COUSSOLE: You’re saying that the same processes exist, just influence the regulation?

MS. MEISNER: Influence the regulation to only name a floor that says this is going to be the primary. So everybody would look to do that, but if two trading partners agree to something else, you would not be out of compliance, as long as the content meets the requirements of that base primary transaction, primary thing.

That was number one, and then two, we thought that the SDOs could go away and try to develop those data dictionary content and rules that would govern future adoption of standards content.

PARTICIPANT: What do you mean go away?

MS. MEISNER: Well, go to their meetings and get their — and it’s not going to happen, I’m hoping it won’t happen before 7030 comes out or the next versions.

MS. DOO: Debbie, what is the timeline for this?

MS. MEISNER: Whenever you’re writing the next regulation.

MS. DOO: So it could be in claims attachments? Okay. So the next available time.

MS. SHEPPARD: Lorraine, are you clear that’s two things? The first thing is that there would be a base syntax. So for example, for X12, that would say the EDI standard, but other syntaxes like XML, JSON, Fred Flintstone, whatever they are would be specifically allowed, and a second point that multiple versions would be supported in line with what some of the other tables have said. That’s a two-part thing.

PARTICIPANT: So who is supporting the multiple versions?

MS. MEISNER: Implementers, anybody implementing.


MS. MEISNER: We didn’t get down to the detail.

MS. DOO: Okay, regulation names, the floor, content compliant, and multiple versions.

MS. MEISNER: Yes, those were the two that we felt could be done right away, and then concurrent to that, which is going to take a long time, is the SDOs sitting around the tables here and operating rule entities look at it from coming up with a common dataset of content with rules, agnostic of the format, the transport method.

MS. DOO: All right. Thank you. Orange?

MS. GOSS: Okay, so we went with the data, nothing else. Thought process, we focused on the governing body for data semantics, for SDOs and operating rules and added the code groups to it.

It was the creation of an organization resulting in data interoperability. Short-term, we were looking at core elements being harmonized. Medium-term, the master data defined. Long-term, semantic interoperability in the United States, achieved with ongoing maintenance in place.

Who should be involved? This diagram will help me in a second. Current SDOs operating rules, terminology, vocabulary, content committees, government, WEDI, and NCVHS.

Challenges are the funding and designating the authority. The barriers, some proprietary aspect of terminologies, and getting everybody sort of at the table that isn’t already there, and ensuring that we have the funding that we needed for the terminology, if there was any implication between the data and its attributes and the code sets that we were using.

So we thought that there would be this new organization. I think that Pink’s team, or comment, that it would have to be probably in the next version upgrade promulgation unless you could do something more slick. Ideally, I would love to be in the attachments and acknowledgements. That gives me hope. Maybe look at those rules.

But you would then have this governing body that would work together and would help bring the data attributes and alignment across all these different organizations who does their normal development process and has a public comment period. It would go then from this development cycle back to DANE for testing and piloting, and also I’d really start the education effort with WEDI, with a further public comment period, but with an intended life cycle to get back into any of the changes that we learn from the real-world piloting experiences.

We come out of this process and we would go into more formal education, the industry, because at this point, NCVHS would be making a recommendation that would result in a final rule, period, no public comment, no NPRM. It’s just a final rule that’s put out there.

So what you do is, this is not very pretty, but it’s intended to be a life cycle that gives you the loop that you need to and hopefully be able to shorten the timeframes. We didn’t have an opportunity to go further.

PARTICIPANT: We think we can build on that.

MS. DOO: All right, thank you, Orange. Lemon yellow, then Green.

MS. STINE: Okay, so over here in the neon yellow world, or whatever color we are, we’re going to kind of build on the same concept. Well, we actually have two concepts.

Concept one, we’re going to build on what you were just talking about. Concept two, I’m going to bypass that for a second, is talking about the law, and trying to get to more frequent updates from a regulatory perspective. That’s our longer-term goal.

We do have that longer-term goal, trying to get to perhaps yearly updates for our transaction rules because right now, there’s too much time in between what allows us to get to those more frequent transaction updates. I know, Gwen, you talked about what’s baked into through the ACA for operating rules. Unfortunately, from the transaction standards perspective, we don’t have that baked in. So that’s one of our goals. We actually created that as one of our goals. So that’s a longer-term view for us.

Short-term, which we feel like we can work on now, is a very similar concept to what Orange just talked about, but less regulatory, more voluntary, creating an interactive group between all the SDOs where we all get together on a voluntary basis to create a common data dictionary with common definitions where we can all agree.

I’m going to go back to the sex and gender discussion that we’ve been having across SDOs right now. We’ve got male, female, but we’ve got the issue of — yes?

MS. GOSS: When you say to voluntarily come together, is that sort of leveraging something that exists today, or creating something new?

MS. STINE: Well, that is a very good question. I was looking for Margaret earlier only from an experience perspective. We’ve got the HSC and I actually, it jumped into my head, we’ve got an organization where the SDOs come together that perhaps could be leveraged.

MS. GOSS: Is that the reincarnated SCO?

MS. STINE: Yes, it is. Now, I can’t obviously speak for whether or not that would be an opportunity, but perhaps from a facilitation perspective, they could be used or could step up and see whether they’d be interested in facilitating discussions, but that popped into my head. Can’t speak for them.

But working on creating data dictionaries and common definitions, not to necessarily make changes but to carry back to their organizations that we have a need and I don’t have something in my base standard today, but I know that change needs to be made. In the meantime, this is how we’re going to handle it with the limitations that we have in the standard today. That mapping could be housed or documented for today.

Once the change is made, it would be brought back to the data dictionary, okay, A, B, C standards development organization has now made the change to react to that need. Update the data dictionary. So maybe minimal funding, someone may have to support that, but we think we can actually affect some changes today with maybe a little bit rather than having to go through rule-making, just using what we have available to us. Tammy?

MS. BANKS: Would that fall under operating rules, data dictionary and common definitions?

MS. STINE: No, this is something that each SDO would own.

MS. BANKS: Because it’s a crossover, or would it be — I’m just wondering what would make sense. I’m not saying it should, I don’t know.

MS. SHEPPARD: About the question prior to that, I think it’d be great if the three main SDOs had a chance to talk to each other and work with each other first before somebody decides something is going to be on top of that. I think we can do that.

MS. STINE: Well, it was a thought that popped into my head. I don’t know.

MS. SHEPPARD: I was answering Alix’s question of whether it would be a new thing or an existing thing. I’m not sure it has to be a thing at all right now is what I’m saying.

MS. DOO: Remember these are just ideas, so put that on that group’s.

MS. STINE: Yeah, I don’t think anybody is making promises today.

PARTICIPANT: Right. These are all just ideas.

MS. DOO: This is not the discussion. Right now, we’re just having the report-outs.

MS. BANKS: Can I make one point because I think it’s so important because the volunteers that are doing all this work are so under-realized and there’s got to be funding if we’re going to do this above it, which is going to be instrumental, just a thought.

MS. KLOSS: Our Green group had, we’re looking to — everybody a little bit, and we thought there was sort of a psychological advantage having one of the short-term actions be to advance this idea of adopting standards through interim final rule. That would be something NCVHS could create a recommendation about and a rationale for, because the experts at the table said that’s a way to lop a year off of a long process, at least.

So I mean, that’s something that could be done with the right thinking about how to affect it and that would be, it would have the advantage of HHS, CMS, stepping forward to say, we’re really in support of finding a way to make this whole process agile and here’s what we can put on the table.

Then we saw that the SDOs themselves could work on taking a critical area and looking at opportunities within their own mechanisms to streamline and perhaps make more consistent. So we’re bringing maybe everybody into the party. HHS does something; the SDOs do something.

For example, Gary said that, and you can explain this better than I, that it would probably be a good time for X12 and to kind of look at ways to support more agile timelines through use of technology, and I think that was kind of the essential notion that we could look to some steps forward from each and maybe some consistency.

Then our third area goes back to this ontology. Sex isn’t something that just is defined in standards. It’s in SNOMED and it’s in everything else. So we actually think the home for this ontology needs to be UMLS through the National Library of Medicine so we make good on what we were talking about earlier in bringing the clinical and administrative datasets into the same world.

The timing on that is pretty good because NCVHS is kind of doing an environmental scan now on health terminologies and vocabularies and having some stepped-up discussions with National Library of Medicine and UMLS. I mean, I think we agree that we need to find some funding. That doesn’t solve the problem of where the authority is, but it does say that once there is a normalized ontology, where it’s maintained, how it’s maintained, how it’s disseminated, how it’s accessed, and that’s often a big part of the problem.

So I think where we were coming from was the way forward would be to have HHS and NLM take a step forward, but also a contribution from the SDOs themselves, and NCVHS could help by writing the necessary sets of recommendations supporting these.

MS. DOO: Thank you. Who is next? Is it Blue?

MR. LANDEN: Blue filled out its nice little form. We have renamed Ted to Speedy Ted. So the name of — Ted’s the name of our project idea. The goals and outcomes are for fast piloting, frequent transaction maintenance, and new transactions and operating rules. Success looks like a shorter calendar-fixed cycle for all the updates and maintenance and new transactions.

What are the actions that need to bring this idea to fruition? In the short term, we need to rally the troops around the concept, get the word out of what we want accomplished through Speedy Ted. In the midterm, do a test run to prove the concept of Ted on maintenance cycle update, and then longer term, pilot new and more complex transactions through this Ted process.

Who needs to be involved? All industry stakeholders. In my spare time, I developed this little model of the industry here.


I just got back from an Alaska cruise. This is an iceberg. And the orange line is the water line. So in translating that to healthcare, those above the water line are those of us who are engaged at this national level through the SDOs, through the ORAE, through a lot of national committees.

Under the water line is everybody who is impacted by the decisions made at those various groups and have to live with it. So we need to, we know we’re not going to get everybody at the table, but those at the table need to be sufficient to do a good job at representing the rest of us.

Okay, challenges. Big challenges to both the feds and to the states at modifying adoptions, this may not be the same process we’re familiar with with NPRM, public comment, final rule, and then the state equivalents there. Challenges on voluntary adoption, how do we convince everybody that this a good idea for them, even though there’s some costs? Education programs lacking, we may not be able to convince them of the value.

Shared strategic planning, that’s another effort that we have to come together with similar to what we’re talking about for the data dictionaries and common definitions. And funding. We assume that the first round, the short term will be able to muddle through, somehow get funding by enough people, but longer term, this is a national priority and has to have reliable national funding. We don’t know what that is.

Barriers, process changes will be necessary for many of the folks in the necessary, including the SDOs and the government. As mentioned, need to find permanent funding solution somewhere down the road, and complacency. Folks are used to the way it works, don’t like change. How do we convince them there’s value to make the investment to change?

MS. DOO: Very good. Very nice and well organized. Thank you. We have White and Transparency.

MS. BANKS: Well, we were watching the eclipse so we kind of stayed on what we had before.


Again, to achieve real-time adjudication, but we did try to answer the question about who should be there, and I think we just echoed what other people had said previously, that it needs to be everyone who touches EDI needs to be a participant, and that includes some of the noncovered entities like property and casualty, and some of the vendors need to be covered entity or we need to extend that business associate so they’re liable for being compliant with the standards.

Again, we stuck with develop a data convergence committee. So I think we’re mimicking what was already said before, comprised of all these covered entities, even those currently considered noncovered today, and SDOs. Focus on that data dictionary across all standards, both clinical and admin as well as the crosswalk of data fields for the standardized data exchange.

Then identifying the best practices, we thought we really need to do a deep dive into what is working across the world so we can make sure that whatever we do, we’re going to be ready with the global. However, we’re in DC, so obviously it’s America first.


MS. DOO: Okay. Thank you. And Transparency?

MS. BHUTTO: Our project idea is similar to what we heard earlier about the plan to do a check and a little bit of what everybody else has mentioned. So project idea is get small and the goal is to have more frequent updates and smaller volume changes over time. Success is mainly what we spoke earlier, allow for budget planning as well as faster turnaround.

The target of this could be once a year like most of you have spoken. Who are the stakeholders involved? X12, CMS, NCVHS, and others. The biggest challenge we see is having additional resources for meetings and things like that. So cost and resources could be a constraint.

An additional barrier is increased human resource engagement is important. So that’s a barrier as well as could be a strength if we have that. I don’t know if you wanted to add something. That’s all we have. Thank you.

MS. DOO: All right, thank you. Very consistent. Madam and sir chair, co-chair, we have gone through the groups and there is still a lot of consistency in terms of the opportunities for the destiny of the group.

It sounds like, from what I’m seeing, a desire for agility, for speedier delivery of certain things, whether it’s sort of the smaller volume, speedier turnaround ability, that means agility both on the government’s part to deliver, as well as on the standards organizations.

These sort of different governing bodies, we haven’t mentioned the DSMO, what I call the Mother DSMO, but it’s a kind of a governing body, but we’ve heard about different kinds of governing bodies. So there’s been some discussion about that kind of entity and then about this data, many different kinds of data groups I’m going to call them, and I think they’ll have to be defined, but as we’ve been talking about for years, this convergence of clinical and administrative data has continued to come up again and again.

That came up when Walter Suarez was part of the committee, but I don’t know if people would agree. I’ve heard it a lot more today. The interoperability challenges, frequent updates, regulation being a floor, not a ceiling, and enabling trading partners to exchange information, and again, sort of this agility, and agile is actually something that’s being used in the federal government now quite a bit more.

So I’d like to, I guess, really, it’d be important to hear from what the NCVHS co-chairs would like to say, if anything else, and then open it up to public comment, and then a close-out of what’s going to happen next.

MS. GOSS: I would like to confer with Nick for a moment.

MS. DOO: Yes, you want to talk to a friend.


I will just tell you briefly, though, just for those of you who haven’t been as engaged with the SDOs and again, I can’t thank those of you who have been participating, for all the information that you’ve given us for the information gathering, for the SDO chart, thank you for your updates.

I will get all of those edits in so the final document will be clean with all the changes that we got because we’ll be doing this final summary report. So we appreciate all of that. There will be a final report that will contain all of the learning that we have done through all of the series of activities with the information gathering, the discussions, and of course, this exercise. Have you decided?

MS. GOSS: Yes, we have decided. We are going to pick door number three.


I think at this point, I think Nick and I both agree that it’s been wonderful today to have all of your creative thinking, to challenge each other, to really put out a number of the issues on the table. There is clearly some commonality and alignment of thinking and I think the subcommittee needs some time to noodle on this a little bit more.

I think all of you need some time to noodle on this a little bit more. So we would welcome any feedback you may have after this, but we are eager to hear if there are any public comments from, I think most of our public comment here in the room was already involved. Was anybody on the web we need to be mindful of? Nobody on there? Okay.

So we would like an opportunity for us to take the feedback and think about how to move this forward because right now it’s a little bit overwhelming.

MS. DOO: Anybody have any last-minute comments? I think my name might be in the book. I think you already know how to get me, but again, I can’t thank you enough for being willing to spend the day and contribute as much as you have. I think as Alix said, the committee needs time to think about it, and you need time, if you think of anything that you want to add, please feel free to send it and it will be considered. I’m assuming there will be a follow-up powwow of the committee.

MS. GOSS: Absolutely. We have biweekly calls scheduled to enable those conversations to happen. I noted at the beginning, this is the beginning, this is a step in the process.

So I think we will synthesize it. There clearly will be a meeting summary put up on the web. We will have subcommittee discussions. We will be probably discussing this in some shape or form during our hour allocation in the September full NCVHS meeting, which I believe will be the 13th and 14th of September.

MS. HINES: Correct.

MS. GOSS: Thank you. So I think we need to let it percolate and I think that we opened the tent and we need to figure out exactly what we’re going to fully put in the tent, and I don’t think we should rush that. This is too important.

MS. HINES: In case you haven’t made it to page 16, Lorraine’s contact information is here. So to just echo what she said, if there’s anything you want to send to the subcommittee, Lorraine’s the way to do it, and her email is here.

MS. DOO: So that’s it for today. Please feel free to take any more gummi bears, goldfish, playdough, anything you like, and safe travels. Take the fidgets and whatever else you like. Those are for anybody. Thank you. Bravo.


(Whereupon, the meeting adjourned at 3:32 p.m.)