This Transcript is Unedited



Subcommittee on Standards and Security

December 9, 2004

Room 705A

Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, D.C. 20201

Proceedings By:
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, Virginia 22030
(703) 352-0091


P R O C E E D I N G S [8:42 a.m.]

AGENDA ITEM: Call to Order, Welcome and Introductions – DR. COHN, Chair

DR. COHN: Okay. Good morning. Good morning, everyone. I want
to call this meeting to order.

This is the second day of three days of meetings of the
Subcommittee on Standards and Security of the National Committee on Vital and
Health Statistics. The Committee is the main public advisory body to the U.S.
Department of Health and Human Services on national health information policy.

I’m Simon Cohn, a physician, and Chairman of the subcommittee.
I’m the Associate Executive Director for Health Information Policy for Kaiser

I want to welcome fellow subcommittee members, HHS staff, and
others here in person, and I also want to welcome those listening in on the
Internet. I do want to remind everyone, as always, to speak clearly and into
the microphone, and I think our speakers will discover that we will be
constantly reminding you to get very close to the microphone because of how all
these work.

Today, we continue our hearings on e-signature standards with a
focus, of course, on its relationship to

e-prescribing. As all of you know, the Medicare Modernization
Act calls on the Secretary to adopt standards for e-prescribing and the NCVHS
has been directed to develop such standards’ recommendations.

This morning, we begin with an information systems vendor
perspective on e-signature, and this will be followed after I think the morning
break by plan and PBM perspective; after lunch, we hear from pharmacies,
followed by standards development organizations, and then have an open
microphone and discussion by the subcommittee on I think what we’re hearing as
well as next steps.

As always, I want to thank Jeff Blair, our Vice Chair, for his
help moving the work plan forward, and of course Maria Friedman, who has been
critical in terms of us putting together these three days of hearings, so thank
you both very much.

I do want to emphasize that this is an open session, and those
in attendance are welcome to make brief remarks or ask questions on issues
pertinent to the topics we’re discussing. I would ask, just because I only have
eyes in the front of my head, that if you do want to have questions or
comments, that you need to come up into my visual field and raise your hand or
otherwise indicate, so you can participate.

Finally, for those on the Internet, we do welcome email and
letter comments on any of the issues coming before the subcommittee.

Tomorrow morning, which also will start at 8:30 in the morning,
will basically be devoted to discussion about HIPAA and a HIPAA update. We’ll
be meeting with industry work groups and hearing updates on work going on to
improve the e-prescribing standards. And of course with that point we’ll also
be talking about plans for January and future hearings, tomorrow morning. We do
plan to be adjourned by 12:30 tomorrow.

With that, let’s have introductions around the table and then
around the room. For those on the National Committee, I would ask if you have
any conflicts of interest related to any of the issues coming before us today,
would you please so publicly indicate during your introduction? With that,

[Introductions. No conflicts of interest cited.]

DR. COHN: Well, thank you all for joining us. I think we’ll now
move to our first panel. I understand, Michael, you are leading off the
presentations —


DR. COHN: — and will be followed by, I guess, Jim, and then
Peter, right? Great. Okay, please.

AGENDA ITEM: Presentation – E-Signature: The
Vendors’ Perspective – MR. BURGER

MR. BURGER: Good morning, everyone. Mr. Chairman, members of
the Committee, thank you very much for the opportunity to make this
presentation today. WebMD appreciates the opportunity.

My name is Mike Burger. I’m the Product Manager for electronic
prescribing for the Practice Services Division of WebMD. In my job as Product
Manager, I have a couple responsibilities. One of them is overall for the way
our electronic prescribing products work and their content, as well as the
implementation and training of those products out in the marketplace. I also
serve as the Liaison for State Regulatory Affairs from the Practice Services
Division to our corporate attorneys, and we do spend a lot of time on many of
the issues that were talked about yesterday in the vicinity of regulatory
affairs and varying regulations.

Since WebMD hasn’t participated so far, or the Practice
Services part anyhow, I thought it might be a good opportunity to let you know
a little bit about who we are and what it is that we do.

WebMD is a pretty common marketplace name; most people know who
WebMD is. And there’s really three parts of it. One of our divisions is called
WebMD Health, which is the that you’ve seen on TV and it’s a very
widely used consumer-oriented health care site. We also have Medscape, which is
primarily physician-oriented information and content. We also have another
division which is called Business Services, and that’s our transaction
processing unit formerly known as Envoy, very, very widely used in the pharmacy
switching business as well as the claims and eligibility business as well as
physician-to-pharmacy EDI.

And last, but certainly not least, is the part of the company
that I’m involved with, Practice Services, and that division primarily is
involved in physician facing software that is used in doctors’ offices, so what
we refer to as a PAMA system for billing and scheduling, accounts receivable
management, as well a full EMR. And that’s the part of the company which I

In terms of Practice Services, we’ve offered an electronic
prescribing product since ’95, so we’ve got an extensive track record in
providing a product that physicians will use. It’s dramatically taken off in
recent years after a very, very slow start.

We have a couple of different e-prescribing applications; some
are PC-based, some are PDA, or hand-held computer-based. We also have Web
applications. They’re either embedded within the full EMR or available as a
stand alone product if the doctor just wants to do e-prescribing.

We have active e-prescribers in 39 states. Our primary pharmacy
connectivity is provided by ProxyMed, and we’re an active participant and
supporter of NCPDP in their efforts towards standardization, and we’re also
participating in just about every other standards organization that there is
out there in some facet within WebMD.

To give you an idea of the size and scope, our physicians that
are doing e-prescribing create 182,000 electronic prescriptions in a month. As
that breaks down, 83 percent of those are new prescriptions — so the bulk of
our physicians are doing new prescriptions — and 62 percent of those are
delivered to the pharmacy via fax; 38 percent are delivered via EDI.

On the refills, we have 31,000 of those transactions, or 17
percent, which are refill transactions initiated by a pharmacy, responded to by
the physician. That’s 100 percent electronic.

In practice, for the EDI transactions, we have very few issues
with electronic signature. Those states that have embraced regulations allowing
EDI have also come to the correct understanding in terms of electronic
signature and we’ve really had few issues. Our primary issues on electronic
signature really pertain to the faxes, and there’s some details that I’ll come

I spent some time last night redoing what I wanted to talk
about, primarily because my initial thoughts were pretty much what everybody
said yesterday; you don’t need to hear a rerun. So I thought that it would be
helpful for you to understand what our experience has been, because we’re doing
this, we have physicians that are using this technology.

What we know, for example, is that electronic prescribing
really deals with two different constituencies, if you will. Physicians are all
about new prescriptions. They’re interested in writing prescriptions. In the
exam room at the point of care, physicians typically will gravitate toward a
PDA or a tablet PC. Physicians seldom are interested in dealing with refill

As a consumer, that’s a problem – bothers me – but in
the real world, it’s primarily nurses and physician assistants that are dealing
with refills from pharmacies and authorizing them. And because of that, the
refills are primarily targeted towards the other staff in the office – the
nurses and the physician assistants. They tend to gravitate toward a desktop
PC-based application because typically they’re sitting at a desk, they’re not
moving around.

And so what we’ve learned is that it’s really two different
things, and to accomplish the goals of physician safety, primarily the
physicians are involved with that because they’re the ones that are initiating
those prescriptions. And that’s really where our strongest hand is, because
most of our physicians are doing new prescriptions. Fewer are dealing with

We know that physicians won’t adopt technology that adds
requirements that don’t exist for paper. If we require that physicians jump
through hoops and use fingerprint technology and have to log in four times to
do e-prescribing, they’re not going to do it. We’re competing with scribbling
something down on a piece of paper and handing it to the patient.

Today, it’s not really so much a question of which application
will be used; it’s more of a decision whether they’re going to use an
application or just continue to hand-write.

We also know that physicians won’t adopt technology if it
doesn’t address all of their patients. So we need to be cognizant of the fact
that if we have an application that’s in place, the doctor has to use it for
everybody, just not for one insurance coverage group of patients or another.

Another thing that we know is that they have to be able to use
this application to connect with any pharmacy. If the physician has to remember
– oh, this pharmacy I can send electronically, but this pharmacy I can’t,
they’re not going to use it because the lowest common denominator is still
writing it down, which is still universally accepted.

Clearly, EDI delivery of prescriptions is the way to go. That’s
what the industry wants, that’s what we want. But, the industry as a whole is
not there yet. Because of that level of technology at pharmacies, fax delivery
is still necessary today, as evidenced by the volume of prescriptions that
we’re sending that way.

Faxes still accomplish a higher level of patient safety because
they’re more legible and because they reduce the transcription errors that are
possible because you’re operating from a typewritten document. It loses the
efficiency that the pharmacy would gain of having the data come directly into
their system, but it still has a dramatic impact on patient safety. So for now,
it’s almost a necessary evil, from where we sit.

In terms of electronic signature, we have adopted the position
of ESIGN and/or UETA, and we talked about this at length yesterday. This is our
definition of an electronic signature: An electronic sound, symbol, or process
attached to the record.

Within our products, this is how we authenticate the
prescriber’s signature, so both the practice and the prescriber need to be
enrolled at WebMD, so we need to know who they are.

We give them – or actually they assign locally a user ID
and a password for the e-prescribing software, so they need to log in in order
to have access to the product itself.

WebMD assigns that practice and that physician a log in that
gives them access to our EDI network, so it’s another point of control.

We credential all the prescribers when we enroll them. We make
sure that they are legally allowed to prescribe and that their license hasn’t
been revoked and that their address and phone number and all that information
matches what’s in the DEA records.

Also, because we use a value added network, the value added
network, the value added network also credentials those same providers, just to
make sure that we didn’t make any mistakes or omissions.

And the pharmacies are also credentialed, and they need to be
enrolled both on our site as well as our value added network and we use the
NCPDP number.

We designate the prescriber’s electronic signature by this list
of indicia. On Page 9 of the handout is actually a picture –
unfortunately, I can’t slip back and forth, but there’s a picture that looks
like this which points out all the indicia.

So we assign a unique serial number as well as the source
system, in other words, the computer system that had generated the
prescription; a date and time stamp; an identifier for the sending system; the
prescriber’s name; DEA number; an internal sender ID number; the name of the
agent, if that’s applicable – if it’s not the physician, if it’s a medical
assistant that’s writing the script; the destination pharmacy, including name,
address and phone number; and the destination pharmacy’s internal receiver

So here’s that picture that I referred to, and I’ve kind of
marked off Sections 1, 2 and 3 so that you can get an idea of what the
pharmacist could look for.

And we have a pretty simple rule: If the transaction is
received at the network and any of this information doesn’t match, we reject
it, because that, we think, is an unsigned prescription, and we send it back to
the submitter and say, something is wrong; we don’t know who you are, or you’re
not enrolled on our network.

This has proven 180,000 times last month to work pretty well.
We seldom have issues with people trying to submit prescriptions where they’re
not authorized. When we do run into a question, it’s virtually always because
it’s a new doctor that just hasn’t gone all the way through the enrollment
process. We have a pretty good system of checks and balances to make sure that
everything is working as it should.

Our experience, of the states that allow EDI or fax, most don’t
anticipate an EDI transaction delivered via fax. You have to remember, from our
system, every prescription leaves the system in NCPDP format and SCRIPT
standard, and it arrives at our network that way. From there, we need to make
delivery of that prescription to the pharmacy in whatever mechanism that
pharmacy can accept it. And if a pharmacy is not yet EDI enabled, because
there’s a market need to deliver that prescription somehow, we need to turn
that prescription which we received via EDI into an E-fax – we refer to it
as an E-fax.

And that’s where we get into some questions about how the
pharmacy identifies what an electronic signature is. Of those states that allow
electronic signature, only nine have specific statutes and regulations which
reference electronic signature. Of the nine, only three of those definitions
match the UETA/ESIGN definition.

Now, you’ll notice that there are varying counts. Medco had a
different number than did NABP, as we do, in terms of the number of states
which allow EDI and don’t allow EDI. That sort of goes to that tremendous issue
that we have of interpretation of the regulations, because there’s an awful lot
of gray areas. And there isn’t really a consistent source of information that
everybody can agree to.

And that’s a challenge for us as a vendor because it causes us
to employ attorneys, and people like myself spend time understanding what the
rules are as they change.

Another issue that we have is that the signature and the EDI
rules vary for the various types of controlled substances from state to states.
In some states, a counter signature is required for a mid-level provider to be
able to prescribe a Schedule III or IV or V medication. In some states, it’s
not required.

So that necessitates us keeping track of all 50 states, plus
DC, to try and understand what the rules are so that we can program our system
to do the right thing. And that is a significant challenge for us.

We come to recommendations. It would help us if we had
standardization of signature requirements for all prescriptions. So, whatever
the rules are for Schedules II, IIIs and IVs and Vs should be the same for
every prescription. And that way we need to deal with all of those issues once,
as opposed to maybe 50 different times.

It would help us to have the standardization of the indicia
required to validate a true electronic signature. We came up with a list and we
publicized that list to the Boards of Pharmacy so that they’ll understand, and
the pharmacist will understand, how they know that it’s a legitimate electronic
signature from our system. But the way our colleagues will do it is going to be
different. So it would help if there was standardization there.

It would also help us if there was recognition of ESIGN or UETA
defined electronic signature for all prescriptions.

It would also help then to recognize an EDI- delivered fax
prescription as an EDI transaction, therefore making an electronic signature

And lastly, it would help if there were some guidelines for
value added networks. We still deal with situations from state to state where
there are anti-depot regulations, for lack of a better term. Those are all
well-intended but effectively prevent EDI from happening in those states, and
I’ll show you an example of that, the specific language that’s this year’s, and
we still have that challenge.

So it would help us in those guidelines of we were to make the
guidelines for value added networks in line with HIPAA so that the data is
considered protected information, and therefore even if a value added network
has to manipulate the data such that it will work with the pharmacy systems,
the data remains confidential. I think that that would be an appropriate
safeguard and it would help us to combat these anti-depot rules.

Also, in that guideline, it would help to understand the
records retention issue. If you provide the industry with a guideline as to how
long that information should be kept for audit purposes, it’s easy for
everybody to comply. It’s incredibly more complex if we have to guess at it
because chances are we’re going to guess wrong and we could run into a problem

To me, the quote of the day from yesterday was Mr. Reynolds’s
“viable versus hysterical.” We believe that a PKI digital signature
would be very costly to implement and it definitely would be an impediment to
adoption. Physicians are pushing back at costs today, so if we add even a small
incremental cost, that’s going to be a challenge to adoption, and as Kepa
pointed out brilliantly yesterday, this is difficult stuff. It’s not easy to
implement and it’s not easy to maintain, and the industry has done a pretty
good job so far of building something that works.

And when you consider that right now in the paper environment,
an orally transmitted prescription, also known as a phone-in, is legal in all
50 states. And I can tell you that I could phone in a prescription to any
pharmacy in the country, as long as I’m not asking for a controlled substance,
because I know what to say and I know how to say it, and as long as it sounds
legitimate to the pharmacist, they’re going to fill it without question. So by
providing an electronic mechanism which is auditable and traceable, it’s far
safer than an audible prescription that’s phoned in.

We also can’t forget that it’s always the pharmacist’s right
and obligation to validate the authenticity of a prescription, so there is that
human factor. The last point of contact before the medication leaves the shelf
is a human being evaluates it and they say, something isn’t right. And if they
receive a prescription whether it’s via fax over the phone or a paper
prescription, if they suddenly get 10 prescriptions for the same patient in the
same day, something isn’t right and they’re going to validate it and they’re
going to make sure that it’s all legitimate.

And the same thing applies for an electronic prescription. If
something doesn’t seem right, it’s the pharmacist that’s going to be the final
say. And they’re licensed health care professionals, they’ve got a license on
the line, and that’s an important safeguard that we need to consider.

Somewhat off the subject of electronic signature and really my
last point is on those state regulatory issues, and I think that the Committee
can play an important part in helping to clarify this, exactly how EDI
technology works and the necessity of value added networks in the marketplace.

This is the language from a law that was passed in Georgia this
year, so Georgia, correctly so, passed regulations which allow EDI in the state
of Georgia, but then, two paragraphs from that, they said that for an
electronic prescription, it can’t be “compromised by interventions,
control, change, altering, manipulation, or accessing patient record
information by any other person or party in any manner whatsoever.”

So they said, sure, you can do EDI, but that requires you to
maintain a direct connection from your system to every single pharmacy in the
state, which logistically is never going to happen.

So we have then gone back and proposed a modification to this
legislation which will allow, with certain rules, value added networks to
participate. The problem is that it’ll take a year between the time that the
original regulations were passed. And hundreds of physicians called us and say,
let’s do e-prescribing, and we say, well, there’s a little problem with those
rules. And now it’ll truly be a year before we’re ready to offer this, assuming
that the regulations which we have proposed are passed in January.

So if there were guidelines for the states to follow, I think
that they would probably take advantage of that, because really we’re having to
go down the same road in each and every state that we participate with. And
that’s a challenge in terms of adoption, from where we sit.

And that brings me to the end of my presentation. Here’s some
information which is on the last page. I’m glad to help, if there’s any
questions following the next group.

DR. COHN: Okay, Michael, thank you very much. And is it a joint
presentation, is that correct?

AGENDA ITEM: Presentation – E-Signature: The
Vendors’ Perspective – MR. CHEN

MR. CHEN: Well, Dr. Kaufman is the Chief Medical Officer, also
Informatics. So I asked him to participate with me in case there are questions
on the clinical side requires a further explanation, he can help. I will do the
primary presentation.

DR. COHN: Please.

MR. CHEN: Good morning, Mr. Chairman, and members of
Subcommittee. My name is Jim Chen. I’m the CEO of DrFirst. With me is Peter
Kaufman, as I have said. He has testified before this Committee in the spring.

DrFirst is a vendor in the e-prescribing area. We are the
winner of the TEPR award this year. And as Michael just said, in the
e-prescribing arena, we think we are one of the largest vendors. We are about
just a little bit fewer transactions per month than WebMD today.

We are pleased to provide this testimony on the subject of
standards for electronic signature in response to the invitation of NCVHS
Subcommittee on Standards and Security.

Prior to my founding DrFirst, I worked in the field of internet
security and pioneered virtual private networks, VPN. I hold six patents in
that area. Also, as a result of my current position, I continue to place
interest in the development of Internet security.

Today, my presentation will be somewhat different from the
angle that Michael took. By the way, I do agree with a lot of things you said;
it’s going to be very helpful to the industry. So I’m going to be focusing more
on the methodology in so far as e-signature.

We believe that the subject discussed this morning translates
across all the electronic health care transactions, and it’s not limited to

We intended to stress three points this morning – the cost
and complexity of PKI. Even though I know much was discussed yesterday, it has
yet to be proven effective enough to recommend for e-health care, especially as
sole standard for the electronic signature.

The second point would be on the use of the unique user
ID/password combination with secondary passwords such as PIN that meets the
requirements for electronic signature. We also recommend allowing various
existing and emerging signature technologies.

The third point, biometric validation, while it is attractive,
it’s not yet accurate enough, affordable enough, or prevalent enough to
recommend for electronic signature.

We also call for a national recognized database, a so-called
“master list” of physicians, or providers, to be developed and
endorsed. I understand this effort has been taken a couple times previously; it
has not really shown the acceptance or success there.

For electronic signature methodology to be successful, it must
satisfy the core tenets of integrity, security, and non-repudiation while
providing for the delivery of health care at an affordable cost.

The following three methodologies are commonly recommended for
electronic signature standards. They should be evaluated for their ability to
provide without introducing excess cost. Those things are PKI, biometrics and
the user ID/password/PIN.

PKI’s strength lies in its ability, depending on implementation
method, to meet the requirements of integrity, security, and non-repudiation.
However, although PKI has been recommended by some organizations as the most
appropriate standard for e-signature, we believe that it fails the
cost-effective test.

PKI, as it has been envisioned for health care, requires a
certification authority to issue, update, expire, and revoke the certificates
associated with PKI systems. Even an efficient, centralized implementation of
certification authority, there remains a high cost associated with this new
layer of infrastructure. Interaction with a certification authority also
introduces increased complexity into an electronic process such as
e-prescribing is attempting to decrease complexity for providers.

Legacy systems have not been built for PKI. Many health care
systems are not Web-enabled or XML-savvy. Often they cannot by themselves
validate a digital signature. Moving to a PKI infrastructure will mean that
many providers will find it difficult to participate in e-health care without
upgrading systems, a significant expense in both dollars and time.

An additional concern regarding PKI is the push to implement
it at the individual user level. It is unclear whether this can be managed cost
effectively. We discussed this question with Dr. Tom Sullivan, the immediate
Past President of the Massachusetts Medical Society. He’s also principal in the
AMA’s attempt at a universal, secure physician identifier.

He said: “The AMA and it’s partner – and it is on its
second partner – have tried for several years to deploy PKI, and because
of the complexity of maintaining the certificate and developing a successful
business case, have not so far succeeded. The real problem was the complexity
of maintaining the certificate – the revocation, the expiration, the
re-registration. The users weren’t willing to pay anything, but though it
should be free.”

PKI remains unproven in terms of its ability to support a very
high volume, real time, clinical transaction network. E-prescribing, for
instance, requires a methodology able to support the real time processing of
billions of transactions flowing between over 50,000 pharmacies, more than
400,000 prescribers, and many payers. To date, we are not aware of successful
PKI implementations similar to those that have been recommended for e-health

There has also been discussion of a federated ID manager –
each enterprise does their own ID access management within the enterprise
–but when they collaborate with other entities, they exchange information
about their validation for the user, or attributes of the user, through a
standard protocol such as Security Assertion Markup Language (SAML).

By introducing additional layers of cost structure and
complexity into health care systems, PKI will by its very nature slow the speed
of adoption. At this point, we cannot recommend it as the sole standard for
electronic signature.

Unlike PKI, it is less clear that biometrics can meet the basic
tenets of a security methodology. Its relative strength is very dependent on
technology involved, and like PKI, it introduces additional costs into health
care delivery.

Affordable, accurate biometrics authentication continues to
elude the health care industry. Although devices with biometric readers,
general fingerprint scanners, are becoming more common. Complaints abound
regarding both the ease of fooling these readers – false positives, a
security issue – and the frequent misreading of authorized users –
false negatives, which will frustrate users. Adding a level of uncertainty to
existing workflows is not the most effective path to universal adoption of an
electronic signature technology.

Implementing biometric electronic signatures also generally
requires the purchase of specialized equipment for all users. Unless these
expenses are reimbursed, biometrics will become another unfounded mandate for

DrFirst believes that biometric technology has promise but will
only recommend the use of biometric authenticators when devices are affordable,
accurate, and common.

Today, in the e-prescribing arena, all participants are
connected through a secure, encrypted network which is accessed by users via
individual user ID and passwords. In the DrFirst system, an additional
password, or PIN, is required in order to actually transmit a prescription.
Like WebMD, we credential all users.

When combined with appropriate management processes, this
system satisfies both the security tenets and the cost effectiveness tests and
meets HIPAA guidelines for security. We do the internal service side private
key/public key, signing and sealing, and then recording for all different
purposes. So that’s why we feel that it does meet the security tenets very

Of particular note, legacy systems do not require upgrades in
order to participate in e-health care using the user ID password and PIN. The
electronic signature method is a standard industry practice and is well
accepted by providers today.

In the drive towards adoption of e-health care, this UPP, the
user ID/password and PIN method, is the shortest, the most cost effective

Finally, in our recommendations, we have at last our
recommendations here. Understand a lot of people made recommendations, but this
is dear to our hearts.

The electronic signature standard must drive rapid adoption,
meet the basic tenets of security, and not impeding progress by raising costs
for participants. It must also meet the test of being a better alternative than
the current paper and pen method, a much better alternative.

At DrFirst, we believe that the unique user ID/password/PIN
method meets the requirements for electronic signature, but we recommend that
the Committee adopt language that is broad enough in scope to encompass
existing standards while leaving room for the introduction of new technologies
when they mature sufficiently to merit implementation.

In addition, we would like to note that the lack of a
nationally recognized database of credentialed physician identifiers has and
will continue to hinder the ability of technology providers to offer universal
solutions in the electronic signature arena. Although physician identifier
databases exist, such as DEA, CMS, AMA, none has been deemed a national
standard and made available to e-health care developers, not just vendors. We
recommend that development or endorsement of such database be considered an
important part of establishing electronic signature guidelines.

Thank you for giving us this opportunity to share with you our
practical sense to electronic signature approach and to assist you in
accelerating electronic health care adoption. We truly appreciate your hard
work in making this a legacy we can all be proud of. Thank you.

Questions, Answers and Comments

DR. COHN: Okay. Well, thank you all for very interesting
testimony. I think maybe I’ll start out with a question, and I’m sure then
we’ll have – I can see Steve and Harry have some additional questions.

You know, we’ve all had a chance, I think, to sleep on our
testimony last night, and the testimony I’m hearing from all of you is not
– as you’ve all commented – is not so different than we heard

I’m struggling with a set of issues, and I thought I’d ask you
all for your comments on all of this. Obviously, right now we’re talking about
e-prescribing, but I think one of the charges of the subcommittee and the full
Committee is to also look forward as we move towards a more integrated,
national health information network, as we move towards an electronic national
health information infrastructure, electronic medical records and all of that.
And indeed, this is sort of the wedge in some ways moving us forward on all of

Now, I sort of hear arguments about technology not being ready,
security – I mean, this is e-prescribing, this isn’t the full suite –
and yet in the next couple of years we’re going to be moving into an area where
we’re going to be seeing much more of the full suite, and I think it’s going to
be very hard as we move into sort of these more robust applications — and you
may disagree with me, so correct me if I’m wrong, or help me with this one
– that it’s going to be very hard if we have a complete electronic medical
record on line for us to be talking about, well, the very basic, I mean, not
very strong level of security in electronic signature.

So help me understand. I mean, first of all, do you agree that
if we were to get a lot more clinical information on line, would you think that
something stronger than what you’re all describing would be appropriate? And
how are we going to move from here to there in some sort of a reasonable

Anyway, I’m just asking all of your thoughts. I mean, you may
disagree with my basic tenet and think that three or four years from now we
ought to be still having sort of basic PINs that – I mean, what’s been
described by the OMB yesterday as sort of a very basic level of security
suitable for surfing the Web as opposed to PKI or whatever. Can you all help me
think through this?

DR. KAUFMAN: I think that this is more than a basic level of
security suitable for surfing the Web because of the credentialing involved by
the individual companies that are touching the users.

I do believe that having a centralized, or a federated
centralized, system in the future is going to be an advantage for the vendors
more than in terms of security in that when we get that secure certificate from
whoever the certification authority is, if it’s the DEA or a third party that’s
been given this job, that we’ll be able to know that this is a credentialized
user right off the bat and we won’t have to go through the credentialing

But in terms of security, I’m not sure that it’s going to add
much to the security process.

One of the concerns is the certificate itself and the ability
for somebody else to get access to the certificate. Doctors are notorious for
being not the neatest people in the world and not always having everything
right at hand. I am a practicing physician, so I feel comfortable saying that.
If you’d seen my desk, you probably would be appalled.

But we can picture the impression of the security certificate
is on a smart card of the physician having an extra copy or passing it around
to their staff or leaving it taped to their wall so they always have access to
it but anybody else can as well. If the security resides on a computer that’s
password protected, well, that’s pretty much the same thing we’re doing now
– you have the password protection to unlock it. If it’s a biometric
security device, there the issues associated with biometrics which I do believe
will get better with time.

So the issue of the certification authority, PKI certificate,
is not so much that it’s going to make the system more secure than it is now
but it will make it easier for vendors and easier for new companies to come
into the marketplace and do this.

One of the discussions we had last spring was that, gee, we’ve
all done the heavy lifting so everybody else can, too, and my point was that
the long-term goal is not to have the vendors do the heavy lifting to have it
working well.

So perhaps a small scale or moderate scale, regional pilot
program of PKI that would be more on a scale that’s been shown to work with PKI
and to prove that it can work and be more scaleable for an area such as
Massachusetts or even a larger area of New England or California or some place
that’s using a fair amount of electronic health care now would be a reasonable
decision to make, to say, gee, we think this might be useful in the long term;
let’s have the government fund a pilot study, look at PKI in a little bit more
complex and larger scale that’s been done before but not so big that we’re
going to end up in a morass that we can’t get ourselves out of.

And also make it voluntary so that we can see if this will
work, rather than saying that the security we’re doing now, which is excellent
security and provides as much security as the PKI probably will in real life
and action, to throw this all out the window when it’s working now and slow
down the adoption of e-health care.

The vendors are willing to do the heavy lifting involved with
credentialing the users to get the security to work and there is a PKI or PKI
of sorts, very secure connections between the vendors themselves. I believe
that the current technology is excellent, and let’s leave the door open and
test the new technology.

MR. CHEN: To some large degree, I think all vendors are using
the public key/private key technology. Like I was describing earlier, we use
internally, using service side to sign and seal and so that we can support
audit in the future. Every transaction is locked. We use very, very good

DR. KAUFMAN: Let the record show that WebMD is shaking their
head “yes.”


MR. CHEN: So I don’t think it’s a fear of technology. It’s
really the cost issues and the impediments I was talking about earlier in the
practical sense, because our company really started five years ago in the
electronic medical records. We actually are the ASP vendor for NextGen. We have
worldwide license from NextGen. We know EMR very, very well and we know the
importance of security and we know the importance of authentication are the
biggest elements for a secure system.

So those are things I would do, and I think with this current
way of practice of security we can make this kind of medical system work for
us, but with an eye for improvement. Like I said, public key/private key
architecture should be looked at, not exclude it, from what is the Committee’s

DR. COHN: Okay. Michael, did you have a comment?

MR. BURGER: One thing to remember in the conversation is that
when you talk about e-prescribing alone, it is very close to an interactive
transaction, and all of this encrypting and decrypting when data is moving in
high volume across the networks takes time and adds overhead. And that’s a
significant issue in the transaction part of this.

Moving all electronic medical records from point to point is
going to be far less volume and it certainly doesn’t need to be interactive. So
to a large extent we’re taking a wait and see approach. Pretty much as with any
technology vendor, we can do whatever is necessary, and it’s a matter really of
the business case from the consumer which is either going to be the patient or
the physician as to whether the cost and the hoops that you need to jump
through are worth the safety that it brings, because in the end, really that’s
all that matters.

And if consumers decide that there’s no way, given the current
infrastructure, that they’re interested in having their health records
communicated between physicians or stored in a central repository, then that
means that the security needs to be at a higher level, and if that’s what’s
required, then that’s what we’ll end up doing. It’s difficult to say. We’re
comfortable, as my colleagues, that what is happening today is safe enough.

DR. COHN: Okay. Well, thank you. I think Steve is next, and
then Harry, Jeff and Judy.

DR. STEINDEL: I’d like to look at the question of
non-repudiation. You listed it as one of the key tenets for the system, and
then went ahead and described, all three of you, and what we’ve heard
yesterday, is systems that I would describe as slightly above what we’re
presently dealing with the paper world in terms of security of identifying the

Again, like yesterday with the faxing the e-prescribing and the
clerk signing it, in your case just picking up the phone and calling, is an
acceptable signature. This indicates the level of security that we have now
with present prescriptions.

But how do the systems that you’re describing, the password
systems, deal with the issue of non-repudiation, and is the question of
non-repudiation, as Jeff mentioned yesterday, something we really should put
high on our list of things to worry about?

MR. CHEN: That’s the biggest challenge in what I call the
unique user ID and password. Non-repudiation can be probably best implemented
with public key/private key technology.

Having said that, you could to better than just simply
encryption in a system to protect records for future dispute on whether or not
this person actually wrote or not.

The way we, as vendor, implement that part is – I work
with people in WITI – Tom Hanks is one person I’m very close to at WITI
– on this subject before when we were trying to design this
non-repudiation portion.

What we’re trying to do is make sure that we fully authenticate
a user as well as we can; then we log that piece of transaction into the system
in the area where no one else can get to, even the programmer. This way we can
try to keep that away from people so that, as described earlier, we use PKI
type of technology, so we take advantage of PKI technology in that sense so
that we’re able to demonstrate that the record, once it’s created in our
system, is tamper-proof, and using the strong authentication as a method to
make sure it was the person who did it.

Like I said, we have PIN on top of password. Certainly, you can
keep both password and PIN to someone else to impersonate you, but it really is
a combination of various technologies to try to meet non-repudiation.

DR. KAUFMAN: And it’s a role-based system. We allow the users
to enter other staff members and other physicians into the system very easily
so that everybody has their own user name and password so you don’t need to
share the user name and password to give somebody access to the system. So we
are audit trailing every touch of the system and every user and who did what,
who wrote it, who signed it, who sent it is all tracked by role.

Perhaps there should be some punishment for sharing user names
and passwords in terms of medical records. It’s a discussion that I had with
Rick Peters, a consultant for the AFP, a couple days, when we were trying to
decide how serious the punishment should be. But really, with PKI, a true user
level certification authority, PKI could also share the user name and password
and get into that system. It really is a matter of how willing people are to
protect what needs to be protected and then for the system for audit trail
everybody who’s doing anything and what they’re doing.

MR. BURGER: We encounter this question fairly frequently, and
it’s interesting to me how often a physician comes to me and says, well, how
can you tell if it was me that was at the keyboard if everybody in the practice
is using the same password?


MR. BURGER: Well, duh! I mean, it’s a liability issue, really,
and we equate our electronic prescribing products to a prescription pad, and as
a physician, you’re comfortable from a legal and a liability perspective, about
leaving a blank prescription pad in the waiting room, with a pen –


MR. BURGER: — no problem!

DR. KAUFMAN: It’s a lot worse than that. I’ve had doctors tell
me that they give their staff a prescription pad full of signed, blank
prescriptions for the staff to send the prescriptions off. When they’ve said,
well, I’m going to give my staff my PIN code, I say, well, that’s just like
giving your staff a signed, blank prescription pad, and they say, that’s what
I’m doing now.


DR. KAUFMAN: And this is not one doctor that said that they do

There needs to be some rule or recommendation to limit that.

MR. BURGER: And to me, the rule already exists.

If a patient is harmed, compliments of a prescription that some
person wrote, it’s the physician that’s ultimately responsible, especially if
they have their signature on it. So, I mean, there is punishment, kind of, sort
of, that’s available.

So technology can only take you so far, but in the end, it only
works as well as the person that’s at the other side of the keyboard.

DR. COHN: Sure you want to address that question?


DR. COHN: Harry, I think we’ll let you go on next. I’m somewhat
speechless here, but –


MR. REYNOLDS: Michael, in your testimony on your Slide 13
– Simon said we slept on everything last night and then you threw water
right in my face on it, what I thought I believe – if you take the first
four words of the second line, the “practitioner to a pharmacist,” I
think of models and I think of how it works, and if you think of where we are
right now, because we’re in a situation where the doctor fills out a
prescription and either the patient takes it to the pharmacist, so it goes from
the doctor to the pharmacist, or the doctor may fax it, which is still dumb
technology, from the doctor to the pharmacist, if you look at the model that
we’re talking about here, regardless of whether you use PKI, you use whatever
sign-ons and passwords, you’re talking about it going from the doctor to a
vendor, they sign on. So the vendor is validated from the doc. The pharmacist
isn’t, anymore. The patient isn’t, anymore. The vendor is.

And then the vendor gives it to a switch, and then the switch
gives it to the pharmacy. So the pharmacy is not validating it anymore. The
pharmacy is not deciding this because a pharmacist can get it from 15, 20, 40
vendors coming through a switch.

So the situation that we face is then the pharmacy has to trust
it, the PBM has to accept it, and so you’ve got a situation where we are
changing that stream. And so when we talk about PKIs and sign-ons and
everything else, we’re not talking about the pharmacy and the doctor anymore;
we’re talking about the mechanism of getting it between them. And so that is a
fundamentally different directness.

And that’s why this wording was so interesting to me, because I
would think they probably wanted to add practitioner directly to a pharmacist,
is what they probably really meant here if you read into the words.

So I think when we talk about whatever we’re talking about, I’m
thinking about it totally differently now because it’s really the vendor, or
the switch, that are validating that it came from an entity and saying that it
came from a physician, because there’s no way the pharmacist, other than
calling, can know that, based on the model.

So I put that out as a premise, and I would like to know
whether or not that’s what –

MR. BURGER: Well, remember that in a paper prescription which
is presented to the pharmacy, there’s no proof that that came from –

MR. REYNOLDS: No, please don’t go back there. I understand
that. No, no, we’re not debating the two. I’m talking about whether the new
model is saying that the validation belongs to the vendor and the switch, not
the pharmacy. That’s all I’m trying to understand.

MR. BURGER: A portion of the validation does belong to the
intermediaries. But, frankly, that’s just as much to validate the part of it
that we’re controlling to make sure that the person that’s using our software
and using our network and our partners’ network are customers in good standing
and are legally allowed to be using the products.

But the final step in that process to insure validity still
belongs to the pharmacist. So in the end, we’re the post office. We take care
of delivery from Pont A to Point B and then the validity –

MR. REYNOLDS: But you set the sign-on and the PIN.

MR. BURGER: That’s true.

MR. REYNOLDS: So you set the validation. And again, understand:
I’m not attacking the model. I’m making sure I understand.

If the pharmacy set the sign-on and the PIN so that they knew
they were validating who they were validating, that’s another model, too. And
then each vendor has to use it or – back to this idea of a national
whatever you have, so it’s —

MR. BURGER: That adds another level of logistics which isn’t
insurmountable, but —

MR. REYNOLDS: But if you read this wording and you read what’s
going on across the state, they’re looking at this directly between, and that’s
what I think is confusing us. So, PKI – if you put in PKI, it’s still not
between the doctor and pharmacist; it’s still between the doctor and the switch
and then on to the pharmacist.

DR. KAUFMAN: If we’re talking about Michael’s slides, let’s go
back one slide where on Slide 12 he says it’s the “pharmacist’s right and
obligation to validate authenticity” – “to validate authenticity
must remain intact.”

And that’s true. The pharmacist is still the one
authenticating. They can say the authentication coming from the switch is
acceptable or they can say it’s not and call the doctor’s office. Or if we send
a fax, we actually have a phone number for the pharmacy to call because we know
it’s secure between the doctor and us, but somebody with a really good page
layout program could probably duplicate the fax and get it off to the pharmacy
and make it look like it came from us even with the digital signature appended.

So they could actually do that, so we also give a phone number
for the pharmacy to call us if they want to, just to validate that this came
from us and was secure from the doctor and save the doctor some business.

But the obligation is ultimately the pharmacists to validate
this from the doctor. So they can call the doctor if they’re concerned and
validate it. A paper prescription can be in the patient’s purse for a week
before it goes to the pharmacy. It didn’t come from the doctor to the pharmacy;
it went from the doctor to the patient to the pharmacy.

So now it’s going from the doctor to the vendor to the switch
to the pharmacy. It’s still the pharmacist’s obligation to validate if they
feel it needs to be validated.

MR. REYNOLDS: Again, not disagreeing with your model. I’m
trying to make sure who’s got the ball. That’s all I’m saying: Who’s got the
ball? Because most of the time, if you think of most of the time when we deal
with connections when you’re using digital signatures, it’s one party to
another; it’s not through lots of other places.

DR. KAUFMAN: One thing that would make this a little more
stable is to have that national list that we called for where we would know
that at least we were all referring to the same, you know, Dr. Peter Kaufman,
when that prescription went through, rather than having a duplicate someplace
or one letter changed in the list. Having a national identifier would make it a
little bit more secure. You are still dealing with a vendor and the switch.

DR. COHN: It sounds like Steve had an issue following up.

DR. STEINDEL: Yes, I have a clarification I would like to find
out, and this goes to Michael, and actually it goes to the DrFirst people
because they kind of picked up on it.

But when you were describing the situation that Harry presented
and you talked about it, I was very comfortable with your use for
identification and you want to validate that this person is entitled to use the
software and the system and then entitled to pass it on to your whoever you
pass it on to. That I’m very comfortable with, that concept.

But then you introduced the word that you have the
responsibility to see that they’re legally obligated. Does that say WebMD is
assuming the legal obligation on this prescription as well? That made me very
uncomfortable, because that puts a different level on this whole system.

MR. BURGER: We’re not making any legal assumption at all. But
what we are doing, because we’re using the DEA number as a method of
identifying the prescriber, we’re looking that prescriber up on the DEA
database to make sure that they’re able to prescribe and that their license
hasn’t been revoked. And if it has been revoked, I guess indirectly we’re
taking an enforcement because we’re saying, sorry, you don’t have a license;
you can’t be part of our prescribing network.

DR. STEINDEL: But that gets to the slide that Peter was talking
about a few minutes ago which I was very impressed with, that the ultimate
authority rests with the pharmacist. And that’s where I would look at where the
really legal obligation resides.

MR. BURGER: That’s where the true legal obligation, from a
perspective of liability, is, with the pharmacist, because they’re responsible.
So we’re helping and we’re trying our best to keep illegitimate prescribers off
of the system so that it makes the pharmacist’s job that much easier.

But we certainly would never expect that they would take our
word for it because we don’t have a place – we’re the post office. We’re
just going to deliver what we receive and in the end it’s up to the pharmacist
that has the final say.

DR. COHN: Okay. Is there follow-up on this issue?

DR. WARREN: Both of my questions are follow-ups on issues

DR. COHN: Okay, Jeff, can you hold for a second? Okay.

DR. WARREN: The first one I have is really for you, Michael,
but DrFirst, chime in, too.

On one of your slides, you said that when you looked at
renewals, 100 percent of those are signed off by RNs and techs. And so now
we’re looking at: How do you validate that?

So are you looking at putting together some sort of technology
that shows that it’s a co-sign, much like we do verbal orders that are given to
RNs that they then file those orders and later they’re co-signed? I mean, how
are you going to validate these refills, because you’ve also said that if you
don’t account for the workflow in the physician office, this stuff is not going
to fly? And so we know that refills are going to be done by staff, not the
original prescriber.

MR. BURGER: Actually, the testimony was that 100 percent of
those refills are routed electronically, but definitely not 100 percent of them
are dealt with by mid-level providers. As a matter of workflow, though –

DR. WARREN: Not mid-level providers which are – or
physician assistants and nurse practitioners –

MR. BURGER: I beg your pardon.

DR. WARREN: — which may have prescriptive authority.

MR. BURGER: Right.

DR. WARREN: I’m talking about the techs and the RNs who don’t
have prescriptive authority.

MR. BURGER: In the course of practice, a physician usually will
assign certain responsibility for responding to pharmacy-issued refill
requests, to respond to the pharmacy yes or no. Those refill requests are
annotated by the user or an agent, if you will, who is responding to that
request on behalf of the physician.

That information is passed back to the pharmacy when it’s
responded to, and that’s valid, as far as the pharmacy is concerned and as far
as the regulations are concerned.

DR. WARREN: Okay. Then I need to understand, too, how you
define refill. Is this the refill in a prescription it says “this can be
refilled three times,” or is this the renewal of a prescription whose
refill has expired?

MR. BURGER: It’s a renewal —


MR. BURGER: — because it’s not required, as you know, for the
pharmacy to contact the physician for each additional fill on the original.

DR. WARREN: I just want to be sure I understood the way you
were using the word so that I don’t –

MR. BURGER: Unfortunately, they are interchangeable and can be
confusing as we use them.

DR. KAUFMAN: If I could make a comment on it also. We do
something very similar to what they do. We allow the physician to assign a
provider agent. It’s done with the physician actually filling out a form
legally assigning the rights to somebody in their office to act as a provider
agent and they can send prescriptions, renewal requests, just like they’re
doing now in the office when the pharmacy calls and the staff person says, yes,
that’s fine.

The one thing that we do, and I’m not sure whether WebMD does
it or not, is that we require the physician to countersign all of those
prescriptions with increasingly annoying alerts if they haven’t done it quickly
enough so that that prescription is sent off but we still want the doctor to
see it, which I believe is the law for the way it’s done on paper and phone
right now but a lot of doctors don’t do that.

DR. WARREN: Okay. So you’re really using kind of a user
name/password for the agent that then is countersigned, or a co-signature comes
with it, which then has its own user name and password?

DR. KAUFMAN: The co-signature does not go to the pharmacy. It’s
stored in the system. The physician has the authority to void the prescription
if they don’t feel that prescription should have gone, which sends a stop
message to the pharmacy and voids it into the system, but the physician is
co-signing it.

The way the system is set up, the physician co-signs it before
it goes. If the practice signs for a provider agent, it does not get co-signed
before it goes; it’s co-signed after it goes, because the workflow in a
doctor’s office is sacred and physicians are impatient people. At least I’m
saying that they’re people.


DR. KAUFMAN: And they don’t want to change the workflow such
that if a pharmacy calls for a renewal, if they get a renewal request
electronically, whatever, that the staff has to come in, they have to log into
the system, they’re in the middle of seeing somebody else, to countersign this.
They don’t want to alter their workflow.

So a lot of physicians really strongly want to be able to do
this provider agent issue, which is what they’re doing now.

DR. WARREN: Okay. So the message then that’s passed is really
the signature of the agent, and that’s all the pharmacist sees?

DR. KAUFMAN: The agent or Doctor So and So. A specific
physician is assigned to that.

DR. WARREN: Okay. That’s the piece that I was missing.

The second clarification that I wanted was back to this Georgia
law, as everybody else has picked up on on the panel. If I think in a very
broad level of technology of which paper is a technology and then we go back to
Harry’s comment of physician to patient, and you’re absolutely, we’re a paper
world, there is an intermediary between the physician and the pharmacy and
that’s the patient who hand-carries it or the family member or the agent of
that patient. So we already have an intermediary here.

So in some ways you can look at electronic e-prescribing of the
services that the two of you provide is the same thing as this agent of the
patient or the patient themselves in transferring that.

So help me understand how this law in Georgia is causing
– I guess what I’m asking is: Has there been a ruling that this kind of
transmission is different than having a patient or a patient’s agent take a
piece of paper from the doctor’s office to the pharmacy?

MR. BURGER: The word “electronically.”

DR. WARREN: And that’s the key piece that’s different?

MR. BURGER: The presumption is made that a consumer wouldn’t be
able to electronically encrypt or issue or produce a prescription, that it
would have to be the physician who is doing the order.

The intent of this is to prevent a third party in between the
physician and the pharmacy to alter or switch the medication to something
different or to direct it to one pharmacy or another or in some way change what
the doctor has prescribed. That’s the intent here.

DR. WARREN: Okay. And with so many laws, the intent is not
actually what is in the words and what’s interpreted –

MR. BURGER: Very true.

DR. WARREN: — later on?

DR. KAUFMAN: Can I add to the intent? Part of the intent also
is to not change the language of the prescription which may be subtle between
the physician and the pharmacist.

As a result of the spring meetings – I sit on three
committees working on a SIG standard, and in fact I believe that Lynn is going
to be testifying on that tomorrow, and I was kind of trying to get her to say
something a little earlier – but one of the very powerful things coming to
us from the pharmacist and NCPDP is that the language of the SIG cannot be
changed to put into electronic form.

So if it doesn’t shoehorn into an electronic form, you have to
send it as a text string, and you don’t want to alter that and then send it off
to the pharmacy differently from what the doctor said.

If the doctor enters it electronically, so they’re entering it
in electronic form, you can send those elements along the system and then
rebuild it on the other end, but if they’re entering it as a text string, if
you want to send it as a text string, it’s important the pharmacy receives what
the doctor was prescribing. Did I say that right?

So that might have been part of the intent of the Georgia law
also. And since I got the microphone and people here know I like to speak, let
me talk a little more about this issue, because I would go a little further
than Michael did in calling for more than guidelines.

I’m currently working with at least one state, along with
SureScripts, to help them find guidelines to rewrite their e-prescribing law,
and they’re using Massachusetts and Maryland as their models. But the boards of
pharmacies who are – I mean, I’ve dealt with a few of them now and they’ve
all been great – but their job is to come up with these guidelines and
regulations and if they get somebody, another state’s, regulations, they need
to rewrite them, and they’re always a little bit different because that’s their
job, is to do this.

I think if we got from the Federal government a set of
standards for electronic prescribing in the states that would preempt the state
laws, it would make life a lot easier for people like Richard Brooks and Rick
Ratliff, and us, who are sending these prescriptions to the various states
where the laws, even if they’re subtly different, are different enough that the
applications need to jump through a lot of hoops 50 different ways.

DR. WARREN: Okay. So my final – just to make sure I
understand what you’re telling me – that if there is

no change in this message from the physician to the pharmacy,
then we’re okay with electronic prescribing. But if somewhere in there there is
a change in that message, then this particular paragraph applies? Okay.

MR. BURGER: This says that even if there is no change between
what the physician writes and what’s received at the pharmacy, if it passes
through in any manner whatsoever, anything between here and there, it’s

DR. WARREN: Oh, okay.

MR. REYNOLDS: That’s why I said “direct.” That’s why
I mentioned direct. They meant directly.

MR. BURGER: And so really there’s the challenge. If it was in
parentheses, as long as it remains in exactly the same form, then we’re fine,
because nobody’s changing the data.

DR. WARREN: Okay. Well, that’s what I thought I heard
initially, and then I was looking at it. I mean, I don’t know how you would do
an electronic prescription without it passing through someplace.

DR. KAUFMAN: A fax transmits through a switching company at the
telephone company, so that should be the same thing.

DR. COHN: Jeff?

MR. BLAIR: I want to get some additional clarification, and I’m
kind of pulling from what we heard from the three networks yesterday –
RXL, ProxyMed and SureScripts – and they indicated that there were three
major impediments towards adopting PKI. And PKI was referred to there as a
technology. And you’ve echoed these, but I want to drive down a little bit for
some additional clarification.

One was the additional cost. The second one was the performance
hit on the network to be able to perform PKI. Actually, I guess there’s four of
them. The other one is the certification requirement, setting up a separate
entity for certifications just for this.

So the fourth one that I’d like you to comment on a little bit
more was the technology function that they told us was essential in the way the
world is today and maybe even the way the world would be in the future, and
that is that it is necessary to open the message, or especially if the NCPDP
version that comes from the prescriber is different than that that would be at
a dispenser, a pharmacy, it may be necessary to open the message to do some
reformatting – not change the content or the intent of the prescription
but to just alter the format to accommodate the different versions of NCPDP,
and that was also complicated by the fact that there might be a prescription
coming from acute care institution in an HL7

format and once again you would have to make format
modifications, and that that required the opening – once you open it, PKI
of course would destroy the ability to do non-repudiation and the ability to be
able the bond the signature to the document with the electronic signature and
the combination of a hashCode.

So in short what I’m getting to I’d like your comments on that
impediment. Do you share that same concern, and if – you’ve also wound up
saying we should have pilot tests; we should include PKI in pilot tests to see
if these impediments can be addressed in the future.

Well, if there are pilot tests, do you see something that
should be included in those pilot tests or constructed in those pilot tests to
try to address or accommodate this particular impediment of needing to open and
reformat to accommodate different versions?

MR. BURGER: Well, as WebMD, we have an extraordinary amount of
experience in the EDI business not only in terms of prescriptions but in terms
of claims and eligibility transactions and pharmacy to PBM transactions. And
throughout all of the years that we’ve doing this and all the experience we
have, it isn’t even theoretically possible for everybody, every submitter of
the transaction and every receiver of the transaction, to all be on the same
format. I mean, it’s just not logistically possible.

And when you consider the number of physicians and individual
pharmacies that would need to be connected, the sheer logistics of that –
and somebody mentioned yesterday the big bang of having everybody switch and
all at the same time – I mean, the logistics of that just don’t even make
it theoretically possible.

And, you know, we depend on third party networks primarily to
do that translation for us, but even at the Practice Services division of WebMD
we have that challenge because some of our products are distributed in nature,
so they’re running on a client server application in an individual doctor’s

So if I have a few thousand doctors that are doing
e-prescribing and the day comes for me to change them from one version to the
next, I need to simultaneously be touching thousands of systems all at the same
time or something is not going to work.

So on a smaller scale we have that challenge just with our own
software, and others have similar issues but in a web-based application it’s
somewhat easier. And so you could only imagine, then, for all the different
trading partners on the pharmacies, I don’t think it would be possible for us
to be able to operate in an environment where some translation didn’t take

MR. CHEN: Yes, we mentioned about the pilot project. That was
because we feel that at some point in the future the PKI technology and the
vendors’ comfort level was the cost and the ability to manage PKI type of
technology become more acceptable at some point.

And because nobody really knows what that some point is, and
being a technologist myself on the security side, I felt it’s important for us
not to exclude them for participation for the future evolvement of e-health

So that’s why we made the recommendation that if we go further
in this area, we should have a federal funded pilot project. Large-scale enough
– it cannot be just a thousand physicians involved – you’ve got to
have enough to show the transaction volume, and as Michael said, those kind of
systems have to enough systems involved in order to assess the impact of
changing certificates and things like that.

DR. COHN: Harry, did you have a clarification or an additional

MR. REYNOLDS: Another question.

DR. COHN: Another question, okay. Well, I would like to ask a
question before you ask a question. It’s on another issue.

Yesterday – and I wanted to ask the same question today as
I asked yesterday, and I think we were talking to the value added networks and
I was sort of indicating that we may make recommendations about electronic
signature for e-prescribing and even for the National Health Information
Network, but obviously there’s an area called controlled drugs and the
prescribing and dispensing of controlled drugs, which is an area that really is
under the authority of the DEA, and at some point the DEA may come up with
whatever level of electronic signature or things that probably you know very
well, unknown possibilities.

Now, the question is, from your perspective, would your life be
better if there were two different levels of security related one to controlled
and the other to non-controlled drugs or would you like to see whatever level
be the same even if it might be a higher level of security for all dispensing?
I mean, what would you like to see in the future?

DR. KAUFMAN: Frankly, I’d like to see the same level of
security being the level of security that we’re using now, which is quite
strong and workable. I’m concerned that the DEA is going to come up with
requirement for biometric authentication and PKI, in which case I’d want two
levels of security so we could continue doing what we’re doing now and ignore
the requirement of the DEA for the level of security that they want to send at
least Schedule II drugs. I don’t see a good reason that Schedule III through V
drugs, which can be faxed now, should require more authentication than we’re
currently using, which is dramatically more than paper or fax.

It frustrates me that the DEA did not attend this meeting and
to hear the vendors and the backbones speak about the experience, wide
experience, I mean. Our company has a lot of experience with security but
nothing in terms of the transaction volume that WebMD has had to know what is
and is not going to work in the real world in a doctor’s office, and I would
hope that the DEA would broaden their range of who they’re listening to to
allow a strong level of security that is currently adoptable, scaleable and
usable as opposed to requiring something that we cannot provide.

Actually, I think our company probably could provide it, but I
think most of the companies are going to have a great deal of difficulty
dealing with this, and the inaccuracies of the biometrics, the current devices
out, are going to frustrate doctors and they will not adopt.

So, personally I think that it should be the same level of
security. It should be the level of security we’re using now.

MR. CHEN: That’s Dr. Kaufman’s personal view.


DR. KAUFMAN: Uh-oh. Then we should have had you go first! It’s

MR. CHEN: We see this opportunity for us to share different

As you said, I do agree that if we can have one uniform
approach, that would be great. If we have to have two layers, our company would
be able to handle it.

I cut my teeth in the Internet security in ’93 and worked with
Jim Bidzos of RSA in those days. I was one of the two or three companies that
RSA gave worldwide license, like Netscape. So I share in the RSA owned product
of my company at the time.

Anyway, so we have the technology; we know how to do this. So
our concern is: How do we make this practical?

So that’s why I was saying in the practical sense of the
vendor. I’m not speaking for DrFirst. I really feel like I’m speaking for
e-health care. If we do not make this happen now, we’re going to disappoint an
entire industry as well as patients, consumers out there. We have to do it

So I’m speaking, and I’m sure Dr. Kaufman is saying the same
thing –

DR. KAUFMAN: If it’s interesting at all, I think we said the
same thing.

MR. CHEN: Yes, but the thing is I don’t want to second guess
what DEA is doing, okay? We don’t know enough about that, and I do think it’s
very important for all of us to come together and treat this as a legacy for us
to work together. And that’s all I want to say.


MR. CHEN: Not so much defense.

DR. COHN: Michael, then I may have to ask the question again,
but go, please.

MR. BURGER: I mean, the truth is that we’re operating under a
dual standard today and the way that our software and just about every other
software that’s out there works is that when a Schedule II medication is
ordered, the EDI function isn’t available and the physician only has the
ability to print the prescription and sign it or else manually fill out the
required blank and give it to the patient.

And somebody asked the question yesterday about the
effectiveness of those regulations in Nebraska and Wyoming. They’ve been
incredibly effective because nobody does e-prescribing.


MR. BURGER: Yes, there’s no EDI fraud because there’s no EDI.

So I think that what the answer will be is should DEA come out
with a PKI digital signature requirement, we as a company would need to be
shown a business case for developing that capability and then pass that cost on
to the user, so I expect that not much would change. They’d say for the two or
three percent of the prescriptions that would require this, it’s just not worth
the cost, so we’re just going to print those.

DR. COHN: Okay, let me just make sure that I really understand
what you’re all saying and it’s certainly may be a conversation we have during
the open microphone later on today.

Now, yesterday we heard that up to 15 percent of prescriptions
were somehow under DEA purview, and obviously I have no insight into whether
they’re going to make a differentiation for Level II versus Level III, IV and V
medications or whatever.

But what I’m hearing I think from all of you is that whatever
DEA comes out with, what you would like to see potentially if your judgment was
it was of too high of a level, you’d like to see a lesser level of security,
something that we might all feel comfortable with with non-controlled drugs, be
sort of what you would generally use and then make the determination about how
you might handle that higher level. And you might, for example, decide just to
print it out locally. Is that what I’m hearing?

MR. BURGER: I agree with Dr. Kaufman’s comments that we’re
comfortable as an industry that the security that exists would work just fine
for all medications. And the way that the rules work is the Schedule II
medications, or the narcotics, which EDI in fax has not allowed under any
circumstance, and for the other, the Schedules III, IVs and Vs, they can
sometimes be sent via fax and sometimes not. Some of the state rules vary

So the Schedule IIs, which are really the ones that we’re
concerned with, are a pretty small percentage of the total prescriptions that
are written.

DR. COHN: Okay. Well, I guess I maybe keep asking the question
the wrong way, but I think I’ve heard the answer is yes, basically, to what I
was asking. Okay, thank you. Harry?

MR. REYNOLDS: I’ll say something a little surprising. I think
HIPAA’s growing on me, so –


MR. REYNOLDS: — you’re going to like this one.

If you look at this process, we have a HIPAA security rule
coming out in March, and that requires covered entities to validate, assess and
to validate, that they’re going to take care of whatever they touch. You
already have privacy. You have covered entities.

If you think of e-prescribing and you think of HIPAA, most of
the HIPAA transactions, they didn’t really actually have some drugs that were
going to be given out or anything else; they’re mostly after the fact or
they’re talking about eligibilities and other things.

So this goes to a new level. This is why this is so difficult.
But if you took anybody involved in e-prescribing and you made them a covered
entity where they have to, under the HIPAA laws, validate that they understand
privacy, understand security, they’re going to handle it right, they’re going
to do everything they need to do.

And then we put these standards that we’re already putting
together as part of that under the umbrella of HIPAA. You have added a degree
of assurance that we’re spending kazillions of dollars paying health care and
everything else through where fraud could be equally as much an issue.

So you have an umbrella. The problem is that covered entities
– that’s one of the issues we’ve dealt with in some of the HIPAAs, who was
the covered entity? Well, with some of these state laws, they’re trying to say
if you touch a prescription, because there’s going to be actual drugs
administered, you’ve got to be in the game. That may be a way, as a Committee
– because our responsibility as a Committee is not really to set policy;
it’s to build something that can allow the industry to go forward.

And then if the DEA and the Secretary decided that they wanted
to up for schedule these other schedules a level of security they wanted to
add, fine, but it comes under the umbrella, and we have some jurisdiction over
the umbrella.

And that is a way to consider, because that covered entity
thing is where you bring everybody in at a new level. You become a covered
entity. When you touch something; the game is different. I mean, you can have
all kind of people all over you, you can have all kind of structures set up on
you; you’ve got to commit that you’re doing it and everybody can watch you.

And let me add one other thing. And we’re also not –
we’re still not getting between the doctor, the patient or the pharmacy. They
all have a right to say, uh-uh, that’s not what a doctor ordered for me, or,
no, I’m the pharmacy, I’m not comfortable with this one – it’s the third
patient I’ve seen come out of that office today wanting something like this.

And a lot of the e-prescribing has said, and all this stuff
has said, don’t get between the patient and the doctor – you know, having
a PBM saying it’s for this or that. And it’s also said, don’t get between the
pharmacy and the doctor.

So that may be time and away, as we look at this, that allows
us as a Committee to stay within a recommendation, but that’s just a thought.
But I would love to hear from them whether or not this covered entity thing
causes you a lot of grief, because some of you are already clearinghouses and

MR. BURGER: Right, we have those agreements in place right
now, so we’re already doing that. And frankly, exactly what you suggested is
what we suggest in states like Georgia, to say, the intent of this is to
prevent altering and diverting a drug to a different pharmacy and as a HIPAA
covered transaction and as a covered entity, we can’t do that. So, really,
that’s what you want to say instead of this.

So we agree 100 percent.

MR. REYNOLDS: You can’t go what again?

MR. BURGER: To treat the prescriptions as HIPAA transactions
and therefore we can’t do things with the prescriptions. We’re just responsible
for routing them.

MR. REYNOLDS: No, you still translate them. Remember, a
clearinghouse is a translator.

MR. BURGER: I understand that, but –

MR. REYNOLDS: Yesterday’s testimony said that there are times
we don’t want people to change all their legacy systems; we want them to be
able to translate. So that would still give you that authority, but again,
under the umbrella of the HIPAA regulations.

MR. BURGER: We are in agreement and that would place zero
additional burden on us.

DR. KAUFMAN: We are, too.

DR. COHN: Looks like the audience is raising their hand on this


DR. COHN: Steve, and them maybe we can wrap up after this.

DR. STEINDEL: Yes, I have a question of Harry.


MR. REYNOLDS: Should I go over there?

DR. STEINDEL: No. Who in this process is not a covered entity
right now? I mean, I agree with what you’re saying.

MR. REYNOLDS: Vendors are not a covered entity.

DR. STEINDEL: But they don’t handle it. They produce systems

MR. REYNOLDS: No, that is not true. They will take in the
original script as selected by the doctor. And my point is, and we’ve had this
issue in a lot of cases. The vendors have been excluded.

The clearinghouses were not, and the clearinghouse is defined
as somebody that takes it in and translates it. But the vendors, the actual
people – so if

I was buying WebMD system to do e-prescribing, in that case
– forget that you were a clearinghouse before – they would not be

DR. STEINDEL: Thank you.

MR. REYNOLDS: That’s the difference.

MR. BURGER: However, in our contract, I mean, we include the
language, although it’s not required.

MR. REYNOLDS: I understand, but under the jurisdiction of
HIPAA, you are not. You would not be covered as a covered entity under that.

DR. COHN: Well, I think the other question was – we heard
yesterday there was some confusion about whether the value added networks

DR. KAUFMAN: We are a busy associate, however.

DR. COHN: — are covered entities.

DR. KAUFMAN: The vendors are business associates and therefore
have –

MR. REYNOLDS: Yes. Well, I know, but that’s a dramatically
different level than up front, in the game, you got the label and you have to
answer to everyone that’s involved, not just your business associates.

DR. COHN: Yes. Okay? Any final questions? Shall we take a
break? We’re running a couple minutes early, so we’ll take a break and we’ll
come back at 10:30.

[Break begins at 10:25 a.m.

[Meeting resumes at 10:40 a.m.]

DR. COHN: Okay. We’re going to get started here, and we’re
happy to have Terri Swanson and Phil Rothermich joining us, talking about, I
think, the plan and really PBM perspective and how this all plays out.

I think, Terri, you’re going to be leading off? Is Phil going
to be leading off? Okay, Phil, you’re going to be leading off then, sorry. I
should have noticed from the overheads here, so – thank you.

AGENDA ITEM: Presentation –
E-Signature: The Plan/PBM Perspective – MR. ROTHERMICH

MR. ROTHERMICH: Thank you for the opportunity to be here this
morning. We’ve coordinated our presentation so I’m going to go through a little
bit of overview and then Terri’s going to take us more on a specific, technical
level the security and authentication procedures that are currently in place
with an end goal of suggesting that the authentication and security procedures
in place today are sufficient for the purpose that we’re all here and should be
adopted as standards. And we’ll walk through that.

Before I begin, I just wanted to make a point in response to
Dr. Cohn’s question earlier about whether greater security may be necessary in
connection with moving to EMR and so forth. I don’t think the argument is
really that the security in place today is somehow substandard.

The issue has more to do, I believe, with authentication, of
making sure that we know there’s a physician on the other end, and what we’ll
walk through today is trying to give you comfort that in fact the information
that’s going through the systems in place today for electronic prescribing are
indeed secure, considerably more secure than what exists today in the paper
environment, and is consistent with what is out there today with respect to
significantly more sensitive kinds of health care information in like health
care claims.

And this is really just sort of perspective, so when we’re
talking about the security pieces, we keep in mind what we’re dealing with,
just an example. We get a prescription from for an antibiotic, whether it comes
electronic prescribing or whether it comes as a claim in our PBM claim system,
we don’t know what that antibiotic is being used for. If the physician office
files a claim for the visit that generated that prescription, there’s going to
be a diagnosis code. They’re going to go through some of the very same types of
security procedures to get that claim to the insurance company that we’re
talking about using for e-prescribing and it’s going to contain significantly
more sensitive information.

So the health care claim is going to have an ICD9 code that
talks about whether it’s an ear infection or an STD. And the security
procedures in place today are very similar to what is being used for
e-prescribing, so again, just perspective.

What we’re going to do today is, with this chart, we’re going
to walk through the specific procedures that are in place at each point in the
chain with respect to e-prescribing and try and take you through why, from a
security and authentication perspective, these are sufficient, and then we’ll
talk about where the improvements are possible.

To your point earlier, if there is additional security or
authentication that could be added later, probably the most significant thing
is on the front end, in other words, the security of the system exists with
respect to securing the information flowing across the wires, but that security
is only as good as the front end system to allow people to access it.

So what we were talking about in the last panel, somebody gives
away their user name and password, it shoots the security that you’ve created.
So, again, just to the next slide which sort of takes us to that.

I want to make a clear distinction between the concepts of
security and the concept of authentication because some of the conversation
around electronic signature at times tends to confuse the two and it’s
important in understanding the difference so that we can tackle each of them

Security really has to do with getting a transaction sort of
from here to there without interference so that we can be reasonably sure that
nobody along the chain has accessed, modified or redirected what we’re trying
to achieve.

And this is really where PKI comes into play, where, again, the
existing systems create good security; PKI arguably is a level high in security
but may not solve the underlying problem if what we decide is the real problem
is authentication.

Authentication has more to do with giving confidence to the
pharmacist that they can rely that the person who they believe is sending the
prescription is actually the person on the other end, and I’ve put in gray here
the second piece of it, which is that the prescription could not reasonably be

And the reason I’ve got that sort of highlighted is because in
the context of e-prescribing, non-repudiation has become a very significant
point where it really isn’t a significant point in the paper world today. In
other words, a physician writes a prescription, signs it, it gets to the
pharmacy; the pharmacist sees a signed prescription and fills it.

If someone steals a prescription pad and fakes the physician’s
signature, the physician could say, I didn’t sign that; that’s not my
prescription, repudiating the prescription, and there’s no way to prove
otherwise, really. I mean, you could get into signature analysis and so on and
so forth.

But what we’re trying to get to with electronic prescribing is
a secure enough system that the only way to get a prescription from this
physician to the pharmacist is with access tools that are clearly assigned to
the physician so that if the prescription comes out of that system, it’s
difficult for the physician to say they didn’t write it or authorize it.

And this where the front end security becomes more significant,
because when you talk about biometric types of access points, that’s when you
really solve the authentication issue, but I think it’s generally believed that
those aren’t yet available.

So, moving from there, just wanted to start with kind of an
overview for security and authentication in electronic prescribing. What’s out
there today is really meeting the HIPAA standards with respect to security,
provides reliable means of authentication and security certainly much more than
existing processes.

There was a lot of conversation yesterday about the fact that
the patchwork of state laws and regulations and interpretations have created a
fair amount of confusion, particularly at the pharmacy and with the point of
care vendors where it isn’t clear what it is they have to comply with.

And there is considerable conversation about taking the
security and authentication pieces for electronic prescribing far beyond what
is really achievable today, certainly as you balance that against adoption and
considerably farther than what is in place with paper today.

Again, there’s sort of a mantra we’ve been pushing this year,
which is “don’t let perfect be the enemy of good.” And I think we
face that again here today.

The next slide I’m not going to spend any time on but really
just speaks to the requirements for HIPAA and makes the point that electronic
prescribing in the systems in place today that are providing this technology
are really meeting all of the security requirements of HIPAA for protected
health information.

I wanted to walk through, just for perspective, and again,
we’re not arguing that today’s world is sufficient, but again, we’re going from
sort poor or reasonably poor security to very good security and want to make
the point that for the 85 percent, if that’s the right

number, of prescriptions that are not controlled substances,
this is a significantly better system and point out the irony that to the
extent there’s conversation about adopting a single system that may be what DEA
is focused on for controlled substances, what we could do is kill the whole
thing, and it’s important to understand that the security and authentication
procedures for paper prescriptions are really extremely poor and it would be, I
think, a tragic result to end up forcing people back to paper because we’re
trying to find perfect.

If you look at paper prescriptions today, the security in place
is extremely minimal in that people may guard their prescription pads to some
extent. The last panel, there was some conversation about people signing

Clearly, within the doctor’s office, there’s the potential for
bad actors and even with patients and people passing through the doctor’s
office, presumably there are regular opportunities to get access to pads.

But there’s also relatively easy ways to copy a prescription.
For people to want to fake paper prescriptions, it really isn’t that difficult.
And when you talk about fax and phone, Mr. Burger made the point earlier if you
know what you’re doing, you can call a pharmacy and get a script filled
relatively easily.

With respect to the wires, they’re sending faxes and making
phone calls across regular phone lines, so we’re not talking about any sort of
encryption or protection of that kind of information as it’s going across the

With respect to electronic prescribing, as Terri’s going to
speak to in depth, there are significant security procedures every step of the
way. There’s channel encryption, there’s all kinds of access restrictions, so
that it’s relatively easy to get comfortable that when you’re trying to get a
prescription from the physician’s office to a pharmacy in a secure manner, we
built a system that gets us there.

I wanted to spend a minute talking about why authentication is
important, and this has been sort of alluded in the last couple days so I won’t
spend a great deal of time on it, but it’s the pharmacist’s responsibility to
authenticate the prescription.

And the way they do that today is really driven in large part
by methods of practice that are accepted within the pharmacy world. So it isn’t
as if what they’re doing is clearly authenticating the prescription; it’s
they’re going through what steps are available to them.

So, for example, a fax comes from a physician’s office and they
validate that the header on the fax matches a fax number that’s assigned to a
physician’s office. IT people will tell you it’s extremely easy for somebody to
change the header on a fax machine to show a different number than where it’s
coming from.

So there isn’t really authentication there, but the pharmacist
and some of the state laws relating to authentication specifically refer to
validating the fax header as one means of authentication.

So there’s methods of practice in place that most people will
tell you are insufficient, but they’re what the pharmacists are used to, and
it’s the pharmacist’s license that’s on the line.

So the conversation in the last panel was about whether this is
really left to the pharmacist, and indeed it is. The question is giving the
pharmacist confidence that the system behind the electronic prescriptions
they’re getting actually does authenticate the physician and give them enough
confidence to rely on it and making it clear in the state in which they
practice that their right to rely on that process that’s in place exists,
because a lot of what the problem is today is the laws don’t deal with it so
they’re not sure what kind of authentication they’re required to do.

They don’t have a method of practice. And so they’re concerned
about putting their license on the line without knowing, and so people feel
compelled to go ask.

And if they go ask, they don’t go ask necessarily, can I take
an electronic prescription? They ask, can I take an electronic prescription
– knowing what I know about the WebMD system? Can I take an electronic
prescription knowing what I know about the DrFirst system?

So it’s a lot of back and forth and it’s not necessarily a
simple answer. Many times, to get an answer from a board of pharmacy, you have
to appear before the board. So you spend time getting on agendas, you spend
time lobbying the members of the board, and so on and so forth, and it’s just a
very, very inefficient process.

One of the points I think that’s key here is the focus needs to
be on substantive authentication of the person on the other end. Some of the
conversation around electronic signature and some of the state laws trying to
deal with electronic signature really confuse the issue because they talk about
electronic signature as the answer.

The thing that electronic signature provides really is
authentication. So what we need is a system where we can be confident that the
person using the system is the person we think it is. And then whether you want
to consider the signature an X or the physician’s name printed or a symbol like
Prince, it doesn’t matter because we know whoever sent that prescription is the
person we think it is on the other end.

And so I would encourage the Committee to think more about
authentication than about e-signature or PKI because the real problem we’re
trying to solve is validating that the people using the system are in fact the
people who we think they are and that they’re in fact authorized to write

Similarly, we’re going to do a short comparison of the
authentication procedures with respect to e-prescribing versus paper. I
referenced this a little bit talking about fax numbers, but again, with paper,
the only thing people have to rely on is what they’ve always relied on.

So a pharmacy gets a prescription with a signature – there
was reference made yesterday to a pharmacist recognizing a physician’s
signature. I don’t believe that. I think pharmacists are busy, and certainly
pharmacists in big cities see prescriptions from a lot of people and they don’t
have time to recognize signatures.

So I think we’re sort of deluding ourselves if we think there
is really much true authentication in place other than these sort of historic
methods that pharmacists and pharmacy boards have come to rely on for lack of
anything better.

But again, if you look at the way the systems are built, the
way physicians are authenticated before they get access to these systems, the
way the systems connect one to the other and verify the links in the chain,
there is significant authentication that takes place that the pharmacist should
be able to rely on.

The question is creating a national system that makes sure that
those processes have taken place and gives the pharmacist the security knowing
that they can rely on those processes without fear of censure.

I’ve got a short slide here on why PKI doesn’t work and I think
I’m just going to skip through it because we’ve had so many conversations about
that. I think that point’s been made, although I guess we’ll just sort of
formally underscore it here.

What we want to suggest is that there is a solution and we’ve
sketched out here a three-part solution.

One is to adopt what is today the best practices as standards,
and Terri’s going to walk through what those standards might look like, and
implement them as a minimum level for security and authentication.

The conversation yesterday about whether or not the Committee
is free to adopt specific technologies I think can be resolved because the
standards really can create a floor. So rather than adopting a specific
technology, you can adopt a specific level of security, for example, that
vendors are free to go above but not free to go below, so that you’re not
exactly adopting a technology as saying your system has to be at least as
secure as these types of technology can provide. If others come and people
choose to adopt them, that helps.

I think it’s important to clarify by rule that the standards
adopted indeed do supersede state laws and regulations pursuant to authority in
the MMA, and I think there’s been some conversation about that we don’t
necessarily need to get into, but both the language in the MMA allows for it,
the jurisprudence around preemption certainly allows for it given what’s in the
rest of MMA, and the need for the industry, if we really are intending to drive
electronic prescribing both from a substantive authentication and security
perspective as well as driving adoption, make it required.

Finally, we’d like to suggest a certification process for
vendors which may be viewed as somewhat controversial but to Mr. Reynolds’s
point this morning, in order to give the pharmacist the comfort of relying on a
particular system, you really need some level of verifying that a given system
complies with the standards we adopt.

It’s kind of like you can’t really have laws with no police.
The question is people are, I think, hesitant to talk about certification
because we’re all wondering who’s going to be the certifying body and whether
or not there are resources to do that.

But I think it’s worth noting that the networks today that are
dealing with point of care vendors – RXHub, SureScripts, ProxyMed –
all of them are currently engaging in processes to essentially certify the
point of care vendors who are using their systems to make sure that the
security procedures are indeed in place, that the authentication procedures are
in place.

So if you created the standards, I think it’s safe to leave to
those bodies the process of certification so that once a script comes from one
of these certified vendors, it’s deemed valid for federal purposes and because
of preemption for state purposes so that every pharmacist can rely that if it
comes from one of these vendors, it’s a valid prescription, they can fill it,
and the fact that it came from these vendors is indeed the authentication that
they’re trying to get to and they can do a side with all of the conversations
with boards of pharmacy and looking at fax headers and so on and so forth.

And with that, I think I’ll turn it over to Terri.

AGENDA ITEM: Presentation –
E-Signature: The Plan/PBM Perspective – MS. SWANSON

MS. SWANSON: Thanks, Phil. Good morning, everyone, and thank
you for affording me the opportunity to speak to you today. My name is Terri
Swanson, and I’m the CIO for Cigna Pharmacy Management.

As Phil discussed, I’m going to take you through more of an end
to end process flow and try to highlight some of the various security measures
that are in place in the electronic prescribing industry today. I think you’ve
heard a better level of detail from the individual entities.

I’m going to try to refer back to the testimony of the networks
and of the WebMDs and DrFirst on the prescriber application side but try to put
these pieces together and illustrate how there are many, many, many different
security mechanisms in place as a prescription flows through the process today.

Starting at the prescriber practice side, the first thing that
I want to re-highlight, I guess, that the technology vendors highlighted this
morning, is that the point of care application providers do authenticate these
providers. They do a fairly thorough job, as thorough as possible,
credentialing them to insure that they are indeed allowed to prescribe. So that
all happens before a physician ever gets a user ID or password or any means of
accessing that prescribing technology.

From a security standpoint, authenticated prescribers are
granted access to the technology and use a user ID/password or more – you
heard about a PIN added to that. There are a variety of different
authentication mechanisms that different technology providers use, but all of
them are contingent on credentialing that provider first.

Once the prescriber is using the system, prescriptions are sent
typically to a point of care centralized application server, so you see moving
out of the physician’s office and into an application server. That transmission
is sent through an encrypted channel, a secure channel, and it’s always 128-bit
encryption or higher. So this is a very secure protocol that’s happening.

In addition, there are typically contractual relationships that
govern the ability again of the physicians to access these systems. You heard
this morning about how those contracts also may govern delegation of authority
to other people in the physician’s practice.

So in addition to the technical security mechanisms in place,
there are also a series of contracts that are in effect.

Last but not least, in the case of wireless technologies, there
are additional security and encryption mechanisms that are technology dependent
that are also in place to insure that the prescriptions cannot be altered or
intercepted or inappropriately accessed.

So what you see here is a variety of different security
mechanisms in place in the physician’s office and then a secure channel that
gets that prescription from the physician’s office to a centralized server.

Once you’re at the centralized server, the point of care
technology vendor and the router — or network as I think we’ve been referring
to them in the past few days — verify each other’s static IP addresses, their
own IDs and passwords before opening a secure channel, again, a secure,
encrypted channel, to transport that prescription.

One thing that I want to highlight here is that the
server-to-server handshake that you’ll see at every step along the way here
typically does employ server side digital certificate technology, so that
portion of PKI is used between the individual servers. It’s in very widespread
practice – it’s feasible, it’s practical, and it’s working.

So I think when we talk about PKI and the challenges with PKI,
the challenges really lie in that end-to-end individual physician to individual
pharmacy type of environment rather than the server-to-server environment that
we see in the networks as they’re constructed today.

The other thing that we haven’t talked a lot about this
morning anyway is that there are significant internal assessments that each of
these environments go through to insure that they are secure. Most of these
servers are in very highly protected data centers that go through rigorous
security audits on a very routine basis. They employ security scanning tools
for intrusion detection and so forth, a variety of technologies, again, that
are and have been in widespread use.

And I think it’s important to understand that once the
prescription is flowing through this environment that these are very, very
secure environments and the industry has invested a lot in protecting those
systems again not just for prescribing but for the broader applications of
other types of health care EDI. So it’s an extremely secure environment, highly

Finally, the use of PHI in this context must in accordance
with the HIPAA standards and so there are also those standards that are
governing this entire environment.

To step forward to the router, or the network, again, many of
the same mechanisms that I just talked about – the router will do a
handshake with the point of care technology and the pharmacy, so the router is
playing that role connecting to both sides, again, prior to opening a secure
communication channel typically which is enforced with digital server side

On the security side, the router adheres to security policies
which are consistent with the HIPAA guidelines, as we talked about, and again,
those same internal assessments are in place just for making sure that the
physical environment and the technical environment is appropriately guarded.

Other things that routers do to try to insure I guess that
prescriptions cannot be used for the wrong purposes or falling into the wrong
hands – the routers maintain typically only enough information to support
routing, auditing and technical troubleshooting and so forth.

I think it was a good point made earlier this morning that it
would be helpful to the industry to have some guidance about what is enough
perhaps and what is too much so that those routers and other vendors along the
way do not have to guess at this, because when you look at the process, you
need to be able to piece together the audit trail from the physician’s office
to the server system to the network to the pharmacy and each of those, you need
to log and store the appropriate information so that audit trail is preserved
from end to end.

And finally, the router cannot view or modify the prescription
other than for standard value added services such as translating either between
versions of a standard or between messaging standards.

Okay, and finally, the prescription has arrived at the
pharmacy. Again, there’s a similar kind of handshake at the server level that
is secured. The pharmacy does have a cross-reference that links back to the
physician. This is used primarily for routing purposes but may provide an
additional level of authentication.

Again, from an audit perspective, the pharmacist does have the
right to contact any one of these steps along the way, but typically they’re
going to go back to the physician if for any reason they feel there’s something
inappropriate or suspicious about that prescription once it arrives in their

We’ve talked about the audit trail already and I think we’ve
talked about authentication.

So that’s really a summary of where end to end the various
security standards lie. And I guess in wrapping up, I would like to highlight
and agree with some of the recommendations made earlier this morning about the
need to set a minimum standard that is very secure, much more secure than
today’s paper-based, fax-based or telephone-based systems and to also allow the
industry to continue to evolve.

The industry has employed more and more and more security
measures over the years and will continue to do so, so I think allowing for
that minimum floor and then additional things that go beyond will continue to
raise the level of overall assurances that we have, moving forward.

Questions, Answers and Comments

MR. REYNOLDS: Simon had to step away and take a call and he
asked me to coordinate the questioning going forward. Any questions from the

DR. WARREN: I just wanted to thank you for the drawings. I
mean, to split it out into each of the steps so that we can really get our arms
around what happens at each step instead of trying to lump it all together and
manage that complexity. This is wonderful. I just need a chance to study the
drawings now.

MR. REYNOLDS: Okay. Stan, you have a question?

DR. HUFF: You and some of the other folks, your recommendation
has basically been let’s adopt best practices. Do you feel it would be
appropriate for this Committee to actually specify the best practices that
should be adopted in our recommendations to the Secretary or do we leave that
for a proposed rule-making process, or what? That might be a question for staff
and other people here as much as for you, but –

MR. ROTHERMICH: Our suggestion here was basically that these
items under each of these categories could be the standard. In other words,
defining the best practices, the point of care vendor authenticates the
physician before giving access to the system.

The level of detail at which you specify that in a standard I
suppose is debatable but there are certain minimum levels of things that you
could require vendors to do so that if they complied with the standards you
suggest, everyone would feel confident that this is a secure, authentic

I think best practices as a term is a little too vague to adopt
as a standard but as we’ve tried to define here and I suppose we could argue
whether there’s a lower level of detail we might want to get to but what we’ve
tried to argue is this is the definition of the best practices, and if all of
these things were standard and everyone could feel comfortable that everybody
in the chain is doing these things, mission accomplished.

MS. SWANSON: Yes, I think the recommendations can focus on the
functionality that you want from the system. So, for example, networks must
employ intrusion detection software blah-blah-blah.

There are probably other recommendations and standards, for
example, the HIPAA standards, that could be leveraged to get to the appropriate
level of detail. But I think it should focus on the functionality rather than
specific technologies to the extent possible so that there will be some
technologies, like recommending a minimum of

128-bit encryption et cetera, that you’ll want to specify, but
I don’t think you want to drive to a level of detail that makes it difficult or
makes the industry have to adopt a specific technology versus come up with
efficient and appropriate ways of solving the problem. I don’t know if that’s

MR. REYNOLDS: Judy, thank you for the charts. I want to
challenge from a – [laughter].

All the players we’re hearing from are the big players. As you
see e-prescribing going forward, are there going to be – you got over here
on the left hand on all your charts is the clinical practice management. I know
a speech I gave in North Carolina I went through the first four pages at WIDI
before anybody put up their hand up that they recognized any of the practice
management systems that we were dealing with.

So we have a lot of the star players and the big players in
here. Does your chart come apart anywhere as we get into the mom and pop
practice management system? Do they have to use the switches? I mean, in other
words, this is a good drawing for the people that have been here with us along
this way. Does this drawing hold as we get into the real world and this passes
and then it becomes free enterprise and everybody jumps in?

MR. ROTHERMICH: I think it actually helps the situation. If you
talk to many of the point of care vendors today, they’ve written interfaces
with certainly more than just the big guys. They can profess to how many
interfaces they have written primarily as they come across them.

MR. REYNOLDS: Point of care, do you mean –

MR. ROTHERMICH: The technology vendors. I’m talking about the
people who would provide the software for electronic prescribing actually
interfacing with a practice management system.

And the practice management system is still extremely
fragmented where you’ve got a few really big players and quite a few mid-size
players and a whole bunch of little players.

But to the extent that you can create a standard and electronic
prescribing becomes sort of the order of the day where physicians are expecting
it and expecting to be able to do it in coordination with their practice
management system, by creating a set of standards that are clear, that tell
each of these practice management vendors “if you build it this way, it
will work,” actually reduces their cost of entry and makes it easier for
everybody to play across a given platform.

I think one of the reasons that some of the littler players
aren’t jumping in, whether it’s by building a solution themselves or partnering
with somebody who’s got one, is they just don’t have the resources because
they’re small.

And I think there might be some backward integration where if
you had a set of standards and these smaller practice management systems wanted
to get on board, they could go to the electronic prescribing vendors and do
affiliation agreements essentially where they cooperate with each other. It’s
relatively easy to make those interfaces.

The problem the point of care vendors have had is a lot of the
practice management systems are closed systems, so they’d either have to hack
in or they’d just have to say, we can’t work with that one, where I think if
you create a set of standards and it becomes an expectation, it becomes easier
for everybody to get on board.

MS. SWANSON: I’m approaching your question in a slightly
different way. I think the drawing does hold and what I would suggest is that
we’re not saying that every single piece of this picture needs to be in place.

So the suggestion isn’t that every cog has to go through a
central server and a network. The suggestion is these security authentication
standards need to be in place at those different points in the chain.

So if I have a practice management system or an e-prescribing
system in the physician’s office that connects directly to pharmacies in a
region, that’s fine. But that server-to-server authentication still needs to
employ all of these different function points for that to be considered a
legitimate and secure electronic prescription.

So I do think that the diagram is helpful in that this is
typically the way people connect and yes, this is mostly how they’re going to
do it, and in the physician’s office, big or small, these vendors do connect
with the various networks who you’ve talked to and they have gone through the
certification processes, so I don’t think there’s a competitive issue at all

But more importantly, I think with the security standards, you
could use different connectivity models and still have a very secure
e-prescribing process.

MR. REYNOLDS: Also on the chart, since the clinical and
practice management vendors are not covered entities, and the charts say that
all this is under HIPAA, using HIPAA standards and everything, so that’s where
I think it also is an issue because they aren’t. They don’t necessarily use the
standard, they aren’t required to use the standard, and they aren’t covered by
the standard.

And so do you see this chart backing up, as I mentioned earlier
today, backing up, that if it’s e-prescribing, then it pulls them in under that
and they have to meet those standards? Is that what you meant by the way you
drew the chart or did you still want to leave that out there as an uncovered

MS. SWANSON: I would support making them covered entities. I
think today, because the next link in the chain is typically a covered entity,
they’re making those requirements contractually of that partner to connect, so
I think the reality is those entities, even though they may not be covered,
they’re living up to or exceeding the standards because the rest of their
business partners expect it and require it of them. But I think your suggestion
of making them covered entities would certainly eliminate any debate or
confusion on that part.

MR. ROTHERMICH: The only question I have, and I’m not a HIPAA
expert at all, but I agree with Terri. I think the HIPAA security procedures
are really in place. The only concern I would have is to the extent you
designate a point of care software company as a covered entity. I don’t know
the full impact of that, particularly from a cost perspective.

And again, if we’re trying to drive adoption, have we
accomplished what we’re trying to accomplish from a HIPAA perspective as far as
making sure people are treating this information securely according to what
HIPAA dictates, and I think we are, if you call them a covered entity, does
that add additional cost for their operations and create another barrier to
full adoption because they’ve got one more piece of cost to figure out how to
create a business model around supporting?

And that’s been an issue to date. You know, everybody says
doctors don’t what to pay for anything. The more expense you load onto these
companies, the more they’ve got to find revenue streams to cover them.

MS. SWANSON: I would agree with that. I am also not a HIPAA
expert and I don’t know what other requirements in addition to the technology
requirements would really be placed on those businesses.

So the question of covered entity is probably a large question,
but certainly from a technology standpoint, it would make it cleaner.

MR. REYNOLDS: Any questions from the Committee?

DR. WARREN: I have just one, and it’s not fully formed in my
head, but in looking at your drawing, where do you see companies like WebMD and
DrFirst entering into the drawing? If you had to map into there, where would
you see those happening?

MR. ROTHERMICH: I think DrFirst is in the second column. I
think WebMD is an example of what Terri was talking about, that not everybody
is going to have four steps, because WebMD is both the practice management
system and the point of care electronic prescribing because they’ve got them

MS. SWANSON: And they’re a router because Envoy has part of the
company as well. So WebMD actually fits in the first three boxes in this
particular model.

MR. ROTHERMICH: Except that with respect to prescribing,
they’re leveraging ProxyMed.

MR. ROTHERMICH: So ProxyMed would be in the chain for

DR. WARREN: So from that perspective then, your drawing still
holds pretty good to help us think about authentication and security and that.

MS. SWANSON: Yes. The way that you might think about these
boxes is think of them as roles as opposed to discrete companies. So a company
might be playing several roles in this process – the role of routing the
prescription to the appropriate pharmacy –

DR. WARREN: You’ve got them drawn there almost like swim lanes.

MR. ROTHERMICH: And if you look at the bullets under each one,
there’s consistency there, so it’s really if you’re following the rules in the
first step and you skip the second step, you’re going to be okay as long as the
third –

DR. WARREN: And then in your solution slide, again you
mentioned the wonderful word of “preemption, except you phrased it a
little bit differently, so again I want to be sure I understand what you’re
suggesting. You said “clarify by rule that these standards supersede state
laws and regulations.”

So does that mean as you are identifying your best practices
over here for authentication, audit trails, that would apply to different parts
of state laws so preemption would not be this overall preemption; it would be
in these different roles?

MR. ROTHERMICH: Well, as written in the MMA, part of the
difficulty is interpreting what superseding any state law or regulation deals
with these issues. I think the solution down here about if you follow these
procedures, the procedure is deemed valid, I think gets to some of the state
laws about what a pharmacist is required to do to validate a prescription.

And the testimony yesterday from NABP I think made a very good
point, where preemption makes perfect sense, but let’s make sure we solve the
whole problem. And so there may be some analysis necessary, say, when we write
the rule.

And when I say “clarify by rule” here, I mean I think
there’s a distinction that probably needs to be made, the extent this Committee
comes up with standards, a recommendation for the standards, and NCVHS comes up
with standards, then the Secretary writes the rule.

And I think when I say “clarify by the rule,” we’re
talking about the Secretary interpreting the statute to say these have to
preempt for the statute to accomplish its purpose.

And then when it comes to what is it exactly we’re preempting,
I think you have to get to some level of detail to make clear that what we’re
trying to say is anything contrary that deals with security or authentication
of electronic prescriptions is preempted and you don’t need to make an
exhaustive list and those sorts of things get resolved by litigation.

But if it’s done clearly enough, then it should be clear to the
states that if we’re talking about rules for pharmacists relating to
authenticating a prescription or rules relating to routing a prescription, that
these are going to be covered.

I think that’s the key point. I mean, there may be some
flow-over from that, but I’m not sure we need to go there right now because the
real purpose here is to make sure we’ve solved the security and authentication

DR. WARREN: I appreciate that. Thank you.

MS. SWANSON: I think we are also — just because it’s not
explicit, but you just said it, so I think our intent is also to solve the
provisions that make it impossible for routers and other intermediaries to
carry the prescriptions, with the example of the Georgia law that we saw. The
way that that’s written doesn’t necessarily fire on security and authentication
for me, but that’s clearly a part of what I think the problem is that we need
to solve.

DR. WARREN: Yes, I like the way that you’re phrasing it, of
taking best practices and then tracking them through to the rule-making. I
think that’s probably the strategy. It’s not an umbrella strategy; it really is
looking at the issues. Thank you.

MR. REYNOLDS: Simon, I’ll turn back over to you. I don’t think
there were any other questions from the Committee, so if you have any, you may
want —

DR. COHN: They probably have already been asked. I’ll be brief
with the subcommittee during the break.

Well, is there anything else? No? Gosh, I miss Michael
Fitzmaurice not asking a mathematical question today.

MR. ROTHERMICH: I don’t know anything about math.


DR. COHN: I actually was trying to remember logs yesterday and
I found that it was a high school discussion, which has been many years ago,
for those of you on the Internet.

I think with that we’re actually running early, which is good,
since we’ve got a long afternoon. I’m going to suggest we adjourn now for
lunch. We will reconvene – gosh, I’m giving this not quite 11:30. Shall we
try to get an earlier start, say, 12:30? I guess I would ask our initial
testifiers, which is Mike Griffiths and Mike Simko, are you all okay with
starting early?

Okay. So we’ll come back at 12:30 then. Thank you.

[Committee breaks for lunch at 11:25 a.m. and resumes meeting at 12:40 p.m.]

DR. COHN: Okay. Well, our session this afternoon describes the
pharmacy perspective, and I want to thank both Mike Griffiths from Albertson’s
and Mike Simco from Walgreen’s. Thank you both very much for coming and joining

And I think, Mike Griffiths, you’re on first, right?

PARTICIPANT: They’re coordinating.

DR. COHN: Oh, you’re coordinating. People are throwing me off
here, people are actually doing this stuff together! I will thank you. And
obviously, we will have to probably call them “Mr. Griffiths” or
“Mr. Simco” because talking to “Mike” is not going to work


DR. COHN: But thank you very much, whichever one –
they’re coordinating, okay. Please.

AGENDA ITEM: Presentation – E-Signature: The
Pharmacy Perspective – MR. SIMCO

MR. GRIFFITHS: We actually were in a different order, but
since we got moved up to 12:30, we thought we’d change it.

MR. SIMCO: Hi. I’m Mike Simco from Walgreen’s. I’m Manager of
Pharmacy Systems. And I really appreciate the opportunity to once again address
this Committee in the area of e-prescribing and today’s topics of electronic
signature and security.

For 104 years, Walgreen’s has been in the pharmacy business.
We take great pride in providing health care in our stores. Currently, we have
close to 4,700 locations in over 44 states and still on an aggressive growth

And we have embraced e-prescribing for a long period of time.
Well over 10 years ago, we initiated what we believe is the first electronic
transmission of prescriptions between physicians’ offices and our pharmacies.
Although it started with a very rudimentary email-type system, we grew that and
saw the benefits from that and grew that into a very robust application.

Recognizing the need for pharmacy participation, market
participation, and a greater group of both prescribers and pharmacies in order
to make electronic prescribing move forward, we sold our pharmacy program not
once, but twice, and currently to ProxyMed, who has made further developments
in that functionality.

We recognize the value of electronic prescribing in both the
efficiencies it brings but more importantly, I think, in the quality of health
care it provides.

MR. GRIFFITHS: Mr. Chairman, members of the Committee, I’m Mike
Griffiths from Albertson’s, and I’d like to thank you for the opportunity to be
able to meet before you this afternoon. Albertson’s has approximately 2500
stores in 37 states across the country.

My past experience – I served as a pharmacy manager in
retail pharmacy for over 20 years and then a few years ago I moved into
administration and pharmacy operations, worked there for several years;
currently, I work in the IT department, giving advice on and assistance with
privacy and health care security matters.

Again, thank you for the opportunity, and Mike and I would like
to speak on behalf of all the retail pharmacists out there as best we can

MR. SIMCO: I kind of want to take you through the path of
prescribing a little bit.

Today, we get prescriptions in a variety of manners. One
prescription written by a prescriber is not always on a prescription pad. In my
practices I have seen a variety of ways prescriptions have arrived at
pharmacies, anywhere from pieces of torn paper to back of menu cards to back of
greeting cards to glitter to markers of various colors, prescriptions of
various colors, shapes and sizes. One guy I remember was into calligraphy.


MR. SIMCO: Others I wish were.


MR. SIMCO: And those were all legal prescriptions.

And in fact today, a physician could pretty much take a crayon
and scribble on a brown paper bag a prescription for hydrocodone and it’s a
valid, legal prescription as long as there’s a valid doctor-patient

And what we have seen is – the testimonies heard yesterday
and today – pharmacists and pharmacies are responsible for approving the
validity of prescriptions.

And today’s method and methods of receiving prescriptions
provide a great deal of challenges to pharmacists not only in the
interpretation issues, the legibility issues that occur, information that’s
missing that a pharmacist is required to verify with the prescriber, but also
the authentication of those prescriptions.

Today’s society, and proven in the volumes of our pharmacies —
and I speak for Walgreen’s and I know Albertson’s and the CVSs and everyone
else out there — pharmacy volume, pharmacy business is growing, and it’s
growing rapidly, and today’s society is very mobile. It’s not so much the
corner drugstore anymore.

So many of our stores that have relocated in urban areas in
downtown locations don’t always have a very personal relationship with
physicians or a personal relationship with patients.

And so just by recognizing a signature or recognizing a
doctor’s name or recognizing a patient is losing its importance and
predominance in the prescription filling process.

And so we have to rely on good faith, we have to rely on a
pharmacist’s judgment that that patient, in data systems that we have, is valid
and that doctor-patient relationship exists before filling that patient’s

Today, prescriptions can be preprinted and in often cases,
physicians do pre-sign prescription blanks, and many times we’ll be notified
from a physician that I think some prescription blanks may be missing.

And then again the pressure is on our pharmacists and on our
stores to police when those prescriptions arrive and authenticate. And in all
those cases, the delay of getting the medication to the right patient occurs.

Prescriptions come by phone, and again, with today’s society
and volume of prescription business, it’s difficult to recognize the caller on
the other end. In some cases, pharmacies may have a good relationship and a
person relationship with particular physicians’ offices, but they don’t always
recognize the caller; we don’t know where the call came from.

And then there’s always the prescription is valid if it’s from
the prescriber or the designated agent. And I use the term “agent”
very loosely. I’ve gotten prescriptions from physicians, from office personnel,
from spouses, from housekeepers and children and family members of physicians
that you could hear in the background they’re relaying information back and

And there’s never an audit trail. In today’s world, if we had a
discrepancy on a prescription that maybe was brought in illegally or maybe it
was even a physician miswriting a prescription in an illegal manner for a
controlled substance, we have no audit trail on a phone call. It’s a valid way
of receiving a prescription and a valid way of dispensing to the patient, but
we’re left with no audit trail.

And again, prescriptions not done electronically, there’s
always the misinterpretation, the miscommunication or essential information.

So when an error may occur, sometimes it’s on oral
prescription, you can say, well, that’s what the physician’s office said, and
the physician’s office would say, oh, no, that’s not what we said. And then it
becomes we have no proof of liability. And not only in errors on prescriptions
but also in the liability as to the legality of the prescription or the
validity of a prescription.

The area of faxes have been growing and again, even with faxes,
we don’t always know where a fax came from. There’s also legibility issues.
Faxes blackened and writing disappeared over periods of time. Some states don’t
recognize faxes for some classes of prescriptions as being legitimate. And
again, in many cases, it requires the pharmacy staff, the pharmacist, to make a
phone call to verify information from a physician.

All these are legitimate means that prescriptions are delivered
to pharmacies and what we’re concerned about has always been our viewpoint on
electronic prescribing is why make that practice more burdensome? It’s been
difficult and a slow, deliberate process in getting physicians’ offices to use

I can tell you that we’re highly encouraged over the past year
that electronic prescribing has now been reenergized. It’s growing rapidly.
We’re seeing huge increases from all over the country in our stores as to the
amount of electronic prescribing that’s going on.

Again, the big benefits – the readability because of text
messaging, all the necessary information is there.

And the big key to e-prescribing is the integration into a
pharmacy host system. And with that integration is reduced key strokes because
all the fields are pre-populated, transcription errors are eliminated.

There’s also the issue of security. In the various types of
practice management systems and physician software programs that have to do
with e-prescribing, there’s a sign-on that’s required and an ID at the
prescriber’s office. There’s always an electronic trail of a transaction log,
and in the past we have used that and it has proven to be extremely beneficial.
It does work and it works very well.

We have maintained extreme secure connections between
physicians’ office systems to ProxyMed and

SureScripts and then between SureScripts, ProxyMed to our
pharmacies. We have dedicated lines with encryption. Our pharmacy system is
protected by numerous types of security and firewalls that there is no
messaging, there is no entry into our system that can take place without proper

And then even in our physician database we indicate on a
physician’s registration which doctors are in e-prescribing and what system
they’re on so that we know if prescriptions come from a particular physician,
he’s authenticated in our system for e-prescribing and we know that that’s a
valid transaction.

The use of modern technology has the potential to transform the
delivery of health care for the better, and so without a heavy-handed
regulation or upheaval in the health care sector.

What we’re saying is that in today’s world we get prescriptions
a variety of ways and electronic prescribing is meant to make the whole process
better, it’s meant to make it more efficient, it’s meant to improve quality

But we can’t have two kinds of standards. We can’t have such an
easy way that I could pick up a cell phone and call in on a controlled
substance prescription to a pharmacy – and that’s valid and that’s okay
– but I can’t send it electronically.

Between us, between our pharmacies, and the pharmacy
aggregators, the ProxyMed and the SureScripts, again we have a very secure
connection – private data circuits, encrypted messages and standards that
prevent altering transactions.

And those NCPDP standards that we use today, I know it was
talked about that if we were at certain version levels, they wouldn’t have to
do the routing and open up the headers, and that’s true.

And it’s incumbent upon pharmacies and practice systems to try
to be on as close a version releases as possible and the closer that they are
and the more compatible they are, the more secure, the least amount of work
needs to be done to rout prescriptions properly.

Again, pharmacy systems are protected by firewalls, encryption,
no unauthorized access, and every single transaction we do in our pharmacies
today, every single electronic refill request, renewal request, we send out to
physicians, every new prescription response we get back – denials or any
other type messaging – we keep very detailed, accurate log files that can
be reproduced over any extended period of time.

We also have encryption with over the Internet with VPN
connections utilizing SAL. Our prescribers have

unique addresses in our database so that even if a physician is
using e-prescribing and maybe has multiple locations, we have that physician
with unique IDs for each of those locations, so for a particular patient which
may see a physician at some site, we can rout prescriptions correctly to that

We have registered users, unique pharmacy identifiers using the
NCPDP provider ID, and a unique sender ID is an electronic signature. And
again, we’ve all heard the definition of electronic signatures.

You’ve seen this chart before. It’s very well done, very valid.
You’ll hear about it again. I think Lynn from NCPDP will be testifying.

Again, this structure does work. It works over a variety of
different kinds and types of connections and participants so that you can use
aggregators, you can use stand-alone physician e-prescribing systems, you can
use systems such as WebMD which not only has e-prescribing capabilities but is
an office practice management system.

E-prescribing in today’s retail environment, there’s security
that’s adequate to insure authentication. There’s no immediate need for
e-signature or digital signatures such as PKIs.

We’re not saying in pharmacy that that may not be the ultimate
solution and we’re not opposed to as secure and as authenticated signature
retrieval and verification as possible. What we’re saying, though, is there’s a
very good system in place today and we don’t want to have a barrier to
e-prescribing moving forward, and we’re very confident and feel very
comfortable that those systems in place today work very well.

We think that there’s a huge complexity to the use of PKIs.
Today we have bi-directional capability with prescribers, they use secure
passwords on both sides, and we think the existing infrastructure is very

Use of PKIs is a very complex process. I’ve attended several
presentations regarding PKIs in pharmacies and what I came to understand, that
each prescriber would have a PKI, each pharmacy would have to have a PKI, each
pharmacist within the pharmacy would have to have a PKI, and if that pharmacist
worked in different locations, a different PKI for every location they worked

And it becomes an extremely burdensome, tough, complex, sounds
expensive, way to manage a system that already works very well. And again, it
may at some point be the ultimate goal that everybody needs to work for, but we
think today that the systems are find, the security is adequate, and we should
keep e-prescribing moving forward.

We also think PKIs really have no guarantee of security.
Today’s world – we heard testimony may give signed pads to various members
of their office staff or authorization for prescription renewals. Same thing
with PKIs.

I would think that physicians may give their smart card or
token to a member of their staff in order to do prescribing or handle things
when they’re busy and in that case we have no 100 percent proof that that
prescriber is the one that sent that prescription other than that’s the person
that somebody is going to hold legally liable for it.

Today, various ways of authentication exist – passwords,
biometrics, secure connections, encryptions, identifiers. They all are working
today to various degrees. Some, we’re still looking for improvement in the
technology, but everything that is in place today gives us a very confident
trail of insuring that prescriptions that we receive electronically we have
much more faith in than any other legally recognized method of prescription
arrivals in our pharmacies.

AGENDA ITEM: Presentation – E-Signature:
The Pharmacy Perspective – MR. GRIFFITHS

MR. GRIFFITHS: And as pharmacists, we’d like to encourage the
growth of e-prescribing. You’ve heard the testimony that the e-prescribing
environment today is a big step forward from the legacy (manual) process.

Our goal is administrative simplification. We want to improve
the quality, safety and efficiency of the health care system. And the challenge
we’ve got is to avoid over-complication and introduction of burdensome
requirements that are not imposed in the non-electronic process.

Our solution is to implement e-prescribing architecture that
supports all prescriptions, both controlled and non-controlled.

Practitioners, pharmacists and patients need encouragement and
training in order to begin implementing e-prescribing and the benefits are not
going to be realized if technology is perceived as too onerous or complicated.

The HHS Fact Sheet, HIT Report-at-a-Glance, on July
21st, ’04, had a comment that I thought was interesting: “The
benefits of information technology have taken hold in other sectors but the
innovation that has made American medical care the world’s best has not been
applied to health IT systems.” We have to ask ourselves why.

We need to address perceived lack of return on investment and
non-financial issues such as training requirements and workflow modifications
both at the physician’s office and in the pharmacy. We have to reduce the risk
of investment. Low-cost, simple to implement systems will be much more readily
embraced by physicians and pharmacies. Simple, low-maintenance technology will
be more readily accepted by small practitioners and pharmacies, especially
those in rural environments and in small mom and pop type stores.

E-prescribing benefits patients. It improves the efficiency of
the prescribing process. New prescriptions arrive faster, refill requests are
processed faster. Pharmacists are able to spend more time providing
pharmaceutical care and counseling to their patients, less time interpreting
and clarifying hard to read prescriptions and time spent on the phone.

It reduces the potential for errors. Cost reductions realized
by health plans are going to happen because we’re going to have increased
therapy and compliance by the patients. Counseling improves the effectiveness
of the therapy and reduces cost due to improved therapeutic outcomes and
increased compliance.

It improves safety and it establishes a dialogue and rapport
between the patient and the pharmacist.

A large number of prescriptions that are written never are
taken to the pharmacy, and with electronic prescribing, those prescriptions are
going to be delivered to the pharmacist and a pharmacist has a chance to review
those with the patient and consult with a physician if necessary to find out
why the patient didn’t get that prescription filled.

As far as patient care, many patients receive a combination of
prescriptions to treat an illness which includes controlled and non-controlled
medications. The benefits of e-prescribing would be mitigated if a practitioner
could transmit a prescription for an antibiotic by e-prescribing but then would
then have to hand-write a prescription for the corresponding cough syrup with
codeine, for example.

So in order to realize the benefits and efficiencies of
e-prescribing, we’ve got to make the system efficient. Important concepts to
keep in mind – there’s no substitute for a pharmacist’s professional
judgment. Ultimate responsibility for insuring the authenticity and accuracy of
prescriptions rests with the dispensing pharmacist no matter how it’s
delivered, manually or electronically. If a pharmacist has any suspicions about
a prescription regardless of how it’s signed, he or she will contact the

E-prescribing is secure. It exceeds the current methods. The
security in place is adequate to support the e-prescribing process.

And let’s keep it simple to start. Over-complicating the
process and waiting to implement the perfect system is going to prevent us from
realizing the benefits that can be derived immediately.

Thank you very much.

Questions, Answers and Comments

DR. COHN: Okay. Well, thank you both for some very good
testimony. I see Judy’s hand up, Steve, Stan.

DR. WARREN: I just had a question as a result of this. We’ve
heard earlier that we need to make it where the pharmacist is assured of the
authentication of the signature. From your perspective as pharmacists, what
would we need to put in place to help pharmacists agree that the authentication
has happened, other than calling back to the office?

MR. SIMCO: In the contractual business arrangements we have
today with the aggregators, there’s a certain amount of certification that has
to take place between physicians, management systems, or physicians’ writing
systems and those aggregators and the practice management systems. And when
we’re given the new physician registrations that may now be engaged in
electronic prescribing, we give those physicians new, unique IDs.

If that prescription message that arrives into our system
matches those IDs in the secure connections that we have that exist between us
and those partners, that gives our pharmacists a very high level of confidence
that that prescription is authentic, it came from that physician, the physician
intended to send it.

As we go forward with different levels of encryption and
different types of identification, whether the use of biometrics or anything
else in physicians’ offices, all that really comes into play is being a much
more higher, secure system than what’s in practice today. And again, because of
the pre-registration identification and validation of who’s registered on the
network, that all kind of comes into play, has given us that level of security.

DR. WARREN: So what you’re really saying is that the pharmacist
needs to be assured that whatever software package they’re using does the
authentication and they can trust it?

MR. SIMCO: Exactly.

DR. COHN: Okay, Stan?

DR. HUFF: Yes – in trying to make an analogy back to
electronic health records, many of the same arguments came up in terms of
security for the electronic health record in the sense of saying somebody in a
white coat could walk up and grab my chart on the floor and we shouldn’t hold
electronic medical records to a higher standard than we hold paper records.

Ultimately, I think we have stronger security on electronic
medical records than we do paper records. And the justification for that was
that we have increased risk because basically, as things become network, you
have more risk because people, anybody anywhere, has the opportunity to try and
break in, and if the information is obtained, they have the ability to
disseminate more quickly, be more anonymous, to do population queries, all
kinds of things that you couldn’t do easily in a paper record.

In thinking about this, do you see any situations of that kind
here? Do you see where electronic prescribing increases our risk in some way
that would require us basically to have a higher standard for electronic than
for paper?

I can’t think of any, but I’m wondering if you guys have
thought of any. I mean, is there some chance now that somebody could set up an
operation that would automate some kind of fraud or other things, any kind of
risk, any kind of new risk that you see from this that goes beyond the risk
that we already have with paper?

MR. SIMCO: What you bring up is a great point and all that
could occur invisible to everyone else where in a paper society you would see
someone in a medical records area and now you can get somebody potentially
trying to break in and no one knows it’s happening. However, for a long time
our pharmacies have been

computerized. Our pharmacies really have been engaging in
electronic medical records for a long period of time, and we take very secure,
deliberate, expensive, detailed, redundant steps to protect pharmacy
information. And pretty much virtually at the point where I could say that we
have been successful in securing our pharmacy information that makes it free
from any tampering or entry from unauthorized access.

I think the same thing is going to have to eventually occur at
physicians’ offices. I’m not concerned with the transmission of prescriptions
from a prescriber through a network to our pharmacies.

I think that they need to build the same kind of safeguards
around their electronic medical systems in their physicians’ offices and to
have security and firewalls and encryption there to protect the records that do

But as far as the transmission itself, I don’t have any issues
with the authentication if I know that it came from that physician’s office and
they’re properly registered and that messaging came through electronic means or
e-prescribing means. I have confidence that’s secure.

I think the other part of that, though, is that they build
adequate security on the electronic medical records part in their offices and
whatever other interoperability and connections they may have to insure the
integrity of those records.

DR. HUFF: But I’m just trying to think of some innovative way
of gaming the system that could occur electronically that couldn’t occur –

MR. SIMCO: And I can’t think of one, either, and the other
thing I could say on it is the advantage is that there’s a very good, very
detailed audit trail that exists and at least that we can know if something was
an invalid, unauthorized prescription or denied as being sent, that we have
that audit trail and we’ll go back to the physicians’ offices.

And I think in many of the practice management systems that
occur, they’re able to review their transactions on a regular basis and so that
they can have very dynamic feedback as to these are the messages you sent,
these are the prescriptions you sent out, and they can review that on a very
timely basis.

MR. GRIFFITHS: I think that’s an excellent point, too, and as
we go forward, we’ve just got to constantly be assessing the risks and make
sure that we’ve got, as HIPAA says, reasonable and appropriate measures in
place. I think that’s the best we can do, going forward.

And I think, again, pharmacy is not opposed to constantly
looking for new and better ways to enhance security. I think what we were just
trying to say is that there’s very good practices in place today and you
shouldn’t delay the implementation of e-prescribing looking for that perfect
model that I think is still some time away.

DR. COHN: Steve?

DR. STEINDEL: Thank you. I guess I’m going to use a little bit
of a preamble before I ask my question, but the one thing that I’ve been
finding striking and it crystallized somewhat during your comments is we’ve
heard repeatedly through the HIPAA era “don’t make anything more
complicated than what existed on paper,” and Stan just gave an example of
that. And we heard the same thing from you just a minute ago.

But one thing I hear repeatedly is actually you’re asking us to
make things not more difficult than on paper but better than on paper, because
what I’ve heard repeatedly over the last two days, that we don’t really have
anything in the paper system; it can be so easily faked, manipulated, changed,
whatever, that we have much more security even by using a very simple security
system in the electronic world, which is what I’ve been hearing repeatedly. And
I see by your nodding of your head you’re reacting very similarly.

And I think, as I mentioned yesterday, I think what we have to
discuss and recommend to the Secretary is what level of risk above what exists
today, or hopefully decrease the level of risk that exists today, is the
Secretary willing to accept, and that’s something we’ll have to discuss.

But this has been very clear and very useful conversation in
this area. I loved the one today about you just telling us about the child
yelling across the room. Yes, it’s getting more interesting.

But the one thing that I do have with that preamble I do have a
question about. And this has to do with terminology, and Stan and I are into
terminology so we always pick on that.

We had a discussion yesterday in Kepa’s wonderful talk about
nomenclature and electronic signatures and digital signatures. And I was
looking at your slide and you were saying no immediate need for e-signature or
digital signature. And yet, what I’m hearing is you’re looking for what other
people have called the electronic signature.

We had one person testifying yesterday – I forget for what
group – that looks for a DEA number on their electronic prescriptions and
that’s what they consider to be their e-signature, along with a set of other
identification information that authorized the person to get into the system.
And by your nodding your head, you agree that that was kind of a subtle
difference in –

MR. SIMCO: Right, exactly.

DR. STEINDEL: Okay. And then the next thing I’ve been hearing
consistently – and I’ve asked this several times – is with
non-repudiation. And you’ve also taken the same path that everyone else has
said, and that is, what it logs and the ability to trace transactions so if
there is a problem, we have a better way to go back and find out how it really
occurred –


DR. STEINDEL: — than exists in the paper system.

MR. SIMCO: Yes, and we have used that in the past and it’s
proven to work, and work very well.

MR. GRIFFITHS: As health care professionals, we’re just
continually asking ourselves: What’s best for the patient? Continuing with the
manual process or implementing e-prescribing? We’re always trying to keep the
patient first and foremost in our mind.

MR. SIMCO: And your other comment was exactly right, is that
just the inherentness of e-prescribing just today is infinitely more secure and
much better authentication than various ways prescriptions get to pharmacies

And I just talked about a couple, but it is totally much to
imagination and to various ways medicine and pharmacies practice, but there is
no standard as to what a prescription is outside of somebody writing something
on a piece of paper or making a phone call.

DR. STEINDEL: And I think this question has been asked
repeatedly of people: What if the DEA comes in with a system that’s not exactly
like the one you described – i.e., a PKI system?

MR. SIMCO: And again, Mike Griffiths touched on it in one of
the slides, is what they were proposing – and they haven’t come out with
their final regulations – but the whole idea of a PKI I think will just
put a barrier on e-prescribing as far as controlled substances are concerned.
And I think in the long run it’ll affect e-prescribing as a whole.

And many times we get prescriptions from physicians in
combinations. You get antibiotics, you get cough syrups, you get discharges
from emergency rooms and hospitals – a lot of it’s for pain medication,
and it’s all immediate need prescriptions for, in many cases, very severe
discomfort, pain, or medical condition of a patient.

I think what it’s going to do is a physician is not going to
look at an antibiotic and a cough syrup and say, wow, I can send this one
electronically, but here I have to write this one on a scrap piece of paper and
it’s okay if you take it to the pharmacy and they’ll fill it.

That’s just going to delay the process. They’re not going to do
it electronically, they’re not going to do two manners of prescribing. What
they’ll do is just end up writing both prescriptions on paper and it’ll just
further delay the e-prescribing adoption process. It makes the patient wait
longer to get their medication. It introduces the risk of error that occurs

So what we’re hoping for is that at least on the Schedule III
through Vs that the systems in place today should be adequate and satisfy those
requirements for validation of prescriptions, especially when Schedule III
through Vs I can call in a prescription over the phone, fax it, write it on any
kind of piece of paper that exists.

DR. COHN: Harry?

MR. REYNOLDS: Yes. Mike Simco, in your comments, you made a
statement that pharmacies give physicians IDs.

MR. SIMCO: In our host pharmacy systems.

MR. REYNOLDS: In your host pharmacy – going back to the
picture everybody likes, where are you talking about in this picture?

MR. SIMCO: It would be your far right end.

When it gets to our pharmacy itself, when messages arrive into
our database, our physicians are registered with IDs. And in some cases those
IDs are unique identifiers maybe provided by the aggregators that we’re
connected to if those physicians are registered for electronic prescribing.

In other ways we give physicians IDs based on the DEA number,
based on their location, based on their address, and if the physicians have
multiple locations of practice, they have multiple registrations in our system.

MR. REYNOLDS: You mentioned DEA. Then you think of NPI, you
think of the other stuff that’s coming out. So would that physician actually
have to use that number when they’re entering a prescription or is that
obviously picked up and done somewhere along here? How do they keep in sync?

MR. SIMCO: I think the software at the point of prescribing
would attach that ID to that particular physician and that message that’s sent
by that prescriber. So when we do receive it, we can validate that that ID is
part of the message and part of that physician’s registration so that we can
rout it and pick the right physician in our database and know that that’s the
physician that wrote that prescription.

MR. REYNOLDS: So do they have a different one for Walgreen’s
and CVS and –

MR. SIMCO: No, and I think the ideal manner would be that they
would have one registration that would work in all systems.

MR. REYNOLDS: Okay, good. Thank you very much.

DR. COHN: Steve?

DR. STEINDEL: Harry’s question just led me to something to ask
in the e-prescribing world that’s been concerning me.

Today, I get a prescription and I decide I’m going to fill it
in my local pharmacy but somehow I got sidetracked and I was driving somewhere
else, and I said, oh, I forgot, and it’s going to be too late, and I stop in
this drugstore and have it filled. And how does that work in the e-prescribing

MR. SIMCO: Generally, what we have seen is a physician, when
they’re writing a prescription, an e-prescription, they’ll ask the patient what
pharmacy they use and they have that pharmacy listed in their directory. In
many cases, some of the software, whatever pharmacy the patient chose
previously is automatically loaded into their registration.

And so if that physician then sends them a prescription –
and I could speak to Walgreen’s on this and maybe Mike could speak to
Albertson’s – but if they sent that to our system and it was routed to a
particular store that was identified by the physician and we would enter that
prescription into our system and match your ID and match all the information,
if you drove to a different location, again, all our pharmacies are connected,
so once it’s entered at one location, all our locations have access to that
information and we can close it out from wherever it was initially sent to and
transfer it to that location.

DR. STEINDEL: Okay, but what if I decided to go to your
neighbor’s pharmacy on my drive?

MR. SIMCO: Then, today several things occur, and it happens a
lot. Physicians will call our stores and the patient may show up somewhere
else. That pharmacy would have to determine where the prescription was sent to
and if the patient knows or a call to the physician, and then they would then
transfer the prescription from one pharmacy to another. It cannot do it
electronically at this time yet, but we would close out a prescription at one
location and transfer it to another.

DR. STEINDEL: So, my summary of what you have just said –
if I stayed within the same system, it’s a minor inconvenience; if I cross
systems, it’s a minor hassle factor. But we are able to do it.

MR. SIMCO: You’re correct.

DR. STEINDEL: Okay, thank you.

DR. COHN: Okay. Well, thank you both very much. Since Steve
asked my question, I don’t have any questions.


DR. COHN: Anyway, thank you very much. Yeah, I think we’ve
been together for too long here! So thank you very much. Shall we take like a
minute stretch break? And I’m hoping that – is Lynn here? Okay, good.
Well, why don’t we take like a two- or three-minute stretch break and let you
and Lori come up and we’ll start on our final panel? Is Lori here?

[Committee takes a break at 1:20 p.m. and resumes meeting at 1:43 p.m.]

DR. COHN: Let’s get started. Our next session is on
e-signature from the standards development organization perspective, and we’re
delighted to have Lynne Gilbertson here representing NCPDP. We understand that
the representative from ASTM, Lori Fourquet, will be arriving later this
afternoon, and we’ll obviously include here in testimonies when she arrives.
So, please, Lynne.

AGENDA ITEM: Presentation – E-Signature:
Standards Development Perspective – MS. GILBERTSON

MS. GILBERTSON: Hi. I’m Lynne Gilbertson from the National
Council for Prescription Drug Programs. NCPDP appreciates the opportunity to
testify on the topic of electronic signature.

As a little bit of history, during the 2000 and 2001 – and
it felt like it went for a couple of centuries –

NCPDP members and staff participated on the ANSI HISB
“Multi-SDO Digital Signature Project.” And this project began with
involvement from ASTM, HL7, IETF, NCPDP, and X12.

NCPDP was very active in the paper that was being created and
was one of the few submitters of the use cases. That was the last deliverable
that we were aware of.

There was a lot of frustration during that project trying to
understand how the digital signature world would work because if we took the
premise of we’ve got real time transactions floating back and forth and there’s
certificates that you have to authenticate.

It became, okay, what if you used certificate authority and I
used another? Now, do I have to download files daily from each authority to be
able to figure out how to authenticate that you’re a new user to that system?
How do I do that operationally? What is the overhead to the payload of the

All that came up, and we just weren’t able to get any
resolution as far as the paper was concerned.

There were a lot of open issues at that point and we didn’t
have a lot of industry expertise even reaching out to financial models and
other models that we worked on during that time frame. To our knowledge, the
project is not active and the paper was never completed. I don’t know if it’s
become something else, but we have not been involved past that point.

NCPDP member companies have participated in the DEA meetings
regarding the security being considered for the prescribing of controlled
substance prescriptions. Companies have expressed their concern for the lack of
health care industry experience and the cost involved in supporting the
security being considered.

As noted by some of the other testifiers, it’s really important
for the continued growth of electronic prescribing to remove or not set up any
barriers that could hinder this growth.

One of the things – the fraud and abuse that was brought
up – there are statutes, there are laws governing the illegal prescription
writing and the prescription dispensing. So it’s possible that those are the
methods to get the percentage of people who try to subvert the system and not
put that on every transaction that is in the way of the electronic prescribing

The NCPDP SCRIPT standard, just as a standard perspective,
supports what you would call signature fields because it identifies three
levels of sender and the receiver and passwords to go with those.

One of the things – it was mentioned this morning as well
– electronic prescribing, as you know, is not a HIPAA transaction. In
previous testimony, we did discuss concerns about rolling, for example, the
SCRIPT standard, into the HIPAA regulations because some of the problems seen
with being able to move forward quickly with versions to continue to evolve and
how in a lot of cases we don’t have those things ironed out in the HIPAA
transactions and code sets of today.

Other NCPDP standards, some which are named in HIPAA, such as
the telecommunication and batch standard, also contain sender and receiver
identifiers. Although the health care information technology industry has
discussed further identification methods over the years through our involvement
in other projects and just general discussion whenever electronic signature,
digital certificates, all that comes up, further need has not been brought
forward to NCPDP for consideration in the standard.

One of the things to consider with the other standards is the
information that is contained on a claim is very similar to the information
that’s contained in an electronic prescription, and we don’t hold claims to a
different standard other than sender, receiver, authentication, things like
that, and so that’s a data consideration, that what are we expecting different
out of an electronic prescription that we might be expecting differently out of
an electronic claim?

So just as a thought.

To prepare for this testimony, NCPDP convened a task group from
Work Group ll Prescriber/Pharmacist Interface and Work Group 12, Education
– Legislation and Regulation. These are led by Dan Stanek of Caremark and
Ken Wittemore of SureScripts. The testimony I’m about to speak reflects their

NCPDP Electronic and Digital Signature Recommendations for an
E-Prescribing Environment.

The recommended definition of electronic signature supported by
NCPDP is as follows:

An electronic signature is an electronic sound, symbol, data
string, or process attached to or logically associated with a record and
executed or adopted by a person with the intent to sign the record. NCPDP
recommends that NCVHS adopt this definition of electronic signature so as to
accept a variety of assurance solutions currently implemented in the industry
and accepted by state pharmacy boards.

NCPDP believes that current business practices for
authenticating prescriptions, which include user registration and verification
processes provided by trusted partners, user sign-on authentication processes,
secure message transmission, and auditing processes, are fully adequate for
assuring the appropriate delivery of the prescriber’s intent to the dispensing
pharmacy. NCVHS should recommend a minimum standard for assuring the secure
delivery of prescriptions that include these basic processes for all
prescriptions, including controlled substances II through V.

The utility of digital signatures depends on the development of
a trust infrastructure, which reliably associates practitioners with public
signature verification keys. To date, efforts to deploy PKI on an industry
scale have been unsuccessful. Requiring digital signatures using authentication
protocols such as PKI – either for all prescriptions or only controlled
substance – would significantly slow the adoption of electronic
prescribing and is unnecessary for securing the electronic prescribing process.

Other auditing or monitoring processes that do not include
digital signatures could be employed to provide additional protections for
fraud and abuse for controlled substances.

NCPDP recommends that for the purposes of electronic
prescriptions, the NCVHS recommend a minimum set of required properties for
electronic signatures and situational properties to be accessible for use by
business partners.

NCPDP asks NCVHS to recognize that there is no current
requirement that the practitioner’s electronic signature satisfy strong forms
of non-repudiation.”

Networks are in place that maintain security without PKI.
Organizations that are supporting electronic prescribing have met with the
boards of pharmacy are satisfied with the registration, logging, audit
processes of the participants.

Consideration that you’ve heard already is that value added
networks and switches who perform valuable services of conversion either
between versions of the existing standard or conversion between different
messaging standards must be able to open the envelope and provide this process
for the participants. We haven’t worked so hard on the HL7-NCPDP collaboration
to see it collapse.

NCPDP recommends that NCVHS recognize that for the purposes of
electronic signature on prescriptions, current assurance requirements can be
satisfied by the imposition of a limited set of business rules upon parties
utilizing the SCRIPT standard. The pharmacy needs assurance that the identified
practitioner intended to issue the particular prescription communicated in the
NCPDP SCRIPT message. That the following business rules provide the required

The electronic prescription application user’s interface must
present the completed prescription request to the practitioner for verification
prior to transmission.

The electronic prescription application must protect against
impersonation of the practitioner. Impersonation is precluded, in part, by a
registration process that verifies the user’s identity and role in a way that
reliably associates the user’s application access credentials with a
practitioner’s attributes such as name, medical license, DEA, NCPDP provider
numbers, and national provider ID.

Protection against impersonation further requires user
authentication procedures to guard against unauthorized access to the user
application. Where the user authentication is accomplished across the
communication network, use of a secure transmission protocol that protects
against masquerading, eavesdropping and replay attacks is needed to prevent
opportunities for impersonation.

You’ve seen the diagram in previous testimony. It shows, from
left to right, right to left, the different electronic prescribing environments
and the different authentication that is in place at all the different points
of view.

It was mentioned earlier as well the diagram represents channel
encryption, which is the rout, versus the data encryption, with protections at
the user and the server interfaces, secure networks even using public
transports for these networks. Like the transportation of HIPAA claims and
other transactions that contain protected health information, the access and
networking infrastructure has security and authentication at multiple points.
Each rout along the way maintains audit and log files as well as registration

One of the things for consideration is, as we hear testimony,
we’re trying to figure out what problems are we trying to solve? We have things
such as the authentication of the prescriber which the different methods do not
control that. Are we trying to protect the transaction in some form or fashion?
So we’re still kind of stumbling with what is the problem we’re trying to solve
so that we can address the particular need.

Thank you very much.

Questions, Answers and Comments

DR. COHN: Okay, Lynne, thank you very much. How much questions
from the – Harry, did you have a comment, please?

MR. REYNOLDS: A question on – Lynne, if you go to your
last page, 5B, I need a clarification. It says: “Electronic prescription
application must protect against impersonation.” Impersonation is
precluded, and it talks about the process.

But basically when you get into the electronic world, the fact
that within somebody’s system they have set up who someone is doesn’t mean that
that is the person who’s actually firing off the transaction. So this is a
pretty strong statement. This sets up an environment that should help preclude,
but I’m struggling that it completely precludes.

MS. GILBERTSON: Well, I mean, it’s not suggesting that 100
percent of the time it’s assumed that it’s always the actual human individual
or – I mean, it assumes that there is designation going on, that there is
controls at the prescriber or the pharmacy systems so that it’s unauthorized

MR. REYNOLDS: Okay. I just wanted – in other words –

MS. GILBERTSON: Yes, if you’re authorized –

MR. REYNOLDS: No, now that you’ve added those other things that
was inherent in here, fine.

MS. GILBERTSON: Okay, yes.

MR. REYNOLDS: Just wanted to make sure; that’s a pretty blanket

MS. GILBERTSON: Did you know what I meant, right?

MR. REYNOLDS: I assumed it.

DR. COHN: Okay. Maria?

DR. FRIEDMAN: Thank you. On Number 3, Lynne, you have a very
general description, or very general recommendation, that NCVHS recommend
“a minimum set of required properties for electronic signatures and
situational properties to be accessible for use by business partners.” Is
there any way we could get a little more flesh on those bones? Sounds good, but
what would you like to see if it were an ideal world?

MS. GILBERTSON: I don’t want to go there! I can’t go to Planet
Utopia! I really think that this becomes NCVHS charge the industry with saying
what is the floor and what are the required guidelines for use of the signature
which starts off with a definition of what the electronic signature is and then
takes it to say what are the elements of what consists of an electronic

So if you use the definition of sound, symbol, data string or
process that the industry actually define what some of the criteria of that is.
If you’re going to use a data string, is it a user/password/PIN? Is it a
user/password? Is it a – whatever? Is it name and address? Those kind of

So it’s a recommendation, but I would take it one step further
and say that it gets punted back to the industry that says you come forth with
guidance of what the data elements should be, because that becomes some of the
best practices that we’ve been talking about earlier, the guidance for what
makes a standard level.

Your brows are knitted, Simon.

DR. COHN: Well, I’m trying to get whether you helped us –

DR. STEINDEL: I have a follow-up.

DR. COHN: Sure, Steve.

DR. STEINDEL: Two follow-up questions. The first – I’ll
follow-up Maria first and then follow up Harry.

WebMD put on one of their slides a set of what they considered
to be the minimum requirements for identification in their system of a
transaction and the person, individual making the transaction. I forgot exactly
what it was, but it was basically a good part of the list of the things that
you just enumerated, including identification that would allow trace ability on
the transaction itself. It had a transaction ID in addition to the individual
ID. Would you propose that as a good starting point?

MS. GILBERTSON: Yes, I think those are common elements to just
about any transaction, whether you were talking about a credit card
transaction, a claim, an electronic prescription, a registration. So I think
that would be the basis of where you start.

DR. STEINDEL: Yes, that was my sense of what I saw when they
put the slide up there. That looked like a very good starting point for a

MS. GILBERTSON: Right, right. And then it also would identify
where’s the source of the information to bounce it against. Now, just simply,
if I’m going to use a DEA number as one of the IDs, so I have to bounce it off
a DEA file to make sure it’s real. Those kind of things, and active in all

DR. STEINDEL: Does that help clarify the response a little bit,

DR. COHN: Yes.

DR. STEINDEL: And the other one – I was a little
disturbed, like Harry was, when you used the word “impersonation.”
And then when you responded, I’m probably more confused than clarified on it
because if you really mean authentication to use the system, why don’t you use
that word instead of impersonation? Because when you say impersonation to me,
that’s a very strong security system. We’re going into something like
biometrics or very strong, secure, card identification, and so you actually
know the human being is the human being that’s typing on the keyboard.

MS. GILBERTSON: No, I would agree with that. I’ll take that
back to the task group and –

DR. STEINDEL: If you make that change, then the paragraph makes
sense to me.

MS. GILBERTSON: Yes. And I appreciate that, yes.

DR. COHN: Other questions or –

DR. STEINDEL: I would like to make a comment. I think the
comment that you made about the hard work by HL7 and NCPDP to allow the
adjudication of that is a very strong message to the subcommittee about the
need to open the envelopes and transform it, and we were the ones that asked
for that hard work and we’re very appreciative of it.

MS. GILBERTSON: Thank you.

DR. COHN: And let me just ask a question about that one because
I obviously heard the issues yesterday and maybe it’s a question to ask all of
our security gurus, electronic signature gurus in back, but I guess I wasn’t at
all convinced that opening a package made the issue of PKI an impossibility.

It just sounded like what we were talking about was various
stages where it was sort of like what we’re dealing with is PKI handles
D-sender and D-receiver and what we’re describing here is manipulation by a
receiver to send it on to another entity. And as long as the PKI captures those
as separate transactions, there’s nothing theoretically impossible about all
this stuff.

I mean, what it does is it tells you that it has been modified
and tampered, but then from the transformation it remains intact. Isn’t that
– am I missing something here?

MS. GILBERTSON: Are you suggesting that the prescriber system
would digitally encrypt the whatever the prescriber sent on the new
prescription, when it got to the router – let’s just say someone who’s
going to transform it from an HL7 to a SCRIPTS message, then a new set of PKI
digital certificate is then attached to that as well, and then that whole
package then goes to the pharmacy?

DR. COHN: Well, I mean, wouldn’t that have to be how it would
go? I mean, because otherwise things wouldn’t match.

MS. GILBERTSON: Well, but then you’ve got inner loops and outer
loops and –

DR. COHN: What?

MS. GILBERTSON: You would have the inner loop of what the
prescriber intended and then the outer loop of what it got transformed to.

I mean, one of the things that would be a problem is whoever’s
in the inner loop, if they expected that HL7 message to turn into a script,
they can’t read what’s in that inner loop anyway because it would be an HL7
language and their system wouldn’t be able to support it anyway if they got in
far enough to figure that part out.

And I’m just trying to figure out how –

DR. COHN: Well, I mean, it’s an issue of – I’m not saying
we should do it.


DR. COHN: I keep hearing this thrown up, and it was thrown up
yesterday a number of times that, well, because it’s got to be transformed or
it’s got to be updated. I mean, I thought the purpose of PKI, as least as I’ve
understood from the last two days, is less to assure authentication and more to
assure the lack of tampering, and so if indeed things are being tampered with,
which may be very appropriate, it just reflects that it has been tampered with
something new is applied so people know that it’s been tampered with and you
know who tampered with it.

And so that’s all I’m saying. And if you think I’m way off on
this one – I mean, it just seems like this is an a priori death to either
transformations or the ability of a VAN pr a software developer or whatever to
deal with looking at headers and all that. It just creates a very accurate
audit trail.

MS. GILBERTSON: Because what I was also trying to think of is
if you just decided to encrypt pieces and parts of the message and those are
the only parts you cared about, but I’m trying to think in an electronic
prescription what that would be. I mean, you’ve got patient information. Well,
if you’re going to transform something from HL7 to SCRIPT, you’d better be able
to get into the patient so you can identify it correctly for the receiver.

So I don’t see anything that would be outside of that piece.

DR. COHN: I think if we’re talking about this that we need to
give people flexibility to do what they need to do. It’s just more of auditing.

MS. GILBERTSON: Trying to figure out if you encrypted something
in the center and then you wrapped something around that, if your system wasn’t
capable of understanding what was in the center – I mean, because that
could still be an HL7 message, for example, wrapped around a script, you’re not
going to get into that anyway because you don’t understand what HL7 messages
are to even get in and figure out where I go find the signature and things like

Now, I’m a little out of my league, but just from a technical
point of view, I don’t understand how that would work when you don’t know how
to read an HL7 message or vice versa anyway. That’s the whole point of why
somebody’s transforming it for you.

DR. COHN: Okay. I had a feeling that I might have enlisted a
couple comments, yes.

DR. STEINDEL: Simon, I think –

DR. COHN: I mean, I’m not saying we should do it. I’m just
saying —

DR. STEINDEL: — your analysis of what would happen is totally

DR. COHN: Okay. So how would we handle this?

DR. STEINDEL: Yes, and how would we handle. I mean, if somebody
sends a digital signature, encrypted, HL7 message to processor, whatever we
call them who does it, who opens it and translates it and then moves it on to a
pharmacy in a rewrapped – well, what would have to happen is they would
have to re-sign it with their digital signature, with the new steps of
encryption and whatever, and pass it on.

And yes, I would feel fairly certain that’s actually being done
routinely in some areas where PKI is done today, so it’s not an unfeasible
thing. It just seems like – I don’t know.

DR. COHN: I’m not suggesting that that be the answer. I’m just
suggesting PKI doesn’t do them all, transformations or transcriptions.

Please introduce yourself if you have a question or comment on
this one.

MR. HAAS: My name is Jim Haas with WebMD and we do
transactions. So a couple of comments on the point that you were making about
sort of the interim decryption and recryption message.

That makes a presumption that really hasn’t been mentioned here
too much, and that is that the sender knows the path of end to end that that
transaction is going to take, and the truth of the matter is he doesn’t
necessarily know that because there are peer to peer arrangements within the
networks that says I may not have connectivity to this guy but I have
connectivity to that guy and I know how to get from here to there, then he
knows how to get from there to the next place.

So while you may know the next destination, you may not know
all the destinations.

There’s also some redundancy, because from point to point, the
telecom, or the pipe encryption, is already in place, so we’re already
protecting the message from one point to the other point. And if you then put
this encryption over that same pathway, you really haven’t bought yourself
anything that encrypting the pipe didn’t buy you.

The real value of the encryption is from originating sender to
ultimate receiver because that’s really the piece that you’re trying to prove,
that that message really came from this doctor.

So I think the thought that Lynne had and maybe something that
we back at NCPDP need to look at is an encryption – and we’ve also had
sort of two directions of conversation. We don’t change the message; the
pharmacist has to see exactly what the doctor wrote. And oh, by the way, we do
all this mapping stuff. And how do you reconcile those two pieces?

And the answer is that you’re very judicious and careful about
what pieces can be touched and what ones do not make sense or you just don’t

And we’ve also talked about the concepts of value added
networks, and in fact some of the values those networks add is to do some of
this translation in behalf of a business partner. They say, well, it’s really
easier for you to do it in one place than me to go to 500 stores and make this
translation. So there’s a value add.

But the point is, I think the industry – and you can kick
me under the table real hard, if you like – can work towards agreeing on
what are the inviolable pieces of that message? And drug name would certainly
come to mind, SIG would certainly come to mind, some other characteristics of
the prescription.

I think we could arrive at those pieces and say, well, those
are the ones that we really need to encrypt end to end because those are the
ones that we need to prove haven’t been tampered with from end to end.

And maybe the message can be structured in such a way that that
tamper-resistant stuff is placed in a certain part of the message, that piece
is encrypted and doesn’t need to be broken into during the course of the
transmission. And that may be a way to have your cake and eat it, too.

MS. GILBERTSON: Although you’re going to have trouble with
translations at that point.

DR. COHN: Yes.

MS. GILBERTSON: If you don’t know where to put the SIG in an
HL7 message. It’s tough.

MR. HAAS: I mean, I don’t know enough about the encryption to
say if you can pick up an entire encrypted piece and move it as a block –
I just don’t know.

MS. GILBERTSON: Yes, if you encrypt data elements.

MR. HAAS: Right. The drug name –

MS. GILBERTSON: As you saw how big each of those encryptions
could be. We’ve got to make some bigger pipes.

DR. COHN: Yes, and as I say, I’m not saying we should
necessarily do this. I was just pushing against the infeasibility of it.

Steve, I think you wanted to make a comment, and then we’ll get
back – we now have Lori and Alan who have arrived.

DR. STEINDEL: Yes, just a comment on this encryption within a
message, an encryption within an encryption. And when I mentioned the CDC
secure data network, we actually do do that fairly commonly on some types of
information where within public health, there’s certain types of information
that only certain people should see and we put very specific encryption keys on
that information as it goes. We decrypt it in the area of public health where
it needs to be.

MS. GILBERTSON: Are those real time transactions back and

DR. STEINDEL: No. As I said yesterday, we’re talking about a
very circumscribed population and a very circumscribed need, and I would not
generalize it to the real world, so to speak.

MS. GILBERTSON: And one of the things that I mentioned earlier,
as Jim is discussing, if you’re doing any kind of encryption between parties
and if you need to know end to end, it’s very important to talk about the
certificate authority environment and how many different CAs would there be and
what kind of information would be required to be local on whatever system is
actually generating a transaction to bounce off to find out: Do I have the
public/private key business? Do I have the ability to ascertain if that’s a
valid certificate? Things like that. Do I need 10 files from 10 different CAs?
Do they interoperate?

We couldn’t come to answers with those on the SDO project, so I
don’t know if there’s any guidance from anybody who’s done anything yet.
There’s not a lot of models to play with.

DR. COHN: And I was not addressing any of that. I was just
saying that given what we’ve described, that what you were describing was not
the death knell for anything that you needed to or the industry; it just was
another – I mean, there actually probably are technically ways to do it,
but certainly we all know the issues of interbridge connectivity, about
certificates and all of that, is something that would have to be solved for all
of this to work or single credentialing authority or whatever.

Now, as I say all this stuff, and this was not actually
intended, this question, to bollix us up for the last 10 minutes, but since
I’ve asked the question, obviously our other two testifiers have actually
arrived, so thank you very much for arriving, and we have Lori Fourquet –
and I hope I am saying your name correctly. I see we are actually trying to get
your computer to work with our projector.

And we also have Alan Zuckerman. We do apologize. As you can
tell, we’re running ahead of schedule, and that’s basically what’s going on

So I guess, Lori, did you want to go first? Do you want to have
Alan go first, given that you’re having some trouble with the connection? What
is your preference?

MS. REED-FOURQUET: Okay, go ahead and have Alan go first, and
I’ll have my –

DR. COHN: And you guys can play with the connection here for a

Well, Jeff had a comment or question. I mean, we’re not done
with the questions, either. Jeff was aware that – well, actually, Alan was
here yesterday, and Lori unfortunately is just arriving, so she’s sort of
coming in here cold.

MR. BLAIR: Alan, have you had a chance to give a little big of
feedback to Lori about the testimony that we heard yesterday?


MR. BLAIR: Didn’t want her to be blindsided about the comments
and concerns about PKI that we heard.

DR. ZUCKERMAN: Yes, we talked last night and I shared my notes
on several of the sessions, some of which I listened to on the Internet.

AGENDA ITEM: Presentation – E-Signature:
Standards Development Perspective – DR. ZUCKERMAN

DR. ZUCKERMAN: Again, I wanted to thank the Committee for this
opportunity to testify and especially thank Lori and ASTM for sharing some time
with me to bring a physician perspective to this hearing directly at the table
rather than at the open microphone.

It’s very appropriate, because over the last year, physicians’
professional societies like American Academy of Family Physicians, American
Academy of Pediatrics, American College of Physicians have become very actively
involved in the work of standards development organizations such as ASTM, NCPDP
and HL7. I work actively actually with working groups on both, but my
connection with NCPDP has nothing to do with digital signature.

I’m speaking today really, I’m basing my personal experience
as a teacher of medical informatics and a practicing physician who has
represented AAP to ASTM. You’ve heard a great deal at these hearings about the
potential cost of requiring digital signature, and what I would like to do is
to introduce the notion that there are very real potential costs of not
requiring digital signature on prescriptions. This is an issue that is not
about security hysteria or about HIPAA regulatory compliance; it’s really about
physician workflow and it does have real impact on the American health care

Physicians who know about digital signature, and I consider
this technology among the basic sciences of medicine and teach it to my first
year medical students, support its use and understand the need for message
integrity, authentication, and non-repudiation of clinical documents,
particularly those that pass through many hands and many institutions. That’s
why the American Academy of Family Practice has endorsed the use of this
technology as a policy on clinical documents.

Physicians who do not know about digital signature are indeed
well=versed in the weaknesses and important limitations of current signature of
clinical documents, which is something that’s easily demonstrated in any health
care institution.

A prescription is essentially a permanent clinical document
and not a momentary blip on the Internet. Many years ago, this was brought
painfully to my attention when I was involved in a malpractice case involving
complications suffered by a young child who was unintentionally given a
codeine-containing cough medicine. And of course, the case involved around
whether this was an error in prescribing or an error in dispensing and whether
some of the damages could be linked to the medication.

Message integrity and non-repudiation are real concepts to
physicians and they’re essentially not addressed by the use of SSL or DES

I’ve also had the very unpleasant experience of having a nurse
borrow my DEA number and name to indulge in substance abuse that was
fortunately quickly detected by an alert pharmacist. Authentication and
identity theft are also concepts that are deeply appreciated by physicians who
are actually not pleased by the growing practice of pharmacies to use DEA
numbers for physician identification and verification of telephone
prescriptions and non-prescribed substances.

I’ve also had patients add a zero to the quantity dispensed on
a prescription and seen my colleagues entertained by electronic signature
images on computer-generated fax prescriptions but remain very realistic about
the limitations of this approach in a world where they’re daily confronted with
documents that are labeled “electronically signed without being
read.” In practice of medicine, electronic signature may actually not hold
up in court regardless of what the E-SIGN act says and some of the JCAHO
regulations on e-signature have in fact shown that in specific court cases.

Patients also stand to benefit from humane and cost-effective
use of digital signature to allow electronic controlled substance prescribing.
We talk about controlled substances; of course, we should be thinking about
things like Ritalin and not OxyContin. Attention Deficit disorders today are
the most common chronic diseases among children and long-term follow-up studies
show how difficult it is to maintain medication over several years and you
can’t prescribe more than 30 days, can’t use a fax, can’t use the telephone,
and can’t use electronic prescribing.

My patients and families who are coping with ADHD repeatedly
request and embrace the kind of benefits that would come in their lives from
electronic prescribing that is unlikely to be realized without the use of
digital signature.

We must also recognize that the Institute of Medicine and many
others have identified security concerns as one of the major barriers to the
adoption of health information –

MR. BLAIR: Could I just ask a question because yesterday I
confused PKI with digital signatures. Are you using them synonymously or is
there a difference? I just want to make sure that as you keep referring to
digital signatures that I know what you’re talking about.

DR. ZUCKERMAN: Digital signature is an encryption technology
for assuring message integrity, third party authentication of the server, and
non-repudiation of the signature. It is usually accomplished through some form
of public key encryption. So if there are other ways to achieve a digital
signature, I would be happy to embrace them. It is the integrity, third party
authentication, non-repudiation that are the essential characteristics.

Again, physicians, particularly in the primary care
specialties such as internal medicine, pediatrics and family medicine, face
very serious constraints that limit their ability to benefit from digital
signature technology because of the constraints on their time and resources.

The fear that digital signature could severely damage the
dissemination of electronic prescribing is very real and very well justified,
but I feel it must be addressed not by abandoning the core functionality but
instead by setting constraints on the monetary and time costs of the specific
technical implementations of digital signature.

When office visits take only 12 to 15 minutes, we cannot add an
additional two or three minutes, but we might be able to tolerate 15 seconds.
We cannot add $100 or $200 of additional cost to the annual direct to
physicians of electronic prescribing; we might tolerate $5 or $10, particularly
if we attempt to include it in controlled substance registration. Essentially,
we must set performance criteria and metrics for digital signature that can
reduce the burden of the implementation.

We also have many options in implementation that may make it
easier to make digital signature work, although they compromise ideals of
security. One of the first things we must do is select a method to carry the
private key used in signature. Now, conventional practice would say we should
be using a smart card or a token.

We also need a method to activate the use of the signature and
special signature passwords have some merits for use rather than biometrics. We
actually could place the private keys of individual physicians in escrow with
their e-prescribing vendor with serious criminal penalties for abuse and allow
release and use of those keys on conventional signature and have a totally
transparent use of e-prescribing that would not visibly change the way
physicians are practicing.

We also have many options in the way we might separate person
authentication from credential authentication, thus allowing the use of any
authentication certificate, including vendor-issued certificates, as long as
there’s cross-recognitions so physicians don’t need more than one certificate.

We also heard yesterday about the use of Web services for
validating expired security certificates and invalid credit card. We could
apply the same instantaneous Web query to validate a physician’s DEA number and
current license to prescribe.

Over several years now, I’ve explored many biometric
technologies including fingerprint, iris, and a dynamic signature, for control
of digital signature and I conclude that it’s simply not ready or affordable
for use today but is likely to be there at some time in the future. Ultrasound
fingerprint readers are an ideal technology for this but simply unaffordable
and not portable for physicians who do much of their prescribing from PDAs and
cell phones.

Iris technology is extremely accurate, but we don’t have
auto-focus cameras and auto-scanning devices to limit the amount of time it
takes to capture an image. But every single biometric has some rate of failure
to enroll that requires an alternative backup technology to be present for some
percentage of those using it. Yet, a good password, perhaps with a smart card
token, is more than adequate and far better than what we’re doing today in the
area of signature of documents.

Before we abandon the digital signature prescriptions, we must
also consider the powerful educational opportunity we have to introduce a
technology that could be used with other clinical documents such as laboratory
reports, discharge summaries, and physician communications that could benefit
in the future from technologies being piloted today on e-prescribing.

In conclusion, I want to offer that we need the message
integrity, third party authentication, and non-repudiation that digital
signature can provide, but our implementations must be creative,
cost-effective, and appropriate to the level of security risk. Any improvement
over what we do today will be a substantial improvement in the risks of
prescription security we now endure.

But our greatest need in the next six to 12 months are real
world demonstrations and evaluations of realistic approaches to using digital
signature so that we can make informed regulatory decisions based on fact and
not on speculation. Thank you.

DR. COHN: Alan, thank you. Lori?

AGENDA ITEM: Presentation – E-Signature:
Standards Development Perspective – MS. REED-FOURQUET

MS. REED-FOURQUET: I’m Lori Reed-Fourquet, and I’m going to go
through the list of standards that I’m involved with because, although I was
invited to this Committee through ASTM, I also participate in a number of
others, and within those other committees, we are discussing the same topics
that I’m presenting here.

I am the Co-Chair of E31.20 Health Information Security and
Privacy for ASTM and the Vice-Convener of ISO TC215 Health Informatics Working
Group 4 on Security. I’m a member of the IHE IT Infrastructure Committee, a
member of the HIMSS Standards Task Force, and a member of the newly formed HL7
Electronic Health Record Technical Committee Expert Panel on Security and
Privacy Functions.

So, we need signatures, and particularly in electronic
prescribing, to prove that the author or the sender of a document is the one
that he claims to be. We need to identify their identity when they do the
signing. We also need to carry along their credentials.

We need to prove that the writing and sending of the document
is something that the individual is consenting with. We need to prove that the
content has not changed and it is complete. It is an integrity requirement. We
need to be able to enable moving from a paper-oriented world into en electronic
world, an e-document.

Standards for the health care signature – the components
are the signature creation. We have to authenticate the signer’s identity. We
need to present the information to be signed to that individual. We need to
capture the signer’s approval. We need to construct the logical manifestation
of the signed signature in an electronic format.

Signature verification at the other end – the relying
party needs to be able to verify the integrity of the record and the
authenticated attributes that may be associated with the signed document. We
need verification of the identity of the signer.

General properties, based on our standards for health care
signatures – we need attestation, such that the user agrees to be bound by

We need uniqueness; the signature must be bound to an
individual and not shared.

Continuity of signatures – signature verification will not
require the disclosure of any confidential materials such as biometric content
used to create the signature.

Fidelity – we need a logical manifestation that captures
the signer’s intent, especially when what is presented to that individual may
differ somewhat from the electronic coding that is actually being signed.

Integrity – the information that is signed will not change
in transit.

And secure user authentication – the reliable binding of
the individual to that signature.

Among the logical properties that we need are multiple signers.
In health care at least, you may have to have multiple parties signing
different parts of the document.

Signature attributes – we need to be able to attach
attributes to the signature such as their credentials, their time stamps, the
purpose and intent of the signature.

Supplemental properties – we need to look at independent
verifiability. We need to be able to verify in the absence of the system that
generated the signature that the signature and the intention is still intact.

We need non-repudiation, proof that only the signer could have
created the signed document, particularly in legal aspects.

Persistence – the ability to preserve the signature over

Transportability – the signed document can be transmitted
to another system while maintaining the integrity of the document and the
signature attributes.

Specific to e-prescribing, the types of security risks we need
to address – in particular is impersonation. This might be conducted
through password theft. Password theft itself may be conducted through
observing the individual putting their password into the computer. Interception
of the key strokes from the input of the password. Auto-complete functions,
particularly in some of the mobile devices, can inadvertently disclose a

Poor password protection is very common, particularly since we
may have many systems to which we need to remember the passwords, too many to
protect, and in order to remember, often they’re written down. They may be
stored in unprotected files. They may be using the same password in multiple
locations. They may have a tendency to use favorite passwords and then they
become guessable by those that know the individual.

The ability to spoof the credentialing process is another
security risk. Theft of a system-stored credential, for instance, a software
certificate or a software-stored signature that one might apply to a document
without the owner of the signature knowing. And being able to force or trick
the individual into unintentionally signing something.

Additional security risks in e-prescribing would be the
misrepresentation of credentials; information changing in transit, which might
specifically be modifications in dose or quantity; controlled and abused
substances – there could be an increase in drug diversion, lack of
accountability, fraud.

There is a high incentive to break the security when dealing
with controlled substances. There is a potential for harmful effects, including
death by suicide, homicide, overdose, et cetera. There is a very strong need
for non-repudiation within the accountability of the clinician who has very
strong power behind their prescribing credentials.

Patient safety is also a potential issue for non-controlled
substances that may have clinical impact on the patient. It is not the same
risk perhaps for antibiotics and some of those therapeutics as there is for
controlled substances and so there may be a two-tiered approach here.

The e-prescribing requirements would include non-repudiation
for controlled substances, interoperability across unbounded systems, high
assurance user authentication and communication of the credential information
such as the DEA number along with the signature.

Electronic signatures in medicine should not be overlooked in
taking a look at what we need for e-prescribing. High-risk clinical orders must
be accommodated as we move into e-health systems and do please beware in
considering this topic separately from e-prescribing so that it does not
needlessly encourage non-interoperable systems. A clinician should be able to
leverage digital signature technology for other electronic signature acts. Some
may have greater risks, some may have lower risk, but to force multiple
signature technologies, when one has gone to the highest approved, would be

We need migration; we need to perhaps enable with the low-risk
opportunity and set of criteria for expanding those opportunities.We need an
interoperability for e-prescribing in particular. It costs more to process
workflow in the lack of interoperability such as examining a wet signature. As
long as we depend on hands-on, out-of-band data authentication processes
performed by the pharmacist, we have a real barrier to cost-effectiveness.

Interoperability of secure clinical systems and prescribing
systems is important to the continued growth of electronic prescribing.

Mobile patients require and use options beyond the
sub-community model.

The signature – what does it prove and what is its value?
If a public and private key pair is associated with an identified signer, a
digital signature by the private key can effectively support the requirements
of attestation, uniqueness, integrity, secure user authentication, and
specifically digital signatures can enable continuity of signature,
persistence, independent verifiability, non-repudiation, transportability and

Digital signatures can enable high-assurance authentication
and may reduce the need for auditing and other monitoring processes that might
otherwise be required to protect the multiple opportunity points of intrusion
and impersonation within the system.

Currently, there are no recognized security techniques that
provide the security service of non- repudiation in an open network environment
other than digital signature-based techniques.

The protected security context and signature generation
mechanism itself may be either totally in the control of the user/organization
or else provided as an application service by the health care organization.

The degree of the signature’s non-repudiation is impacted by
the extent to which the signer maintains control over the protected security
context. Where the control of the security context is subject to the health
care organization’s administrative processes, the signer can repudiate the
signature on the basis of a failure of control over those administrative

Digital signatures associated with trust-based entity
registries can provide a higher level of assurance of practitioner identity and
intent, can provide and enable a one-time registration process, can provide the
same registry and registry interfaces used to support automated exchange of
other health care documents and other health care messages.

Vendors can share authentication information infrastructures
without compromising propriety value adds, and digital signatures eliminate
redundant, proprietary implementations of infrastructure-level system

Trust in a digital signature can be obtained when a private key
is kept secret. The storing of the private keys in a secure, tamper-proof
device such as a smart card is important so that the owner of the signature
maintains control over their signature.

When the association between a public key and the key holder is
guaranteed, a trusted third party should guarantee the link between a key
holder and their public key.

There are multiple trust models. A PKI was asked earlier if
that is a requirement for enabling a digital signature, and it is not. There is
a direct trust model which would be an out of band verification of a
certificate binding to the user signature key.

This does require manual processing of agreements for using the
specified key for user intended signature. It requires manual processing in key
compromise. But this is a method that is currently used by the FDA in the drug
approval process described by 21CFR Part 11.

There is also a closed community trust model whereby the signer
and the relying party may be in the same enterprise or the same controlled
environment, these bounded communities where all communication parties are
pre-determined. This unfortunately has fragmentation and limited
interoperability across those bounded environments and upon crossing the
boundary of a closed community of trust, you must rely on manual and secondary
systems in order to obtain trust of the signature.

Mail-order pharmacies, Web-based approaches, portable patient
record-based approaches and other new pharmacy and e-business-e-health
approaches to workflow automation, patient choice, quality of care and cost
control cannot rely on closed boundary options.

Consumers of health care and prescriptions are not within
bounded communities; they cross these communities.

We need to eliminate the requirement for a pharmacist to have
personal knowledge of the practitioner’s prescribing patterns. We can use the
same interoperability framework used for other documents and messaging. And we
need to work toward national interoperability rather than sub-community

The PKI trust model is typically based on an infrastructure but
this does not need to be a national infrastructure. There are a number of
countries out there that are implementing national infrastructures and it is a
very valuable approach.

It can be done through regional infrastructures, however. It
can be done through private sector infrastructures. It can be overlapping
infrastructures. And it could be at the enterprise level.

Standard health informatic PKI policies enable interoperability
across multiple PKI environments. This is seen through federal bridge
approaches. Cross-certification is an approach from certification authority to
certification authority or trust structure to trust structure.

The applications and the enterprise – trust can be enabled
at the application level or at the enterprise level for those multiple PKIs
that may be trusted. At the individual level, it can be enabled. And we have
standards in place that support policies that we can enable this cross-trust
without a great degree of examining multiple policies.

PKI has increased prevalence in technology today. We have the
growing experience in PKI both in health care and in the technology industry in
general. We have off-the-shelf product support from Microsoft, Sun, Novell,
Lotus and many others.

We have application support today for signed and encrypted
emails, for VPNs based on digital certificate technology, for Web-based
authentication using these digital certificates, for database authentication in

There are numerous software developer toolkits available. These
APIs are available for multiple platforms to enable the application vendors to
conduct signing, signature verification, PKCS11 support, which is talking to
the smart card in a cryptographic manner.

PKI increased technology prevalence is also within the
industry. IHE is adding profiling support for PKI and for digital signatures
within their existing and new profiles. This itself will stimulate the health
information system vendor adoption of the supporting technology.

HIMSS is supportive of propagating the digital signature
technology and the uptake of security in the industry.

International health informatics PKI standards have been
defined and are being adopted around the world as each of the countries gropes
with the same types of health information security issues we have here.

Community demonstration projects are out there that are
beginning to incorporate and test the PKI and digital certificate technology.

And as we’ve heard from Dr. Zuckerman, there is increased
physician acceptance of the technology and the approaches.

So how many keys do have? There seems to be quite a bit of
concern about how many key chains we will have, how many digital certificates
we’ll have. How many keys do we need to manage?

We have defined in our standards that we should minimally have
an encryption key and a signature key, and this is because for the encryption
key, we need to enable key escrow. Key escrow is a mechanism to back up data,
and for health information, we need to protect the health information retention
should that information be encrypted. An individual who is also a practitioner
may very well want to separate their personal use keys from their professional
use keys; because the escrow requirement for health care, they may wish to
control the escrow with their personal key.

Secure tunneling keys which do not impact the individual
necessarily would be for big systems. Organization keys would be available for
your communication to an organization.

The signing key, separate from the encryption key, is intended
for non-repudiation. There should be no key escrow; this does not preclude high
SIPS Level 3 access to the keys on a hosted system.

Strong key protection, however, is critical to a signing key in
order to accommodate non-repudiation.

It is not necessary to have a separate key for each certificate
created. You can make a new certificate with the same key to multiple
authorities. Many keys can be stored on a single smart card or chip, so even
when you do use multiple keys for multiple purposes or multiple organizations,
it does mean that you’re walking with numerous cards or tokens on a key chain.

Attributes for credential certificates have been defined within
our international standards and are important for the conduct of health care
credentials and the assurance of health care credentials.

Health care transactions and security – it provides an
assurance of the individual’s identity, and we also need an assurance of
clinical and regulatory credentials when we’re conducting health care

We have identity certificates for certificate types and
attribute certificate. These can be bound in a single certificate, as we’ve
defined in our international and national standards on PKI whereby we attest to
the individual’s identity and their health care credential, typically their
license, and we put that information in the same certificate. This approach is
commercially available and is being conducted today.

Attribute certificates are typically associated with an
identity certificate. They are, while commercially available, highly limited,
and experience with them is also limited, but there is great promise for using
these in the future.

Identity and attribute key management – they may be bound
to a single organization being both an attribute authority, as we call it, and
an identity certification authority. The could be de-coupled whereby the
identity authority is different than the attribute authority. Or they could be
missed – it doesn’t mean that you have to go with one approach or the

Certificate types – we have the public key certificate.
This uniquely links a public key to a person or an organization issued by a
trusted party called a certification authority as opposed to an attribute
certificate which links the attribute characteristics to a person or his public
key. Similar techniques are used for the attribute certificate as for the
public key certificate. They’re issued by a trusted party, in this case called
the attribute authority.

This diagram is borrowed from the Belgian proposal for
application of digital signatures in health care, a very similar approach being
considered for management of health credentials there. They will have a
national identity card with a public key certificate and they will issue
attribute certificates for the health care credentials.

Within that model, they have also described an approach for
signing the document and attaching the attribute certificates associated with
the individual and also an approach for verification of the signature that has
the attribute certificate attached to the document.

Key protection we’ve discussed as requiring a tamper-resistant
media. We need the keys to be portable, protected by a PIN or biometric. If
it’s on a card, we can enable a single card through multiple certificate and
key storage. We can allow the use of private keys for requests to multiple
certificate authorities and essentially create a virtual attribute certificate
even if the technology for attribute certificates themselves are not available

Smart cards – there is a growing a number of form factors
for tamper-resistant storage of keys. There’s the classic smart card that we’ve
seen and looks very much like your credit card. There’s a combination smart
card and proximity reader which is good for an institutional level where they
can also make that an ID badge and incorporate some of the other
functionalities of e-wallet.

There’s the USB-readable token which is much like the USB
portable drive. There is also emerging and existing mobile technology support
for chips and readers with SDIO interfaces, compact flash interfaces, sleeves
for PDAs, GSM and CDMA chips for wireless communications.

And the capacity of these technologies are increasing, enabling
us to store more certificates or keys on those cards and potentially storing
other application features on those cards and data. The cost of this technology
is coming down as well.

We have a number of ANSI-accredited balloted and health
informatics security standards which support digital signature. The ISO/TC has
generated three documents for health informatics public key infrastructure.
This is technical specification 17090. It has three parts, an overview, a
specification, and a policy component. This is in the process of being
converted into a full international standard and this is the one that is being
considered for adoption around the world.

ISO/TC 215 also has the technical specification approved this
last week, 21091, for health informatics directory services for security,
communications, and identifications of professionals and patients.

ISO/TC 215 also has a draft technical specification in three
parts for privilege management and access control, and this is being harmonized
with efforts in HL7 and ASTM.

ASTM has E1762. The original document was from 1995; it is in
the process of being updated. Originally, it was a standard guide for the
authentication of health care information and it’s under revision as a
specification for authentication of health care information using electronic

Within this document, we discussed the requirements of
signatures and we discussed where it is appropriate to have strong approaches
and other technology approaches.

ASTM has E2084, standard specification for the authentication
of health care information using digital signatures. We also have ASTM E2212,
which is a standard practice for health care certificate policy, which has been
harmonized with the ISO health informatics public key infrastructure.

DICOM has Supplement 41 and there is also ISO/IEC 15408.

Of course, there’s the supporting IETF/RFCs regarding X.509
PKIX and S/MIME and IHE, interconnecting the health care enterprise, is
incorporating digital signature support and PKI support into its profile on PWP
specific for pharmacy. Perhaps this will provide the directory for the pharmacy
contact information. And the XDS potentially can be used for e-prescribing if
has agreed upon documents for medication lists.

PDQ could be used to obtain the demographics and even

And this year we’re looking at a new profile development
entitled Digital Signatures for Attestation and Authorization.

There is also the Enterprise User Authentication.

There is quite a bit of cooperation among the SDOs and the
industry in this area. Multiple individuals represented in multiple SDOs for
the health information security are on these committees from ASTM, ISO, HL7,
IETF, DICOM. HIMSS urges and supports the adoption of the standards that will
lead to digital signature. There’s physician participation in these groups, and
the DEA has and will continue to participate and interface.

Secure e-prescribing test beds for health informatics security
standards are beginning to form.

We have local information infrastructure community test beds
and grassroots initiatives in Connecticut – Danbury Health Systems,
Middlesex Community, and we are in discussion with others to establish a secure
e-prescribing pilot based on these health informatics security standards.

The Community Foundation of Central Florida similarly will be
incorporating these health informatics security standards with a continuity of
care record community profile.

We have health informatics standards. We’re in need of funding
for these projects and we recommend that these types of pilots and
demonstrations of health informatics standards be part of the pilot testing in
support of MMA.

Secure e-prescribing stakeholders need to be involved in all of
these – the health and pharmacy regulators, the DEA, the drug controls,
the pharmacy commissions, the state departments of health, clinicians,
pharmacists, patients, insurance companies, drug manufacturers, industry
vendors, industry standard development organizations.

We would like to recommend that we create a collaborative road
map with buy-in from multiple players including health information security
standards, IHE, with industry support from HIMSS, recognize the end objectives
and the risks of all stakeholders and define reasonable steps get there,
including the objectives of law enforcement, the objectives of clinical care
providers, objectives of pharmacies, objectives of insurers.

We recommend that we do not prevent the momentum of enabling
application, communication and workflow progress for non-controlled and
low-risk prescription drugs as we have quite a momentum already underway in
e-prescribing where there is low risk.

Do not, though, preclude the incorporation of digital
signature for those that adopt the technology for other security functionality
in their environments.

Encourage the interoperability with electronic medical record
systems, not just at the data level but the user interface level and electronic
medical records security approaches.

Provide funding for standards development, for test beds of
health information security standard pilots and demonstrations, fund progress
and enhancement of the supporting infrastructure technologies, assess the
efficacy of the test bed deployments, and roll-out nationally. Thank you.

DR. COHN: Lori, thank you very much, and thank you, Alan, for
very useful additional testimony.

Questions, Answers and Comments

Let me just start off and ask others for questions. I just
obviously was listening to both of you and I just want to make sure that I
think I’m hearing right. I think both of you are sort of indicating that PKI is
very promising and is probably where we should be going. I’m not sure that I
heard either of you say that either of you would recommend starting in January
of 2006 that everyone immediately implement PKI. I think I was hearing that
both of you felt that there needed to be some demonstrations, particularly some
pilots, to make sure that this can scale and that the standards really work as
intended and all of this. Is this sort of what I’m hearing? I think maybe what
I’m hearing – I guess I should ask all of three of you; is that sort of
what everybody is saying?

MS. REED-FOURQUET: Yes, I would recommend that we begin with
the pilots, we make sure that all the concerns are addressed, that we can
demonstrate that it is successful. We don’t necessarily have to wait until
2006; we have these communities that are ready now to begin and to begin their
architectures and getting their communities together, but yes, begin with
pilots and test it and deploy it.

DR. ZUCKERMAN: There’s a possibility of being ready in January,
2006. We can’t make statement today. There’s too many unknowns, too many risks
of causing serious damage both to the health care industry and the
e-prescribing component of that simply because there are so many alternate

A lot of us have a lot of hope in the W3C consortiums, XML
signature approach but we still haven’t moved all of e-prescribing into XML. We
still haven’t heard enough from the DEA to really know what the bar will be set
at. And we still have many serious state and other coordination issues.

DR. COHN: Lynne?

MS. GILBERTSON: I think, to tag onto what Dr. Zuckerman said,
but my answer would probably be no, that there’s enough that’s already thought
to be for January, 2006, and it doesn’t appear that this is as well along as it
could be. Future? Possibly. But I think it’d be recommendation that it not be
one for 1-2006.

The other is, once again on the pilots, to clearly state what
problems we’re trying to solve so that we can measure what it is we’re fixing.

DR. COHN: Okay.

DR. ZUCKERMAN: I think that what we can say with a certainty,
though, if we don’t try, we’re never going to get there. We have to get out and
attempt to use these technologies or we’re going to be in the same place five
years from now. We need to begin to use them. We need to have an incentive and
a sense of urgency.

DR. COHN: Okay. Steve, did you have a question or are you

DR. STEINDEL: Yes, I have a comment and a question and
unfortunately I have to get to another meeting in the next few minutes, so
please forgive me; I’m going to be like the panda: Eat, shoot and leave.

I think it was a very interesting discussion and I think
there’s two components to the discussion. And one component is the need for
security and maybe PKI et cetera in the world of the electronic medical record
and in the world of data at rest and maybe in the world where removing
electronic medical record information from point to point. I think there’s a
different burden on non-repudiation, security, encryption and privacy in that
environment than in the environment where we’re talking about a single point in
time transaction that’s going from one place to another and really has a
limited lifetime in the transport phase, because the actual prescription
itself, from a medical records point of view, what caused this generation et
cetera, would be in the electronic medical records system, assuming that was
used. And that, I’m talking about, is a different environment and we can talk
about different encryption technology et cetera there.

And likewise, we’re talking about a different security exists
on the receiving pharmacy side and perhaps the intermediary side. They have a
different burden with the data at rest.

But the action e-prescription itself is a one-time transaction
that’s sent from one point to another point source perhaps through
intermediaries, and we’ve heard a lot in the last couple of days about how
weaker security systems that are being used today are effective for that
limited time transaction.

And I want some sense of why we should think differently, based
on what you have said. Now notice, I’m not saying anything about not using the
stronger encryption which I totally agree is something that we need to look at
and we need to discuss, we need to think about, and probably will be the route
that we have to take with the data at rest.

And I’m also implying that perhaps we need it in data in motion
where the data is of much more intensity than it is with the prescription

So please comment on that because I think that’s a very
important point of introducing a PKI system for e-prescribing and not a PKI
system for medical information. And I likewise agree that maybe five or 10
years if we have a PKI system for medical information and have a lot of
experience in it, it will be easy to roll the e-prescribing environment into
that, but as you two acknowledge, well, it’s not ready for prime time yet. I’d
like some comment on that.

MS. REED-FOURQUET: I will start backwards. The ready for prime
time is more a matter of any given community establishing an e-health
interoperability more so than whether or not digital certificate technology is

DR. STEINDEL: I accept that point. This is not a technology
issue; this is an implementation issue.

MS. REED-FOURQUET: Yes, and we have the same issue in looking
at the national health information infrastructure.

The encryption technology happens to be able to use the same
infrastructure for conducting encryption as it can for attestation to the
content of the information and accountability to the content of the

And it is not the encryption that is of concern so much because
that can certainly be accomplished through other mechanisms and other virtual
private networks and technologies and whatnot. It is the accountability behind
that signature and somebody to be able to non-repudiate that that transaction
was intended and that somebody who acted on the transaction received did so
knowing the origin and the credentials of the sender.

DR. STEINDEL: But we have heard the last two days is from the
e-prescribing community there are methods to do that, which it can be done
outside of digital signature that they are comfortable with, with time-tested

DR. ZUCKERMAN: I have a great deal of difficulty n three of
the things that you’re saying that I think are wrong assumptions.

One is the one-time point-to-point assumption. A lot of
e-prescribing is not done during continuous connection, is not immediately
transferred. The ultimate recipient pharmacy is determined more by the patient
than by the physician who actually writes the prescription.

The second issue is that others are going to lead and we can
follow. I think e-prescribing is absolutely in the minds of most physicians.
The poster child for e-signature – this is the place where it can and will
happen, if it’s going to. So I think to wait for others to go first is a
mistake because others are waiting for us to go first because this is the area
that seems easiest to do and it has the most incentive. Comparing this to a
laboratory report, to a medical record, this is something that’s doable.

And the third thing – the relationship of the
e-prescription to the medical record. A great deal of e-prescribing, much of
the success of e-prescribing, because it’s taking place outside of medical
record applications is the users of e-prescribing far outnumber the users of
electronic medical records.

Back in 1975, I did a study documenting the number of
prescriptions that never make it into manual medical records, and this is
something that we’re always going to live with. The reality is that the
e-prescribing records are our best and most complete records of prescriptions.

Starting next January, JCAHO wants every hospital admission to
have a record of medication histories that’s going to come out of the
e-prescribing system. That’s because we have so many failures in our medical
records system and failures to transfer information.

So I think this is an important opportunity to lead, not to
follow others.

MR. REYNOLDS: Stan? Steve, are you done?

DR. STEINDEL: I probably have some follow-up on this when we
have Committee discussion.

MR. REYNOLDS: Okay. Stan?

DR. HUFF: Could you address the usual kinds of costs people are
seeing in the prototype experiments they’re seeing, the per-person costs or
some aggregate system cost to implement digital signatures?

MS. REED-FOURQUET: I’m not sure how best to give you figures. I
can tell you that the costs have come down tremendously from where they were
several years ago, specifically four or five years ago when they first started
attempting to use digital certificates in health care. It is probably about
one-quarter of the cost at this point in time.

DR. HUFF: And what was it estimated at back then?

MS. REED-FOURQUET: I don’t have figures for what it was
estimated at. I know what the drop has been. So,

for instance, a smart card reader when they first were being
used – actually they’re about $12 now and they were at about $45 to $60
before, depending on quantities.

The certificates themselves have come down from prior they were
several hundred dollars and now they’re certainly well under $100, depending on
how it’s deployed and who’s deploying it.

The requirement to have a separate card and reader is now
condensing into the single device which has both the reader and the chip in it,
so you’re not needing to provision as much hardware on the deployment.

DR. ZUCKERMAN: I think that we still have to think of numbers
that can approach, at least in the past $200 to $250, it’ll be an achievement
to keep it under $100, and we need to distribute that cost and attempt to
leverage it against other entities. Hospitals are getting under $50. But this
is not a trivial cost.

DR. HUFF: Second question. I think everyone here would agree
that digital signatures offer potential advantages, without question.

And what I think is in my mind and many people’s mind is at
what cost and when, and in particular, for instance, I would say, do you know
of any studies, for instance, that have shown decreased frauds and abuse by the
use of digital signatures within medicine so that we can offset the costs that
we’re conjecturing for actual benefit?

In other words, it could be stronger but in fact it’s like
every tradeoff in medicine; there’s some balance in costs versus the benefit
that we gain. And so without question, it’s stronger. At what cost and are
there studies that demonstrate what the real savings would be in better
conviction rate of fraud or anything like that?

DR. ZUCKERMAN: We clearly do not have that today. We have some
experience in the Partners HealthCare system that’s shown the lack of economic
effectiveness of biometric. The VA is getting close to implementing some
digital signature; I don’t know the details of that. It may well be that the VA
may be our best source of some of that data if they’re able to do it.

That’s why I say we need studies, we need facts. We can’t today
prove that this technology is going to be cost-effective, and therefore we need
to make tradeoffs between risk and quality. This is why I feel it is worth
trying to use the technology without the smart card. If the readers and the
cards are too expensive, we could allow our e-prescribing vendors to hold those
private keys in escrow and control them by the same kind of passwords we have
today. But at least we will be adding the signature data to the record.

There’s a lot we need to learn. We don’t have hard data today
about what the improvements will be because no one has had the courage to use
this outside of a few individual institutions and applications.

MS. REED-FOURQUET: There may be some data available out of
Australia where they have converted PKI-based systems as an infrastructure. I
believe it was a few years ago and they’ve been completely electronic for
approximately two years. I don’t know –

DR. HUFF: Do you know a citation, or how would one find out

MS. REED-FOURQUET: I don’t know of a citation in particular,
but I do have colleagues there that would know if there are publications.

DR. HUFF: Another question. I mean, since you’re one of the few
physicians that we’ve had actually testify, how would you assess the general
level of knowledge in the usual physician on the street, practicing physician,
in terms of distinguishing the things that we’ve been talking about and their
knowledge and desire for such things? In particular, the ability to distinguish
between digital signature, electronic signature, PK – you know,
private/public keys, certificates. What would you gauge is the general level of
knowledge and ability to make a judgment and have a desire for this kind of
technology in their systems?

DR. ZUCKERMAN: The knowledge is extremely low. The desire
specifically is not there. The desire for some of the capabilities is there.

But education is changing. A few weeks ago, I spoke to the
American Academy of Pediatrics national meeting, spoke for an hour in the lab
about this technology, did present some of these differences, and people are

When they come to town next year, we hope to have hands-on
laboratories to teach people and give them the opportunity to use these
technologies. That’s one of the problems with January. We have a long way to go
in education, and in fact, as part of our national framework and national
strategy for health information technology, we need to begin educating
physicians, and that education has to occur at all levels.

It isn’t there today. There’s concern for security, there’s
awareness that electronic signature is not going to be adequate. The knowledge
of the alternatives, the willingness to engage, and the experience in seeing it
used, using it themselves, needs to become part of our continuing medical

MR. REYNOLDS: Jeff, did you have a question?

MR. BLAIR: Yes, I was looking for Simon’s guidance here because
Lori, I don’t know if you knew, but we always identify any potential conflict
of interest, and since Peter Waegemann is my employer and he’s Chair of ASTM,
there’s a bias and I want to make sure that I don’t do anything that is

I think this is a neutral question, just for information, and
that is, you indicated that you’re working with Connecticut and Florida on
demonstration projects and that you had asked to be part of the MMA demos and
you thought that those might fold into the MMA demonstration projects, so my
questions are: Is the demonstration project that you have in Connecticut and/or
Florida, is that e-signature – excuse me; e-prescription? And if it is
e-prescription, are you using NCPDP SCRIPT in those demonstration projects or
is it something else?

MS. REED-FOURQUET: I’ll start with answering in the state of
Connecticut. It is very much a grassroots effort. We have the health care
communities that are ready and willing to demonstrate to uptake the standards.
We have the e-prescribing vendors. Specifically, we have HealthRamp and
Allscripts and we’re talking to others. We’re willing to incorporate the
digital signature into their application for testing.

We have had some discussions with RxHub and with SureScripts
to be able to take some approaches to processing those as value added networks
and pass them on to pharmacy.

I’ve been in discussions with the pharmacy commission, the
drug control officer for the state, and the associations in the state to
establish the stakeholder involvement.

That one is specific to e-prescribing.

The Danbury health system is also looking at affordable
patient record whereby they would very much like to have the patient carry
their information from site to site.

In Florida, it is a community-based initiative for a personal
health record that is the foundation project. And as part of the personal
health records is communications involved with the clinicians and exchange of
health information and they would add to that the electronic prescribing

This would be using NCPDP SCRIPT format.

MR. REYNOLDS: I have a question. I think I heard during your
testimony that minimally you want to make sure that any standard that comes out
does not preclude use of PKI at some point.

DR. ZUCKERMAN: That’s right, that’s correct, right.

MR. REYNOLDS: Any other questions from the

Committee? Maria?

DR. FRIEDMAN: This is for Lori. This gets back to the
demonstration projects that you hope to ramp up. You said they weren’t funded.
What kind of ballpark funding were you looking for?

MS. REED-FOURQUET: That’s going to very much depend on the size
of the project and it’s a little bit of a chicken and egg problem because we
could easily do a statewide project. The state has worked together, in
Connecticut, that is, before in some leading edge technologies and building a
network information infrastructure, which we did back in ’94. Yet, without the
funding, it’s difficult to say that we would do that statewide.

I have a handful of communities and we have vendors who are
willing to in kind some of their products but they can’t bear the whole burden.
And unfortunately, I’m in the process of trying to compute what that funding
requirement will be.

MR. REYNOLDS: Any other questions? Thank you very much, all of

We’re going to take a 15-minute break, till 3:30, and then
Simon hopes to be back by then for our discussion.


MR. REYNOLDS: Yes, open mike, and then our discussion, so we’ll
plan to come back then.

[Break begins at 3:17 p.m. and meeting resumes at 3:42 p.m.]

DR. COHN: Okay, we’re getting started here for our last
session of the day.

This starts with really the open microphone, and we wanted to
offer people an opportunity, who have been sitting here so patiently, if they’d
like to come up and make brief statements on any of the subjects being
discussed today.

And then I am sure we will gradually transition into just sort
of a discussion of what we heard as well as asking questions. I mean, we may
ask questions of the experts who are sitting here so gracefully in our panel
and otherwise have a conversation as we try to sort of identify sort of what we
heard, what we’ve learned, and next steps.

Please identify yourself, and thank you for coming.

AGENDA ITEM: Open Microphone

MR. BROOK: Thank you. Richard Brook from ProxyMed. And again,
as you know, I’ve had the privilege and the pleasure of being here on several
different occasions.

One of the things I want to get pretty clear is – I
believe Mike Simco made comment to it – ProxyMed over the last eight or
nine years, or 10 years actually, has done over 19 million electronic
transactions between physicians and pharmacies. Not all of them initially were
in the NCPDP standard; some were in our proprietary Proxy script standard.

However, the point of abuses could be either at the point of
prescribing or at the end result where the pharmacy fills the prescription. We
have had nobody ever break into any of our communications after the
prescription has left the physician’s office to our network and from our
network to the pharmacy, to our knowledge.

So, we just want to be clear about whatever processes and
procedures have been in place as far as the secure log-ons and whatever issues
we had even earlier on with point to point connectivity et cetera.

So, understanding about PKI and really sitting here listening
about that, what we have in place today works, and I just want to make sure.
And obviously, moving forward with PKI and getting much involved security-wise
and getting involved with the DEA, but I just want to be clear about the one

The other part is I believe Harry made a statement yesterday,
or it could have been Stan, saying, well – I think it was you had asked
somebody about who do you think is the best people or committee to make
recommendations about e-prescribing and what’s taking place.

After sitting here for the last two years when we first started
talking about this, and as MMA has evolved, and this is much, much bigger than
MMA, we thought that we’d hear when we made the recommendations to MMA about
e-prescribing and how this group, NCVHS was the point people for that.

But you folks have – listening to the questions and being
involved with this space for about 10 years – it’s really interesting to
see how I’ve sat here and watched all of you evolve, and the questions that are
asked and even questions after doing this for 10 years I haven’t even thought

So you are in such a great position to recommend to the
Secretary, and I really believe that you’ll do what I think that we have really
said, in the best interest of the community pharmacy today as well as physician
groups as far as the levels of security that are in place, but just in general,
even all the things and seeing the processes and the procedures taking place
here has been just a real pleasure for me to be involved. Thank you.

DR. COHN: Well, thank you. Well, I think we’ll all smile.
Appreciate it –


DR. COHN: Until our next set of recommendations, in which case
people may not be quite as happy, but we’ll see what happens. Actually, anybody
have any questions for our last commenter?


DR. COHN: Yes – actually, I don’t think we’re going to
let you off the hook quite that easily, even though we were smiling just a
second ago, but –

DR. WARREN: Yes, I had one, but it was Lori.

DR. COHN: Next one and we can sort of pull Lori in with your
question here.

MR. HAAS: I’m not really Lynne. Jim Haas, WebMD. And I also
appreciate the opportunity to speak.

One thing that dawned on me as I was listening to the
conversation on PKI, and maybe it’s only dawning on me and everybody else’s sun
is already up in the sky, but one of the hallmarks that we’ve talked about is
the patient’s freedom and flexibility to choose a pharmacy as being very
important to preserve that.

And for all the shortcomings that a paper prescription has,
there’s nothing quite as flexible as driving around with a piece of paper in
your pocket and you can pull into any pharmacy on any corner and if that
physician has never written a prescription and it was filled at that pharmacy
before, if that patient has never been at that pharmacy before, nevertheless
that prescription can be filled, the patient’s needs can be taken care of.

Now if you take it one step to the e-prescribing and there is
somewhat of a reduction in that flexibility because that choice now is made
before the patient leaves the physician’s office, so he’s not driving down the
street; he has to have made that decision so the prescription can be routed.
And he’s limited to an extent to the prescriptions that are available on the
e-prescribing network.

Now, one of the things that Mike Burger talked about was
that’s the reason that faxing plays an important role in e-prescribing. It
increases the size of that network to keep the patient’s choice as broad as it
can possibly be.

Now, when we move to a PKI, we move to a situation where there
really has to be a pre-existing relationship between a specific physician and a
specific pharmacy because that pharmacy has to have the key in order to decrypt
that message. Or there has to be a way that that can be done in a time that is
commensurate with the normal prescription filling process.

In other words, if the patient wants to go to a pharmacy and
that pharmacy isn’t prepared to handle the transaction from that physician, he
may not be able to read that prescription because he doesn’t have the key, and
he needs to be able to obtain that key so that he can decrypt that prescription
and fill it.

DR. COHN: Can I ask a question there? I mean, because you were
sort of talking about faxes and all of that and the ability to be there, I
presume, under those circumstances, that the value added network would
translate it and send it over. Is that correct? They would have the public key.

MR. HAAS: Well, that gets back to the conversation we had
before. Is it encrypted from point to point to point or is it encrypted from
the inception to the end point?

And I was assuming a model of it was encrypted at the
physician and not decrypted until it arrived at the end point, the pharmacy.

DR. COHN: I guess that’s something which might have to be
explored. I don’t have the answer to your question about that, but –

MR. HAAS: I guess I’m asking the question, sure.

DR. COHN: You need to come to a microphone and introduce
yourself. We’re going to ask you questions anyway, so –

MS. REED-FOURQUET: You’re confusing a little bit the
encryption component and the signature component. The encryption could be done
with PKI, doesn’t have to be done with PKI. The PKI’s strength here is in the

The signature itself does not encrypt the document. The
signature verifies the integrity of the document and its origin and the origin
of the signer.

The encryption could happen through a VPN tunnel, it could
happen through any other encrypted mechanism. The pharmacy does not have to
know in advance the public key of the signer. Typically, the signature is
appended with a public key for verification purposes.

So I could send you an encrypted email into your Microsoft
package, and as long as you can trust the certification authority, your product
already knows how to verify your signature.

DR. COHN: Yes?

DR. ZUCKERMAN: In fact – Alan Zuckerman – PKI
actually extends the flexibility in the process considerably over where it is
today because of all the information about the prescriber that is on the
certificate that either physically travels with the signature or is readily
available from a separate source, as was pointed out in the first session

I am personally licensed in three different states, here in
Maryland, DC and Virginia. I have three

different DEA numbers, I have three different state licenses.
Two of the states have their own controlled substance things. If my patients
choose to fill that prescription across the river in Virginia, through a PKI
architecture my Virginia DEA can be immediately linked to my signature, just as
my Maryland DEA could be linked if they choose to fill that prescription in

So the beauty of PKI is that all of this information travels
with the signer and that’s a better situation than what we have today. And
furthermore, you can authenticate if those licenses and those DEA numbers are
still valid at the time the prescription is being filled.

DR. COHN: Judy, I think you had a question for Lori? Did you
want to – since we have her here?

DR. WARREN: Yes. You had talked about pilot projects not only
in Connecticut but also in Florida and one of the things I was wondering is do
those include this PKI technology and what are your findings, and is it
including more than just e-prescribing? Could you just kind of tell us what’s
happening in the pilots for us to kind of pull it together as a more cohesive

MS. REED-FOURQUET: The pilots are in a planning phase, so I
won’t say that they are today using it but the one in Florida is a community
project. It is for the personal health record and that one will be deploying in
the beginning of 2005.

DR. WARREN: Are you going to use PKI in that?

MS. REED-FOURQUET: Yes, that will use PKI and that will be
using it for the purposes of patient identification and authentication purposes
with the clinicians in the environment.

And the e-prescribing will begin as an alpha pilot in the
Connecticut initiative and we will beta it in the Florida initiative.

DR. WARREN: Okay. So right now you don’t have any information
for us, just that it’s being planned to roll out in both of those –

MS. REED-FOURQUET: We’re in the planning and architecture

DR. WARREN: In your planning, have you run across anything that
we should pay attention to as we’re thinking about making recommendations?

MS. REED-FOURQUET: I’m finding a great deal of acceptance and
willingness to try the technology and I don’t think that we will have barriers
to get the pilot going other than trying to get the resources to get the pilots
off the ground.

DR. WARREN: Well, I think the resources we’d be interested in,
too, because quite a few people have questioned about how much money and
resources and things like that some of these technologies will cost.

DR. COHN: Harry, did you have a question? No. Are there any
– actually, since we have Lori here, are there any other questions since
she’s sitting here right now? Okay.

Are there other testifiers in the open session?

MR. BLAIR: I guess I can ask a question here of Lori.

DR. COHN: Don’t you want to go to a mike?

MR. BLAIR: I guess I ought to get to the mike.

Lori, what vendors or networks have or are working with you
with respect to either of the pilot tests in using PKI technology?

MS. REED-FOURQUET: I have a long list of vendors; I’m afraid I
might some of them out. But these include Novell, RSA, Custodix, AET Europe,
HealthRamp potentially, Allscripts potentially, Danbury Health Systems,
Middlesex Hospital, Community Foundation of Central Florida, Dell, and I should
have my notes in front of me because I have a list of approximately 20. Okay?

DR. COHN: If you would send it to us, it would be great.

MS. REED-FOURQUET: Okay, I will do that.

DR. COHN: Other questions? No? Okay.

AGENDA ITEM: Subcommittee Discussion – DR.
COHN, Chair

Well, let’s transition then into sort of talking about what
we’ve heard, and I think probably most importantly at this point, sort of next
steps in relationship to all of this, and I know Stan’s been taking very good
notes, as has Margaret. But I guess, I mean, even without the notes, I guess we
sort of need to begin to think about how it is we want to – I mean, both
think about this one and the open questions that we may wish to explore.

Now – and maybe I’ll start out with just a couple of broad
statements that I will say posit based on the testimony that I heard and sort
of see if any of this makes sense. And Stan, did you have some broad statements
you want to start with? Please.

DR. HUFF: I wanted to ask stupid questions first.

DR. COHN: Oh, please, ask stupid questions first.

DR. HUFF: I just wanted to frame it as: In terms of the
legislation, what are we charged with in terms of what we’re supposed to
recommend to the Secretary about this subject?

DR. COHN: Okay. Well, let’s start with that.

Yes, first of all, this is really a continuation of our
previous set of recommendations, so, I mean, we’ll start with the narrow world
and then we’ll talk about the wider world, but I won’t describe e-prescribing
as a narrow world, but there’s the very specific use case of e-prescribing.

If you remember, in our first set of recommendations, we
talked about things that would be useful or necessary or helpful and are ready
for 2006. We talked about things that needed to be piloted or tested in 2006.
Some things we said are so firm – those were foundational standards, if
you remember the term we used.

DR. HUFF: Yes, and if the Secretary adopts them as
foundational standards, what does that mean?

DR. COHN: Well, that means that we’d have to talk to Maria,
but the question really was: Are there things that might really be ready for
2006? Maria, do you want to finish up that sentence?

DR. FRIEDMAN: The foundational standards were ones that –
and I forget exactly the language of the statute – but had such already
broad industry acceptance that they didn’t need to be piloted, and those were
the ones that we proposed.

MR. BLAIR: My understanding of foundational standards was that
these are standards which no matter what else we do, and no matter what other
standards we might select, these are the foundations. NCPDP SCRIPT was a
foundation and I guess AST X12, 270/271 was a foundation.

And we might indicate that there might be other messages that
might be added to them, there might be other terminologies that might be used
with them, but these were the foundation ones.

So, in short, even if there were other things we would test, we
still had to go back to these foundational standards to test them with whatever
was going to be tested. Now, that was my understanding. Is that — do you feel
comfortable –

DR. FRIEDMAN: That’s true, but it’s also to have foundation
standards that can be used for Part D going live and for the pilot.

MR. BLAIR: Right, yes.

DR. FRIEDMAN: And the critical takeaway on the foundation
standards is that they don’t need to be pilot tested because they’re in such

DR. HUFF: So the foundations don’t need to be pilot tested —

DR. COHN: Yes.

DR. HUFF: — and the time frame for going live?

DR. FRIEDMAN: Same date for both is January 1st of

MR. BLAIR: They don’t need to be tested for them to be
recognized and adopted, but in fact we probably will have to include them in
the pilot tests because they’re needed to test the other things that we’re

DR. COHN: Yes.

DR. HUFF: I remember all of the definitions of foundational but
I just need refreshment. So when whatever standards are adopted by the
Secretary, when are they mandated for use?

DR. COHN: Okay.

DR. FRIEDMAN: There’s Karen. Karen? Just in time! Wake up!


DR. COHN: And let me try to begin to answer this and Karen
might be able to jump in if I’m misstating this.

One of the characteristics of the foundational standards was
since they actually had widespread industry acceptance and were relative mature
et cetera that they actually could be, if the Secretary saw fit, and obviously
Mark McClellan and others I think had gone publicly trying to jump-start all of
this, could actually be put into use in 2006, not as a pilot, but as, if you’re
going to do this, we think you ought to be doing it this way. And that was
really the characteristic of a foundational standard.

Now, beyond a foundational standard are things that we thought
were potentially promising but really needed to be piloted or tested, and
remember, we had a whole set of things that we felt that were sort of the next
phase, things that were improvements to foundation standards, terminologies,
certain uses of identifiers, but other pieces that we really felt that needed
to be tested in a pilot.

And that pilot would go on in the year 2006. The Secretary
would create an evaluation which would be shared with Congress in mid-2007,
would identify sort of the final standards, or at least the official full set
of standards, in 2008, potentially for implementation one year thereafter.

And Karen, if I have misstated this all —

MS. TRUDEL: Through notice and comment rule-making.

DR. COHN: Through notice and comment – thank you –
through notice and comment and rule-making. Thank you.

But the timetable, I think, is basically overall the right
table because obviously a very deliberative process with all of the rest of it,
and so does that help with your first question? Do you have other questions or
do you want to make other comments?

DR. HUFF: Well, I guess there is one lingering question. I
mean, in all that you said, I mean, for one of the foundational standards that
we’ve approved –

DR. COHN: If we recommend it, if we recommend a foundation.

DR. HUFF: — if we recommend it and that was adopted by the
Secretary or through rule-making or whatever, by whatever process that
happened, when would IC be found non-compliant if it wasn’t adhering to that

DR. COHN: Without having seen in those proposed rule-making, I
don’t know.

MR. BLAIR: Could you restate your question? I didn’t quite
understand it.

DR. HUFF: I don’t know – I’m wondering if in the
legislation it says a date by which if I’m not using the standards that were
adopted that I will be considered non-compliant.

MR. BLAIR: Possibly, April, 2008.

DR. COHN: Karen, do you have a response to that?

MS. TRUDEL: It basically depends on when the standards are
published as final standards. You can’t find anyone non-compliant or not
following something that is not effective. So it would key off the effective
date of the final standards themselves.

And what we are hoping with the foundation standards is to link
the effective date of the standards with the beginning date of the Part D
program, but that again is a matter for – you know, we’re still in the
beginnings of the regulation phase. Does that answer the question?

DR. COHN: Okay. But I think regardless of all of this, I mean,
I think the key view of a foundational standard is that you would have to be
pretty confident that this was a mature, industry-accepted standard.

DR. HUFF: Well, that’s what I was getting – I mean, that’s
really what I’m trying to understand, is how much time do we have? I mean, if
we’ve got 12 years, then I would say, gee, let’s do lots of interesting
experiments with PKI and –


DR. HUFF: Twelve is hyperbole. I don’t think it would really
take that long.

DR. COHN: Yes. But now, let me layer on another piece of all of
this, that I think, as I said, during my introductions which were of course
– let’s see; it was 6 a.m. California time yesterday morning and 7 a.m.
mountain time yesterday morning – one does observe that e-signature has a
variety of potential uses and use cases in health care that are beyond

And one of the things that we really have a charge as a
subcommittee and full Committee is to make sure that what we do really connects
in with the larger national health information infrastructure, national health
information network. So we need to make sure that all of this does come

This is really what interoperability is all about, so that we
don’t wind up with certain approaches for e-prescribing that turned out to be
completely different than for what we eventually do when we’re doing other
aspects of all of this stuff.

And so we do need to be aware of that and we do need to realize
that we actually potentially could give other recommendations which aren’t just
MMA recommendations, but we could suggest to ONCHIT or the Office of the
National Coordinator that they go off and do something. Or we could ask CMS in
pilots to do things, going up for MMA, or some combination of all of it.

So I don’t mean to confuse you, but what I am saying is that we
have a couple of different tools that we can use, and I think the bigger
question is figuring out where it is we think we need to go, both what it is we
think at this point as well as what it is we need to find out more about,
because I don’t think that we necessarily believe this is our last hearing or
investigation of this investigation but it’s sort of that a question like,
well, where are we now, what open questions do we have? If we decided to do
another half-day or day on e-signature, who might we need to hear from? As well
as do we have any initial sort of views on all of this?

DR. HUFF: So you’ve answered all my questions, so you can go
back to your opening statements.

DR. COHN: Assuming that I can even remember them!

I guess what I was going to start by commenting on – let’s
see how I can say this one. I find the PKI and really digital signature, and
obviously the PKI infrastructure is a very fascinating and potentially very
valuable sort of in terms of technology or set of approaches in health care.

I’m not at all certain about how exactly it works in with Part
D and e-prescribing and certainly I don’t think there was anything I’ve heard,
at least from any of our testifiers today, though I think I’d want to hear more
from people who have actually tried to implement it, that would make me believe
that it is something that obviously I would feel comfortable with, maybe
saying, this could be implemented widespread in the industry in 2006.

So I guess I’m just sort of positing this out – once
again: Not having heard from groups like the VA or DOD or others who have
really maybe tried to put this into a health care environment, you know,
interesting but didn’t feel to me that we were ready to say 10 months from now
that people should immediately start with widespread implementations, which
would be really sort of my definition of a foundational standard.

On the other hand, and something for the subcommittee to think
about, is whether or not there ought to be some pilots or whether this ought to
be part of an evaluation as you move into the pilots for MMA to figure out what
sort of applicability might there be and should this really be the way, because
I think one sense is that it’s obviously a stronger set of security
protections. It certainly, if connected with some sort of reasonable biometric
authentication identification, that does really create that sort of chain of
trust through the system, or at least helps cement it.

But that’s something that would really have to be proven to
make sure that it actually really worked as intended as well as opposed to as
suggested and didn’t overwhelm the industry, didn’t bring down e-prescribing
systems or otherwise.

So, I mean, that was sort of where I guess I was going, but I’m
curious about what others think. But once again, as I say, we would want to
hear probably from people actually using it to make sure there isn’t some fatal
flaw there. Other comments about this? Stan?

DR. HUFF: Yes – well, I can start off by saying

I can tell you a few things that I added to my list of sort of
stuff from today if that’s okay.

DR. COHN: Please.

DR. HUFF: Okay. So I won’t repeat the ones that I said
yesterday, but we had one at the end of yesterday that was preemption of
heterogeneous state laws by a national e-prescribing standard would be
important in order to achieve national standardization. And you’re welcome to
disagree with that.

DR. COHN: Okay. I don’t think we said that; I think you noted

MR. BLAIR: I think what he’s saying is that some testifiers
said that.

DR. COHN: Oh, okay.

DR. HUFF: Well, I’m sort of asserting that I thought that was a
consensus of what we heard, not that there wasn’t some dissenting voice or
something else, so –

The second one. So yesterday I said that we want to use the
same e-sig process for scheduled and non-scheduled drugs, but then I think from
testimony today, I added the statement: However, if the DEA decides to require
digital signatures, then most folks thought that they would still want to use
something, basically e-signatures, for the non-scheduled drugs.

MR. BLAIR: Could you clarify that one? You lost me on that.
Would you restate it?

DR. HUFF: However, if the DEA requires digital signatures

MR. BLAIR: For maybe the 15 percent –

DR. HUFF: — for –

MR. BLAIR: — yes, whatever.

DR. HUFF: — scheduled drugs, and who knows whether it’s just
Schedule II or Schedule whatever, but then people would still want the ability
to just go ahead with e-signature for non-scheduled drugs.

MR. BLAIR: When you say “with e-signature,” are you
saying –

DR. HUFF: Current best practices, basically.

MR. BLAIR: Oh, okay. In other words, have two different
standards, one for DEA controlled substances and another for non-controlled

DR. HUFF: Yes.

DR. FRIEDMAN: I got the sense that people weren’t happy about

MR. BLAIR: You know, actually I don’t know that I really heard
a consensus. I kind of thought that that was one option, and maybe after we
hear from DEA, we’ll see if that’s valid, if folks continue to say that or not.

DR. FRIEDMAN: The other thing that I heard was that if DEA
proposes the digital signature that people essentially are going to drop back
to paper.

MR. BLAIR: Yes. That was another.

DR. HUFF: Well, what I heard is they would drop back to paper
for scheduled drugs —

DR. FRIEDMAN: For scheduled, yes.

DR. HUFF: — not for all drugs.

DR. FRIEDMAN: No, because the DEA will only be for the
scheduled drugs anyway.

DR. HUFF: So we’ll have to sort that out, okay?

Another thing that I heard and thought made sense was
standards should not allow the content or the intent of the prescription to be
changed and we must especially preserve the transmission of sigs that are
entered as free test without change.

MR. REYNOLDS: Say that again, Stan?

DR. HUFF: The standards should not allow the content or the
intent of the prescription to be changed as opposed – we’ve said
explicitly before that we were allowing the format to change.

MR. REYNOLDS: Can be translated, but not changed.

DR. HUFF: Translated, but not changed. That’s probably better

MR. REYNOLDS: Why don’t we add that?

DR. HUFF: Okay. Can be translated, but not changed.

And the second part of the sentence was: “And we must
especially preserve transmission of sigs that are entered as free text.”

In other words, if some comment was made – and I happen to
agree – that if somebody types a free text sig, then it would be
inappropriate to change that into coded stuff that would have lossy transform
and then try and change it back into something that the person at the pharmacy
had to –

So, I mean, it doesn’t preclude you from making a coded
representation, but you still have to – I think the implication was, and I
agree, that you need to send the text as it was entered by the physician in all

MR. REYNOLDS: Would we want to expand that to be “any free
text field would not be translated into a code?”

DR. COHN: Stan, I guess we would ask: Didn’t we already make a
recommendation on this? Am I confused?

DR. HUFF: You’re right. This was probably one of those that’s
true but irrelevant.

DR. COHN: No, no!


DR. COHN: But one of the reasons why you thought it was true is
you had already recommended it.

DR. HUFF: That’s right. No wonder it sounded so good!


DR. COHN: I mean, no, no, don’t delete it, but let’s hold it
and let’s verify in our previous letter that we actually did say that. I’m
pretty certain that I thought in our sig comments that we at least had made
that recommendation.

DR. HUFF: So I think it probably is one of those things that’s
true but doesn’t have any impact on what we’re talking about here, so I think,
good point.

So another one was, before I said allow for evolution that the
recommendations should allow for approved experiments in new technology and new
versions of standards or new standards. And then I added this sentence:
“In particular, our recommendations should not preclude use and
experiments with demonstrations of digital signatures.”

DR. COHN: Say it again.

DR. HUFF: We want to allow for the evolution of standards. That
is, that the recommendation would allow for approved experiments in new
technology and new versions of the standards or new standards. And in
particular, our recommendation should not preclude use and experiments and
demonstrations of the use of digital signatures.

MR. REYNOLDS: That’s our theory of a base set of standards, and
then if people can go up from there as either experiments or pilots, and then
if those are adopted, then the ceiling moves. I think we talked about that at
our last –

DR. COHN: Yes. Let me just ask: Would those base set of
standards be foundational standards or —


DR. COHN: What?

DR. HUFF: I didn’t say or hear anything about foundational

DR. COHN: Well, I was just going to ask. I mean, when you said
“base of standards,” I just wasn’t sure whether you meant these were
all – I mean, we talked earlier about best practices and all of that; I
just wasn’t sure whether –

DR. HUFF: Harry said base standards. My thing didn’t say
anything about base standards –

DR. COHN: Oh, okay.

DR. HUFF: — or base or foundation or any of that.

DR. COHN: Okay, fine. Thank you. I withdraw the question. You
ask Harry that question.

Carol, did you want to make a comment? Please.

MS. BICKFORD: I have a question, and I have been listening to
the discussion today, and it’s us taking technology and replicating an existing
system. And I wanted to know how we’re going to be addressing the clinical
decision support that needs to occur at the time the clinician is making the
decision to prescribe and giving that individual the correct sig or the correct
dosing or so on and moving it across the system. And does that occur before
they file – in which case that becomes a constrained prescription and
there is no change for it.

And we’ve only been looking at one direction in that the
clinician sends the prescription off and it goes to pharmacy land, but the
pharmacy may have a clinical decision support system that identifies that this
is the inappropriate prescription for this patient. There might be drug
allergies or wrong dose, wrong format, something. Then what happens to that
prescription and the changes that occur in the pharmacy component? But then
does it go back? Does that become encrypted then and PKIed and all those sorts
of things? And what becomes the prescription then?

I’m throwing a bunch of things together that have been
troublesome as I’ve been listening to this wrap-up. We’ve not talked
necessarily about the re-work that occurs if something’s wrong going through
the system. But we’ve also not talked about the clinical decision support as
being part of the e-prescribing solution.

Okay – well, okay; if you haven’t gotten to that, fine. I
just wanted to throw those two cents in. Thank you.

DR. COHN: Stan, did you want to try to comment on that or

DR. HUFF: Well, I can say what we do in our own system. I mean,
I think good informatics would say that you don’t override the prescription you
had with the changes that were made in the pharmacy, that you keep a separate
record of that so that you know what came from the physician and you know what
the pharmacy filled. And those are two separate and distinct records.

And if you have an interchange that goes back to the clinician
and the clinician updates it, then that is an update. But even in that case,
you don’t override in some destructive way the previous prescription. You then
have a copy of the original prescription, the updated prescription, and the
prescription as filled, which are all separate and distinct information
entities with their own audit trails and own audit ability.

MS. BICKFORD: But that’s not been articulated in any of the
discussion and it is obvious to us, so I just made the question.

DR. COHN: Alan, did you want to comment on this one?

DR. ZUCKERMAN: Yes, because this is extremely well articulated
and documented in the NCPDP SCRIPT standard 4.2 which has a very clear set of
two-way transaction.

Now, admittedly in today’s world we don’t see a lot of
physicians having two-way communication with pharmacies; it’s primarily one-way
delivery of prescription. But locally I know several physicians engaged in
this, and there is an initial new prescription transaction that goes to the

There’s a transaction back to the physician completely separate
that has pharmacist advice on recommended changes and new medications, new dose
adjustment from the pharmacist, identifying both the person pharmacist and the
pharmacy that this is coming from, and cross-referencing the prescription.

The physician then has a response transaction NCPDP SCRIPT that
identifies his acceptance or rejection of the changes and creates in effect a
new prescription which gets a new prescription number that cross-references the
original prescription.

So if people use the NCPDP SCRIPT in its full two-way
interaction, all of this is clearly documented.

What is a little bit different, though, is there are different
clinical decision support systems to consider. Here we’re talking about the
pharmacist making advice back to the physician on changing a prescription and
there’s a way to do it. At the same time, there are clinical decision support
systems embedded within the e-prescribing systems like DrFirst and others, and
then there are clinical decision support systems embedded in EHRs such as
NextGen which then has an interface to the DrFirst e-prescribing. So there are
actually three different clinical decision support touch points within

But the basic thing that you’re talking about of a pharmacist
recommending a change in dose or medication is very well handled, very well
documented, within the NCPDP SCRIPT 4.2.

DR. COHN: Yes. Margaret, did you have a final comment on this
one or is that well said?

MS. AMATAYAKUL: No, I was just going to say that one of the
standards within SCRIPT is a change required.

DR. COHN: Okay. Stan, did you have other –

DR. HUFF: Two more quick ones.

DR. COHN: Okay, and then I want to go back to your first one
for a second.

DR. HUFF: These are just assertions again, just like all the
rest of them, and could be true or false.

Current e-prescribing best practices, if implemented as a
national standard, would be more efficient, safe and cost-effective than
current paper-based processes.

MR. BLAIR: I think that is a valid statement of the request
that we heard from testifiers. I don’t know if we can declare best practices to
be a standard, and I noticed that when we tried to get them clarified, they
were very ambiguous.

But I think it’s proper to note that that was advice from the
testifiers that we do that.

DR. HUFF: The last one was standards adopted should permit
facts of e-prescriptions. That’s all I had.

MR. BLAIR: Could I add one?

DR. COHN: Sure. Jeff, added one?

MR. BLAIR: And actually the one that I’d like to add didn’t
come from the testifiers; it came from our Chair. And our Chair pointed out
– well, actually there were some others that also made comment about this
as well – that when we look at the pilot tests in particular, and correct
me if I’m misstating, that we should keep in mind that, whatever electronic
signatures recommendations we go forward with, we keep in mind that they should
be consistent with potential e-signature requirements for electronic health
records as well, to the degree that we could do that.

And that seemed to me to be kind of a statement of our scope as
we look at e-signatures. You broadened the scope. And did I state your
assertion correctly?

DR. COHN: I think you did state that assertion correctly.

DR. HUFF: I mean, we had something close to that yesterday, and
that was you said for e-prescribing to be consistent with e-sig and the rest of
the medical transaction and data interchange, especiallly with HIPAA
transactions. And we could just say “and other functions in the HER”
or something like that.

DR. COHN: Sure.

MR. BLAIR: Well, actually, the HIPAA piece – I’m not sure,
in the sense that HIPAA was the transactions between payers and providers, you
know, on claims –

DR. HUFF: My example was claims attachments.

MR. BLAIR: Claims attachments, but I guess my thoughts –

DR. HUFF: In other words, I mean, all I’m really saying here is
not all HIPAA. Maybe I should restrict it and just say that if e-signature for

MR. BLAIR: The potential use for electronic health records. I
thought that’s what you were saying.

DR. COHN: Yes, and I think that Stan is obviously talking
about, given that most of the HIPAA standards don’t require signature, I think
Stan was obviously coming up with the specific piece. And I think that’s
probably consistent with what you’re describing.

So hopefully both of you – hopefully the wordsmiths get
together a bit. Steve, you had a comment?

DR. STEINDEL: I have a question. Is this is a goal –

DR. HUFF: Yes.

DR. STEINDEL: — or a requirement? Because we don’t know what

DR. HUFF: We have all these goals, assumptions and guidelines
in what we might recommend.

DR. STEINDEL: — the signature requirements are going to be for
the electronic health record.

DR. HUFF: I’m just saying in an appropriate world, if we did
know, we would want them to be consistent.

DR. STEINDEL: As a goal statement, I can agree with that.

DR. FRIEDMAN: I think I made that statement yesterday that some
of these, or at least for e-sig, that were out in front of the standards for
electronic medical record and a lot of other things like that, so it’s hard in
my mind to conceptually think about how to reconcile consistency with something
that hasn’t been invented yet.

MR. BLAIR: But could I just clarify one little piece?

The reason that I reacted, Stan, on the HIPAA piece is that we
had been told that a lot of those financial claims transactions didn’t require
electronic signature, so that was why I didn’t feel like that was something
that was playing in as much.

DR. COHN: Stan, I’d actually like to just go back to, I think,
your very first bullet, which had to do with federal preemption. And I would
certainly say that we heard a lot about that though I’m just not sure I’ve
heard quite enough about it to put my arms around it in any way that is beyond
a high level piece.

I guess as I was listening to things, and I’m just sort of
curious about what others think, I think I came away feeling that there really
does need to be as much as possible increased consistency between state and
federal practices and rules and all of this in this area. And certainly you
don’t want a situation where Part D prescriptions are somehow handled
differently or governed by different rules than non-Part D prescriptions, which
is, I think, where we’re all trying to drive to.

The point that I would, however, make is that that’s an outcome
that we seek, and federal preemption is one tool to get to that outcome, and
we’re probably, if we’re talking about all this, at least need to be aware that
there are probably other approaches that can get to the same ends.

And once again, I’d almost need to hear more, but, I mean, one
sense is when one was talking about the e-sign and UETA stuff and all that, you
sort of saw an example of where there were federal things but there were state
things and by everybody working together, yes, there are some variations there.
But it seems to sort of work by everybody collaborating together.

So I’d only say that there are probably some different models
that we may want to at least provide for, or at least to further investigate.

DR. HUFF: I would agree with the further investigate, but I
tend to adhere to Clem’s adage, which is you’ll end up with the number of
standards as you have standards bodies.


DR. HUFF: Well, human dynamics being what they are, if
independence is allowed, it’ll be exercised.

DR. COHN: Well, Stan, I was actually noting with Kepa here
yesterday that we were missing somebody, and maybe we needed to ask Dr.
MacDonald here for some of his wisdom and guidance on all of this.

DR. STEINDEL: Well, I’d like to make a comment in that area. I
mean, it is the observation that the number of standards is related to the
number of standards bodies.

But I would also like to make the observation that the amount
of time it would take to get the same standard using federal preemption may be
longer than if we found another way to do it by consensus process, because we
already don’t have a very clear articulation of what the federal preemption in
MMA means.

And we also have enough instances where federal preemption has
been enunciated in multiple laws where it takes a while before it actually
diffuses out and becomes the national standard, and if we want a national
standard for e-prescribing in the few year time period, you know, that that may
not be the way to get it.

DR. COHN: I keep looking to you to make a comment.

MR. REYNOLDS: Yes, I’m going to. Let me speak on that one

MMA is a federal program, We’re talking about – right now,
our only charge is to put together standards for that federal program, even
though we’re trying to keep mindful of everything else that’s going to happen.

And no matter what we put together, it’s going to trip over
every one of these state situations, and you can pilot forever. So you’re
talking about, you’re putting in a benefit as you think of health care. You’re
putting in a national benefit and trying to run it through a state filter.

And so as we put this together, I like the way Stan said it
because I think we do have to be focused, that the only way it’s going to be
successful and not trip, and the only way you’re going to get general adoption
– as we’ve heard from the testifiers – and the only way a standard’s
going to a standard a little bit like HIPAA was, where an 837 is an 837 is an
837 and the states really don’t have a whole lot of say in it, I think the
umbrella is there. I think the philosophy is there, and I think in this case
– I liked a couple of the words that were said today, mobility of people.

You know, you’ve got so many – there’s a lot of
consultants in this room, that they may call their doctor at home today and get
it filled down the street here.

Depending upon how that’s going to work, they may or may not
get it filled down here, based on this state versus the state they live in
versus everything else.

And back to your earlier point. We may want to not only just
hear more; we may want to have – I know I’d love to see the DEA in here at
some point because you have a couple things, philosophically now, not in any
derogatory –

We have a speed bump called the state differences. We have a
speed bump called what is the DEA going to do – not good or bad, just what
is it going to do? Because that’s another one.

And so if we’re trying to set a standard that’s going to move
and be adopted, I mean, those are two bumps that are going to need to be looked
at and either smoothed out or accepted that they’re there and then build
whatever our standards recommendation is around them because otherwise, I mean,
they’re not going to go away. And they’re going to be clear and they’re going
to be precise.

So I think in going forward, we’re going to have to deal with
it. I struggle right now making a recommendation because I think we’ve heard
probably DEA said 150 times today and yesterday – not negative or
positive; it’s a fact.

And so we’re about to recommend something which could be
trumped by something else, and that’s a little disconcerting just because
there’s not even a framework up there now. I mean, I don’t care what they put
on the board, but at least it would give us a framework just to find out if
we’ve got any chance of even – so that’s my comment. Later on, I want to
comment on just some other stuff. And I’ll leave this one on the table.

MR. BLAIR: I would hope we don’t make recommendations before
we’ve heard from the DEA.

DR. COHN: Well, it sounds like we’ve identified something we
need to try to do in January. And I think just for the record, at least my
understanding is that the DEA is going to do something as a proposed rule; it
isn’t a final rule. So just be aware their process is the same as HHS’s process
in terms of that. So what comes out as provisional versus what finally gets
decided sometimes does change.

DR. FRIEDMAN: Speaking for us, if our rule is out by the time
of the next hearing, we will brief you on what our rules are.

DR. COHN: Sounds good. Now, other comments about this
particular – we’ve heard that we’ve probably got to get the DEA there and
obviously, you know, you’ve made a couple of comments about federal preemption
as it applies to all of this.

Now, you had some other things that you wanted to talk about.

MR. REYNOLDS: Yes, I do, yes, I wanted to mention a couple of

As I think of Stan’s list, this whole federal assurance level
thing that came out yesterday – you know, the one that was presented that
went through all the different levels, and as you try to build something,
because as I sit and look at this, and whatever we would recommend is going to
go through some filter and this could easily be a filter.

And you think about like it has a Level 2 here where that was a
PIN and a password. And I think Lynne said it in her discussion today; you
know, you have a registration, password and a PIN, in a secure network. Now,
you start layering those together, you move off of 2 closer to 3 and 3, if you
remember, is high confidence in asserted identity.

I’d have a hard time not at least considering and recommending
some standards that at least put you close to the 3, because the 2, the words
in the 2, kind of make you uneasy, and that’s some confidence! [Laughs.] Some
confidence in the identity.

And I think that what we’ve heard with the process that is
currently in place with everyone is the whole idea that somebody’s got to be
registered with one of these networks and you’ve got to put in the PIN and a
password and it’s going through a secure network. Those layered together, and
again, as I mentioned to Simon, I just went through some of the Sarbanes-Oxley
stuff and the more you can layer on, the better your thing is.

So as we look at how we view this, there’s a difference between
just picking PKI or just picking something else and making sure that we’ve put
together a package of a recommendation of a layered structure. I

don’t know exactly how to term that so that’s why I’m
struggling with the words, because this thing, this is a very valuable tool. I
mean, this is an interesting tool to use. And it’s obviously a tool that’s not
going to go away and it’s obviously a tool that’s been well thought out and
it’s a tool that’s going to keep showing up.

And I would have a hard time not seeing us push closer to 3, as
close to 3 as we could, at least philosophically, as we think about what we
recommend, because you can pick one piece or this piece. I mean, I think that
whole thing, because that high confidence – the whole thing about the
electronic signature is it’s a high degree of assurance, a reasonable degree of
assurance that that person did it and that everybody in the game takes that

And then one other thing I’d like to add is I feel that with
HIPAA security and privacy – and I actually will withdraw my earlier
discussion yesterday – where I don’t necessarily feel that the vendors,
based on the further testimony, and one of the reasons I threw it out there was
to try to learn a little more, I don’t feel that with what I’ve heard on the
way this goes from the physician system and then it gets into the other process
and goes to the pharmacy and what the pharmacy does and everything, I don’t
feel an overriding necessity now to include vendors, which would take a change,
a significant change, in the reg as it is now, and I think would impede
progress. And going to have it wouldn’t necessarily do that much for it.

DR. FRIEDMAN: To clarify your saying about broadening the scope
of covered entities –

MR. REYNOLDS: Yes, but I think anybody under e-prescribing that
is translating should be considered part of a clearinghouse which – that’s
a clear definition already that’s out there in the industry.

MR. BLAIR: Harry, could I get a clarification? When I think of
vendors, I think of the health care IT software developers that develop the
e-prescribing systems, the DrFirst, the Allscripts.

MR. REYNOLDS: No, I’m thinking more of the practice management

MR. BLAIR: Oh, you’re thinking of the practice management

MR. REYNOLDS: Anybody – once it leaves the doctor’s office
and goes into someone, in my opinion, they are in e-prescribing.

MR. BLAIR: Okay. Now, then help me a little bit further because
I had thought when you made your comment originally about a clearinghouse that
you were thinking of the networks, the ProxyMed and the SureScripts.

MR. REYNOLDS: I was, but if you remember, Jeff, they stated in
testimony that they were not part of the HIPAA regulation. But yet if we
authorize people to translate the information, then by definition they are a
clearinghouse and that’s my point.

MR. BLAIR: Okay. Then I think that we agree.

DR. HUFF: Isn’t that only true if it’s a HIPAA transaction?

MR. REYNOLDS: That’s a good question.

MR. BLAIR: And my thinking on this is that I don’t think it’s
necessary – well, how do I want to point this out?

Functionally, if they’re opening up and they’re looking at PHI,
protected health information, which the prescription probably would be, then
from a functional standpoint I would think that that’s analogous functionally
to a clearinghouse function.

As to whether or not a regulatory or legal action is taken to
declare that SureScripts and ProxyMed become clearinghouses when they do that,
I really – to be honest with you – I don’t really care whether
they’re – that’s a regulatory issue and a legal issue.

I do think from the standpoint of our subcommittee, we have to
recognize the reality of that function and that it is opening protected health
information. So I think we have to treat it from a standards standpoint. And I
won’t use the word “clearinghouse.” I’ll just wind up saying we have
to recognize that their level of security and privacy has to be consistent with
what they’re looking at.

MR. BROOK: Legally – and you brought up the term before
– we have an obligation with PHI regarding security and privacy. So you
did bring that comment up, and that’s a fact, and all of our contracts clearly
state that regarding PHI.

MR. BLAIR: I think that’s all that’s necessary at this stage,
unless there’s some other rulings that HHS feels they need to do.

DR. COHN: Maria?

DR. FRIEDMAN: As I heard the discussion yesterday, it seemed
that the people who are involved in the chain, switches and all those other
people, while they consider themselves covered entities, they felt like they
had met the HIPAA security and privacy threshold and in addition to which were
covered under their business or their trading partner agreements that were
mentioned, their contracts.

MR. REYNOLDS: The only reason I continued to make the point is
they are not translating information, and that is a clear stipulation. When you
start manipulating data, you’re going into a new game than just passing it
through. I mean, you’re into a whole new world of responsibility.

That’s why I’m struggling as we go forward. We’ve got a HIPAA
umbrella, but what are we doing?

DR. COHN: Yes, and I think we need to do a little more research
on that, but Karen, maybe you have either some clarity or I mean at least we
can hold that out as an issue that we need to, I think, go back and look at the
security rule and other things about. Karen?

MS. TRUDEL: I believe that the regulations stipulate that a
clearinghouse is an organization that translates transactions for which the
Secretary has adopted standards into and/or out of standard transaction

So what that means is that if someone is just translating
prescriptions, it doesn’t make them a HIPAA covered entity. If they are
translating – and many of them do, and I think I’m seeing maybe some nods
back there – retail pharmacy claims, 270/271, et cetera, they’re a covered
entity already because they’re doing those other HIPAA transactions.

MR. REYNOLDS: You’re saying that the law says that anything the
Secretary sets standards on, then they would under HIPAA privacy and security?
Is that what you’re saying? Or a covered entity under that?

MS. TRUDEL: But if you look back at the HIPAA law, it specifies
that 10 or so transactions, including claims attachments for which the
Secretary is expected to adopt standards, and then it says and any other
administrative transactions, or some language in that vein.

So it leaves the door open for the Secretary to adopt standards
for additional transactions at some point in the future. But remember, when you
do that under HIPAA, you’re doing it for the entire health care industry and
it’s required and there are implementation dates and it’s very different than
doing something just for Part D of Medicare.

MR. REYNOLDS: Well, and that’s what I’m saying. I mean, our
only authority right now to recommend is on MMA, right, basically?

So I just want to make sure. Again, if they hadn’t testified
that they weren’t involved in this, I wouldn’t have been maybe as adamant.

DR. COHN: Okay. Well, I have a sense that we’re sort of dealing
with an issue of fact here and I think that we probably can just go back and
take a look back through the legislation, the regulation. I think we know how
privacy plays, which is different than how the best of the HIPAA regs play in
terms of their interpretation of things.

And I think I was observing that I was a little less certain
exactly the wording around the security rule, so I think it’s something where
we can go back just as a matter of fact and review it and then come up with a
recommendation that sort of reflects that bit of information.

So I think we hold this out as something that we’ll probably
want to comment on, but exactly how we comment on it requires a little more
research. Is that okay?

MR. REYNOLDS: I’m good with that, yes.

DR. COHN: Okay. And other people have comments about what they
either heard or what they believe or what they would like to see at this point?
Do we want to talk a little more about the sort of unanswered questions that we
may want to – or things that we may want to hear in January? Margaret?

MS. AMATAYAKUL: I had noted two things that didn’t seem to be
included in Stan’s list. And one of them really kind of surprised me a little
bit, was the issue of record retention. And in association with electronic
signatures, I know a number of the state laws address signature in relationship
to retention.

And so it might be prudent to look at the record retention
issues that were brought up by several of the testifiers in relationship to how
that is handled with respect to e-signature. This is something to keep on a
laundry list for.

And the other thing that was mentioned that I’m not sure is on
Stan’s list, maybe it is, was a certification process for vendors. We do have a
certification commission that has been started under the ONCHIT to look at EHRs
for physician practices. And the thought was that they would then move down the
chain to have other types of products. It may be appropriate to look at
e-prescribing products as the next task.

DR. COHN: Okay. And I only would disagree with you – since
that was one of our earlier recommendations which you helped us craft, which is
why I think you remember it so well. I guess we need to see if we needed to
redouble in whatever letter, so –

MR. REYNOLDS: I think back to the federal structure again;
that’s the other kind of thing that moves you from the 2 to 3, your certified
systems, and you need to do these other things also to start moving it up.

DR. COHN: Well, Harry, I’m getting the sense that we probably
as bedtime reading over the next month need to review the 2 to 3 definitions. I
think we actually all have the NIST documents, and we want to thank Judy for
giving that to us, and it’s actually in 12-point type so it means I can read it
without a magnifying glass, so that’s always a good sign. But I think that
that’ll be something we can, I think, talk about.

DR. STEINDEL: I have a comment about certification.

DR. WARREN: No, mine is just trying to understand something.
You can go first.

DR. STEINDEL: I just wanted to point out, and maybe I should
either make a non-disclosure statement or something since I chaired the group,
that the HL7 EHR TC has posted and is reviewing a set of conformance criteria
for e-prescribing I can share with the group, if you wish. So that’s a start of
forming certification.

DR. COHN: Okay.

DR. STEINDEL: But this is not an HL7-approved document in the
sense that it’s being developed, and it probably will not go to ballot for a
while but go out for public comment in the near future.

DR. FRIEDMAN: It’ll be interesting to see where you are,

DR. COHN: Judy?

DR. WARREN: Well, I’m still trying to connect the dots on all
this. I think that I’ve heard – and if I’m wrong, I need to know now
before going further and connecting the dots – is the statement that
e-prescribing is outside of HIPAA, is that something we’re saying?

DR. COHN: Yes, it is actually not one of the HIPAA

DR. WARREN: Then the problem I’m having is under HIPAA we have
this whole thing about the private information about that patient. It would
seem to me that what drugs that patient is taking is – okay, Steve’s over
there nodding his head “wrong.” Somewhere I’m not making the right
connections here on what we’re doing. I don’t understand why knowledge about
what drugs the patient has been prescribed is not protected information.

MR. BLAIR: It is.

DR. COHN: It is.

MR. BLAIR: It is. The thing is, HIPAA was passed in ’97. pr
’96, and MMA was passed in 2004, so when HIPAA was passed, it focused on the
transactions between payers and providers, all of the financial administrative
transactions that were built in the enrollment, all of those things, and the
only reference it had to clinical information was that it asked NCVHS to wind
up setting four standards for patient medical record information. That was what
it referred to it as – patient medical record information.

And we sort of went down that path, but it wasn’t as mandates,
and those turned into the CHI standards, and e-prescribing wasn’t on the legal
or regulatory radar screen until the MMA law was passed. So now you could now
look back and try to integrate those, and in that case you’d look at protected
health information that’s in e-prescribing and say, hmm, that does fall under
the privacy and security portions of HIPAA.

DR. WARREN: Okay, so it’s a technical –

DR. COHN: Yes, and I think we have lawyers that can help us on
this one, maybe to further clarify and – should I try, or Karen, do you
want to try?

MS. TRUDEL: I’m not a lawyer, but I’ll try it anyway.

The actual importance of being or not being on that list of
transactions in HIPAA is twofold. One is that we haven’t at this point adopted
any standards other than the ones that were originally on the list so we can’t
require the industry as a whole to right now implement, for instance, the NCPDP
SCRIPT, without going back and doing another HIPAA regulation. So that’s one
part of it, that there simply isn’t a legal base right now for us to adopt and
enforce rules about that without going through notice and comment rule-making,
which we’re not doing.

The other thing is that whether you’re on that list or
transactions or not is part of the threshold issue of whether or not you’re a
covered entity. For instance, a provider is not a covered entity under HIPAA
unless it

conducts one of those transactions electronically, and since
the electronic prescription is not one of those transactions, if that is all a
provider did electronically, that wouldn’t push them over the threshold where
security and privacy then become engaged. Does that make sense?


MR. REYNOLDS: Does the same thing fall for a clearinghouse?

DR. WARREN: Karen, can I get a clarification?


DR. STEINDEL: I have a clarification. You said security and
privacy. Is it both, or does privacy still apply because privacy applies for
electronic and non-electronic whereas security I would agree with does not

MS. TRUDEL: The threshold is still there, Steve.

If you get over the threshold and you become a covered entity,
then privacy applies for both electronic and non-electronic.

DR. STEINDEL: So if they stay out of the HIPAA transactions

MS. TRUDEL: If you don’t go over the threshold.

DR. STEINDEL: — they don’t have to worry about privacy.

MS. TRUDEL: It’s moot.

MR. REYNOLDS: So if you only are only the business of
prescriptions and only in the business of e-prescribing, you would not fall in

MR. BLAIR: We’re not going to be able to keep that separate
because we’re looking at getting medication history and medical history and
information, all of the information for decision support. So we’re not going to
be able to keep it separate.

MR. REYNOLDS: That’s my point, Jeff. The whole point I’m
talking about is we’ve got an umbrella and how do we –

MS. TRUDEL: The HIPAA threshold still stands.

MR. REYNOLDS: Yes, and so how do we make this work, so I don’t
know. It’s interesting.

DR. COHN: I think I’m once again reminded that we may actually
have a little homework.

DR. WARREN: I just don’t think I understand.

DR. COHN: Well, no, no, I think that we’re talking about fine
differentiations here and I think what Karen said is absolutely true, what Jeff
said is actually absolutely true also. One could imagine use cases or business
models where maybe not everything that was recommended by NCVHS is implemented.

So maybe all of the HIPAA transactions that we’ve been talking
about or recommending maybe aren’t be used and only NCPDP SCRIPT, and in those
circumstances, without the 270/271, without the 275, and if they’re not dealing
with other parts of the transaction from the pharmacy to the PBM, there really
might be some examples there. Now, they may be rare, but it probably is worthy
of some sort of an observation about all of this. Yes, Karen?

MS. TRUDEL: If I could just add one thing. I think this issue
is relatively immaterial when it comes to pharmacies because so many of them
already do the electronic NCPDP retail pharmacy drug claim. The penetration of
that transaction is so high that I would think there aren’t too many pharmacies
that would do e-prescribing but not do electronic claims. That just doesn’t
seem to compute.

But I think the issue is more on the prescriber side.

DR. STEINDEL: Karen, do you have any idea of what percentage
of prescribers would not be doing electronic claims? That would seem like it
would be very low.

MS. TRUDEL: I think it would be very low because I think
you’re going to find that anyone who is thinking about getting into the
electronic arena is going to do it first through administrative transactions
which are relatively straightforward when compared to e-prescribing,

HER et cetera. So I see it as a progression.

I’m not sure this is a huge issue in reality. It’s an
interesting legal discussion, but I’m not sure that practically speaking it’s a

DR. STEINDEL: Yes, and then my other point of view is even if
there are some, I would imagine the volume of transactions is so low that

DR. COHN: Yes. I guess I wasn’t necessarily singling out any
particular entity; I just thought we needed to make sure that the beginning to
the end is appropriately covered. And I think, Harry, you at one point had
brought up issues about the value added networks and all of that. That all may
be covered. I’m just sort of priming myself sort of like I think we need to go
through a map and make sure that all the groups are appropriately covered with
the right umbrella of security and privacy, and if not, we need to comment
about it.

Or if there needs to be potentially some clarification from HHS
around all of that or some comment in future rule-making or other, that to me
is – I don’t know whether there’s a problem here, like Jeff; I’m not sure
that there is, but just that we need to do our homework and make sure that this
is all connected. Harry, does that –

MR. REYNOLDS: That’s exactly – I just want to make sure
that we’re clear either in not making a recommendation or in making a
recommendation for clarity if it isn’t clear exactly how people fit and don’t
fit and what is the umbrella over them, because on the one hand you might be in
the case of a blue, we might be getting the transaction from a PBM and
protecting it under HIPAA.

And that’s also electronic health record data and that’s also
claim data – I mean, it’s also everything else. You want to make sure that
the rest of the food chain also has taken equal care because our responsibility
is to our member, the doctor’s responsibility is to the patient, and you’ve got
to make sure that when it gets outside that little loop that the world’s
covered. That’s all we’re doing. So I just want to make sure that we know that
that loop is covered, and then whatever recommendation comes out of that, or
doesn’t come out of that, is just – well –

DR. COHN: Margaret is keeping these things as
“to-do’s” for the Committee, so we’ve got reading the NIST Level 2
and 3 document for January and we needed a little bit of mapping for the
process flow and to make sure everybody’s we think appropriately covered.

Now, let me just ask – I’m just going to sort of move the
conversation because I think we have things; we can look at them, we can think
about them.

Now, we will talk tomorrow something about the January hearings
also, but since we’re really talking about the whole issue of e-prescribing and
e-signature and all that, I mean, I’ve heard so far that we need to see if we
can get the DEA and probably the Department of Justice sort of involved. I
mean, and really the Department of Justice – and maybe DEA and Department
of Justice are the same in this one; well, it may be all handled – but I
just sort of thought that the issues about business cases and use cases and
their perspectives about this issue of non-repudiation and all of this are I
think an important thing for us to at least understand.

MR. BLAIR: I suggest we give Maria subpoena authority so she
requires –


DR. FRIEDMAN: I just want a badge!


DR. COHN: So I think we’d like to get them if we can, and if we
can’t, we will sort of just so note in our letter.

DR. FRIEDMAN: I think it’s going to be a timing issue.

DR. COHN: Well, if not then –

DR. FRIEDMAN: We actually hoped to have them this time and the
timing was not right.

DR. HUFF: A question related to that, Simon.

DR. COHN: Sure, okay, we can move on.

DR. HUFF: I mean, is it our feeling that before we could make a
recommendation relative to e-signatures or digital signatures that we have to
have the input from the DEA? The corollary question is: Is there anything we
think we could recommend without knowing what they’re gong to do or is it
entirely dependent upon what they’re going to do?

DR. COHN: No, I think that what I was trying to say is that it
would be very nice to hear their perspectives on all of this, and even without
hearing whatever they may be thinking about in terms of a rule, I’m actually
thinking more about what it is that they need to do and the strength of things
like non-repudiation and all of that that they believe that they need to have,
which to me is – and those were a proposed rule. A final rule was the
implementation of that. But it’s really more the questions of what are their
use cases, what are their business cases around this, just so we can understand
better, because I think that’s very useful.

Is it essential? I don’t think it prevents us from making
additional recommendations to HHS but I think whatever recommendations we might
make, I think we would want to note whether or not we had heard from them or
not just because I think it would be an important thing to put in the letter.
Do you feel otherwise? I mean, do you feel that we need to hold everything up
until we can hear from DEA?

DR. HUFF: It was my feeling not. But then, on the other hand, I
think a lot of what – well, put it this way, so I’m just conjecturing. I
mean, at this point in time, without further information, I would be thinking
along the lines of figuring out some way of recommending best practices in
certification and other things that seem, you know, testimony said would
reasonably meet today’s needs and would not be an impediment to implementation
of these systems.

On the other hand, once something happens, it’s hard to judge
the effect of that on your impression because all of these guys who testified
that way might say, oh, if this is going to be mandated by the DEA, we’re going
to have to do the software work in our systems anyway, and doggone it, we hate
it, but we think we would want to just do it one way anyway. And that’s what I
worry about. I don’t know the answer to that question.

DR. COHN: And I think we did ask them during testimony.

DR. HUFF: Yes, and I think conjecturing about how you might
respond is different than actually responding when it happens.

DR. COHN: Well said. Jeff?

MR. BLAIR: The other piece that I think really has us in a very
difficult situation is what you alluded to just a few minutes ago, is we don’t
really understand the risks and exposures that the DEA is trying to mitigate
with its ruling. And for us to start to make recommendations without
understanding that, I just feel like we’re on shaky ground.

DR. COHN: So I guess what I’m hearing, we should invite the DEA
to come and meet with us in January. Was that our conclusion here?

I had one other area. The other piece that I thought we needed
to hear from and I was just observing as I was listening yesterday and today is
that we need to hear more from physicians, physician users of all of this. And
I’m thinking of – we heard from Alan Zuckerman, who was, I think, unique
in the fact that he was a physician user, but we need to be hearing from other
specialty societies as well as the AMA to get a better feel for sort of their
perspectives on requirements, so that was the other piece I was going to say.
I’ll stop.

DR. STEINDEL: I thought we heard from the physicians early in
the process. A lot of physicians.

DR. COHN: I don’t think we heard about e-signature.

DR. STEINDEL: Oh, not e-sig – oh, you’re talking

DR. COHN: I’m talking about the e-signature.

DR. STEINDEL: I’m sorry.

DR. COHN: No, we heard lots from others. We just never heard
it from them about PKI, all these other things. I’m sorry.

DR. STEINDEL: Maria, what’s holding up DEA is the release of
the regulation, which is why they won’t – you know, if we’re going to hold
up our process waiting on the regulation where the Department of Justice has
just changed Attorney General and HHS is just changing the Secretary, I don’t
know when we could get this letter done.

MS. TRUDEL: I think we can go back to them and ask if they
could come in and talk at least at a fairly high level and especially about
their business drivers and what’s causing them to think that they need certain
levels of authentication. We had hoped that we could just have them come in and
do a presentation on the MPR and I think that having them come and do the one
is very different than the other.

DR. STEINDEL: Thank you. So they were invited specifically to
talk on the NPRN.

MS. TRUDEL: And I also asked them if they could talk about the
MPR and could you do the other and the were reluctant to do that. But that was
then and this is now and we can go back again. We’ll do what we can to make
that happen.

MR. REYNOLDS: We saw this picture a lot – your picture
– and I think a couple of questions were asked; so, are there any
standards – when you take your blocks 2, 3 and 4 – that are what they
might want to have accepted?

I mean, obviously the data flown across here is an NCPDP
SCRIPT. But are there any standards? And it might not hurt to just ask the
industry one more time whether or not there are any standards.

When you talk about a secure POC network, when you talk about a
secure network, when you talk about these other things, is there any already
accepted standard that would be worthwhile? And then obviously you add the PKIs
and you add the other stuff in there, but is there any other thing that would
be a part of this that would be in place that we could adopt or recommend
adopting? Other than just saying “a secured network.”

DR. STEINDEL: There are a lot of standards that are being
used. SSL is a standard.

MR. REYNOLDS: I understand that.

DR. STEINDEL: Yes, and they’re not in the world that we deal
with; they’re in the IT world and the security world.

MR. REYNOLDS: I live in this world.

DR. STEINDEL: I don’t know if we’re really skilled enough to
pronounce specific standards to use there. I mean, there are people in HHS. I
can bring people from CDC who can give you the whole list of standards that are
used in that area. There’s people just down the hall who can do it here within
this building. They exist in their standards; they’re just not the ones that
we’re familiar with.

MR. REYNOLDS: I understand. My point is – you may have
already answered the question. You’ve made a statement that we don’t need to
worry about that. If we don’t need to worry about it, I’m good with that.

DR. STEINDEL: We handled it. I think we handled it –
Karen, you can address this a little bit better. We handled in somewhat of a
vague way in the security standard because we knew that there were industry
standards in that area and we basically alluded to them, didn’t we – best
practices, document the systems –

MS. TRUDEL: Well, we talked a lot about scalability and
flexibility. In terms of specific standards, no, we didn’t do that in the
security rule, deliberately so.

DR. STEINDEL: And deliberately so. And I think we need to
remain at that level.

MR. REYNOLDS: And that’s fine. Then you answered the question.
All I was looking.

DR. HUFF: Well, I guess I would ask the more general question
which maybe comes back to that same question – I mean, if our intent was
in some way to “approve or suggest or adopt best practices,” I think
our only pathway to do that is by reference to particular standards that we
would recommend that they adopt as “best practices.” Otherwise, I
think all we can say is a fairly generic statement about, you know, go forth
and do good.

MR. REYNOLDS: If you look at the security reg, Simon, the
security reg says do your assessment, put in place what you think will protect
what you have, and then you got to kind of live with it.

DR. COHN: Let me make a comment on that in just a second, but,
Stan, I would certainly deputize you to review the standards that Lori put on
her overhead and come back to us.

I think an equally valuable piece might be this NIST document
that one might want to reference also.

Lori, did you have a comment?

MS. REED-FOURQUET: Yes. There are some additional ASTM
standards that don’t necessarily talk about PKI that you might want to take a
look at that address health care specific transport and the encryption and
general frameworks. ASTM 2086, which is the standard guide for Internet and
Intranet health care security and ASTM E2085, which is a standard guide for
security framework for health care information. Those two build on the
underlying IETF standards in the context of health care.

MR. BLAIR: Lori, are you able to make those available to the


DR. COHN: Okay. Thank you. I think we have a comment from
Phil. Please introduce yourself. Thank you.

MR. ROTHERMICH: Phil Rothermich from ExpressScripts. I just
wanted to underscore the point we made when we went through this diagram.

I mean, the bullet points that we included were really
intended to be sort of a straw party for what the standards could be. So the
first bullet under Practice is the point of care vendor authenticates a
prescriber before assigning a unique IDM password.

So while that’s sort of vague, in the context of a standard,
authenticating in the prescriber could be a standard and you could list the
things they have to do to authenticate the prescriber. In other words, check
the state license, confirm that it is current; check the DEA number if that’s
important to you. Make a list of things, and the standard is the point of care
vendor does all those things to assure that this is really an authorized
physician to do prescribing, and then check the box and you’ve met that

And, you know, you go down the list – authenticated
prescribers are granted access to POC technology using unique user ID –

DR. HUFF: But if I understand it, our usual mode has been to
adopt standards. I mean, that would imply that we’re actually making a

MR. ROTHERMICH: Right. This is an area where standards don’t

MR. REYNOLDS: That’s designing a process.


DR. HUFF: Is that part of our subcommittee charge, to make
standards? That seems a little outside of –

MR. ROTHERMICH: That’s exactly the charge.

DR. HUFF: No, I would have thought it would happen the other
way, that you would take that kind of recommendation to NCPDP or HL7 or
somebody; they would create that as a standard, then we would approve that
standard as meeting the needs.

MR. ROTHERMICH: My recollection is that somewhere in the
statute or something it says that the charge is to leverage as many existing
standards as are possible, but it seems to me there was a recognition that
there isn’t a standard for everything when it comes to using a secure network.

DR. HUFF: Well, but that was in reference to the government in
general and I don’t think the charge of this Committee anywhere says we should
create standards. But maybe I’m wrong.

DR. COHN: Without answering that question, I’ll let Margaret
comment. Maybe she has a suggestion on this one.

MS. AMATAYAKUL: I think we should review the existing standards
in ASTM because I think some of the language we’re looking for really does
exist there. Many of these are fairly new standards, within the last couple of

And then, if it seems like those standards don’t suffice, then
I think maybe a recommendation along the lines of passing a specific standards
group or a group of standards groups to come together and develop those
standards would be appropriate.

DR. HUFF: But I appreciate, Phil, your clarification of what
you hoped would happen.

DR. COHN: I think once again I don’t think we have enough data
at this point to make a decision, but I do like Margaret’s idea of reviewing
the standards, which I think makes a lot of sense. I think, Phil, you guys
produce a wonderful framework for all of this and I’m finding myself looking at
this, thinking about the NIST document. Hopefully, Margaret will tell us about
the ASTM documents that she’s going to review for us.

And try to figure out how it all fits together and whether
– yes, one would observe that the HIPAA security standard is basically the
script of an evaluation standard. So I don’t think that we necessarily at this
point would tell you how it is we’re going to approach this. I think we do need
to do our homework.

MR. ROTHERMICH: Yes, let me just make one clarifying point. I
mean, I guess my assumption is the charge of the Committee was to create
standards for electronic prescribing.


MR. ROTHERMICH: Recommend, okay, to recommend standards –
even better.

In other contexts, before we got to this problem, we
recommended that we take what ARTP(?) was doing with respect to a certain
couple transactions and recommend those as the standard. And to get people
comfortable, we said we’ll take those through NCPDP to get them validated by
the industry.

So in a way we would be doing the same thing here. We would
recommend the way people are doing things today be recommended as the standard
and maybe go to NCPDP or somebody and say, get the industry to agree this is
the right way to do it.

I mean, to me, there’s a very parallel analogy there.

DR. HUFF: I think it is parallel, but I think you need to go
back and look what we did because what we did is said these are proposed or
non-foundational standards because they weren’t true standards and that we
would reserve judgment based on the process in those committees about whether
we would truly adopt them as standards or not.

So the point being that if for some reason that process breaks
down, we have the discretion to say no, those are not the standards.

MR. ROTHERMICH: Right. I’m just suggesting you could use and
sell the process for these to say if the point of care vendors are
authenticating prescribers this way today, we think this a good way to do it.
Get the industry to agree this is the right way and then call that the standard
and say everybody’s going to do it one say.

DR. HUFF: I mean, I think, again, the right process for that
would be the way that you know that’s an industry standard is that NCPDP, ASTM,
HL7, DICOM, somebody, convenes an open consensus process to approve that, and
then we feel comfortable that we could go ahead.

DR. COHN: Feeling badly for Lynne, who I notice is not
commenting in the corner.

MR. BLAIR: I almost feel like there’s a potential convergence
here and I just know some bits and pieces, so I’m just trying to connect them.

Margaret pointed out that we ought to review the ASTM
standards. I remember four to five years ago there was an ASTM standard
guideline for health authentication and maybe if we all get a chance to review
that, that’s an ANSI-accredited standard for authentication of health care
information or health care – I’m not exactly sure what the words are, but
I guess it’s authentication of a person who’s entering health care information.

And if that turns out to mirror very nicely with Phil, the
industry guidelines that you have suggested, then in a sense we not only have
adopted the industry guidelines but we’ve done with a standard that’s already
ANSI accredited and we’ve been able to expedite these things by connecting
these pieces.

So we just want to examine that to see if that’ll work.

DR. COHN: And I think you’d certainly want to examine it

MR. ROTHERMICH: That makes sense to me if that’s the way people
do – I’m not familiar with the ASTM standards.

DR. FRIEDMAN: Help me to understand –

DR. COHN: Okay – Maria?

DR. FRIEDMAN: — what was just said. We have the standard that
exists. We have industry practice today. So if we crosswalk the industry
practice and it comports with the standard, then we’re cool?

DR. COHN: Yeah.

DR. HUFF: Lucky!

DR. COHN: Though, one of the things we need to look at –
once again, as I said, we’re all – I mean, I’m flying blind on this one; I
have not reviewed those standards for a number of years. I think many of them
were actually initially developed by CPRI when CPRI used to exist as a separate
organization. But that’s been a number of years now.

So I think it’s just a question we need to review it. Phil, I
would certainly suggest you and NCPDP and others take a look at it. I always
worry that sometimes some of these standards are at a high enough level that
– well, I mean, it’s just a worry that I have that one can get to a very
high level of discussion where things are not specified, and I think we heard
– I’m trying to think of who was yesterday who was describing that they
had to spend a lot of time specifying how things actually would happen.

So it’s one of the things that we’ll just have to think about
as we look at these. But without having looked at them, this is conjecture at
this point.

MR. ROTHERMICH: I guess the thing I don’t understand is to the
extent this group is charged with recommending standards, if we’re talking
about an area where there are no standards, what then? And that’s really why we
took the approach we did, because if there are no standards and if ASTM has
some, that’s great, but if there are none, and there’s a charge to recommend a
standard, don’t you have to create something to recommend?

MR. BLAIR: We could do kind of like what we did, is where RXHub
had some messages that appeared to be well accepted in the industry and we
simply encouraged that it go through the consensus process, and in this case,
NCPDP appeared to be an accredited ANSI standards organization that would be
the logical organization to transform that into an ANSI-accredited standard. So
that was one thing that we did.

DR. COHN: If you remember back under HIPAA, obviously the
Secretary’s preference to use ANSI-accredited standards but if not, the
Secretary reserved the right to develop their own if there were some compelling
reason. I have to say as I think about standards, there’s a couple of elements
of standards that you just need to be aware of and I’m sure you weren’t very
familiar with.

One is the development of the standard, but there’s also the
maintenance. And I think most of us have felt that there needed to be some body
that could not just come to consensus on the initial standard but that also was
invested in – would develop Version 1.1 and 1.2 and 1.3 of that standard.
Especially in the world of security, this is going to be a rapidly, as you
know, evolving area and has been so far.

So it’s a question of finding a home, and once again, I think
most of us are convinced that the ANSI standards development organization and
process is a pretty good process for not just to develop initial but ongoing
maintenance, the evolution of these.

So I think that’s where we’ve tried to be. But once again,
security is a little different than everything else. Harry, do you have a

MR. REYNOLDS: Yes, let me push it back to you a little bit
about what you said.

The reason I asked the question initially was we’ve heard from
the industry over and over again. You recommended the RXHub thing and you
recommended NCPDP and you recommended and you recommended and you said, here’s
how we’re doing business, and you continue to testify that this is all going

We couldn’t get anything out of the industry today as to what
you’re doing in these boxes and whether or not you’re using 40 different ways?
Five different ways? Two different ways? Or you’re all doing the same thing.

That’s all I was pushing on, is to try to find out. And if you
say there is no one way and if you say there’s 400 ways and we’ve agreed to
disagree, then obviously as a member of the Committee, I have to think about
it. Whatever your answer is, I have to think about it appropriately because we
have tried to work with the industry throughout this to see what you’re doing
because we’ve heard continually e-prescribing is going on and everything is
happening. We’re trying to formulate this.

So that’s my whole purpose for the question, is give me a
framework, if you’re doing something that works.

MR. ROTHERMICH: Well, I guess I would beg to differ with you
because I think you did today that the industry is doing essentially one way.

Now, there may be some variation in the detail, but the point
of care vendors are all authenticating prescribers before they get access to
the system. I mean, that’s going on today. They’re all using secure networks to
transfer data.

MR. REYNOLDS: I don’t want to debate it because I think I’ve
made my point clear. But I think the point is: What is a secure network to you?
What standards are you using to decide what a secure network is?

DR. COHN: I think Steve may be want to say –

DR. STEINDEL: Yes. Within the U.S., every time I’ve heard
people talk about the issue of computer security, authentication or anything
that revolves around it, it all goes back to base NIST documents. NIST is the
primary source in this country for the levels of authentication that are used,
the security systems that are used, the strength of encryption that is used,
the encryption algorhythms that are being used.

And if you ever take a look at standards like ASTM or anyone
else, you’ll find that what they are just a collection of what NIST recommends.
And, you know, we were handed the NIST document, the 75 pages, and it actually
has that material enumerated in it in various places.

And then if you go back, as she mentioned, there’s a thicker
document that’s associated with it, and a whole slew of other thicker documents
associated from the NIST website describing this even further.

So what I’m concerned about actually is going to the direction
of going to standard development organizations and asking them to codify what
is standard business practice today, which is coming out of what they put
together within their computer systems from the NIST system. And I believe that
the way the security rule handles it in this very complex world is the best way
to handle it, and that’s do your assessments, state what you’re doing, and be
very clear about it and make sure it meets the need.

And I think if we go further with recommended a specific
standard – you know, we can say that we recommend that we authenticate at
this level, and maybe point to the NIST document or something like that, but I
don’t see how we can or should say how to do it.

MR. ROTHERMICH: Teri, you can speak to this better than I can,
but I think the assumption when we talk about secure networks on this diagram,
and I’m not nearly as familiar with it as you are, but that was sort of the
assumption, that there is an industry standard for secure networks and that
that’s sort of baked in. And that’s why we didn’t get to the level of detail of
what does a secure network mean.

MS. BYRNE: Yes. And this is Teri Byrne of RxHub. But just to
address your point, Harry, we did talk about what we’re doing specifically. We
talked about the fact that we’re using SSL encryption. We talked about the fact
that we do direct lines.

So we did talk about some examples. We don’t have just one that
we use; we use multiple, depending on who we’re talking with. And SureScripts
and ProxyMed talked about the same thing.

So – but again, it does go back to we didn’t want to
specifically name anything because as soon as you name something, something
better comes along and you want to follow the industry standards for what is

MR. BROOK: One of the things – this is Richard Brook from
ProxyMed – you know, it seems like we’re talking about the standard
registration process. It almost seems, at a very high level, all of us have the
same unique ways that when we connect with point of care vendors, we know how
this system operates with user name and password.

I was just talking to Lynne a second ago. I mean, if ASTM
possibly has a standard way to the registration process and then the
registration process between each entity, that might be something different.

Or, again, as you said before with NCPDP, we might want to come
up with and make a recommendation again, but I don’t know we’d be able to get
this solved by January, 2006, a recommendation about a registration process,
and I just think what Steve is saying – there’s all these different things
and how all the different networks and software. If we got into real detail,
we’d end up having to bring SYSCO here and all the routers when a prescription

I’m just saying I don’t want to get to that point, Simon, but
if you started to talk about how when you asked a question before, within the
network – well, if you use SYSCO, use the NETS router. How is this stuff
encrypted? How does it get there? And then we’d all fall asleep a lot sooner.

But anyway, but there are those points now, again, the standard
operating ways that ProxyMed works, RXHub works, and SureScripts works.

DR. COHN: Lori, did you have a comment?

MS. REED-FOURQUET: Yes. Again, relative to both ASTM standards
and ISO health informatics standards for security for the credentialing
process, or the identification on binding of the individual to their identity,
even though it’s been defined in the context of PKI, you may want to take a
look at the process that we defined as part of that, even if you’re not going
to consider the PKI because we do have ISO standards which are about to be full
international standards and the ASTM 21, 22.

MR. BROOK: So what you’re saying is we’d use the piece of that,
the registration process not necessarily using the PKI, but to get from Point A
to Point B.


DR. COHN: Margaret, do you have a – please. And then we’ll
try to wrap this one up.

MS. AMATAYAKUL: I’ve been taking notes here, and I just
scrolled up and it says standards for the networks are out of scope. And now
we’re back talking about what standards we would recommend for the networks.

MR. BLAIR: They’re out of scope.


DR. HUFF: And the reason it came up is because I disagreed,


DR. HUFF: But in a way, I don’t, so –


DR. HUFF: There’s a level of standard that we can specify, but
it’s a level of mis-standard; it’s not at the level of a particular
implementation that you have to do. And so I think the only way we can make
recommendations is in fact to point to standards. And I think the only
disagreement is what level of standards really makes sense for us to point at.

We don’t want to point at the level of standards that lock us
into a particular technology or a particular vendor. We do want to point at
standards that insure a certain level of functionality and I don’t know the
details to know what exactly we can say in that regard, or if we need to say
anything, because we might be preempted by the DEA, so –

DR. COHN: Please introduce yourself and –

MR. SCHUETH: Tony Schueth, Point-of-Care Partners. Simon, I
have a question and a comment. And I know it’s running late, but I feel it’s
important that this question be asked today while Dr. Zuckerman and Lori are
still here.

So my question is, there was a discrepancy in discussion on
PKI. So Lori and Dr. Zuckerman strongly advocated PKI, and I went through the
testimony – we’ve got DrFirst – there’s four different pieces of
testimony – ProxyMed, NCPDP and I’m not sure who this one is, but there’s
four different pieces of testimony that says that there are problems with PKI.

Reading from DrFirst, they talk about and they quote Thomas
Sullivan, the past-president of the Massachusetts Medical Society; the AMA and
its partner, and on its second partner have tried for several years to deploy
PKI, and because of the complexity of maintaining the certificate and
developing a successful business case, have not so far succeeded.

I don’t want to get into the debate on this. I’m certainly not
qualified to debate on this. But the question that I have for the Committee:
How are you going to resolve the differences between these two testimonies?

MR. BLAIR: I don’t think we can answer that right now.

DR. COHN: Yes, I’m actually trying to think of which
differences – you mean between –

MR. SCHUETH: Well, you’ve got one group of industry advocates
that are saying, you know, look, PKI is too expensive, it doesn’t work, it’s
not the right thing for the industry right now; it will impede adoption.

And then you have two folks that testified later, at the end of
today, that said this is something that we absolutely for several reasons.

And so my question just is: How are you going to resolve the

DR. COHN: Okay. And I guess what we were doing was trying to
take a different path or I guess what I think we’re taking is a different path,
which is beginning to look at the NIST documents and beginning to look at what
we think the right level is for e-prescribing and working back from there, and
then, at that point – I mean, we’ll have to see if everybody else agrees,
but sort of looking at it from that perspective with the idea of then backing
into whatever technology and then recognizing the realities of the world today
which may be that everything is being done

absolutely fine or that technology needs to be piloted or that
something needs to be developed or whatever. But sort of trying to work that
from the principled stand. I don’t think at this point we have enough to –
I mean, we’ve heard a lot today and yesterday that PKI was not ready. And I
mean I think we heard a lot from that.

But I think we’re all still sort of trying to figure out sort
of the business case, the use case, where we need to be, if not next year, in
three or four years. I mean, the question is, is there a business case to have
PKI being piloted? Does there need to be more work on it?

These are questions that we’re still asking but which we don’t
have any answers on. But I think we think as we come up with – I think as
Harry was commenting when he says a 2 or 3 — and how do we mitigate all that
and what are the options? Maybe we’ll all get a little smarter, and so I think
we were going to think about doing some homework.

I mean, it’s not much of an answer but it’s really just sort of
a reflection on the process and where we are at this point. Does that help?

MR. SCHUETH: That helps. Thank you.

So the last thing I just – I feel the need to comment on
the fact that anything like this that’s introduced into electronic prescribing,
we need to look at

it from sort of a cost-benefit ratio and from my perspective,
and I’ve explained that before, I just think adding additional cost right now
with adoption it the way it is, I would strongly advise against doing that.
That’s my comment.

MR. ROTHERMICH: I just wanted to sort of ask a rhetorical
question on the topic of maybe more research is needed, and it really goes back
to Stan’s question.

As I understand it, and I don’t have a picture recollection of
what the MMA says, but my recollection is there was a task given to create the
innards for electronic prescribing with the idea that there’s something ready
to do by 1-1-06.

And I guess I’m wondering in the context of that statutory
language, if when they said “standards,” they meant ANSI-accredited
standards or if they meant recommend a standard for e-prescribing and sort of a
broader use of the word standard so that it’s all done the same way.

And while I wouldn’t debate the value of leveraging
ANSI-accredited standards organizations, I guess I’m left scratching my head to
the extent there are none, if the idea is to have something in place for 1-1-06
to say how is this system going to work? How do you do that without
recommending standards for every piece of the chain? Again, it’s not a question
that has to be answered today, but –

DR. COHN: I’m really happy that Steve has his hand up, so,

DR. STEINDEL: There are some overriding government policies and
practices, one of them coming from OMB, with regard to the standards process.
And overall, unless we’re told otherwise, the government is to look first to
nationally accredited consensus standard development organizations as to what
we should recommend for us.

MR. ROTHERMICH: I don’t have any problem with that. I’m not
debating it; I’m just saying when that’s all and there’s a charge to create
standards, what do you do?

DR. STEINDEL: And it also states in there fairly clearly that
if we find an area that we do need standards in, that first we should consider
working with the standard development organizations to fill that hole. And the
option that they sort of don’t want us to do is fill the hole with a government

So we do have a process that we do go through in our thoughts
in filling holes that we find.

DR. HUFF: The only thing I would add to that is that the charge
in the legislation to make the standards is a charge to HHS, not a charge to
this Committee. So HHS might, in fact – if you went through that whole
chain that

Steve just went through and in fact we needed standards that
did not exist anywhere and couldn’t be created, the charge to create those is
to HHS in general, not to this Committee.

MR. ROTHERMICH: I guess the only place I was going is to the
extent you heard consensus from the industry today on what standards for those
kinds of things ought to look like, it strikes me that it makes sense to
include it in the recommendation.

DR. HUFF: Yes – I mean, the thing that we could do, I
think, appropriately is say – recommend to HHS that a standard be
developed along these lines or whatever.

MR. ROTHERMICH: That’s a sense of ours.

DR. COHN: I think Karen’s going to reflect probably the fact
that it actually isn’t HHS; it’s probably us – but please.

MS. TRUDEL: No, actually I’m hoping I can put this to bed with
some statutory language.

DR. COHN: Oh, that would be good, good!


MS. TRUDEL: I never leave home without this!

The MMA actually says two things. In terms of the role of the
NCVHS, it says the National Committee shall develop recommendations for uniform
standards. With respect to the Secretary’s authority, the statute says the

Secretary shall develop, adopt, recognize, or modify additional
uniform standards. So it gives the Secretary a certain amount of leeway.

However, when you look at that in the context that Steve just
drew, which is government-wide and bolstered our experience with HIPAA and CHI,
you see that there’s a very logical progression here and that it makes a lot of
sense to do things the way the subcommittee’s been doing them.

DR. COHN: And Phil, I think I’ll go back to my earlier comments
about the standards piece. And as I said, it isn’t just development, it’s also
maintenance, which are really key issues as we sort of move forward.

Now, I don’t think anything that the subcommittee or full
Committee might say will prevent you from working with NCPDP around the issues
of security, and I actually suspect that NCPDP has a relatively robust area
already in reflecting on some of these things.

I think what we are saying is that probably the first step,
though, for all of us to review the various ASTM documents, the NIST document
or whatever before you start plotting a course. And that was really, I think,
the view at least that I have. It just seemed premature to start running north
where maybe something else already else that would do. And so that was really,
I think, the reflections that we’ve had. And so once again it’s one of those
frustrating areas that we are actually in the middle of process. We are not
coming to recommendations today. We’re talking about issues, things that we
need to study more, recognition that there needs to be some next steps and not
firm answers.

So I really do want to emphasize that.

MR. ROTHERMICH: I won’t belabor it any longer.

DR. COHN: No, that’s fine. I mean – we still have
tomorrow; don’t worry. Alan?

DR. ZUCKERMAN: There is one more standards development
organization I haven’t heard mentioned too much today regarding digital
signature, and again that’s the WACO, the World Wide Web Consortium. And a lot
of the ASTM standards, others much like the NIST documents, also go back to the
WACO as a very important primary source of information. And they have, I
believe, it’s now from 2002, a standard for PKI digital signature and XML.

And should we move forward with something like this, I believe
the feeling at ASTM is that we would implement their particular technical

But again, the reason you hear such diversity from the vendors
today has been very well identified. Until we hear from the DEA, we’re really
paralyzed in having an understanding of the cost and the practical realities of
doing anything about digital signature.

So that’s really an essential first step that will probably
very quickly bring consensus in the industry by setting a standard that people
can’t walk away from.

DR. COHN: Judy – please.

DR. WARREN: Well, I was just responding to Alan because one of
the things that I was trying to get at earlier today when Walgreen’s and
Albertson’s – we kept hearing testimony about we need to have the
pharmacist feel comfortable the prescription has been authenticated.

And so what I may be thinking from Harry’s questions and now
from what Alan is saying is maybe we need to identify some of these standards
that will assure and make people comfortable, that this really is, has been
untampered, so some of the secure socket stuff and all that. Maybe not so much
that they’re mandated, but identify them in a dialogue in our recommendations
that what our recommendations are based on is the existence of these more
sub-foundational standards or whatever.

And that might help us kind of close the snap when we get
uncomfortable. It seems to me it really is that this more general standards
layer, that everybody that’s doing business on the Web is having to deal with.

DR. COHN: I sense that Phil wants to make another comment.

MR. ROTHERMICH: Again, just to your comment. I think it’s
important to remember the difference between security and authentication
because a lot of your comment was about security but you started off talking
about what the pharmacists were talking about and their primary concern, given
their confidence in the security that exists today, is authentication.

And authentication in this context isn’t really about signature
because if you remember, eSign as legislation was about contract law, about
intent to be bound. And signing a prescription isn’t intending to be bound;
signing a prescription is clearly for authentication, meaning I the physician
want the patient to have this drug. And it’s a subtle distinction but it’s very
important because it’s really not about the signature. It’s about making sure
the physician intends, the person that you think intends, to have a certain
patient have a drug.

So it’s not all about just a signature and whether it’s an
electronic signature or digital signature; it’s about authenticating that that
physician that you think is on the other end wants this patient to have that
drug. And there’s lots of ways to do that. And so the signature almost becomes

DR. COHN: All right. A new point. Steve?

DR. STEINDEL: I was just muttering I think what Simon just
muttered underneath. That’s a nice articulation of what we are really dealing
with in this area of e-signature with respect to e-prescribing and that it is a
slightly different piece than we talk about e-signature in the contract world
and a legally binding document between two people et cetera, and I thank you
for enunciating it.

MR. ROTHERMICH: Well, and the reason I’m beating it to death
is because I’m concerned if there’s a feeling that if there aren’t a standard,
we can’t go there or we don’t have to go there because to make e-prescribing
work, to make adoption take off, you’ve got to have, first, a single way of
doing it, which is the preemption piece, but also a way to make the pharmacist
comfortable that we know who’s on the other end.

And to me, for that, you’ve got to create, recommend, however
it gets to be a standard, you’ve got to have a way for everybody to do it so
people feel comfortable and it can take off.

DR. COHN: Very well said. Okay, now is that the last word?
Okay. That’s unusual for this committee to be at a loss for words, but –

MR. REYNOLDS: No, we decided to stop, Simon. We’re not at a
loss for words.


DR. COHN: Okay. Now it is 5:45. Now we have – the meeting
starts at 8:30 tomorrow and we’ll start out again and we will start out with an
update, after introductions, on HIPAA and discussion.

John Paul Houston will be calling in as we talk somewhat about
the security role. A very appropriate introduction this afternoon to that.

And then we’ll be talking about some of the work that NCPDP has
sort of been sponsoring with the industry to sort of improve the e-prescribing

And then I’m presuming we’ll have some additional thoughts on
some of these other pieces as we do sort of a final discussion about planning
for the next set of hearings.

So thank you all, and we’ll see you at 8:30 in the morning.

[Meeting adjourned at 5:45 p.m. until the following day.]