[This Transcript is Unedited]
THE NATIONAL ACADEMY OF SCIENCES
Workgroup on Quality
January 28, 2004
Hubert Humphrey Building
200 Independence Avenue, SW
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, Virginia 22030
TABLE OF CONTENTS
Call to Order and Introductions – Robert Hungate, Chair
Review Quality Report and Production Schedule
P R O C E E D I N G S (12:57 p.m.)
Agenda Item: Call to Order and Introductions
MR. HUNGATE: I think it would be useful, since Dr. Justine Carr is joining us, that we spend a reasonable time on introduction again, so that you know who she is, and it might be nice if you’d think about giving a little update of the tasks of the committee, because it’s helpful. I found it helpful to know a little bit more about what had gone – five minutes maybe –
DR. GREENBERG: The past, you said.
MR. HUNGATE: Of the past, yes, because it’s helpful in terms of the report germane to it, which is the current – perspective – probably already covered it in the report, but –
DR. GREENBERG: Okay.
MR. HUNGATE: – emphasize it.
DR. GREENBERG: Do we have a copy of the report for Dr. Carr?
MS. WHITE: She has a folder.
MR. HUNGATE: And by way of starting introduction, I’m Bob Hungate. I go under the label of Physician Patient, Partnerships for Health, which is basically me as an individual advocating for the dyad as an informed health manager and the information structure that goes with it.
I chair this workgroup and chair the Group Insurance Commission in Massachusetts. So we have a common geography.
DR. GREENBERG: We’ve got several Massachusetts here.
MR. HUNGATE: Yes, Massachusetts manages to get into some of these things –
DR. GREENBERG: There was one point at which we were told we had too many members from Massachusetts, but – they got over that.
MR. HUNGATE: If you look at the health care research, health policy community, half of it is from Massachusetts.
DR. EDINGER: Who knows, we may have a president from Massachusetts. (Laughter).
DR. GREENBERG: Maybe a presidential candidate.
DR. EDINGER: Or a candidate –
MR. HUNGATE: Okay. Kathy.
MS. COLTIN: I’m Kathy Coltin, and I’m working as a consultant to the workgroup, having previously chaired the workgroup and been a member of the committee, and I, in my other life, I worked for Harvard Pilgrim Health Care part time as a quality consultant to the chief medical officer, and I also do independent consulting, and so this is part of that hat that I wear.
In terms of a history that Bob asked me to provide, do you want to finish the introductions first, then come back to that?
MR. HUNGATE: Yes, let’s go to – that would be good.
MS. COLTIN: Okay.
DR. GREENBERG: Okay. I’m Marjorie Greenberg from the National Center for Health Statistics, CDC, and the hat I am wearing here is that I am the Executive Secretary to the National Committee.
DR. EDINGER: I’m Stan Edinger. I’m from AHRQ, and I’m staffed to the subcommittee, and try working on behalf of the agencies that are here – in my checkered career.
DR. GREENBERG: Gail, you want to introduce yourself?
DR. JANES: I’m Gail.
MR. HUNGATE: Welcome.
DR. JANES: Are we –
DR. GREENBERG: Well, one of our new members has joined us, so we thought we would go around and introduce ourselves.
DR. JANES: Oh, I’m Gail Janes from CDC.
DR. HAYWOOD: Hi, I’m Trent Haywood, and this is my first –
MR. HUNGATE: Yes, it’s your first meeting. I neglected to –
DR. HAYWOOD: Don’t feel bad. (Laughter). I have one over the phone, so this is my first in person.
I am in the Centers for Medicare and Medicaid Services in their Quality Management Group, Deputy Director for the Quality Management Group in CNS.
DR. CARR: So I’m Justine Carr. I’m a physician, a hematologist by training. I’ve been at Beth Israel for, I think, 25 years – a long time – and my roles have been varied, beginning with clinician and then Director of Blood Bank, Director of the Hem Lab, and, in that role, adjudicated a lot of the kind of clinical, administrative interface. I was the resource person for medical records – and now I am in the Division of Health Care Quality. My title is Director of Clinical Resource Management, and I try to – I spent a lot of time with Harvard Pilgrim – I work in an array of settings. One is just looking at our own quality outcomes using our administrative data set and trying to identify processes and quality improvement initiatives.
I also work with our payer contracting group, where we – again, the information that goes across – work on the quality initiatives. I also chair a clinical resource management committee where we evaluate new technology and fiscal impact, the clinical impact, and then we review to see if we achieved those benefits.
So having been there 25 years, I’ve pretty much been in all different areas, but the agendas that I see here are exactly things that are right on of what we are dealing with, in fact, with our Blue Cross Quality Initiative, and then the Leapfrog, which is a little different from ACC, which is a little different from Jayco(?). It is sort of trying to define an MI 15 ways was the meeting I was at yesterday.
So I am very interested in this, and, hopefully, bring some street experience. So I’m happy to be –
MS. KANAAN: I’m Susan Kanaan, and I’m a contract writer for the committee and have been for a long time, for the full committee, and have done it – worked on a variety of reports with them, and my role in this project is sort of the managing editor and a contributing writer.
MS. JACKSON: I’m Debbie Jackson. I work for Marjorie, the National Center for Health Statistics staff to the subcommittee and the full committee.
MR. HUNGATE: And transcriber, right?
THE REPORTER: Yes.
MR. HUNGATE: Welcome and thank you for joining us.
THE REPORTER: Thank you very much.
MR. HUNGATE: Okay. So why don’t you give us a brief –
MS. COLTIN: Okay. Actually, there is a little bit of history in the report, but since you just got it – I’ll try and summarize quickly.
Back in late 1998, the former chair of the full committee, Don Getmer(?) had taken recognition of the fact that quality was beginning to go through a resurgence in interest, and I say that because back in the ‘70s, it was a very big topic area and then kind of got overshadowed by cost issues through the ‘80s and the growth of managed care and so forth, and it has come back to the forefront in the late ‘90s as being a major issue of concern, and this was at the time when the IOM’s committee on the quality of health care in America had just been formed and the President’s Advisory Commission on Consumer Protection and Quality Health Care had just released its report and recommendations around quality measurement, and so we had the benefit of that confluence of events and looked at where this workgroup could make a contribution, and it appeared to us that given that this is a committee on health data and health-data policy, that the best avenue for us to pursue would be to identify where the data roadblocks were, where the gaps in data content were, where the barriers in data sharing, data linkage and so forth were that would hinder the implementation of the recommendations that had been articulated in the advisory commission report and that were also being debated and would subsequently be articulated in a number of different reports that have since come out through the Institute of Medicine.
And so we – being a very small workgroup – and you are still a small workgroup. I think we had four members at the time, all of whom also served on other subcommittees, so I think the best way for us to get our work accomplished was actually to try to schedule our panels and take testimony within the context of full committee meetings, and another reason for doing that is that there was a lot of interest in issues around quality and data issues around measuring and reporting and improving quality that were shared by others who weren’t on the workgroup as well, people who were on the subcommittee on standards and security or the privacy and confidentiality subcommittee and so forth, and by having these panels within the context of the full committee meeting, everyone got to benefit from the information and the discussion that followed.
But it lengthened the process considerably so that instead of having two days of testimony a couple of times, we usually had no more than three hours available, often only two, at one of three full committee meetings held during the course of a year, and so it took us a long time to really hear from all of the stakeholders that we felt it was important for us to include in trying to identify the data gaps and barriers to measuring and improving quality, and so that is the body of work that we are actually try to summarize in this report, and then to make some recommendations really for next steps around what needs to happen to fill those content gaps and facilitate some of the data-linkage issues and other problems that we identified, and recognizing that that is likely to spur another round of testimony from those who will have to make the changes necessary to implement some of these recommendations and who will need to be heard from in order to identify the best way to solve some of these problems. So that is kind of where –
MR. HUNGATE: Great. Thank you.
Any question that come from that?
Well, let’s move to the report.
Agenda Item: Review Quality Report and Production Schedule
MR. HUNGATE: I want to congratulate the writing team on moving it to where it is. It looks pretty good to me.
I would like to get a sense – maybe just go around the room and let each of you comment generally about where we are, what omissions you feel we’ve got, what are the tuning steps we need to do from where we are, from your viewpoint.
DR. JANES: You’re speaking of the report.
MR. HUNGATE: I’m speaking of the report.
DR. GREENBERG: Okay. Well, I submitted some comments, and they were all just details. They weren’t in any way suggesting changes in the basic structure. I mean, I think – personally, I feel the report is in pretty good shape. I am very keen to see it – I think it makes a contribution. I think it pulls together a lot of important information that had been gathered over a period of years. As Kathy knows, I have been keen to see this happen for some time. So if there were constituencies for or against doing a report –
MR. HUNGATE: If there’s been a driver, it’s been Marjorie.
DR. GREENBERG: I don’t know about that, but I have certainly always – I have been a force for doing this report, and now would be no time for me to abandon it, obviously, but I continue to feel that these are – a lot of these data issues are ones that do not always get a lot of attention, but they are critical to whether or not you are able to use the administrative data, in particular, but the clinical data as well for these purposes of quality measurement and performance, and, in some cases, fairly simple changes would make a difference. In others, it is going to be more of an uphill battle to get the industry to agree to them, but I would say let us begin. So some of this is work underway, and so, basically, I think it is supportive of all of that.
I have a little bit of concern about maybe whether – and I know it has been pared back so much – but whether we have maybe a little bit too much background in the beginning before we just got to the – what we really wanted to say, but it will be an executive summary, and I think we do need some background, and if it weren’t here, it would have to be in an appendix, and then nobody would really ever read it, and I don’t believe we’re in context.
So I think I stand by the few comments that I sent in and I’d say let’s go forward.
MR. HUNGATE: You don’t see any major omissions that –
DR. GREENBERG: No, I mean, on the other initiatives, we need to mention CHI, we need to mention the consumer-disclosure project and put them into the matrix as well, but that is easy enough to do.
MR. HUNGATE: Right.
DR. GREENBERG: And I did – the really – only real substantive thing related to the – because I don’t know if you were able – I think you had left before my comments came out –
MR. HUNGATE: I had.
DR. GREENBERG: – that I had regarding the recommendations was that I had thought the one and two, test results and vital signs, were related to both outpatient and inpatient data, and in the body of the report they are only associated with outpatient data. In the matrix, test results is associated with both, but vital signs and objective data still only with outpatient, and that needs to be resolved, but I would advocate for them being in both – for both outpatient and inpatient, as appropriate.
MR. HUNGATE: Does that make sense to everyone? Okay.
MS. KANAAN: Could I ask a process question before we go any further?
It’s my assumption that, at a minimum, Kathy, you will revise the matrix, based on this conversation.
I want to make sure that I get detailed enough notes for anything that I need to be responsible for, but maybe if there’s any ambiguity about the text sections as we go along, we ought to check in right then and there, since we are not going to wait for the transcript before we do the next – but for the matrix, Kathy, you’ll do it, right?
MS. COLTIN: Right.
MR. HUNGATE: So anytime we talk about content change, we end that discussion with who is going to do it.
MS. KANAAN: Thank you. Perfect.
MS. COLTIN: Well, I will be responsible for any changes in the recommendations themselves, because they appear in both the text and the matrix. So make the changes in both places.
DR. JANES: And I, obviously, won’t be responsible for any of the changes in the ongoing initiatives, which, at this point, as far as I know, represent just your comments and suggestions which I thought were well taken –
MS. COLTIN: A lot of Marjorie’s suggestions were editorial in nature –
MS. KANAAN: Yes, I can take care of those.
MS. COLTIN: – and I’m assuming Susan will take care of those, like whether we use CPR or DHR.
Part of the difficulty I had with that is in some places I was actually – I didn’t have it in quotes, but I was drawing from like a letter to the Secretary –
DR. GREENBERG: I know. We were still talking about CPR.
MS. COLTIN: – written at a time when it was still called CPR –
DR. GREENBERG: I know.
MS. COLTIN: – so I was torn, you know, do I call it EHR, which we are now –
DR. GREENBERG: I know.
MS. COLTIN: – or do I call it CPR, which is what we actually called it in the letter.
DR. GREENBERG: I thought maybe the first time you mention CPR, you could put EHR. Of course, the problem with EHR is the computer wants to make it her.
MS. KANAAN: You can take that out of your Auto Correct, of course. Just go to Auto Correct in your drop-down menu and find it on the list of – you just type in E-H-R and h-e-r, you know, replace one with the other. You can say delete and then –
DR. JANES: We aren’t going to turn this into a word tutorial – (laughter) – but you obviously have my attention. Where do you find the Auto Correct?
MS. KANAAN: It’s a tool.
DR. JANES: It’s a tool. From the tools? Great. That’s great.
MR. HUNGATE: I could sure use the help. (Laughter).
MS. COLTIN: Me, too. That one, in particular, drove me nuts. Every time I typed it in the report, it kept automatically changing into her.
DR. GREENBERG: I know.
MR. HUNGATE: Okay. Stan.
DR. EDINGER: I’m sorry – hard for me read, but I heard the discussion yesterday about the patient medical history. Is there anything in here that we have included about the – I knew we didn’t really get into a lot of testimony about the patient medical history being an important concept we should be looking at.
MR. HUNGATE: I don’t think there is any reference to that, and I think it’s an important – whether we –
MS. COLTIN: Actually –
MR. HUNGATE: – put that in – Is there?
MS. COLTIN: There’s an indirect reference, and maybe we need to make it a little bit more explicit, but under the building the information infrastructure, where it talks about standard formats for exchange, I believe we referenced the continuity-of-care record, which essentially is a way of transmitting patient history – you know, allergies, problem list, et cetera – among care givers, and that really was the main intent in that one. So if it’s not explicit, then I need to find it to make myself a note to make it more explicit.
MR. HUNGATE: I went to the discussion yesterday as well, partly to understand where the standards and security process kind of intersected with what we were doing, because I have not really understood it well, and it helped, and I found out that the personal health record is not part of what they are dealing with at this stage of the game, which I needed to know.
DR. GREENBERG: The CHI.
MR. HUNGATE: CHI.
DR. GREENBERG: Although, they have deferred the history and physical domain to Phase 2, and I am actually going to a meeting on Friday about Phase 2 – if there is going to be some kind of Phase 2, how robust, I’m not sure – and it may be that place where it will be addressed.
I mean, when we started to have some discussion about that domain previously – you know, issues like personal records and vocabulary in lay terms – it did come up. So –
MS. COLTIN: I think it is not referenced explicitly. I just found it. It’s on page 28, and it’s built into Recommendation 20, which covers both open systems, architecture and common record formats, and so I think I can certainly add a – the way it is written it says, likewise, the lack of common record formats for sharing relevant clinical information among care givers could make it more difficult to do so under incompatible electronic health-record systems than under traditional paper records, and so we can add a statement – you know, as an example, the ability to transfer information about a patient’s prior medical history is an important element and that there is work going on to develop a common format for a continuity-of-care record.
And then, Gail, I think it would make sense in your section to talk about that initiative, which is being conducted jointly by ASTM E-31 and the –
DR. GREENBERG: Medical Record Institute?
MS. COLTIN: – Mass Medical Society and HIMS(?) and – no. I don’t think so.
DR. GREENBERG: I thought the Medical Record Institute was involved.
MR. HUNGATE: Medical Record Institute.
DR. GREENBERG: Because Jeff said his employer was involved.
MS. COLTIN: Okay. AAFP, the American Academy of Family Physicians, the Mass Medical Society and, just this past week, the American Academy of Pediatrics signed on to it.
DR. GREENBERG: Okay. Do they have a website?
DR. JANES: And tell me again what the name of the initiative is?
MS. COLTIN: It’s on the Initiative 1(?) website, the ASTM website. It’s the Continuity of Care Record.
MR. HUNGATE: Acronym, CCR.
MS. COLTIN: CCR. Yes.
In fact, I printed out a whole thing about it that I can give you.
DR. GREENBERG: Oh, good.
MR. HUNGATE: What do you think about having this discussion of the personal health record in close proximity to the unique patient identifier? Because it may be interrelated.
DR. EDINGER: Probably is because without one, you can’t do the others, actually.
MR. HUNGATE: Yes, without an identifier, you can’t reference it. So it’s an argument –
DR. EDINGER: – in a lab and he was telling me it was very difficult to do any research on it, because it wasn’t standardized and it was –
MR. HUNGATE: Okay. Correct.
DR. GREENBERG: I’m passing this on, but does a continuity-of-care record involve as well a personal health record or is this pretty much –
MS. COLTIN: It’s really a summary, and it was derived from – I think the model for it and the reason the Mass Medical Society was actually the initiator of this, it derives from a form, a paper form that the Mass Department of Public Health had always required, particularly in facilities, and I don’t know, maybe Justine knows more about this than I do, but it was a form that was recommended to be used as part of the medical record, and it had very standard connect what they’re like – immunizations – so that you knew that the person had had a flu shot or had a pneumovax(?) already, and allergies, and then a relevant problem list, so that when a patient – and active medications, I think, were talked about as well, so when a patient was referred to a specialist that they would at least get that minimum content and that it would be standard and shared, so that – you know, if it’s part of the medical record, then you don’t necessarily have the same problem of a patient who is hospitalized having to run through their medical history with every intern resident –
DR. GREENBERG: Kind of like a base-sheet thing –
MS. COLTIN: Yes, it kind of gets the bare-bones stuff out of the way, so you can then dig in and get –
DR. GREENBERG: That was a paper? I mean, it was –
MS. COLTIN: Well, the original form was a paper form, not unlike the UBO-2, UB-82 – being a paper form that became an electronic format.
DR. GREENBERG: Yes. Okay.
MS. COLTIN: It evolved from a paper form, but the idea was to say, you know, this is a good form. It captures all of this kind of minimal content that ought to be transmitted. Can we create a common electronic format for sending it?
And so that is how the project began, and then it came – it was being done jointly with ASTM and MMS, and then they’ve brought on all of these other parties since then who had an interest in it, and that was proposed to become part of the standard functionality of EHR is that they could produce this kind of a continuity-of-care record.
DR. GREENBERG: Do you know what the connection is with the EHR activity going on now with HL-7, based on the IOM report and –
MS. COLTIN: I believe that the idea was to have it become part – because they are defining the standard functionality –
DR. GREENBERG: Right.
MS. COLTIN: – and I think the idea was to make it one of those standard functions that the system could generate in continuity-of-care record.
DR. GREENBERG: Okay.
MR. HUNGATE: That’s my impression last night.
DR. JANES: Was the specific initial suggestion that this be only used or primarily used as part of an inpatient encounter whereby it would be generated –
MS. COLTIN: No, no. No, no, and the idea was that it is actually an XML document. It is not necessarily something that is ever stored anywhere. It is a document that can be transmitted. So it could actually be sent like as an attachment to an email, in a secure email message. Doesn’t have to be an EBI transaction in the way we think of the HIPAA transactions. It could be that way, but it also could be –
DR. JANES: I’m just wondering –
MS. COLTIN: – a document that somebody could print out.
DR. JANES: I mean, a lot of these things – certainly allergies – well, what I was wondering was how they updated it, because some of these things wouldn’t need to be updated, but, actually, some of them would.
MS. COLTIN: I think the idea was that it would get generated every time the patient was referred to another provider or that if, in fact, you had inter-connectivity and a patient showed up in an emergency department that one could, if records were virtually linked, actually grab the relevant pieces and create it on the fly.
DR. CARR: Our high school(?) is very electronic, and what you describe is what is a part of our primary-care encounter.
The weakness is, first of all – someone might say asthma, someone might say – and also the endocrine problems go away, and presumably you didn’t have a cold for the entire life, but it is extreme, and the updated medicine – you know, so the providers are incented to update particularly the medications.
I think the problem – there’s variable compliance, and then the other issue, in terms of allergies, is what is the definition of an allergy versus an adverse reaction and so on, but we do use it. When a person comes into our emergency room, we then immediately look that up and get pretty much up-to-date information.
DR. GREENBERG: Are you at all involved in this continuity-of-care –
DR. CARR: I’m not in Mass Medical. I’m not in it –
MR. HUNGATE: The context of this discussion seems to me alters two parts of the report, in connection with Recommendation 20 or to add a description of the continuity-of-care record.
And then I think from line – basically, 905 – 906, that the part after the word adopted – the third word in on 906 – that we strike the content between there and line 920 and replace it with a statement that the national provider identifier was finished real setting.
DR. GREENBERG: Right. Did I make that edit?
MR. HUNGATE: Maybe you did.
DR. GREENBERG: About the provider ID?
MS. COLTIN: No.
DR. GREENBERG: I meant to.
MS. COLTIN: Well, maybe because I had already sent it out in my email, but we may want to revise this –
MR. HUNGATE: And then in that vacated space –
MS. COLTIN: So where is it that you want to – you don’t want to strike the entire paragraph, starting with 905?
MR. HUNGATE: No, I want the first sentence to add to it the – I think the first sentence is fine.
MS. COLTIN: But it’s no longer true, because it says, to date, only the employer identified has been adopted. Now, the national provider –
MR. HUNGATE: It needs to be changed. It needs to be altered. The first sentence needs to be altered, but not struck.
MS. COLTIN: Okay.
MR. HUNGATE: But the rest of it, between there and line 920, needs to be struck, and I would advocate for replacing that with some discussion of a personal health record, because of its interrelationship to the desirability for a voluntary patient identifier. It’s an argument for that, I think.
MS. COLTIN: I think what you are bringing in right now is very new content on which we didn’t take in any testimony, and if this is a summary of testimony taken, I don’t think we have a basis for making that recommendation from the testimony we took.
DR. GREENBERG: Now, when you’re talking about –
MR. HUNGATE: I’m not making a recommendation. I’m adding content for an issue that has evolved in the press. We haven’t taken hearings on it, but it’s a terminology that will effect quality. It’s a data input that is visualized.
DR. GREENBERG: It is mentioned under the connecting-for-health section.
MR. HUNGATE: In the later section. Okay. Well, maybe that’s enough.
DR. GREENBERG: About the personal health record. So it is mentioned in the report.
MR. HUNGATE: Okay. So you think there will be adequate?
DR. GREENBERG: I think so. I mean, unless – when you are talking about the personal health record or personal identifier, you could – maybe a sentence about a personal – how this also is relevant to the personal health record. See below or something. See later.
DR. EDINGER: May just say that the – it is related to the first – that part is basically they are hand in glove with each other, something to the effect, without making a big production over it.
MS. COLTIN: Well, I think – I mean, I think Bob’s point may be that the – if you look at line 898, it says, standard identifiers for patients and providers, and then the next two paragraphs only talk about the provider identifiers.
When you get down further, under 21, where it talks about a unique patient identifier, I mean, maybe that is the place to make a comment about – you know – that it would also be important for a personal health – to implement a personal health record.
DR. GREENBERG: Right. I agree.
MS. COLTIN: Are you okay with it there?
MR. HUNGATE: Yes. Sure.
DR. GREENBERG: I think regarding the –
MR. HUNGATE: It is germane to the same content –
DR. GREENBERG: Provider identifier, I guess that – I mean, obviously, it’s been published and we are all happy about that, and I guess because they have an effective date of – is it May or something 2005? – when people can begin to request a number, that the funding issues have been resolved, because that was what was keeping it from being published all those many years.
On the other hand, I mean, I don’t know whether a recommendation that – you know, it is only going to be required to be used in the HIPAA transactions, but I would think what one would want is that even if people have their own internal numbers, that they’ll all map them to – that everyone, for all purposes, will embrace this NPI, and so you could still have a recommendation related to that.
MS. COLTIN: Well, and I think we could even talk about it being useful for the exchange of clinical records.
DR. GREENBERG: That’s what I mean, yes. I mean, you don’t want the Tower of Babel that exists now to continue in the clinical field. That doesn’t mean that internal organizations won’t have their own numbers that have meaning in them and all of that, but they need to map them –
MR. HUNGATE: I’m comfortable with that.
So we would change the wording on lines 917 and 918 to a different wording.
DR. GREENBERG: Right. But still kind of embracing the NPI and its uses for clinical as well as –
MR. HUNGATE: Right. Okay. That has your name to it.
DR. GREENBERG: Yes. Yes, this is in the recommendations. This is something you didn’t do, Kathy, right?
MR. HUNGATE: (Laughter).
Okay. Gail, any observations to make?
DR. JANES: No.
MR. HUNGATE: You think we’re there?
DR. JANES: On this?
MR. HUNGATE: The overall report.
DR. JANES: Oh, are we there? Sure. (Laughter).
MR. HUNGATE: Ninety-five? Ninety-eight? Ninety-nine?
DR. JANES: That’s a hard question.
Certainly, I think it’s in reasonable shape. Like I said, I went through and looked at it before the final edits came in and thought it was coming together nicely. I looked at the – I guess the final set of edits – that were sent and I – let’s put it this way: I seemed to me that what we wanted was something that not only nicely summarized and articulated the gist of this considerable body of testimony that we took, but that would also set us up for our next steps, and I think it certainly does that.
MR. HUNGATE: Any suggestions of additional content or any –
DR. JANES: I actually think that – I think it’s – if anything, I kind of agree with – I don’t know whether it was Marjorie – somebody who made the comment that we might even want to think about – and, admittedly, this is more related to stylistic issues than content – is actually shortening the introduction, you know, is to keep –
DR. GREENBERG: The background.
DR. JANES: – short and sweet, then kind of get to our points as quickly as possible, which really are the recommendations, without sacrificing enough context to help the reader understand what we are doing.
MS. KANAAN: Gail – you mean the second section –
DR. JANES: Actually, I don’t mean the introduction. Yes, right. I mean, yes, it’s the second section.
MS. KANAAN: Leaping in out of order here, I would like us to spend some time thinking about that, because it is a concern of mine, too, that if we take too long to – we kind of slice it two ways, that worker – initiative section, particularly the overview of findings, which is, I think, the second subsection – yes –
DR. GREENBERG: I like that.
MS. KANAAN: – it kind of slices it – you know, it sort of does the big themes and – what do you think about that, Kathy? It’s part of your section.
MS. COLTIN: Well, I mean, I was struggling with that when I reorganized the whole report, and I did cut out about two or three pages worth of text, but I think it was harder for me to cut than it would be to have others say, I don’t think you need this paragraph. I mean, people going through it could send – Susan, I think, because this is –
MR. HUNGATE: Would you be comfortable with just asking Susan to edit that section?
DR. GREENBERG: Now, which section are we talking about, pages three through seven or pages seven –
MS. KANAAN: No, three through seven.
DR. GREENBERG: Three through seven, yes. I think that could be –
MS. KANAAN: No, not three through seven – excuse me – three through 14.
MR. HUNGATE: Three through 14, right.
MS. KANAAN: Bob, if you think we have time, if we could just kind of very quickly look at this – you don’t think we have time.
MR. HUNGATE: I want to go around. We might be able to.
MS. KANAAN: Yes. Okay. You want to –
MR. HUNGATE: But I know how long it takes and how hard it is to cut, and I would rather that we do an assignment, we do what paring you feel is appropriate and if people lost their heart in the process, they gotta scream.
MS. KANAAN: Okay.
MR. HUNGATE: At least that’s my sense. Now, if we have time, we can try it, but –
MS. KANAAN: I’d just like to get a little input about anything that people think is essential in that content.
MR. HUNGATE: Okay.
DR. GREENBERG: I mean, my sense is that it is seven, eight and nine are – you know – the Federal overview of findings up to priority areas.
I guess this is stuff I eat, live and breathe, so that’s why I like it, I guess, but I think if you just refer to it as like cross-cutting, data-quality issues can be broadly characterized or something, so that it is clear that – just talking about some cross-cutting data-quality issues, and then we are going to get into priority areas of focus. So I think that distinction – I would hate to see that section go.
My feeling is the pages three through seven probably could be condensed more, and I would be comfortable with Susan just taking a crack at it.
MS. COLTIN: I was happy to cut anything in three through seven. I mean, I don’t feel wedded to anything there, and I was trying to be consistent with some of the other reports the committee has done that talk about what was our process, but if we went on too long, by all means, cut whatever you see.
Well, I’m sort of with Marjorie. I think in the overview of findings, changing it from key data issues to cross-cutting data issues is absolutely okay with me, and I do agree that I think three through seven belong. I think it would be important in the section on priority areas of focus to compare what is written under each one of these with what is written in the specific section and get rid of any redundancy, so that –
DR. GREENBERG: You’re talking about seven through nine and then –
MS. KANAAN: Seven through 14.
MS. COLTIN: Seven through 14.
MS. KANAAN: Nine through 14, right?
MS. COLTIN: Yes.
MS. KANAAN: Nine through 14, the priority areas, which is really laying out, on a theoretical level –
MS. COLTIN: It’s really building the case. I mean, for me, it was building the case –
DR. GREENBERG: It’s sort of rationale.
MS. COLTIN: – for these recommendations, and I felt that while we have been living and breathing this stuff and have read it three or four times, and, now, it kind of is seeming old, somebody picking up the report for the first time and jumping right into the recommendations –
DR. GREENBERG: No, I agree. We need rationale.
MS. COLTIN: – you need rationale, and so this was building the case, but it may go further than it needs to, and if there are sections that can be shortened or deleted –
DR. JANES: I’m sorry, Kathy. Repeat again. You said look for redundancies between – initially, I was thinking you were talking about the bullets and then the paragraphs, but that doesn’t make any sense.
MS. COLTIN: Well, for example, if you look on page – starting with Priority Areas of Focus – okay? – the first one begins on line 288, Assessing and Improving Health Care and Health Outcomes, and there are seven paragraphs about that. Some of the information in those seven paragraphs may also be imbedded in – starting in line 447 under specific findings and –
DR. JANES: Oh, I see what you’re saying –
MS. COLTIN: – imbedded under the specific recommendations –
DR. JANES: Okay. It doesn’t have to be in both places.
MS. COLTIN: Yes, it doesn’t need to be both places.
DR. JANES: Okay.
MS. COLTIN: So the question is where does it have the greater impact, up front or right in there with the recommendation? It’s a little bit of a balancing act. I tried to eliminate some of that redundancy, but I know that some still exists –
MS. KANAAN: One very big question is do we feel that we need one or so pages on drawing the comparisons to the HHS objectives, which is page 6?
MS. COLTIN: Well, that was the advice we were given at the last meeting. So –
MS. KANAAN: Right. So I know why you put it in. Yes.
DR. GREENBERG: Yes, I think it’s good to say, you know, this isn’t out of left field. This is right in – right what you’re talking about, Secretary Thompson.
MR. HUNGATE: Reinforces agreement with the objectives.
MS. KANAAN: Good. Okay.
MR. HUNGATE: Okay. Is that enough guidance, Susan, for you to feel –
MS. KANAAN: Thank you, very much, yes, it is. Yes, that’s helpful.
MR. HUNGATE: Okay. Trent.
DR. HAYWOOD: I think I have more questions – coming in the first time, reviewing this –
MR. HUNGATE: Sure.
DR. HAYWOOD: So maybe you can just help me understand it, particularly organization-wise.
Under, I guess, 2-C, just on the outline, at the beginning of it, the overview of the findings, they don’t necessarily correlate with the specifics, meaning like you have an overview of findings, which have certain categories, such as access of data, timeliness of data, et cetera, but the specific findings are different. They are broken down kind of according to those objectives that you just discussed, and I didn’t know if the overview was supposed to somehow relate to the specifics or whether it was intentional that specifics would be totally different than how you approach the overview.
So, for me, as a – first time reading it, I got kind of lost as to why the overview had no correlation with the specifics.
MS. KANAAN: Maybe our word, overview, we need a new word, if that’s misleading. I can think about that. Is that –
DR. GREENBERG: I wonder if it makes sense to talk about these priority areas of focus and then say, and there are some – all of these are impacted by some cross-cutting, data-quality issues, and then give these ones about availability, completeness, accuracy and timeliness. I wonder if it doesn’t flow better that way.
MS. KANAAN: You’re saying within C, reverse 2 and 1 –
DR. GREENBERG: Oh, I wasn’t looking at the outline. Sorry. Yes. Yes.
MS. KANAAN: Okay.
DR. GREENBERG: So get your rationale and priority areas out there and then say, and all of these are impacted by these cross-cutting issues. I think that makes more sense that way, now that I think about it.
MS. KANAAN: Yes, it does. Because within each of those priority areas, some of the recommendations deal with the data gaps, sort of, what are called here the – you know, the data is just not available. We don’t have data –
DR. GREENBERG: Right.
MS. KANAAN: – on vital signs and test results and things like that, you know, for quality improvement in an electronic infrastructure, no common way of transmitting that information, and yet, in that same heading of assessing quality and outcomes, you have issues around things like procedure coding, which have to do with accuracy of the data, and the fact that global codes often represent an episode of care that isn’t accurately coded.
DR. GREENBERG: Or it’s a completeness issue, too, with capturing the full span and all that.
MS. KANAAN: Right.
DR. GREENBERG: So I myself think that would put it better.
MS. KANAAN: Makes sense to me, too.
DR. GREENBERG: Because I think what Trent is saying, too, is that it didn’t kind of make that much sense –
MS. KANAAN: Didn’t meet your expectations.
DR. GREENBERG: They weren’t tied together as well.
MS. KANAAN: And maybe we can add a little language that kind of manages people’s expectations a little better and explains – before we go into the priority issues, we say, the specific recommendations are outlined in the next section, you know, something like that.
DR. GREENBERG: Yes, it kind of lays out where you are taking people.
MS. KANAAN: Yes. Okay.
MR. HUNGATE: Somebody questioned whether overview was the right word or not.
MS. KANAAN: Yes, can anybody think of a better one?
DR. GREENBERG: Although, maybe if it’s organized that way, it would still be all right.
MS. COLTIN: Well, maybe we could just take that out.
DR. GREENBERG: To say findings or I don’t know.
MS. COLTIN: Why not just have the subheading, Cross-Cutting Data Issues in Quality Assessment and Quality Improvement and not even have that?
DR. GREENBERG: Well, but that’s a sub-sub-head.
MS. KANAAN: Yes, that’s a sub.
MS. COLTIN: I’m just saying move it up.
MS. KANAAN: Well, but then what would you do –
DR. GREENBERG: Well, the overview of findings, I think, is a reasonable title if you then got into the priority areas of focus right away, because that is where the findings are going to be. They are all going to be there.
MS. KANAAN: Let me try to just add a sentence, kind of letting people know that they are not going to actually get to the findings and recommendations until the next section, and this is kind of the theoretical constructs and the cross-cutting issues that are laid out in this section.
DR. GREENBERG: And reorganizing of what we were just talking about.
MS. KANAAN: And reorganizing. Yes.
DR. GREENBERG: Okay. See how that works.
MS. KANAAN: Because that – we’ll take another crack at it after that, and, Trent, you and others, we can see if you think that solves the problem.
DR. HAYWOOD: Thanks.
And then just, again, for my own edification, the recommendation is – all the recommendations – there’s no prioritization to it whatsoever. So we could care less whether the Secretary ultimately goes with 3, 10, 12, 20 versus the top five, theoretically. Is that the way it’s structured?
MS. COLTIN: That’s the way it’s structured.
MR. HUNGATE: I think that the issue of priority will be resolved by what action is taken by further subcommittee work. I sense that that is the way that it will get dealt with. We haven’t assigned specific priority, and that is because there is more work necessary in order to advance the agenda.
DR. GREENBERG: But there’s a little history that probably neither Trent nor Justine would be aware of.
A few meetings ago, we circulated to all the members and interested staff kind of a matrix of all the recommendations – more than are here, actually – and asked people to kind of rate them as to what kind of priority they would give to them, whether they thought they were – how important they thought they were and then how do-able they thought they were. I think those were two of the main – and this reflects that feedback, actually.
MR. HUNGATE: Yes, it does.
DR. GREENBERG: And I think everything that survived, everyone thought had a fairly high priority, mixed as to do-ability.
MS. COLTIN: I mean, you know, if I look at this, would I say that some of these are more important than others? Yes.
DR. GREENBERG: Yes, sure.
MS. COLTIN: Absolutely –
DR. GREENBERG: Sure.
MS. COLTIN: – some of them are more important than others. Sometimes, the ones that are more important are more difficult and more long term –
DR. GREENBERG: Right.
MS. COLTIN: – and some of the ones that are less important lend themselves to quick fixes, and so to not have them in there –
DR. GREENBERG: Like low-hanging fruit. (Laughter).
MS. COLTIN: – doesn’t seem like – you know – so that is part of the dilemma.
DR. HAYWOOD: Well, and the reason why I raise that, though, even kind of dovetailing on what you were just saying, is if one is looking at it fresh, that does allow one to understand what can be gained in the short term versus what needs long-term strategic planning versus having kind of it all mixed together, and I don’t know heads from tails when I’m looking at it fresh.
So I hear your point. So I’m just saying I guess another way of approaching it is to somewhat putting together, whether it be low-hanging fruit or things that are short term that are able to do right now or things that you think in the short term, if we don’t get a quick fix, we’re having problems with, like some of the things just internal with CMS, we definitely know kind of short term, meaning six months to a year, we continue to have problems around data gathering, HIPAA concerns, things of this nature, where we are going to build out quality measure with our initiatives, but every time we’re doing that, whether it be HIPAA or whether it be IRB issues, each institution is questioning, okay, do we need to get a lab from OCR? How does this all work out? And this is just stuff where we already have the data flowing, but someone is just feeling nervous about the fact that OCR hasn’t weighed in on it.
So we have like little things like that that keep coming up that every day, if they’re to be a quick fix to it, then at least it allays those type of concerns versus going in and trying to do some of the electronic-transaction things that we know that we are going to have to – it’s going to take longer to get those resolved.
MS. COLTIN: Well, I think it would be feasible – one of the things I left out of the history of this report is that this is the third organizational framework. (Laughter). I have cut and pasted –
MS. KANAAN: Your life is in danger, Trent.
MS. COLTIN: The first framework, actually, organized it the way these data problems are, the availability of the data –
DR. HAYWOOD: Okay. Right.
MS. COLTIN: – the data gaps, the data accuracy, they were organized that way.
The second one, I’m trying – I’m forgetting –
MR. HUNGATE: I don’t even care.
DR. GREENBERG: We don’t want to remember.
MS. COLTIN: All I’m saying is I think we can work within this current framework, that within each of these priority areas we could separate the recommendations into two buckets, you know, short-term recommendations and longer-term recommendations.
DR. EDINGER: Maybe if we don’t do that, we can at least address Trent’s issue that we should say up front that we – kind of get consensus on which ones are do-able in which time frame. Some of them may or may not be, but at least address the issue, so if somebody reads it, they don’t think 1 through 21 is the order which we are saying it should be, but at least address this problem.
MS. KANAAN: We do say that, in a sense. We say committee sees – well, we see implementation as a collaborative – but that’s – we take the long view – where is that paragraph? You know, we expect that some of these will be resolved very quickly and easily and others will take considerably more time.
MS. COLTIN: Yes, it’s line 68, committee sees implementation as an evolving and collaborative process. While some improvements might be accomplished in relatively short order, others must wait –
DR. HAYWOOD: Yes, I don’t doubt that the verbiage is in there. I mean –
DR. GREENBERG: But, no, your point is well taken.
MR. HUNGATE: Justine.
DR. CARR: I didn’t read it, but following up on what you say, I’ve been a fan off and on of the Health Care Advisory Board, and they have great graphic displays, and maybe if we had these things in terms of easy to – you know, difficulty, easy, low benefit, high benefit, and you put a bubble in terms of whatever we are measuring or counting, you know, volume of people effected or quality of outcome, and you just kind of have a grid, and then the reader, it’s there for the – they make their own decision by saying this will be a big impact, a lot of work, but I’m ready for a lot of work or I have no resources and at least we can get this done this year –
MR. HUNGATE: I like the idea. We ran into a content difficulty.
Let me let Marjorie –
DR. GREENBERG: Okay. Well, I was kind of going potentially where Justine just went, although I think we don’t have a lot more time to spend on this if we are going to get this report out by March, which I feel strongly about doing, and, of course, one person’s easy is another person’s hard, and famous last words are, yes, we can do this pretty easily, but, at the same time, I was thinking about the core health-data elements, which is a little bit more clear cut, but in that report, if you recall – because Kathy was around then, too – we had things that were already – were ready to go, needed more research – I don’t remember, there were a few different categories, and then we had some tables or grids that displayed that. So right away you could – you had all these recommendations, but then you could say, oh, these are the ones that – you know, if someone is ready to implement them, they are ready to go. These are the ones where we actually need to do more research or we are not ready for prime time, and there were some others that needed – and if there’s some way we could do that graphically or in some tables –
DR. CARR: Well, it’s like quadrants, I think, is what I’m trying to recreate here.
DR. GREENBERG: – that might be helpful.
DR. CARR: Low and easy – all right – difficult and – you know, high yield, but difficult is the other quadrant.
MR. HUNGATE: The survey that we did was intended to illuminate that information, and the problem that we had was the data. We had people that thought one was very easy and others thought it was very hard.
MS. COLTIN: Same thing.
MR. HUNGATE: There was not a consensus in the group –
DR. CARR: Right. Right. And it depends where you’re coming from.
MR. HUNGATE: – in the judgments, and so I kind of gave up in terms of that ability and said, hey, there’s more work that maybe all we can achieve is to outline the work in a visible way and rely –
DR. CARR: Well, maybe it’s that electronic fixes, paper fixes, you know –
MR. HUNGATE: I think –
DR. GREENBERG: Yes, we talked about that.
MS. COLTIN: I think the concept of short term and long term is a little bit easier to deal with, because, for instance, have to be something that is really simple in the context of having an electronic health record, but since we won’t have an electronic health record for a while, it needs to go in the long-term bucket, even though it would be a very simple thing to do, once you had the electronic record. You know what I mean? So –
DR. CARR: Right. Well, I mean, or that might – I don’t want to rewrite the point now, but just in terms of stratifying, because across the country you probably have a certain percent of hospitals that are electronic and can be sort of your beta site to begin to get something up and running and work out the bugs and other folks that are going to be working on just simply collecting the data, and, over time, when you have a well-oiled electronic setting in leading-edge hospitals, then the transition from paper to electronic – at least you have created the thought categories that will feed into that electronic model.
MR. HUNGATE: To me, part of what Trent has suggested is what are the next steps, and I think that is right. We haven’t made that clear yet, and we put down a category that is not here yet for that with the intent that it come out of this discussion, in terms of what the committee thought should be the next steps following up this report.
So I think the discussion of this content is entirely apropos of where we are, and that my intent would be to not try to build that back into what we have covered so far, but to put it in to this last kind of concluding – here is what we are trying to tell you, folks – and do it that way, if that fits.
Susan, you had something you wanted to say.
MS. KANAAN: Yes, that’s very much what I was going to say, too, that I think we can discuss this in the next steps. I wonder if we wanted to also say it even in the introduction, that – you know, maybe expand that paragraph that we were just talking about that – sort of foreshadowing the fact that the next step is not only eliciting the input from more stakeholders, which we do talk about in the introduction, but also the other next step is beginning to prioritize these and put them on some sort of a timetable from short term to long term, and we do – you know, if the report raises that question or if it is hard for people to sift through all the recommendations, maybe we want to even create that expectation right in the introduction. What do people think about that?
MS. COLTIN: I think that’s fine, but I think Justine made a good point. I mean, if you are already there with an electronic health record, then it’s not necessarily long term, so I see that.
I’m wondering if maybe the framework of existing systems and evolving systems is a way to deal with that, because existing could be paper. It could be whatever, but it’s kind of easy to do with the prevailing, existing systems, and it would be to do with evolving systems that some folks are there, others aren’t close.
DR. GREENBERG: Is there anything that could just be added to this matrix – if we knew what the metric was, but, you know, whether it would be short term, long term, existing, evolving. I don’t know.
I mean, I am concerned that people see 20-some recommendations and they go like, oh, but what do you really want us to do?
But, on the other hand, this is a complicated area, and we are also trying to bring together recommendations out of years of testimony. So I wouldn’t cut any of these out.
MS. KANAAN: And we are trying to hook into other initiatives and other things that are already going on out there. So –
DR. GREENBERG: Right. Right.
MS. KANAAN: – we’re not sort of driving the process.
DR. JANES: How clean do you think we could do that if we took your approach of adding – basically framing a dichotomous variable – you can tell I’m a statistician – (laughter) – basically, classifying them as – what was it? – existing versus evolving systems, and then using the matrix as a very simple way of not adding a lot of additional to the text, but being able to address this point.
MS. KANAAN: A dimension that is like impact or benefit and the other one being existing and evolving, and then putting numbers in here that correspond to the numbers of our recommendations?
DR. JANES: Right. And I’m guessing that what Justine is passing around here would be probably a variable with four levels, maybe using these quadrants.
DR. CARR: Sort of four quadrants, but I like your idea, existing systems, so probably a paper system. Evolving systems would be the electronic, and I do think that as we are going toward electronic, we have just implemented our provider order entry, and a lot of things that seemed like a good idea, you know, when you get down to it, they were more complex than you thought. So developing something in an electronic system with the people that are committed to it, so that it would be seamless, but keeping the paper world informed that these things are going to be important.
MS. COLTIN: And it isn’t even necessarily the paper world.
DR. CARR: Yes.
MS. COLTIN: I mean, I think what we are really talking about is administrative transactions which are often electronic –
DR. CARR: Right. Right.
MS. COLTIN: – versus electronic record, medical records, health records.
DR. CARR: Yes, right.
MS. COLTIN: So by using the term existing systems, rather than paper gives you – it encompasses paper, but it also gets you the electronic administrative transactions.
DR. GREENBERG: I mean, I think particularly, too, if we sort of say this is the workgroups and then maybe – you know, it has to be endorsed by the committee, but sort of best thinking about this right now, then it doesn’t have to be in cement.
MR. HUNGATE: We’ve got until four o’clock to work on this, and so it seems to me that somebody’s got to do the thinking work to try to put things in the right place, and if we have time, it might be that if we do a little loose polling around where we are that it would inform this better than other things we can do, and so I would say let’s finish our completion of the circle and then maybe come back to that one and see if we can populate the quadrants from our collective knowledge.
DR. GREENBERG: Maybe we could have John introduce himself and meet our new staff person and our new member.
MR. HUNGATE: You have to introduce yourself. We’re not going to –
DR. LUMPKIN: Okay. I’m John Lumpkin with the Robert Wood Johnson Foundation.
DR. CARR: Justine Carr.
DR. LUMPKIN: Welcome.
MR. HUNGATE: You and Trent know each other?
DR. LUMPKIN: Yes.
DR. GREENBERG: Oh, you know each other.
DR. LUMPKIN: Oh, and where did Trent come from?
DR. GREENBERG: CMS.
DR. LUMPKIN: And where did he come from in CMS before that?
DR. GREENBERG: Ah-hah.
DR. LUMPKIN: The Chicago Regional Office.
DR. CARR: John was your boss?
DR. HAYWOOD: No.
DR. GREENBERG: John was in the Department of Health, so –
So you’ve just come to headquarters now?
DR. HAYWOOD: Yes, in the last nine months.
DR. GREENBERG: Oh, okay. Great.
DR. LUMPKIN: All sorts of folks –
DR. GREENBERG: That’s the great thing about our liaison, Judy Barrack(?). She is able to reach out to those regional offices. She knows who is out there.
DR. LUMPKIN: She is not going to be here.
DR. GREENBERG: I know. She has back problems.
MR. HUNGATE: Oh, that’s too bad.
Here’s where we are in the process, John, we are going around, one by one, around the table to access where our report is and working on content as we go in a fairly general way, and we’ve gotten around as far as Trent’s may be finished, maybe not finished.
DR. HAYWOOD: Yes, I’ll defer, because I have some real specifics later. So I defer ‘til we go around the rest of the room.
MR. HUNGATE: Okay. So we’ll pass on –
DR. JANES: It might be reasonable to just briefly summarize for John, since it sounds like the most substantive thing that we have talked about has been this idea of using either the grid or some way of labeling the recommendations in terms of how ready for prime time they are, if I can really loosely summarize it. I think Trent was the one who actually suggested that as an addition, and that was something that we were talking about and are going to talk about some more, probably before the afternoon is out.
MR. HUNGATE: Trent raised a concern about the lack of prioritization in our recommendations, importance or timeliness. Urgency, I guess would be the – short term, long term, and so we are working on a matrix where we’ll use our combined judgment to try to see if we can populate a matrix of that sort, as the next steps – input to the next steps, after we get through our first round of the discussion.
Is that an accurate summary? Did I miss anything?
DR. JANES: Are you asking me?
MR. HUNGATE: Well, or others.
DR. JANES: I mean, it sounds reasonable to me. I see John’s got a perplexed look on his face. I know it’s hard to walk into these things blind, but, yes, and I think generally just some relatively straightforward way, without doing a lot more work and generating a lot more text, that we could label these recommendations, perhaps with a variable that would have, say, somewhere between two and four different levels that would just give the reader some sort of input as to the workgroup’s sense of – isn’t so much how critical it is, but how close we are to actually being able to act on that recommendation. So it would be a sort of loose prioritization process.
MS. KANAAN: It’s more do-ability than priority, isn’t it?
MS. COLTIN: Well, I don’t know. I mean, if you look – where’s the part of this that you can write on?
MR. HUNGATE: I’d like to come back to that after we get around and everybody’s had a chance to put their two bits worth in on where the report is, because so far we have illuminated quite a few things that way.
Justine, did you have –
DR. CARR: Well, I haven’t had a chance to read it.
MR. HUNGATE: Okay.
DR. CARR: So I’m just taking –
MR. HUNGATE: Well, you were doing pretty well – (laughter).
And Eduardo Ortiz, who is lead staff, has joined us, and Dr. Carr has signed up for our committee, and so you two need to introduce yourself to each other –
DR. GREENBERG: Dr. Carr at the end there, and have you met Trent?
DR. ORTIZ: Yes. Nice to see you.
MR. HUNGATE: Susan, did you have any further comment at this stage?
MS. KANAAN: No, I think I’ve gotten my questions answered.
MR. HUNGATE: Okay.
MS. KANAAN: And my comments made.
MR. HUNGATE: All right. John and Eduardo, you’ve got to flip for who goes first on the next –
DR. LUMPKIN: Well, I agree with everything that has been said before.
DR. ORTIZ: I concur as well.
MR. HUNGATE: Okay. Well, if we’re –
MS. JACKSON: It’s been a good discussion –
DR. HAYWOOD: Go into the specifics or are we going to –
MS. JACKSON: Oh, I have –
DR. HAYWOOD: Okay.
MS. JACKSON: The only comment that I had was I was able to really appreciate getting into the issues, if you’re going to do the cutting of some of this earlier – the front section, that’s fine, but for some of us who are just – need to get familiar with the points, the text was very helpful to me, and making a depiction in a graph is one thing. I thought that’s what Justine was saying. I didn’t know you were really saying change any of the recommendations or –
MS. COLTIN: No.
MS. JACKSON: You have to hit them, deal with what the issues are – and having a visual, but cutting it various ways, it would be probably the next step.
And my final point was in terms of the communication of the report to your public is – I think it is well positioned considering the other reports that have come out, the quality report. It’s great timing for that as well as what you are doing for the committee itself, because already, from this morning’s session, the committee – some section of the committee are looking towards this to see how we can interface, interact and cross cut, you know, issues, you know, that way, and so I see this as a –
DR. JANES: Could you clarify that, Debbie?
MS. JACKSON: This morning, in the Subcommittee on Populations, the issue came up in looking at some of the health-plan component –
MR. HUNGATE: Vickie was leading a discussion about the effectiveness of the population subcommittee in getting their issues addressed and expressing respect for what standards and security was able to do in moving their agenda forward and asking for comment on their content in that, and I raised the issue of the race and ethnicity claim administrative coding has raised in our report as a content where we had felt that it was a lot of their content, and, hence, important on their – we, the quality workgroup, to the population subcommittee, which they agree with.
The substance of that is we tentatively agreed to conduct a hearing of health-plan input on the issues that we raise in this report, and so that is the sort of thing –
DR. GREENBERG: A joint hearing or –
MR. HUNGATE: A joint.
DR. GREENBERG: Great.
MR. HUNGATE: A joint.
And so that is taking a piece of the content we have been dealing with, which is population-committee germane, and picking an approach to do it in some collegial way within the structure –
MS. COLTIN: One thing that you may or may not be aware of, I think it’s RWJ that is actually funding AAHP, HIAA. They are doing a survey of all health plans about what they are currently doing with regard to collecting, using race and ethnicity data, and that survey –
DR. GREENBERG: Who is funding that?
MS. COLTIN: I think it’s RWJ that’s funding it. I’m pretty sure it is.
DR. GREENBERG: Oh. Oh, yes. I saw that myself somewhere.
MS. COLTIN: And – because I know I participated in the design of the survey, and I believe it is out in the field now. It’s in a web-based survey format, and so they should have some results, I would think, that they could come and tell us about. I guess they have to tell you first, but – come and tell us, but I think that is something that ties in nicely with what you are talking about.
MR. HUNGATE: It’s the kind of thing that we were trying to do with the way we restructure –
MS. JACKSON: Right.
MR. HUNGATE: – and so I feel like it’s –
MS. JACKSON: It’s working.
MR. HUNGATE: It’s working, right.
MS. COLTIN: Another area would be the area that we have a recommendation around standard survey items –
MR. HUNGATE: Yes.
MS. COLTIN: – in federal surveys and proprietary surveys. I would think the population subcommittee is a good nexus for that to happen as well.
MR. HUNGATE: Right.
I had to leave before there was more discussion of that. Was there any other thing that came back –
MS. JACKSON: No followup, but just that that kernel was there, so see how this report helped to really place the next steps.
MR. HUNGATE: Okay. Good.
All right. I don’t really want to go through specific wording inputs. Send them in to Susan for inclusion in the next round, if that’s okay, because I think we probably should work on this content issue of a matrix.
MS. COLTIN: Trent, were your suggestions editorial or did you have questions or suggestions about the recommendation?
DR. HAYWOOD: Well, I just had – just clarification questions type, like I was looking at page 26 about –
DR. GREENBERG: Which page?
DR. HAYWOOD: Page 26. I was looking at recommendations about – Recommendation 15. I just want to be clear. I understood what the recommendation was, which sounds like we are comparing the ICD-10 versus the CPT, and like just the language that I was looking for seems to suggest that we would be saying – well, it says – this is line 822, Classification systems such as ICD – are preferable for quality measurement over non-hierarchical code instructions such as that employed in CPT.
And the reason why I’m bringing that up is because I’m sure some of you know the AMA is busy doing kind of these Category 3 Codes all around quality management, and so are we, in fact, saying we were disagreeing with kind of their activities or we prefer one versus the other or – I just didn’t know if we were stepping into that or whether that is exactly what we want to say. So that’s just – I’m just raising the issue for clarification.
MS. COLTIN: Yes, I think we actually are being more diplomatic here than we have been in previous versions of the report – (laughter) – when I said, Why do you have three different computer codes, Ms.(?) Thompson? And I think this was an attempt to say can we at least try to crosswalk these systems in a way that –
DR. HAYWOOD: Oh, okay. So this is in a crosswalk.
MS. COLTIN: – one can use them to aggregate as well.
I mean, the big problems with CPT for quality assessment are not only is it non-hierarchical, so that you can’t just say this range of codes or that you can easily collapse codes to aggregate, but every year new codes are added and old codes are deleted, and so if you are trying to look at – you know, did someone get screened for colon cancer in the last five to 10 years, you have to have 10 CPT books in front of you to think of how it could possibly have been coded at any point during that interval, as opposed to ICD-9, which adds but doesn’t take away, and so you can’t – you know, with CPT, you can’t just look at this year’s book. You’ll be missing codes that were being used three years ago to represent that service and aren’t used any longer, and you’d say the service wasn’t done if you didn’t include that code. So it’s a big problem, and so we were trying to get at all of that in here, and if we didn’t, then we need to put back some of our concerns, but –
DR. HAYWOOD: I see what you’re saying.
DR. JANES: I think the AMA is well aware of – the committee, I think it’s safe to say, has a long track record of making public statements along the lines of what Kathy has just said. So I don’t think we are going to catch anybody by surprise in this.
DR. GREENBERG: Although, I think this is going to be a red flag. I mean, you criticize CPT in any way and you get a very strong reaction from its sponsors.
I myself would be just as comfortable here if we said that a classification system is – are preferable for quality – well, what we’ve got here, over non-hierarchical coding structures, and not even say, such as that –
MR. HUNGATE: Period?
DR. GREENBERG: – in CPT –
MR. HUNGATE: Period after coding structures?
DR. GREENBERG: Well, comma, since they permit straightforward aggregation, and the stability of a classification system –
MR. HUNGATE: Oh, okay.
DR. GREENBERG: – is also helpful, and anybody who knows these classification systems will know –
MR. HUNGATE: Understand without being singled out.
DR. GREENBERG: – that these are problems with CPT.
I just would not say here – because –
MS. COLTIN: So just take out the words, such as –
DR. GREENBERG: Yes, because it’s – you know.
MR. HUNGATE: Thank you. (Laughter).
Keep going, you’re on a roll.
DR. HAYWOOD: I think that was it, with the exception – I just wanted, again, clarification on the very end with the ongoing – I think those were maybe – are these – were we looking at – specifically at those that involved EHR-type activities or like system activities, such as bridges or –
MS. COLTIN: I think they are –
DR. HAYWOOD: Because we kind of used the word most promising, and I’m like there’s a lot out there for us to say if we are only going to limit it to kind of these – only, I think, four or five activities that’s –
MR. HUNGATE: Which ones were you thinking of that you thought you might have found?
DR. HAYWOOD: Well, like, for instance, the Department of HHS, Secretary Thompson works with us on all our public releases for all of what is called the DHHS Quality Initiative, which is – nursing home, home health, the Hospital Reporting Initiative. So all of that is departmental, considered quality initiatives.
MR. HUNGATE: Yes, I think that’s –
DR. HAYWOOD: And that’s not –
DR. GREENBERG: So we should add those.
DR. HAYWOOD: – but I didn’t know if that’s the angle that you were looking for –
MS. COLTIN: No, I think that absolutely does belong here.
DR. JANES: The only angle we were using was starting with – how many recommendations have we got, 20 some? – starting with the recommendations, and then trying to – basically just using the combined information that we have around the table to come up with initiatives people could think of which were ongoing, which either surely would support those recommendations or likely might support them at some point. So –
DR. GREENBERG: So we may need that section on CMS initiatives.
MS. COLTIN: I actually think we need a section on sort of convergence on a set of quality measures.
DR. GREENBERG: Oh, yes.
MS. COLTIN: Because every time I am aware of – like I know this came up in the Consumer Purchaser Disclosure Project, when they went to the NUBC, it came up in the context of a lot of recommendations that have gone to the CPT editorial panel for Category 2 Codes for performance measurements – they’ll say, you know, this guy’s out here measuring and he wants that code, and you’re over here measuring and you want that code. If everybody could agree on what they want to measure, then we can come up with a common set of codes and we can add those codes, but we can’t please every Tom, Dick and Harry who wants a new code –
DR. GREENBERG: Right.
MS. COLTIN: – or a new data element added to a transaction, and I think by having a section on convergence on a common set of measures and talking about things like the National Quality Report, the National Disparities Report, the CMS Initiatives, the National Quality Forum that we are converging –
DR. GREENBERG: JCHO.
MS. COLTIN: The National Hospital Voluntary Initiative adopting the JCHO – CMS working with JCHO in adopting a subset of those core indicators for reporting, that the field is moving toward that convergence, and that convergence facilitates the notion of parsimonious improvements being made to both the addition of data elements and codes. Does that sound like it would cover what you’re –
DR. HAYWOOD: Right. Because that’s what I was wondering, because I know you – starting out, you were giving us that background of how this process has been evolving, and we are just now, I think, with some of the players that you mentioned – ARC and JAYCO and NCQA, you know, the ambulatory side, and even with RWJ and Commonwealth Fund, all of these discussions have been around that convergence – Blue Cross, Blue Shield, United Health Care – to where we are now at the point of saying what we think is going to be the process, and then, ultimately going through NQF for endorsement, that type of activity. So I think it would be at least something worth highlighting, if nothing else, to show that the industry is moving towards that convergence.
MR. HUNGATE: And I think there is a discussion there of the mixture of process and outcome measures that is important to have.
I remember participating in a QMMP project in Chicago that was directed at getting agreement among everybody on the quality measures, and it was unsuccessful, and –
MS. COLTIN: Another part of that, I think, is –
MR. HUNGATE: – it’s going to be difficult.
MS. COLTIN: – the registries that people already participate in. I mean, there are state registries for cardiac surgery, also for interventional cardiology, so that they put enormous resources into the data collection by this definition. When you introduce a variant on that, it wreaks havoc in terms of how do we collect and regenerate the data. So I think sometimes the weight of – may not be our favorite definition, but the FDS is using it, and every cardiac surgery program is already reporting on it, it’s a mistake to now define it differently, because of the resources required.
DR. HAYWOOD: Where we are with a lot of that is kind of there’s that whole – data warehouse that UMS has, and the thought behind it just kind of – for your own information, at this point – is that you will allow all that data to come in, then on the back – so we gotta get consensus around, down to the micro-spec level, which is what we are doing with the J(?), so that you will have consensus that there’ll be kind of that one measurement set, and then on the back end, whoever of the individual end users that need to cut –
MR. HUNGATE: I think that is a very big subject where we can discuss the parameters of it, the participants.
DR. HAYWOOD: And we’ve got – in the Medicare legislation, we have that contract that we let to IOM that the legislation require for IOM to do that full-blown study on performance – measuring the landscape on performance measures well. So that’s – within the next couple of months they’ll be underway with that as well.
MR. HUNGATE: So how do we proceed on that content?
DR. GREENBERG: Gail interviews Trent –
DR. JANES: Exactly.
DR. GREENBERG: – and gets the information she needs –
DR. JANES: I’ve got a note down here, convergence on quality, and I already told Trent I’d hit him up for details.
MR. HUNGATE: All right.
DR. ORTIZ: I just want to make a comment about that CPT thing, that I don’t necessarily think that we should strike it without people agreeing that it should be stricken, because I disagree with that position. I think that – I would leave it in, and I would leave it in personally – I mean, I know there’s political reasons, but I don’t care about politics, and maybe that’s enough the reason, but, to me, I would leave it in because, number one, everybody that reads this will not be an expert on all this stuff. There will be a lot of people that read this that are not experts and they would like this. So when they read over non-hierarchical coding structures, they are going to say, well, what does that mean? But if you say, such as CPT, because – I mean, say what you mean, but that is what we are concerned about. It’s a problem. Tell people what you are concerned about.
The other issue, too, is I think if we put it in, I think it would be good to put in the other – if we are going to talk about CPT a little bit – I know this isn’t a focus of CPT, but I think something besides the non-hierarchical model thing, the coding structure is that’s a real big deal that people understand – normal people understand if they read this is the fact that CPT codes get deleted and added all the time –
DR. GREENBERG: Well –
DR. ORTIZ: I know she said it, but is it in here? Because that is something that an average person that reads this, that makes sense to them. They go, well, that’s idiotic. You know, why the hell would you use something to measure quality when it’s totally inconsistent year to year?
So, I mean, if you are really trying to get a message out to people, you have to want to assume that people reading it are not experts, and, number two, I say say what you mean and mean what you say.
Now, people may override that for political reasons, and that is fine, but I don’t want us just to say, okay, strike it. I say, let’s decide and as a majority of people say strike it, then that’s fine.
DR. GREENBERG: Well, I had an alternative suggestion – and that is to state that sentence without that phrase in it, and then you could say, for example, CPT –
DR. ORTIZ: Sure.
DR. GREENBERG: – does not have a hierarchical – or something about its hierarchical structure – and does delete – and so you could say that, but there was just something about the way it was right there that was just sort of like an attack that I thought might be problematic, but what do you think?
MS. COLTIN: Well, actually, I think – you suggested after the next sentence, because the next sentence is the one that talks about the adding, deleting. It doesn’t specifically say adding and deleting, but it talks about the stability of a system which enables the addition of new codes to address the need for greater specificity without losing the ability to trend data historically, and then you could have a sentence about –
DR. GREENBERG: For example, issues that have been raised about CPT, because, actually, the CPT Five Group looked at these. I don’t think they really resolved them, but they did look at how to have more – you know, what to do about the hierarchy issues, what to do about this retention of codes and stuff. So I think you could have a follow on sentence.
DR. ORTIZ: And my point isn’t to attack CPT, but it’s to make sure we convey a good message and we educate people that are reading so they understand. So that’s more my point, and I think that would address that.
MR. HUNGATE: Let’s give it a whirl.
DR. GREENBERG: John.
MR. HUNGATE: John.
DR. LUMPKIN: I’m not sure if the hassle is worth the message, because I know that the AMA will just bristle over that.
I think that we could – if where we are going is saying we believe that there shouldn’t be hierarchical, for instance, people who have used the CPT nomenclature have had difficulties because of the following things or you could say a well-known coding set – Chicago-based – coding set – you know, I think it’s a very valid point. We’ll see. We’ll see if Jack gives me a call and –
DR. CARR: I mean, can’t you just say the goals are to be able to do trended data? Programs that don’t trend data compromise that ability with or without CPT, you know, that has a value – we also want details. CPT has that. You know, it’s sort of like it is what it is.
DR. LUMPKIN: Can we pick on somebody – I mean, can we pick on somebody or somebody other than CPT?
DR. GREENBERG: Well, that’s –
DR. LUMPKIN: I mean, are they just –
MS. COLTIN: They are the main one. I think that’s problematic. I don’t know –
DR. GREENBERG: How about HICPIC(?)? CPT is part of HICPIC. You can call it HICPIC’s Level 2 and nobody will know what you are talking about.
DR. JANES: I do think that it is important to focus on the qualities that make CPT unacceptable to us, rather than just alluding to it and sort of – I mean, I didn’t become aware of this – nobody’s still sort of talking about this, but as it stands now, there actually is relatively little of the text that talks about – it’s a very superficial treatment of why we don’t like CPT, and I think it’s quite fair to reverse that and focus on why we don’t like CPT and either don’t mention CPT at all or – you know, I mean, your point is well taken, Eduardo – at least not make a big point, not make it look like we are going after the AMA and CPT.
What was it you said? You know, you could put something in, for example, CPT or –
DR. LUMPKIN: For the record, we love the AMA, as we like all of our – groups that help us –
DR. GREENBERG: And then our recommendations about ICD-10, the committee was very careful.
DR. LUMPKIN: Yes, we were.
DR. GREENBERG: – not to tread on CPT.
MS. COLTIN: Well, and they actually complimented CPT earlier on in terms of modifiers.
DR. GREENBERG: You did. You did.
MS. COLTIN: Talked about modifiers –
DR. CARR: I mean, I think that is a fair statement. Here’s where it’s good. Here are the best practices that we want to embrace. CPT modifiers help us do this. Trended data is better accomplished, however – I think it’s fair. It is what it is –
MR. HUNGATE: It is clearly a challenge for the AMA to deal with it, and how to respectfully recognize the challenge in terms of the content, it seems to me, is the political challenge, to make it a statement to say this is a challenge that leadership in the physician community faces in dealing with the hierarchical need of records for longitudinal use or some – recognizing that it’s something that they’ve got to deal with. Is that fair or not fair?
DR. LUMPKIN: Our recommendation is for ICD-10.
MR. HUNGATE: Yes.
DR. LUMPKIN: I’m not sure that – I think that if we were to focus on why we like ICD-10, as opposed to focusing on why we don’t like CPT that may be another way to approach it. The AMA won’t be happy with that either, but if we say that the things that we like about CPT is because it is hierarchical, because – you know, there’s some consistency over time, and when you’re trying to look through it, and that’s –
DR. GREENBERG: ICD.
DR. LUMPKIN: I mean, I’m sorry, ICD has these things – characteristics – that may be a positive way to say what it is we want, rather than spend time saying what it is that we don’t want, because we don’t want HICPICS either.
MR. HUNGATE: Does what we have here, without addition of more information, do that clearly enough?
DR. JANES: Give me the line number again, if you will, please.
MR. HUNGATE: It’s 831, I think, but I’m not sure.
DR. JANES: 831, you said?
DR. GREENBERG: Well, I think we have all agreed that – we have already removed, such as that employed in CPT where it currently is. If for no other reason than the stability of the classification system, it is also relevant to CPT, and that wouldn’t be obvious. So we are going to take it out there. So I think the remaining – and then, you know –
MS. COLTIN: And then the question was do we add a sentence –
DR. GREENBERG: A sentence about –
MS. COLTIN: – that says, for example, issues have been raised about both the non-hierarchical structure and the routine deletion of CPT codes.
DR. GREENBERG: I mean, I think you could say that. I mean, those are just facts, as opposed to saying one thing is preferable to another –
DR. ORTIZ: Not like it’s going to be new news to them.
DR. GREENBERG: No. No.
DR. ORTIZ: I mean, they have heard these criticisms before.
DR. GREENBERG: And those are issues that have been raised. To me, that isn’t inflammatory. Whereas, I felt like anything that said ICD is preferable to CPT was going to start getting people upset, because it might be taken out of context. Whereas, a statement like that is just a factual –
MS. COLTIN: Well, we could say CPT and HICPIC – then they wouldn’t be singled out.
DR. JANES: Actually, I like that. Yes. Because it’s true. We don’t want HICPICS.
DR. GREENBERG: Yes.
DR. JANES: Nothing personal.
DR. HAYWOOD: None taken.
MR. HUNGATE: All right. Have we settled?
DR. GREENBERG: All right. Thank you, Eduardo, for keeping our feet to the fire.
MR. HUNGATE: This is good.
DR. ORTIZ: You’re welcome. You know, I’m a rabble rouser, so – that’s what I’m here for. You’re here to keep me in check.
MS. COLTIN: Any other substantive comments, other than – if you have editorial comments, you should email them to Susan, but anything that we need to discuss –
DR. LUMPKIN: But if we do get questions, we should let them know that Eduardo is the arch enemy.
DR. ORTIZ: That’s right. That’s right. That’s right.
DR. JANES: Did you have others, Trent?
DR. HAYWOOD: No, I’ve done enough.
MR. HUNGATE: (Laughter). Thank you for your help.
DR. HAYWOOD: Right. Yes.
MS. COLTIN: Yes, but these have been good. I mean, if you have others –
MR. HUNGATE: Okay. Let’s take just a minute before we take a break, and would you kind of talk through the production schedule for just a minute, Susan, and –
MS. KANAAN: Unfortunately, I didn’t bring it, but it is going to happen very quickly, like in the next week, and I think those of us who are responsible for the next phase have a copy of the time line with us. I mean, we have the dates, but I think we have about a week to turn around another draft, or you two do, to get it to me, and then it goes back to the committee.
I think maybe we should actually discuss again how – at what point we bring the executive subcommittee into this. Do they need to see this before the full committee does, and do we need to try to squeeze in another round of edits or can the exec subcommittee see it at the same time that the full committee does?
DR. GREENBERG: The process that we agreed to is it is supposed to actually go to the executive subcommittee, not giving them a whole lot of time, but, I mean, I don’t see a report like this I’d give them less than a week probably, and just for any kind of real hot-button issues – we have just addressed one – and give them an opportunity to send comments, and then if they really call into question the whole report – which I really hope they don’t –
MR. HUNGATE: I really don’t think that is going to happen this time.
DR. GREENBERG: I don’t think so, at this point, either. Then we would have to rethink bringing it forward in March, but, otherwise, either make what changes you can before it goes out to the full committee or –
DR. LUMPKIN: I think, looking at the people on the exec subcommittee, there’s a good reason to get their input before we move it forward, which will, hopefully, prevent any obstacles at the full committee meeting.
MS. KANAAN: Yes.
I’m sorry that I didn’t bring that timetable. Debbie, you don’t happen to have a copy of it, do you?
MS. JACKSON: Well, generally, you know, next week, we are four weeks out from the full meeting. So –
MS. KANAAN: Right. Yes, I got through the whole timetable. I just don’t remember it. I don’t have it in my head.
MS. JACKSON: No, I don’t have it.
I would see this going out to the executive subcommittee no later than about the 16th or so, because, by giving them a week, that’s a Monday, and we get the comments back by Friday or the week before, the Friday before, to give them a weekend to take a look at that. So you can get comments back by the 20th. It wouldn’t give you much time to do with much changes, because we have to get everything out to the full committee that next week, February 26th, in preparation for the meeting the week after, but you’re cutting it close. It just depends on how much you think you are going to wind up doing – getting comments back.
MR. HUNGATE: How does the committee feel about having its next round of review be shared with the executive subcommittee?
MS. KANAAN: Yes, we don’t really have time to put it through the subcommittee – through this group again.
DR. JANES: I don’t know about other members of the workgroup, but, I mean, my feeling generally is you send it through for one set or review and then, particularly when you get to the point where we are now, in which you are making small changes, yes, I mean, I’m perfectly happy with making these changes and sending it straight forward to the executive subcommittee and not sending it around to the workgroup again for more – otherwise, it becomes an unending process.
DR. GREENBERG: Well, if we have little edits here and there and everything, we can just deal with those.
DR. JANES: I mean, the things we are talking about today are relatively small changes, and they are not divisive issues. So –
DR. ORTIZ: This is pretty close –
MR. HUNGATE: I think we are very close.
DR. ORTIZ: Yes.
DR. GREENBERG: Yes. So that would work.
MR. HUNGATE: So let’s do those concurrent reviews between the executive subcommittee and this workgroup.
DR. GREENBERG: Yes, I think we have full confidence in our writing team.
MS. COLTIN: So you are saying it needs to go to the executive committee and this group by the 16th?
MR. HUNGATE: Well, if we –
MS. JACKSON: Maybe even earlier.
MR. HUNGATE: If we have moved it to a single review staff, let’s move it up a little bit –
DR. GREENBERG: Well, you all – I mean, you both – the two of you need to do some work, and Susan needs to do some work, and then she needs to do work when she gets your pieces. So it’s really a question of when – that’s only how much time you need to do that.
MS. KANAAN: I probably won’t do anything ‘til I get your pieces, and then I’ll do whatever editing needs to be done.
DR. JANES: And I’ll work on – I’ll get mine done over the weekend, so you’ll have it.
MS. JACKSON: Maybe February 10th, we’ll have something to send to both the executive subcommittee and to us.
MS. KANAAN: And then you’re saying that we need to give them a week?
DR. GREENBERG: Well, you can’t really send them a document like this and give them two days. It’s not real.
MR. HUNGATE: I think that we inform the discussion better by giving them enough substance and enough time, so that if they want to talk to their committee members, they have time to do so.
DR. GREENBERG: I wouldn’t give them more than a week. At this point, we don’t have it.
MS. JACKSON: Right. If we get comments back from them on the 16th, then you would have that week, the 16th to the 20th – oh, okay. That’s a holiday. Then it would be the 17th –
DR. GREENBERG: Wait. So you’re saying –
DR. JANES: You keep backing it up, Debbie.
DR. GREENBERG: No, wait. Yes, I don’t know why you’re backing – you’re backing it up too much.
You said you could have your stuff maybe done by Monday.
DR. JANES: Oh, yes.
DR. GREENBERG: Okay. Even though you’re going to have to add some things, but you know what you have to do and you can –
DR. JANES: Yes, frankly, I’ve got – I have most of this. I mean, I’ve got projects sort of stacked up. I’ve got to do this now, because, otherwise, I’m going to be into other stuff –
DR. GREENBERG: Okay. So you are going to get yours to Susan by the end of the day on Monday.
DR. JANES: Yes.
MS. COLTIN: I can’t even start it ‘til Monday.
DR. GREENBERG: Yes.
MS. COLTIN: So I doubt that I can get mine to Susan until maybe Wednesday –
MS. KANAAN: What’s the date of that?
MS. COLTIN: What’s the date?
DR. GREENBERG: Well, that’s the 4th is Wednesday. So midweek maybe.
MS. KANAAN: Well, in that case, I can certainly get it turned around by the 14th, but are you saying that’s too late? And then we would get comments by the 21st.
DR. GREENBERG: That’s okay.
Wait, the 14th is a Saturday. The 16th is a Monday, which is a holiday.
MS. KANAAN: Thirteenth. We’ll say by the 13th.
MS. JACKSON: Going out, then, to the full executive, you mean?
MS. KANAAN: To everybody.
MS. JACKSON: Okay. That’s fine.
MS. KANAAN: And then you need it by the 26th or so, is that what you said?
MS. JACKSON: I didn’t know when you needed it –
MS. KANAAN: No, when do you need the final version that’s going to the committee?
MS. JACKSON: By the 26th. That’s right. Before it goes out to everyone.
MS. KANAAN: Okay. I think that’ll work.
DR. GREENBERG: So you’ll get it to Debbie or you’ll send it directly? You send it to Debbie by the 13th.
MS. KANAAN: At the latest.
DR. GREENBERG: Debbie will send it – you’ll be around the 13th?
MS. JACKSON: The executive subcommittee.
DR. GREENBERG: Yes. Okay. You’ll send it out to the executive subcommittee, give them that week.
MR. HUNGATE: And this group.
DR. GREENBERG: Oh, and this workgroup. Exactly.
MS. COLTIN: And it’s getting sent out on the 13th, and then –
DR. GREENBERG: Email the 13th, I guess.
MS. JACKSON: And then comments back the following week, that’s the 20th, Friday, and that would give you all the week – really, that week, and get it back to me by the 26th to compile for the full –
DR. GREENBERG: Well, I think that’s do-able.
DR. JANES: The full committee is the 4th and 5th?
DR. GREENBERG: It is the 4th and 5th, right? Because Simon had the 3rd and 4th on his –
DR. JANES: Well, I think I had 3rd and 4th.
MS. KANAAN: I do, too.
DR. GREENBERG: No, I think it’s the 4th and 5th.
MR. HUNGATE: I have 4th and 5th on my calendar. It’s a Thursday and Friday.
MS. KANAAN: Which is a Friday.
DR. GREENBERG: Yes, Thursday, Friday, 4, 5.
DR. EDINGER: Oh, it is? I thought it was Wednesday, Thursday.
DR. GREENBERG: Hum?
DR. EDINGER: Thought it was Wednesday, Thursday. It’s Thursday, Friday.
DR. GREENBERG: March 4th and 5th are Thursday and Friday, unless Dr. Lumpkin tells us otherwise.
DR. ORTIZ: Okay. John, you have to break the tie.
DR. GREENBERG: I mean, you can’t change the calendar, but let’s make sure we have it right on your –
DR. ORTIZ: He has it the 3rd, 4th and 5th.
DR. GREENBERG: (Laughter).
DR. EDINGER: But he’s going to be here the whole week.
MS. KANAAN: Definitely originally said the 3rd and 4th.
DR. GREENBERG: Really? Because I got the 4th and 5th.
DR. CARR: I think I didn’t go through. I think I saw something for the 4th.
DR. GREENBERG: Obviously, the 3rd and 4th was floating around somewhere, because that is what Simon had, but I had the 4th and 5th. John, you have it on your calendar?
DR. LUMPKIN: Actually, I was looking for someplace else, but, now, I will go actually to the date – looking for a shortcut. I thought I had a copy of the agenda –
MR. HUNGATE: The agenda that was just published and I have in my hot little hand says March 4th and 5th –
DR. GREENBERG: Oh, yes – that’s what NCHS thought it was.
DR. LUMPKIN: So that must be it.
MS. KANAAN: Okay. It may have just been a typo on an old agenda.
DR. GREENBERG: Is that consistent with your – John, I mean –
DR. LUMPKIN: Yes, that’s what it says.
DR. GREENBERG: The 4th and 5th.
Now, the subcommittee on standards may actually grab the 3rd for a full or half-day hearings, as they were discussing this morning. So it’s not like we won’t have anything to do on the 3rd.
MR. HUNGATE: Okay. I think we are done for now. Let’s take a 10-minute break, make – eight minutes, if you can do it, because we’ve got actually two more subjects that we are going to try to cover in about an hour, cross-cutting issues and next steps.
* * *
MR. HUNGATE: All right. I want to pick up on the idea that has evolved from the discussion of the content toward looking at the recommendations and their possible implementation in existing partially-paper information systems and evolving an electronic health record.
Have I captured the substance of the suggestion in that? Against the two matrixes –
MS. COLTIN: That’s a suggestion, except I would characterize existing as not so with paper. I think the HIPAA administrative transactions belong in the existing category. So it’s sort of electronic, but not the physicians –
MR. HUNGATE: So, now, let me see what the understanding is. Are we going to take a recommendation like test results and evaluate it on this matrix and this matrix? Is that –
DR. CARR: I think so. We could come out with –
MR. HUNGATE: That’s what I thought –
DR. CARR: – if you’re in an existing system with no electronic physician order entry or collect data – on-line medical record.
DR. LUMPKIN: Well, I think we just should do a quick statement that existing system is paper based, plus HIPAA transactions.
MR. HUNGATE: Okay.
DR. LUMPKIN: And then evolving would be EHR plus –
MS. COLTIN: PHR?
DR. LUMPKIN: No, probably plus Leapfrog.
DR. JANES: Plus did you say Leapfrog?
DR. LUMPKIN: Leapfrog. Leapfrog is CPOE, electronic laboratory reporting. I think those are the two electronic –
DR. CARR: I think it’s just CPOE.
DR. LUMPKIN: No, they just added –
DR. CARR: They added –
DR. LUMPKIN: Yes, that was like within the last month or so.
DR. JANES: What is CPOE?
DR. CARR: Computerized order entry.
DR. LUMPKIN: Right. Because I think you can do an EA(?) chart without a CPOE. So –
MR. HUNGATE: I think the process of enumeratively going through 22 recommendations in as many votes as we have will exceed the allowable time. So what I would like to try to do is try one with each of you drawing your two matrixes and positioning test results, Recommendation No. 1, in the matrix, and then we’ll position your positions on the matrix and see if we have coherence in that.
DR. LUMPKIN: Can I suggest maybe a different one? Why don’t we just go up and put a dot on the board where we think it should be, each of us?
MR. HUNGATE: Because you’ll be influenced by other’s judgment.
DR. LUMPKIN: I’m happy to be influenced – (laughter).
MR. HUNGATE: I would like individuals to exercise their own judgment.
DR. GREENBERG: And then hand it in?
MR. HUNGATE: And then call it out. Now, you may change your vote after you – you may lie and do one thing and then change it. You know, the claim may be different than the – So the one we are going to try is Test Results.
DR. LUMPKIN: That is going to be our test case?
MR. HUNGATE: Our test case is Test Results.
DR. LUMPKIN: Reportedly.
MR. HUNGATE: Yes –
DR. GREENBERG: Create a mechanism for reporting selected outpatient – Do we agree that it’s outpatient and inpatient?
MR. HUNGATE: Outpatient and inpatient. For both of them? One and two? Okay. Good.
DR. LUMPKIN: Now, this is high-quality yield.
MR. HUNGATE: High-quality yield, high-information yield to improve quality. High-system improvement.
DR. GREENBERG: And easy to do or difficult to do.
MR. HUNGATE: Easy to do or difficult to do. And so we are going to see a relative now and future judgment.
DR. LUMPKIN: Let me just add one other parameter to this. It’s not only will it – the yield will be its importance in quality measurement as well as its importance in improving quality.
MR. HUNGATE: Yes, both.
DR. GREENBERG: Why are we talking about measurement?
DR. LUMPKIN: Because –
MS. COLTIN: I think we are assuming – we are making an assumption here that improvement begins with measurement. It doesn’t end there?
DR. LUMPKIN: The difference is is between quality improvement and rapid-cycle quality improvement, which EHR allows you to turn the – you know, turn it in a very, very short cycle. So we are really talking about two different kinds of yields in the existing versus the evolving.
DR. GREENBERG: What you’re saying, in the evolving, you could immediately put it into decision support and then –
DR. LUMPKIN: Right. So we really have to talk about EHR plus Leapfrog without decisional support.
DR. GREENBERG: Well, why? EHR, I think, should include decisional support. That’s –
MS. COLTIN: Yes, we actually made a recommendation about that. In fact, that was one of the things I thought people might raise, and I don’t mean to divert us, but one of the emails that I passed along was the Health Beat article that said that HHS had sent a letter to HL-7 urging them to focus EHR functionality on the core functions, and we are recommending two functions that are not necessarily core functions, the clinical decision support and the population theory and reporting.
DR. GREENBERG: Right. And I think that’s okay.
MS. COLTIN: And that goes directly against what HHS said. So I just want to make sure that everybody was still comfortable with –
DR. GREENBERG: Well, there could be short term, long term.
MS. COLTIN: Yes.
DR. GREENBERG: I think HHS’ position is let’s get something out there, but –
MS. COLTIN: Okay. I just wanted to make sure that that was okay with everybody.
MR. HUNGATE: We are in a position where we are beginning to understand the complexity of these judgments, and it is my sense that it is that complexity of things that has hung us up each time we get to the full committee, and that if we attempt to do this, we will raise more questioning of our judgment than we will speed –
DR. GREENBERG: So you’re saying that’s a down side.
MR. HUNGATE: Yes, I just – I’m fearful of – there is a lot of judgment that if we do this well has to go into it.
DR. GREENBERG: That’s true.
MR. HUNGATE: If we do it poorly, we ask for trouble –
DR. GREENBERG: Then we could always just eliminate it.
MR. HUNGATE: No, I think, conceptually, it’s good content.
DR. LUMPKIN: Can we score two of them?
MR. HUNGATE: Can we score two of them?
DR. LUMPKIN: Um-hum.
MR. HUNGATE: Sure.
DR. LUMPKIN: The one I would like to contrast this with would be collection of race and ethnicity data.
MR. HUNGATE: Okay.
DR. GREENBERG: Something easy like that. I wanted to contrast it with the diagnosis modifier, which I think is easier.
MR. HUNGATE: Okay. In that context, events earlier today – the context of the population subcommittee there is interest in conducting a joint hearing between the workgroup and the population subcommittee around the collection of race and ethnicity data in the near future. So there’s an action item that is bubbling up –
DR. ORTIZ: Also, just a comment on the EHR and CPOE issue, which may or may not help – I don’t know if it does – but a while back I was at this meeting up at Harvard where there was a bunch of people up there talking about these issues, and one of the things I brought up is, you know, over the last 30 years, as these computerized systems had evolved, there really was a distinction between EHR and CPOE, because some systems did not have full capability, but I really kind of pose the question now, knowing what we know about EHR from CPOE and knowing that you get tremendously more value by having both combined versus one or the other, does anyone in that room really think that as we move forward that we are going to continue to make that distinction or are we really, in the future, talking about EHR with CPOE? It’s one entity, because it doesn’t make sense not to do it, and 100 percent unanimous everybody felt that that is the direction, so as we move forward, they said we really should be thinking of them as one entity, not separating them out, because what occurred in the past we have learned from and is not what is going to happen in the future.
DR. LUMPKIN: But if you are buying a Subaru Legacy versus, let’s say, buying a Cadillac, when you buy a Subaru, you gotta order automatic windows, because they don’t come on the base model. They come on the base model of the Cadillac. So if I’m selling a system and I’m trying to think of pricing strategies, they are going to tend to separate those two, because they can charge differently, and what we want to do is convince people that they ought to buy them together whether they are buying a Cadillac or Subaru.
DR. ORTIZ: I understand that, but I’m saying that at least the consensus of that group, which is a lot of the big hitters out there, thought that in the future that all the HR’s that are out there will have some component of – even if it’s electronic prescribing with a certain amount of decision support, that that will be part of it, that vendors will not be – maybe small, little vendors might, but any of the big vendors are not going to be supplying EHRs without the decision support. It just won’t happen because people will not accept that anymore. They will package it and have to make it attractive enough to get people to buy it. I’m just throwing that out, that that was the discussion –
DR. CARR: As one of those Harvard hospital representatives, that sure isn’t – like it’s been very modular, I guess, because – but we began with an electronic outpatient medical record of history – and so on. In the coming 12 months, we’ll get order entry on the outpatient side.
On the inpatient side, we have order entry intact by house staff, not by attending – but we don’t have a history. We have bits and pieces of history, and knowing the magnitude of the implementation of all of the above, I think it would be hard to just take it off the shelf and plug in all of those. So I’m pretty sure I know who you were talking to, but we might have a middle time when we still have the notes versus the orders.
MR. HUNGATE: Okay. Well, I’m recording the test results. Everybody work on race and ethnicity.
DR. GREENBERG: Wait. Have we given our answer to test result?
MR. HUNGATE: We have to do them kind of one at a time. Would you like to go first?
DR. GREENBERG: I thought I was ready to go until John Lumpkin confused me.
MR. HUNGATE: Well, I can put my dots down.
DR. GREENBERG: Okay. All right. Put yours down.
MR. HUNGATE: Somebody’s gotta start someplace, right? So I put that one there.
DR. GREENBERG: What? Test results?
MR. HUNGATE: That’s test results.
DR. GREENBERG: You think is – wait.
MR. HUNGATE: I put it as fairly high yield.
DR. GREENBERG: Yes.
MR. HUNGATE: And more easy than hard.
DR. GREENBERG: Oh, okay. So I thought we just put one in one of those four boxes.
MR. HUNGATE: Well, this is a very analog thing, you know. You can do it just in the box, but I like to see gradations – I wasn’t as sure it was as easy as I thought, but I thought it was more easy than hard. You don’t need to be that precise.
DR. GREENBERG: A little more sophisticated than I was prepared to be.
MR. HUNGATE: All right, John.
DR. LUMPKIN: They go right there. (Laughter).
MR. HUNGATE: Same place?
DR. LUMPKIN: Upper right quadrant.
MR. HUNGATE: Upper right quadrant?
DR. LUMPKIN: Yes, a little bit easier than where your hand is, right about there, and then, on the other side, they went all the way to yours, but maybe a touch lower.
MR. HUNGATE: Less yield?
DR. LUMPKIN: Less yield, but a touch lower, but the same difficulties.
DR. GREENBERG: You feel the yield is less from an electronic –
MS. COLTIN: Why would the yield change?
DR. LUMPKIN: Well, no, because – well, let me see.
MS. COLTIN: You’re saying the yield is the same.
DR. LUMPKIN: My dots were the same height, but –
MS. COLTIN: Yes, yes.
DR. GREENBERG: They should be the same height –
DR. LUMPKIN: Okay. So you can put them in the same place as yours.
DR. GREENBERG: Yes.
MR. HUNGATE: Oh, it’s a little higher.
DR. LUMPKIN: Yes.
MR. HUNGATE: You got a little more out of it.
DR. LUMPKIN: Okay.
MR. HUNGATE: Any other volunteers?
DR. CARR: I had the same as John, exactly.
DR. GREENBERG: I had the same as John, also.
MR. HUNGATE: Okay. Eduardo, you’re here? All right.
DR. ORTIZ: Right there.
MR. HUNGATE: Any other ones?
DR. ORTIZ: And then over here, I’d go – I’m right around the same area.
MR. HUNGATE: Same area.
DR. ORTIZ: Very similar.
MR. HUNGATE: Any – Trent?
DR. HAYWOOD: Mine, I had – on this side, I had it on the high yield, but to the right, so maybe just the opposite of yours on the –
MR. HUNGATE: Over here?
DR. HAYWOOD: Right –
DR. ORTIZ: Mirror image?
DR. HAYWOOD: Right.
DR. ORTIZ: I guess the other question is is whether – it’s technically easy or altogether easy, because there’s technical issues in everything. Everything?
DR. LUMPKIN: Technically, it’s altogether.
MR. HUNGATE: Over here?
DR. ORTIZ: Okay.
MR. HUNGATE: Right in there somewhere? Okay.
Any other –
DR. GREENBERG: I was with John, pretty much.
MR. HUNGATE: Kathy.
MS. COLTIN: I had mine at the same height as John’s, but over above the other one. Yes, right above that other dot, yes.
MR. HUNGATE: This one?
MS. COLTIN: Yes.
And right where your cluster is, I was in the same spot.
MR. HUNGATE: Over here. Okay.
The future is always easier than the present.
Okay. Is that enough dispersion or – Ed?
DR. ORTIZ: Yes, I would probably be basically the same place on – the difficulty would probably go up near the – to the left, a little further left, yes.
MR. HUNGATE: In here?
DR. ORTIZ: Yes, about there – and probably the same height as the lone dot – up there, yes.
MR. HUNGATE: Okay. We all think it’s a good thing. We have variation in feeling of the difficulty.
DR. GREENBERG: And we all agree that it would certainly be easier with the evolving –
MR. HUNGATE: Right. Right. Yes. Right.
DR. ORTIZ: And I do have to say that with mine, I was just focusing on the technical difficulties, not overall. So if I focused on overall, it might shift some to the right – not as far as these guys, these radical, pessimists.
DR. LUMPKIN: Conservative, right? Conservative.
DR. ORTIZ: That’s right. Yes, I don’t think I’ve ever been that far to the left of anything.
DR. GREENBERG: Fair amount of consensus, except two people think it would be easier than –
DR. CARR: But the thing is that – I think the take-home message is that if we are trying to pilot this and make it happen we might have a beta site of where we could see what happens when we do it in a place that is electronic, work out the kinks, so that –
MR. HUNGATE: Well, what I think, we have a model here for discussion, and I think we probably need to broaden our arena of that discussion, because there has been some debate about whether test results should go in an administrative transaction, in a new quality transaction, in a claims attachment. You know, there are some options on how to approach this, and that is probably content for a broader discussion than we want to have just within our own –
DR. GREENBERG: But after the report is published.
MR. HUNGATE: After the report is published, and so I think this kind of analytical development of the fundamental recommendations is the fundamental of our next stance, but it’s not for us to do that. It’s for us to get that done in a little more collective way, at least that is my sense of it. Is that –
MS. COLTIN: Well, I think what you are saying is, particularly on the existing system graphic, that depending on which of those options is the option that is the one that seems to be the most acceptable, given the testimony and whatever – whether it’s a claim transaction or a claim attachment or a new transaction – is really going to impact the ease and difficulty.
DR. GREENBERG: In either system.
MS. COLTIN: Yes.
MR. HUNGATE: I think that our work agenda is going to be more set by this one than this one, in the long run, and I say that because I think we are inclined, as people that have too much to do, to say, well, the future will solve it, and so we don’t need to work on it now, and I have the feeling that the future may not solve it correctly unless we work on it now.
DR. GREENBERG: Yes, I think that’s the Consumer-Disclosure Project’s position that we can’t really wait.
MR. HUNGATE: And so – we can’t wait. We’ve got some things that need doing, and we need to do them. So –
DR. GREENBERG: And, of course, if you have electronic lab data, which is short of having an EHR and all that, it would make this one easier. That’s a – I mean, you know, that is a point that Stan and Clem(?) are always making. Even if you don’t have an electronic health record, if you do have some electronic lab data, you could produce these lab-results information a lot more easily than if you didn’t.
DR. LUMPKIN: Which – not for the same reason, but that’s the reason why Leapfrog has added as its next leap that they want to work on it.
MR. HUNGATE: Okay. John, can you give your score on population – race and ethnicity?
DR. LUMPKIN: Yes, my little star on race and ethnicity was one thumb’s width above the center line and parallel – parallel – the center line, right – to the right, to the right.
MR. HUNGATE: One thumb length.
DR. LUMPKIN: To the right. About there, and then about there.
DR. GREENBERG: Do an X.
MR. HUNGATE: I changed colors.
DR. GREENBERG: We can’t tell.
You think it’s really difficult.
DR. LUMPKIN: Yes.
DR. GREENBERG: Okay.
DR. LUMPKIN: Not technically difficult, but –
DR. GREENBERG: Oh, I know.
DR. LUMPKIN: – overall difficult, and I actually put my X in the same place.
MR. HUNGATE: The issues are not related to the methods –
DR. GREENBERG: You’ve been hanging around him too long.
DR. LUMPKIN: And that the yield in quality is lower than the yield in labs.
DR. GREENBERG: But it’s above the line.
DR. LUMPKIN: But it’s above the line.
DR. GREENBERG: And because the issues are political, et cetera, it’s not that much easier in an electronic record than it is in the administrative.
DR. LUMPKIN: That’s right. Because it’s not –
DR. GREENBERG: Technical.
DR. LUMPKIN: It’s not the transmission –
DR. GREENBERG: Yes.
MR. HUNGATE: Is it useful for us to articulate this method of matrix analysis?
DR. HAYWOOD: Well, the only thing that I was thinking was, in looking at your recommendations, is there anything that anyone would consider to be low yield at all? Because I’m assuming that, given all the testimony, there’s nothing that you guys are going to consider to be low yield.
DR. GREENBERG: That we would bother to –
DR. HAYWOOD: Right.
DR. LUMPKIN: I think the value of this would be in doing a delphi(?) process with a lot of our contacts that we have on the committee. If we could give them a few points to normalize what high, easy and difficult is, what low and high yield is, so you would give them an example – a couple of examples – to define the range, send it out to 200 or 300 people and ask them to fill that our for our recommendations. I think it would give a lot of power to recommendations for change in saying, you know, people really think this is important to do. They think could be – you know, some assessment of these, and I think you could do that at a relative low cost.
DR. GREENBERG: But not before we complete the report.
DR. LUMPKIN: But not before we complete the report.
DR. GREENBERG: Am I sounding like a broken record?
MR. HUNGATE: Yes, Eduardo.
DR. ORTIZ: Well, actually, two comments.
One, I like that idea. I didn’t think about sending it out to 300 people. I think that would be kind of interesting, actually, as a study as well, not just for our own purposes, but a publishable study. As you guys know, I like to publish. So that is – I think –
The second thing is the – I actually – I see the value in this. Even though, on the yield, though, I still see the value, because although we consider everything is going to be somewhat important, there’s still a relative difference in these, and so, given the fact that we may need to decide what to focus on, you know, one cutoff, of course, is things that are very difficult to do right now, because you are going for the low-hanging fruit, but even with this, we have already shown that at least – mine is actually kind of lower as well in terms of yield for this race, ethnicity, and so already I’m separating out that the lab data, to me, would be more important if I had to prioritize than the race, ethnicity data, and so I think it does help us from that perspective as well.
MR. HUNGATE: Yes, I think we tend to put the baseline here.
DR. ORTIZ: Right. I think so.
MR. HUNGATE: That’s probably all right.
DR. ORTIZ: Here’s mine – I’m right here. Okay? All right? The other one. I’m right in the center.
MR. HUNGATE: I think we could more, but I think it is more important that we have a process that we are going to apply in a broader arena, but that is what needs to go into the next stage.
DR. LUMPKIN: Can I change my vote?
DR. ORTIZ: I think it does help to do this.
MR. HUNGATE: I think it does, too.
DR. ORTIZ: And also kind of – you can change your position and listen to the context and it changes your anchoring points. I think it does help, versus – you know – and maybe you had an argument for something. You know, like, for example, to me, race, ethnicity is probably good in terms of measuring stuff, maybe, but it may not be so powerful in terms of really improving quality at this point, versus lab. I could see this both as a measurement and as a quality-improvement thing you could do.
MR. HUNGATE: Well, this is a piece. Let’s talk some more about – we’ve got two subjects, cross-cutting issues and next steps that are on the agenda to finish today.
DR. GREENBERG: Well, what are we going to do about this? No, I mean, are we going to include it in the report or not and how would we generate the information if we were?
MR. HUNGATE: We are not going to include it – but I think we should talk about the concept.
DR. GREENBERG: Okay. As a next step.
MR. HUNGATE: As a next step.
DR. EDINGER: Marge – if we sent it out – it’s something they might like, but –
DR. GREENBERG: The national committee has an ability to circulate its recommendations and ask for feedback in a way that an agency doesn’t, at least, that has been our history.
DR. LUMPKIN: And that’s our story and we’re sticking to it.
MS. KANAAN: So what we are saying is something along the lines of that we will survey stakeholders for their views on –
DR. GREENBERG: Just don’t use the word survey.
MS. KANAAN: We will –
DR. GREENBERG: Solicit feedback.
MS. KANAAN: We will solicit feedback from –
DR. LUMPKIN: Structured solicitation of feedback.
MS. KANAAN: – comments from stakeholders on the – sort of – the difficulty, the achievability and – well, not versus, but and – do we want to call it –
MS. COLTIN: And value.
DR. ORTIZ: Value or –
MS. KANAAN: Value of each of the recommendations.
DR. GREENBERG: It’s very easy to do this with people who have already testified to you or you are bringing in for testimony. It’s just part of the whole testimony, hearing, collection process. And, I mean, I think nobody has ever complained about it. So, as you said, that’s our story.
MS. KANAAN: Well, it’s not that different from what Bruce-what’s-his-name did way back when they were – they did a lot of that kind of soliciting.
DR. GREENBERG: Yes, yes, gathering information –
DR. CARR: And it also defined what type of institution a person is from, one of these or one of those, you know, because their perspective on how hard or easy it is is going to be informed by where they live –
MR. HUNGATE: We are going to need someone to be the content manager of this piece, and I expect that is you, Eduardo.
DR. ORTIZ: I wonder, for this, though, too, if we send this out, I see the value of doing the existing versus the future, but whether, in a way, that gets a little confusing for people, and whether we should maybe do this in pieces and think about focusing on existing at this point. Just something to consider.
DR. CARR: Well, I mean, when we first were talking about this – I mean, I live in the future one, so I can answer that one. It isn’t the future for me. It’s the present, but I remember the other one, so I could answer both. I think it is hard if you are in the existing one to answer what the future is, because you haven’t really –
DR. ORTIZ: Except that your existing is your existing, you know, it’s kind of what –
DR. CARR: Right. But, I mean – but we start out by saying paper and electronic, you know, and that’s kind of –
DR. ORTIZ: I don’t know. I just think – even for me, who deals with this stuff all the time, and I’m very close to this, I find it a little hard to rate this on an existing and a future basis, you know, especially because – separate these out and say, we are defining the future for you, but it’s hard to do that, because we don’t really know what the future holds.
DR. LUMPKIN: Right. But I think we could dissemble the future, so we could say – rather than having three – two, we could have maybe four or five existing EHR, existing CPRE, existing –
DR. GREENBERG: That gets pretty complicated, though.
DR. CARR: Or you could just define your responder groups. You can send it to your group at Harvard or at Lee Prague(?)-compliant hospitals and say, would you answer this? And let the people that live in that environment –
DR. ORTIZ: I think it would be easier if – and it is probably the same thing we are doing, but maybe it’s just communicating it better – that instead of using the terminology – we use the terminology paper-based system – EHR with – decision support. Something that is very explicit, because that makes it easier for me to go, uh-huh, I know what they are saying, because it is a little tough –
DR. GREENBERG: Right – we can’t make it too complicated.
DR. ORTIZ: Right. I mean, maybe just have – I think more than two is pretty complex.
DR. LUMPKIN: So – we need to make sure we have decisional support for them.
DR. EDINGER: You also want to put a time limit for future, whether you’re talking about zero, five, 10 years, something like that.
DR. GREENBERG: Well, it’s whenever you have – however you define what is in the future, then whenever you have it.
DR. ORTIZ: Yes, because we are defining it –
DR. CARR: I would call it a paper-based system –
DR. ORTIZ: But it’s based on system capability. So the future should have an EHR and it should have order entry and it should have decision support. I mean, those should be all component. Now, whether there is anything else you want to add, you know, this whole e-com or other things. I don’t know if you want to do that.
DR. GREENBERG: But it’s got to include not only the paper-based clinical records, but the HIPAA transactions, which are electronic, because it’s – I do think that – well, it’s administrative records plus your paper record versus the other.
DR. ORTIZ: So, that, I think would be fine.
MS. COLTIN: And the variability you’ll get in there is the extent to which they have like a clinical laboratory information system.
DR. GREENBERG: Right. Because that can help –
MR. HUNGATE: You should probably write something – draw it, whatever – and get it to Susan as quickly as you can.
DR. EDINGER: Would you want to do it, though, for different discrete groups –
DR. ORTIZ: So, basically, you just want a written description of what we plan to do in terms of this process and –
DR. GREENBERG: What we feel would be useful.
MR. HUNGATE: What we think would be useful.
MS. KANAAN: Well, for the report, do you think we need to say more than the sentence that we talked about before: We will solicit comments from stakeholders on their views about the achievability and value of each of the recommendations? Do we need more than that?
DR. GREENBERG: I think that’s fine to say that.
MS. KANAAN: I think that’s enough, yes –
DR. ORTIZ: Be enough at this point.
MS. KANAAN: – because we don’t – at this point, right. Yes. So I don’t really think I need anything from Eduardo.
MR. HUNGATE: Okay. Is there any other comment for the – to the report?
Okay. We’ve got a schedule and we’ve got an organization and structure –
Now, let’s talk about activities of the committee. Let’s think about that aspect of our own activity.
I have already raised the issue of the population subcommittee in a wish to deal on the race and ethnicity and probably add survey approaches to that, since it is a common agenda.
I did some thinking about next steps as it relates to this committee, which Debbie made some copies of. I think I’d have to admit to its being a little heavy and biased in the direction that I think is most important, but I would be dishonest if I didn’t speak my voice.
I worked through the Patient Safety Report from cover to cover and see some things that are left unresolved in that.
John made a strong statement at the executive subcommittee retreat about the problem of business case for quality improvement.
Marjorie sent me a copy of an analysis by a Scandinavian – I think – author of the worldwide implementation of quality improvement in its demonstration of success or failure or – and you can read that very much to say the same thing that John did, that there is no business case, no benefit for the improvement of quality using volume group, at least that is the interpretation that I can take away from that.
When I read the Patient Safety Report, I say, yes, this is important, but they have not grappled with some things. They say, and I agree, that quality improvement, to work, has to operate in a non-punitive environment. They say, and I agree, that for product safety to be improved, you’ve got to be able to share your process vis-a-vis other people’s process. You’ve got to be able to see where your errors happened and share that information so others can avoid the same error. In my job as a general manager at Hewlett Packard, I implemented quality improvements and understand, in my gut, the wisdom of what they are saying.
On the next page, they say that this data set will also be used for regulatory purposes. Well, come on, guys, you know, which way do you want it? You can’t do both. Regulatory things are, by necessity, in a way, punitive, and so there is a conundrum left there that is unanswered, and it is my firm belief that risk-adjusted outcomes are the piece that has to compliment that, and my next step kind of argues that.
I don’t think that is an easy task. As John put it, it’s muddy water. You might want to say more, John, but you might not, too. I don’t know, and I don’t get to set the agenda for this workgroup, you know. It’s a mix of the NCVHS itself saying what it should do and those of us that participate saying how we can make a contribution, and that mix is what will make this a constructive piece of the evolution of the health-care system.
I think there are some things that we need to do, as a result of the report, to follow up on race and ethnicity with the population subcommittee is a next step. I think it’s a hearing with the appropriate people where we think about that content in conjunction with discussions with the population subcommittee.
I think there are many issues raised by the administrative claim, claims attachment, quality, transaction alternatives for dealing with some of the other information, test results, et cetera. I think that is a work content, again, which is probably hearing related, where the interested parties in those pieces talk about those, and then there are the other issues that we’ll follow beyond those.
So that’s my sense. I’d like to hear others’ thoughts about what you think we ought to be doing.
DR. EDINGER: I’m just curious. On the issue of quality and the patient safety, the voluntary versus non-punitive, non-punitive on both. The regulatory part, I think they were suggesting that there’s a set of events that should be in the regulatory domain and a set of events that probably are in the sort of non-disclosable domain. I’m not sure how one actually determines which are in which sets, because there is overlap and you’ll probably get into a lot of controversy when you start trying to stratify them with each set. I’m wondering if that’s water we should – that’s probably water that needs to be explored, but is it water we want to get into?
MR. HUNGATE: I’m not sure it’s water where we belong, but I’m – you know, this is a discussable – there’s a lot going on, and we have limited time. We can get some people’s attention focused. We have that power.
DR. LUMPKIN: I think that there are two questions that we have to ask for next steps. The first is what are we good at; and then the second one is, given all that is going on, how can we take what we are good at and throw that into the mix?
So while the – I think the key component of the quality agenda in a near term is going to be to push the agenda for public reporting, there are significant forces involved in that.
Bob Galvin opened up the health-policy conference over at the Renaissance Hotel and talked a fair bit about quality – you know – public reporting –
DR. GREENBERG: Who?
DR. LUMPKIN: Bob Galvin from GE.
MR. HUNGATE: GE. Was in Massachusetts. I used to be on the workgroups with him. I know him.
DR. LUMPKIN: So I think that within that – the context – I think, that what we’re good at are two things. One is reviewing standards that have been adopted by an SDO or SDO-like organization and recommending their adoption – and SOD-like organizations, for instance, are the NQF in this regard.
And two is presenting high-level vision that sort of sets direction, and I think we are good at both of those kinds of things.
I’m not sure what it is that we should do, but I think that within that context of recognizing what we are good at may help guide us in trying to select from a list of things that we might do.
DR. GREENBERG: One other thing I think the committee is good at is bringing in stakeholders and getting feedback and synthesizing that and seeing where there is a consensus and where there isn’t, but not – I think what you are saying is – I mean, the committee isn’t really in a position to do a lot of developmental research work. That is not –
MR. HUNGATE: It’s not our –
DR. GREENBERG: We don’t have the resources. We don’t – we’re not structured that way, but to encourage others to do it and to point out the need for it.
DR. LUMPKIN: And that would be – for instance, a higher level thing would be to set up a research agenda in quality measurement, reaching a consensus on that, making a recommendation to the Secretary. The Secretary does sit over NIH and other entities that have – ARC(?) and others that have research budgets, but –
DR. GREENBERG: Is that something HRQ is doing, evolving a research agenda?
DR. LUMPKIN: That goes into the – I mean, I’m just using that as an example, where – to use our convening ability to –
DR. GREENBERG: Yes.
DR. LUMPKIN: – to pull together something like –
DR. HAYWOOD: Well, let me just ask a quick question – real quick, so I can – because I was thinking about something specific, but I didn’t know if it ties into what John is saying, which is this whole – people are starting to get upset or continuing to have frustrations as to what really should be measurement for the sake of public reporting and what should be measurement for the sake of quality improvement and what should be measurement for the sake of pay for performance, you know.
So I don’t know if NCVHS is the type that would be able to have kind of convening around that or, as you mentioned EQF, and, ultimately, some of this is going to play out there. Either EQF or IOM or some them are going to ultimately have some recommendations around that, but that is one of the big things that I – internally and externally – continue to have discussions around is now that we already have people starting to have this groundswell around human data, give me data, when are we really going to set the limits as to what should be data for the purpose of public reporting, accountability, pay for performance, things of that nature?
MR. HUNGATE: A bias that I have on public reporting is that it help patients, that we think about where the patient is in this, because when I look at all the boards that deal with e-health, with connecting for health, it is 95 percent supplier. You know, it’s either health-care provider or it’s a supplier to health-care provider. You know, it is internal to the system, and that is important, but my quality-improvement model says the customer is pretty critical in this, and I think we need to make sure that that is part of this in an effective way, and I was part of the board at Washington Business Group on Health and the early work that led to HETUS(?) and all of that, and it has not succeeded for beneficiaries. It was done for employers, not for beneficiaries.
DR. LUMPKIN: Right. But I think the factoid that sort of has to be taken into account – at least with where we are at right now – is the data shows that when you make quality information available it has a much bigger influence on provider actions than it does on consumer choice.
MR. HUNGATE: Yes, it does.
DR. LUMPKIN: And so looking at that, we can say – you know, there are a couple of conclusions you can take away from that. One is is that maybe we just haven’t figured out how to provide the information to consumers, which is what I subscribe to, versus those who say that it is just not a value to do that, except for the fact that you can influence provider actions by reporting clout(?).
I think that the issue that Trent was raising of is there a range of quality measurement approaches, is there a difference between the measurement approach if you are a purchaser, versus a payer, versus a consumer is actually an interesting one, and –
MR. HUNGATE: I think it is, too.
DR. LUMPKIN: – I don’t know if there is enough out there for us to comment on that. I mean, can we pull in enough, other than opinions? But it certainly is of value to say are we trying to build three things or will one suffice or –
DR. HAYWOOD: Because I can tell you where the internal discussions that we have had – and even external with kind of Alan Korn(?) and Reed Tuck(?), Blue Cross/Blue Shield, United Health Care – is will someone actually ultimately come up with kind of standards as to if it is going to be for public reporting purposes, these are some of the threshold issues that have to be resolved for that to be the kind of quality measurement data that allow for scrutiny.
If it’s going to be internally for a QI – quality improvement – then should that be kind of lesser standards and less threshold because that’s going to be internal information or if you are going to link it to paper performance, what other certain standards, and so the notion which you were talking about about NCVHS being able to at least adopt or encourage certain standards, and I was wondering whether or not there would be a role there for us thinking about whether or not there needs to be kind of standards of –
MR. HUNGATE: Um-hum.
DR. HAYWOOD: – as we talk about the different –
DR. EDINGER: Maybe it’s a good idea to basically set up the format of what standards are needed and what they are needed for, and maybe bring some of the consumer groups in, to the extent that they exist – or even patients, I mean, people who have had experience – of what information would be helpful to them. I don’t think anybody has really ever asked an average patient, what do you need? And what kind of data would we need to support that kind of information, and as well as the – maybe we should explore having groups come in, just tell them what they need, what kind of data we need to actually support these different efforts.
MS. COLTIN: Actually, there have been a number of groups that have done extensive focus-group work – including CMS – with consumers. I don’t know that anyone has done systematic research outside of a focus-group context, and one can argue the benefits of qualitative versus quantitative research, but there’s been a lot of qualitative research done in this area, and I was just looking for something that – the other thing is the Kaiser Family Foundation published two different reports, back in 2002 I think was the last one, where they asked consumers about quality information and did they want it and so forth.
We just completed, in November, a statewide telephone survey of Massachusetts residents, asking them specifically about quality information and what kinds of information they want, and we asked them if they had seen any information, were they aware of it, and then we asked them what kinds of information would be helpful to them, and we asked them to rate the helpfulness. So things like percent of patients in the doctor’s practice who receive preventive-care services, percent of patients in the doctor’s practice who receive tests or treatments for chronic diseases like diabetes, cure rates or death rates, patient satisfaction with their health care, the doctor’s training and years of experience, the number of patient complaints or lawsuits file, a rating or report card by independent experts, and we asked each one of those how helpful did they think it would be.
We asked if they would be interested in information that compares the quality of care by different individual doctors, and we asked would they be interested in information that compares the quality of care by groups of doctors.
You only lose five percentage points going to the group level, which was interesting.
MR. HUNGATE: Doesn’t surprise me.
MS. COLTIN: So –
DR. GREENBERG: Who is we?
MS. COLTIN: This was done by Massachusetts Health Quality Partners –
DR. GREENBERG: Um-hum.
MS. COLTIN: – which is a stakeholder organization in Massachusetts, and –
DR. GREENBERG: Um-hum. Fascinating.
DR. EDINGER: Would it be helpful to actually hear some of this information –
MR. HUNGATE: I think it would be.
DR. GREENBERG: Are they going to publish the results?
MS. COLTIN: Yes, actually, they are going to have a public release of data and they are going to resurvey. They are releasing the data at the health-system level in September, October of 2004, and they’ll resurvey in November, and then they are releasing it at the physician group level in October of 2005 and they’ll resurvey in November of 2005, and we are trying to see if the awareness dimension of this changes as a result of that.
DR. GREENBERG: What do you – they don’t rate health systems or physicians. So what do you mean –
MS. COLTIN: No, they are actually – they have a grant from RWJ –
DR. GREENBERG: Yes.
MS. COLTIN: – rewarding results grant, and they are evaluating financial and non-financial incentives for quality, and what’s happened is the five largest health plans have pooled all their HEEDIS(?) data at the physician level and it’s been aggregated across Blue Cross – all of them – to produce information at the group level, not at the individual physician level.
DR. GREENBERG: Oh.
MS. COLTIN: So it’s being aggregated –
DR. GREENBERG: Okay.
MS. COLTIN: And that is part of the reason they were interested in how much do you lose if you are only giving the information at the group level.
They are going to go down to the lowest level at which they have a reliable estimate. So –
DR. GREENBERG: I mean, are they going to release –
MS. COLTIN: – it could be a practice site or it could be a risk group, an IPA-type –
DR. GREENBERG: Are they going to release – the survey, though?
MS. COLTIN: Eventually. I don’t know if they are planning to release each iteration of it or the change over time.
DR. GREENBERG: So they’ll see how people react after they’ve seen some data.
MS. COLTIN: Yes.
MR. HUNGATE: The leadership of Mass Medical Society has basically gone on record as favoring transparency, which is an important decision on their part. So I think there are places where this agenda can work very well. I’m not sure of certain –
MS. COLTIN: One of the –
MR. HUNGATE: I’m also worried that we are about out of time. We’ve got seven more minutes, and we are going to need some time to concentrate on this work pretty quick.
DR. GREENBERG: One part of the report we didn’t talk about is the afterward, which has to actually be part of the report. I mean, it’s part of the report, and, Susan, do you have enough – you’re kind of ghost-writing that one, right?
MS. KANAAN: Well, Bob and I are working on it together, but, yes, I think I’m –
MR. HUNGATE: It’s mostly, I think, this discussion –
MS. KANAAN: So, yes. I’m listening very carefully.
MR. HUNGATE: – filling out the matrix, that’s mostly what that is.
DR. GREENBERG: Okay.
MS. KANAAN: We don’t have a lot of concrete things to say yet.
MR. HUNGATE: And we are not trying to make that very concrete, because I think it is a process.
DR. GREENBERG: But does the workgroup need to see that before it goes to the executive subcommittee or does –
MR. HUNGATE: Probably be a good idea.
DR. GREENBERG: I think it – but that is not something we have seen a lot of – I mean, we saw some of your – you know, we know – I don’t think we are going to be shocked or anything, but I think the workgroup needs to react to that before it goes to the executive subcommittee, which pushes that up on the agenda a bit.
DR. ORTIZ: Two things that I am interested in, whether or not it is applicable to our group or not, part of it plays on to what Trent was saying, but I know that – because I have been involved in a lot of these – there’s a lot of initiatives going on nationally on collecting this data, improving quality, the DOQ project, the DOQ IT project, the Bridges to Excellence Project. There’s just lots and lots and lots of things going on, and all of these are looking at collecting quality data. They are not necessarily all talking to each other or working together. They are not necessarily all collecting the same data.
I think since so many things are going on, but they are all going on kind of separately, that it seems like we may have a role in looking at those issues and whether it is bringing these people together and finding out if there’s a way to come up with some standardized things that should be reported, if there’s a way of getting these things to work together, if there’s a way to looking at is it making any difference, is it improving anything, is this just a waste of time, is this what we should be collecting? How should we be presenting it or allowing people access to it? And all those are issues that I think if somebody is not bringing this stuff together it is a little scary, because everybody’s off doing things in different directions, and if you look at some of the measurements, some are okay, some are not evidence based, some are doing this, some are doing that, and so that is one thing that I am very interested in. I don’t know if it is something that we would be able to play a role in.
And then the second piece that I have talked about before, which I think would be nice if we could find a way, which can tie into this or may not, is the fact that we still have nothing good there in terms of collecting consumer-oriented stuff and providing consumers, patients, members, whatever, with information that they need to make their decisions, and to the extent that we could somehow work on that aspect or be interested in working on that aspect, bringing in people in terms of people that are doing this, in terms of people that have ideas in terms of how to do this, because there is really nothing like that out there, and I think that would be very valuable.
And if we did bring in people, consumers, too, I would advocate that we don’t just bring in consumer-advocacy groups, who don’t necessarily represent the consumers that they think that they are representing. You know, we tend to bring in like AARP to represent seniors, which oftentimes do not represent seniors. So actually bring in real people. I don’t know if that is something we want to do, but it is something I am interested in and I think we may be able to do something in that area.
DR. LUMPKIN: The only thing – I mean, that is interested. I think we just need to see to what extent that may or may not be being done by someone else. I think some of those issues are being addressed by the Connecting for Health, personal-health-record work that is being headed up by David Lanksy of FACT(?), who is fairly good at addressing the issue.
DR. ORTIZ: That’s the latter piece that you’re – because the former piece, they’re not dealing with that. The thing about all the different initiatives going on and trying to –
DR. LUMPKIN: Right. Right.
DR. GREENBERG: Were you here when we were talking about convergence? Maybe not – already raised that, and –
MR. HUNGATE: We gotta talk about calendar. We’ve got five minutes.
DR. EDINGER: You think maybe just bringing somebody for a general overview, some people – before we go into –
DR. LUMPKIN: Right. Yes, and I think that after the report is over, I don’t have a problem with the workgroup taking some time to figure out what to do next, and, for instance, the workgroup on the NHII, it really took us about 18 months or so to really lock in to where we are going to be heading next. So I think that looking at things, doing some investigation, doing hearings to bring people in as part of the decision-making process is appropriate.
DR. GREENBERG: Justine, you wanted to say something?
DR. CARR: Well, I was just going to say yesterday afternoon from four ‘til seven we were defining myocardial infarction for Leapfrog, for ACC, for Crusade, for that, and each one includes or excludes a piece of information, and we can’t even say ourselves what our door to balloon time is because we can’t get one definition, and you end up thinking I don’t even know what I’m doing or if I’m measuring something important. So I really underscore that, because trying to implement and report out and you have one data set where you are this percent, another data set you’re that percent and it makes no sense.
So I think there is an urgency to getting some overview on what is important and then how we are going to define it, because the hospitals can’t possibly keep up with all these definitions.
DR. GREENBERG: Well, Pat Merriweather, who probably both of you know, from Illinois – I mean, this is absolutely her passion, this problem, and I think we have a recommendation about survey data. Don’t really have a recommendation about this, but I guess it’s maybe the next step.
MR. HUNGATE: It seems to me we’ve got a lot more discussion to do in this context.
DR. JANES: Well, I mean, I like John’s suggestion that there’s no imperative to race through this process, and, in fact, there’s lots of precedent for taking our time, and, actually, one of the things I was thinking as you were talking was wondering whether or not there was precedent for actually reaching out and bringing in people from outside the workgroup and perhaps outside the committee to talk to us and help us with that process in drafting our next steps, and I heard you say, yes, there is. So I would respectfully submit that we take our time with this process.
MR. HUNGATE: How about the afternoon of March 3rd?
DR. GREENBERG: The report won’t have been issued.
MR. HUNGATE: That’s okay.
DR. JANES: You mean continue the discussion.
MR. HUNGATE: We need to continue the discussion –
DR. GREENBERG: It won’t impact on the report.
MR. HUNGATE: It won’t –
DR. GREENBERG: Okay.
MR. HUNGATE: Report, we’re through talking about the report.
DR. GREENBERG: You’re just talking about the workgroup.
MR. HUNGATE: I’m talking about the workgroup and where we are going, and I think we need more time in this discussion, and the next meeting of the NCVHS is the 4th and 5th, and I’m proposing the preceding afternoon as a content time, if that works for people.
DR. EDINGER: Do you want to have like Vickie or Simon or somebody come in to see – some of the overlap? You want to have a discussion before you get to that level of involving some of these people?
DR. GREENBERG: Well, as I told you, I think standards and security might be meeting that day also, which there isn’t a lot of overlap in membership, but –
MR. HUNGATE: I don’t think we’re ready – I think we need a lot more seeing where we are and how we feel about it, and what is going to work and what you think is most promising. So I think that’s where we belong next time.
DR. GREENBERG: And I think what John says. You don’t have to have closure. You can just decide, well, this is how we want to come to closure on it though.
MS. KANAAN: So it seems to me that the implication, in terms of what we do say in the report, is that the next step for the workgroup is to work on next steps. Probably not going to say a whole lot more than that.
MR. HUNGATE: This is the content.
DR. LUMPKIN: Well, I think maybe that we believe that this workgroup has value, that we have something to contribute related to our ability to convene, to identify broader trends, to encourage convergence and that the next steps of the committee will be to see what areas will best benefit from our focus.
DR. GREENBERG: Sounds good.
MR. HUNGATE: Okay?
DR. GREENBERG: Okay. Next door.
MR. HUNGATE: We’re done.
* * *