[This Transcript is Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Subcommittee on Standards

February 10, 2011

St. Regis Hotel
923 16th Street, N.W.
Washington, D.C. 20006

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030
(703) 266 8402

P R O C E E D I N G S (8:30 a.m.)

DR. SUAREZ: Good morning everyone. This is the meeting of the Subcommittee on Standards of the National Committee on Vital Health Statistics. My name is Walter Suarez. I am with Kaiser Permanente and I am one of the co-chairs of the Subcommittee. We are going to start by doing introductions around the table and then on the phone. Do we have a phone connection? We will go to the phone and then we will go to the public and that will be easier.

So let’s just start off with introductions. We can start with you, Raj.

DR. CHANDERRAJ: Raj Chanderraj. I am just newly appointed and just temporary. My presence is no conflicts.

DR. OVERHAGE: Good morning, Marc Overhage, Regenstrief Institute, member of the committee, no conflicts.

DR. CARR: Justine Carr, Steward Health Care, chair of the committee, no conflicts.

DR. WILLIAMSON: Michelle Williamson, CDC, NCHS, staff to the Subcommittee.

DR. SCANLON: Bill Scanlon, National Health Policy Forum, member of the committee and the Subcommittee, no conflicts.

DR. HORNBROOK: Mark Hornbrook, Kaiser Permanente, member of the committee, no conflicts.

DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and Quality, liaison to the full committee, staff to the Subcommittee on Standards.

DR. WARREN: Judy Warren, University of Kansas School of Nursing, co-chair of the committee, no conflicts.

DR. EDWARDS: Brenda Edwards, liaison from NIH.

DR. DOO: Lorraine Doo, OESS, CMS, lead staff to the committee, no conflicts.

(Intros from phone and around room)

DR. SUAREZ: Okay, thank you very much. Today we have really three very critical objectives. The first one is to go over the letter of recommendation on EFT and ERA and finalize the letter to be presented later this morning to the full committee for action. The second objective we want to try to accomplish is to finalize and confirm our work Subcommittees’ work plan for 2011 and define the hearings that we will be having throughout the year. Then the third one is to talk about acknowledgments and talk about the additional report from 2010, talk a little bit about the need to move and take action on this topic. Then I guess there is a fourth one now that I see this. We also want to finalize our HIPAA report to Congress: the outline and sort of the next steps.

Those are our four objectives. We should go ahead and start with the letters. Let me ask if there are any comments on the agenda. Any changes or additions anybody wants to make?

DR. WARREN: Okay, so let’s start looking at the letter. We presented this to the full committee for discussion yesterday and actually as a result of the discussion there were only two areas for editing and then one area for discussion so what I would like to do is look at the editing areas and actually they were not about content. They were more about format of the letter. So I think we have done a pretty good job on this. Let me show you my suggestions for the edits.

We wanted to be sure that the Secretary understood the flow of the letter so that there would be no misunderstandings and so the suggestion was is that we actually add a header that highlights the organization of the letter because the letter is coming out as part of our responsibility under PPACA to designate operating rule entities. In this particular situation for EFT we also had to identify the standard that the operating rule would be formed. So what I did with that was put a header in there, organization of this letter, and then under number one overarching themes I clarified that by adding, concerning the selection of operating rule offering entities in the implementation of standards and operating rules.

Is there any discussion by the committee? Any edits you want to make on that?

PARTICIPANT: Looks good.

DR. WARREN: Justine, does this satisfy?

DR. CARR: Yes.


DR. SUAREZ: If I can, so confirming that this is part is okay, I think there is one other change that we talked about at the very beginning of the letter in the first paragraph I think we wanted to highlight a bit.

DR. WARREN: Right and when I tried to fit something in the paragraph because we were talking about adding something right here for the standards, I think we broke it up.

DR. SUAREZ: Yes, I was looking really at the specifically part of it, the last sentence before the A, B, C, D where we say specifically with respect. My thought was specifically with respect to standards NCVHS was tasked to identify and recommend a standard for EFT.

DR. WARREN: So instead of operating rules?

DR. SUAREZ: And then and for operating rules, NCVHS was tasked with A, B, C, D and E. It is just this particular paragraph only talks about the operating rules when we are actually tasked to all also define a standard for it.

DR. CARR: Right, so I think that if we are going to frame and I think it is probably worth with each letter framing we were asked to do five things. The first thing was this and that is done. The second thing was this and that is done. Today we are focusing on the third thing and then what we are asked to do. I think the two pieces of structuring of this are where are we in our assignments and for each assignment? What is it that we are specifically asked to do.

I think then you have read the front and it needs to be clear on the front page okay when I read this letter what you are going to tell me is what you recommend about X and I think that the struggle we had yesterday was that this referred to the first two letters and what we are asked to do, we need to highlight what we are asked to do in the third recommendation.

DR. WARREN: So does this capture what we need to have?

DR. SUAREZ: That we should have responsibility for recommending standards for the HIPAA transaction. It is not really recommending HIPAA transactions but standards for.

DR. WARREN: So with respect to standards, we have responsibility for recommending standards? I was just trying not to use standards twice.

DR. SUAREZ: Actually with respect to the HIPAA transactions sent to NCVHS has responsibility for recommending the standards.

DR. CARR: Why do we have to specifically with respect to anything? Why don’t we just say NCVHS has responsibility for recommending HIPAA transaction standards?

DR. WARREN: I am sorry, say that again.

DR. CARR: Just why do we need specifically with respect to the transaction standards? Why do we need that?

DR. WARREN: Because that is how we started the previous sentence and we were editing. So how do we want this to start?

DR. CARR: I would just say NCVHS has responsibility for and just take out the first seven words.

DR. WARREN: HIPAA transaction standards.

DR. SUAREZ: It would say standard for HIPAA transactions then.

DR. SCANLON: Maybe eliminate the and, and put a period there and start with respect to operating rules NCVHS has been tasked to.


DR. WARREN: I didn’t hear that. I am sorry.

DR. SCANLON: Drop the and, and start the new sentence, with respect to operating rules because it leads into the bullets.

DR. CARR: The separate requirements.


DR. WARREN: Does that read the way you wanted it, Bill?


DR. WARREN: The other place was down in our recommendations. We were asked to take the sentence out from recommendation 1.5 about future and to put it in a footnote and so that is what I have done here. Then everything else in the letter is the way it was. Okay?

DR. CARR: I am just looking for the problem statement here. So the problem we are trying to fix is what?

DR. WARREN: The committee didn’t ask anything for a problem statement. Sorry, I have lost my piece.

DR. SUAREZ: Problem statement in terms of the entire letter or?

DR. CARR: No, why am I getting this letter? The banking da, da, da, da, da doesn’t work right and we are.

DR. WARREN: The banking works fine.

DR. CARR: I mean you know what I am saying.

DR. SUAREZ: The problem is stated in the second page of the letter.

DR. CARR: So I think it is helpful in the very first page to say you are getting this letter because in today’s world this does not work optimally and therefore we are tasked with addressing this piece of it that will make it work better; something like that.

DR. SUAREZ: Sure, yes, that is fine. We structured these letters always with an introduction about the NCVHS because the Secretary doesn’t get these letters very often.

DR. CARR: That is true.

DR. SUAREZ: We can do the NCVHS, the responsibility under the Act and then we state specifically for the subject matter of the letter the problem statement.

DR. EDWARDS: Again, I think I am not an expert at this, but usually when you are writing a letter to people that are high officials, you want to get in the first paragraph or so why you are writing a letter and what you are going to address so that they get oriented and sometimes we even have to come up with a one page summary of the whole report. So I think that is part of what I am hearing that sort of helps.

DR. WARREN: So the fact that we were tasked by law to write this letter which we have in the first paragraph is not sufficient?

DR. CARR: It is just so I think you have it here. This letter addresses the transactions for electronic funds transfers specific to health care use and health care payment and advice. But what I am saying is why? In other words we are not as simple as we had hoped to be in HIPAA to put it simply and one of the obstacles to the simplification is the problem statement.

DR. WARREN: So at this point just to move this along, I don’t think we have time to talk about generalities. We need verbiage and specific location of where you want the verbiage. Either that or I think we need to have some time to go back and re-look at this. I understand what you are asking for. I don’t know what words you want and I don’t know where to put it.

DR. CARR: Okay, so let me make a recommendation. We have a big agenda and I think that this is just; we are just talking about structuring this letter so if two people want to go off or three people and work the letter and the rest of this committee get to the rest of the agenda and then come back with the restructuring.

DR. WARREN: Okay, we can do that. There is one more piece of the letter we do need to discuss though.

DR. SCANLON:: I think we do two types of letters here: ones that are of our volition. We believe there is an issue and we want to raise it for the Secretary and there I think the motivation is very important to have at the beginning. This is very different. This is the Congress has told us and the Secretary to do something, okay? We are fulfilling our obligation. The Secretary is going to be very well aware of that and so I think we make a number of references to ACCA sort of at the very beginning. That is what is going to be the flab for the Secretary.

DR. SUAREZ: I am with Bill. I mean we have written enough of these letters of recommendation. This is actually the third really, on the ACA and we have a structure and a rhythm already in these letters that we are beginning to consider this point to change and I think we have all of the elements in there for the Secretary who is going to read the letter but is going to have people briefing her about the letter and the people that will be acting upon it will be others so I.

DR. CARR: Okay, fair enough. If I come up with a sentence or so maybe if there is at the end.

DR. WARREN: Okay, are we ready to go on to the last piece then that needs to be addressed in the letter and that was our recommendation 1.1. We had a comment from NACHA about the definition and we said we would give them time to do that. What I would like to do is for Lorraine to talk about maybe it is Walter that needs to chat about it. For us to adopt operating rules for electronic funds transfer we first need to have a HIPAA transaction standard. And so that is what we are doing in this letter is recommending the standard to the Secretary be adopted as part of the HIPAA transactions. We have a template for doing that. One of them and this has to do with writing the regulations then that enact standards. So with that we have a definition, et cetera. Walter, do you want to go through that is?

DR. SUAREZ: Yes, I think it is important to remind the committee this is the first time in a number of years that we are dealing with a brand new transaction. Basically we have in place eight or nine transactions in HIPAA started and we have not, we just modify the standard when we went from 4010 to 5010, modified the covered service when we went from ICD-9 to ICD-10. So this is the first time we are dealing with a brand new transaction.

So as reminder in the HIPAA framework, regulatory framework of the administrative simplification and standard transactions, each of the transactions defined in HIPAA have three very basic components. The first one is the regulation defines what the transaction is. Health care claim and encounter is the following. Claim payment is the following. Eligibility is the following. So the definition of the transaction is the first thing.

The second thing is to define directionality. The transaction goes from here to here. So a health care claim goes from a provider to a payer for example and health care claim payment goes from a payer to a provider generally. The third thing that it does it identifies the parties engaged. So this transaction goes from a provider, a health care provider, to a payer. So that is what we were trying to do with this recommendation. The first recommendation was to define the actual transaction. This is an electronic message from health plans to the health plan financial institution to order or authorize or instruct them to do a transfer of funds. That is the definition of the transaction itself. Then the 1.2, 1.3 define the actual standards and the entity responsible for the standard.

This is important. This particular transaction applies and will apply exclusively to health plans. Health plans are the ones of the three entities that are covered by HIPAA: health plans, health care claims and health care providers. Health plans are the ones that are subject to comply with the use of these standards because it is the health plan is sending the order to the bank. The provider is not really subject to comply with any EST transaction because as the recipient of the information about that payment in the flow of the information the health plan sends the EST order using the recommended standard to the health plan financial institution and then the health plan financial institution is to send an EFT to the provider of the financial institution for deposit and then the provider of the financial institution sends a note to the provider telling them you have a deposit and here is the information about that deposit. That part is not an EFT. So the important thing about this is that it defines the standard transaction, establishes the standard and identifies who is the subject to. Those were the important elements about this. While there are other industries and in other contexts the definition of an EFT might be different in health care the definition of an EFT really applies to that relationship and that entity.

That is why the definition was provided as stated here so I don’t know if there is any questions from the committee members, Subcommittee members or any comments I guess if you want to make a comment. Jan, so why don’t you come and sit at the table?

DR. WARREN: Be sure and identify yourself too, Jan.

DR. ESTEP: I will. Thank you. This is Jan Estep with NACHA. Walter had the opportunity in about thirty seconds yesterday during our lunch break, to provide me with some of that same description that was very helpful. My point yesterday and one you reiterated at the end is that the terminology EFT transaction has a very specific definition in financial services. This is an area obviously where the health care industry and the financial services comes together. So recognizing this as a health care HIPAA EFT transaction with a unique definition as you said is very appropriate for the task at hand but I think it is important to note that it might be source for great confusion in the future. So as much as we can do to label it health care HIPAA EFT transaction even if it is HCEFT or some else it just kind of reinforces this is different than how others view what you use as the more public term of an EFT I think would be helpful.

The second portion –

DR. WARREN: Jan, can I just interrupt?

DR. ESTEP: I am sorry.

DR. WARREN: Look up there. What we have done is we have said exactly what you just said.

DR. ESTEP: No, I know that is why I am reinforcing that in the way you use it in the context is good.



DR. WARREN: I am not so sure we have addressed that.

DR. SUAREZ: Pretty much all of our transactions in the definition is a health care claim, health care claim payment so it is very clear.

DR. WARREN: Just to make sure it can kind of come up no matter what we do.

DR. ESTEP: We will try to define that way and again this is a health one. It doesn’t change the definition at all.

DR. WARREN: I just want to be sure that the words up here were what you were wanting to clarify the issue.

DR. ESTEP: Yes, but I do have a second point that goes with that definition and two other points so I will try to brief again knowing the agenda that you have this morning.

Because this definition only speaks to the first part, the plan to the bank and defines that as the standard and Priscilla maybe you can hand out the form because I thought having it on paper would be helpful. This does potentially create the definition of any bank as a clearing house. If in fact they receive from the plan instructions to create a CCD and then create a CCD at the bank which is exactly what they do today we have defined the CCD Plus as the transaction. Are you handing that out?

Because of the definition of a health care clearing house that says you take a non-standard format and turn it into a standard HIPAA format, the plan who sends a flat file or interest information to create a CCD into the ACH network now would have the bank create a CCD which is the standard format, they would then be creating from a non-standard to a standard. I don’t think that is the implication that is intended because banks are doing that every day today for many health care institutes as well as for many industries across the board.

So with this talking to only a piece of what we generally refer to as the EFT transaction, it creates that definition when you translate it back into HIPAA health care clearing house definition. So we offer up a clarification to make sure that that does not occur because we think it is an unintended consequence perhaps of this definition of a standard and the way banks do the work in support of plans and providers today. So it merely says you are doing it today. Don’t let this definition now call them a covered entity because we are talking about just the financial transfer.

DR. SUAREZ: Are you saying that health plans sends to the bank a non-standard or a non-standard?

DR. ESTEP: In this definition, I would say CCD Plus is the standard. Right? So non-standard would be something that is not fully enveloped in the CCD Plus to be ready to enter the ACH network and it could just be a flat file with all of the information but according to this definition, it may be viewed as non-standard and then would fall under the definition. So I think a simple clarification would also help with that.

DR. SUAREZ: Its typical application in where?

DR. ESTEP: Which is written in the bottom paragraph.

DR. SUAREZ: Oh, I’m sorry. Yes.

DR. ESTEP: So it just said to provide exactly the words to make it easy.

DR. WARREN: I am trying to figure out where we are.

DR. SCANLON: Could I ask a question, Walter and Judy? To be a clearing house do you have to receive personal health information?

DR. ESTEP: No, the definition is at the bottom. That is where we refer to that. It could be any public or private entity and it talks about. The issue here is because EFT which is now a generally acceptable banking function is labeled a HIPAA transaction as we have just talked about.

DR. CHANDERRAJ: You are referring to 1.1 in the definition, right?

DR. ESTEP: One point one can stay the way it is but because it is defined the way it is it creates this issue.

DR. CHANDERRAJ: Yes, I would find that saying that existing or actually transferring into a standard format rather than non-standard.

DR. ESTEP: Relative to EFT does not create a covered entity or clearing house function. Does that make sense?

DR. SUAREZ: I don’t know that the way currently things work would create any big issues about that.

DR. ESTEP: It is the letter of the law that we are concerned with. I mean clearly it is not what is intended which is why I say it may be an unintended consequence of the words in the usage now calling it EFT transaction a standard HIPAA transaction.

DR. SUAREZ: Yes, I think what this is doing is really establishing the standard and so saying the health plan should be able to and will be required to generate and send an EFT.

DR. ESTEP: Most entities today do not enter and are not mandated to create a full CCD Plus before it goes to their bank. Many enter information on a web screen with the information that is not a CCD Plus. A CCD Plus is created at the bank. So again it doesn’t change what they do. It just makes sure that we haven’t because of the function and the definition of it that we haven’t created banks as health care clearing houses doing this non-standard to standard.

DR. SUAREZ: I think we can certainly take this under advisement. I don’t know to what extent we can incorporate it specifically this recommendation because this will require some modification of the definition of a clearing house in some respects because it would say except in the case where a health plan does not send a full CCD Plus. I don’t know that we can create those kinds of exceptions.

DR. ESTEP: Right and the issue again is if 1.1 was defined as a standard all the way through the banking system, it would not be an issue. But because the narrow view as you have defined it is only the plan at the bank, it creates that.

DR. SUAREZ: Why wouldn’t that be the same issue?

DR. ESTEP: Because if the standard was a full EFT passing from the plan to the provider’s bank to, excuse me, the plan to their bank, from the bank to the bank if that was full standard, then the CCD Plus would be part of that and the translation would not exist.

DR. SUAREZ: No but we are talking about the let’s just say from the health plan to the bank; only if that happened. It would not matter the other parts. So it would still be an issue if, the issue really is whether they are health plan sends a full EFT flat formatted or not.

DR. ESTEP: That is the issue. If the other scenario would have caused a change to the definition so we do not need to go there.

DR. SUAREZ: If the health plan sends a message to the bank in a standard basically they have, well if we are to define the standard for EFT as not just CCD Plus and for every transaction just like any other part of HIPAA the covered entity has two options. They can generate a transaction fully and send it or they can send a non-standard transaction to an entity that will be converting it into a standard transaction. Those are the only two ways under HIPAA that we can.

DR. ESTEP: And that is the issue because banks do this every day today without an issue relative to the health care issues that are defined traditionally as a clearing house. That is exactly the issue.

DR. SUAREZ: So what would be the implication for banks being defined or as clearing houses? I mean many banks are today clearing houses.

DR. ESTEP: There may not be an issue but it would then just from a regulatory standpoint say that if any of the definitions or provisions around the health care clearing house change than the bank would have to be reviewing it subject and this transaction itself, which is only financial data as we have now defined it with CCD Plus would add regulatory burden and or things that are again unintended because again they are doing the function today exactly as you have defined it here without that provision so it is adding additional regulatory potentially confusing environment without the benefit to the economy as a whole.

DR. WARREN: So Walter, Mike has a suggestion and then I do.

DR. FITZMAURICE: It seems that the question that we have been discussing for the past five or ten minutes is should commercial banks that handle electronic fund transfers from health plans to banks and then go to the providers be considered clearing houses. I think the committee is well within its rights to make recommendations to the Secretary on that, but it seems that we have not had hearings on it and that CMS is the one who right now who would decide whether something meets the definition or doesn’t.

It might be something we would schedule hearings on in the coming year, but I am not sure that we have enough knowledge to make a recommendation banks should be clearing houses or shouldn’t be clearing houses.

DR. WARREN: So the recommendation that I put up here is to consider applications of banks becoming clearing houses as defined by HIPAA because I agree with Mike. We don’t have, we have not collected the data or the evidence to even answer these questions. Therefore we do not have anything to make a recommendation about and it goes beyond the banking industry to talk about clearing houses.

DR. ESTEP: Just to clarify Michael’s comment though what we are asking banks to do with this transaction is exactly what they have been doing for many, many years. So I think the answer has been given that there is not an issue because it is exactly what they are doing.

DR. WARREN: Right.

DR. ESTEP: But this is changing but this definition infers a change has occurred.

DR. WARREN: But for us to recommend that banks not become a clearing house as defined by HIPAA goes beyond what we can do because it causes us to take a look at the definition of a clearing house. So I mean there is more than banks here when we look at those definitions.

DR. ESTEP: Understand from the legal definition.

DR. WARREN: Yes and so I think if we just recommend that this needs to be considered, explored and now we have documented the concern that banks have in a letter. That will allow us to go forward.

DR. SUAREZ: I think that is an important part.

DR. WARREN: Right, and that is the win that we want here.

DR. ESTEP: Thank you.

DR. WARREN: Then we can come in later because that is probably a good thing. There are a lot of things that are coming up in HIPAA now that have been around a while, and now with the ACA in there, adding more stuff to HIPAA, they probably need to go back and be reconsidered and this is not the only issue we have seen of this caliber. So thank you.

DR. SUAREZ: We appreciate certainly you bringing this up to our attention. By documenting it here we now have it on record as an issue that we need to explore.

DR. ESTEP: I did have two other areas. Because again we had just viewed these yesterday and again there are two other pieces of paper to try to make it clear, if I may.

DR. SUAREZ: Well, if you could, are they specific issues about the recommendation?

DR. ESTEP: The recommendations themselves; only the recommendations, yes.



DR. SUAREZ: If you could very quickly go through them.

DR. ESTEP: If you could hand those out please. You saw I labeled this one 1.7, it assumed an inclusion of a 1.6 and it was an alternative for the committee to consider and that is the request that as opposed to simply saying CTX might be considered later. That a pilot might be recommended in regard to the testimonies that I think all recognize CTX and CCD Plus as existing standards. A vast majority asked for an option versus one I think only testimony clearly asked for only on standard, and as opposed to just footnoting it as a later action, a recommendation in regard to all of the testimonies could be as proposed here, recommending a pilot that could not only help HHS with guidance that was asked for many years ago, but also call up functionality cost and benefits, that were referred to in the testimonies but where maybe asked for more specificity.

The reason CTX is not being used today is because HHS guidance has not been given, as I called out. So it is kind of a circular logic. If guidance isn’t given it will not be used. If it is not used it will not be named a standard. So a pilot could afford this opportunity, and I think meets the needs of all.

DR. SUAREZ: I think the statement about authorizing NACHA to conduct a pilot. NACHA can conduct a pilot I think. There is no need for us to establish a recommendation to the Secretary to authorize that because that can still happen and there is no reason to. There could be pilots of other standards and other transactions. There is no restriction on those.

DR. ESTEP: Our understanding is that the Secretary would need to authorize a pilot approved by the Committee.

DR. SUAREZ: No, there is no reason for that. Your transactions –

DR. ESTEP: Simply used by health care given the rest of the legislation?


DR. ESTEP: Then that is the reason for the request.

DR. DOO: You are invoking 162940, which talks about pilots for a standard that has not been adopted having the authority to request it? Would that do it?

DR. SUAREZ: Yes, I mean personally I do not know that there is a –

DR. ESTEP: It would provide the committee with documentation and evidence that might be helpful for the future action which is referred to in a footnote.

DR. SUAREZ: Yes, there is in my thinking, I don’t know what the other members of the committee think.

DR. WARREN: In my thinking, NACHA can do whatever they want in a pilot and then share the results of the pilot. As soon as you say authorize, you are telling the Secretary to authorize the pilot which implies official sanction and resources.

DR. DOO: In the regulation I do not, if you look it up, you don’t have to make that recommendation because anyone can apply to the Secretary and then under her authority she could review that application. It doesn’t need to be in a recommendation from NCVHS. There is no role for NCVHS for that.

DR. ESTEP: I thought it might be appropriate given the footnote.

DR. DOO: It is not necessary. I mean the committee can decide but it is not part of the regulation. I know the section you are talking about.

DR. CHANDERRAJ: Is there any problem in recommending it?

DR. SUAREZ: Well I think Judy pointed to that. I think by recommending it, the Secretary would be then having to make a determination about authorization, resources, and I mean there is a process I suppose to do that whereas we are not required to or expected to provide any recommendations about pilots. In fact the idea is actually that pilots could happen and the recommendation from those pilots could come through the committee for the committee to make a recommendation about well there is a new standard that should be defined and talked about.

DR. WARREN: In the past when we have recommended pilots, we recommend to the Secretary that the Secretary conduct the pilot then she decides is it CMS that is going to do the pilot. Is it one of those folks or does it get contracted out to a third party? So I mean you have to look at who the consumer of the letter is and it is the Secretary. The Secretary is not going to authorize a private entity to do something because that would be impinging upon your own organization so it seems like a moot point. It would be nice for us to say that there is a pilot that what we are telling is we need this wording says we want the Secretary to do the pilot and own it and be responsible for it and I don’t think that is what you want.

DR. ESTEP: The wording is certainly something that has to align with regulation that Lorraine called out. The authorizing action to do it was our way of thinking we are not putting the burden on the organization but we do need the guidance as part of it in order for a pilot to even occur so that you can apply to the Secretary.

DR. SUAREZ: So the last point?

DR. ESTEP: The last point was a minor one but I think it would be helpful given the discussion of the PHI and that is to more precisely call out content as including simply the re-association trace number which I think is the intent of the committee and again in recognition of the difference between CCD Plus and CTX.

DR. SUAREZ: So this is the TRN section.

DR. WARREN: But 1.5 is more than just a trace number. When I read what you have got here, it is only talking about the trace number. It is not talking about the whole CCD Plus.

DR. ESTEP: It is not.

DR. WARREN: We looked up and had the number of the, we actually looked to see how this was phrased so that we would include that and so the TR3 Report does address the re-association number.

DR. SUAREZ: We tried to find out the quantum requirement specified in X12-835 particular to the CCD Plus. So the place where in the 835 there is references about CCD Plus, that is implementation.

DR. ESTEP: The definitions here raise up two new terms: content and format that are not used and again content is 1.5; format is 1.3. The CCD Plus includes everything except for the reference to the content in the re-association number so again not having formal definitions of format and content, we wanted to make sure they were clear as used here and I think it helps to define that again if we understand 1.3 appropriately.

DR. SUAREZ: If we constrain this to TRN are there any other places in the 835 I am trying to think where CCD Plus is referenced.

DR. ESTEP: No, our idea here was really to be helpful because 835 could include much more than a trace number including PHI and this would help because everything else in CCD Plus is only the banking information. Right?


DR. ESTEP: And that is all included in the format.

DR. SUAREZ: My question is in the current statement is stating the content requirement particular to the CCD platform so wherever in the 835 there is content requirement for CCD Plus that is where the content should be. Now we don’t name really necessarily specific segments. That is perhaps too specific. What if there is a change in 835 and 6020 that has something about CCD Plus and some other segment. If the regulation says specific to TRN then we are locked to have to change the regulation again to say CRN and now this other segment. So that is why we try to keep it more generic but generic in the sense of any place where the content requirement in 835 refers to CCD Plus. So if right now I think it is only maybe it is right now TRN that is fine but we don’t want to necessarily name that it is only the TRN because it could potentially be changed in the future standards and we don’t want to have to change the regulation because it was too specific.

DR. DOO: Again that would not be necessarily be a role for NCVHS as something we would do in the regulation.

DR. ESTEP: Yes, just trying to make sure the precision is helpful, understand that relevance. Thank you.

DR. SUAREZ: Well thank you for the comment. Thank you for the expertise. Any other questions from the committee members?

DR. WARREN: Yes, I just want to be sure are the committee comfortable with the phrasing of 1.6 then going back and forth between consider and study and I think consider leaves the option open that the banks may not be clearing houses where study in there kind of says they are. I didn’t want to.

DR. CHANDERRAJ: But they are already a clearing house. Some of them are clearing houses.

DR. ESTEP: I apologize because I think phrasing it this way, sends exactly the opposite understanding that I wanted to happen. I know we are trying to be cautious here but the fact is what is asked for in the standard and the function is exactly what is happening today, that to raise up to consider them as a covered entity versus the request which is to insure that they are not defined that way as an unintended consequence, I think is very inappropriate given my comment.

I know I am trying to be precise with it but it would be better to leave it as it is and try to define it in another place rather than raise it up as something that is unintended, and then bring perhaps further unintended consequences.

DR. SCANLON: So because there is a question though Judy, whether it should be could become clearing houses.

DR. WARREN: Could become?

DR. SUAREZ: Well they are.

DR. ESTEP: No, no, no, based as functioning in the EFT definition are not clearing houses today.

DR. SUAREZ: They are not today.

DR. ESTEP: But that is what I am saying. When we are talking about only the EFT transaction, they are clearly not today and they are not changing what they do today. So it has never been an issue, a discussion or concern.

DR. SUAREZ: Absolutely, there are in other transactions, we did not have this transaction as a HIPAA transaction standard, so it is important to consider the implications.

DR. ESTEP: We are clear by naming only CCD Plus that PHI should not be included and should not go through the banking system so it does not change the EFT function that exists today. So I think raising it this way makes the concern worse. It doesn’t address it as I had requested.

DR. CARR: What would your recommendation be?

DR. ESTEP: My recommendation was what was handed out.

DR. SUAREZ: You are recommending that we recommend that –

DR. ESTEP: That this definition not change.

DR. SUAREZ: That the new definition of the standard create an exception in the classification of an entity as a clearing house. That is in effect what this is doing. I don’t know that we can go that far because we don’t know the implications yet. So that is why we are saying we need to consider the implications about that and understand it.

DR. ESTEP: Then it may be appropriate to have it discussed in committee before raising it up to the Secretary. Do you know what I am saying?

DR. WARREN: Well, this is a place holder to let the Secretary know that more is coming.

DR. ESTEP: Okay.

DR. WARREN: And that we will have hearings about it. There is no decision here.

DR. CARR: Is the recommendation, I mean is the Secretary supposed to consider or NCVHS?

DR. SUAREZ: It is the Secretary. We are recommending that the Secretary consider the implications.

DR. ESTEP: It could be perhaps more precisely stated to consider the appropriate definition of a clearing house given this additional –

DR. WARREN: That is way beyond.

DR. SUAREZ: That is already in the law – the HIPAA law. It is not even in the regulation.

DR. SCANLON: How about consider the implications of whether as a result of the adoption of the EFT standard banks could become clearing houses as defined by HIPAA?

DR. WARREN: Good, say that one more time, Bill.

DR. SCANLON: The implications of whether, as a result of the application or the adoption of the EFT standard, banks could become clearing houses as defined by HIPAA.

DR. SUAREZ: I would change could to would.

DR. SCANLON: Okay, would is fine.

DR. CARR: And just add health care to the EFT standard.

DR. SUAREZ: And to be more precise, become health care clearing houses as defined by HIPAA. There are other clearing houses.

DR. WARREN: Got it.

DR. ESTEP: Thank you.

DR. SUAREZ: Okay great. Justine has a paragraph I think. Do you have it?

DR. CARR: I have worked through my issues so I think what I would suggest is on line 53 or 54, have a heading that says, the problem. I see that you have defined the problem but it doesn’t have an urgency I think and I thought it might be restated in the following way which I can give to you if you want.

According to the U.S. Health Care Efficiency Index, the usage of the standard electronic remittent advice is only 46 percent today, a full seven years after the compliance date. If the intermediary third party clearing houses are excluded, the rate of adoption of electronic funds transfer is only ten percent.

Is that the statement of the problem? The problem that we are not using it? If I have read it wrong that is okay, but I am trying to understand what we are saying.

DR. WARREN: I am not sure it is the problem.

DR. DOO: You were tasked with identifying a standard and operating rules for EFT to increase the use of the standards.

DR. CARR: Right, so then the problem is we are not using it fully seven years after. So I am just trying to say here is the problem. If we were using this perfectly we would not be writing this letter. We are halfway using the ERA and ten percent of the people are using EFT.

DR. SUAREZ: That speaks only to the operating rules of ERA, doesn’t speak to the – adopting a standard of EFT is we haven’t adopted it between, we are not using it in these others because it hasn’t been adopted.

DR. CARR: With respect to the topic of rate of adoption of EFT in health care as reported is only ten percent. That is what you said.

DR. SUAREZ: Let me put it this way maybe just to simplify it. The goal was to make the whole payment process more efficient and automated. And the payment process includes not just the transfer of funds but also the clear understanding of what was paid, what amount was paid and for what purpose, what procedure.

So that is the ultimate goal to really increase use, advance improvement of use of electronic standards to achieve the payment and the appropriate verification of a remittance advice, and that was the main goal.

Then by adopting a standard for EFT and establishing the operating rules, the expectation is that that will actually improve the adoption and use of the ERA itself. Those are the main goals at the end of the day.

DR. CARR: Well, maybe I did not say it clearly but I don’t think this says it clearly either. I think we have, just as you are trying to say, we have a problem. We were supposed to simplify seven years ago and this is where we are today with X percent of utilization. So we do not need to take up the whole time, but I think it if helpful to say here is the problem and the approach was to convene these people and then the observations overarching and then observations specific.

DR. SUAREZ: Maybe we can, I think it is in the environmental(?) standard a statement of the problem itself that we can actually transfer to the – well.

DR. CARR: Some of it we can.

DR. SUAREZ: We can look at that and between now and the meeting we can actually finish up that perhaps and try to incorporate it if that is okay. Would that work, Justine?

DR. CARR: Yes.

DR. SUAREZ: I see your point.

DR. CARR: I just feel like we are always saying we are holding the Secretary accountable for did you do this, what happened? I think we have to hold ourselves accountable for saying, here is a problem that we think we are fixing. Here is what we heard. Here is our recommendation. It needs to tie back to what is the problem that needs to be fixed.

DR. SUAREZ: I can read you in one second. In the environmental standard we talk about all of the aspects, but we say the Affordable Care Act calls the Secretary to –

DR. CARR: What page are you on?

DR. SUAREZ: On page three and top four, five of the top five, page three after the letter of the agenda on page three, the environmental standard introduction says, the public act, the Secretary adopts operating rules for EFT and ERA, together this should and it is in quotes, allow for automated reconciliation of electronic payments with remittance advice.

DR. CARR: Right and then what is the ten percent and the 46 percent. Aren’t those indicators of –

DR. SUAREZ: That is indication of low penetration of the usage of transactions.

DR. CARR: Right, so that is my point.

DR. SUAREZ: So it sort of both goals. It is really to improve the efficiency and improve the adoption.

DR. CARR: If you improve the adoption, will you improve the efficiency?

DR. SUAREZ: If we establish the standard, we improve the efficiency. Well if we establish the standard and the requirement of EFT, we improve the adoption of ERA and EFT and we improve the efficiency.

DR. CARR: I think that is what we have to say. This is really complicated stuff and if other people are reading this they have to understand what this is all about. It is very complicated.

DR. SUAREZ: I think we should from this point on, I think establish that as a standard, our own standard of in the letters.

DR. CARR: Here is where we are, why.

DR. SUAREZ: The specific problem.

DR. CARR: Here is where we are headed; here is how.

DR. SUAREZ: Yes, but specific problem for this context of the letter not for the whole adaptation of application.

DR. CARR: The headline is simplification.

DR. SUAREZ: So maybe that is what we can do. We can perhaps just to move on since we only have like half an hour, we can try to finish that up in between the end of this meeting and the presentations of the full committee, which happens at 11:00, I think.

MS. WILLIAMSON: Judy can you also go back to the recommendations 1.6. I think we wanted to specify health care EFT, as a result of the adoption of the health care EFT.

DR. WARREN: Good point, Michelle.

DR. SUAREZ: Okay, any other comments on the letter? What we will do is bring this up to the full committee for action at 11:00, and we will walk the full committee through the changes.

Okay, the second item we wanted to talk about is the work plan. This is a very important part. If you go to the very end of the document that you were handed a booklet, the booklet we have the very last tab number has the work plans for the various committees.

The second page of that page two is sort of our work plan. We put together this a couple of months ago, actually in December, and circulated it to the full committee, to all of the members of our Subcommittees. What we tried to do was look at what needs to be done this year and look at what is coming out in the following years. We were able to actually scope out some activities that are going to be recurrent every year, every other year, and line up some activities all the way from 2011 this year to 2014. So I think we have a kind of a framework of responsibilities and activities.

Rather than going through all of this for all of the down to the years 2012, 2013, I want to try to concentrate on 2011 because we need to by today, define what is it that is going to be our agenda.

So as you can see when you read and when you look and if you have looked at this before, you will see it on 2012, 2013, 2014 some recurring activities: our HIPAA report to Congress; report from the DISMOs coming to us; assessments of how things are evolving and going in terms of the standards and those kinds of things.

This year we need to have what I would say are four or five very critical priorities to address. The first one is I think we need to by completing the EFT ERA letter there is some additional activities we need to do. The first one is in the letter we say we do not have operating rules. So we have already started the process of identifying alternate entities for operating rules and we have received three proposals Lorraine mentioned during her report yesterday for operating rules offering organizations. So we have three proposals to sort through and decide what is to be done. These are proposals to be the offering organizations. These are not really, they propose operating rules themselves.

Now we have the responsibility of really identifying what is the proper course and we have a couple of options certainly. The last thing we want to do is ask the three entities will often write the operating rules and come back and present those proposals because it would be waste of time for everyone. I mean all of our organizations participating in all of these entities that have proposed and each of them having to go on their own would be inappropriate.

I think we need to look at the three entities and decide whether we recommend one entity to be the operating rule offering entity or we recommend other entities work together to develop the operating rules for the ERA and EFT. Or, we can recommend that one of the entities be the one and involve the other two as well. So there is some stuff that we need to decide. We are not going to decide it today or anything like that, but I just wanted to bring that as a very immediate priority.

We need to decide that within the next few weeks because the ERA operating rules have to be written and presented to us. We then have to decide whether they are sufficient and then recommend it to the Secretary in time for them to be incorporated into the regulations for EFT and ERA. So that timeframe is coming up very short my expectation is Lorraine probably has a better sense of the timeframe but the operating rules have to be decided upon this year basically before the end of the year in order for them to be incorporated into the proposed regulations for EFT and ERA. So that is the first priority we have.

DR. SCANLON: Can I ask a question about the process? Yesterday we talked about doing a PCAST letter and there was the issue of we can do certain things by phone and then we can even have a public meeting. So the question for this since you talked about weeks as opposed to months, what are we talking about in terms of the process here?

DR. SUAREZ: The process I think and I will just mention a few ideas and we can add to that is we are going to use our Friday calls, one of our Friday calls coming up in the next maybe next week even, not this coming Friday but the next Friday, to have a Subcommittee to discuss the criteria for evaluating and there is already written documentation of the criteria out of the regulation, out of the law and discuss the proposals from the three entities and make a determination.

So I think that is the next step is really meeting a week from this Friday and evaluate and start the discussion there. Maybe we will use not just one single call to decide this but if we don’t finish that we can do the next Friday call and then no more than those two we would have to decide the course. That is just the process. I don’t Judy or Lorraine.

DR. SCANLON: I was thinking about do we need to involve the executive Subcommittee and then the whole committee?

DR. SUAREZ: Oh yes, yes.

DR. WARREN: Oh, yes.

DR. SCANLON: So the thought of bringing them in is also part of it.

DR. WARREN: All of our processes, we do our deliberations, come up with our decisions, recommendations and then those have to be submitted to the executive Subcommittee and then they come forward. Now if we do it right, we can all of that by phone because we need to get this done before the June meeting.

DR. SUAREZ: We are not really going to wait for June. We are going to have to do this within the next month basically. The good thing is I think there is some other reasons why the full committee might need to meet and so within the and between before February is ended, before June certainly. So I think we will have that schedule. That is recognizing priority number one. This one is listed for this year.

Priority number two is a discussion about acknowledgments. So let me just very briefly say a couple of words about acknowledgments. Acknowledgment, as many of you know, all of you probably know is another transaction, standard transaction. It is not a HIPAA transaction but it is a transaction that is happening all of the time today. It has different versions of it in terms of there is acknowledgment for eligibility. There is acknowledgment for a health care claims submission. An acknowledgment means basically a quick message back from the recipient of the if I sent a claim, a quick message back from the payer that received that claim saying yes I got it. I got it and everything looks fine and that is kind of a first quick response, an electronic response. That is the acknowledgment transaction.

So there are different applications of that acknowledgment transaction: one for eligibility; one for claims. So we receive recommendations from the DISMO back in February of last year during the snow storm that we could not have a meeting in person but we had it on the phone and we had a presentation from the DISMO and then the DISMO is the vehicle by which we receive recommendations hey there is a new transaction we should adopt standards for. This is the transaction. We recommend that you adopt a standard for it. They did that and we didn’t act upon that over the last nine months or ten months, a year now since the report.

There are a couple of other things that have happened. Some states have actually started adopting state laws that require now they use an acknowledgment in sort of impose on them require this transaction. So the states already are pushing for it because the industry says this is good. We want this. We need this but we need it in a standard way. We need all of those balanced.

Then the other important aspect is in the operating rules of eligibility we recommended to the Secretary office, there is certainly requirements to use the acknowledgment transaction. That is part of the operating rules. So all of that together, means basically we want to make recommendations to the Secretary about adopting first of all acknowledgments of the transaction and then defining the standards. In order to do that we need to do that very quickly and in order to do that we certainly need to convene the industry to provide us with input so that is kind of the process we always follow. We convene a hearing. Hear about the transaction. Hear about the recommended standards and then provide us with input.

So we want to do that as, this will be our second priority is to focus on acknowledgments. This will have to happen also between now and June. We have sort of a small window of opportunity to add this possibly adoption of the recommendation of the adoption of the standard into the regulations related to transaction and we will have to think about how to incorporate the acknowledgment transaction for all of these transactions like claims and others.

But anyway, so we would probably need to convene a hearing of the industry. It might not necessarily be a full day for this particular topic, to hear about the acknowledgments, hear about their endorsement because I expect that will be very much in support of this and then recommend the standard. So that is our second priority. We are probably looking at convening a hearing that will likely be, if possible, linked to the hearing that is being now convened for the Privacy side so we only have just one block rather than having them separate hearings.

DR. WARREN: You mean Populations.

DR. SUAREZ: Population and privacy one. I mean not to incorporate this into their hearing but just to tag it along so that we have just one block of hearings which is coincidently in a good time frame because I think it is like by the end of April hopefully or early May I think is what they were talking about. So that is our second priority.

DR. WARREN: Part of that hearing would be to allow time for the annual report of the DISMOS not only to address the acknowledgment transaction but also to get their annual report. So we can bundle that up.

DR. SUAREZ: Yes, exactly. I think that is the third important priority really. As we noted in this letter in the observations, the very first observation we need to create an open and transparent and participatory process with all of this operating rules and standard development process so we want to bring in everybody to the table and talk about this. There is already work being done to try to bring all of the parties to the table all authorizations, the members of the DISMO, standards and organizations. But we need to establish that because we cannot continue to see that there is a big separation between the two. We need to try to, between the two groups of organizations they are offering entities. They are offering rules and the standards of the organization. So part of that hearing will be to invite all of the groups to the table and present ideas and recommendations on how this can be harmonized or put organizing to a more harmonious process. So that is our third priority is DISMO.

The fourth priority really is a priority that comes from I think fortunately we do not have any more of this need to develop and recommend or need to adhere and then recommend standards and operating rules for transactions. We don’t have that for another probably year. The next round is basically the claims and the enrollment and the other transactions referral. So that is not going to happen until next year so that is in our list of activities for next year. We do have one that I think is an important priority. I have been bringing it up a couple of times and that is claim attachments.

Now with regard to claim attachment that is way down the road the rules are not due until 2014 and the implementation is not due until 2016 but there is a need to really convene the industry to understand the direction of where the standard development process is going with respect to claim attachment. There is a lot of new developments in the standard development world that are now linking sort of claim attachment with what was an administrative transaction with the attachments and with the clinical messages that are being now required in meaningful use and sort of the standard that we used providers to send a clinical summary to another provider for referral is not going to be that different from the attachment I am going to have to send to a payer for payment when they need clinical notes to settle it.

I have many conversations with the Health IT Standard Committee, the HIV standards committee which has jurisdiction if you will over the clinical messaging standards and we are looking at potentially holding a joint hearing of both the Subcommittee on Standards and the clinical operations workgroup of HIT Standards Committee which is responsible for the messaging standards, clinical messaging standards toward the end of this year, probably November or December as a joint hearing to hear about all of this work that is being done around the claim attachments and attachments in general. So we are not going to necessarily call a claim attachments hearing. It might be something different.

So that is the other priority. We wanted to bring this up this year to sort of set the stage for where the direction is and let industry express their perspective of this into their profit.

So those were the four priorities that have for this year. We had a few other ideas but I think those are with the amount of work that we have so far I think this is going to be very difficult.

Now the last point is really the HIPAA report to Congress. So we have laid out an outline of the report, a timeframe of the report. You should all have received that. The outline and the timeframe basically the idea is that we would have a report presented to this full committee in September. We have between now and September to develop a report so that would be something that we will be working on.

MS. GREENBERG: We have talked about your plans for that because I think that is the type of support that you need and all of that is clearly really important that we accomplish that now rather than I mean obviously this is going to be too late for the next time we meet.

PARTICIPANT: But the last time, in a phone call, Walter and I talked with Marjorie and Michelle about the report and Lorraine, because this will be the tenth report to Congress. We wanted to give them a little bit more oomph than the prior.

MS. GREENBERG: I do think some of the issues that Justine was raising could be addressed maybe more fully in the report like that: what have we accomplished; what still needs to be done; where are we headed been successful; where haven’t we? I mean I am sympathetic to your desire to kind of hatchet that.

DR. SUAREZ: What is the problem first of all that we?

MS. GREENBERG: I think that report is probably the more of a place to do it than we probably can in these more routine letters but in any event so I am quite keen that we get on with this.

DR. SUAREZ: We had in a timeline and during that call I think, at the end of the call we talked about needing to develop sort of a work plan in more detail.

MS. GREENBERG: Do we have the outline here?

DR. SUAREZ: The outline was it included in the packet?

DR. WARREN: So the draft outline is we were going to do a history of HIPAA so what was passed in HIPAA and what the accomplishments were and then what we still needed. What was passed in HIPAA? What the accomplishments were? What was added by ACA and then what the current status of adoption is? What the barriers and challenges for the adoption? So we get into the problem statement of how much adoption and then our recommendations for removing barriers for adoption.

DR. SUAREZ: We had a one pager if you remember it was three sections. Section one was the HIPAA standards, the journey through administrations or the occasion as we call it. So when we talk about the journey that is the problem statement and then the sources and resources would be more like this would be a write up someone would just pull it together not a lot of data collection or anything like that. The second section was implementation of the HIPAA standards. So here is where we would talk about the differences in the codes and the identifiers and where is industry in terms of adoption. Now rather than going out and doing a national survey about this, it was more the idea of gathering input from other surveys and other data collection.

MS. GREENBERG: That is more resources intensive part but I want to make sure we have a strategy for it.

DR. SUAREZ: Yes, then the third section was the future of administration implication looking at the next version of the transactions and the ICD 10s and new identifiers. This whole concept of operating rules new areas for administrative publication by adoption of the standards and transactions, the opportunities, the link to EHR standardization and the HI adoption, those kinds of things. So that would be also a standard of write up more than a data collection.

What we have laid out in terms of the time of what when we would do the data gathering between January and May.

MS. GREENBERG: January is over; February is half way through.

DR. SUAREZ: Through February so we have until May to do the data gathering. The report drafting would be between May and June. Review of our initial report draft in June at the June meeting. Finalize the report between June and September then present the final report in September. That was sort of the timeline.

MS. GREENBERG: And I think you were going to develop something like a scope of work so we could kind of engage someone to help us with that.

DR. SUAREZ: Exactly.

MS. GREENBERG: It is all coming back to me now.

DR. SUAREZ: My task was to develop what would be a task order if you will.

MS. GREENBERG: It doesn’t have to be at a real formal level. We can turn it into because we will do it through our normal procedures.

DR. SUAREZ: I will be developing that and then sharing it with the Subcommittee to get feedback very quickly and then.

MS. GREENBERG: I think the sooner we get going on that. You have been doing so many things I do not mean to be pushy here but I just want to make sure we stay within our timeline.

DR. SUAREZ: Oh, absolutely.

DR. CARR: I think too we have an opportunity as we get to our full complement of members that we can properly resource the initiatives and standards.

DR. WARREN: One of the things that Walter and I talked briefly about yesterday is as we come into this next set of hearings where we are going to receive the DISMO report is to actually ask not only for the DISMO leaders but for representatives from each of those standards organizations. So that will give us an opportunity to collect data as well. I know Marc was talking to me last night at dinner this would be a good opportunity to bring these SPOs back in and see what the state of the art is. What it is going to accomplish things like that. Did you want to add any more?

MS. GREENBERG: DISMOs includes some SPOs.

DR. SUAREZ: Includes SPOs.

MS. GREENBERG: Then you want to also bring in the operating rules offering these.

DR. WARREN: We know how everything is going together because when we add the ACA, what the ACA has added is the operating rules.

MS. GREENBERG: I think if we just report and clarify it all, it fits together, all that has been done with the adoption rates, the efficiencies, what is still left to do.

DR. WARREN: We could get a lot of the information gathered and consolidated before that hearing then you can engage all of them about that.

MS. GREENBERG: In that way you could have the hearing count in a couple of different places, a couple of different paths.

DR. WARREN: Just one day, right?

MS. GREENBERG: Well we don’t know yet. We need to schedule out who we need to hear from. It may be a day and a half.

DR. WARREN: So we need to poll all three Subcommittees. There is some overlap but to get some dates. I think having them the same week probably from a fiscal point of view makes sense.

DR. SUAREZ: I am not sure how long the hearing from the Population and Privacy was going to be a day and a half. So I think one day we can take the next day and then the half of the following day and people can go out.

Any questions about this work plan? Yes, Mark.

DR. HORNBROOK: This is just a question. I am aware of how many times claims data go back and forth between providers and insurers. I am wondering if any of that can leak into the banking system or if somebody could make a human error and have certain kinds of data that are PHI get attached to one of the money back and forth when you are sending money to pay the doctor but then your doctor is sending back money to correct the fact that they were overpaid. I mean there is a tremendous amount of churning going on and I don’t know whether we are talking about that at all or whether we should care about it.

DR. SUAREZ: Well again I can tell you that strict regulations today any kind of proper disclosure was through the breach. Right? So whenever those kinds of things happen, entities have to basically do the process under the new breach notification regulations follow up and flow through that.

DR. HORNBROOK: Would we ever want to survey the reporting of those breaches and how they are handled as a consumer protection?

DR. SUAREZ: OCR today collects and reports and in fact any breaches over 500 get reported on their website. I mean they get reported to OCR in additional to the individual that were subject to the breach and OCR publishes those on the website so there is I think the last count was 2,000 something breaches or maybe more that are posted on the website with names of them.

MS. GREENBERG: So if you look at is it responsibility of this Subcommittee to survey all people who are using things the answer is no. However, full committee does get reports from OCR and those concerns can be surfaced in that area. I guess part of my answer too is to take on any more task and responsibilities of the Subcommittees than we are already dealing with.

DR. HORNBROOK: No, I am trying to understand. It is the whole committee versus the Subcommittee. Yes, thank you.

DR. SUAREZ: Any other questions or comments, reactions from the Subcommittee members on the work plan. Does it look okay those five or four priorities that we laid out?

MS. GREENBERG: So you are talking about the one hearing in the Spring.

DR. SUAREZ: We are talking about basically one hearing in the spring and then either a September hearing or the claims attachment. It all depends who is coordinating with the HIT standards committee. It might be more in November. September might be a November meeting. I think those are our two hearings because we are trying to tag along in one single hearing briefings acknowledgment, DISMO, and the status of implementation of transactions.

DR. WARREN: If we have just from a point of view of this fiscal year, we have one in December which is after the full committee and now there is talk about a second one and so if you are going to need a third one this fiscal year, we have got to try to figure that out.

DR. SUAREZ: The second one might be actually after the end of this fiscal year in November.

DR. WARREN: Well, I am talking about the December one.

MS. GREENBERG: She is talking October to October.


DR. WARREN: So if we have a September meeting that would be three meetings.

DR. SUAREZ: Do we want to push it to November?

DR. WARREN: That might be better.

DR. SUAREZ: That would be better.

MS. GREENBERG: Unless there is a requirement that you have it earlier and then we have to deal with it.

DR. SUAREZ: No I think that will work fine.

DR. WARREN: Thanks. Anybody from the Subcommittee, is there anything we forgot?

PARTICIPANT: Don’t you dare say a word.

DR. CARR: I want to compliment you on the work that you have done. It is extraordinary that you have been able to master all of this and put it all together. I mean the committee owes you an enormous debt of gratitude so thank you. Since you are doing so well at it we look forward to you continuing. Thank you very much.

DR. SUAREZ: I think we are going to adjourn our Subcommittee meeting and I will turn things back to Justine. Thank you.

DR. CARR: Why don’t we take a five minute break and start at 10:05.

(Whereupon, the subcommittee adjourned at 10:00 a.m.)