[This Transcript is Unedited]




June 10, 2009

National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782

Proceedings By:
CASET Associates, Ltd.
Fairfax, Virginia 22030

P R O C E E D I N G S (3:30 PM)

DR. WARREN: So we have an agenda in the book. Our main point of business is making corrections in this letter and then we would like to follow what Harry told us to start looking at, next topics, next issues. Harry is coming to the table. And then one of the things that Harry mentioned that I thought would be really worthy of us discussing after we finish the letter is the challenge for us to educate the full committee about the work we do. Because I think a lot of the questions and stuff that came up in this letter and they continue to come up in almost every letter we generate, as having to explain a lot of the background and technical components and stuff like that.

I don’t know even how to go about doing this. So we probably need to do some brainstorming. Okay, are your fingers ready Denise? So the first, and I’m open to doing this, I had several places where people wanted edits. We can go line by line and then discuss where recommendations are and how they’re phrased and where they go. Or we could talk about that first. Or what is your pleasure?

MS. BUENNING: Why don’t, I’m kind of looking at this, just let’s start out from the top and work our way down. I think the biggest issue in my mind, from a writing perspective, is if we move the recommendations up in the text, what does that do to that first paragraph? Does it still make sense or whatever? So

MR. BLAIR: Could I suggest a way to handle that? Number one, let’s keep the recommendations where they are but at the end of the first paragraph or the second paragraph, we have one sentence that says this letter will be recommending dot and dot. Just very briefly, very succinctly. And I think that that will address the request that was given to us.

MS. BUENNING: If the end of that, that first paragraph is bullet point number three and it says, it goes through the one, two, and three, and it says and three, our recommendations regarding adoption of e-prescribing standards for use and long-term care. Perhaps we change that bullet point to say our recommendation to adopt NCPDP script 10.6, for use of e-prescribing in long-term care settings.

MR. BLAIR: Does that begin with this letter, will recommend?

MS. BUENNING: Yes. This letter will specifically address these three topics

MR. BLAIR: Perfect.

DR. WARREN: And I’m wondering too, when I’ve seen that you’ve now numbered those, if maybe we do it like the bullets? Keep the numbers, though. But so after topics, do a carriage return? Yes, and then indent that, yes, and then do the same thing with two, yes, and then come down to three. That I think might make it read better. Justine, you’re our resident readability person. Go ahead.

MS. TRUDEL: I don’t think we’re adopting 10.6 just for use in long-term care.

MR. BLAIR: That’s exactly my

PARTICIPANT: It’s for everybody.


MS. TRUDEL: So if we take out for use in long-term care.

DR. WARREN: Right. Just put a sentence after the standard.

MS. TRUDEL: E-prescribing, period.

DR. WARREN: Standards.

PARTICIPANT: Or is it Medicare Part D

MR. BLAIR: Karen, may I suggest that we do make a statement? I think a lot of people were confused about that, that we’re adopting it for all users of e-prescribing.



DR. WARREN: Which means we need to change our tag line up there.

MS. BUENNING: So it’s recommended, so is the third bullet point stating our recommendation to adopt NCPDP script 10.6 for use in e-prescribing?

MR. BLAIR: For all users of e-prescribing.

MS. BUENNING: For all users?

DR. WARREN: Yes. For all prescribers. No, because we’re doing

DR. OVERHAGE: For all e-prescribing transactions.

DR. WARREN: There you go, I like that.

MR. BLAIR: Thank you Marc. I wasn’t sure whether you were here or not, but now I know you are.

DR. OVERHAGE: I am. Hello Jeff.

PARTICIPANT: For all e-prescribing transactions?

DR. WARREN: Right.

MS. BUENNING: Can we go back up to the subject line for a second? Do we need, I think there was a question about whether we needed to put in the subject line, recommendation to adopt NCPDP script standards, to get it up front there.

DR. WARREN: Yes. Right. And that’s probably all that’s needed, or for use in the Medicare Part D.

PARTICIPANT: Although, there you go.

MR. BLAIR: Recommendations to the Secretary to adopt

DR. WARREN: No, that’s just that real short second line at the top.

MS. BUENNING: Recommendation to the Secretary? A recommendation –



PARTICIPANT: Just recommendation for adoption


DR. WARREN: There you go.

MS. BUENNIN: Okay, so the subject line there reads, recommendation to adopt NCPDP scripts standard version 10.6 for use in Medicare Part D e-prescribing.

DR. WARREN: Works for me. Justine.

DR. CARR: Yes, okay. So then I’m just going to that third rec, so does the third bullet tie out with what we’re saying at the top about not e-prescribing in long-term care settings?

DR. WARREN: No, we’re not, this is not for

DR. CARR: Oh, you took out long-term care. Okay, great.



DR. WARREN: Does that work?

MS. BUENNING: Okay. The next –

PARTICIPANT: Anybody else want. The facility needs to be included there.

MS. BUENNING: The next change that I had

DR. WARREN: Was second paragraph of background.

MS. BUENNING: Was that second paragraph where we had the question about whether it was voluntary or not. And I changed that to read, the MMA does not require that prescribers or dispensers implement e-prescribing. However,

DR. WARREN: Right. This time.


DR. WARREN: No, I wouldn’t


MS. BUENNING: However, prescribers and dispensers will electronically transmit prescription and certain other information for covered drugs prescribed for Medicare Part D eligible beneficiaries directly or through an intermediary would be required to comply with any applicable’s final standards in effect for e-prescribing.

DR. OVERHAGE: Just a clarification for me, this only applies to prescription transmission, we’re not talking about medication, history retrieval or eligibility inquiries, which also use, I believe, the script standard?

MR. BLAIR: Actually it’s a good question. Eligibility uses, still uses ASCX 12, even in AN e-prescribing environment.

DR. OVERHAGE: I’m sorry, yes, but then you, the medication history inquiry

PARTICIPANT: That is a part of

DR. WARREN: Right, script.

DR. OVERHAGE: And so my question was this as electronically transmit as opposed to receive. So I wasn’t sure if we were in some way saying don’t, we’re not talking about the retrieval part.

DR. WARREN: We meant transmit.

MS. TRUDEL: Communication? Electronic implies both ways.

DR. WARREN: But transmits both ways.

MS. TRUDEL: Communication?

DR. OVERHAGE: Well, no, you, I transmit to you if I receive from you.

MS. TRUDEL: Well, or electronically transmit and receive.

DR. OVERHAGE: That sounds good.


DR. OVERHAGE: That elegantly solves the problem.

DR. CARR: I would find it easier to follow this if there were some kind of framing introductory sentence that says, there has been a long history of challenge for e-prescribing in long-term care history for the following reasons or something, because it just, and then you go into the background. But we’re, is that what we’re trying to say? We’re trying to explain why, you know, give me a headline of why are we, this much background on what?

MS. BUENNING: I think it’s background, it’s kind of telling us how we, the MMA created this voluntary drug-benefit program, what it requires, what the standards are that were adopted were and why there were some exemptions and then we go into more specifically the exemption for long-term care.

DR. CARR: Great. But the point of giving the background is to say we’re going from, there’s been a long history of challenge for adoption of e-prescribing in long-term care and here’s the background. Is that headlines?

MS. BUENNING: So you’re asking for, at the very top paragraph before the MMA established, you’re saying you want a su? Is that what you’re?

DR. CARR: I don’t know. It just, it begins at the beginning and it’s, just trying to figure out why a person would read on with this. Where is this going?

MR. BLAIR: Right. It’s a phrase, right at the beginning of the background section for what is the rationale for the program exemption.

DR. CARR: Right, exactly, the rationale for why we need to know this background. So, and I may not be saying it correctly, but you know, there’s been a long history of challenge or complexity with regard to e-prescribing in a long-term care setting. And then you go on to say what that is.

MS. BUENNING: Well, what if we, what if we go back a little bit, maybe we qualify that in one of the bullet points above that says that the letter will specifically address three topics. So in, maybe we just put something in that first bullet point that says the history of, or, and/or current exemption for long-term care facilities as opposed to it starting in the background with

DR. WARREN: Just, just a minute. Karen, you want to chime in and then

MS. TRUDEL: I was going to suggest that Justine’s point makes, it makes a lot of sense, but it doesn’t fit in my mind with that first paragraph in the background. But it does seem to fit with the second paragraph and I was wondering if we could take out the first paragraph because it is a little bit redundant and just have that be the beginning of the second paragraph.

DR. CARR: Right, and actually if this, if in fact, this background follows the one, two, three. I mean, I get that we have one, two, three, but I can’t quite find where, you know, do we want a header, a headline. What is one, for an exemption for long-term care, dada, dada, dada. Two, progress in modifying standards, dada dada. Three.

MS. BUENNING: We can put some sub-heads in there if that would be helpful to make it mimic that first, the first bullet point.

DR. CARR: It’s just that, it’s a rather a long letter and I think it just is helpful if it’s clear.

MS. BUENNING: Okay, so I think the recommendation is, under the background section, to delete the first paragraph, perhaps put a sub-head in that says current exemption, or exemptions, or, and then start out with the MMA does not require? Walter?

DR. WARREN: Yes, Walter, sorry.

DR. SUAREZ: I think the two paragraphs are talking about two different things. The first paragraph established the fact that MMA established a voluntary prescription, and then he talks about the sponsors being required to establish networks. That’s separate from the fact that MMA, it’s separate from the fact that providers or prescribers and dispensers can choose to electronically transmit. So it’s two different, I think they’re two different things. One is the fact that the Medicare program, MMA requires establishment of these networks. And then the second paragraph that talks about prescribers and dispensers can choose to electronically transmit and receive.

MS. BUENNING: So is the recommendation then to eliminate that and move the second paragraph up?

DR. SUAREZ: No, I was suggesting not to, I was suggesting that is actually a sentence, a statement, that is not repetitive from where I see it. That’s a statement, because the first part of the statement is stating a requirement different than the voluntary adoption for prescriptions.

DR. WARREN: To me, that first paragraph states what is in law, you know, and is useful, I think, to state that, especially for people who may be new to dealing with MMA and some of the results of that law.

DR. CARR: I think what would be helpful for me is if you could just state what the outline of this background section is. You know, the first part is to say the law. Second, second is, what?

DR. SUAREZ: The second is that, and that’s what I was going to suggest when I raised my hand, the second is the fact that prescribers and dispensers who choose to transmit or receive electronically prescriptions must comply with the applicable standard. And that’s what is not

MR. BLAIR: Tag on the second paragraph is compliance with the standards.

DR. SUAREZ: Yes. So I would say that where it says however, prescriber and dispensers who choose to transmit or receive electronically prescriptions and certain other information, ddddda, and that at the end, I would replace would be with must, would be required to comply with must comply.


DR. SUAREZ: But that is, I think what

DR. WARREN: Does that work?

DR. CARR: So first it’s the law then we’re saying that you must comply with the standard. And then the third thing is to say why the standard, why it has posed a challenge to long-term care. Right?

DR. WARREN: Right.

MS. BUENNING: So, so, do you, where I have the cursor up there, do you want me to put something that says the law, or legal back, I’m fishing here.

DR. WARREN: See, I’m not sure you need it there. I think where it’s needed is right before the third paragraph. Because the third paragraph is now getting into what the problem is. Right. Because the first one’s saying, this is the law. The second one is, if you use e-prescribing, you’ve got to, here’s a standard. And then the challenge to using the standards in long-term care.

Does that have it right, Walter?

DR. SUAREZ: Yes, that’s exactly right.

DR. WARREN: Actually I won’t

PARTICIPANT: No, that’s good

MS. BUENING: Want me to bold that? Okay. Does that help?

DR. CARR: Yes. So now we’re talking about e-prescribing challenges in long-term care.

MS. BUENNING: Okay. And the only other change I made in that paragraph that begins November 2005 is we put in after therefore long-term care facilities to find under Medicare Part D, is skilled nursing facilities were exempted from the requirement to use the NCPDP script 8.1 standard.

DR. CARR: So at any point and time, feel free to take my microphone away, but I’m going to tell you what I think. The, the, let’s see, you said the November 2005 regulation that adopted foundation standards for e-prescribing contained three exemptions. I thought I was going to see one, two, three. But we don’t talk about three. We only talk about one. Right.

MS. BUENNING: That’s because the other two don’t relate.

DR. WARREN: Right. So let’s not confuse people. Let’s just say the 2000 November ‘05 regulation adopted foundations

PARTICIPANT: exemption


MS. TRUDEL: But it wasn’t to version 8.1 because that’s not what we adopted in 2005.

PARTICIPANT: Oh, in 2005 it was five.

PARTICIPANT: It was 5.0.


PARTICIPANT: You’re right.

PARTICIPANT: So what was adopted?

DR. CARR: So it contained an exemption and then tell us, you know, the reason was

DR. WARREN: But wait a minute, go back, so you want us to take out November 2005 or

DR. CARR: No, I’m fine with that. But I’m just saying don’t say there’s three exemptions and I’m only going to tell you about one.

DR. WARREN: Oh, oh. It’s version, no, no, no, I’m, the wording of the standard. Was it version 5.0 that we started with?


MS. BUENNING: Does that help?

MS. TRUDEL: Then it should say it was based instead of one was

DR. CARR: Just take out one was. Just say based on comments from the health industry. No, no, make that a capital B.

PARTICIPANT: Just run the whole sentence together.


MS. BUENNING: I got it.




PARTICIPANT: Make it a capital.

DR. CARR: Begin, this is a new sentence now. Begin

DR. WARNER: Wait a minute. Are we at a new sentence now. I can’t tell if there’s a period. It was a new sentence.

DR. CARR: You know, you should make this like 200 percent, you know, so everybody can read it, go up to it.

DR. WARREN: Try 150 and see if

MS. BUENNING: Does that help?

DR. WARREN: There you go. Right there.


DR. WARREN: Okay, so there’s a comma there now, not a period.

DR. CARR: But we could just say November ’05 regulation adopted foundation standards for e-prescribing

DR. WARREN: Boy that makes that sentence really long. You combined two long sentences together.

DR. CARR: So period, then, based on comments from the health industry

DR. WARREN: Make that capital B, there you go.

MR. BLAIR: You know, sometimes blindness is a blessing.


PARTICIPANT: You’re right about that.

DR. WARREN: Because even with seeing it, it’s hard.

MR. REYNOLDS: Jeff, I wish I couldn’t hear right now.

PARTICIPANT: I thought that’s what we had before we decided not to put

DR. CARR: Let’s take it out. Let’s try to make a goal of taking out 250 words out of this thing.

MS. BUENNING: Well, but I think that if we put a comma after standards, that becomes an incredibly long sentence.

DR. CARR: No, make it a new sentence. Based on comments from the health care industry


PARTICIPANT: Okay, hold on.

PARTICIPANT: That’s what she did.

MS. BUENNING: Based on comments from the health care industry that indicated that the proposed standards, while well accepted in the ambulatory setting, were not proven to sufficiently support the work flows and legal responsibilities in a long-term care setting

DR. WARREN: That’s not a complete sentence.



MS. BUENNING: I got it. I got it.

PARTICIPANT: There you go.


PARTICIPANTS: comments indicated that

DR. CARR: for Jeff, comments from the health care industry indicated that the proposed standards, while well accepted in the ambulatory setting, were not proven to sufficiently support Do we have to say were not proven or how about did not sufficiently support the work flows and legal responsibilities, and take out the, did not sufficiently support work flow and legal, no, the one above, sorry, the work flow, take out the work flow, did not sufficiently support work flow and legal responsibilities in a long-term care setting.

PARTICIPANT: But it’s work flows. There’s more than one work flow affected.

PARTICIPANT: It’s work flows.


MR. BLAIR: Thank you.


PARTICIPANT: Therefore, long-term care facilities were exempted from the requirement to use NCPDP’s, yes.

MS. BUENNING: Karen, do we want to specify that it was a 5.0 standard there?

MS. TRUDEL: I thought that was something that John had suggested. Somebody suggested that today while we were talking.

MS. BUENNING: Well, you know the problem was that we kind of had that shift. We were going to do 5.0 and then when we started the pilot testing, we shifted it, vowed that it could test 8.1 because that was what was available at the time. And I’m trying to remember back, did we actually exempt them from 5.0? We must have because we didn’t start pilot testing until after the exemption was in place.


MS. TRUDEL: But I don’t think it’s relevant. I was going to say I don’t think it’s relevant because it’s whatever standard was in place at the time and the reason, because otherwise we’re going to have to do a paper trail of 5.0 to 8.1 to 10.2 and it’s

MS. BUENNING: I think take out the version

DR. WARREN: Yes, take out version

MS. BUENNING: That’s fine. Leave it the way it was. Okay. It was exempted from the requirement to use the NCPDP script standard. Okay.

DR. WARREN: And then you were going to take out that CY from the

MS. BUENNING: Did I not do that? I think I already did that.

DR. WARREN: You’ve already taken it out.

DR. CARR: Can we go up to health care delivery in long-term care settings is unique for several reasons? Why don’t we say instead, one work flow issue was that nurses, how do you say it, what is the issue, nurses are the caregivers, but that, what’s the prescribing issue?

MS. BUENNING: The issue is it’s a three-way prescribing communication between the facility, the physician, and the pharmacy and then you also have, when they say the facility, i.e. it’s a nurse or nurse practitioner.

DR. WARREN: The nurse may initiate the prescription even if you don’t have a nurse practitioner in a long-term care facility. It’s the nurse who says we need to renew this and it’s the facility that holds on to the drugs, not the patient.

DR. CARR: So the problem is that the nurse initiates it and

DR. WARREN: And stores and dispenses. Where if you were an ambulatory, it’s the patient that stores and dispenses. So you’ve got a third party in here that

DR. CARR: Right. But the paragraph doesn’t exactly explain to me what the issue is, so one work flow issue was that the nurse initiates the prescription, that in contrast to ambulatory, where the doctor initiates it, and in this setting the nurse initiates it? I mean

DR. WARREN: On behalf of the patient.

DR. OVERHAGE: But in a lot of ways, in that example, the nurse is just a proxy for the patient. So in the typical ambulatory, you prescribed in the scenario, the patient would call the pharmacy and say I need a refill. And the pharmacist would look and say oh, I don’t have any and make the request. And so in a lot of ways, it’s analogous except that we’re now saying we want the proxy to be able to electronically communicate the request.


DR. WARREN: It’s trying to document the both the nurse and the long-term care facility in that e-prescribing transaction. And there weren’t any fields to do that because before, you just had the patient, the doctor, and the pharmacy.


DR. CARR: Right. So maybe that’s what you need to say, a key issue was there was no field for nursing initiating a prescription, or whatever it is, and then say

DR. WARREN: The thing is, is that, I’m wondering if, because if you go to the next page, that is spelled out.

MS. BUENNING: I need to go back down to 100 just so I can kind of see the main context.

DR. WARREN: We’re looking at the paragraph, health care delivery. But if you look at the paragraph right below it, it starts spelling out where these problems are, within the next two paragraphs, as to fields and stuff like that. So what I’m thinking is maybe

PARTICIPANT: Move that paragraph.

DR. CARR: I think that’s helpful, moving that paragraph up makes it more understandable to the reader, this reader.

MS. BUENNING: So do you want to take the paragraph that starts, in long-term care, and move that above where it starts, health care delivery? Or do you want it, use health care delivery in long-term care is unique, and then eliminate the rest of this paragraph and put that one in it’s place?

DR. CARR: Or what about this, introductory sentence, one work flow issue, because I’m just trying to tie it to the previous paragraph. We’ve set it up in the paragraph and following through, one work flow issue had to do with a nurse initiation of a prescription, or whatever is the right word. And then go into, in long-term care prescription order typically remains open.

MS. BUENNING: So one work flow issue had to do with the role of the nurse

DR. CARR: And then, then maybe you say then go to nurses are frequently the primary caregivers

MS. BUENNING: I guess I don’t have a level of comfort with talking about the role of the nurse in long-term care prescribing because I don’t want to, it’s illegal.

DR. WARREN: It’s the whole issue of, instead of having three individuals involved, we now have a fourth one that’s in there. And I’m drawing a blank because when I read it, it’s pretty clear to me what’s going on but then I have a mindset having done some long-term care stuff myself, about how that’s done. But one of the main issues that we heard in testimony is that a lot of the long-term care facilities, their legal department did not want them doing e-prescribing because it left them open to risk and also the way they interpreted the regulations is that it wasn’t, regulations did not specify that they should use e-prescribing. And long-term care wanted to use e-prescribing in order to reap the benefits that come from that.

MS. BUENNING: I will be honest with you, the language that we have in here was lifted literally from the regulation. And I know it was crafted very carefully just to avoid that issue, so, you know,

DR. WARREN: Right.

DR. CARR: Which language?

MS. BUENNING: This, these two, these paragraphs, health care delivery in long-term care settings is unique and the next one, and the next one.

MS. TRUDEL: Yes, this comes from the language in the regulation that explains why we established the exemption in the first place. I think that’s why it seems so familiar to me.

DR. CARR: I’m just being like the objective person who isn’t familiar with this, but maybe it would be helpful to say, in an ambulatory setting, a doctor writes a prescription, a patient goes and picks up the prescription, a pharmacy gives it. In long-term care, the doctor writes it, the nurse acts on behalf of the patient. Is that the part that we’re saying?

DR. WARREN: Well I think that, okay, let me, in order to do that, it would add almost half a page and we would be summarizing a previous letter that we’ve already written about what happens in in-patient and ambulatory care. And that wasn’t really the intent of the letter. It is to show why the previous standard was insufficient in one particular place and why we need to go to the new standard, which still works perfectly well in ambulatory care.

MR. REYNOLDS: Well, in between there, should we reference, should you reference the previous letter as an explanation because then, Justine, I think if somebody reads it and, that isn’t, I think you’re making a great point, then they could go back to the other letter, possibly.

PARTICIPANT: We could do that. Yes.

MS. BUENNING: Can I make a suggestion? I’m just looking at these paragraphs again and I’m wondering if we take this section, which really basically talks about the pilot testing, and move that here, before we actually talk about the pilots, and move long-term care up here, because it really kind of, it talks about the work flows up here, it talks about what actually happens to a prescription in long-term care. I think it groups it a little bit better.

DR. WARREN: Why don’t you go ahead and move it and maybe look again?

MS. BUENNING: Let me, yes, let me look at it again, let’s make a copy on this, delete. I think we can take this, perhaps, because you already talked about the uniqueness.

PARTICIPANT: Can you enlarge it again?

MS. TRUDEL: I don’t think the second sentence in that paragraph actually says anything useful.

MS. BUENNING: Specialized long-term care pharmacy

MS. TRUDEL: No, this pilot setting provided

MS. BUENNING: So get rid of that?

MS. TRUDEL: I don’t, well, does anybody else think it does? I mean, I don’t think we need to talk too much about the pilot. I’m not sure we need to talk at all about the pilot. The pilot was kind of the, the catalyst for the discussions, but,

PARTICIPANT: And we’ve reported on the pilots before anyway.

MS. BUENNING: Okay, why don’t we try this. Well, I was going to say, do we have

PARTICIPANT: Do we need that?


MS. TRUDEL: I mean, it seems like we’re reciting the whole history of every step in the process to get to 10.6 and if you’re trying to make the letter shorter, I’m not sure how much that has.

DR. WARREN: Yes. Well especially if we put an asterisk and footnote the previous letter.


MS. BUENNING: So do we want to get rid of this piece of it? I’m trying to figure out how we lead into the changes that were made as a result of the pilots because they are significant.

PARTICIPANT: Well, I don’t

DR. OVERHAGE: But why not just say the pilots led to significant changes which have been incorporated into version 10.8 to accommodate the needs of, while preserving backward compatibility of further settings, or

MS. BUENNING: Could you repeat that?

DR. WARREN: Okay, so, it’s kind of up there with the given.


DR. WARREN: Because I think most of that paragraph can probably be, actually, just take all of that out and then what Marc said.

MS. BEUNNING: On completion of the LTC pilot proposal, does that work?

DR. WARREN: Well I don’t think we need to, do we really need to talk about the pilot?

MS. BUENNING: Well it depends, I mean, it depends on, I mean, we can take this whole thing.

DR. WARREN: I don’t remember how you started that out Marc, but it was something about in order to

DR. OVERHAGE: Just based on the experiences or learnings from the pilot, or something more elegant.


DR. OVERHAGE: Beautiful.


MS. BUENNING: That work?


DR. OVERHAGE: That’s perfect.


PARTICIPANT: It gets rid of some


PARTICIPANT: Did we take out, that it was a pilot

DR. CARR: The beginning sentence says upon completion of long-term care, a long-term care pilot demonstrated, or whatever

MS. BUENNING: Didn’t we refer to a long-term care

DR. WARREN: Did we take it out?

MS. BUENNING: That’s true. Hold on. I think we did take that out. So on completion of the

DR. CARR: Say a long-term care pilot demonstrated

DR. WARREN: Wait a minute. Did we say anything about the long-term care pilot before this?

PARTICIPANT: No, no, we cut that out.

MS. BUENNING: So, hold on, hold on.

MS. TRUDEL: No, it wasn’t a long-term care pilot. E-prescribing, no, e-prescribing standards’ the pilot.

PARTICIPANT: Was it a prescribing?

DR. WARREN: In a long-term care setting.

MS. BUENNING: That were necessary

DR. WARREN: Yes. To support e-prescribing in a long-term care setting. Yes.

MS. BUENNING: To support e-prescribing in long-term care settings.


MS. BUENNING: These modifications, not requests.




DR. WARREN: Okay, so we have,

PARTICIPANT: Then Jeff seeing multiple commas everywhere, so

MS. BUENNING: I’m sorry, what?

DR. WARREN: He’s over here correcting her grammar. Just ignore him.

MS. BUENNING: Okay. Do we have anything else through here. I know

DR. CARR: It is the differences among more than two, it’s 10.5, 10.6, and what’s the other one?

MS. BUENNING: It’s 10.2, 10.5, 10.6.

DR. CARR: Alright.

MS. BUENNING: That’s why it’s among. Because we talk about the fact that the standard, that the updates were based on 10.2.

DR. CARR: So it’s differences among NCPDP, not updated? It’s just the different versions.

MS. BUENNING: That’s fine.

DR. CARR: Is it standard versions or just versions?

PARTICIPANT: Versions because we’re

PARTICIPANT: Versions, differences among

DR. CARR: But not standard?

PARTICIPANT: Because we mention 10.5, 10.2, and 10.6 in there.

MS. BUENNING: Differences among NCPDP script versions?


DR. WARREN: There you go.

MS. BUENNING: And I think we had put in all of

DR. CARR: Since what time, since that time

MS. BUENNING: Since, it refers to the paragraph previous to that because it talks about modifications were made in July 2007, indicating that 10.2 meets the basic needs, and then it just says, referred since that time

DR. WARREN: Should say since 2007.

MS. BUENNING: Since 2007?

DR. WARREN: Yes. Make it clear.


DR. CARR: Well, why don’t we just take out since anything? Just say, because it says NCPDP was approved in 2008. 10.5 was approved by NCPDP Board of Trustees in June of 2008.

PARTICIPANT: That’s fine.

DR. CARR: And do we have to call it this updated standard version? Can’t we just call it this version built upon script 10.2? Or, it just, it goes without saying that it’s updated if it’s a later version. So I’d take out updated too.

DR. WARREN: Okay, then, down in the bullets, Walter wanted us to put in quotations the names of the data fields, so in the second one, okay, this is different from what I have, oh.

MS. BUENNING: Right. But I made those changes as Walter was speaking. Is that, did I not put the quotations in the right places? Did he want, for example, in the first bullet, did he want the quotes around

DR. WARREN: There was a second bullet that’s not, the first bullet was identification for facility, I’m not in the right,

MS. BUENNING: Hold on. Oh, we got rid of that. You’re looking at the previous paragraph that we deleted.

DR. WARREN: Sorry.

MS. BUENNING: That’s okay. Underneath the section

DR. WARREN: Yes, I see where we are.

MS. BUENNING: Okay. Are there any other changes on

DR. WARREN: So medication history response, and then under allergies, yes, you got the S there, okay.

DR. CARR: So what these, the problem was the nurses and the prescribing. And these updates, how did they fix the nurses’ problem?

DR. WARREN: They provided a slot in the standard to put the data.

DR. CARR: Okay. Does it say that somewhere?

DR. WARREN: I mean, these are segment names, that’s what that means. Functions, if you look there, the paragraph, the additional new functions offered by NCPDP script 10.6 are primarily related to the medication history functionality and then the bullets specify each of those pieces.

DR. CARR: Where does it say anything about the nurse? But shouldn’t we have something that says, which thereby enabled the nurses to do what they needed to do, you know.

DR. WARREN: Well it doesn’t, I mean, the standard has nothing to do with what nurses do. The standard is only about transmitting information so that we have an identity, a facility identity in there.

DR. CARR: But if we say, there were challenges to using this in long-term care, shouldn’t we say by implementing these changes, this challenge a, b, c, were thereby remediated?

MS. BUENNING: Well, we kind of, I think, didn’t we address that in the previous paragraph? We talked about the pilots, identified modifications that were necessary. Modifications were fully incorporated in 10.2. And then this one goes on to say oh, yes, and by the way, 10.5 is based on 10.2 and it has these additional changes. And then 10.6 adds these additional functionalities. So I think it’s a layering. I think

DR. CARR: I would just somewhere say thereby eliminating the earlier challenges of

MS. BUENNING: Well we talk about the fact that the identified modifications that were necessary to support e-prescribing in long-term care settings, the modifications were incorporated in script 10.2.

DR. WARREN: So maybe the place to put what Justine’s talking about is after those bullets, you have these additions, facilitate better record-matching, do we still have that in there? Okay.

MS. BUENNING: These additions facilitate better record-matching, reduction in duplication, and richer information being presented, and

DR. WARREN: And to satisfy the challenges, or alleviate the challenges posed by e-prescribing in a long-term care setting. Does that

DR. CARR: Or, more importantly, since it’s about the long-term care setting, in addition to remediating the long-term care setting problems, it also affords better record-matching, reduces duplication, and provides richer presentation at the point of prescribing, because those are by-pro, that’s not what we’re writing about. We’re writing about fixing long-term care and these, while true, aren’t really related to the problem statement.

MR. BLAIR: Good distinction.

DR. CARR: A Harry note. Brings back memory here. Harry sat next to me on a

MR. REYNOLDS: We got the right dog chasing the right rabbit. I think it’s just great, you know.

MR. BLAIR: Justine, with that change, even a blind guy could understand it.

MS. BUENNING: Okay, let’s try this. So that

MR. REYNOLDS: The committee will not recognize a single thing. They’ll think we brought a new letter in. No, keep going, make it right.

DR. WARREN: But we’re going to say that Justine cut out words and made it short.

MR. REYNOLDS: That’s right.

MS. BUENNING: In addition to remediating e-prescribing issues in long-term care settings, these revisions facilitate better record-matching, reduction in duplications, and richer information being presented to the prescriber at the point of prescribing.


MR. REYNOLDS: What I think is most exciting is that Tom Brady’s back and so Justine’s back. That’s what, isn’t that great.

DR. WARREN: I have a little editing thing that’s bothering me. We have a list of things there and everything is in the right order except we have a prepositional phrase. Could we do duplication reduction?

MS. BUENNING: Yes. We have to do one way or the other.


MS. BUENNING: Facilitate, it facilitates three things.

DR. WARREN: Now they’re all at the same kind of thing.


DR. WARREN: Okay, so

MS. TRUDEL: I don’t think that there’s been any discussion to date to this point on the fact that it’s backwards compatible. I think the first time that comes up is in the recommendation. And I’m wondering if it might be a good idea to just put a, right down where you were before Denise, where it says the long-term care industry is in favor of it, could we also just have one more actual statement that says NCPDP certifies that this is backwards compatible with version 8.1, which is already in use. That would be, just have that kind of up front statement, because I’m going to need that.

DR. WARREN: Yes. That’s excellent. So it looks like we’ve cut out page four.

PARTICIPANT: Widespread use?

MS. TRUDEL: Well no, I think what we say is version 8.1, which is currently the adopted standard.

MS. BUENNING: Okay, I’m still looking for something which is

PARTICIPANT: There you go.

DR. WARREN: Because the backward compatible stuff was all bad in the recommendations.

MS. BUENNING: Well we get into that a little bit where we get under the differences section, the second paragraph talks about NCPDP is further advanced it’s script to 10.6, preserving all the previous NCPDP scripts stated requirements needed to support e-prescribing in long-term care settings. So we kind of allude to it. We don’t usually actually say backward compatible.

PARTICIPANT: We don’t use the words. Yes.

PARTICIPANT: Needs the words backward compatible.

PARTICIPANT: I don’t think it hurts to have it where you just finished typing it.

MS. BUENNING: Okay. Karen, is that okay with you? Okay.


MS. BUENNING: Okay, then, we have the recommendations?

MS. TRUDEL: Could the recommendation, could the first recommendation just be cut off after the first sentence? It says NCVHS recommends that NCPDP script version 10.6 be adopted by the Secretary for voluntary use under the streamlined process for backward compatible standards. And maybe we can do the same thing on the second one.

DR. CARR: I agree. I think it makes it stronger.

MR. BLAIR: Karen, I’m assuming you’ve done a scan on the text that we’re deleting out of, that follow each recommendation, to make sure we haven’t lost anything because you picked up the backwards compatibility, so


MS. TRUDEL: Yes, we got it.

DR. CARR: So the recommendations, Jeff, we, the first recommendation, one, the NCVHS recommends that NCPDP script version 10.6 be adopted by the Secretary for voluntary use under the streamlined process for backward compatible standards. Recommendation two is the NCVHS recommends lifting the current exemption from the requirements to use the NCPDP script standard for non-prescribing providers in a long-term care setting.

DR. WARREN: In the old one, we deleted the sentence on recommendation two that we might want to put somewhere. We said that the voluntary use of 10.6 standard, even while the exemption is in place, we believe lifting the exemption sends a clear message to the industry about the desirability of e-prescribing in long-term care.

MS. BUENNING: Do we want to put that?

DR. CARR: Or we could put that with the recommendations, saying, just add a sentence saying this sends a strong message of the importance of e-prescribing.

MS. BUENNING: Hold on, I’ll get back to there.

DR. WARREN: Yes, if we just put the last sentence back, I think that to me would be better.

MS. BUENNING: Okay, long-care settings.


PARTICIPANT: Right there.

PARTICIPANT: Lifting the, you don’t need





DR. WARREN: Alright Jeff, you had a question?

MR. BLAIR: I have a question. In the first recommendation where it winds up saying that we’re recommending it be adopted by the Secretary for voluntary use, we don’t say use by who. Do we need to here or not?

MS. BUENNING: Well, we talk about, we previously talked about the adoption under MMA and who is required to, the fact that it’s, hold on, where is it, the fact that plans are required to establish drug programs, but it doesn’t require prescribers or dispensers, only those who, I think, I don’t know, I think because we talk about it previously, and I think the fact that we talk about the fact that it’s voluntary use kind of covers it?

DR. WARREN: Well, the script standard, the script standard is not voluntary use. E-prescribing is voluntary use. If you’re going to do e-prescribing, you’re required to use the standard.

MS. TRUDEL: Right, but because the way backwards compatibility works, we have two standards in place. So basically what we’re doing is saying 8.1 is the standard of record, but if you want to, you can use 10.6. So in that case, it is voluntary.

DR. WARREN: Oh, okay. I don’t think that recommendation will be read that way.

DR. OVERHAGE: Yes, so this is, we’re recommending 10.6 in addition to

MS. TRUDEL: In addition to, that’s the way backwards compatible process works, right. And that’s why we’re allowed to do it, using a final rule with comment instead of the whole notice and rule-making process because we manage to work it out. It doesn’t hurt anybody.

MR. BLAIR: Right. I opened a Pandora’s Box.

DR. OVERHAGE: No, no, no. You asked a very important question.

PARTICIPANT: This is a critical piece.


DR. OVERHAGE: So can, I mean, I don’t think it changes anything too dramatically other than to somehow make clear that we’re saying we’re recommending 10.6 while retaining the option to use 8.5 or in addition to the existing standard, or something, I mean, in particular, for somebody’s that not close to this reading the letter and saying oh, I can’t use 8 any more.

DR. WARREN: So you’ve got 8 and then think of 10.6 as a shell that’s been added around it. So eight is still there.


MS. BUENNING: Yes, we’re not saying to eliminate 8.1, we’re just saying

DR. OVERHAGE: No, I know we don’t say it explicitly, but I think we need at least a phrase in the recommendation or maybe not in the recommendation, but in the body that says

MS. TRUDEL: Could we take out, by the Secretary and say the NCVHS recommends that NCPDP’s script version 10.6 be adopted in addition to version 8.1 for voluntary use under the streamline process, does that, for backward compatible standards.

MR. BLAIR: Yes, well, it’s, I, maybe confusing to people seeing in one part of the sentence it’s saying is adopted and the other part it’s saying for voluntary use. So if we don’t indicate adopted by who and used by who, then I’m just concerned that somebody that’s not in this room might find it confusing.

DR. WARREN: See, I, still the word voluntary use there, where we’ve got it, we, it bothers me because to me if I read it like that, it says that even version 8.1 is for voluntary use.

MS. TRUDEL: Okay, could we take out the, for voluntary use and try to, I think there’s a place earlier where we talked about the backward compatible process, maybe we could add it there, or maybe not.

DR. WARREN: Well, I think we’re real close, back to the recommendation, because I think it was the word voluntary that was bothering me. Okay, you scroll up to

MS. BUENNING: I’m sorry, scroll up?

DR. WARREN: Right there. I can’t see, I need to see recommendation one.

MS. BUENNING: Okay, I’m sorry.

DR. WARREN: Recommends the NCPDP version 10.6 be adopted, why should you say under the streamline process for backwards compatibility?

MS. BUENNING: We’ve got to have that in there, I think, because that’s

DR. WARREN: You don’t need in addition to 8.1


MS. TRUDEL: Okay, then I think, yes, you need to take out, yes, okay, but do we, then want to put a sentence in the paragraph right above the recommendation’s heading that explains that backward compatible standards, just that explains the backward compatible process? I’m sure I could write something that basically says that under this process you can use either one and it’s a streamline.

DR. WARREN: Let’s go back, we were, there was one point where we going to put an asterisk and put a footnote to our previous letter that explains all that. So do we need to pull that out again, or just put, again, same footnote here?

PARTICIPANT: Okay, that would be fine.

MS. BUENNING: Okay, I’m sorry, where are we putting an asterisk?

DR. WARREN: Well, there was some place earlier in the letter where we said that we wanted to reference our previous letter

MS. BUENNING: I thought it was the paragraph that started, health care delivery in long-term care

DR. WARREN: Yes, there, and then again right before our recommendations.

PARTICIPANT: That’s the same letter.

MS. BUENNING: Okay, asterisk there and then again, before, at recommendations, at the header

MS. TRUDEL: Yes, right up at the end of the paragraph before.

PARTICIPANT: Here. Exactly.

PARTICIPANT: Right there.

DR. WARREN: Okay, and the asterisk is going to say

MS. TRUDEL: Something about for additional information, please refer to, and I’d have to look and see what the letter

PARTICIPANT: Maybe it’s recommendation letter dated blah?


PARTICIPANT: We’ll have to get that off the website.


MR. BLAIR: Karen, is the backwards compatibility, does that enable us to avoid going through the MPRN process, the dreaded MPRN process? So I am assuming that that’s the sentence that you, that you really want to add, is that it helps us avoid the MPRN process.


MS. TRUDEL: Absolutely. Well, no, the only, I just needed the words backward compatible in there so that we know that they were certified to be backward compatible and that you’re recommending, because they’re backward compatible, that we adopt it through this process. And the rest of it, I think, as we asked questions, there started to be a need for more information. I don’t know that it needs to be in the letter.

PARTICIPANT: I think this is great.

MR. BLAIR: Okay.

DR. WARREN: Is that the only letter that we wrote about the backward compatibility? Didn’t we also write one with 10.2 because as I remember, that letter is really brief, the one from June 8th.

MS. BUENNING: I’ll have to go back on the website and check, but I think that, I mean, we’ve talked about backwards compatibility in a number of different areas, but I think the one specifically to the script standard was a 10.5 one. I don’t think we ever wrote one on 10.2.

MS. TRUDEL: No, but we did write on on 8.1, yes.

MS. BUENNING: Which may have more of that background in it.

DR. WARREN: Right. So I think we need to refer to both letters.


MR. BLAIR: In a situation like this, is it helpful or useful if we had an appendix and the appendix had the 8.1 letter?

PARTICIPANT: No, I think that

MS. BUENNING: We would probably include it with this letter. I think we’ve done that before on another letter that we had. We referred back to a previous letter

DR. WARREN: Then what I would, I, you know, I just have problems sending it with all that in an appendix. Be better to just put the two URL’s up there and then people can go to the URL if they want it.

MS. BUENNING: Okay. What I’ll do is I can put in this note, refer to the NCVHS recommendation letter on version 8.1 dated, and I’ll put the date in there, and then I’ll give the URL address because that way they won’t have to sift through stuff.



PARTICIPANT: Trying to get away from paper.

DR. WARREN: Anything else on the letter? Done enough editing and. The next part of our agenda talks about a discussion that we need to have. And Harry, I’m going to need some guidance from you since I missed the morning due to my airplane issues.

MR. REYNOLDS: You’re compadre was here this morning.

MR. BLAIR: Yes, and I paraphrased what you said, which is why she’s checking with you.

MR. REYNOLDS: Oh. Yes, put me in context.

MR. BLAIR: Actually what is was Harry, sure, if I were to paraphrase the guidance that you’ve given to all of the different sub-committees, is on the one hand you really are encouraging us to move forward to bring up new initiatives that could help the Nation to improve health care, with respect to standards in our case. And but you did it with a caveat that we respect where CMS and ONC and other agencies are at this particular time.

So while there are areas that we recognize need attention and work, where we could contribute, we do it with that caveat of respecting a timing factor of when they would be able to find our recommendations helpful. Did I paraphrase it rightly or not?

MR. REYNOLDS: Adjust it a little bit.

MR. BLAIR: Please do.

MR. REYNOLDS: They’re moving forward, they’re moving forward and I thought Chuck hit it well. They’re moving forward in trying to help implement, select standards and do other things that already exist. I think we were on a track looking originally at, as it relates to standards, looking at the whole standards process. And we’re looking at whether or not it was, it would support, in many cases, where we’re going. We slowed that down. Now the committee has to decide if we pick that back up again. I mean, because that’s, let me make my whole statement Jeff and then you can jump in.

Second, I brought up this morning that when the three of us had talked, I had mentioned to you guys to check with CMS, and Karen and them, to make sure if there was anything that we ought to be looking at. And Karen gave an excellent overview today on 50 10, IDC 10, which I think she said it perfectly, has been a bit cloaked by the brewhaha over the other stuff.

But to most of the industry on the street, it’s still one big opportunity to change. And maybe as I’ve heard some of the actual estimates from some people I was talking to, could be the biggest thing we’ve done. And so that’s, means that, and we’re still focused on that and we still need to consider whether, you know, how we help the industry go through that, because there’s a lot.

I know CMS is doing a lot of things. I know there’s a lot of things a lot of the rest of us are doing, HEMA and others, you know, conferences and everything else that are going on, so how do we help guide the industry?

The third thing is, with everything we heard this morning, everything we’re continuing to hear about what’s going on, is there thought leadership that we could bring forward? You know, I mean, if you just took an example, if you just took this whole idea of what we’re going through with NCPDP and those, you know, remember we had a subject a long time ago called streamlining.

Well, maybe, I mean, if we did, we just did a, we’re producing a paper tomorrow on stewardship. It might not be bad for us to produce a paper on the way that an SDO working with the industry has done an excellent job to move a standard forward in a way that’s not nearly as encumbered as, again, I’m throwing, I’m speaking as a member of the committee, I’m not speaking as the Chair of NCVHS.

So I guess what’s exciting to me is man, there’s so much change going on and there’s, you know, you take standards, you take everything else. So what, we have the opportunity since, for example, I wouldn’t see in many ways now, with what they’re having to do, is, has to follow a clear path because man, they’ve got to get some things to happen. And they’ve got to select standards, they’ve got to talk about certification, they’ve got to talk about, well, we have a little more of a blank slate to decide what we think we ought to do.

Now we want to stay close with HIPPA. We want to stay close with anything but also it’s not going to hurt us to make a list of some things. You know, on back when Jeff, you and I were Chairmen, we drew this picture of near-term, short, you know, short-term, near-term, and long-term. And maybe we need to step back as a group and talk about that again. And so that do we want to be, are there any subjects we want to be the thought leaders on?

And I tell you right now, that’s not necessarily going to be certification or something else. That stuff’s moving a hundred miles an hour. So that’s the context.

MR. BLAIR: You just asked that question. Could I ask a couple of other questions that kind of feed into the major theme of what you just said?

MR. REYNOLD: Yes, and I would want those questions to the whole committee that’s here today.


MR. REYNOLDS: Okay. I know, I guess, I gave guidance as a Chair. I don’t want to overpower this discussion as the Chair of NCVHS. So yes, I will comment on anything you say, but I would like to turn it back to you two as the Chairs of this as quickly as I can otherwise I start directing the sub-committee, which is not my charge.

MR. BLAIR: One of the things that Judy and I have been intently involved in pretty much this last year, was this focus on how to improve the processes for developing, implementing, and selecting HIT standards. Now, the thing is, at the time we began this, we had Marc, he’s still with us. Okay, I heard the giggle. I recognize the giggle.

So Marc had made some suggestions to us, about a year ago, that we really thought needed to be addressed. And then you attended the HIT summit, the standards summit, which echoed a lot of similar themes and we reviewed that with ONC, if they would support us on those.

So my questions are, I don’t want to kind of reverse our time to a year ago, when things have changed. So Marc, a lot of the suggestions that you had made a year ago to the standards sub-committee, in terms of what we should be focusing on, with ARRA coming out, and with the two, and the planning

DR. WARREN: Well, and Marc sits on the HIT standards.

MR. BLAIR: I know, I know that. So I’m wondering is this still an issue that you feel should be a high priority for us to be looking at or with the changes that have happened, especially in the last several months, have you re-thought what you would suggest to us?

DR. OVERHAGE: One is I guess I’m pleased that I sense, and this is purely sense a trend towards some sort of simplification, rationalization, when you have John Longker writing in his blog the source of all truth, that we’ve got enough codes and we can do that, you know, I mean, there’s at least some, I feel like, movement away from the, okay, we’ve got twenty-two more years of work to do on standards before we have anything usable to, and I think ARRA has helped a lot by putting a stake in the ground of, you’ve got eighteen minutes to get something done. What are you going to do that fits in that box? And I think that’s very helpful.

So I think there is movement in that direction, although we’ll have a better sense in another week or two. So I think that’s good and helpful. The, so that was one of the major themes, I think, in my thoughts, you know, a year or so ago. So I’m glad you made that happen, Jeff. The whole ARRA thing, your idea.

The other thing that I still worry about, and I’m not sure how to pull in, as we tend to focus on EMR’s and provider applications. And yet a lot of the work is in other systems, pharmacy systems, radiology systems, laboratory systems, transcription systems, you know, sort of on and on.

And that’s generally not on people’s radar screen. Everybody talks about interoperable EHR’s, but they don’t talk about interoperable laboratory systems very often. And yet, I think for a long time yet, that’s where a source of a lot of the structured information is going to be.

The other area that, to me, seems to be starting to shake out, and especially the comments of the ICD 10, is ICD 10, ICD 9 SNOMED space has gotten very confusing to people, I think, especially with the shifts in SNOMED’s availability and its structure with ICD 10 being recommended for adoption. And, so that strikes me as one potential area that we might want to make a contribution in because it’s obviously near and dear to our hearts for a lot of reasons and highly relevant

DR. WARREN: Just to interrupt your thoughts, when Dr. Eosonie was talking to us, I know that there are efforts going on in CMS to map the MDS, the OASIS, and Earth Pie into some semblance of either like SNOMED pairs. So it is, more in the space than what it’s been before.

DR. OVERHAGE: But that’s just one thing, as things have re-shaped, feels like something that we might want to consider delving into and I don’t think it’s a simple answer. We have a mandate for ICD 10, there’s the work that Paul Tang and others have done and the things that are being done in the, I always get the acronyms wrong, the HITEP, in terms of quality reporting, and so on. And I think that’s a space where there’s more confusion emerging than clarity.

MS. TRUDEL: I just want to tack on to one thing that Marc said because the linkage between EHR’s and all of these peripheral systems like the labs and the radiology, to, there’s one other link that I think people aren’t talking about. And that’s the link between the EHR and whatever administrative systems, practice management systems, whatever.

And what I’ve been hearing from vendors anecdotally is that every time somebody implements an EHR, somebody has to build a custom interface to get the data from the charge master, or whatever, moving it around, and getting the eligibility data moved, and patient mapping, and that’s really important. And I think it’s a big barrier.

MR. REYNOLDS: Well, if you categorize, can I speak, Judy? If you categorize that, there’s a whole eco system out there around EHR. And so, as we, again, as we frame subjects, the eco system around EHR’s and what those would be, a thought leadership position, because everybody else is focused straight towards the path, because they have to, I mean, and that includes, and so those are the kinds of terminologies, Jeff and Judy, that I was alluding to earlier that we go ahead and declare that we’re in the space. We declare how we’re in the space and we can declare that we’re not in the way of others moving forward to do things.

And that’s what I’m looking for from the committee so that we declare where we are. So that if anybody has a problem with that, they know where we are. But the other hand, we don’t apologize for being there because we do have a diverse enough group around this table that we know what’s missing. And they cannot, nobody else can select a standard that’s there right now that’s been adopted and grabbed to pick it through HITSBE or something else to say that’s what you’re going to do.

And that’s, so I think that’s where we start to maybe be able to make some headway and continue to move this forward because I like the way everybody has said it, implementing one system that doesn’t relate to the others, that pulls data together, is implementing one system and there’s going to be, and there’s a lot of requirements on people to get some things done.

DR. WARREN: And that also relates back to this new initiative that’s going to come out to have these regional centers to provide support and training for people to really address the issues that Marc’s talking about, how to use different systems and how do you stitch them together, what kind of problems do you get into when you do that?

Or even just, well I’m thinking too fast, I tend to go from the weeds to the sky and back again, but yes, how would you go about even training some of these people that are going to work in these extension areas to give good advice on how an institution would implement some things?

MR. REYNOLDS: There’s another opportunity for my standards standpoint. So you’re not saying, again, people have to put people in place, and right now, it’s depicted on training on EHR’s. But if there’s anything around that, or any segments of that, then nobody else is working on the opportunity.

MR. BLAIR: Should we cap, because from what I could see, we’ve got two very attractive initiatives to go after, so far, that we’ve mentioned. One of them is, well, maybe there’s three. One of them are the moving the interoperability standards for provider systems other than EHR’s so that we have greater interoperability, like between practice management systems and EHR’s, and lab systems, and radiology systems. So that, maybe that’s one.

I guess maybe I’m looking that somebody is capturing this, sort of on a list. Then the other one is Harry, what you mentioned, which is the other things that EHR’s have to connect to. I don’t know if that’s the same thing. I had a sense that it was a little bit different. I was thinking that it was a beginning to, well, I’m not exactly sure, but, is that the same as the first one, or was something different.

MR. REYNOLDS: No, I’m, again I’m purposely trying not to be prescriptive, Jeff. I look forward to the committee, sub-committee, deciding that.

DR. WARREN: So your first one was about interoperability?

MR. BLAIR: Interoperability

DR. WARREN: And the second one was about the linkages and things that Marc was talking about?

MR. BLAIR: Well, it was what Marc was talking about. It was interoperability with systems other than, in addition to EHR’s, like lab systems, radiology systems, or am I not saying it right Marc?

DR. WARREN: Right.

DR. OVERHAGE: No, I think you’re saying it fine. I like the eco system notion that Harry threw out.

MR. BLAIR: Okay.

MR. REYNOLDS: Yes, I’ll tell you, I used that in a speech the other day and if you list all the things, that you got the copy of it. If you just look at what’s going on in these doctors’ offices and medical centers and everything and you list everything that’s going to happen between now and 2015, as Justine looks at me intently, there is an incredible change to that eco system and it’s not just implementing this or that.

It’s an entire, so how can we, and you know, the other thing is, I think it’s important for us, there are standards that are SDO-based, and maybe there are standards about how to approach things, how to think about things, how to. I mean, I’ll give you an example, as we’re working with some people on ICD 10, they have a way of asking our business areas questions. Well I can comfortably tell you if some of these extensions centers just had, we could come up with what of the best kinds of things that people are doing out there in helping people think about, doing these things.

That’s a standard, just not an adopted standard under a reg, but it sure is a template. I would think right now she doesn’t have to shake her head yes or no. I think right now with all hospitals that Justine’s dealing with and all the change that’s going on, if there were just templates of even how to think about approaching some of these things, that you could hand to department heads or others to do this, so that’s why I say the eco system.

Man, if we just drive down the system path, we’re leaving the whole landscape on both sides of that road completely barren and just running right down the middle of it. I mean, I’m facing that at home. I’m facing that as a member of a committee in North Carolina. And so I’m seeing it all day, every day in my day job.

How do you go pluck from the shelf enough collateral to give to somebody that’s not sitting there, I don’t know how to do that? In every single entity, whether it’s a doctor’s office, a hospital, an ancillary service, a lab company, or anything else, is all facing this exact same thing.

DR. WARREN: Well and I think they’re facing it too. I just had an instance where a couple of nurses made an appointment with me and they were very concerned because their hospital is implementing physician order entry. And the vendor that they’re working with has told them that they’ve already done all the work flows, but when they ask to see them, they only get the physician work flow. Because the vendor tells them that’s the only one that’s important.

Justine’s just nodding her head. I knew you would understand that. And they’re anticipating all these problems with pharmacy, with nursing, with, you know, discharge and all of this. And the vendors’ not getting that. And so they’re kind of stuck. So if we’re looking at trying to what Harry’s talking about, to me I don’t like to call them standards, but they’re the best practices of implementing these things to get these different perspectives of

MR. REYNOLDS: And see that’s what’s fun. We can be, and that’s what’s fun about it, we can be thought leaders and not use just terms of art that we’ve been stuck with before. That’s the great thing about this table.

DR. WARREN: If we could pull in testimony and even kind of lay out what the field of standards is that you need to implement the EHR and its AVA system, that would be helpful. Almost down to your, the same thing as the data stewardship.

MR. BLAIR: Could you clarify for me a little bit because I’m hearing what Marc has said and then that’s kind of also in the environment of the echo system. But Judy, what you indicated, is what about doing things in a way where we could help with the regional extension centers and then Harry seemed to go to that. So I’m not sure, is that all part of this or is the regional extension centers a second initiative?

MR. REYNOLDS: I don’t want to use the term regional extension centers. That’s why I used eco system. If you use regional extension centers, and then you start talking about what you’re going to do with them, you just, we just got in the way. We just jumped right in front of the bus. Just my feeling.

DR. WARREN: I thought that Chep indicated that it would be helpful for us to work with him on the extension centers? Because neither one of the committees are looking at that.

MR. REYNOLDS: It would be, but anything that we’re doing could be couched under the eco system around this whole thing and could be used by them. I just don’t think it’s

DR. WARREN: Well I guess what I was saying is, I mean, following your suggestion about the data stewardship document that we produced. If we produced a similar, very high level lay out of here are standards and the different kinds of standards that you need. So it’s different than, I think, what the new FOCCA committee is going to look at because they’re looking probably at the ones that are developed by the SDO’s and stuff like that. But we’re looking broader. But that can provide information for these extension centers, for various entities implementing

DR. CARR: Are we talking about standards or best practices?

DR. WARREN: What I’m talking about is laying out that typology.

DR. CARR: Of best practices or areas that need to be visited?

DR. WARREN: Yes, areas that need to be visited and normally we call, we call them best practice standards.

DR. CARR: Yes, there’s a need for that. But with HIPPA

MR. REYNOLDS: Justine will be a customer.

DR. WARREN: Like a secondary use that morphed.

DR. CARR: Yes, but when HIPPA came out, now you go on websites, in a matter of time, they were all a manner of kind of bringing those HIPPA requirements down to an operational level. And that’s what we’re talking about, that what does it mean to have an EHR, and it’s not just about the doctors. It’s not even just about the clinicians.

It’s about the, but even, we found in the home grown system that the work flow, which was tell your admin to call this number, wasn’t accounted for in the work flow in the EHR. So I think that would be absolutely huge.

I don’t know that, I’m not sure that we need to do it, but that, there needs to be an overview of what are the, it sounds like you’re already starting to do it with the ICD 10, but what’s the universe of considerations where all this, the people in an organization, whose lives will now change irreparably.

MR. REYNOLDS: And even if we just took ICD 10, and we started helping with that as to what the things are and could share those in this public forum along with what Karen and them are doing, it’s, I tell you, there’s a, this is really going to change how people do business. So those are some examples.

MS. TRUDEL: One thing that I think would really help that CMS could use a lot of assistance with is best practices in terms of how to bring everything out of ICD 10 that we possibly can in terms of benefits.

MR. REYNOLDS: ICD 10 has strategic advantages is what we’re calling it. That’s exactly how we’re approaching it so that we talk from that end of the spectrum, not talk from just another code set, just another process.

MS. TRUDEL: Right. And I’m thinking of it in terms of secondary uses and quality and research and all the way out as far as the data goes and is used. Because I think a lot of times when people think of ICD 10 implementation, it’s in a business operations setting and it’s not in terms of okay, well I’ve got all this body of data and it has all of this richness of codes in it, what could I do with that? And we’re trying to do a little of that in our analysis where we’re going through and with each business operation, we’re doing what we call an opportunity analysis. So, you know, once you get over the headache of having to do it, how could it make your life better and how do we build for that?

MR. REYNOLDS: Yes and I’ll give you an example only as an example, not an endorsement, just an example. We had Steve Steindel come down to our company and he spent two days. And he met with eight of our departments on the origins, the meaning and the structure, of ICD 10. Not how to implement it, not, and met with eight business areas. Because the goal is to teach the business areas how to think about ICD 10, not implementing it. ICD 10, then talk about how to do it.

And so those are some of the things in this eco system. As I’m saying, how do we bring the education, and Karen’s doing the same thing, we’re all trying to do it, how do you bring the education of what the heck this even is? Yes, you could say well here’s how it’s different than 9, but if you don’t teach, like if we don’t teach our business areas what it could bring, then how do we expect to ever get that? We’re just going to implement a new code set and go on and hope that’s right. So, again, that was incredibly helpful and I’ve had business areas calling like, man, that was great, that was great.

Now, again, I’m not saying, I’m not evaluating the quality of the process. I’m talking about those are the things that are missing out there that nobody even knows what to do and nobody even knows how to think about it. And even a primer on what are, back to Karen’s point, even a primer that we could put out on what are the real possibilities of how you would use 9 in the standard way or other ways, are the kind of things that we could bring to the table because that’s an

MR. BLAIR: So that’s initiative number two, then? I can’t see whether you’re

MR. REYNOLDS: I don’t know. I’m, again, Judy, that’s up to you guys.

DR. WARREN: I don’t think we’re down to that yet. We’ve talked about four different things and they’re, all four of them are kind of interrelated. And so probably part of our challenge is to pick something

MR. BLAIR: Could I add another thing just to make it messier?


MR. BLAIR: One of the things that I guess I’ve been struggling with for just such a long time and I’m not, I’m not really sure how to address this, but I just worry that with the implementation of ICD 10 and then meaningful use winding up implementing SNOMED, LOINC, an RXNORM probably, at least on a trajectory for that. Maybe not in 2011 or ‘13, but maybe by ’15 or whatever. I’m just worried that we’re not, we don’t have a strategic, a strategy for convergence. And Karen, is this, is this a concern that you share or is this something where you’re not worried about it, or

MS. TRUDEL: Convergence of what?

MR. BLAIR: Well, if we’re going to wind up getting to a point where we really have meaningful use and we could measure it with SNOMED, LOINC and RXNORM, and be able to improve health care with decision support using those terminologies, we begin to move things forward quite a bit. And then we’ve got this separate coding system for reimbursement, which is ICD 10, whether it’s 9 or 10, and I’m sort of feeling like we’re maintaining a duality.

And I kind of wonder is there a, are we building in a gigantic inefficiency without having, well I’m going back to the concept of secondary use of the data, not, why can’t we use secondary, the use of the clinically-specific terminologies at some point? It just seems like to me like things are not connected. They’re not, we don’t have a strategy for convergence.

MS. TRUDEL: Well I think this links to the point Marc was making earlier about mapping SNOMED to ICD 10 and yes, there are a lot of issues there, but I think a lot of people would argue, or at least I would argue, that you are always going to need a structured code set on top of the vocabulary. And that there are needs for both of them and there are processes that use one better than the other. And that you are always going to have a certain amount of research being done with claims data simply because claims data, unless you establish a really huge clinical repository, is where large chunks of data are available.

MR. REYNOLDS: And with ICD 10, your claims data is bigger and richer. So you take one code now and you turn it into two or six or ten or fifty, you get a dramatically different view of

MS. TRUDEL: Yes. Right. Sure, so I see it as being the, more EHR’s makes for more available clinical data. ICD 10 makes for better claims data. And so the question is, how do you get the two to marry up in the middle so that you use the best of both?

DR. WARREN: The concern I have is, what I’m beginning to see in my contacts is, the people who are doing the 50 10 are over here doing their changes and there’s another team looking at ICD 10 that has no contact with 50 10. And then there’s another group that’s trying to get hot on whatever quality indicator it is lately that we’re going to have pay for performance attached to or a regulation or whatever kind of thing. And people aren’t really looking at how all these tie together. Each one’s done in a silo.

And I think we’re going to run into real problems and that maybe what you’re trying to get at, Marc, is, as long as we keep doing it that way, we’re never going to get to interoperability, no matter how great the standards are. It’s because the thinking was done separately.

DR. CARR: Yes. I thought a great example of that was at the meaningful use hearings where the Leap Frog Group had done this survey of actual use of EHR’s, or order entry I think. And so they took the CCHIT certified programs and they demonstrated a complete bell-shaped curve of performance with the same certified EHR. And so I think it gets to your point of the intersection of both this certification and the use of it and then these other things, the 5010 and the ICD 10.

DR. WARREN: Yes, well, it always amazes me that people believe that just because a piece of software has been certified to have certain functionalities that the implementation is going to be a good one. And those two have, I mean, the only linkage that I can find with that is usually the person that writes the check also hires the people to implement it. But that’s about it. And you can take any of these EHR softwares, whether they’re home grown or they’re from one of the top vendors, and your implementation is going to be totally different than the guy across the street with the same vendor. You know, you still can’t share data.

We have news articles all the time, either about people turning these systems off or they’re switching software vendors because their stuff doesn’t do well. And when you really look at it, it wasn’t the software that failed. It was the implementation that failed because something, a work flow wasn’t considered or too many changes were made in the organization to change what they were doing and they were all conflicting. And so it was really that kind of piece that caused the failure.

MR. BLAIR: Let me elaborate on that because a few minutes ago I was going down this path of we’re going to have SNOMED and ICD 10 and better clinical specificity and all of this stuff. And yet, when we were trying to put together the hearings, both for the processes, improving standards processes, we had a number of folks that were winding up saying we’ve gone too far trying to meet everyone’s needs and the complexity is becoming more of a problem than the value of the clinical specificity and the detail and the interoperability.

And the answer, they were winding up saying, look, you have folks out there that are still on HL7 2.2. And you have folks that are back level on a lot of these standards or are reluctant to move forward. I don’t know how, I don’t know how to solve this problem.

MR. REYNOLDS: Well, I think one of the things, Jeff, that’s going to change the landscape in my opinion, is the whole discussion that went on a little while ago in the full committee, which was certification. Because you probably have four or five subjects that fit under certification. What is a certified system? What is a system that allows you to get to meaningful use? What are the practical uses of that? What then are the characteristics of that? And then how do the current standards that would relate to that play in that environment.

So, good example, I’ll use a personal example.

So the HIPPA standards came out on eligibility claims status and so on. And then some of us that are on some other committees took that and made that robust. On the other hand, we may actually have to go, almost, there may be some of these standards that go backwards a little bit to a lesser common denominator than where they had hoped maybe the large players could be to get the small players, who have nothing now.

And we were talking about dates today, which actually troubled me because if you think of the extension centers and everything and you say that they’re going to take awhile to get in place and you’re going to start paying incentives in ’11, nothing can take any period of time to get ?, because that means that somebody has to be buying a system in the middle of ’10 and having that thing full go, which means that if you’re going to do that, you’ve got to have people out there, training them pretty quick.

So I think we may actually find, and I think, Marc, it’s what you were kind of touch, we may find that we’ve got more standards, philosophically, than we need. And we have some standards more robust than they need to be, to be plugged in.

DR. OVERHAGE: We need to write that letter.

MR. REYNOLDS: We need to write that letter?

DR. OVERHAGE: Because we have too many standards, we need

MR. REYNOLDS: No, no, no thank you. But you understand where I’m going with that. Because I tell you, now we’re down, what’s interesting, up until now, we’ve been able to talk to the theory of the future. However, the practical of the future is on us right now. It is, right this minute. And so wherever you think you are, whatever you think you’re doing, or whatever you think the standards are, once it’s decided what this meaningful use is and what it looks like and how it plays, then everybody needs to converge to that and help people get there.

So, for example, if I was to take the HIPAA transactions or something, there was a lot of chat about the 837 and what it should look like and then all of sudden a rule passed, you knew what an 8, you knew what a claim looked like, didn’t you? You didn’t have to check with anybody else. You didn’t have to go running around the building. There it was.

Well I think the same thing as this meaningful use comes out and it comes out as EHR’s and other things, damn, something is going to have to be clipped.

DR. WARREN: I want to take you to an HL7 meeting and have you talk about 3.0.

DR. CARR: I’m just looking at the time. So what’s the goal of the next ten minutes? Are we trying to decide on next steps, or?

DR. WARREN: Yes, and I don’t know that we can do that in ten minutes. Maybe require a call or some email? Does anybody have anything that they want to add to this? Let me summarize the four points that I thought heard people say. We were talking about continuing on our set of hearings about interoperability and the processes of adopting and implementing standards. We also talked about, so the second one is

MR. BLAIR: Could I add carefully to that?


MR. REYNOLDS: We’ll do that carefully to make sure.

DR. WARREN: Not right, carefully, Jeff, but that’s okay. So the second one was getting to really re-visioning the EHR and looking at the ecosystem that it sits in and identifying what that eco system is and trying to broaden our perspectives. Did I kind of capture that, Marc?

And then the third one was to really take a look at ICD 10 and to start laying out the benefits and the ROI of doing ICD 10, what kind of data is there, how to use it, what it can do for the organizations that they may not have thought about. In other words, how to think about ICD 10 as much more than just a billing classification.

And then the last one was the one that I was trying to get at, is really to put together a paper that kind of follows the format of the data stewardship. That takes a look at what are the standards that we really need in order to have HIT or our vision of sharing health information going in there.

So they would be standards that are developed by SDO’s. Standards that are developed for the best way to implement. Standards that are developed for this and whether we call them standards or best practices or whatever, but to kind of lay that out and make some distinctions.

DR. CARR: And I’m going to try out something that I’m going to try tomorrow with quality too, as we have a couple of different things on the table, to say, kind of create the checklist of things that we’ve talked about in the past. Number one would be is there a customer. Number two, is it duplicative of any other efforts. Number three,

MR. BLAIR: Criteria for making the decision.

DR. CARR: Yes, exactly, and do we have the expertise on the committee or the sub-committee to achieve what we’re setting out to do. So I forget what the other things are, but I think it’s helpful. We’ve had a lot of really good discussion about, over the last couple of meetings, about how we choose what we do, and I think it’s been helpful in doing that. But categorizing, standardizing, going through that checklist sometimes helps prioritize.

And the other thing would be also to put it out tomorrow, if we wanted input from the larger committee about where we should go. But I do think that we’re in a little bit of a holding pattern for the next few weeks, waiting to see what comes down. So what I’ve done in those situations is go the primer route, both for the summary of the quality work that had been done over four years and then a summary of the stewardship work. Because I think that does add value and its work that can continue to be done while the rest, all these other committees, especially with regard to Sanders, so many other, there are many other players, and many agendas going on. So that would be the way I would think about it.

DR. WARREN: So just looking at the letter that we wrote, some of the notions about what backward compatibility is how it helps with the MPRN process, all of that stuff, as your primer idea?

DR. CARR: Well, at first I would say who’s the audience and who’s the customer. Okay, so they’re probably different. Thinking about that, because, how you write it or what you include in it depends on who the audience is and then trying to think in terms of who also is the customer, or who would want this? How would it help?

CMS might be our customer and the audience might be primary care docs or offices or hospitals or whatever. But I think we need to state that and then kind of take these ideas and retrofit them into something that is focused.

MR. BLAIR: One of the other comments to add to the criteria list that you’re developing there is, we, Congress has indicated that NCVHS has responsibility for the HIPPA transaction stators and for e-prescribing and we, that ought to be one of the criteria. Because if it’s in an area where we have responsibility, as designated by Congress, then that tends to reduce, I won’t say eliminate conflicts, but it reduces a potential conflict.

MR. REYNOLDS: Karen, is ICD 10 considered HIPAA?

MS. TRUDEL: Definitely. Yes.

MR. REYNOLDS: No, no, that’s fine. The other thing I would play off of Justine’s is I think with where the industry is right now in this, the rapid pace of trying to move it between now and 2015, that the more we can do things for the industry as an audience, and especially those who are trying to help make this stuff happen between now and 2015, the better off we will be and the more influence we will have.

I’ll give you a great example, I mean, the stewardship document alone, I’ve been able to use that in my company, whether or not I ever had anything to do with NCVHS. It just gives you the things to think about, and the same thing with secondary uses and the same thing with other things. So I think, but picture, again, and I keep going back to it and the leg is up, picture the number of doctors’ offices that are at zero now.

PARTICIPANT: They all report to me.

MR. REYNOLDS: Yes. That have to be light years different than they are. I mean a good example, just, so what do they even think about. And yes, there’s going to be extension centers, but is there anything, with everything that we’ve seen around the table, is there anything that you can put together that would even say these, I got a new term now, thinking about how to think about it. No, I’m serious. And, you know, because that is a struggle for so many that are going to be in this industry, getting moved along quickly.

PARTICIPANT: It’s like making a plan for a plan.

MR. REYNOLDS: Yes, no, no, that’s right. And so those are the kinds of things that I think we can also

DR. OVERHAGE: And I don’t know how this fits in Harry, but a friendly amendment to that notion is that given health care reform, I think it’s highly likely that the entities and players that we think of, day to day, as being in this business, are going to change over the next five years.

And so as we think about this, I think we’ve got to at least keep in the back of our minds, it may not be acute care hospitals and chronic care hospitals and doctors, there may be a whole other set of some bodies

MR. REYNOLDS: Yes, but no matter who it is, wouldn’t you agree they still got to implement the same thing?

DR. OVERHAGE: Yes, absolutely.

MR. REYNOLDS: No, but that’s what I’m saying. That’s why it’s even more important in a changing landscape, having something that people can pull off the shelf to do something.

MR. BLAIR: So that they go that direction too.

MR. REYNOLDS: It’s not a bad place to be.

DR. WARREN: So we need to adjourn because Jeff and I have a cab waiting and it’s all about us.

(Whereupon the subcommittee adjourned at 5:30 PM)