[This Transcript is Unedited]



June 11, 2009

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

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



Agenda Item: Call to Order, Review Agenda

MR. REYNOLDS: Good morning. I would like to welcome you to the second day of
the meeting of the National Committee on Vital and Health Statistics. The
national committee is a main public advisory committee to HHS on national
health information policy. I am Harry Reynolds, chair of the committee and I
work at Blue Cross/Blue Shield of North Carolina. I want to welcome committee
members, HHS staff, and others here in person. Also, I welcome those listening
on the Internet. I would like to remind everyone to speak clearly and into the
microphone. Let’s now have introductions around the table and then around the
room. For those on the national committee I would ask if you have any conflicts
of interest related to any issues coming before us today would you please so
publicly indicate during your introduction. I have no conflicts. Marjorie.

MS. GREENBERG: Good morning. I am Marjorie Greenberg, National Center for
Health Statistics, CDC, and executive secretary to the committee.

DR. CARR: I am Justine Carr, Caritas Christi Health Care. I am a member of
the committee. No conflicts.

DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and
Quality and Office of the National Coordinator.

DR. SCANLON: Bill Scanlon, Health Policy R&D, member of the committee,
no conflicts.

DR. MIDDLETON: Blackford Middleton, Partners HealthCare, member of the
committee, no conflicts.

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

MS. MILAM: Sallie Milam, West Virginia Health Information Network and West
Virginia Healthcare Authority, member of the committee, no conflicts.

DR. GREEN: Larry Green, the only guy on this side of the room.

MR. REYNOLDS: Larry, I actually thought your questions were better than that
yesterday but obviously the people around you just didn’t quite hear them like
we did.

DR. GREEN: University of Colorado, member of the community, no conflicts and
no friends.

MR. HOUSTON: I am John Houston. I think I’m John Houston from University of
Pittsburgh Medical Center. I am a member of the committee and I have no

MR. BLAIR: Jeff Blair, Lovelace Clinic Foundation. We do have an NHIN
contract but I don’t believe I have any conflicts.

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

DR. SUAREZ: I am Walter Suarez with the Institute for HIPAA/HIT Education
and Research and member of the committee and no conflicts.


MR. REYNOLDS: I thought yesterday was a very good day and especially from a
standpoint that I think we need to keep this in mind as we do our other full
committee meetings. We got a good chance to talk to each other about what’s
going on and I thought the questioning in general and people building off of
that questioning was very helpful. I would be anxious to hear from the
subcommittees and their breakouts later, but what we plan today is Judy is
going to go through first the updated letter so that we can pass that letter on
the NCPDP. But before you do that, Judy, I would like to recognize Marjorie for
an item really quick.

MS. GREENBERG: Since we have you all here together we thought it would be a
nice opportunity to recognize some staff who were mentioned yesterday by Harry
and I wanted you all to know the staff who helped make the meaningful use
hearing happen. I wanted you to know they haven’t gone unrecognized by the
management here. We have something at NCVHS called on the spot awards. We have
initiated and like anything else in the bureaucracy they take a little while to
actually happen but since they don’t require anyone else’s really approval
other than the initiator, we can say with confidence that our being given so we
have initiated on the spot awards for Marietta Squire and Cynthia –

Often what happens is the money just -– this is actually some money
involved here. It goes into their paychecks and then they say where did this
come from so I’m giving them a heads up and I thought it would be nice to do in
front of all of you.

Now the problem is that on the spot awards are only for full-time employees
and Jeannine is like we consider her a member of the staff but she is actually
a contractor so I think Katherine Jones who is the leader of the NCVHC team
which provides all of the logistical support for your meetings has a little
something to recognize Jeannine as well. Thank you for letting me do that.

MR. REYNOLDS: It was well deserved no matter how many times we say it. It
was quite an event to be swept up in. It felt like we got to be part of their
magical event and all we had to do is sit here and act like we knew what we
were talking about. Thank you to all of you again and again. So with that,
Judy. Everybody you have the letter in front of you.

Agenda Item: NCPDP 10.6 Recommendation Letter

DR. WARREN: You have a printed letter in front of you so we didn’t throw
anything up on the screen. If people need I would be willing to do it because
Marietta knows where it is at and pull it up. Does anybody need it to be

What we did yesterday is we spent a little bit of time and I want people to
notice we were able to take off at least a half a page. The letter is shorter
than what it was before. We have changed the tag line now reads recommendation
to adopt NCPDP SCRIPT Standard Version 10.6 for use in Medicare Part D
e-prescribing. We reformatted the initial paragraph to make it a little bit
easier for someone who is scanning through the letter to really find out what
the letter is about and so there is really no difference in the wording of the
letter other than we bulleted it out to the three things. So we had this last
sentence is this letter will specifically address three topics: one, the
current exemption for long-term care facilities from use of the adopted
e-prescribed standards; two, the progress that has been made in modifying the
standards to make them workable in long-term care; and three, our
recommendation to adopt NCPDP SCRIPT 10.6 for e-prescribing transactions.

Anybody have any comments? The last one is modified a little bit. If we took
off for long-term care because really it would be e-prescribing transactions
for everyone not – care.

MR. HOUSTON: I guess the primary focus is not long-term care because a lot
of what the letter is about, right? I will make another point if you say yes
that is the case.

DR. WARREN: The reason we had to go with 10.6 was to make the standard
usable for long-term care. It was usable before for ambulatory care so what has
been added to 10.5 are the fields needed in order to communicate e-prescribing
information for long-term care.

MR. HOUSTON: Wouldn’t it be good for number three than to say that comma
after the transaction were transaction and comma including on a voluntary basis
for use by long-term care facilities?

DR. WARREN: That comes later in the letter.

MR. HOUSTON: I know but this is a recommendation and that is a core part of
the –-

DR. WARREN: No, this says that these are just to be topics that are being

MR. HOUSTON: Do you say our recommendation?

DR. FITZMAURICE: Could I make a suggestion on how to handle that? We could
have one of the current exemption, two of the progresses that have been made,
and three our two recommendations and then bullet to adopt NCPDP SCRIPT and
then another bullet to require long-term care facility is to use script when
electronic prescribing.

MR. HOUSTON: But it’s not requirement. I thought it was voluntary.

DR. WARREN: Anybody who does e-prescribing to be reimbursed by CMS must use
the standard. Now it is voluntary to e-prescribing. It is not voluntary to use
the standard. It’s not said that way in the law but that’s the way it works.

DR. FITZMAURICE: I would say it bluntly here and then I would put it as you
have it in the back the way the law required to be, exemption lifted, but here
you’ve got background, background, and then are two recommendations. You have
summarized the letter right in that first paragraph.

MR. HOUSTON: I am just trying to think and if the intent in the opening
paragraph is to try to verify or summarize the letter which it appears in some
ways to be the case is adding something very short about transactions common
including long-term care. Take it or leave it.

DR. WARREN: Let me work on that and we will try to come back to you about
–- I’m just trying to figure out how to reword this so that people can do
it now.

DR. HORNBROOK: Is the reader in this case the secretary on your staff going
to have sufficient context so that they know exactly what you are talking

DR. WARREN: Yes because we have put a footnote in here with two previous
letters that have all of the background in it.

DR. HORNBROOK: As you know in my world long-term care covers the gamut from
assisted living, home health hospice, nursing homes, and assisted living and
all those range of things.

DR. WARREN: We could also append the entire MMA law and all the regulations.
Where do you stop?

DR. SCANLON: You did define long-term care facilities later in the third

DR. WARREN: Yes. The challenge that we had is we needed an introductory
paragraph. We had it before when it was all in a paragraph. Everyone seemed to
be okay with that. As we worked with the letter it seemed to us to break it out
into points that we had about the topics to be covered in the letter. The topic
here is the recommendations. We didn’t want to restate the recommendations at
the beginning of the letter. We wanted to end with that and lead the reader
through to why those recommendations were appropriate.

DR. SCANLON: To Mark’s point though maybe in number two it should say
long-term facilities because we use the word long-term facilities later on.


DR. SCANLON: We’re not talking about home care.


MR. REYNOLDS: One other thing I would add is in these particular letters as
it relates to e-prescribe we have had excellent guidance from Karen Trudel and
Denise in the fact that their departments are going to be working on this. How
can it be most helpful to them as one of our customers of this letter besides
going to the secretary to use as they are helping within the government work on
it? So some of the wording that you see in here that may at times not on this
particular one but in other times may seem almost could appear laborious, could
appear to be explaining maybe a little more than we need to. It then allows
them to have that for use with others as they are moving this through the whole
government process of getting this stuff accepted. We have had excellent input
and help from them in what’s the best way to allow this to be taken as this
letter not necessarily ruled on by the secretary but moved into the government
process to actually make a difference. She was very hands on yesterday along
with Denise in helping us as we edited the letter. That’s not defending the
letter. That’s having you see the process.

If we would look at a letter that was just kind of going normally we might
not have had some of these other things in here that you are going to see in a
few minutes. Thank you.

DR. WARREN: The next change that we made was to try to break up the
background so that the reader can follow with the topics to come are. Let me
read the two paragraphs that are in just the generic background and these are
very similar to the two that were in there before with us trying to clarify
about the requirements of using the standards. The first paragraph. The MMA
established a voluntary prescription drug benefit program for Medicare Part D.
Prescription Drug Plan sponsors and Medicare Advantage organizations offering
Medicare Advantage-Prescription Drug Plans are required to establish electronic
prescription drug programs to provide for electronic transmittal of certain
information to the prescribing provider and dispensing pharmacy and pharmacist.
The reason that was done that way in sequence was some advice that Denise and
Karen gave us.

The next paragraph. The MMA does not require that prescribers or dispensers
implement e-prescribing. However, prescribers and dispensers who choose to
electronically transmit and receive prescription and certain other information
for covered drugs prescribed for Medicare Part D eligible beneficiaries,
directly or through an intermediary, must comply with any applicable final
standards in effect for e-prescribing.

DR. SUAREZ: One quick comment. Direct or through an intermediary. Does it
refer to the transmittal received information or does it relate to the
prescribed drugs to Medicare Part D? In other words, —

DR. WARREN: Drugs are prescribed directly or through an intermediary
especially in long-term care. It is through an intermediary.

DR. SUAREZ: Is the act of prescribing which can be done directly or through
an intermediary. It’s not the act of transmitting or receiving data.
Transmitting or receiving data can be done directly or through an intermediary
as well.

DR. WARREN: It is about the covered drugs prescribed for the beneficiaries
and the drugs are prescribed either directly by the physician or through an
intermediary. Is that clear for everybody?

Then what we wanted to do is really talk about the challenges that long-term
care faced in adhering to the standard. In the first paragraph. The November
2005 regulation that adopted foundation standards for e-prescribing contained
an exemption for long-term care facilities from the requirement to use the
standards. Comments from the healthcare industry indicated that the proposed
standards, while well accepted in the ambulatory setting, did not sufficiently
support workflows and legal responsibilities in the long-term care setting.
Therefore, long-term care facilities (defined under Medicare Part D as skilled
nursing facilities) were exempted from the requirement to use the NCPDP SCCRIPT

The next paragraph. Healthcare delivery in long-term care settings is unique
for several reasons. Nurses are frequently the primary caregivers, with
physicians (who are often not at the site of the long-term care facility)
monitoring care. Specialized long-term care pharmacies are located off-site
with drugs being delivered to the facility. In long-term care a prescription
order typically remains an open order with no end date, or with an end date far
in the future. A prescriber may need to modify this order and notify the
pharmacy. Changes might include dose, form, strength, route, modifications of
frequency, or a minor change related to the order. Also, in the long-term care
environment, there is a need to send a fill request from a facility to a
pharmacy. An example is when a medication supply for a resident is running low
(two to three doses remaining), and a new supply is needed from the pharmacy.
The facility needs a way to notify the pharmacy that a refill for the
medication is needed. And here we put an asterisk and at the end of the letter
it refers to our previous letters about the e-prescribing standards and if you
note there we also have the URL. We talked about actually appending those
letters as appendices and then decided the URL is probably a better way than
adding more paper to the letter.

DR. SUAREZ: I would recommend deleting on the first line in that paragraph
LTC in parens. It is never used and the only place it is actually used is in
the other parens that says LTC, but throughout the paragraph you keep saying

DR. WARREN: And actually in reading this it is much easier to say long-term
care than it is LTC. Anybody object to that?

DR. FITZMAURICE: LTC in both places, right?

DR. WARREN: We will just spell it out. We’re not going to use any
abbreviations. I will go through the letter and make sure all of those are

A 2006 e-prescribing standards pilot, and that probably needs an apostrophe,
identified modifications that were necessary to support e-prescribing in
long-term care settings. These modifications were fully incorporated in NCPDPD
SCRIPT 10.2, and approved by the NCPDP Board of Trustees in July 2007, with
industry feedback indicating that NCPDP SCRIPT 10.2 meets the basic needs of
the long-term care industry relative to e-prescribing. That now ends the
history. Any comments there?

DR. FITZMAURICE: At the beginning under e-prescribing challenges in
long-term care the second sentence reads comments from the healthcare industry
indicated that the proposed standards, while well-accepted in the ambulatory
setting, did not sufficiently support workflows and legal responsibilities in
the long-term care setting. I would question where did the comments come from?
Did they come from testimony at NCVHS or did they come in public comment to
CMS’ notice of proposed rule making?

DR. WARREN: That is why we referenced the letters.

DR. FITZMAURICE: So they came from us. I would tell the secretary comments
to NCVHS and I would say comments at that point because you are saying
something is changed over time to make the recommendation different.

DR. WARREN: So that’s in the second sentence of –

DR. FITZMAURICE: Second sentence which says comments – I would say
comments at that time November 2005 indicated. Comments to NCVHS at that time
because then you are coming back in the third paragraph under that dark
heading. I would say something like later in 2006 an e-prescribing pilot
identified modifications et cetera and then these modifications are fully
incorporated in NCPDP SCRIPT 10.2 and approved by the NCPDP Board of Trustees
in July 2007 with industry feedback to NCVHS if in fact we got industry
feedback at that time. So that the secretary gets a picture painted of we have
this and because of industry response we recommended that and now things have
changed. Here’s how they have changed.

DR. WARREN: Why do we need to keep saying that the comments come to NCVHS?
This is a letter from us about stuff we have done. Isn’t that redundant or is
there a reason?

DR. FITZMAURICE: You have a new secretary. The secretary wants to know that
you are talking about comments that have come to NCVHS rather than comments
that were received by CMS or other places that we have heard about.

MS. GREENBERG: I think that is fine but I wouldn’t use that phrase at that
time because it actually had to have been before then and that’s why the
November 2005 regulation contained the exemptions. I would leave out that
phrase at that time.

DR. FITZMAURICE: We are painting the picture that things changed between
then and now.

DR. WARREN: Yes, but we are using a past tense so I think that is obvious.

DR. FITZMAURICE: Sometimes you can’t state things too bluntly for the
secretary and her staff. Give it some thought and whatever you decide is fine
with me.

DR. WARREN: Okay. Or you could say comments from the health industry to
NCVHS had indicated. So that’s definitely before. Is that acceptable with

DR. FITZMAURICE: You can say have indicated. Put it in the past as opposed
to they still have indicated.

DR. WARREN: In this paragraph we are talking about the past.

MR. REYNOLDS: Judy, I am struggling with one. That last paragraph you read,
the one that starts with a 2006 e-prescribing standards pilot. It said that
10.2 met their needs.

DR. WARREN: I was trying to go through that because 10.2 –-

MR. REYNOLDS: You said 10.2 met their needs and now we are saying if you
don’t 10.6 then you are not going to meet their needs.

DR. WARREN: We did a lot of cutting and pasting. Originally what we had in
here was met basic needs.

DR. FITZMAURICE: I think Harry is right and what you need is a sentence that
continues to paint the picture of the time that over time these things have
improved and now we are up to version 10.5, 10.6 with the following
improvements which you have added there. Just painting the timeframe so that
they get a picture of things change over time and we want the standards to be
the most current because they support the industry.

DR. FRANCIS: Why don’t you just change meets to met and put that in the past
tense following Marjorie’s suggestions?

MR. REYNOLDS: If it is history then at that point it did.

DR. WARREN: Right. So it met the basic needs and then what we are doing is
fully fleshing out the final.

DR. SCANLON: I guess I am confused now because it says these modifications
were fully incorporated into 10.2. Does that mean it is 10.2 or is it 10.2 as

DR. WARREN: They incorporated into 8.1 which then became 10.2.

DR. SCANLON: And then somehow we jumped to 10.6.

DR. WARREN: And that’s coming in the next piece.

DR. SUAREZ: One other quick question. Through the letter it seems like
somehow I missed the part where in addition to the Board of Trustees of NCPDP
approving this. There is an action of adoption by the secretary. In other words
when you read this paragraph it seems like NCPDP decided to go and then approve

DR. WARREN: I mean one of the things we were able to do with 8.1 is when we
went into rule making, notice of vital rule making. We were able to say in
there that you can adopt any version that was back with compatibility to 8.1.
If we didn’t have that then we had to go into a whole new rule making process
for regulations. We didn’t want to get into that because that adds like a year
to the process. What 10.2 was was background compatibility. There did not need
to be a requirement for the secretary to adopt it because it met the criteria
back to compatibility. So CMS just went ahead and did that. Now we talk about
10.6 in order for CMS to go with it it also has to meet the criteria of that
compatible, which it does. Does that make sense? I mean we are going to be
talking about that later.

DR. FITZMAURICE: We are talking about the November 2005 regulation on the
first page. Are we recommending that that regulation be modified?


DR. FITZMAURICE: Are we recommending a new regulation be put out?


DR. SUAREZ: We are recommending that the secretary adopt.

DR. WARREN: Adopt 10.6, which is backward compatible to 8.1. We don’t want
to go through final rule making again.

DR. FITZMAURICE: Agree but we can modify regulation without going through
rule making if it’s backwards compatible. We ought to think about telling the
secretary what we want her to do.

DR. WARREN: We do in the next section of the letter.

So now differences among NCPDP SCRIPT standards or SCRIPT versions. NCPDP
10.5 was approved by the NCPDP Board of Trustees in 2008. This version built
upon NCPDP SCRIPT 10.2, supporting an XML implementation section and a Health
Information Technology Standards Panel recommendations for Medicare management
use cases; making changes to the PVD Segment prescription fill status
notification and inserting the new PVD Segment fields and additional clarifying

The NCPDP has further advanced its SCRIPT standard in other areas to achieve
Version 10.6, preserving all the previous NCPDP SCRIPT standard requirements
needed to support e-prescribing in long-term care settings. The additional new
functionalities offered by NCPDP SCRIPT 10.6 are primarily related to the
medication history functionality, which was adopted in the April 7, 2008
e-prescribing final rule. These include prescriber order fill number added to
medication history response; source and fill number information added to
medication history response; a sold date value added into the DRU segment
date/time period qualifier; enhancements to the DRU segment enabling a
physician to include prescribing-time drug utilization review alerts and
comments to the pharmacist when communicating a prescription. This applies to
retail, mail order and long-term care pharmacy settings; and an allergy segment
and diagnosis segment for use in the CENSUS transaction that allows sharing of
a person’s full allergy and diagnosis profiles with the pharmacy at time of
admission and/or changes in their allergy diagnosis status, to help pharmacists
catch additional, potential drug-drug interactions.

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

The long-term care industry has expressed its readiness to NCVHS to embrace
e-prescribing so that it can enjoy the potential workflow and patient care
benefits. NCPDP has certified that Version 10.6 is backward compatible to
Version 8.1, which is currently the adopted standard. And then we put the
footnote again referring to our previous letters.

Does that answer the questions about where we are going and why we are at

DR. FITZMAURICE: I think it does and as far as to what the secretary has to
do, the secretary will figure it out or the people she gives it to will figure
out what they have to do.

DR. WARREN: Let me get on to the recommendations. Recommendation one. Notice
that we shortened these given the guidance that we got yesterday from the
committee. Recommendation one. The NCVHS recommends that NCPDP SCRIPT Version
10.6 be adopted under the streamlined process for backward compatible

Recommendation two. The NCVHS recommends lifting the current exemption from
the requirement to use the NCPDP SCRIPT standard for non-prescribing providers
in long-term care settings. We believe lifting the exemption sends a clear
message to the industry about the desirability of e-prescribing in long-term

Any questions?

DR. SUAREZ: The second recommendation requires rule making?


DR. SUAREZ: The lifting of the exemptions. Exemptions were under the rule.

DR. WARREN: No. It told us it didn’t. That was the advice.

PARTICIPANT: Probably just publishing under the federal literature.

MS. GREENBERG: Who are non-prescribing providers?

DR. WARREN: That’s the hang up that we have in long-term care. We have a
third party that is involved in long-term care with prescribers.


MS. GREENBERG: But that’s the nursing facility itself, skilled nursing

DR. WARREN: But this standard is used to prescribe medications, right? So
the way it works in long-term care is we have patients in a facility that are
cared for usually by a nursing staff. We have patients in a long-term care
facility that are cared for by the nursing staff. Physicians are not in
residence. They rarely come to see those patients unless they are called on to
come monitor those. When they write prescriptions the prescriptions are written
in a very different format than ambulatory care. Ambulatory care has an in date
and they only authorize so many refills. In long-term care it’s an open-ended
prescription. So there is a different way of writing that. Also, in an
ambulatory setting it is usually the patient or family that dispenses the
medication. In long-term care it is the nursing staff that dispenses the
medication. There needs to be a way that we document in the e-prescribing what
those different roles and responsibilities are.

MS. GREENBERG: It is still the physicians who are prescribing, right?

DR. WARREN: Or nurse practitioners that may be servicing the facility.

MS. GREENBERG: Who is the non-prescribing provider?

DR. WARREN: The facility. Facilities can’t prescribe.

MS. GREENBERG: But they want to use the standard.


DR. HORNBROOK: To enable their nurses to facilitate management of the drug.

MS. GREENBERG: They want to use it for prescribing purposes.

DR. WARREN: Yes. Because most of these patients are –

DR. HORNBROOK: — nurse facility.

DR. WARREN: It is a way to attribute responsibility of getting the
prescriptions and dispensing the drugs. Otherwise most of the long-term care
facilities or the skilled nursing facilities will not be able to comply with
the Medicare Part D and probably most of their patients are on that insurance.

DR. FITZMAURICE: I may be taking out a couple of words that Karen will want
in there, but if we read it as NCVHS recommends lifting the current exemption
from the requirement to use NCPDP SCRIPT standard for and I would say for
prescribers in long-term settings. Well that skirts the issue of who is doing
the prescribing which says for prescribers in long-term settings.

MR. BLAIR: Well actually both Karen and Denise spend a fair amount of time
yesterday on the language of that. Unless it is really necessary I sort of feel
a little uncomfortable making any changes in the language because I felt that
they had it the way they needed.

DR. FITZMAURICE: I think you are right. We want to be guided by what it says
because they are going to have to respond what it says and that is why ref(?).
If they want those exact words, let’s leave it an even. If we’re confused they
won’t be confused and they need to get this in front of the secretary.

DR. WARREN: These were the words that they wanted in the recommendation.

DR. HORNBROOK: I don’t know. Does it help to realize that most of these
patients are institutionalize for a very strong reason and it would be torture
to move them out of the facility to go to a doctor’s office? The doctors of
course don’t want to spend the time to travel from their office to the nursing
facility and do rounds everyday to update medication. -– and changes on
updates on a daily basis without having physicians having to get in their car
and drive.

DR. WARREN: I don’t think we need to go through the workflows on that.
Walter and then we can start –

DR. SUAREZ: Just to suggest a link being so that there is no confusion that
the first time that the known prescribing right up here is the very last
sentence. I would suggest in the first page in the last paragraph, first page
of the letter, last paragraph, last sentence it says therefore long-term care
facilities were exempted. I would just then suggest adding therefore
non-prescribing providers in long-term care facilities were exempted. That way
when the recommendation comes in it says lift the exemption.

MS. GREENBERG: Maybe prescribing providers in long-term care facilities were
also –

MR. BLAIR: That’s exactly right.

MS. GREENBERG: They both were. But I do agree that this introduction in the
recommendation of this term of art non-prescribing providers, which almost
seems like an oxymoron when you are talking about prescribing, is confusing. It
is confusing to me and I think what people focus on are the recommendations and
if you have never defined what you mean by a non-prescribing provider in a
letter about e-prescribing. Unless you are really into the art –

MR. HOUSTON: Is that an accepted term a non-prescribing provider or is that
just something that –-

DR. WARREN: It was a word that Karen and Denise both –-

MR. REYNOLDS: Let’s do this rather than just throwing it up in the air to
Karen and them. I think it is a great point. I think it is something we need to
do. I think I would like to recommend that if we accept the rest of the letter
that we work that out with CMS so that it is not hanging there on its own at
the very end and somebody would want to do something and give the leverage to
the co-chairs and then I will assure before I sign it that it is there. I would
like to see if that is acceptable to the committee. John, you were going to say

MR. HOUSTON: I am just thinking. I understand the point. I am just thinking
that maybe we better think of the solution, but basically these are providers
filling prescriptions on behalf of providers. Long-term care facility is for
filling a prescription ordered by prescribers.

MR. REYNOLDS: Filling it.

MR. HOUSTON: On behalf of the patient. I thought they really were acting on
behalf of the physician who is actually writing the script.

MR. REYNOLDS: Again, we have a string of letters. This is a strong subject.
I think that we do need to clean that up. We do need to do that.

MR. BLAIR: Could I make a motion that –

MR. REYNOLDS: I would rather that the co-chair not.

MR. HOUSTON: Then I will make the motion to Harry’s point which is to allow
them to clarify the language in this letter to satisfy the concern and that
based upon the discretion of the co-chairs as well as Harry that we complete
the letter and have it issued.

MR. REYNOLDS: And if you would consider amending that that we only change
the item around that subject then I would like that as a much better motion.

MR. HOUSTON: Subject to the sole change based upon style -–

DR. SUAREZ: I will second that but just to clarify. There were some changes
done during this discussion.

MR. REYNOLDS: Those were already incorporated. As amended already and then
we only amend the issue around non-prescribing –-

DR. SUAREZ: I will second that.

MR. REYNOLDS: All those in favor. Opposed. Okay. The letter is passed. Thank
you very much.

Let’s go on to our next item. Susan, Have you dialed in?

PARTICIPANT: Are you in your pajamas?

KANAAN: Yes. No, but I have my coffee.

Agenda Item: Health Data Stewardship –

MR. REYNOLDS: That’s good. We will try not to say anything that will make
you spill it or anything. All right if you will turn to 10 of 5 of the book. If
you remember in a few others of our discussions we decided with a lot of the
work we had done in secondary uses and especially as it related to stewardship
that we would actually put together and we had talked about it at some other
these meetings. Put together a primer that could be used on a continuous basis
by people. Let me give you a good example of how some of our documents are
used. I was speaking to somebody that was at the quality meeting and this
person spends a lot of time talking about meaningful use. They took our
document and then the 17 observations put it into a PowerPoint and it made 30
presentations using it.

Okay so understand a lot –- by condensing a lot of this stuff thinking
about the subject we are not leading anybody to a final answer in some of these
cases; however, we are teaching people how to think about thinking about it and
then how they might use it. That’s what the purpose of this is to let people
start somewhere using the benefit of what we have heard from a lot of people.
This is just not us right now and that’s how I think we can make a continuous
difference because there are very few committees that are in that position on
some of these subjects.

So as we go through this the first thing I would like to do I would like to
highly commend Justine and Susan Kanaan. They have done a great job in helping
out with this. So those were the two real players and I just happen to tag
along. Thank you to both of them very much in putting this together.

Again, other than the first page and kind of our vignette everything else
pretty much comes straight out of some things we have done plus as you go to
page seven it talks specifically about other things that are going on. So this
would allow a person to read the first six pages that are bulleted and set in
good categories and then actually go to other people’s work besides ours that
has been created to really get a good sense of what this subject is about. This
has been out to all of you. We have gotten limited comment back assuming that
you like it. I’m not sure it is necessary to read it, but I will be happy to go
through page by page and if there are considerations because this is not a set
of recommendations. This is not adjusting anything we have already said. This
is solely taking a look at what the industry has done using our own work and
packaging in a way very much like we did the privacy and confidentiality
document that all of you got a copy of yesterday.

DR. SUAREZ: I think the document is great. It is great and short as opposed
to some maybe other documents that are produced in our industry. This is very
short and sweet. My question is really about I tend to think all the time about
what is the outcome. What is the deliverable? And what is the purpose of doing
this? Are we to say we are just assembling a number by items and helping to
clarify this issue? Is the purpose of doing this setting the stage for
developing a framework that people should follow or that people should look
into or what are the actionable activities out of this? What would be gained in
the industry by having this in place? Who is going to follow it? What it is
going to be used for? I think it would be helpful to define those items so that
we can give those that are going to read this and look at a sense of what is
expected to be done with it.

MR. REYNOLDS: I would say we don’t necessarily expect anybody to do anything
with it. We’re not being prescriptive in any way as to what people should do. I
think the key thing is and I hope I had said that earlier is this whole subject
of data stewardship, this whole subject of all this data moving around,
everything that we are talking about right now. The EHRs and everything that
are going on is – and one of the things we said before we started this is
we spend a lot of time in our meetings with the learned on these subjects.
There are a whole lot of people starting from zero out there about how to deal
with this stuff. The reason it is called the primer and not an advanced degree
document or nothing else is to really have it out there available. It is a
little bit like our thinking on meaningful use and some of the others. A primer
on how to think about it. A primer on how to do (?). Carol had a comment.

MS. MCCALL: I guess my question would be for our discussion is given that we
do have this, are there other things that we would like to see done? Are there
other things with the document or the ideas? Are there other things that we are
being asked to do to try to take it to another level and if not then it is what
it is. So it’s really are there next actions for us? That is my question.

MR. REYNOLDS: It is a by-product. Remember it is a by-product of work we
already did and others have already done. So it is not that we have taken up
-– now we could and that is part of what I hope to hear from the
subcommittees. You know we could take up any kind of subject we want to. We
have already taken this subject up through secondary use and some of the
stewardship stuff that came out of that. So have others. But there has been no
way to synthesize that in any way that somebody could deal with the subject
other than trying to go out in the Internet and other places and find it.
That’s what we have been doing. Marjorie.

MS. GREENBERG: Just getting back to Walter’s question. Obviously we are
going to post this on the website but are we going to send it to somebody
because then just a brief cover letter from you could say why we did this. It
is a product of the committee. Although we are not telling people to do
anything we did it for a reason.

MR. REYNOLDS: Let me go back to yesterday. We didn’t do that here. We didn’t
do that with this document.

DR. SUAREZ: The first word in that cover is very important. The very first
word in that cover is very important.

MR. REYNOLDS: This was our recommendation. The very first word will be very
important on this one called the primer.

DR. WARREN: I would just like to answer Walter.

MS. GREENBERG: Excuse me. Could I just clarify this? We are sending this out
to the whole NCVHS mailing list, right, with a little cover letter from you. We
could do the same thing with this primer. We could send it to the whole mailing
list with a cover note from your or we could send it to ONC, the data council.
It is relevant. I mean I think we should push it out.

MR. REYNOLDS: Well one thing I have been responding incorrectly. Let me step
back for a minute before Judy you get your point. We have discussed this in
this group two or three times. We were assigned to do it. We did it. We weren’t
done with it. I’m not going to sit here and defend it. I’m not going to have
Justine and I. We were assigned to this. We were asked by you as a committee to
do this. We did it. What do you want to do with it and that’s going to be your
further input in this subject. So Judy and then Larry.

DR. WARREN: From my perspective as an educator right now there is enormous
pressure for us to educate new health professional students according to the
standards that were laid out by the IOM report that laid out five criteria. One
of those is informatics. Most of our faculty regardless of what discipline they
are teaching in have not a clue how to incorporate informatics into their

I have been asked to come speak at two our major in nursing accreditation
forums and also in dietary and nutritional sciences. They are desperate for
something that is to the point that they can get their arms around. The data
standards, stewardship thing is a little heavy where the primer would be ideal
for faculty to say here it is. Not only faculty but students to ask it for as a
reading to help faculty understand where this fits in because while they do a
lot of the stuff with secondary use of data they do not see it as an
informatics or an information technology or any of those things. So it is hard
for them to talk to their students.

So we are still turning out a lot of brand new practitioners who really
don’t understand how we manage statistics and data in this country and it is
vital that we put them out. So I think that even if we don’t send this out to
anybody, the fact that they will find it on the website that there are a lot of
us that are going out and giving presentations, using the URLs, and especially
this is short enough that I can duplicate it and put it as a hand out to one of
my talks where the other manuscript wasn’t as huge. So don’t underestimate how
this can have a generator effect when it goes out.

MR. REYNOLDS: Okay we got Larry, John, and Dr. Sondik.

DR. GREEN: I agree with Judy. I think it is important to push it out. It is
just another product as a regular product. Whatever mechanisms we use for our
reports I believe should be used for this. I think it is quite useful. I do
think it needs as Marjorie was suggesting an explanation possibly from you,
Harry, as the why so to position it properly. One detail I would ask you to
consider getting rid of one thing and that’s HIPAA defined de-identification.
The real issue is de-identification however it is being used or whatever HIPAA
has one way.


DR. GREEN: Well, in the summary it is in what specific practices we are
suggesting for data stewardship and then in the body of the letter it is on
page five number five. HIPAA defined de-identification. It is not just about
HIPAA. It is about de-identification.

MS. GREENBERG: You could say HIPAA defined or otherwise.

DR. CARR: I think it was coming from the other direction that when we had
the secondary uses hearings we heard all manner of de-identification which did
not meet the criteria of HIPAA de-identified so I think we were trying to make
it more stringent. I have two comments. One is the Center for Democracy and
Technology as a draft that I saw in April and I think maybe it’s about to come
out about de-identified data so I think we should reference that, and here
somehow, Susan, if you could find out if it’s out yet. Then we can fix that so
that it represents that at least HIPAA and beyond.

DR. GREEN: The key point that I think is evidence underlying this that
requires us to be attentive to in some way is we came to the conclusion that
there is no such thing as de-identified data anymore. Remember? I said that if
you want to badly enough you could basically re-identify just about anything.

DR. CARR: So the CDT has done just a wonderful summary and narrative on
that. There are a couple of things in here that I see we need to tweak too. If
the outcome of today is that we approve it then we can make sure that gets

MS. GREENBERG: There is a reference to the center, reference 11 so maybe it
just needs to be updated or something.

DR. SONDIK: I actually had I guess a concern about the list from 1 to 10 in
that I think that is really the core of this and yet people who need a primer I
think are going to look at the list and not know what it means, not know what
any of the 10 actually mean. For example, you sent this out to I don’t know
here is something you could give to students and so forth. When it says
transparency for the individual about the use of his or her data, I think it
needs an explanatory –- for me it would be deal to have an explanatory
paragraph to what transparency means and since de-identification again is
something that for the uninitiated I don’t think they are going to understand
it. The oversight of data uses I think is really -– that’s an extremely
important point, but what does that mean oversight by whom and what does
oversight actually mean. Obviously this is a very difficult subject or complex
whatever but I think my suggestion is to add something under each one of these
so that people can walk away with something.

The other point I would make is this emphasizes evolving. I don’t know that
the principles and practices are evolving per se. I would think the principles
are pretty set. I would not emphasize the evolving. I think clearly it is
evolving but I think to give somebody something and say well it is evolving and
this maybe you know not useful in six months. I’m not sure that much of a

MR. REYNOLDS: Are you responding to Ed? I’m going to come right around the
table. I see everybody’s hands. I’m coming right around the table.

DR. CARR: I think that there are two considerations with regard to your
question about further detail in the 1 to 10. I agree with you that we can put
more definition around what do these words mean but I think we intentionally
did not go down the path to say so is oversight an entity, a person. This is
the evolving definition of whether there will be a national entity or a local
entity or one person or many people. We wanted to stay out of how it will
ultimately be solved by simply to raise that it is recognized that whatever the
configuration there needs to be oversight or de-identification. I think we can
probably improve this a little bit to take some of the words down to more lay
person language or a little parenthesis or something about what the term mean
not what the solution is.

MS. MILAM: My question is for Justine and it is probably because I am fairly
new to the committee just a year and have not been involved in the quality
discussions, but my question does go to the 10. When I look at the framework it
is very similar to privacy principle framework with the exception number 5 so I
am wondering what the difference is between data stewardship and privacy and

DR. CARR: I don’t think it’s an either or. I think stewardship is sort of an
overarching concept and rather than take it to quality, privacy standards or
whatever just an overarching construct that applies in an array of venues.

MS. MILAM: I guess I am saying when I look at the 10 this is really
identical to a privacy framework and these principles –- and there are a
variety of those frameworks out there that have varying degrees of height, very
global ones that fair information practices that are identical to this ONC
issued one in December that gets into some drilled down a little bit with
health information and movement of health information. This really is a
discussion for me about privacy.

DR. CARR: Well I mean there is more to it let’s see in terms of the use of
data and sound statistical principles aggregating and so on. So that’s a little
bit beyond privacy. Are you saying we should be referencing? Again, this has
been evolving because so many publications even have come out since we began
this. Are you looking to reference some of the prominent privacy documents or

MS. MILAM: Not necessarily. What you just said with respect to the sound
principles that guide how you use data I am wondering if they should be more
reflected in your framework. You could capture all but number five and say
application of privacy framework in one and then have more and unless that’s
not the emphasis. To me this is a privacy framework and it doesn’t capture what
you spoke to in terms of appropriate use of data in research and in other

DR. SUAREZ: What number five are you referring to?

MS. MILAM: The HIPAA defines de-identification in the list. When you look at
privacy frameworks that are typically not an item but all of the others are.

MS. GREENBERG: Six is an item too?


MS. GREENBERG: In a privacy framework?

MS. MILAM: Right. Security is typically the item and data quality and
integrity are part of security.

MR. REYNOLDS: Okay. Carol, let me hear your comment and then I am going to
recommend something here. I know the rest of you have questions but I am going
to say something that will make you not have questions right now.

MS. MCCALL: First of all a quick response to the current discussion. If it
is very similar to a privacy framework then I think that that can be addressed
and it can be changed because it is not meant to be the same. I would say that
data stewardship subsumes privacy and not the other way around. Part of
stewardship is privacy but it is also integrity. It also is all the things you
need to do to enhance meaningful use and measurement and all the good things
you want to get from data. If that were the case if they are too familiar now
then I think that would be on our list.

The second is that as a primer these are sophisticated concepts so I would
certainly support adding a paragraph or something to introduce it not to teach
everything there is to know.

The third would be that in terms of our actions look we are not going to
start publishing massively on data stewardship, but I do think that the concept
is evolving and that we should start to use it more and more in our own work.
The question is could it actually be a living –- maybe not document per se
where we will always be writing but the links become –- that we become a
place where people can come and kind of say well I’m data stewardship. Is that
something that we could do? That is one idea.

The other is to make it a more intentional part of our own work product that
every point that when we are talking about future publications or future
recommendations that we always make sure to have a section on what the data
stewardship principles are. Make it part of the language. So that’s the other.

MR. REYNOLDS: Okay. Here’s what I am going to do and I stop there because
here is what I have to say. This document has been in all of your hands. We got
no feedback. What we have set is ground rules in this committee is if you get
something out and it is coming in this room and we ask you for feedback well in
advance and you don’t give us any, I don’t find it at all comforting. It has
nothing to do that I was part of the author of this. I am speaking as the
chair. It is not comforting to come in here and now everybody decides that they
care. We have all signed up for something. We have all signed up for a
responsibility. I asked you to please take it. When it comes out we have said
to each other many times we want stuff sent out so we can have a chance to look
at. We can have a chance to comment. It’s not working guys. I know everybody is
busy. It’s not working. Great discussion. I’m not even going to act like we are
going to pass this today because now we are finally getting what we want and
after we spend the time putting it together at your request I am not anxious to
sit here and now get it and try to react in a time where we can say okay can we
add this, can we add that, can we pass it, is this okay. I’m not going there.
That is not the way we have agreed to work with each other and so consequently
we wanted that input. So I welcome it. Everything everybody said we greatly
welcome. Man, let’s do it earlier guys. Let’s don’t do it after we have two or
three meetings on it and then we discuss it and then we come in here and
everybody now has an opinion of what it looks like.

DR. CARR: Well, Harry, I would add though that I for one think better when I
am in dialogue as opposed to in isolation editing. I have edits from before now
but when I hear what Sallie says and what Carol says and what these questions
are it stimulates a higher level and I think that’s what makes our product
better. I agree with you that we are not ready to pass it today but -– if
we could have more input.

MR. REYNOLDS: I love the discussion, but to have had no comments. Some of
these things are base beliefs. I know you guys well enough. Some of these
things you have looked at it and they are your base beliefs. Those base beliefs
if you looked at it and you even perused it those base beliefs would have
jumped in your face. That is all I am asking as we go forward. I am going to
stop the discussion and put all your hands up you want.

DR. FRANCIS: When a document comes around and I read a written document I
think in terms of editing or making little comments on the document that is one
kind of thing you can do. This is a just a proposal. I wonder if there is a way
to set up a little blog that we could communicate with and post some more
general comments like Sallie’s because I don’t want to hit the reply button and
send an email around to everybody that says gee I like this and I wonder about
that. People don’t read those either and it is kind of irritating and I don’t
whether to send it to the author or you. But if we had a little forum that we
could each post our comments, we could have something like -– I don’t know
what we would do about having it be public but we could have something like the
discussion that just –- envisions.

MR. REYNOLDS: Blackford and then I’m going to cut this off.

DR. MIDDLETON: Actually I think it is a very important sort of line of
reasoning that we might want to pursue, Harry. I struggle in the committee
sometimes and this is now a generic comment not about this document
particularly about the group editing process. It’s not what I am accustomed to
and any other committee I am in typically there is a subcommittee which is
responsible for authoring and when it gets it right it submits it to the full
committee or even to the executive committee depending upon the channels and
the authorities for approval and then action. So that is one observation. I
wonder if we might model that process a little bit more in this committee
because personally I find it very difficult to group that and I tune out.

Secondly though I think Leslie’s idea is very interesting. There might be
ways in which we can play gosh some technology to have a way for us to
communicate with each other and to share and comment on documents that is
extremely efficient. It is asynchronous. It allows me to do it when I can do it
and all the rest of it. I would be happy to help look into some of those.

MR. REYNOLDS: Okay. And on this particular one so as we move it forward for
our next meeting. Susan, you are the repository of the comments, is that

MS. KANAAN: Correct.

MR. REYNOLDS: So I would like anybody that has any comments about the style,
about anything to go to Susan. Susan will work with Justine and I then we will
be the ones reporting to the full committee if there are style changes if there
are other things that are going on as we do it.

DR. WARREN: Harry, how do we know what comments that are there? I mean I
have comments that comments that were made here that those comments were made
just to –-

MR. REYNOLDS: We just did meaningful use exactly this same way. We passed
them all to Margaret. She came out with what the questions and comments were.
We sent them back out to everybody. I am saying we got to go in one place. We
have asked Susan to kind of help us coordinate this so she sees the whole
picture. That’s what she has been doing. Then we get the comments in and then
we shoot them back out. If somebody says a style thing, this doesn’t happen,
this doesn’t work then fine. We put that back out to everybody and then we come
out with a recommendation. So basically we are the subcommittee in this just
like I would expect the quality subcommittee to do something or something else
and then we say what’s going on. Again, it has to come to this full committee
anyway. Walter, Mark, John.

DR. SUAREZ: I do take full responsibility for not looking at this before and
yes needed is an issue. I just fell through my pile.

MR. REYNOLDS: I don’t need an apology. I am just making a point. How do we
go from here?

DR. SUAREZ: This is a very important topic. This is a topic that is out
there as a new concept. Data stewardship is something that in the context of
all the discussions that we have about privacy and security data stewardship it
gets kind of down in the not so noticeable area. With my original comment when
I started this, which might have caused some of the issues here, my intent was
to actually elevate this because I think it is too important. I think it is one
of those leading things that a committee and we talked yesterday about what
this committee can do to take certain items and ownership on certain items.
This is one. I think there are parts where we talk about a framework, an
opportunity to create a framework and data stewardship that others can look
upon and reflect on and probably follow because that is what we want. As much
as this is a very useful element where (?) and I also teach and I also use this
or would be looking at using this. I think it goes beyond that. I think it goes
into the opportunity of actually demonstrating how organizations can
incorporate this into their practices.

ONC published in December the nationwide privacy and security framework for
health information exchanges. Five of the principles are identical to the ones
that we have here. It is going to be very important to create a document that
has something goes beyond being a primer and that’s my point. That was my
original point. I think a primer is good but I think we have the opportunity to
take this and elevate it into a much larger discussion and much larger
opportunity for the committee.

MR. REYNOLDS: And that will be our next assignment. The current assignment
was a primer. If we want to change it to something different, good. I’m in.
Mark, John, and Jeff.

DR. HORNBROOK: I just have a question for clarification. Is the primer
supposed to be aimed at anybody including all healthcare workers who have
access to healthcare data as part of their jobs or is it supposed to be aimed
at researchers?

MR. REYNOLDS: The word primer should play across all audiences.

DR. CARR: Paul isn’t here but he raised the issue that he felt that the
story in the beginning, the example of the parent, the child was kind of
simplistic for a sophisticated audience. I think it may be and especially now
with ONC coming out with there thing. It may be that we want to get to a less
sophisticated audience. I think it is important.

MR. HOUSTON: I actually think the primer is really good. I think that the
one area that I would be interested when you talked about putting a cover
letter in place. I think that is the one area that I think that I guess knowing
who the audience that the cover letter this is going to and what the cover
letter is going to say I think is extremely important. Judy had made mention
informaticist. I think data stewardship is an overarching principle that
-– the principle is wide reaching. The question is how far do we want to
send the letter or how far do we want to send this out is really my only
question at this point in time. I think the tone of the letter then chances
based upon who we think we want to send it to initially because I think data
stewardship is a great description. I think the letter though can set the tone
of how important it is, how public trust is part of this, and that I just want
to know what the scope of distribution is going to be.

MR. REYNOLDS: And I welcome recommendations. So whatever we think is right I
want the input from you so please send that in. Jeff.

MR. BLAIR: I wanted to echo Harry’s observations about the process. As
difficult as it is for many of us to break the time to wind up responding to a
document when it is set out for comments and edits. If we don’t do that and we
save all of our comments to these meetings, the agenda has a limited amount of
time for each item and we need to manage the process in a way that when we get
all together it should be the fine tuning, the final edits. If we start going
through with 18 people around the room going through basic reconstruction then
our productivity will be reduced tremendously and we have years and years of
NCVHS being very productive but it is critical that all of us need to get most
of our comments in before the meeting and not let it wait until these open

MR. REYNOLDS: Okay so to close this. Great conversation. Understand we are
about to put a document out from the entire group. We need it to be the
document that the entire group wants. We need to make a difference in this
environment. I would say I would add one other thing. Any company in healthcare
right now that is being audited this is helpful too. I don’t care who you are,
what you are, where you are, what your title is, and where you play. If you are
a department that is getting audited, this is something you ought to be
thinking about as a company and then the education I think can’t overestimate.
Marjorie, myself, Justine and Susan will get together and figure out exactly
how to do this. Blackford, thank you for your offer to help and it may not be
on this one. It may be the next one. I want some people to work on that. But we
will get together to figure out how to tell you to get the comments in and I
want those comments and as those comments come in we will categorize the
comments so that Judy back to your point. If somebody makes a point or there
are a number of points made, everybody knows that that point was made and maybe
what we did with it a little bit like we just do some of our other and
especially where they are conflicted. So we will be happy to do that. Great

MS. KANAAN: Harry, may I add one thing if I may? Just to assure people that
-– it is very interesting comments about the sort of bilateral
conversation between individuals and need versus the multi-lateral
conversation. In terms of substantive comments or sort of global comments
versus micro comments I want to assure people or remind people that they are
always welcome to send an email just a general comment and I will take that
just as seriously in terms of the way I approach a document. This is kind of a
general comment about our process in the future. You may very well have
comments that transcend specific parts of the document. Please don’t hesitate
in the future to send me those kinds of comments.

MR. REYNOLDS: We will set up exactly what the process is. I like that but
you and I will talk some more. Marjorie.

MS. GREENBERG: I just wanted to follow up on Blackford’s comments because
Blackford has also mentioned in previous meetings and I don’t want him or
members to think we have ignored that. You know the fact that it would be
helpful to have some kind of just to use a term like SharePoint where you
mentioned the blog. Something that is just within the committee and password
protected whatever where people can be working on documents or having
discussions or comment. This room is crazy because I can’t see anyone who is
behind this post. Could you come to the table? I know Kathryn has looked into
this. I can tell you that I have like in my WHO work. We have a SharePoint.
There have been lots of problems with it. There has been minimum use of it. It
has its down side, but the idea of it is very good and certainly this committee
should be as you said oh my gosh harnessing technology to the extent that we
can to improve the way that we communicate. We obviously use email a lot. We
can send emails. You know list serves. But there are other more current modern
technologies, but figuring out how to use them in the context of where we sit
here in CDC and the department has not been entirely easy or clear. Do you want
to say anything about that? But we don’t want to give up on it. We accept your
offers to work with us on it.

MR. REYNOLDS: I want to assign it to somebody here today. I’m going to
assign it to somebody.

DR. MIDDLETON: One quick follow up and I would love to hear where we are it
is gosh we can make this also part of a green initiative. I don’t give paper
for a lot of meetings I go to. This is one of the few meetings that I still go
to and I get paper. Other boards and committees and what not use the web,
director’s desk, and other things to make it –-

MR. REYNOLDS: Kathryn, go ahead.

MS. JONES: I guess it would be nice to understand how many folks here would
be interested in something like SharePoint. Unfortunately we can’t because
-– at least CDC has determined it is not very cost effective at this point
but we have something similar called sitesby(?) and that is something that we
can offer to the committee, but we wanted to make sure we had enough people who
would support the product because it is going to require quite a bit of time to
build it and it is going to require quite a bit to train staff to continue to
support it. We certainly would be happy to work with –-

MR. REYNOLDS: I would say this as having been on the committee now for just
over five years. Email when we are doing this letter when you get 25 emails and
you are trying to chase the thought process it’s got to be better. It’s got to
be better some other way where you can pull up one document and you see the CEC
the deal. This chasing the string sometimes leaves some people out because if
you can’t read all 26 comments on something you can’t stay current.

MR. HOUSTON: I apologize for missing the first conversation. This is just
one piece of the bare puzzle though. I know privacy is going to be doing more
and more conference calls and doing collaboration during conference calls are
of really great importance. You know whether it would be putting up a
PowerPoint which is easy but often interactive editing via the web while you
are on a conference call is hugely importantly to us because the amount of time
you can save by being able to look on a screen as you are talking as somebody
is typing just like we do here as we are doing conference calls I think
something that I think we need to do.

DR. SUAREZ: It sounds like we are talking about three different things. One
thing is the web X type tools for meetings. Another thing is the SharePoint
type tools.

MR. REYNOLDS: Here is what I would like to recommend. Who is willing to work
on this issue with somebody maybe Kathryn from Marjorie’s staff to understand
what we need to do. We’ve got Blackford. We’ve got Leslie and we’ve got Mark
and John. The point is who will take the lead?

(Dr. Middleton raised his hand)

MR. REYNOLDS: Okay. Set up some calls. Put it together or do whatever. Do
whatever you want to do. The point is if we are going to change it, let’s
change it. If we are going to change let’s get people together to do it and
that’s great. I’m all for that. Because I will tell you email is becoming a
struggle when we are doing any of these documents because you really do have to
chase a lot of comments and as soon as the next person agrees or disagrees now
you are really weaving. I look forward to some kind of a comment at the
September meeting.

On this document we will get together. We will figure out how we are going
to handle this one. Great discussion. Exactly what we wanted. Nothing should
come out of this committee that doesn’t make a difference and doesn’t make a
difference the right way. I don’t care if it takes until the end of the year to
get it out now because we are not going to put it out before its time and help
us understand when its time is and what it should say at that time. Any

MR. HOUSTON: Who uses Facebook here? The reason I ask the question is in
terms of setting up groups and having group dialogue in an informal way
sometimes is very helpful when you are trying to simply get a little bit of
information about something. I mean I think we can set up a link in.

MR. REYNOLDS: You are part of the committee that is deciding this and your
committee can meet whenever. Next item. Health statistics for the
21st century.

Agenda Item: Health Statistics for the 21st
Century – Update

MS. GREENBERG: Let me just tell you what just got on the agenda. At one
point we actually thought we would have our consultants on the phone today and
give us an update. Instead they provided you with an update under tab six and
since this project is really being overseen by the population subcommittee,
they were on the phone yesterday during the population subcommittee break out
session. Before or in lieu of Debbie and I saying anything at this point I was
going to ask Bill and I am sorry I didn’t ask you in advance, but since it’s
probably part of your report anyway if you just wanted to provide from the
co-chair’s perspective an update on what is happening with this project and
then we can add anything.

DR. SCANLON: Let’s start with the premise for the project. The premise for
the project was the vision was done a number of years ago without sort of the
appreciation of what might be happening with respect to information technology
and that the idea of updating the vision to take that into account seems as a
good thing. Now I think if the update project if we think about that sort of as
a discreet event and to start with it that it’s been transformed dramatically
by the fact that now we no longer have ITs as this hypothetical potential
future tool. We suddenly have this reality where there is going to be a lot of
it. The question is how well are we going to be able to harness it and so the
environment is incredibly dynamic and moving rapidly.

The issue here is now the work that Dan and Gib are doing in terms of trying
to update this vision seem even more strongly than before as the jumping off
point for the population subcommittee to think about how do we transform. What
is happening in terms of the collection of population health data and take sort
of as full advantage as we can sort of the IT investing that are being made.

We are in the conversation that we had yesterday with Dan and Gib we agreed
that they are going to come and report to the full committee here in September
but we are going to try and coordinate through populations in August sometime
sort of when they reach tentative conclusions about what information that they
have gathered so the population can think about its next steps at that point.
The anticipation always that what Dan and Gib are doing is interviewing a
series which might call key thinkers about this topic, but they are obviously
not having hearings and the idea was that the populations would follow with
both hearings as well as a set of potential actions in different reports,
different recommendations. We want their input to be able to plan that next
phase and we can come back in September and talk about what that next phase is
going to initially be involved.

MS. MCCALL: Just a few questions on where they are. Were they able to share
any of the content on their interviews or are they still just kind of saying
here is where are process was?

DR. SCANLON: They did not share the specific content. I think they are about
half way through their interviews and what that characterization of those
interviews was that they were getting very different input from all these
different people. It’s probably not necessarily an issue of conflicting input
but just –

MS. MCCALL: So with that as a backdrop my broader question is whether or not
the update will actually come out and result in a document that is published
under our names or is it going to result in something that is not going to be
published or would it be an update to the 21st century document
under their names? Then I think I am going to go back and pull on your theme
and pull it into this particular subject if it is going to come out under all
of our names I think we all better be deeply involved in terms of when they
finally do have the content coming from the interviews and there are points of
view around that how we are all as a group kind of the raise your hand, jump in
are going to be involved with that. So what in fact is the output going to be
and is it going to be a paper published or a book with our name on it?

MS. GREENBERG: This has evolved a bit and is still evolving, but the
original idea was that it actually that the national committee with the help of
these contractors would come out with an updated vision for health statistics
in the 21st century. Now to do that in a comprehensive way, fully
comprehensive way it probably would have been necessary to revisit every single
one of the recommendations. If any of you were around then or maybe you weren’t
but you heard about the process, it was certainly -– Ed Hunter was here
but Ed Sondik was very involved. He in fact initiated this project. It involved
workshops. It involved hearings. It involved a lot of work that much of which
is captured in the report but also was captured in an entire volume on health
statistics sort of one of a kind because about how statistics that was
published a number of years ago now. Well not that long ago or maybe five years
ago. When that came out I said to my staff I could now die happy. I think it
was a premature statement on my part. It was a big effort.

We have scaled this back for a lot of reason not only resources but just
utility to say okay we have worked with the committee, Gib and Dan, on
prioritizing the recommendations. We know that some of them had no traction
whatsoever. Others had some. But we do know that first we got feedback from all
of you that the basic concepts, the vision, the principles still resonated as
Bill said, but they did not reflect what’s happened in the 10 years since then
particularly the HIT potential revolution and now even since then the reality
that real money is going into this.

Based on an iterative process we prioritized to eight recommendations that
you all felt were still the most relevant and had the most priority and would
benefit from revisiting. We can send this out to you, but they were pretty
broad, nonetheless, some of the broader ones rather than the more specific
ones. Now they are doing literature reviews and these key informant interviews.
I would say they are about a third of the way through those, but just
encouragingly everybody who we asked to have such an interview or phone
discussion with maybe one or two exceptions they all agreed almost by return
mail. There was a lot of interest in this and a lot of -– some of them
thought they were going to be talking to you, Bill, and Don since the letter
came from the two of you. But even after they found out they weren’t talking to
the two of you they still agreed to participate it. And like Ed I think you are
having your interview on Friday. They have already talked to David Blumenthal.
They talked to Elliott Fisher. You know various people who have been at our
hearings and whom we work with.

They are facilitators for us. This isn’t something for them to publish on
their own. What they will do in September is report to you on what they have
heard and what they have found and what they think might be next steps to
really to more fully update this vision. Now as Bill said the population
subcommittee agreed to have some conference calls in probably August and
September to help shape what they will bring forward then. But when the privacy
has had calls I think we could definitely make these open to anybody on the
committee who wants to participate.

MS. MCCALL: I am trying to get at what the intent of this subcommittee is.
There has obviously been a lot of discussion and talk about the topic. Is the
intent to publish a larger document under our name that’s refreshed number one?
Number two is it the intent and the desire on the part of the committee to have
the members from the full committee not just a subcommittee be a part of that

DR. SCANLON: On the second one I think the answer is definitely yes. On the
first one in terms of publishing a bigger document that remains to be
determined because I think that we have to again maybe this is too much of a
broken record. I think we have to be sensitive to resources and timing. There
are more important shorter things to do than we may do them in the interim.

MS. MCCALL: So that’s really exactly what I am trying to get at.

MS. GREENBERG: The document that we get in September I don’t think we have
an intention of publishing that or even probably sending it to anyone. I mean I
think we can post it but it is really input to the committee. This segues
really into the next -– the idea was to have something substantive in the
way of an update or updated reflections on the report by the 60th
anniversary celebration a year from now.

DR. SUAREZ: I mentioned this yesterday. We are about to embark on the
largest healthcare reform in this country. We just are in the beginning of the
biggest health information technology movement ever. We are about to start the
second decade of the century. We are celebrating the 60th
anniversary. All these things seem to me create the opportunity to not just
revisit and do a quick evaluation of where we are with things on the shaping
health statistics systems in the 21st century but it gives us maybe
the opportunity to define the vision for the next 10 years as I mentioned
yesterday. The 20/20 vision for the health statistics system in the country. So
building this from the work that is being done between now and September and
then from there expanding into the larger work that need to be done is what I
hope will happen.

MS. GREENBERG: Well, I think Larry. I don’t know if you want to comment
here, but in the quality work subcommittee this morning you were commenting on
some of the discussion yesterday in populations about the health statistics and
the enterprise and the ability to improve that enterprise that I think would
fall into here.

MR. REYNOLDS: Last comment and what I would like to say is this appears to
be under the jurisdiction of your subcommittee, yours and Don’s and working
with Marjorie. However you can bring this group along on this journey so that
we don’t end up like our last discussion where it is a big enough subject if we
are going to have to help educate the committee to get them to a point where
everybody says yes this is a good idea then let’s purposefully include that in
whatever you doing whether it is calls, whether it is anything else so that we
do move. That is a general recommendation I have for all the subcommittees
going forward because I can tell you right now the next level of stuff that is
going to come out on privacy is going to be the same way and some other things.
As you say Walter there is a big change going on. Well, we can’t act like we
come to this room and people haven’t been involved and we are going to assign a
big change with one conversation. I think that is a good point. Leslie and then
we will move onto our next agenda.

DR. FRANCIS: This is a fly on the wall observation from yesterday. Three was
a comment made that there is no money for new methodologies.

MS. GREENBERG: That is what I was referring to.

DR. FRANCIS: And that just blew me away because it seems to me that if ever
there were a time to think about leading out about some of the importance of
new methodologies given new kinds of data it is right now. I would urge
wherever you go with some of this to be thinking about having that on the

MR. REYNOLDS: Bill, let’s move onto our next topic.

Agenda Item: NCHS/BSC Update – Vital

DR. SCANLON: Leslie and I arranged that perfect segue before because
actually what I was thinking about doing here was trying to repeat what Ed
Sondik said yesterday at our breakout session in terms of NCHS kind of the good
news and Leslie just described some of the bad news about resources and where
there are. Since Ed is here I don’t want to fail the test and sort of missing
out in terms of my memory of what he said. So maybe we could ask Ed to kind of
give us an NCHS update. I think that would be the most useful use of this time

DR. SONDIK: I said yesterday I would do it briefly and of course as usual I
didn’t so briefly but I will try and do it briefly. A major issue for us has
been budget and because of the efforts of lots of people including people in
this room, this committee, the support from many, many places we received a
budget increase for ’09 and we are in the President’s budget for ’10 as well
for a budget increase. This really saved us from having to continue with the
draconian measures that we took. We cut the health interview survey in half. We
were having great difficulty in paying for the vital statistics. We cut back
our healthcare surveys and we were not investing in the future, which is
perhaps the most important thing. Doing the kind of methods work, internal
research we are doing a very small amount of it but nowhere near what we should
be doing.

The budget increase for this year has enabled to bring back the health
interview survey to a good level but not where we would like it and enabled us
to not take actions that were going to take with the vital statistics to cut
back on the amount of birth data that we were collecting that would in turn
give us some money to invest in electronic systems and in quality control
research and measures, but we don’t have to do that. We’re not going to do it
and our plans are not to do that in ’10 either that is to cut back but to
collect the full range of data.

The increase in ’10 will help us with personnel cost, the vital statistics
and enable us to do several other things. One is increase the sample size of
the HIS even higher up to its real design level. It is still not where I would
like it to be but it is design level that gives us information on the diverse
populations in the US. I said yesterday I don’t like the term subpopulations
because it seems to inherently to me seem to create priorities so maybe diverse
populations. I am searching for a word but anyway the country continues to get
more diverse and we need a better handle on this.

It has also become really clear that and this was brought up by – it’s
terrible. I am blanking from the name of the person I have known for 20 years
from NCI who was there yesterday at the population – Nancy Green, right.
Don’t tell her I blanked. They actually have a project that they are doing in
which they are looking at the varieties of more local and state data collection
that are going on. They are not quite sure exactly what they are going to do
with the results of it but I think it is going to be very informative. There is
no question in my mind that the drive is toward more local and state data. That
has been the cry that we don’t have it and the drive is toward that and I think
that is terrific, but the more we get of it the more we need a really solid
benchmark to know how good that data actually is. I think that is a major role
that NCHS we play it now and I think it will be an even stronger role in the
future which is why I think in the future we need an even larger size for the
health interview survey to give us those figures, those information on these
diverse populations that then can be compared to what people are actually
getting through phone surveys that get 30 percent response rates and that sort
of thing at the local and the state level.

For ’10 if we get it we will be I would say in pretty good shape with the
vital statistics and I hope that we can pay for the majority of the year of
data. Every year we don’t pay for a full year it just means we start at the
next fiscal year paying for data. We get further and further behind in actually
paying for the data. These two years will really help us considerable, help us
with the HIS. We won’t make any major changes in NHANES but we will pay some
sort of maintenance and trailer cost. The trailers are what we use to collect
the data. I think most of you know there’s a very large outfitted trailer
trucks and we have quite a fleet of them, 12 of them plus a couple of spares in
any case.

So budget wise we are doing okay but then the question came up well what are
we doing. What are the major issues? I said the major issues are one we really
have no extramural research program that enables us to do the methods
development and the quality control research that we really should do. I think
with a relatively small amount of money we could be giving grants to people who
could work with us and I think that is the way to do it to couple that with our
internal program. As the person who heads the internal program tells me I just
don’t have the money to do what we should be doing and part of that money would
be directed through that program, but part would be really investigator
initiated as well. So we don’t have the money for that. We need to increase the
sample size of the HIS and we could also stand to increase the sample sizes of
the healthcare surveys.

In one thing I didn’t mention that in ’10 we will put back in the field or
we will initiate a residential care survey. This is one of the frontier areas.
Particularly a frontier area in that we have very little information on
residential care and assisted living care. We are basically the agency that
gets that. There is really no duplication here that I know of elsewhere in the
federal government. We will continue our hospital discharge survey with an eye
toward the redesign that we have already done but we still won’t have the
resources to actually put the redesign in the field and we want to make sure
that this dovetails really well with what AHRQ does, A-H-R-Q.

So we need to increase the sample sizes of those surveys again to be able to
give us the diversity of the populations. We also need to better secure the
future of NHANES although thus far it looks it is in pretty good shape. It
certainly could stand to be increased in sample size. Sample size continues to
be actually quite small when you consider that it gives us information that is
really unique in the Federal Government. I will just tell you what it is. The
nutrition information that we have whether the US eats a healthy diet or a
nonhealthy diet. That comes uniquely from NHANES. Information on the key
cardiovascular risk factors and their control the solid information not the
self-reported but the solid clinical information comes from NHANES and that
reason it is solid is because it is a very precise representative sample of the
US, but it is not as diverse as it should be. If we were able to increase the
sample size, we would be able to do more and we are looking at more innovative
ways of doing that not simply replicating the whole survey but considering how
we can add pieces to it that would target particular populations.

MR. REYNOLDS: Carol, do you have a question?

MS. MCCALL: No, not a question. It was more kind of a –

MR. REYNOLDS: You have the floor.

MS. MCCALL: It reminds me of listening to your comments of essentially the
informatics equivalent of Chuck yesterday because what I can imagine is that
there is both a need and an opportunity beyond methods research to put smaller
groups on the ground. Think about everything that is needed in terms of new
sources of data that you talked about that are locally relevant. They are much
more diverse. They go beyond healthcare and into health. The training and use
issues of the informatics that is out there today, what’s actually happening in
universities, how do you actually train people, let’s not forget data
stewardship and all of that, but also those might be the vehicles through which
you begin to talk about similar instruments. They would be similar in that
there would be continuity across different regions or local areas so they can
tie together, but there might be uniquenesses that you can then begin to
represent and create kind of a cycle feedback and innovation that you can do
and those are the types of things because this is about money. That is how we
go there. Is there a way to ask for money that begins to anticipate the
statistical enterprise of the 21st century that is fractal? It’s got
national. It’s got regional. It’s got local. I don’t know how Chuck got his
money, but where is this stuff for the meaningful measurement side?

DR. SONDIK: Health reform I think is critical to this. There seems to be
complete agreement on both sides of the aisle and certainly within the
administration itself that adequate information is crucial to monitoring and
evaluating this. One thing that I didn’t say that I want to emphasize is that
if our highest priority in this or certainly we have none higher is to build a
vital statistics system that is 21st century. A lot of it is not.
This is a partnership with Nafsis(?) and the registrars. WE were in one of the
stimulus bills for $40 million to do that and for reasons I don’t understand.
It came out and it doesn’t seem to fit any of the pots of money but as I said
to the committee yesterday we are working on it. But I can’t say that I am
particularly optimistic at this point.

MR. REYNOLDS: Carol, follow up and the Mark.

MS. MCCALL: What it does for me this helps me understand maybe some of our
relative priorities about 21st century and what we might do with
that. I would want to do more rather than less right now and the other is
around meaningful measurement if that becomes a companion to meaningful use,
measurement will end up being the key. It is not clear to me that we have
articulated the necessary – okay so what does it mean to actually make
that happen? All of the necessary elements. People go well of course we want it
to be valuable but we haven’t said what that is going to require which means
that chances of getting there is not very good.

DR. HORNBROOK: Two points. One on the vital statistics system. There is a
table inside epic and I am sure every other electronic medical record system
which links mothers and babies. Right now the vital statistics system sort of
waits until everything is all done before they send the data up and there is a
different kind of informatics modeling theory which says that as soon as you
know something we send it electronically. So as soon as the baby is born and
linked to the mom you have that record sent to you electronically and you know
there should be a birth certificate some time coming. As long as you are
sending that you can also say something about the baby and something about the
mother because it is already there in the chart.

Then on another whole different matter is I know that the primary culture of
NCHS is extremely high-quality data from original sources the best you can get.
The culture of NCHS right now is very high-quality data from primary original
sources and yet the whole economic enterprise in this country works off of a
lot of secondary data and there is a possibility of doing health statistics
from inferential sources in terms of people’s web browser patterns. I am sure
there are lots of reasons why people buy web data or their own marketing
purposes. In this case we are marketing the national health system. I didn’t
know whether anybody had ever thought about how to do the surveillance using
inferential and non-obvious sources for NCHS.

DR. SONDIK: We would love to pursue that. It would require staff. It would
require some money and it would require extramural partners. We would love to
do it but it is extremely important that there be -– and this is true for
the economic data as well. There needs to be a set of standards and I mean
standards in the sense of the atomic clock or whatever. There is something
there that is the benchmark and you can go back to that. My view is that you
should look at the quality of the data that you need in terms of the
sensitivity of the decisions that you have to make to that data. I think people
buy that, but at the same time that is a hard thing to actually implement. We
need more information really on how to use the data. That is why I don’t want
to go back to the stewardship document, but that notion of use is in there. I
think we need more research on the kind of data that we need for the uses that
we have. If in a community, for example, periodically you get really solid data
and you can use a variety of other kinds of information over time to make
decisions knowing that sometime down the line you are going to get another
really solid benchmark.

MR. REYNOLDS: Bill, back to you.

DR. SCANLON: This will be quick and actually could substitute for the
populations subcommittee report later because it is the second half of the
populations subcommittee theme. It is this whole issue of resources. When we
had done the letter back in February in terms of the stimulus monies and we
also had a second letter that Walter had drafted in terms of broader
perspectives and final resources for the statistical enterprise. Given what has
happened since then we decided not to pursue that letter yesterday but to think
about the changes that have happened with respect to the 2009 appropriation and
the 2010 budget. Considering for September a letter that in essence might say
thank you very much. This is a very positive thing to have this investment. It
is very important to continue this kind of investment because in September the
department will be thinking about the 2011 budget and also point the fact that
even greater investments will have significant payoffs. That is another thing
that the populations subcommittee is planning on working on this summer so that
we can be prepared when we come back in September.

MR. REYNOLDS: Marjorie. Let’s go on to the celebration.

Agenda Item: NCVHS 60th Anniversary

MS. GREENBERG: Okay. Are we ready for that? Debbie as well. I will just give
you a broad overview and then Debbie is going to tell you specifically about
what we are planning in Charlottesville, Virginia on the 24th and
the 25th of September. We have already as you know launched the
60th anniversary as a series of events, small ones so far but I did
the poster, which you may recall for the WHO meeting last October. We had the
lecture yesterday from Lisa Iezzoni on -– status and revisiting of that
report that the committee had done and we did it in conjunction with something
that we have called ICF week. We have actually had web seminars Tuesday. Today
there will be another one 1:30 to 3. Any of you who are interested actually it
is going to be upstairs. There will be a third one tomorrow. Those are all
being delivered by my colleague John Huff. We had a hundred people participate
in the first one and in addition to whoever listened on the web on the VA site
yesterday to Lisa’s presentation we had about 50 people listening on the
GoToMeeting as well.

These are individual events, but now we are having to get real. We are
working with on this 21st century vision for health statistics. We
don’t know exactly what we will have available for the roll out a year from
now. We hope to at least to have some kind of draft report and that is what we
did for the 50th. We rolled out some kind of preliminary reports,
but that is certainly a big piece of our 21st century vision update
is part of the 60th anniversary.

PARTICIPANT: Sorry for interrupting. In this vision have you explicitly like
we have already for the comparative effectiveness eliminated health utility
from any of the framework?

MS. GREENBERG: Nothing is off the ground and nothing is off the table at

PARTICIPANT: Europe and Canada have already strongly adopted health utility
measures using societal preference weights and nothing from Lisa added any
utility weights into the ICF yet and I was thinking and if we are thinking of
the 21st century vision and we are going to think about how to
allocate resources to the most health problems having some kind of health
utility weights to help us guide that would be very critical at least for
health economists anyway.

MS. GREENBERG: I know that the center has had a few workshops around that
topic. It relates kind of doesn’t it to the DALYs and all that. I don’t know if
you want to say anything about that, Ed. That certainly could be an area for a
future hearing or workshop. I don’t know whether anyone in these key informant
interviews will mention that, but you all are also key informants. You are a
member of the subcommittee populations subcommittee, right? So that’s where I
would suggest introducing that. Do you want to say anything about that Ed?

DR. SONDIK: No, I think it would be very good to discuss it. We have every
opportunity to be actually collecting this information. AHRQ collects this
information. I say always spell it out because there is a CDC component that
has no relationship to the other. The maps collect this information and we
could do that as well in HIS. There are issues in terms of actually how it gets
used. There is a sort of fundamental question of do we want to build an overall
health index and that is controversy to whether anybody wants to do that, but
in terms of getting preferences it is something that one can do. There are some
who are more skeptical than others about how useful that actually is in terms
of priorities, but that is why it would really be good to bring it up with the
subcommittee and actually it could be a topic for a hearing as well because
there is a great deal of interest in this in the world, but it is still highly

MS. GREENBERG: I know there are ethical issues and everything else, but we
won’t go into that now. Nothing is off the table. After I give you all of these
things then I’m going to give this to Debbie to talk about Charlottesville.

In September the two days after or a day and a half after the full committee
meeting we are convening the chairs of the former chairs of the committee whom
we have contact with going back to Carl White who was Dr. Carl White who was
chair in the ‘70s and then Ron Blankenbaker who was the chair in the
‘80s and everybody since then including yours truly here on my right. So
far we have them all coming. Simon Cone, John Lumpkin, Don Detmer, Judy
Miller-Jones. We hope to be convening them all in Charlottesville. We are doing
this in Charlottesville because for a few reasons but two of them are there of
course. Don Detmer and Carl White but Carl White is vigorous and in his 90s and
we thought that we should go there to him rather than ask him to travel to us.
Debbie will tell you more about that. Susan Kanaan is going to be part of that
picture. We are going to do some oral histories and discussion et cetera. That
will also be something. We will have videotaping that will be available. There
will be a document coming out of that that will also be available by the
60th actual celebration a year from now.

We also are doing a 10-year update to the 50-year history rather than doing
a 60-year history. A 50-year history we feel is very good solid document and we
will do a 10-year update which will pick up on everything in the committee not
just the health statistics vision but certainly a big emphasis will be HIT and
how that has come on to the scene of our work. Susan Kanaan is doing that. That
is in lieu of by the way an annual report. We haven’t done an annual report for
a few years. Instead it is all going to be captured in this 10-year update.

I had suggested that individuals around the table in addition to myself. I
have tried that you can see inserted into various activities of my office, but
might want to piggyback on the 60th anniversary and Judy, it seemed
you said you were going to do something.

DR. WARREN: Yes. So I have been looking for a venue to submit because we
were going to do this in 2010 to do the presentation.

MS. GREENBERG: In 2010 the national committee, I mean the National Center
will have its data users conference. It is a data users conference. I see a
session there, which would be after -– that would probably I think it is
July or maybe it is August. Ed, do you know? We are planning to have one in

DR. SONDIK: You know I really don’t know —

MS. GREENBERG: I know we are planning on it.

DR. SONDIK: No, we are. I think it is August.

MS. GREENBERG: There are those opportunities. Is there anybody else who has
seen through their professional associations or anything that they might be
able to do something?

DR. SUAREZ: There are several. I will bring up JPHIT again the Joint Public
Health Informatics staff for us, which involves seven of the largest public
health organizations. All of them have their annual meetings. It could be a
great opportunity to bring them. So if you give me something we can take it to
JFED and –

MS. GREENBERG: Well, we can talk to you about that offline also. I mean
certainly anybody can use this poster also if they want to.

Then we have the 60th celebration that is going to be at the
National Academy of Sciences where the 50th was. Although that was
downtown where the Einstein statue is or sculpture. That building is under
renovation so this is going to be at the Connecticut Avenue near Georgetown.
You know that facility, Ed?

DR. SONDIK: Yes. They still have it?


DR. SONDIK: I didn’t realize that. I thought they closed that when they
opened the other one near the building museum.

PARTICIPANT: It is at 5th and F. It is across from the Pension

MS. GREENBERG: Oh, is that where it is going to be? I am really confused.

DR. SONDIK: I really thought they closed the other one.

MS. GREENBERG: Wherever this building is they have agreed to hold it.

MR. REYNOLDS: We can work that out.

MS. GREENBERG: We can work that out. We will invite all the former members.
We will certainly bring in the former chairs. It is going to be -– do you
have the dates?

MS. JACKSON: The second day of the full committee meeting, June
17th, 2010.

MS. GREENBERG: For the June NCVHS meeting what we will do is we will meet on
the 16th and -– then probably the morning of the
17th until 11 or something and then we will all adjourn or progress
to wherever this building is and have a celebration at the Institute of
Medicine or at the National Academy of Sciences which will have about a 2-hour
probably or 2 to 3-hour seminar and then refreshments actually which is
unusual, a reception in which the 50th Secretary Shalayla actually
came. So we will certainly invite Secretary Sebelius. Give us your suggestions
about people whom we should invite in addition to the usual suspects.

We really have to get serious as I said about what we are going to do with
that let’s three-hour period. We know we are going to have something from the
21st century vision. When Debbie and I were knocking this around,
Debbie said and I just said yes. She said shouldn’t we have something whether
it is a roundtable discussion even if there isn’t a committee document at that
point around what we have graced as our theme which is person-centered health.
So I think, yes, but I am only one voice here. You are the ones who said you
raised the theme of person-centered health. It doesn’t have to be a document.
It could be as I said a roundtable of discussion. This morning the quality
subcommittee was talking about some hearings and some areas that you all want
to go in that I thought could be appropriate to preview or roll out.

MR. REYNOLDS: For September why don’t we have subcommittees come back with

DR. FRANCIS: I have a slightly off the wall suggestion on this. Most people
think that statistics are nasty and dry. So what does statistics have to do
with improving my health? So if you were going to do person-centered health and
do it at NCVHS twist, wouldn’t it be how are all the population health, vital
statistics, and all the kinds of things that NCVHS has been famous for 60
years. How do those make a difference to the individual health of people?

MR. REYNOLDS: Okay, Bill, you’ve got that. Your subcommittee will answer

MS. GREENBERG: I think this executive subcommittee will have a conference
– but we really have to decide in September what we are planning for that.
It is going to be a high visibility effect. As Harry said and I certainly
agree, every subcommittee should be thinking about something that they could
bring forward and we will have to decide. So I’m just going to ask Debbie to
say a few words about Charlottesville.

MS. JACKSON: The confluence of themes and topics that we have been talking
about you have been talking about over the last couple of days and this morning
is just really pull together that we can include into this. The people moving
aspect of Charlottesville is that the chairs will be coming in that afternoon
the second day of our meeting and then that first morning, that Thursday
morning they will have individual sessions. As you have heard already heard
from Susan Kanaan’s great work, which she can do in pulling out topics and
issues, is amazing. Individually the chairs will get a chance to give their
insights and views on a number of topics. We will script that. That afternoon
we will have a roundtable. We will all get together. The chairs will get
together and then again that will be scripted but they will get a chance to
bring out a lot of the issues. In fact as Marjorie mentioned some of the topics
that are coming up from the interviews from the populations as well the
21st century. It is an amazing time to get this kind of
brainstorming and norming together and Friday morning more individual
interviews and all this will be videotaped to be packaged and pulled together
for the next year of celebration then that Friday afternoon we are out. So that
is the people moving us.

MS. GREENBERG: And a dinner actually honoring and recognizing these former
chairs and chair.

MS. JACKSON: Anyone is invited to participate. Drive down on your own I
think you mentioned, Marjorie.

MS. GREENBERG: We obviously can’t bring the whole committee there. We would
not turn you away if you showed up. Like we were talking to Walter. He lives an
hour or two from Charlottesville. So anyway if you want to participate. Larry
is coming because we are doing this in conjunction with the Department of
Family Medicine at UVA where Carl White has a library and is an important
mentor and person there. That is another reason we are doing it down there. I
think that is about it.

What we want to get out of these individual interviews are all histories and
then the discussion is some history, some perspectives of each of the chairs as
to really the role of a national advisory committee like NCVHS, its longevity,
its strengths, its whatever, and we also want them to be because they are
thought leaders and they continue to be looking forward as to what is in the
future here in national health information policy. Any suggestions? We will
also be working with the population subcommittee on the questions for the
interviews and for the roundtable discussion. Any suggestions as to how we can
make all of these different events more meaningful, productive include your
input are welcome.

Agenda Item: Follow-up to Subcommittee Directions –
Next Steps Closing Comments

MR. REYNOLDS: Thank you. Moving into our next item, which is to hear from
the subcommittees, but again another theme what a time to make a difference. As
you think about what you are going to say and as you update what is going on in
your subcommittees, this is a prime time to be in the game. Let’s make sure
that we really do look at this from that standpoint. So Bill, you have given
yours more or less, right? Justine.

DR. CARR: We are not quite ready to make a difference just yet, but we will
be. Our initial intent had been to hold a hearing about meaningful use, but
obviously that was preempted by a larger body. Today we spent time talking
about kind of the continuum of care and the role of HIT in this evolving
landscape. Starting with simply the understanding that we want a care delivery
system from competent clinicians and then enter HIT we have a couple of roles.
One is a facilitator of care delivery of population care and of prevention. We
also have the role of HIT as a facilitator of measurement of care. We discussed
that measures of care need to be on care delivery outcomes as we heard
yesterday also on preventive measures, also on the continuity of care. We
believe that there are gaps and we are not sure. One concern we have would be
the raising of the gaps where we are not looking that we should be looking. Are
we looking at it and getting outcomes in addition to the process measures?

A second area is measures of physician competence. Larry brought this
forward. Maintenance of physician certification, which is under the purview of
American Board of Internal Medicine. But I think a very key issue that
continued to come up throughout our discussion was that HIT as a facilitator is
only as effective as the implementation and not just the implementation of the
HIT and the software, but in fact the redesign of workflow and the redesign and
reconfiguration of culture, which is critical. The goal of course is improved
care for better health for persons and populations and key to this in keeping
to our goal is the person’s experience of care.

I think in summary we have a number of opportunities and we have not yet
decided where we need to go and those opportunities would be quality measures
of care of clinicians. Another would be the implementation of HIT and what is
needed there and redesign of workflow and culture. We recognize that there are
a number of things that are becoming more defined in the next few weeks so we
are looking to see what the committees under ONC are coming forward with.

We also raised the issue –- you know over the years we have been a part
of populations then we have been separate from populations and we feel once
again that three is a lot of resonance in the two agendas and so we would like
to ask perhaps that we might have an executive subcommittee call where we can
reconcile PHRs being another issue area that we have a call and maybe
coordinate where we go from here.

I think the other thing I would just like to add is sort of the checklist of
things in trying to put together of criteria for deciding on hearings or areas
of focus. We have about 12 things, but paying attention to who is the audience.
Is there an engaged customer? Is the project consistent with the charge? Is it
data related? Is it relevant to current issues? Is it non-duplicative of other
efforts either within the committee or outside? Is it complementary to ongoing
issues? Does it anticipate dynamic healthcare, the dynamics, and the dynamic
nature of healthcare reform? Can the deliverable be achieved in a timely
fashion? Does it align with the skill of the subcommittee and committee and is
it in an area mandated by regulations?

But I put those forward just because we have a lot of good ideas but in some
cases it might be duplicative or it might be out of our skill set.

MR. REYNOLDS: Any questions?

DR. SUAREZ: Where do you see comparative effectiveness play a role into this
approach? In other words is there an opportunity for the committee to consider
looking at the whole issue of comparative effectiveness now that we are about
to begin bounce into something so sensitive?

DR. CARR: Well, would we be duplicative of other initiatives in comparable
effectiveness? Is there a gap that we can bring to light? Is there something
that we can do knowing that we have maybe three or four days maximum of
hearings that can give a timely value added input?

DR. SUAREZ: My sense is there is no committee working on this. There are the
three agencies: AHRQ, NIH, and I suppose the other one. They are the ones that
receive each one about $300 million or so to invest in comparable
effectiveness. My thought was there could be an opportunity to give some advice
or some -– I don’t know what to call it. I don’t want to use the word
recommendation -– to frame the whole concept around comparative
effectiveness so that investment of NIH and AHRQ and others are going to make
have some sort of a framework for that.


DR. HORNBROOK: As we look at health reform in the case of all of our huge
deficit, the way to pay for it seems to be on the one hand a one and a half
percent real growth every year for the indefinite future and/or cost
containment in healthcare. I look around from a perspective of a healthcare
system which has always cost conscious and see the biases in the disease
associations, American Cancer Society, American Heart Association who are
always pushing the frontier of new technologies earlier than our physicians are
comfortable with and even the National Comprehensive Cancer Network their
recommendations, their guidelines are much more expensive than what our
oncologists generally practice. Inside of our medical industrial complex is a
whole set fee for service driven standards that have implicit untested as yet
cost inflation that their bear to effectiveness agenda is really supposed to be
targeted at and so the success of comparative effectiveness agenda is what we
are really get to the point of extinguishing things that are over promising and
extinguishing things that we should have gotten rid of years ago because they
don’t do anything.


DR. FRANCIS: I just wanted to say that we are going to have a brief summary
of what transpired at the PHR hearings and that will be available, Justine.
We’re not going to be doing any kind of work on the relation between PHRs and
quality but certainly we will make sure that what happened in our hearings you
can use and quickly.

MR. REYNOLDS: Anything else on quality? There will be no action item that we
would have to take up in the September meeting from quality, is that correct?
No letter I mean.

MS. GREENBERG: But you are thinking of using the day before the full
committee meeting for a hearing.

DR. CARR: Yes.

MR. REYNOLDS: That’s fine. Larry.

DR. GREEN: One comment from our meeting and I lean on both Justine and Bill
to correct this. This is partly in response to Walter’s comments a moment ago.
I think it is very important that we focus on what this committee particularly
needs to be doing as opposed to others, national quality forum like people that
are doing other stuff. I would challenge the whole committee to hold the
quality subcommittee responsibility for finding that sweet spot where we are
doing the work that we are best suited to do that is non-redundant –

MR. REYNOLDS: That challenge rings clear for all subcommittees. I will amend
your comment and then I can use it too. So everybody needs to do the same
thing. Jeff and Judy.

DR. WARREN: Our subcommittee met yesterday and we are still –- I like
the opening lines that Justine gave. We are not ready to make a difference yet.
Because of the meaningful use hearings are really kind of going back and
relooking at what our tasks are with that and also with the two new FACA
committees trying to look at where our standards are. We had quite a good
meeting in doing some brainstorming of where we need to be doing things next.
We will probably have a conference call sometime within the next month or so to
really hone that down. We have come up with one thing that we did overlook and
we are going to be going back and try to fill that in. We are required by the
HIPAA legislation to an annual report on implementation of HIPAA. We did not do
that report for 2008 so we are going to be looking at coming in and doing that
report again.

We also had a request from Karen Trudel to really take a look at things that
are happening with the implementation of ICD-10. She had several ideas of
things that we could do to help them with that initiative and so that is also
on our list to begin to consider. That is kind of where we are with our report.

We may have something in September but I don’t know today whether or not we

MR. REYNOLDS: John and Leslie.

MR. HOUSTON: I think we gave much of our update yesterday. Again, just to
remind in terms of I guess upcoming for September and shortly thereafter we
clearly need to get something out the door late fall so we are going to try to
have something together in some form for committee consideration. If nothing
else the principles that we put into a letter. Hopefully we will have more than
that in place.

Again, I think to Leslie’s point as well which is we are going to be having
a series of conference calls throughout the summer. We want to actively engage
those individuals who have an opinion or desire to engage on this. I know we
talked to Blackford about his involvement.


MR. HOUSTON: Carol. That’s right. Yes, I think September we are going to
have something that we want to tee up for some substantial dialogue and

DR. FRANCIS: I would also add that this might be just the one to try out
some of the new technological opportunities for communication since John and I
and Blackford are all on the –-

MR. REYNOLDS: We will either try out something new or use the heck out of
the old stuff because this one will take your involvement and maybe John is a
little bit, but every time we have brought anything related to privacy in here
in the five years that I have been here if you don’t think you have an opinion
you will the day we show up with documents. I would recommend to you that you
might want to go ahead and buy in yourself. It is something that immediately
–- it is the hardest issue that we face that you can’t step away from it
personally because we are citizens of the United States and when you hear about
privacy it does jump in your personal face and then you will have an opinion
and we have to help everybody to deal with that.

MS. GREENBERG: Since we are talking privacy, I know you have all seen this
report. We are sending as I said to the entire mailing list. I particularly
want to thank Debbie Jackson who I think the report is just beautiful and she
did a lot of work. Susan Kanaan also assisted. The privacy subcommittee. I
think, Leslie, you were the point person working here with our publications
group. You see a nice report like this. It is sort of like sausage. You don’t
want to know how it all came to be, but I think it came out beautifully so I am
very pleased and I thank Debbie and Leslie.

DR. FRANCIS: I want to echo that and just say I was thinking of the report
as going to things ahead and I apologize for not having – I hope you all
will take copies of it and distribute it widely because it is –

MS. GREENBERG: If you have a group that you want us to send copies to are
not currently on our mailing list or you want 10 or something to distribute,
just let Debbie know.

DR. SUAREZ: Again, I think this is a great opportunity to have something
some standard email message that the chair can put together that we can just
send out for distributing. We – not create our own little message saying
hey here is a – just a suggestion.

MS. GREENBERG: We have a cover letter we can –

DR. SUAREZ: — have that in the email and then we can –

MS. JACKSON: This is hot off the press. We haven’t even gotten it out to the
department. We are getting that downtown and then we will get all the –

DR. SUAREZ: Is there a PDF file –

MS. JACKSON: Yes, but I’m not forwarding anything until I get it downtown.

MR. REYNOLDS: Anybody else have any comments on any of the items?

MR. BLAIR: One of the things that I would say is Harry has encouraged us to
reach forward and make a difference and it is actually consistent with the fact
that NCVHS over the years has a history of making a difference and it is
carrying forward that legacy, that history. I was wondering in some of these
documents that we are talking about where we would be looking for and maybe a
theme with respect at NCVHS. Harry, we might consider using that as a theme
that if we look at the last 60 years of NCVHS we have made a difference and we
can articulate how we have over the years.

MS. GREENBERG: That is actually I think the title of my poster. NCVHS 60
years making a difference.

MR. BLAIR: Seat telepathy does work.


DR. SUAREZ: For the next 60 years. I think it will be great to begin to
think. Each of the subcommittees is now looking at what are the immediate
priorities. Wouldn’t it be good to have some sort of a vision of the
committee’s next set of visionary activities, if you will? At some point
bringing us together to talk about besides the work that is being done
immediately, what are some of the next year, next five years kind of priorities
or areas to focus on. In light of all the things that are happening and this
community being created finding the right message to tell people. Everybody is
asking about what is going to happen with NHIC. What is going to happen with
this group compared to this group? What is it that you are going to do with all
these questions that people have in mind? It will be nice to have a common
message but also sort of a message of the next set of activities that the
committee will be doing set of priorities and put it in the perspective of this
is a 60-year-old committee. It wasn’t created by the recovery act or by this or
just last year or something like that. Would there be an opportunity to do
something like that in the year?

MR. REYNOLDS: I don’t think there is any question. You can do that through a
planning session or again I continue to challenge the subcommittees. You are
the experts in those environments. I, as the chair, would much rather take
input from the subcommittees because you spend more time together, you think
about than us putting together some kind of executive subcommittee planning
session and then telling the subcommittees what to do. Until we hear different
right now one of our focus has been person-centered health. That is what we all
agreed to. Now have we all executed against them and are we still using it as a
guiding light? Not necessarily.

Again, I also say to each of you who are each of you are leaders in the
industry in one way or the other including the staff. That if you have
suggestions then please submit them. I think number one I’m sure not going to
picking them myself. We are a very collaborative group. Somebody wants to start
that discussion. Somebody wants to say whether or not continuing person
centered is the right thing or not to do. Please put it on the table. Don’t
assume there is some kind of magic structure that allows you to share your
voice. There is not. The subcommittees I really expect and those of us that
have participated in subcommittees when we are in the room I heard a little bit
of the end of the quality one. We play hard. You hear the enthusiasm. Well, I
want that same enthusiasm rolled up here if you think we should be grouping up
on things and do that. Not necessarily wait for certain subset of us to come up
with what these answers are.

DR. SUAREZ: Quick follow up. Yes, I mean sending suggestions to someone.
That is good. That is a good start. I am really talking about not just sending
a series of suggestions so some people can think about it. I am really thinking
about –- as an organization every year when I used to direct a non-profit
every year I would have to come up with a two-year plan that my board would
look into. I still have to do the work that had to be done during the year but
still have the two-year plan. Because of budget purposes there are all sorts of
things. It is sort of like keeping that not just an accumulated set of lists of
suggestions of people saying but it is sort of every year having some devoted
time at some point to think of a little bit longer than just the next six
months or the next year more into the next two years and five years or
something like that.

MR. REYNOLDS: Well, I’ll hearken back. All of us run those things at work. I
am very comfortable doing that in my day job. This is a consensus-based
organization of stars. What I am saying is I could sit down and write something
right now. I have personal feelings about exactly what is going on out there.
But what I am saying is that the subcommittees are our power, not sitting down
and coming up with -– so each of you ought to be answering the same
question. We roll it up and we see how we go as a group because that is where I
am going. Understand I have no problem whatsoever coming up with thoughts of
that and getting the executive subcommittee together. We have done that but
things have changed so much now. A good example is I know that each of you are
struggling how to make a difference out of your committees. I am not sure we
group up a three or four us and we group up and we write something down and say
okay your attention please, here we go. I understand. I am not shirking the
task but there is a lot of power around this room and there is a lot of
thinking around this room and there is a lot of capability around this room and
so give it up as the kids say now.

MS. GREENBERG: I think right now there is a lot of uncertainty. I think the
way every one is trying to figure out how each subcommittee can make a
difference is good. I was just looking that we had a full committee retreat and
I was trying to think was it 2007 or 2008. It turns out it was 2006, three
years ago. It is something we could think about in 2010. Let’s just chew that

MR. REYNOLDS: I think that is great.

MR. FERRER: Harry, could I make a small observation. I think to Walter’s
point I think the subcommittees are still struggling a little bit with this new
transition of phase. How long are we going to be in it? This formalization of
our committees and actually are going to be doing a good bit of the work that
this committee has done. –- is a perfect idea. They are about to begin
three subgroups with – so Jeff and Judy have got to be close in mind with
the work they are producing and evolving. They are having their meetings, but
it is still a little unclear, for example, how do Jeff and Judy have any
interaction in that type of -–

MR. REYNOLDS: As I mentioned yesterday I can promise that minimally at least
Jim Scanlon, David Blumenthal, and I have to work on that. I mentioned Marjorie
yesterday. The point is that I will be sending to Jim every opportunity I am
when I am in Washington and we are going to try to get together. I sent David
Blumenthal a number of emails. We will get together and we will work on how
this works. But I would say this to you. If you listen to everybody’s charge,
they are in charge of implementing and putting the things in place to
implement. There are a lot of things we talked about here that are not anywhere
near their list, are not anywhere near what they are going to try to do, and
Walter was talking about a two-year goal. I would love to see a goal of 2015
because there is a whole lot of change that has to go on in this industry
between now and 2015 and there is a lot of money going to be bouncing around
related to it and there is a lot of change. So if half of this change happens
we ought to have plenty of space to be talking about things that are going on
or not going on and especially in areas where they are not even thinking about
right now because that’s not their charge.

They have a very clear and precise -– if you read it, they have a very,
very clear and precise charge. I don’t want to over blow that we are worried
about getting in their way. There is one clear, very clear one. We were talking
about and I don’t want to say this just to get this on the record. We stopped
the standards hearing last time because we needed to make a difference. That is
the whole reason we did it right then, right there. We had people scheduled. We
had everything set. Boom. We did that.

We also had a subject that was under and here was the subject. What is the
right way to do standards? Now, we were working that with a customer called
ONC. There are now very few of those bodies playing in that game at ONC. We had
a customer. We had a partner. Excuse me. Let me say it differently. We had a
partner and we were marching with that partner to talk about what’s the right
way to do these things between now and then. Now all of a sudden they have a
standard subcommittee. You got to step back a minute and go time out because
the minute that we would continue hearings philosophically and talk about let’s
change the way we do standards and they are going out and saying that is the
way we are picking standards. Whoa, got to call time out on some of this. So
that is why we had such a precise and energetic discussion yesterday, but there
are plenty of things that we can do. I am not at all fearful of what they are
doing. I am not at all fearful of the fact we are all in the same department as
the chair of this committee. I’m not worried about that. I am worried that we
make a difference. Both of us doing it at the same time one or two different
ways we don’t buy them much.

MR. BLAIR: Not only do I feel the way Harry does about this, but you know
maybe I have been around long enough that I can sort of see history and
evolution and we were struggling for quite some while to try move things
forward with health information technologies in particular the standards and
security subcommittee as it was called then and we wound up coming up with a
proposal for the National Health Information Infrastructure proposing that ONC
be created and it was. We have made a number of other proposals in terms of
foundations and message format standards, terminology standards, how these
things would work forward as well as the HIPAA pieces. In a lot of ways
Congress in enacting creating these two committees, the HIT policy committee
and HIT standards committee, building on the foundation that this committee has
laid and it didn’t just lay it in terms of concepts. It laid it in terms of

Now that a lot of the concepts and standards and frameworks and policies
were laid down we’re not moving into high gear in the country in terms of
healthcare reform. As we move into high gear, it is more than with the National
Committee on Vital and Health Statistics can do by ourselves. I don’t look at
those two new FACA committees as being competitive or taking away from what we
have done. We need them to be able to move the country faster. We still have
the same mandate that we always had.

I think that we still have opportunities to blaze new trails and see things
out 5, 10 years and start to lay those frameworks too, but in addition in our
meeting yesterday we still have customers coming to us saying that they need
help with particular standards that are coming down the track in the next three
to four, five years. So I would say that we have more on our plate than we
could handle and we need to intelligently decide which activities we commit to.

MR. REYNOLDS: I want as many suggestions. I want directions. I want
structure and we will sit down and help understand if that appears anybody that
we are going to get in anybody’s way, but I would say probably 9 out of 10 that
we are not. We are not going to be so let’s go. Last comment and we will
adjourn. But Jorge exactly right. We got to keep playing hard. Let’s don’t
assume there are ghosts out there to play through.

DR. WARREN: One of the things that I did yesterday was have a conversation
with Marc Overhage who is on our standards subcommittee. He is also a member of
the HIT standards committee and asked him how we could start collaborating and
knowing what goes where. We agree to have those conversations although I will
say at this point Marc doesn’t know where that line is or anything else because
they have had one meeting. They organized themselves. They have not talked
about content or projects yet, which will be at their next meeting. We will
continue to have that kind of dialogue. I thought that was very fortuitous that
Marc was appointed to the committee and allowed us to have collaboration. I
think we need to remember that Paul Tang was appointed to the policy committee
and then figure out how he allies with this committee so that we do have these
collaborations going.

MR. REYNOLDS: Very few terms we overlap in my opinion. Thank you very much.
I appreciate everybody, your energy. Let us know in between meetings if you got
any issues you want to deal with and let’s go make a difference. Thanks.

(Whereupon, at 12:50 p.m, the meeting was adjourned.)