[This Transcript is Unedited]




Thursday, June 17, 2004

Hubert H. Humphrey Building
Room 742G
200 Independence Avenue, SW
, D.C.

Proceedings by:
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
, Virginia 22030

P R O C E E D I N G S [8:35 a.m.]

MR. HUNGATE: We’ve got about 20 minutes so I want to march us quickly through introductions which we’re probably not going to have to spend much time on. I want to first though thank Debbie for all her work, and transit to welcome Anna, especially from Debbie, and I want to pose a question for discussion in the next 20 minutes, which is a little different from the way the agenda shows. And the question basically is this, when will we know when we’ve heard a business case for the candidate recommendations that we’ve got? What is it that we’re going to expect to take away from the first set of hearings, which we in a sense present to the second set of hearings? I hear the term what is the business case and I must confess that I don’t have as good an understanding of what the content of a business case is as I would like to. And so to get my own thinking in good order for that hearing, which now looks to me like it’s in pretty good shape and we can spend a little more time talking about that in a few minutes. But before John gets out of here I’d like to try to talk about this particular issue.

Now part of what I think is, let me give you my impression and then you can beat against it and see if I’m wrong or not. As I listened to conversations around the selection of people I kept hearing well, they’re probably not using claims to do their quality measurement, they’re probably doing abstraction from a medical record or collecting the information through a medical record in order to make the measurement. And so I’m wondering, that sounds to me and feels to me like an expensive process so I’m wondering is part of the business case that the way we have to collect the data now is extremely expensive and we need in order to have it better reliable, accurate and automatic. So is that a piece of the business case —

MS. JACKSON: And I have a qualification from Marjorie from her notation of business case I can share whenever that helps.

DR. LUMPKIN: That’s a great question, I think that’s the question, and I think you have to start off with a little bit even higher question which is when we look at each transaction what is the function of that transaction. The 837 serves as a communication between a provider and a purchaser to adjudicate a claim and so anything that’s put on that besides what’s necessary to adjudicate that claim is in the terms of a transportation industry a non-revenue bed head whatever rider on that particular transaction. So our argument despite the cost savings because I don’t think cost savings is going to be it. Truth of the matter is just about anything associated with whether public reporting, whether it’s quality reporting, whether it’s research, we can demonstrate that the savings are there if the information that we’re trying to dig out is put on the bus instead of having to drive it separately.

But how has the process of adjudicating claims changed? So let’s take for instance the issue of to what extent of the market, and here’s where I don’t know the answer, it’s the marginal cost of adding an item to the claim that’s useful to some payers, that isn’t used by most payers. What’s that percentage that then makes it cost effective or makes the “business case” for putting it on the 837? For instance pay for performance. GE is now doing pay for performance, a lot of what they’re doing right now is associated with what they can get off the claim so it’s are you doing eye exams, are you doing foot exams, those sort of things, you can get that based upon the billing codes. But there are other aspects of pay for performance that they may want to do but just don’t have the vehicle to do that. If just GE is doing that, so they are in some instances the payer, other instances they’re the purchaser and on their behalf the payer is adjudicating the claim, so to what extent do they want this additional information in order to do what they now consider as value based purchasing and therefore value based adjudication of the claim. And I think that defines the business case.

MR. RODE: I just remind you to take that one step further and look at what it takes to get the data to the claim because right now the data going to the claim may be inaccurate because the goal of an institution is to get the claim out as quickly as possible and get the bill paid. And if you’re not looking at that data as a piece of what will do that and you throw it on the claim too quickly you may not have the data integrity and the data that you’re actually looking for. Way back in Minnesota we would run the claim twice, once to adjudicate and get the claim out to be paid, once a month later to come up with the accurate data because by then it was in the record and it could be put forward. And until we have electronic records and the ability to have much more prompt database then we have right now to take that data too quickly in the claim process, well it would be fairly easy and the marginal costs would be kind of low, may impact the data that you’re going to receive because the data may not be accurate or it may not be there. And that’s the difficulty that we face. As we go to the electronic record that becomes less of a problem and the problem we all have right now is what do we do in the interim.

MR. HUNGATE: It seems to me that we have to be thinking toward the emergence of electronic record but we have to be thinking about what the dataset is that’s going to be important for transfer between the institution doing the work and the one paying the bill. How do we integrate that paying for performance in a way that the information is better and that to me moves me very quickly to the risk adjusted outcome aspect of it to say if diabetes is a complication of a particular management of a patient then that comorbidity ought to somehow show in the claims transaction that reflects that case. Now I don’t know whether that’s part of this particular discussion but I think it is.

DR. CARR: Can I understand a little bit more about what you’re saying? Are you talking about inpatient or outpatient?

MR. RODE: Either, and in any location.

DR. CARR: So you’re saying on an inpatient side all the ICD-9 codes aren’t there so you put what you can and take the DRG that you can and then you go back and add the other ones and it might be a different DRG?

MR. RODE: It probably would not be a different DRG but what you’re looking at is detailed beyond what goes into a DRG right now because the data we’ve got right now isn’t that accurate, we want the additional indicators —

DR. CARR: So I’m asking really, I’m into granular, I just want to understand —

MS. POKER: Can I give you an example? Okay in some databases, and this is a problem, there’s an additional factor here, you have to train the people using the system because one of the things is using the MDS in long term care the people who enter the data for example don’t understand what they’re capturing. There is not enough weight put on filling out the assessment and that is the one single system that’s used for reimbursement, MDS, and the people just don’t know how to fill it in. And the disconnect between what’s filled in in MDS and what you see in the patient is extreme. And I think that’s what you’re talking about where —

DR. CARR: I’m just trying to understand the process of it —

MR. HUNGATE: Dan, do you want to join us —

DR. CARR: In my hospital I can think of disconnects but this isn’t one of them, it gets coded once and it goes out unless an error was found and all the up to 15 procedures and 15 diagnoses or whatever it will hold —

MR. RODE: You are so far ahead of where the rest of the world is, the hospitals that have put in some kind of an electronic record system are way ahead but those are in the minority right now. When you get to long term care or home health or any of those their systems are even further behind so if you’re looking at a continuum of care to collect data I think you need to come up with, I think John’s right that there’s a vehicle and there’s nothing to prevent us from saying that you couldn’t use an 837 for purposes other then a claim, that just becomes an add on transaction that’s approved but it’s a question I think of when you collect the data. And if you’re going to collect the data and it’s got a use then I think it also becomes the issue of making sure the data is accurate.

I always remember before DRGs that for three years we threw data into a system that nobody cared about because nobody had ideas that DRGs were coming. All of a sudden DRGs were on board, boy did we change the way that we dealt with records and documentation because now we were getting paid. Well, it was pay for performance, but I think we’re beginning to recognize pay for other reasons but then it becomes a question right now I think of what’s the timing to get the information. If we just want information and we’re not worried about the integrity of the information we could pull it off the claim form. Minnesota is trying to do that right now, they want to get all the data from the payers that came off the claim forms. But if we were looking at dealing with good accurate data down the line then I think we have to look at what is that process that’s being used in different arenas of care and go from that direction.

MS. HANDRICH: I think you’re touching on a critical thing which is that people have to be motivated to provide accurate data and have the, first of all they have to be motivated to be trained, I mean it has to have a consequence.

Let me just take this discussion in a slightly different direction for just a moment. In Wisconsin AHRQ sponsored a two day conference on making a business case for quality in May and there were leaders from all the national quality organizations and a lot of the big companies and a lot of companies that we don’t think of as having a presence in health care who talked about how they measure for quality and what their business case for quality is. And the consensus that seemed to emerge from all of these leaders of industry and health care and these LeapFrog and other groups was that the business for quality has to be thought of differently then we in traditional quality arenas think of it. If you think about how business makes a case for quality they identify their cross drivers, they identify the places where they’re bleeding, and they want to get information to stop the bleeding, and to turn things around. So the business case for quality has to become identifying those critical benchmarks that are making a difference in terms of the outcomes you want to achieve and then collecting information that is accurate and timely and meaningful on those critical benchmarks so that you can make a business case.

And it was fascinating, first you have a high exec from a cheese company talking about how they identified the quality measures that they wanted to have, then you had somebody talking from UCLA and it’s the very same paradigm. They’re going with where their money is going and how they want to stop that and then they’re working backwards from that. That really challenged me to think that when you ask the question how are we going to make a business case for quality we need to understand what the business needs are of those that are involved, the business needs of the data providers, the business needs of the purchasers, and the business needs of all of us involved in kind of big picture quality, population based quality. So I would say when we get done with all of this, we’ll learn more about whether or not the technical kind of data requirements that have been identified will result in a better assessment of what actually happened but will we have gotten to whether or not those data elements are critical to a business case. And I don’t think so, I think we have to do more exploration to get there.

DR. LUMPKIN: A couple of things and Dan’s comment sort of made me realize that we need to reassess the business case. Because really when we’re talking about business case it’s not the business case for quality, it’s the business case for including items on currently existing transactions. And I don’t think that that really addresses the issue of the quality of the data, that’s a whole different discussion. But it does address the issue that according to the president we have a ten year window so another component of the business case is what is the marginal advantage of adding it to a currently existing transaction versus discussing how an electronic health record can generate a 892 which is a quality transaction, I just made that up, that would contain the data that we have all been talking about that would have a negligible cost in creation in an environment where you have more universal electronic health records. Because the same EDI engine that maps the data in EHR to the 837 could just as easily map the data to any other transaction that you may want to communicate.

That has two implication, one is I think when we talk about the business case we really have to talk about what’s achievable in a relatively short timeframe, in the next three to five years, in moving to three to five years because it would take somewhere around a couple years to get it on the 837 even if everybody agreed. But then from there until that window, which closes when EHRs are available, so we need to talk about that business case but also I think somewhere on the back of our minds in the work of the Quality Committee that we need to think about generating the conceptual model for a quality transaction that we would then hand off to an SDO, or encourage the development of a quality transaction, that would then be a work product or something that we would work towards in the long term. So the short term activity is the business case for moving to modifications in the current transaction and the long term conceptual model is developing a quality transaction.

MR. HUNGATE: Let me try a different cut at I think the same answer. In the terms of the broader NHII architecture I think what we’re talking about is the package of information that must be common between the providing system and the paying system that enables the judgment of quality by both in the same terms. So that the providing system is self judging its performance in the same way that the paying system is judging its performance but that’s where we want to get to in the system that works better in the long run. That’s our objective and that package might include the 837 plus the new what, 592, and it might include some other pieces that are judged to be the common information module that both depend on. It seems to me that’s where we get a more efficient information system and that’s our quality objective ten years downstream. Is that different or is that in alignment with what you said?

DR. LUMPKIN: I think that’s what I said.

DR. CARR: So integrating also what Peggy said would be we want to construct a vision of what are the drivers of quality and begin with our long term plan of where we’ll be ten years and then work back and say what’s the low hanging fruit that we could accomplish in three to five years but building towards, it would be target diseases and capturable elements and actually kind of building on what’s already being done by CMS, heart failure, MI, diabetes.

DR. EDINGER: There’s another party argument because we always leave that out, and I heard at a different AHRQ meeting somebody get up and ask this, this is a CEO of a hospital, his argument was I hear what you’re saying, it’s nice for the public health people, it’s nice for the payers, what the hell is in this for me, it’s costing me money to make you money. I mean that simplifies his argument but his argument was money was out of his pocket, it’s making the payers richer, it’s making the public health people happy, who the hell is going to pay for this.

MS. HANDRICH: You need to make a business case for me to invest in the electronic health record system unless you do X, X, X, or something.

MR. HUNGATE: I think you then have to answer that one with what’s the individual getting from this whole information system.

DR. LUMPKIN: But here’s a story Arnie Millstein tells, in a negotiation that he had with a hospital where they had folks from the aeronautics worker’s union and I think maybe Boeing and they were negotiating on the issue of a CPOE. And the hospital said well we don’t have the money to do this and for the first time in five or six negotiating sessions the guy from the union finally says do you have a capital budget. Yeah, and how much is it? $20 million dollars. And what did you spend it on? A new parking lot. And then the question was don’t you think a CPOE is more important then a new parking lot. And so the issue is not that they don’t have the money it’s how the decisions are made on allocating the resources. That works on the hospital side, I think that argument completely falls out on the outpatient side where I really truly believe that that’s a totally capital poor environment.

DR. CARR: Well the other thing though in the current payer environment that if you have fewer admissions and less complex patients the current model with few exceptions will reimburse you less so from that, I think that’s the CEO perspective, that it’s sort of you’re the middle man and doing the right thing but that all of the, that there’s a resource drain out and no compensatory reconfiguration, except as we move towards pay for performance. But I think the alignment of pay for performance becomes very important to identify now because in fact one of the things, as a person sits down to code a record and has some oversight and some understanding it’s important to get every hemotoma(?) with every cardiac cath and places that have been diligent about comorbidity capture are the exact places that are now being held up on public websites from Blue Cross saying they have way more complications then their neighbor next door who’s probably doing the same cases but just didn’t have that initiative for comorbidity capture.

DR. LUMPKIN: But let me just kind of respond on that one and that I think represents a significant market failure in health care because why is it that a manufacturer of CD players tries to figure out a cheaper way when in fact if they built the larger and more expensive ones it’s because of market pressure and competition. In the health care sector at some point you have to ask what the mission is and the mission in health care is to help people get better and the reason why people should be adopting quality despite the fact it may return, have lower cost, is because it actually gets you closer to your mission. It’s like the dentist, if they didn’t do fluoride treatments they would be able to do many more restoration but at some point there’s a mission based decision to do the right thing.

DR. CARR: But the economic driver, you have to pay for the fluoride, and you have to pay for that —

MS. POKER: You get money back in different things, you get money back in staff retention, staff retention could be a potential also for getting money back. In other words the mission statement I was going to say is not only to provide good care but to minimize harm you do to patients along the way and that’s also a potential for making money back. Not having the revolving door of staff which is a huge cost for hospitals, there’s a lot of potential of where to make the money doesn’t always have to fall with claims or the quantity of patients, that’s a portion of it. But you’re right, capturing the comprehensive care that we give is one of the places we don’t make enough money. Sorry I went out of line, I apologize.

DR. EDINGER: No I was going to mention one thing, get to pay for performance the next issue is going to be, and I’ve already heard it and it came up many years ago, it’s not the first time it’s ever come up, is if you’re paying for performance why are you paying for non-performance so to speak. So at some point you’re going to get back to paying the same or else excluding people who aren’t performing. So the pay for performance is probably going to be a finite window of opportunity, it will go, but I’m willing to wager at some point in time —

MR. HUNGATE: It will be replaced by something else.

DR. EDINGER: It’s going to be replaced by something else because nobody, if I was a patient I’m going to say why are you paying that nursing home down the corner or that hospital who’s a poor anything and this other one maybe you’re paying them five percent more, why not just stop paying that other one who’s doing crummy work and let us invest more in the one that’s doing a good job.

The other issue is, I don’t know how to tell this story because I would probably get into trouble if I said who told it to me. But a large hospital executive one time when I was working in Congress, the discussion came up of the quality of work and how much money they were investing in quality. His argument was, which was not on the record but off the record, but basically I have to have a board of directors to pay and I want to make money for them and for myself. This to me is a business and a way of making money, I do not consider this necessarily, it’s like making anything else, airplane parts or cars, I am not as “help save humanity and improve the world.” I’m here as, this is a profit making business just like any other. And I wont’ tell you who said it because we’d all be in trouble if I mentioned which hospital corporation executive it was —

MR. RODE: — already in trouble.

DR. EDINGER: But anyway I think the issue is that some people look at it one way, some look at it a different way, and you have all these different people with different ideas providing it. People are in it as a business, there are people who feel truly it’s a mission and you have both to deal with and the logic of both of them is different.

DR. STEINWACHS: It seems to me that the payment system issues are fixable issues and so in Michigan Blue Cross Blue Shield there is giving $10 million dollars to hospitals who are participating in a patient safety initiative Peter Ponobo(?) and others are leading because it realizes it’s the likely beneficiary for few ICU errors and shorter length of stay and so they recognize, and if you look at per case payment in hospitals which most hospitals are getting at least under Medicare, in our hospital Peter’s work has cut ICU length of stay roughly in half because the average ICU patient has one significant adverse event during their stay and by dropping that rate they’re making more money. Is that fair? Well, it’s like anything else, ultimately —

MS. HANDRICH: You picked a class driver, I mean you picked a target.

DR. STEINWACHS: I’ll tell you the other thing, a lot of hospitals are facing occupancy levels that are unsustainable, they need to open up beds or America is going to have to invest a lot more in that kind of capital. Well where do you put your capital? Well, I’d rather have the shorter lengths of stay, I’d rather have them out, healthy, and not readmitted, so I think there are a lot of decisions but it always seems to me the financing part is a much more solvable because you can bring people to the table to work up a strategy that is a win/win if you’re saying you do something, we do something, we all win together.

MR. RODE: Unfortunately the largest payer usually is controlled by Congress which is a harder group to sometimes convince them of. I wanted to follow-up —

MR. HUNGATE: Let me let Peggy comment here first and then —

MS. HANDRICH: I’d just like to suggest that we might, we around this table have kind of an idealistic notion I believe of the business case for quality and one could argue the business case for quality has been out there for ten years, it’s not new, it’s not news —

MR. HUNGATE: I could argue for 20 years.

MS. HANDRICH: Okay then —

MS. GREENBERG: It’s like race and ethnicity.

MS. HANDRICH: Right. But —

DR. STEINWACHS: The data keep getting better.

MS. HANDRICH: That’s beautiful, that’s just beautiful. But the reality is that across the country except for these very, very big corporations that have kind of leaped on board these national initiatives, everybody is doing their own thing about defining what quality means. And I just want to say that I think this endeavor that we’re going to be in next week when we’re talking about these kind of marginal improvements in the way we collect a lot of different data might appear to some people to be a laudable exercise in seeking perfection on a technical level but missing the point. Because the way in which people select their quality indicators is not uniform, is not standard, it’s based on their business needs. This is what I was saying before and I’m not sure that we would, we might all get buy in from the people that will come and speak to us who are kind of national leaders but I’m not so sure that at the day to day level of hospitals and outpatient clinics across the country there is a business acceptance of more better technical reporting for every single procedure that’s done or whatever, so I just want to throw that out there. And we might not even hear that.

MR. HUNGATE: That’s good food for discussion. Dan and then I’m going to try to see if we can summarize what we’ve got here and see what we do to put this in a framework that helps us do our hearings.

MR. RODE: I hope you’ll take Peggy’s suggestion and Justine’s suggestion and Stan’s suggestion and John’s suggestion and look at the one other issue we seem to be facing right now which is the medical community saying I really want to participate in this but I have no clear picture of where I’m going and how I can invest in this. What scares me every time Congress starts to deal with medical errors or patient safety or any of this is we’ve not defined some kind of a picture of dataset, data collection, whatever, that an institution could invest in moving in the direction of electronic records and reporting for various reasons in various ways whether it’s attached to the claim or not, and so the question right now is well until I hear a clear picture I’m not going to do anything with some exceptions. And the exceptions need to be lauded, people need to see it —

MR. HUNGATE: I’ll respond to immediate political demands but no more.

MR. RODE: But I think this group, if this group could begin to show people how data collection for a variety of reasons, medical errors, public health, quality and the rest could come together and be done in one way I think people would begin to then see some value in investing. It’s right now give me the seed money and if LeapFrog comes to me and gives me money I’ll put it in but I don’t have a picture of what I could do in the long run to do all of these things. And we get a lot of resistance, we get a resistance right now at ICD-10 because people say well what else am I going to have to do, I want to make this data change but what else are you going to make me to down the line, I just finished HIPAA, that mindset with no conception or picture of how this all could come together and give them a means to do it. And if you can provide that picture, that value, we’re not talking about it anywhere else, we’re talking about it in little pieces.

MR. HUNGATE: I think this is your starting observation of measurement system frankly.

MS. HANDRICH: I’m all for electronic health records, two of the national corporations are located in Wisconsin —

MR. HUNGATE: Anna and then I’m going to take the floor back.

MS. POKER: I just wanted to relate to what Dan said, and I think it’s what I heard you say, Bob, earlier, that one of the strategies maybe is to look at the NHII and that infrastructure and when that structure is a little bit more, there’s a strategy to it, how does the quality piece fit into it seamlessly. Because I think it’s going to have to be the way HIPAA is going to have to fit seamlessly in it, so is quality, and recording —

MR. HUNGATE: I think that’s right but I think that we have a need for some current deliverables, that’s the political reality. And so I think our challenge is to have the vision of where we want to be where there are electronic health records and then have some kind of an understanding of a process of moving from where we are today to where we want to be ten years from now. I had the fortune or misfortune of participating in a quality measurement and management program sponsored by the Hospital Research and Education Trust, Dan Longo(?) was in charge of the project. And they built a national project to say we need national measurements so the hospitals don’t have to do all these hoops to respond to all the local demands. Brent James was part of the group, it was a good group, several people from the health policy community, very representative and strong group.

It failed, and it failed because the specific demands were too great and they couldn’t get them all to reconcile, the same thing that you observed. And so I think our task is to try to set in place from the pay for performance initiative, which may give way to something else in a next step, the what are the small things everybody can agree on now that meet a standard of accuracy and reliability that serves to make them more universal and diabetes seems to have some pieces to it that are gaining universal understanding in coherence. And so maybe taking the things that are the low hanging fruit of the measurement system that are effected and saying how does that work under a claims based system and how does it transition through the addition of a quality whatever to some longer term system. It seems to me to be where we are.

DR. CARR: The other thing that I think is helpful for us to have clear in our minds is that quality can be depicted in three ways really, LeapFrog is looking at volume thresholds as one, CMS is going with the process measures of did you prescribe this or that, and then the third would be outcomes and there’s very few, I mean CABG mortality is one but I mean there are very few disease states where we’re confident that we have a uniform population we can look at. And I think people get very confused in terms of what part of the quality continuum are we focusing on at any point in time and I think it’s helpful for us to get that separation.

MR. HUNGATE: And I will make the argument that our unique place for contribution is at the level of the individual and the interface with the health system because that’s the commonality between both payer and provider —

DR. CARR: I’m just saying what would you say is a quality outcome, that the person went to an institution that did 1,000 of this instead of 100.

MR. HUNGATE: I think outcomes are not based on volume per se, I think they’re based on result.

DR. CARR: Well, I think all three are, they’re surrogates, to get a precise outcome in a medical condition at the individual level often has so many variables that for this particular person it was a good outcome but as a population study it might not look that way. I’m not proposing the answer but I’m saying have that nuance to say that moving the quality agenda forward in some cases might be to focus on volume and other places on processes that everybody gets an eye exam or whatever, and in a small subset where there’s consensus on outcomes.

MS. HANDRICH: You’re suggesting that pursuing those three dimensions might afford more opportunity to identify more things everyone can agree one.

MS. GREENBERG: It gets back to that immediate doesn’t it, I mean if you want to say thresholds as sort of structure I don’t know but this has been —

DR. STEINWACHS: [Inaudible.]

MR. HUNGATE: Patients don’t care about the structure, you don’t want patients to have to look at what the structure is, you don’t want to patients to have to worry about the process —

MS. GREENBERG: But right now people are selection surgeons by ones who have done a lot of something.

MR. HUNGATE: I understand, I understand, but if I’m trying to talk about where I’m trying to get to, I’m trying to talk about objectives, I’m going to recognize that we’ve got some limitations in what we’re doing now that we can remove downstream —

MS. GREENBERG: I don’t think I understand what you’re saying about the individual, I mean I think it has to be, the individual has to make decisions based on population based data —

MR. HUNGATE: Yes, but that population based data has to be risk adjusted for the individual’s characteristics. And that’s the part that Justine has said.

DR. CARR: But I’m just saying that it is vanishingly small how many venues there are that you can say here’s the risk adjusted expected mortality for whatever and for cardiac surgery, for CABG —

MR. HUNGATE: Existing state of the art.

DR. CARR: Right, but most, that’s the tip of the iceberg, the vast majority of health care exchanges don’t have outcomes let alone risk adjusted outcomes.

MR. HUNGATE: I realize that and that’s the market failure that exists.

MS. HANDRICH: It’s also, it’s just kind of a technical challenge —

MR. HUNGATE: It’s not a technical challenge, it is a motivational challenge —

MS. GREENBERG: It may be partly the nature of medicine.

MR. HUNGATE: Wait a minute, wait a minute, excuse me for getting incensed, but I do because prostrate surgery is a known procedure, there are known complications of prostate surgery. The data is not taken of the rate of those adverse outcomes and is not available to prospective patients who face that surgery, it’s just not there. Now that is a quality failure and it’s not that we don’t know those things exist, we don’t think it’s important to take note of them. That’s the part that I’m trying, I as a male if I need that surgery would like to go to a surgeon who has a good record. You have a good one in Hopkins so that’s where John Kerry went for his prostate surgery.

MS. GREENBERG: But he might have had a bad outcome even having gone to him.

DR. CARR: And it might have been unavoidable given his comorbidities.

MR. HUNGATE: I agree with that but that doesn’t, it might have been unavoidable but you still take the data and make it available prospective to people, that’s the argument I’m trying to make.

DR. CARR: I think you’re saying evidence based medicine and there’s a continuum and there are places that we’ve done it well and in part with like national state initiatives, and there are places where we could be doing in prostate where the data exists, but I guess we’re also focusing on the things that are harder to get statistical significance or randomized control trials or whatever, to be able to make a statement about —

MR. HUNGATE: We can argue that if we’re moving to electronic medical records the availability of data is going to be vastly improved in terms of its level of specificity by patient and its ability to aggregate —

DR. CARR: I’m not so sure, I think ICD-10 will make us better able to look at things, I don’t think the electronic medical record has, at least as I know it, it doesn’t have fields for every data element, it has a lot of narrative and it has rapid communication but it doesn’t have selected fields that a person could slice and dice and tell a story with.

MR. RODE: Both pieces, it’s the record that can contain the data and part of that gets back to making sure it’s documented, it’s the ICD-10 and other classification systems that you’ve decided for quality reasons you want to then bring that data together so you get your answer. And so both pieces are needed, 10 coming in now might give us more information then we have with 9 because it’s more detailed and that will work for a while. When we eventually get to SNOMED based records you’ll have even more and that’s your progression.

DR. EDINGER: I guess too the argument which some the grantees of AHRQ has done is that if you came in to see Dr. X and he had a decision support system and an electronic record, he could probably print out information that you would need on your prostate surgery either prior to or while you’re there telling you your risk for your kind of condition and your specificities and the kind of surgery that’s being done on you. In theory there’s no reason why you couldn’t do that, the information is there, it should be done. That may be something we might want to address in ourselves, if the information is there and how we get that at the patient level as one of the elements of the patient.

Also in the case of you coming in, like in my case, I have, an Ashkenazi Jew, I have a factor 11 deficiency which is common but nobody ever asks, nobody ever things to ask me, my kids have spine problems, they had to do some spine surgery, they probably want to know that, the factor deficiency, you wouldn’t want to cut my spine open without knowing this. However, one of the other things is the electronic, the personal health record. Well, if I’m not too well that day and I come in there I may have to tell them that gee whiz, I have a factor 11, I have this, this, and this, I may not be in the shape to tell these people. However, information readily available will also impinge on your risk, they may decide somebody whether or they should do it or should they even call on someone else who is a more experienced surgeon saying well I’d like to do it but I’m not going to touch this person, I’d like Dr. Superstar to come in and do this because he’s had more experience. Maybe we should look at some of those kinds of elements on both sides of the issue that might help in framing a decision for a patient, where to go, assuming he has a choice.

MR. HUNGATE: Well I will apologize for getting back onto my risk adjusted outcomes but I think that there is this continuum and having worked on the purchaser side, and I still do with Group Insurance in Massachusetts, until we get something that helps the individuals deal with those issues the purchaser is stuck with proxy measures in between which are inadequate as you point out to deal with individual patients. Now the adverse outcome is still there but if those end up in the statistical information then I don’t need to judge case by case performance.

DR. CARR: I think that the point that we hit on is just the data elements and as we go through the electronic record what is getting better, so ICD-10 is better then ICD-9, a narrative having your problem list is better then, that travels with you is better then information that’s not accessible so I think thinking about the building blocks, I mean I just would be worried about putting patient able to make risk adjusted decision as an end point of our immediate goal.

MR. HUNGATE: I would say physician able to make —

DR. CARR: I would say data elements available for this kind of clinical decision making.

MR. HUNGATE: I don’t think we can get this outline completed by our hearing next week is my guess but I think we need to do it, I think we need to finish this discussion in a way that we have a model that we all feel is a good model for ten years —

MS. GREENBERG: I apologize that I was late but I was down at Standards and Security, so I’m not quite sure what you discussed before I got here, I guess we’re all set for the hearing next week from the point of view —

MR. HUNGATE: We started on the business case because John had to leave so we started to talk about what’s the business case that we’re trying to build.

MS. GREENBERG: Because I’m just wanting to make sure that we’re fairly squared away on the hearing next week and then also whether we are planning to have another hearing in September or what because this whole issue has, it’s been going back and forth in emails, etc., about whether we should have the people there that we want to make the business case to. As you know such as NUBC, NUCC, I did finally hear back, I heard back, I haven’t heard back from AHA, they had an awful time for some reason emailing George Argus but I think he got my last one because it didn’t bounce back but Jean Narcissi said actually there was a lot of conflict next week and ANSI HISB had forgotten and so these people are going to be at this ANSI Health, is that on our acronyms? ANSI Health Informatics Standards Board meeting which is actually taking place in Chicago. So I don’t think we’re going to get any of the people there but we have, next week, but that we have put out the possibility that we then want to bring them in in the future. And if it’s going to be September we need to settle on that or when it’s going to be or what it’s going to be, I think we need to have, so I’m just kind of being practical here as opposed to philosophical —

MS. HANDRICH: What was the thinking about what the second hearing would be again?

MS. GREENBERG: In which you would bring in, to the extent that you’ve had some consensus these are the highest priority data elements that we would try to add now, I mean I do think this is incremental, I really feel like we cannot, I feel the same, not that I agree with all of their recommendations but I really feel the same way that the consumer disclosure project feels, that if we just say we’ll just wait until we get electronic medical records a, we’re going to be waiting a long time because with all of the hoopla about electronic medical records I still don’t see any real money out there, and even where they put real like in the UK it’s an uphill, it’s not a piece of cake.

So that’s one thing, the other thing is that even, and I think we’ve been talking around this, even once we have electronic records they could be, the data could be so granular that still there’s no guidance on what is it that we actually need from the point of view, it’s like the people who think that once we have SNOMED why do we need ICD at all, I mean they don’t get it, that you can’t really do population based data or indicators at that granular a level.

But in any event so I think we need a short term strategy and a long term strategy and by identifying this now or in the next year or so as John said even though maybe we can only get it once there’s more penetration of electronic records at least then that will be something for people to shoot for and we’ll make sure that that information is in the electronic records in a way that’s retrievable. So that was the idea that if we identified either the highest priority or a scale of things then you bring in the people who have to make it happen because as I said in my little email here about the business case once a legitimate business need has been defined it’s the obligation of the standard development organization to figure out a way to meet the requesters need and it may not be the way you asked them to, and they have been engaged on some of these issues already, NUBC and NUCC, by the consumer disclosure project. But I don’t think HL7 and X-12, and I do have names that I talked to Bob Davis about people that we would, who would be the right people to talk to at HL7 and X-12 also but if we want to then set up something with those folks we need to decide when and do it —

MS. HANDRICH: Have the presenters then cued that this question of priority is something that the committee would particularly like to hear about?

MS. JACKSON: We asked them to set up their assignments according to our eight questions and that’s really it, candid recommendations —

MS. HANDRICH: But that’s true for all of us when you’re talking about being ready and what is it we want to ask.

MR. HUNGATE: Does everyone have the most recent line-up for the hearing?

MS. JACKSON: Is everyone, all the members in the workgroup planning to attend except for I know Dr. Lumpkin can’t, everyone’s coming in?

DR. STEINWACHS: I can be there Friday but I can’t bet there Thursday.

MS. POKER: I won’t be there part of Thursday.

MR. HUNGATE: Any questions about the listing that we have here, any suggested changes?

MS. HAYWOOD: Of course I think these have all gone out to the speakers by now, I mean I think we’re pretty locked in —

MR. HUNGATE: I think we’re locked in with what we’ve got here.

MS. HANDRICH: Theoretically they’re going to talk about the priorities —

MR. HUNGATE: And Michael Bellman may well be back on the list, Carl Voldy(?) was going to talk to him further. Michael had said, and all his work had been at the physician level, not hospital, and it looked like we were asking hospital but I think why he went there is still an important bit of input for us so I’ve encouraged Carl to encourage him to come.

MS. HAYWOOD: And that was not our intent was to limit this to the inpatient world.

MR. HUNGATE: Is there any problem with locking down, I think it was September 14th that we had as the tentative next hearing?

MS. GREENBERG: I wasn’t even sure if we had a date.

MR. HUNGATE: That’s what I have on my calendar.

MS. HAYWOOD: And are those the big four Marjorie that you have in mind, HL7, X-12, NUCC and NUBC, I mean certainly it would be hard to imagine that if you’re going to talk to the SDOs that you would go forward without those four.

MS. GREENBERG: Well it would have to be those four and I don’t know who else.

MR. HUNGATE: The feedback I’m getting from Simon on these issues is that we are talking to the quality people in the organization and not the people who do the work.

MS. GREENBERG: What do you mean do the work?

MR. HUNGATE: The coding, the data people.

MS. GREENBERG: In the hospitals you mean?

MR. HUNGATE: In the hospitals. In the providing system, whether it be vendors or providers.

MS. GREENBERG: Well, that’s true, that’s our purposes in this hearing.

MR. HUNGATE: But those people are effected by the result and so they need to be, part of representation of that body has to also appear at the September 14th —

MS. GREENBERG: I think we’d want to hear, maybe have someone from AHIMA, maybe AHA, like he mentioned the American College of Surgeons, he said you’re recommending that the operating surgeon, one of these aides is the operating surgeon ID or something like that and he said well, maybe you should have the American College of Surgeons there. I said well can you recommend someone from there and he couldn’t but I imagine with some effort —

MR. HUNGATE: I met a fellow named Scott Jones who does the database for the American College of Surgeons around quality and so on and I think he might be a good person, I met him at last year’s —

MS. GREENBERG: I mean this is always the problem and particularly in a larger organization, we met somebody from Estonia, she was responsible, in the statistics office, she was responsible for everything, the coding, the morbidity data, the mortality data, I mean she can implement whatever she wants, let’s move to Estonia, it’s like everyone wants to move to Canada. But once you get into an organization which is more then one person, or many departments, it’s the same thing at the NUBC, the people, or the NUCC, you don’t have, you might have Blue Cross there but you don’t have the people from Blue Cross who are interested in quality or who are working on quality, you’ve got the reimbursement people. And it seems like even when they get back to their organizations they don’t necessarily talk to each other so it’s a challenge unless you’re in Estonia.

MR. HUNGATE: So what we’re trying to do is use this first set of hearings to build a quality case, the business case for what’s to be done and then we’re to listen to the implementation issues related to that case in the September 14th hearing.

MS. GREENBERG: Oh, I do have that on my calendar, the 14th.

MR. HUNGATE: That’s the one we picked last time and unless there’s some serious, September 14th, arbitrarily, let’s stick with it unless there’s a substantial reason to change. I think we should hold it to one day.

MS. GREENBERG: A one day hearing, and I guess we wouldn’t have a room for it yet but the idea is have it in D.C.

MR. HUNGATE: Yes, right.

MS. GREENBERG: Although many of these people are in Chicago.

MR. HUNGATE: And this is basically to encompass the people effected by the business case having, to do work.

MS. HAYWOOD: And then request for clarification from the staff, are we still on track with the idea that I think we articulated last time that once we get through these two sets of hearings that then we will have the information we need to write up this business case, wrap it into the report, represent it to the full committee with the recommendation that they go from tentative to —

MS. GREENBERG: I don’t think we necessarily take the report, I think we would do letters or something like that, pointing to the report. I think the report —

MR. HUNGATE: We would expect to deal with the change of the candidate to a real recommendation or its dismissal.

MS. HAYWOOD: Are we going to stick just with these first eight? I mean everything we’ve done so far has pointed specifically with the eight recommendations.

MS. GREENBERG: Well I know that the Populations Subcommittee —

MR. HUNGATE: I talked to Vickie a little bit about the two there and it seems to me that the second of the two population ones largely gets dealt with in what they’re now doing, that that which is before us today deals with the survey questions, which is one of the recommendations so that’s taken care of. Now the other one is not —

MS. GREENBERG: The race ethnicity on claims, or the encounter or the enrollments, and these are the same people but certainly —

MR. HUNGATE: I don’t think we want to try to move that into this —

MS. GREENBERG: So I think we really have to talk with Vickie and see what —

MR. HUNGATE: She’s interested in pursuing having a separate hearing on that issue if that’s what it boils down to.

MS. GREENBERG: Do you know a Wes Rischel(?), do you know where he lives?

MR. RODE: He’s with Guardian.

MS. GREENBERG: I know him but where does he live?

MR. RODE: I think he works in Connecticut or Massachusetts.

MS. GREENBERG: He’s on the east coast?

MR. RODE: — HL7 —

MS. GREENBERG: Oh, I know that but I just wanted to know where he was physically located because I was just wondering if we should think of doing this in Chicago on September 14th. Because NUBC, NUCC are there, AHIMA, you’re here, but it wouldn’t be you in any event, a lot of the people are in Chicago and Chicago is reasonably convenient to get to, you could almost fly in and fly out the same day.

MS. HANDRICH: They have meetings right at O’Hare.

MR. HUNGATE: Well, maybe that’s a better venue.

MS. GREENBERG: I’m just wondering, I’m thinking it’s not that far now until —

MR. HUNGATE: Why don’t we leave that to staff to decide —

MS. GREENBERG: Okay we can check into it, but if we’ve agreed on September 14th we can start contacting these people and seeing whether they could come and if they’ve got conflicts that being in Chicago would facilitate their being there then we could think in terms of that.

DR. CARR: The VA is not represented here and they have a very big quality program, did we not intend to invite them?

MR. HUNGATE: Someone came from the VA to the meeting yesterday for the first half hour or an hour, it’s a name that I’ve had before and I haven’t had a chance to contact him and he left so I didn’t get a chance to, I would like to draw them into this venue —

MS. GREENBERG: Well, we could still try to get someone, have someone there —

MS. POKER: I think we should, I think they have a very, he’s there and he came from there, I mean he’s, Eduardo —

MS. GREENBERG: I know, he was supposed to still be involved with our work but I haven’t seen him.

MS. POKER: And he would be, I get emails from him, I don’t know what happened.

MS. GREENBERG: Well then maybe you could contact him then.

MS. POKER: So would that be —

DR. CARR: If he can speak to their quality data collections methodology and how it has worked for them, because with their electronic record they developed it and they live with it, it’s not perfect but they’re light years ahead of where we are today with the simple concepts they began with.

MR. HUNGATE: And where does Barry Digman(?) fit in —

MS. POKER: And I have the name at the AMIA, there was somebody who presented also but I forgot his name.

DR. EDINGER: The only thing about Eduardo is actually Eduardo represents a hospital not the VA system —

MS. GREENBERG: I would contact actually Gary Christopherson, who is the CHI person, the lead person with CHI.

MR. HUNGATE: Barry Digman came and announced himself, his presence, at yesterday’s meeting, Barry Digman, and that’s a name you had given me Stan of someone at VA.


MR. HUNGATE: I think so.

DR. CARR: I’m not sure who the players are but the question that we would to ask is someone who speaks to the evolution of their electronic record and how it has impacted their quality and their —

MR. RODE: Gail Graham that sits as a staff member to Standards and Security from the VA heads up their medical record piece and she might be able to give you a contact.

DR. STEINWACHS: Aren’t you trying to look at the business case? Because the business case is buried in the query system which is —

DR. CARR: Right but they’re closer to the vision, if we’re trying to say what are the building blocks to get us from here to there there might be some experience that they can offer that we’ve struggled with this and this is what we decided so that we could move ahead.

MR. HUNGATE: Their surgery quality improvement program is one of the best around.

DR. CARR: Right, and what made me think of it is American College of Surgeons is now modeling, I think we’re a site for this, modeled after the VA, so I think we’re using, American College of Surgeons is recognizing VA as a system that’s working and again —

MS. GREENBERG: We should try to at least get someone there and then it might be a good person to have at the September hearing also.

MS. POKER: For which panel would you consider this person, would it be for the quality measurement?

PARTICIPANT: Depends on which one you got, the business case —

MS. GREENBERG: Provider organizations, maybe a provider organizations —

DR. CARR: I think the quality measurement might be interesting, the sort of what did they collect, again was it volume, process, or outcomes, how did they do it and how are they better for it.

DR. EDINGER: I would probably suggest the quality measuring, if you got them in a provider organization and you went to the evolution of their system, that would probably be an area, it’s very different and there’s a lot of political issues because they’re basically a government agency so it’s probably a different issue then you think —

DR. CARR: Exactly, but the fact that they’ve done what we’re trying to do is extremely valuable —

DR. EDINGER: Right, I think the quality measurement is probably —

MR. HUNGATE: I think it would be useful to have them there, it would be helpful.

MS. POKER: Okay, so he would go with provider section —

DR. CARR: We said quality measurement.

MS. POKER: Oh for quality measurement. By the way do you also think, there’s this lady who’s being very, I thought she’s been speaking very well from the ANA, Carol Bickford, who’s been also talking from ANA, I was thinking she might be, should I approach her for the quality measurement organization also? I mean I think the ANA is looking at that, is that something that the group would be interested to have an additional panel member for that?

MR. HUNGATE: We’ve got an hour and a half —

MS. POKER: Is that too many?

MS. HANDRICH: What is the format?

MR. HUNGATE: We’ve asked them to speak for 15 minutes —

MS. HANDRICH: And then does the committee ask questions or let everybody speak first?

MR. HUNGATE: Well, what’s your pleasure? I think there’s a lot to be said for asking all the speakers to stay and having a general discussion after all presentations —

MS. HANDRICH: I like that, I like that a lot. If they come all that way you want to give them all ample opportunity to speak.

MR. HUNGATE: And otherwise you tend to favor the early —

MS. POKER: You do have a lot of representation because some of these speakers are going to speak longer then 15 minutes, I just know that they have a lot to say.

MS. HANDRICH: People are having ideas and I notice the Medicaid people didn’t get anybody on, there’s going to be this other hearing, we can get more people to come to that one too.

MR. HUNGATE: We have tried to set up time for us to discuss deliberately and so we can see what’s the follow-up, what are our gaps. It seems to me that we need to try to put down on paper a little bit some of our early discussion which relates to the business case for quality, the business case for measurement if you will as a separate business case, and then some of the spectral model of what we see over time. I don’t think we present that, I think we continue to work on that but I think we need some vision articulation of what our common understanding is around what we’re trying to do here. And probably that’s part of your work contact.

MS. POKER: Right, and I think it’s going to be easier to synthesize that after the two hearings hopefully.

DR. CARR: We should have a timekeeper, when they have two minutes remaining just hold up —

MR. HUNGATE: I will consider that my responsibility, I’m going to have a red one and a green one and the green one will be apparent until the red one, or yellow on for the last couple minutes, Senate methodology, you need to do it.

MS. POKER: [Inaudible.]

DR. CARR: Same way with some of these speakers, if they’re going to be speaking longer then 15 minutes —

MR. HUNGATE: I’ll warn them in advance that I’m going to be pretty harsh and ask them to respect our wishes.

MS. POKER: it also maybe kind of gently as a facilitator guide them back, sometimes people tend to talk about their personal agendas which is fascinating but this is a purpose what we need from them, if they could just stay on that.

MS. HAYWOOD: I’m hoping that one of them will come with, we asked them I thought to bring prepared comments, written comments, which helps a lot, it helps both —

MS. HANDRICH: It helps if you can follow along as they’re speaking.

MS. HAYWOOD: It does, it certainly helps the staff after the fact when you need to summarize things.

MS. JACKSON: They have asked about that and some of them are not as comfortable wondering if they could bring their notes, if they could bring bullet points, that kind of thing. And just kind of create from there, it’s not as much prepared remarks so I saw more strategy and we’re really leaving it up to them.

DR. EDINGER: Are there any questions we’d like to address either of Dr. Brailer or Mark McLellon(?) since they’re going to be here today that might help us in some of our deliberations or something specific we’d like to draw out of one or both of them? They’re basically researchers also besides they’re all here, well, Mark actually worked in your neck of the woods a long time but they have done research, they both have been, they’re now in the department on the other side of the fence and maybe there’s some questions you’d like to draw out of one of them in either their current life or their past life that might help us.

MS. HAYWOOD: You mean in terms of drafting our thoughts for where we’re going from here?

DR. EDINGER: No, as far as questions this afternoon, they’re going to be on the panels this afternoon, if there are any specific questions we might like to ask them that might help us in our future hearings or framing our questions that might be useful to one or both of them.

MS. JACKSON: Because you also would need to start developing I assume business questions for the September hearing, is that right?

DR. CARR: I think the basic one, from what I heard last night at dinner we want, this is just kind of get acquainted with David Brailer and not ask more questions then he’s had a chance to answer but I think John’s concept, that if we have a financial transaction, do we have a quality transaction as part of electronics I think is an interesting one, obviously not one he’s prepared to answer but that put a placeholder in for should quality be able to be sort of fluid and communicated.

MS. POKER: It’s okay to even ask him at this point maybe he doesn’t have a strategic plan for it but what is his vision, like how does he see that quality be part of that EHR concept and what weight, if he has any thoughts about it, I think that could also give us direction, a roadmap kind of thing.

MS. HAYWOOD: Actually hearing from both of them will —

DR. EDINGER: Mark has done a lot of work in quality himself outside of the CMS role.

MS. GREENBERG: He seemed to be talking about quality too isn’t he?

DR. EDINGER: He’s had a lot of hands-on research, he actually knows the database, he’s actually had hands-on with all these databases so Mark is very familiar with the database, since he was over in your neck of the woods he’s put in electronic health record and all, so it might be good to get his vision even outside of his HCFA role.

MS. POKER: On a practical note for September 14th do we know who we want to invite or we don’t know at this point?

MS. GREENBERG: I have four names —

MS. POKER: You also rattled off some initials I don’t know, some acronyms I don’t know.

MS. GREENBERG: You didn’t get the acronyms?

MS. POKER: I get the acronyms but I just, okay, I got a list of acronyms but the acronyms you specifically, those are people who are going to be represented September 14th —

MS. GREENBERG: I think we can invite George Argus from NUBC, Jean Narcissi from NUCC, Wes Rischel, George Argus from the National Uniform Billing Committee which is the committee chaired by AHA that maintains the uniform bill for hospitals, which pretty much defines the content for the 837, I’m sorry but that’s the HIPAA transaction, claim transaction standard, the 837I no less, the institutional claim transaction. Then Jean Narcissi from the National Uniform Claim Committee which is responsible for the professional bill, so they basically, their groups define the content, she’s at AMA, American Medical Association, they’re both in Chicago. I think we’re shifting to you as the lead staff but I’m happy to give you all their contacts, I will email you their contact information.

MR. HUNGATE: Let me put this in the mail.

MS. GREENBERG: And Wes Rischel from Health Level 7 —

MS. POKER: But if anybody doesn’t agree with that or has anything else —

MS. GREENBERG: Let me just say who I’m suggesting, I mean I got that from Bob Davis who’s our consultant working with the standards organizations and Wes was actually the chair of HL7 which is the standards development organization, I almost said SDO, that is responsible for clinical standards and they have taken the lead in defining the content of the claim attachment which could be a vehicle for collecting some of this quality information.

MS. JACKSON: And he’s where?

MS. GREENBERG: That’s what I was just asking Dan, I’ll get his contact information, he’s with some company in Connecticut. And Alex Goss(?) who is a woman, she’s the person at X-12 which is the group responsible for the administrative transactions that he thinks is the best person. And then we can ask Dan Rode for a contact, whom we should invite from AHIMA, we can also ask George Argus if an addition to his representing the NUBC, whether there’s somebody else should come from AHA representing the hospital community, I don’t know if that’s necessary although there’s a woman from the Florida hospital community, Florida Hospital Association, they’re a state uniform billing committee too who’s a very influential person the NUBC and she might be a good person.

MR. HUNGATE: Peggy, you had a quick comment, we’re going to have to break here.

MS. HANDRICH: I realize that we don’t have time to talk about this now but I am wondering if at some point we can talk a little bit about the future direction of the committee. This thing is kind of on a path and we’re going to follow this path along and we all talked about how this report really focused on the primary and acute care side of health care and an argument could be made that quality measures and quality development and standards and so forth is much more mature in the acute and primary health care world then it is in the long term care world which is where most of the money is going. And I am wondering whether at some point the committee is going to have any interest in pursuing a similar track for long term care. I’m just going to put that out, I know we can’t talk about it now but getting back to the business case where you look at where the bleeding is —

MS. POKER: Did you say where the bleeding is?

MS. HANDRICH: The money, where the money is going —

MS. GREENBERG: Certainly the Medicaid money.

MS. HANDRICH: And Medicare.

DR. EDINGER: You don’t immediately recognize Peggy as a blood and guts person but she is.

MS. HANDRICH: Yes, a lot of Medicare, they pay for the first 60 days of nursing home care, they pay for a lot of home care —

MS. POKER: It’s up to the first 100 they can technically —

MS. HANDRICH: So I’m just throwing out that —

MS. POKER: And it’s going to be increasing, it’s going to be an increasing thing, and ESRD, ESRD is a big thing.

MS. HANDRICH: I don’t know what we’re going to end up doing but I know the committee has given probably six or seven years to the development of this report and getting this report on its way so I’m just throwing that out as an agenda item for the future.

DR. EDINGER: Well, and the new CMS administrator told me once his mother told him follow the money so he might —

MS. HANDRICH: Right, that’s the principle of quality.

MR. HUNGATE: Part of it is how can we as a unit contribute effectively in the arena given, the problem that we have had with the last report is that it tried to cover six years with no institutional memory to make it work so whatever we pick has to be doable in an 18 month to two year timeframe.

MS. HANDRICH: I agree, there are no standard accepted measures for quality although, in the long term care field —

MS. POKER: — they’re worse then home health, they’re much worse.

MS. HANDRICH: There’s a lot out there and the same kind of effort at identifying where there is agreement might be very useful on a national level.

MR. HUNGATE: I think there’s a useful discussion there. My sense is that the QIOs at least believe that their nursing home quality measures are better then their acute care quality measures. They may not be right but I think they believe it.

DR. STEINWACHS: And we collect a lot of data.

MR. HUNGATE: There’s more data, it’s more complete —

DR. STEINWACHS: There’s not a shortage of data, it may be the wrong data —

MS. GREENBERG: It apparently isn’t helping to identify quality —

MS. HANDRICH: Exactly —

MS. GREENBERG: There’s a case where we are data rich and information poor I guess because they’re collecting a heck of a lot of information, of course it’s different in every setting and that’s a big problem —

MS. HANDRICH: It’s a big mish mash —

MS. GREENBERG: And this committee tried to take that on about ten years ago, there’s no reason not to take it on again. But we did commit I thought to having a meeting in Boston on risk adjustment and I think that should also, I couldn’t agree with you more. There’s been a whole long term care, originally before 1996 we had a long term care statistics subcommittee, we had a mental health statistics subcommittee, we had a minority health statistics subcommittee and now everything is standards and e-prescribing, it frustrates me but these are important issues to the committee.

MR. HUNGATE: We need to move to the other meeting so thank you all.

[Whereupon at 9:59 a.m. the meeting was adjourned.]