[This Transcript is Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Workgroup on Quality

June 3, 2005

Hubert H. Humphrey Building
Room 705A
200 Independence Avenue, S.W.
Washington , D.C. 20201

Proceedings by:
CASET Associates, Ltd.
10201 Lee Highway, Suite 180
Fairfax, Virginia 22030
(703) 352-0091


P R O C E E D I N G S [8:17 a.m.]

Agenda Item: Welcome and Introductions – Robert W. Hungate, Chair

MR. HUNGATE: We’re talking shop; let’s get going.


MR. HUNGATE: Well, our introductions will take less time this

Welcome to the second day of the planning session of the
Quality Workgroup of the National Committee on Vital and Health Statistics.

Since so far we have the same people that we did yesterday, we
just need to, I think, introduce by name; no need to talk about any conflicts.
I’m Bob Hungate, Chairman of the Workgroup, member of NCVHS and Principal of
Physician Patient Partnerships for Health; Chair of the Group Insurance
Commission in Massachusetts.


MR. HUNGATE: And we’ll have others joining us as we go
forward, so as they arrive, we’ll have them introduce themselves and try to
keep the record straight for our Internet audience as well.

I know we’ve had a lot of little discussions. The topic
yesterday was marvelously enlarging in understanding, broad in its content, and
challenging, and I think we got a lot of food to work from.

I think our initially what was called the “Carol
matrix” — [laughs] — you know, sometimes you get immortalized that way.
You want to rename it? What should we rename it, the matrix.

MS. McCALL: We’ll move forward.

MR. HUNGATE: The matrix —

MS. McCALL: The Workgroup.

MR. HUNGATE: — which, you know, puts down the individual
health, population health, system health, as important aspects of what we’re
talking about. I think it’s a good construct.

I’m hoping that Don can join us today because I think that
maybe it’s here that we should try to see what the Population Workgroup does on
this kind of an issue and what we try to do.

I think this’ll be the right arena to kind of work that out,
and I personally think that there is a lot of potential synergy in those two
activities if we think it through in a work plan way so that we know how those
work plans dovetail.

That process involves both what we do here, the Executive
Committee retreat, and then finally discussion I think at full Committee later
this month. But I think after that, it’ll be pretty well clear.

I think we’re scheduled to have Carol lead off the next round
of trying to pull us together on this thing, and I think that’s where we should

The only thing I wonder about is whether we should try to
finish up what we think our charge should be. Because our charge relates to
what the work plan finally ends up being, then we probably can’t really do that
until we have our work plan, so maybe that would be putting the cart before the
horse in this case, so let’s just go ahead.

Agenda Item: Summarize and Facilitate
Discussions of June 2 and Focus for June 3 – Carol McCall

MS. McCALL: Okay. And we will be having some guests come?


MS. McCALL: All right.

MR. HUNGATE: Welcome, Carolyn.

MS. CLANCY: Good morning.

MS. McCALL: Good timing.

MR. HUNGATE: You’re set up right up there with the microphone
and a label.

MS. MCCALL: Good morning, Carolyn. You’re timing’s good.
Actually what we’re getting set to do while you get yourself settled, and maybe
right before you get yourself all settled, do you want to have her introduce
herself for the record?

MR. HUNGATE: Why don’t you introduce yourself? We’re on the
Internet, and so we’ve gone through and told our names and functions.

MS. CLANCY: Great. Good morning. I’m Carolyn Clancy. Sorry to
be a little bit late. The good news is no accidents for me, but people go very
slow, they’re very cautious. And I’m the Director of the Agency for HealthCare
Research and Quality —

MR. HUNGATE: Welcome. Thank you for joining us.

MS. CLANCY: — and I work with Anna.

MR. HUNGATE: And we’re just starting to kind of rehash what we
went through yesterday and talk through that, so please interrupt and ask
questions as you hear things that you wonder about.

MS. GREENBERG: Do you want me to?

MS. McCALL: Yes, that would be great. We’re asking Marjorie to

Normally what I would do is I would jump up to a flip chart.

MR. HUNGATE: Yes, me, too.

MS. McCALL: I don’t have to do it as long as I can be miked.
Don, is there a way for me to be miked?


MS. McCALL: Okay. All right, so I would love to do that, and
I’m going to be right up here.

MS. GREENBERG: You want to do it?

MR. HUNGATE: Yes, right.

MS. McCALL: Yes.

MR. HUNGATE: That’s what I figured. [Laughs.]

MS. McCALL: Perfect.

What I’m going to recommend while Don is going to get that
mike and some markers and all that set up is that we do a couple of things.

The first thing that I’d like to do is just, for the folks
that were here yesterday, try to capture not so much what you think the work
plan should be, although it could be that, what the key conclusions were, what
you thought some possible and important actions would be, so that we just get
those down in a visible way that we can all see them, okay, because we will
probably be working with that either in its existing form or in some modified
form as we go through into the afternoon.

So I thought that might be a really good place to start. And
with Carolyn here, it would be a great way for you to get the condensed
version, although, you know, some of the meat and the color and all of that
will be missing, but, you know, we obviously have some time here this morning
for you to ask for clarification, for you to

amplify, and all different types of things.

I think we’re ready to go.

There will be times when, as I try to facilitate this, I may
violate it by actually having some things to add, but I will not confuse you.

MR. HUNGATE: Justine, go ahead.

DR. CARR: Carol, are you ready? I’ll start.

MS. McCALL: Not quite.

MR. HUNGATE: We were quiet too long on the Internet; music
came on, right? [Laughs.]

MS. McCALL: Okay.

MR. HUNGATE: “There’s no activity in this

MS. McCALL: I think we are ready, so I think —

DR. CARR: Okay, thanks. It was a wonderful day yesterday. I
think we all had our horizons expanded.

I, at the end of the day, had two observations.

Number one, which was very stark and dramatic, is that John
Halamka, who probably has the most robust electronic health record, has no road
map for quality. And I think if he doesn’t have it, no one has it.

So, in terms of our thought about identifying gaps, I think
that one is huge, so I would put that out there as number one, the crosswalk
between quality and the electronic health record.

And the second theme was the considerable discussion about
what is quality and how do you measure it, and the subheadings under that would
be, number one, are we talking about quality or value, value being defined as
the interface if cost and quality?

Second, that was brought up by Don Detmer, was the interactive
and perhaps multi-dimensional concept of quality, and this, I guess, was also
seconded by Brent James, that one metric over time is not a satisfactory
definition of quality, that there needs to be more dimensions to it, but most
importantly a kind of massaging of it, watching over time, checking and linking
back to find out whether what we thought was a measure of quality is a measure
of quality, and then perhaps an iterative process of refining the denominator
or refining the definition, and in some cases deleting things that we once
thought were measures of quality.

MS. McCALL: Okay. Just want to make sure that these capture
what it was that you intended for them to. There’s actually, I guess —

DR. CARR: Well, there’s two things. One is the electronic
health record has no chapter on quality today.

MS. McCALL: Okay.

DR. CARR: Number two, our definition of quality is not
represented by a consensus. And I think that there

are more dimensions, that the definition about whether we’re
talking about quality or value, value also being the part that would align
incentives with the patient, I think the point was made yesterday the patients
aren’t so much concerned about how many stars you got on health grades but they
are concerned about the interface of their expenditures and their outcomes.

So I would say the definition of quality — the two things are
the crosswalk, the electronic health record; the second is the definition of

That is simply elaborating on some of the dimensions that were
raised by the speakers yesterday.

MS. McCALL: Got it. So it’s kind of these two, one, two, with
A, B and C.

DR. CARR: Right, yes.

MS. McCALL: Got it. Okay, great.

Now, hold on — before you begin, I don’t have any place to
put these so the folks can see them.

MR. HUNGATE: Do we have tape?

MS. GREENBERG: Well, we’ll get some tape.

MS. McCALL: Okay, that’s fine. This is so that people can feel
free to — we can add on.


MS. GREENBERG: We had a memorable meeting — I think it was
the Quality Workgroup — where we were writing on white boards in the
conference room and at one point we started writing on the wall and didn’t
realize it.

MR. HUNGATE: She was nice. There was one guilty party.


MS. McCALL: Okay, great. Mr. Bill?

MR. SCANLON: Maybe it’s partly a clarification, because I
guess I think that within the electronic health record, in some respects there
are fragments of quality, I mean that there have been steps that have been
taken to try and influence quality.

I mean, we hear, you know, over and over again about some
checking for drug interactions — I mean, there’s clearly steps in that
direction — but nothing that’s systematic, more comprehensive.

And I think that’s true as we move out and we think about
taking data out of the electronic health records and moving it into some other
context, because I think the one thing that struck me yesterday was the morning
presentations about applications of information and how we’re always focused on
sort of a partial view of the quality and that in some instances we’ve got sort
of problems in terms of (?).

Brent’s presentation about — we had a discussion of use of
Caesarian section rates and sort of how they can

be misinterpreted or not interpreted correctly — then he came
back to an issue of risk adjustment, that we can get information about the
provider, but if we haven’t adequately risk adjusted, we don’t know anything.
It’s not that C-section rates are necessarily a bad measure, where risk
adjustments can be the ultimate problem.

MS. McCALL: So I want to make sure that I adequately captured
that point about risk adjustment.

MR. SCANLON: I mean, in terms of when we move outside of the
delivery context, I mean, we’re trying to use information in different ways to
influence quality, and we heard a lot from Brent yesterday about what CMS is

The issue is they’re trying to influence behavior by in some
ways scoring providers, providing information to beneficiaries and consumers
for choice. The issue is the appropriateness of the measures, the accuracy of
the measures, and part of that relates to — in addition to the issue of risk
adjustment, there was another piece that he talked about which is the issue of
translation and how do we translate this information to consumers? And we may
be able to rate sort of delivery of services from a professional perspective,
but how do we use this information in a market context to try and inform

MS. McCALL: Okay. So I want to make sure that I’ve got it
right, that somehow the appropriateness and accuracy of the measures may not
translate into how they’re being used? Is that —

MR. SCANLON: They need to be appropriate and accurate before
we think then about sort of how they can be then translated sort of for use.

And I think from what we heard yesterday morning that we’re
not there.

MS. McCALL: Right.

MR. SCANLON: We’re not there in terms of comprehensiveness. We
have a lot on the measurement side that we need to do, and this kind of, I
think, goes to, in some respects, Justine’s comment about the electronic health
record not having sort of a chapter on quality. We don’t have a chapter on the
use of information for quality outside of the delivery system, either, and we
need to get there sort of as well.

MS. McCALL: Okay.

MR. SCANLON: The other thing, I thought this afternoon
discussion where Don was particularly talking about the interface between sort
of quality and the IT, is the issue of how do we deliver the information that
we want to use outside of the delivery sector to influence quality.

You know, we’ve got a lot of applications sort of

waiting in the wings in terms of information to consumers, pay
for performance, et cetera, but we’ve got a real problem in terms of thinking
about how are we going to have the information to actually implement these

MS. McCALL: Okay. So you said it’s how we want to deliver it
outside of that?

MR. SCANLON: How are we going to get the information delivered
to the policy makers and to the program managers that we want to use this

MR. HUNGATE: Let me interrupt the flow just a little bit and
get our new additions introduced. So, Stan, Dan —

MR. ETTINGER: Stan Ettinger, AHRQ.

MR. RODE: Dan Rode.

MR. JENCKS: And Steve Jencks.

DR. STEINWACHS: And Don Steinwachs.

MR. HUNGATE: And Don. Finally made it! Welcome, all four of
you. Marjorie?

MS. GREENBERG: Okay. I also found yesterday not only
fascinating but also very clarifying in some ways for me. Maybe I got too much
into that simple box rather than the complexity box because Don Detmer was
talking about, because it is all very complex, but a few things that I took out
of it, and as I just said to Anna, I said the whole thing became very clear to
me in the shower this morning but I’m not sure that I’ve retained it.

Obviously what we’re looking for is what unique value can the
Committee contribute here, because there is a lot going on? There’s a lot going
on in the government, there’s a lot going on outside of the government, and yet
the bottom line doesn’t seem to be everything’s under control; we don’t need to
do anything.

And what Don talked about was the Committee being the keeper
of the vision, first of all, helping to lay out the vision, and then sort of
the keeper and the expander and enhancer of the vision.

Sort of, I think, what he had in mind as a parallel was the
way that the Committee has functioned with the NHII. And so when you mentioned
about the synergies, Bob, with Populations, obviously I think the synergies
with the NHII Workgroup also became even clearer yesterday.

And so he talked about the keepers of the vision, and that
doesn’t mean it’s a National Committee vision really so much as the vision that
the Committee is able to articulate through its usually effective process of
hearing from all the stakeholders.

That relates to the matrix, because it became very clear that
— I mean, we knew this, but it was, I think, well articulated I believe by
Joachim, or maybe it was Ernie Moy, I’m not sure which one, but that the
different players here and the different stakeholders have very different
perceptions of what they need.

That was very obvious from our meetings with the purchasers
and the providers, but that goes broader, and I think both Brent James and then
our other speakers, including Richard Klein from NCHS and Ernie talking about
the quality and disparity reports et cetera, and of course CMS talking about
the pay for performance.

It started to flesh out that not only are there many different
needs for information on quality performance measurement and value but that in
some cases those are oppositional. I mean, they’re not all complementary, and
focusing on one may create issues with the other.

But they go across this whole spectrum which you have on your
matrix from the system, or as Don Detmer I thought very well put it, he said
the real challenges to us is: What do we do until we get an American health
care system?

I said to my husband this morning, “Gee, spending five
years in England was really good for Don,” but —

MS. McCALL: Can I put that on a slide?


MS. GREENBERG: You agree with that, Carol?

MS. McCALL: Yes.

MS. GREENBERG: And so, I mean, from the system or the
non-system all the way down to the individual, as Bob pointed out, you know,
what kind of information do I have if I’m faced with a health condition and the
choice between a number of interventions and no interventions?

So I think that that idea of sort of filling out the matrix
and as part of really articulating the vision — and then he also mentioned the
gaps, and we’ve talked about the gaps.

Now, my own personal epiphany was that we have been debating
and discussing in this Committee, not just this Workgroup but in the Committee,
for the last 20 years what started off as being “describe the statistical
aspects of physician payment systems” and now is more, you know, do we do
administrative data, do we enhance administrative data, do we put all our eggs
in the EHR basket, and we, you know, had hearings on that in the last year et
cetera, and I know I have been a protagonist in these discussions, but let’s
forget mode, in a sense, that we can put mode to rest, because I think — not
that we could have 10 years ago, but I think now the administrative systems are
poised to collect quality performance data if we want them to.

But we all realize that the real benefit will come from the
electronic health record, but properly configured and designed and properly
linked with decision support and population-based health and all of that.

So we’ve got that goal, and everybody realizes that’s the
goal. You know, people have different views on how long it’s going to take to
get to that, and so, you know, I continue to feel that some segments are still
going to need to use what they have, which is an enhanced claim or some kind of
combination of an enhanced claim and a claim attachment standard which may not
go to the payer but, I mean, those sort of HIPAA standards may still be
vehicles for quality, but what the vision needs to do is to kind of lay out
what people need, what the minimum — one place I do kind of disagree with Don
is I’m still a believer in core data sets, not maximum data sets but
articulating what you really at a minimum need.

For example, I mean, you just cannot look at disparities if
you don’t have information on race and ethnicity; there’s no way to do it if
you don’t — I mean, racial and ethnic disparities. You can’t really look at
socioeconomic if you don’t either have something about the patient or can’t
link it with community variables and all that.

And I think like with the mortgage information, that just was
so stunning to me when they were able to come out and show the disparities on
being able to get mortgages, and low-cost mortgages, and it was because they
collected the information. I mean, you can’t just, you know, figure that out if
you don’t have the information, but I’ll get off that soapbox.

But in any effect, we can, I think, lay out functional status.
You know, we know we need functional status, we know we need information about
labs. But whether that be collected through this enhanced administrative or
through the electronic health record, I think we can in a sense just say,
“Those are options. We think the best option is really pursuing
aggressively the electronic record.”

And the other thing that I heard and that I think is
consistent with certainly what’s coming out of Dr. Brailer’s office et cetera
but that maybe we haven’t focused on enough is these regional community
solutions. And I thought it was absolutely stunning — well, two things were
stunning that John said, and thank you, Justine, for bringing him; I mean, all
together it was very useful having him here.

One was the fact that here he has this whole advanced system
and he still is like — I think he was being a little modest but he says he
still really doesn’t have a road map as it were for quality.

But the other was that he said return on investment of the
HIPAA transactions — incredible in Massachusetts, went from $5.00 a
transaction to 10 cents a transaction because they had a community solution,
and they don’t have every payer with their own companion guide et cetera.

When we had a hearing two months ago from the Standards and
Security Subcommittee, we couldn’t really get information on ROI. Well, we’re
not there yet; right now it’s costing us more than we’re, you know, making back
on it. And yet we have him come in and say, “I’ve got the data,” you
know, the $5.00 to 10 cents. So that’s because of the community solution and
the regional agreement and the trust that’s been built there over a period of
25 years, of course starting with the Massachusetts Health Data Consortium.

So I think there ways that the incentives maybe are currently
being aligned and be aligned better. And my bottom line is that what was really
effective, I think, was the NHII Workgroup and the 21st century vision for
health statistics, though unfortunately we haven’t really picked up on the
latter the way the former has taken off, but got a lot of testimony, developed
visions, and then we went out and had hearings — we actually had regional
hearings — to get feedback on those visions and on those kind of conceptual
models and principles and guiding principles, and then put out something that
then people could run with.

And I could see a very similar thing being done here around
this quality/value model.

DR. CARR: Can I just add? One of the other, I think, powerful
points that Don made was just that we organize around the IOM Dimensions of
Care —


DR. CARR: — and that we use that as an overview to have a
balanced approach so that we don’t overlook in particular equitable — you
know, in favor of safety.

I mean, and I think that, you know, to your point of what John
said, by making an electronic health record, it’s true, Bill said it, that,
okay, writing is legible and drug/drug interactions are checked, and actually
it’s more efficient, more timely, if you do e-prescribing and so on.

So we’re moving ahead on those areas, and I think, you know,
in a way I like his idea because it resonates with mine, but, you know, when we
made that grid and you could see all the things that we’re doing on
effectiveness, whether it be process measures or outcome measures or data
registries, but as you go down and start trying to look at what do we have on
patient-centered, what do we have on equitable, not quite as much.

So I think that that is a good grounding as we, you know,
focus on what is quality, what is value, that we not lose sight of any one of
those dimensions.

MS. McCALL: Okay.

MR. HUNGATE: Carol, do you want to add yours?

MS. McCALL: Yes, I would like to do that. It’s going to be a
little odd because I have to write and talk.

MS. GREENBERG: Do you want me to write while you talk?

MS. McCALL: That’ll be great. A couple of things. First, some
observations from the day, and then I’ve got some specific things that I think,
you know, we want to do and you can capture as much or as little as what you

I was struck by this continuum that Brent put out in the
morning from this accountability to learning, and there were just so many
things that I took away from that, but a couple of clear ones is that if we
kind of design a system at the wrong end — I think I said this yesterday —
we’re going to kind of paint ourselves into a box and we’re not going to be in
a position where we can really get something to adapt.

And I think this links with, Justine, something that you were
talking about just in terms of having specific metrics and kind of multiple
dimension of metrics so they’re very clear and very detailed.

So some things that I took away is that we do need a clear
vision of what we want in about 10 years. Okay, so if we can articulate that,
and then I think that we can try to build toward that.

And they have to take a lot of these things in account,
everything that we have so far up there, everything from an IOM type of balance
to the fact that we want to have some accountability. We do have pay for
performance, but we also want to learn.

So we have to take all of that into account and try to
literally create a picture in our minds and maybe on paper of what, if you had
it all, what would it do, okay, and what would be different? Then I think we
can begin, because — some notes that I made around the metrics, I think
there’s a paradigm shift that we need.

I was talking a little bit about this, before we officially
got started, with Anna and with Bob, that we tend to think, or I hear us say a
lot, that metrics — that it’s about reporting, and that the paradigm is that
somehow metrics is a very passive thing, that if we can just get the data out
and get some metrics built that we can look at them and see what to do.

And there are some thoughts, and it’s that to know and not to
do is really not to know. So if we want metrics, if we think they’re valuable,
they have to be designed into the very fabric of what we do. And that means at
that point of whatever it is, point of decision, point of care, many points,
it’s not one point, it’s many points, it’s not just for breakfast any more;
they have to be about everything.

So it has to literally be embedded into a flow, in two ways.
It has to alter that flow by informing it and it also has to learn from that

So we’re talking about an adaptive system, we’re talking about
one that learns, okay, which is both a cognitive process as well as it has
technology implications.

There’s another quote that came to mind, kind to follow. It’s
one of my favorites, so I’m going to bring it up, which is that “We are
what we repeatedly do. Excellence, then, is not an act but a habit.” And
that’s Aristotle.

So if we seek excellence, again to the point of trying to
embed it into what we do, then we have to do that. And so it gets back to —
okay, we have a hand signal from yesterday, Carolyn — it’s this, okay? And
what this means is the IT/quality intersection that we’ve been talking about,
because it’s not just a system, all right?

It is in fact, first and foremost, a paradigm that is driven
from a vision that has implications for mechanisms as well as systems.

So I think there are four take-always that I came away with,
with all that as kind of preamble.

It is this IT/quality intersection, all right?

It’s also having these conceptual models that Brent talked
about, and he talked about ultimate metrics and kind of intermediate metrics,
and the more robust those become in the chain, the more that — you know, it’s
a false choice to say I have to pick between an intermediate metric and an
ultimate metric, that if the intermediate ones are robust, that those are the
ones that you really want to work with. The volume is great, the time lag, the
latency, is shortened, and you can really get a feedback loop that’s fast and
you can truly learn from.

So we need those, and I think that that’s that kind of shared
intellectual property, that if we cooperate on quality and compete on service
that that’s a paradigm that’s valuable.

And so if we have a shared intellectual property around what
those metrics are, what is scientifically sound, what it is that we know so
that we have a mechanism to know what we know and to know what we don’t know
and to distinguish between those, so that’s a to do.

I still also believe that there is a need to link quality to
pay for performance. And that may be a two-step process because we still
believe in some sort of P for P, I believe.

So the question is, even with these new world metrics and how
it’s going to work and it’s all embedded into the flow and life is great, I
still won’t know how that links to actual payment, and I think that there’s
work to be done there. So in this intersection, in these mechanisms, we still
have to say how that link would happen.

And then the other thing I think we have to do is we have to
care very much about what the link is today in any sort of quality or value
metrics to current pay for performance because maybe there’s a bridge, and
that’s kind of, Marjorie, what I heard you talking about — is there a bridge
between today and administrative and tomorrow and the EHR? We have to care
about that from the metrics standpoint; we also have to care about that from a
P for P standpoint because, by God, if we do something wrong now, we’re really
going to mess it up for 10 years from now.

So we want to make sure that we are directionally correct,
even though that what we can do with administrative data, what we can do within
P for P is going to be just a small subset of what we think we can do in the
future, it still needs to point and be aligned in the same direction.

And I think that if we are going to be stewards of a vision
that part of that stewardship is making sure that we don’t mess it up today. So
that would be a fourth, any sort of bridge to the current P for P.

So those were my kind of specific take-aways.

MS. GREENBERG: I think I got it, the last two.

MS. McCALL: Okay. Thank you. All right, other things, other
reactions, common thoughts from — now I’m back to facilitator.

MR. HUNGATE: I had a couple I wanted to highlight.

I thought we really kind of clearly stated in the context of
discussion that the electronic medical record was a necessary but insufficient
way of addressing quality issues. And I think that’s an important thing for us
to state as a conclusion, because I think it is kind of where we ended up on
that. And it relates to your, you know, thinking through that.

MS. GREENBERG: Well, it was Simon’s first comment also, I

MR. HUNGATE: Right. So if that’s a given, then it should help
us think through.

And related to that was Don Detmer’s making a distinction
between infrastructure and knowledge management.


MR. HUNGATE: And I think that’s a very important distinction
and should also help inform our work because the attention has largely been on
the infrastructure and not on the knowledge management, and I think our vision
has to deal with the knowledge management as it relates to performance measure,
that that’s kind of the core, what the vision is about.

The other piece that was a specific is the graphic that Don
Detmer used of life in the complexity zone. You know, I thought it was very
descriptive, and if we’re trying to work on a vision having descripters that
help us describe it is a big piece of it.

Brent’s continuum of accountability and learning was one of
those, and I think this life in the complexity zone is another.

In the hand-out, there are more pieces in Don Detmer’s
material than were actually presented and I would encourage people to look at
them because I think they’re additive to that.

There also was a suggestion by Kelly Cronin that attention
needed to be paid to the requirements of decision support systems, and I think
that ties to the knowledge management and is an important piece of it, and it
was raised as an issue.

MS. McCALL: Pay attention to the — what was the specific word
you used?

MR. HUNGATE: Decision support systems.

MS. McCALL: Yes, but what about them, just kind of the content
of them or —

PARTICIPANT: The requirements.

MS. McCALL: The requirements, thank you.

MR. HUNGATE: The term “audit” came up periodically,
not in any clear way, but I think that when you start talking about knowledge,
the verifiability, the credibility, of knowledge and audit are interrelated
pieces, so it’s a concept that we probably need to have in there in some way.

DR. CARR: I think they used the word “integrity.

MR. HUNGATE: Integrity? Yes, integrity.

MS. McCALL: Okay, great. Other things, take-aways?

MR. SCANLON: I had one footnote to —

MS. McCALL: Sure.

MR. SCANLON: — the comment about the electronic health record
is a sufficient but it may be a necessary —

MR. HUNGATE: Necessary, but not sufficient.

MS. McCALL: Right.

MR. SCANLON: I think it’s necessary for, in some respects,
sort of achieving optimum quality or efficiently achieving quality, but at the
same time I would be concerned that we don’t think of it as the prerequisite;
we stop doing everything else until we get —

One of the issues that we did yesterday was: How do we
encourage the electronic health record? And one of the strategies that’s been
put forth is the idea of we just move forward on things like pay for
performance. It’s going to be a whole lot easier for people to comply if they
have them. And then that’s going to be one form of encouragement of the
electronic health record, so that’s —

MR. HUNGATE: I agree.

MR. SCANLON: — a footnote to that.

MS. GREENBERG: And that relates to my sort of mode epiphany
that —


MS. GREENBERG: — that if you want to try to do this some
other way, good luck!


MR. HUNGATE: Steve, you were discussing yesterday. Do you want
to add anything to those lists?

DR. JENCKS: [Off microphone.]

MR. HUNGATE: Okay. You’re going to lie in the weeds for a few
minutes? All right.

MS. GREENBERG: Shall we see if Susan —


MS. GREENBERG: — or anybody else who was here —

MR. HUNGATE: Dan, you want to make any comments? You didn’t
say anything yesterday.

MR. RODE: [Off microphone.]

MS. McCALL: Okay. Now, we may add to these, but these are
important, so we may change their locations so everybody can see them, but
they’re important in that we will use them.

MR. HUNGATE: Let’s let Dan put his two cents in —

MS. McCALL: Oh, I’m sorry.

MR. HUNGATE: — if he’s got something. He’s been a regular
attendee at these —

MR. RODE: Dan Rode, American Health Information Management

The issue of value came up yesterday, associated with quality,
and for many years we’ve equated, I think to some degree, quality and value in
that it has affected the way that we use our administrative data and
unfortunately has gone through some of the channels Marjorie’s talked about.

We need to, I think, as we look at the electronic health
record, as we look at any dataset, make sure that we have a consistency in
these datasets so that in the future, as data’s taken and then used to evaluate
for quality and other things that there’s no misnomer, because right now we
change the basic data in our systems to meet payment mechanisms.

And that thought came to me partly because in the next part
that she talked about yesterday was the use of value and how it relates to
policy decisions, how it relates to pay for performance.

But I think just that population piece, and what struck me
about New England was to recognize that if we have a chicken-and-egg situation,
if we can begin to collect some of this data and establish some metrics, then
we might be able to answer the question we’ve not been able to answer before,
and that is: What is the value of different care that we render on the
individual themselves? What’s the ROI for better data?

As went through the ICD-10 discussion, the question always
came back as: What’s the ROI to have

ICD-10 data instead of ICD-9 data? And we couldn’t answer
that; Rand couldn’t answer that.

New England started to be able to put some value in those
kinds of discussions, but it’s kind of a chicken-and-egg thing; you almost have
to have the data —

DR. CARR: Exactly.

MR. RODE: — in order to begin to discuss it. And then look at
Brent’s continuum yesterday, and as has been mentioned so often, make sure we
go at that continuum in the right direction.

And that was for me a great take-away because it really gets
down to the discussion not only of can we go from $5.00 to 10 cents on the
administrative side, which is something I’ve been working with for too many
years, but can we take the data and actually equate it to better care for the
individuals that are receiving the care which I think we all believe in turn
will also lower the cost of health care.

You have an interesting role as a Committee, and you didn’t
talk about it yesterday, but you sure talked around it. One role is education.
I don’t think, as I’ve gone through various meetings of various groups, outside
of the IOM, I don’t think anyone’s talked about how do we educate the
population to these needs and the values that we’ve heard?

I can’t clone New England; I don’t know why but it’s
uncloneable, I’m told. But how do we translate those experiences to something
that becomes of value to other communities, that they can begin to see that?
And I think that’s a role the Committee can serve.

The other thing that we didn’t discuss yesterday that I’m
beginning to view is we’re going to have some challenges in the metrics,
competing metrics, and at some point the Secretary is going to need some

And whether it’s in this Committee or one of the other
committees associated with NCVHS, you’re the advisory body, and I think you’re
going to have to keep a pulse on these metrics and maybe play the role that
Brent’s playing, or maybe Carolyn plays the role that Brent’s playing, to say:
Is it time to review this metric, and do we change it?

And if you can to get to Marjorie’s point on the data itself,
we’re very involved in putting together the standardized electronic health

But I think of the standardized record as a record of data and
data elements; I don’t think of it as a record trying to collect quality
information. I think it’s collecting the data that someone will turn into
quality information, but it’s key to have an independent body like this and the
IOM talk about should be in that record. That’s an arm-wrestling that’s going
on right now in HL7 and one that, you know, as we come out with these
standards, is not going to be conclusive. We’re going to add to this record
over time, so that becomes an issue.

And of course I have to say any promotion of data like ICD-10,
functional status and the rest certainly wouldn’t help us because I agree with
Marjorie — it’s going to be a while before we see a standardized electronic
health record in enough facilities around the country to give us that kind of
information, and hopefully communities like New England will push their end.
We’re looking at a national database.

We need to do that, and I think a move to 10 would start the
structure, that it’s the experience that you can then apply to metrics, too.
Right now, we’re applying metrics to a very old and very limited database and
we’d need to expand that database, and if we started today, we still wouldn’t
even begin to collect that data till about the late part of 2008, so how long
do you want to wait?

MR. HUNGATE: Very good — thank you.

The footnote I might like to put on that is that the issue of
competing metrics makes me think of chaos theory and complex adaptive systems
and the core that, you know, that is kind of what’s happening, it seems to me.

MS. GREENBERG: If I could just say —

MR. HUNGATE: Margaret?

MS. GREENBERG: — something on this classification. Obviously,
one of my deep interests and responsibilities is — we talked about outcomes,
and the ultimate outcome obviously is mortality. We’d like to have more
intermediate outcomes because there’s no way ultimately to avoid the latter.

I once heard an expert on – Joanne – what’s her name from
Georgetown — say that our goal for ourselves and everyone we love is that no
one will care what we died from because, you know, it’ll just be the end of our
life at a reasonable time.

But in any event, right now when our mortality data is based
on a different classification than our morbidity data, we can’t even do that
continuum of outcomes in an effective way, which somehow doesn’t seem to
resonate with people as an argument but it certainly does with me coming from
the National Center for Health Statistics, because before we die, we’re usually

But in any event — but not always — the other thing that was
striking was that John said, “I’ve got lab data and I’ve got functional
status data. I don’t have vital signs unless we’re, you know, actually for
those people that we’re actively monitoring.”

That in a way kind of, I thought, complemented what we had
heard about the difficulty of really trying to build measures around vital

So when I probed him about the functional status data, he
would seem to be collecting a lot of the right things. But then when I said, is
it standardized, or are you coding it or is this all pretext? He said, oh,
yeah, we have a way that we’re coding it but it’s completely, you

know, our own thing that we’ve come up with, which is going to
happen more and more, which is why I think we not only have to advance the
collection of functional status data because it’s so critical to patients and
as outcomes measure short of death, but also we need to advance a standardized
way to gather this information. Everybody’s going to have it, but we’re not
going to be able to use it in performance measurement because everyone will
have captured it differently.

MR. HUNGATE: Okay. Stan, did you have a quick one? We’re going
to move along.

MR. ETTINGER: I just wanted to mention maybe one of the other
issues is what is performance? We’re paying for it, but what is it? There are
various measures of performance.

For example, maybe it was discussed before, but the so-called
“certification program” in CMS, 266 as you pay, because I’m going to
need certain standards. You have outcome measures, you have mortality measures,
but how do they relate to each other and exactly what constitutes good

I think in general we all know something better; we pay more
for it, or don’t pay for it.

And actually one of my colleagues actually once brought this
up. He was looking at the certification data, and he says to me, you know — he
was looking at it; he was sort of surprised it was very difficult to draw
conclusions of how various facilities compare from the way the statements —
they’re a lot of regulatory language but it doesn’t really tell you what’s
wrong in a facility or what’s right in a facility.

MR. HUNGATE: Okay. Very good.

Thank you, Carol. That looks like that’ll challenge our minds
for a little while this afternoon.

The next phase is to broaden our horizons once again. As I’ve
looked at when NCVHS is effective in its work, the most effective work comes
when the activities here at the Committee are aligned well with work going on
within the Department someplace that makes what we do synergistic with what
they’re trying to get done and makes an amplification occur.

So that’s what we’d like to get developed in this next section
so that we understand better where we fit and what others are doing and how
that goes.

So with that, Carolyn, it’s your turn. Feel free to comment on
all of this and –

Agenda Item: Perspectives on Prior Day’s
Subject Matter — Interactive Discussion – Carolyn Clancy

MS. CLANCY: Yes. Well, first of all, thank you for inviting me
to be here. Boy, you’ve surfaced a whole lot of really, really important

I think the good news right now is that there’s a lot of
activity and certainly a strong interest in quality measurement at the moment.

And there’s even a little bit of alignment, which seems almost
breathtaking. You know the hospitals and a variety of folks have come together
and agreed on some measures. A similar sort of activity is taking place in
ambulatory care and so forth.

But the landscape is incredibly cluttered, to put it mildly,
and there are days when it’s a little bit difficult to see where this is all

The question that came up from me yesterday was: Well, gee,
should we just continue to add more and more of these disease measures or
condition measures or population measures, a specific focus, or should we be
moving more in the direction of Baldridge?

I don’t know the answer to that question. I mean, my answer
was something along the lines of Baldridge to me seems to apply more to fairly
tightly organized systems, which seems to me to be a relatively small subset of
health care delivery.

But that begs a larger question about why we couldn’t be
thinking about that on how do you apply Baldridge-like criteria to more just
first actors because my guess is, in most communities, even if there are no
financial or formal arrangements between actors and sectors, you could
probably, with some kind of data analysis or maybe John Halamka could help out
here or one of the other community RHIOs, you could probably draw some pretty
clear lines in terms of pathways that people traverse for most of health care
and so forth.

Just thinking about I’m really, really thrilled that you spent
a lot of time on the intersection between health information technology and
quality. I think there’s a lot of myths out there right now as in we dump
computers in everybody’s offices and suddenly we get to the promised land. I
think John clearly, from the notes that Anna took and shared with me, and from
your discussions, kind of made it clear that we have a long way to go.

Very interestingly, Beth McGlynn recently tried to take the
study they had published in the New England Journal a couple of years
ago and apply it at the VA. VA’s got an electronic record; they’ve achieved
some breathtaking performance goals and so forth.

In order for her to apply her metrics, they had to print out.
So, you know, the mental image here, visual image, here is carts with tons of
paper being printed out because their system is not configured to do that.

MS. McCALL: Right. Yes. One other thing on that is that the
other data that Beth has been working with is Humana’s. And I have
responsibility for that.

So what’s fascinating is a comparison that we’ve looked at
between what she was able to do at the VA and what she was able to do with
administrative data. And right now she’s not able to do a lot more with the VA
than she’s able to do with administrative data.

So I understand, you know, it’s like the red-headed stepchild.
But there is something that it’s going to be used for, you know, and so I think
we need to pay very careful attention to what’s being done, note what the
limitations are and things like that.

So I think your comment about what we’re able to do with the
VA’s data, it’s not going to be magic; there’s work to be done.

MS. CLANCY: I would agree.

I guess two other points I’d make on that front. From talking
to a lot of physicians in organizations, I think one little secret that no one
wants to talk about very much is that safety and quality are not primary
drivers of a reason to invest in information technology. I mean, everyone says,
oh, yeah, yeah, quality and safety, we’re there now. But there’s a whole array
of reasons, some of which relate to up-coding and getting better value from one
perspective, I guess, being able to get better reimbursement and so on and so
forth, which I think trump everything about quality and safety because right
now we don’t have a market that really demands it.

So I think, Carol, I think it was your point about staying
connected to pay for performance.

MS. McCALL: Yes.

MS. CLANCY: Now, that actually leads to a very interesting
conundrum. You can do all kinds of things with payment systems. They can’t all
be efficient.

And the level of specificity that is being developed now in
quality metrics and our current payment systems — I’m trying not to look too
hard at Steve —


MS. CLANCY: — I mean, trying to imagine administering that in
a fee for service way becomes a little bit daunting.

So, where’s that lead us to? I think that leads us to an
opportunity and great need to learn much more about predictive power.

You know, every year in open season I get phone calls about
“I need a new doctor” or, you know, “My doctor isn’t taking
people,” or “We moved,” or, you know, “I’ve had some family
change,” and so on and so forth. What one or two things could I look for
in a doctor? Should I ask if they have an electronic health record? Should I
ask if they do this or that?

And the short answer to that question is: I have no idea. I
mean, usually I say, “Oh, I’ll call my colleagues at GW,” and that
kind of gets me off the hook for the moment. Or if I know someone that I trust,
based not on any of the kind of empirical information that we’re talking about
in terms of quality measurement.

And I think we need to learn a great deal more about if a
system practice physician, other health professional, does well in areas A, B
and C, is that a reasonable expectation that they’re going to do well in other
areas? Or to put it more in policy terms, MedPAC has recently recommended that
CMS increase reimbursement for “quality enhancing activities.”

Now, they came out with some examples. How to do that without
breaking the bank, I have absolutely no idea.

In theory, a practice that’s set up to be able to assess their
patients as a group in some fashion, you would expect is learning something and
you would also expect that they’re doing something with what they learned.

But we don’t have a very robust evidence base to demonstrate
that at all, which I think is a big challenge.

A couple of other areas where I think we need clarity, and I
think I want to underscore Dan’s comment about the great opportunity for this
Committee as an educator, because you haven’t lived till you’ve actually talked
to reporters or gone on talk shows. And we recently released some state reports
on quality this year from our quality report which was quite educational for

What do we exactly mean by “benchmarking” and what
are people doing with the information? Everybody’s benchmarking — NCHS has
data for benchmarking, we have benchmarking. I don’t even think we look at it
very much.

I mean, we look at our data and we worry about that. What we
don’t look at is how people are using that, what does it mean to them. Is it
just a reassurance value that they’re not worse than the bottom, or what? I
absolutely have no idea.

There have been some very clever tools developed, one being
the achievable benchmarks of care that I think that quality improvement
organizations use a lot which give you some sense in a local or a regional area
what’s best in class and where you are compared with that best in class locally
so you’re not telling people you’re down here; you ought to be up here — good

You know, you’re essentially saying to people: Your
performance is here and there are people in your area with practices that look
like yours that are up here; that ought to be achievable. But I don’t think
most people grasp that or how to implement it in a very clear fashion at all.

In safety in particular there’s been a lot of discussion about
learning from other industries.

And the one experience that I’m kind of struck that we’re not
learning from is education. The other day, a front page story in The Times
claimed that because of systematic reports on school systems and so forth,
now some communities are really being driven to do something about schools that
enroll a disproportionate number of minorities.

Now, I don’t actually know if this is true, but if it’s true,
it’s incredibly important.

The same issues around the psychology of measurement I think
are quite relevant to those providing health care and those teaching, and if
you haven’t spoken to a teacher lately, I can tell you they hate it as much as
doctors. Somehow, they don’t get to make as much noise, but they don’t like it
at all.

And the other area that I have no idea how to assess, but I
know it’s incredibly important to doctors, is: How do we incorporate when docs,
or health care systems for that matter, do exceptionally well with incredibly
unusual patients? Because at the end of the day, I think a lot of us want to
know that.

I mean, Dan Streyer, who just passed away a couple of weeks
ago who had been directed our Quality Center, was initially told by a physician
at Hopkins that he was inoperable. It was probably a very rational decision. He
went to a surgeon at Duke, and when I asked someone at Duke about it, he said
“this guy’s great. You would never, ever want him working for you if you
were running that health care system, but if you had an exceptionally unusual
disease, you would want him to operate on you.” And I thought, whew, good
to hear it; this is just who he needs.

But doctors feel like they don’t get credit when they take
care of very difficult patients or solve problems that were not anticipated and
so forth. I think that links back to the concept of being able to predict
performance or predict how a system or practitioner will do when faced with
exceptional challenges.

And we’re not looking at any of that right now. And that’s

MS. McCALL: The other thing that that brings to mind, Carolyn,
is that if we don’t allow for that, how can we honor innovation?

MS. CLANCY: Right.

MS. McCALL: Okay? And that our measurement systems could
literally drive it out of the systems. Okay, people that want to break tail
with whatever is, you know, acceptable practice.

DR. CARR: And we have examples, at least in cardiac surgery,
of people modifying the population on whom they operate based on publicly
released outcomes data.

DR. STEINWACHS: Everyone has to give their spin on this, I can

I remember once being an ROTC candidate and having a sergeant
who I decided if I had to go into battle, I’d want to be with him, but I
wouldn’t want to live next door to him because he had to always pack a gun with
him wherever he went.


And so it sort of, you know, made me think about, when you
saying this, you know, sort of you have a military that’s there in this country
to take on extraordinary kinds of situations, as different from, you know, say,
the police force and other things. And it just made me think a little bit
about: Do you deal with sort of the average and extraordinary all the time by
the same people in the same system?

And you sort of said it when you said “this is not the
person you’d want to have as your employee” sort of statement; at the same
time, it is the person, if you are a patient, in an extraordinary category.

Sort of interesting to think about how do you manage those
kind of things within —

MS. CLANCY: No, I agree. And, I mean, I’m all too familiar
that docs often use this as a shield. “Well, you know, I have sicker
patients.” And we say, “No, no, no, we can risk adjust for
that,” and so on and so forth.

But, you know, the truth is that any system that promotes
quality has to allow that flexibility.

But that brings us back to, I think, a very important
political dilemma, which is we talk about assessing and improving quality of
care from several perspectives all at once all the time. One is learning,
another is a sort of business, market-oriented approach. A third is a sort of
regulatory approach. And they’re incredibly different.

And the implications for how we think about quality
measurement I think are very important there. This point was really underscored
for me recently. Pennsylvania has a new Patient Safety Authority I think is the
word, and they’ve got a place where you can anonymously report near misses.

So they came down to meet with us, and they have big needs for
benchmarking because, you know, all this data are flowing in and they don’t
exactly know is this too much, too little, and so forth, and we were
strategizing about that, and it’s going to be very, very important to the
agency if this patient safety legislation passes this year. It would be good.

But what really struck me was how clearly and how much energy
they’re putting into distinguishing themselves from the Health Department,
which is perceived as regulatory. They’re learning — those guys regulate.

And I thought, well, you know, as you’re trying to launch
something, this probably makes a lot of sense. On the other hand, this can’t be
all that sustainable, I don’t think — but I don’t know about that, either.

A couple of areas for opportunities I think you might want to

One is there’s an awful lot of large, organized systems, or it
feels like it, anyway, that are now installing the EPIC system. I’ve been
impressed visiting Geisinger that they have actually a couple of former Hopkins
folks who work quite closely with the folks from EPIC to try to customize it
for their needs, their population, and also for research.

So I think ultimately we have to move beyond an information
infrastructure and talk about a knowledge infrastructure. We assume that
they’re equivalents, and I don’t think they’re equivalents at all.

If you are, you know, ultimately with a set of metrics, you’d
like to think that a system that sees a fairly select population is focusing on
the issues of greatest interest and importance to their population. We’re not
anywhere near there. And at the same time, those same systems have the
capacity, or at least in theory have the capacity, to be a very important
source of new knowledge.

Now, the good news is that the HMO Research Network actually
has one of the contracts under the NIH Roadmap for reengineering clinical
research. So they’re starting to focus on how much does an electronic health
record overlap with an electronic research record and so forth. But I think
there’s a lot that can be learned right there.

I think there’s a lot that we could learn outside the state of
New York in terms of public reporting, although I have not seen very much in
terms of what happens in cardiac reporting or anything else in Pennsylvania,
Florida or a few other states that have gotten into that. That may just be
because AHRQ didn’t have a bigger budget.

But I think it would be really important to understand both in
a rigorous empirical sense but also at the level of policy-makers — do they
think this is worth it? — because the question that Dan proposed, what’s the
ROI for more data, is both a political question as well as an empirical one,
and if we forget that, we’re not going to make a whole lot of progress.

And then the last area I’ll just mention, and Steve may want
to add to this later.

You know, recently, there’s been an alliance put together
around ambulatory care measurement and there’s a starter set of 26 measures,
and I see this as very much getting a toehold, a little bit of traction, and
it’s been a very, very interesting process.

But they’re mostly primary care-like measures, in part because
most of the measures we have derive from the ability to compare some sort of
organizational level and don’t necessarily get to any of the important stuff
because the sample sizes are too small in some of the plans that are being
accredited and so forth.

But the specialists are now chomping at the bit to be part of
this. How do they get to be part of the alliance? How can they develop
measures? And so forth. There’s obviously a huge spectrum of capacity and
capability, but again, underscoring the educational possibilities here, I think
that that might be something you’d want to keep your eye on.

MR. HUNGATE: Is there a reliable set of definitions of what’s
a good measure? You know, these people they keep getting developed, is it just
that there is agreement or, you know, Brent’s spectrum of accountability to
learning? Is there some way of ranking things on the accountability side or the
learning side? Just a question of information.

MS. CLANCY: There are certainly specifications around what
makes a good measure.

For example, we have a quality measure clearinghouse and a
technical expert panel which has been very, very helpful in developing criteria
for that, and some have suggested that the Quality Forum should use those
criteria for all those measures.

I think we would be foolish not to acknowledge that of most of
the measures that are currently in use, feasibility probably outweighs
everything — is there a data source, can we get it? And so on and so forth.

That’s practical. I understand all that.


MS. CLANCY: But I think that has very much suppressed the
level of thinking that Brent is talking about. But I think what he is
describing is incredibly important.

MR. HUNGATE: Thank you.

DR. CARR: Yes, I was impressed also with what he said because
we have criteria for measures — what’s available, you know, what’s big enough,
important? But what we do with it and how we understand it — and his example
of the C-section rate high in the community of midwives was a very good one
because I think we get to that level; we have all this data, and then we have
an outlier, and we don’t have a robust process of understanding or drilling
down or sharing what we learned and modifying.

Don Detmer brought up the NNE group and how they take their
data and look at it and what seemed like an important thing sometimes gets
thrown out, what seemed like an unimportant thing suddenly becomes a major
metric. And that is the knowledge, the education and the ROI, because just
having these dashboards with a little bit up or a little bit down, or even, as
Carol said yesterday, you may be inside two standard deviations and still have
a problem.

The other thing that came up, too, yesterday was you have the
data elements, and what you package for a regulator versus a health care
quality department versus HealthGrades.com are very different, and the
audiences are different, the questions are different.

And, you know, we gave the example, a true example, you know,
the difference between a 95 percent performance and 100 percent performance, is
it three stars versus two stars? So what is a patient thinking — that, oh, I
don’t want the second best when in fact 95 percent probably is 100 percent, you
know, when you actually drill down.

So I think we haven’t articulated what’s the question this
person is asking, and now are we answering it with information relevant to
their question?

And the other thing that we heard, too, yesterday was about
all the focus on looking at doctors’ performance without acknowledging the fact
that this system is a key driver in how those outcomes look.

And I’m intrigued by your idea, you know, the Baldridge idea.
I think one comes away with a sense that quality has been truly vetted if
you’ve gone through the Baldridge process. And I don’t think one comes away
with that if there’s a high score, a little bit higher score, on this or that.
It’s sometimes hard to trace back, you know, are we good? Why are we good? How
do we know we’re good? You know, what good outcome accrued because we had a
higher score?

MS. CLANCY: Well, you know, there’s a paper that will be
published soon in the American Journal of Medical Quality which
compares how hospitals did on JCAHO accreditation. You may not want to bring
this up with Jerod; it’s still sensitive with him, with RX patient safety
indicators. And by the way, I need to say we don’t actually endorse any of the
health grades analyses using these indicators even though they’re very quick to

DR. CARR: Right.

MS. CLANCY: — always say these are ours.


MS. CLANCY: And there’s very little correlation.

Now, I don’t think that’s a surprise. I’m not actually sure
that finding is necessarily publishable, although some of these are colleagues,
or former colleagues, of us at AHRQ.

But I have to say, in thinking about the counter argument, I
don’t have a lot to rely on, right? In theory, an accreditor goes in and what
they’re looking for is predictive capacity, what do I see now that will give me
some sense of how care will continue to be delivered?

Now, clearly I think the fact that JCAHO is moving to
unannounced inspections is a really very, very important move. My brother asked
my sister-in-law once, “So what does it mean when the Joint Commission is
coming for inspection?” She paused and said, “They have to put the
hand lotion away.”


MS. CLANCY: Which is kind of, I think, how most people have
thought about it.


MS. CLANCY: But with unannounced inspections, I think that
really ups the ante. But that’s totally different than the kind of rear view
mirror approach that you take with performance measurement which assumes that
there’s a correlation between what’s going to happen next week, which is what
we’re really interested in, or next year, and what happened previously.

DR. STEINWACHS: Just to pick up on part of this. You know,
measurements, a lot of them fit very nicely into sort of a production kind of
model that says “health care’s an industry and being trained in
engineering, it’s very nice,” but production processes also have
predictability, which is part of what you’re talking about here, which
sometimes strikes me as part of the disconnect between those of us who are
interested in sort of building both the quality monitoring and hopefully the
learning and feedback and those who approach it from a clinical point of view.
As we measure those intermediate and longer term things, I don’t think they
come very close to how clinicians generally say, “Well, how do I feel
about the quality of what I’m doing?”

And I just wondered if you had any comments about are there
ways in which we could be tapping in to aspects that clinicians would feel come
closer, saying, “Yes, this is the way I’m looking at what I’m doing,”
and the way in which if you tell me that, you know, it’s different may mean
something more personal to me than what becomes sort of these things that are
part of that production process, which is also important.

MS. CLANCY: I think it’s a very important area to explore.
Having said that, there’s sort of a chicken-and-egg feature here. I think most
clinicians do their best for each patient one at a time and they move on, and
the vast majority have no capacity whatsoever to look at how they’ve done for
the last 10 patients. There’s not much of a cultural tradition of peer review.

I used to review for the QIO in Virginia before I came to
Washington and it’s kind of breathtaking in lots of ways. I thought this was an
area where I could do research. I actually didn’t understand a lot of issues
around protections for providers in terms of making the data usable, but —


MS. CLANCY: — I thought that I was always waffling, and it
turned out I was like the toughest reviewer they had, which told me they were
doing nothing at the time — this is before Steve actually totally revamped the


MS. CLANCY: I mean, late ’80s, early days of the QIOs. Then
the PROs. That mindset, I think, is hugely important, to shift from saying not
just how did I do on this patient but I need to take a new view of the
population of patients I see because absent that, most people think that
they’re doing much, much better than they are, with no miss in prevention for
20-odd years. You know, docs think it’s important they get the right answers on
the test. If you ask them, which test should you be getting for which patients,
and do you think you’re doing it? Yes. And then you look at what they’re doing
and there’s a huge gap.

Arnie Millstein calls this an optimism bias. I don’t have a
better term for it.

MS. CLANCY: But, you know, we were talking about this last
night as well, and you sort of evolved from our discussion about would you
collect vital signs. So if you collect a blood pressure and it’s 139/89, you
pass, and if it’s 141/90, you fail. And I think that kind of uni-dimensional
assessment is distasteful to physicians.

So as we’re thinking about the electronic health record, you
might be able to say: “Is your patient normotensive?” And the
physician might have — you know, using John’s model — their home blood
pressure measurements and the multiple ones in the office and might be able to
say, “Patient is normotensive.” Or they might be able to say,
“Patient is borderline hypertensive and I’m watching,” you know, or
“Patient is hypertensive; I haven’t done anything.”

But looking back then, it affords an opportunity to look at
the gray zone. So just like NNE where half the people gave aspirin on the day
of surgery and half the people didn’t, and they could say, “I was doing my
best,” but someone could go back and say, “Okay, we’ve aggregated
everybody’s best and here’s what we’ve learned: You should give the

And, you know, I think to just take a number, it eclipses the
whole judgment factor of here’s my patient who is at risk for all these
side-effects of anti-hypertensives and here was what I’m doing, so make me
believe that these borderline patients belong. Not to perseverate, but I think
the piece is engaging and aligning the physician in issues that they are
invested in, so the borderline patient, you know, they retake the pressure and
they can make it normal — okay, fine, I passed — but if we really engage
around what do you do with that borderline patient, let’s get an aggregate
experience, it would feel more value added to the physician and more engaging.

MS. McCALL: You had some fascinating sort of comments about
different models — a learning model, kind of a market- or a business-oriented
model, and then a regulatory model and that those paradigms, they will bring
with them, whether you know it or not, a whole kind of different set of

So can you talk a little bit more about that, some of those
tradeoffs, which ones you think kind of work well together, which ones you
think don’t mix well, and how you think that we could approach it?

MS. CLANCY: I guess I’m having the brief thought that it’s
easier to introduce a topic than to —


MS. CLANCY: — digress quite knowledgeably.

I think I was servicing it as an issue that needs more
exploration. My greatest fear with the quasi-regulatory model — and by that I
would mean both stuff that’s required or publicly reported or that is in some
way linked to payment — is that at the end of the day we’ll get better coding.

And, you know, we actually have an industry that’s prepared to
do that, and miss a huge opportunity to bring along practitioners who are still
living in a one-at-a-time world.

MS. McCALL: Yes.

DR. CARR: And that, I think, would be a big miss.

Now, having said that, to the best of my knowledge, one huge
weak link of electronic health records currently is the registry function. I
mean, in theory you ought to be able to sort of, as Beth McGlynn often says,
hit F7 and, you know, pull up the registry of folks with diabetes or whatever.


MS. CLANCY: And I think there’s like a huge opportunity to
engage docs in focusing on what they consider the most important, which doesn’t
overlap very much with what would be publicly reported. You know, public
reporting, right at the moment we tend to focus condition by condition. I think
a lot of docs would be really engaged by saying, “Okay, where are we
really screwing up for people with diabetes?” You know? It’s the
intersection of diabetes/hypertension control and a couple of other things.

That, I think, would be far more engaging because at the end
of the day I think you can sell practitioners and persuade them that there’s a
lot of routinized stuff that’s not happening and life would be much, much
easier if we just had a system for it rather than always running around after a
piece of paper or trying to remember whose job it is to do what.

But the judgment part and the part of how do we make sure that
the people most in need of our services are routinely getting what they need, I
think you actually need some of the best minds that you can get.

MS. McCALL: I guess when you laid this out, the thought that
came to mind is: Are there couplings or pairings of these things that work well

And the reason — you made a comment there’s not a culture of
peer review, which really struck me. And I thought, okay, if we’re going to go
kind of down the learning paradigm or maybe the learning paradigm coupled with
a market model, and then somehow watch-dogged by regulatory just kind of out on
the side.

The learning model requires a different culture. It is a
shift. So if there’s not one there today, do you think that it’s going to be
easy or hard to kind of bring in, usher into being? Do you think that it’s not
there because there’s nothing to look at and so they’ve learned not to ask for
anything or do you think that even if we had F7, hit a button, let me show you
that they kind of go “no, no, no, no, no?”

MS. CLANCY: Well, in my experience as an educator, I once
tried to persuade some residents to peer review for each other.

Now, how this worked was we provided care in a clinic of
patients, about two-thirds of whom lived in the city of Richmond and another
third came from outlying areas where their capacity to show up for an
appointment was critically dependent on getting a ride. So to say that there
were gaps in continuity here would be an understatement.

So we always had to have one or two residents in any
particular session being the, you know, urgent care doc for people who needed
to be seen but they didn’t have their appointment that day and all that kind of

I thought this provided a great opportunity for them to kind
of give each other feedback. I clearly needed to know more about how to present
this —


MS. CLANCY: — with the primary care residents, you know, with
whom we have a very close working relationship and so forth. And let me just
say the consistent universal response was, “We’re not going there.”

And I thought, wow, this is really incredible because for a
couple of research projects when I had looked at a pile of charts over, say, a
month, looking at variations in test ordering and things like that, I came away
with some fairly stunning conclusions. You know, one was that we needed to
educate the interns a lot better and so on and so forth and the other one being
that senior residents would ignore anything.


MS. CLANCY: (?) of two? Not a problem. Just keep moving.

But they absolutely would not go there.

Now, some of it is probably that that’s not been part of their
training, and I could imagine building that in at the undergraduate level that
this is kind of a routine part of business. I think the potential points of
alignment there are slowly I think the CME enterprise is starting to realize
that it’s really important to link more directly with performance improvement
rather than just sort of stuffing people with knowledge and assuming that that
translates as improved performance and that medical specialty boards are now
trying to do this through maintenance of certification.

And if you think about it, the idea that a physician is
involved or engaged in some fashion in quality improvement, that that should
count for other purposes, is a very powerful idea. The extent to which that can
be exploited I think remains to be seen.

MS. McCALL: Right, yes. One thing that — I don’t know if it’s
something that we would have an opportunity to do as a group, but somebody to
bring in to a meeting sometime is John Seely Brown and talk about — there’s a
book called The Social Life of Information , which is just an
exquisite piece of work, and to really talk about some of the paradigms of what
it means, whether as communities of practice, but to really make some of this
information have a social life — you know, kind of get out, throw a party a
little bit, that —


DR. STEINWACHS: Does this go with the martinis, or not?

MS. CLANCY: It does — always. But it really is about CME
enterprises, undergraduate, you know, education; it’s about, you know, some of
the medical specialty boards, that to make it live, it needs to know where to
go to live.

And so I think it’s having a list of things, and you’d said
earlier, our opportunity as an educator. Well, we may not educate, but we may
go talk with people who are in that business or could be in that business to
pull this through. That could be some ways to kind of leverage a learning
approach and then maybe link to a business- or market-driven approach.

MR. ETTINGER: I was just going to mention that actually when I
was in New York, somebody had a very good educational intervention.

MS. McCALL: Well, you had better talk into the mike.

MR. ETTINGER: When I was in New York at one of the hospitals,
one of the other hospitals, the lab director and the head of internal medicine
had a very good intervention for the residents and interns ordering testing at
all hours in the night. They changed their policy so if they ordered anything,
they must call both of them, no matter what time of the day or not, if it
wasn’t on the list, at home, and ask them for permission to order it. Test
ordering went way down.

DR. STEINWACHS: Let’s hope it was good for the patients.

MR. ETTINGER: Usually it was.

DR. JENCKS: Let me just add one thing about the educational

The enormous force which is coming into play in education is
recertification, and it isn’t at all clear what that’s going to mean, but it
has just changed the landscape of CME.

And it reveals very interesting things sometimes. For example,
in 2006, the ABIM will require for recertification that its diplomates present
evidence that they are using data from their practice to improve the care that
they deliver.

MS. CLANCY: Yes, that’s what I’m talking about — they’re
calling it maintenance of certification. Now that’s the direction they’re
moving in.

DR. JENCKS: Now. What’s interesting here is that this is not a
requirement for initial certification. And according to the people at ABIM, and
I can’t think of anybody who’d be more likely to know, the reason is that the
teaching settings don’t have the infrastructure to support it.

So if we want to understand why people are coming out of
training with not quite the habits that we were hoping for —

DR. STEINWACHS: Let me come back to the peer review because
I’ve for a period of time tried to use that concept, at least my thinking, in a
positive way, and, you know, we always characterize professions as using peer
review as their fundamental mechanism for quality, but, you know, it reminds me
that peer review generally is viewed as a process of sorting out that which
will be funded, that won’t, that’ll be published, that won’t, that which will
be punished, and then won’t.

And so peer review, even though, you know, a lot of us like to
think of it as a positive sort of supportive learning, is really in many
people’s minds pretty punitive as a process. And so you made me think about it
again. Is there another way to talk about this collegial evaluation and
feedback that doesn’t quite conjure up what many times peer review I think does
within professions, that it’s the police force? It’s our version of regulation
in a sense or the sorting out of the marketplace.

MS. CLANCY: Yes, I mean, when you said that, what came to mind
was the vision of morbidity and mortality conferences, which I’m told that at a
lot of institutions are not being done anymore. Not only can you not share the
information or discussion beyond the walls of your institution but some are so
paranoid about potentially discoverable issues that they simply don’t have them

But I do remember that as being very confrontational. I mean,
boy, did you learn. And sometimes we made great jokes about it — but later,
many years later.


MS. CLANCY: It strikes me that if this patient safety
legislation passes that that’s going to create a huge opportunity to kind of
turn that around, because the irony is —

I think one of the reasons the peer reviewers stay on our
study sessions — it’s a boatload of work, and we certainly aren’t paying
people very much; we’re not even paying them much for the day they spend there,
much less all the hours they put into reviewing grants — is that they do get a
chance to learn and it’s a great time to hear new ideas and new ways of doing

I think there’s a little bit of this going on in the U.K. and
Ireland and possibly other countries. This is really in some way the Royal
College’s efforts to reduce the isolation of people practicing alone in pretty
rural areas. It’ll be interesting to figure out if they’ve learned how to move
beyond that.

MR. HUNGATE: Very good. Other questions, comment?

I’d like to welcome Dr. Jerod Loeb —

DR. LOEB: Thank you, Bob.

MR. HUNGATE: — to our discussion. Glad to have you. I think
we’ll charge right in to your —

MS. McCALL: Actually, we were scheduled for a break. Do you
want to do that now, before —

MR. HUNGATE: Well, that’s what I was debating. Everybody want
to take a break now?


MR. HUNGATE: All right, let’s take a break now. Come back at
10. Good, okay.

[Break from 9:48 a.m. to 10:00 a.m.]

MR. HUNGATE: The deliberative process continues.

MS. GREENBERG: Oh, great! Somebody already typed these up?

MR. HUNGATE: So, Carol has worked with Susan to get a printed
copy of what’s on the wall so that you now — and Carol, why don’t you go ahead
and describe it.

MS. McCALL: So, first, thank you very much, Susan, for typing
up what’s on the flip charts.

You should have in front of you — this is essentially a
stapled two-page document. These are the notes as written from the flip charts.

Just a little note about process, and then we’ll kind of get
to Mr. Jerod.

What we’ll be doing with this sheet are a couple of things.
After we’ve had an opportunity — we’ve heard from Carolyn, we’ll hear from
Jerod — what we will be doing is adding to this sheet any observations that
you would normally have added had we heard — you know, everybody yesterday.

And at that point, and you can add them directly to the sheet,
we will be going through a process whereby we essentially, using some different
techniques, are going to identify and pick those things that we believe are the
highest priorities. It’s a technique called a “nominal group

You’ll be given a certain number of votes for those things
that you believe are the most valuable.

There are some things in here, obviously, that won’t be
picked. That’s the essence of NGT. And yet some that are not picked, they will
in fact be kind of related to those that were, so they may be subsets, and
we’ll identify those that are kind of natural hangers-on from other ones.

At that point, it becomes the basis for the beginning of what
will be a work plan. It won’t be the work plan, but it will be the ideas from
which a work plan flows. And time permitting, we may then say for those big,
kind of headline areas, we will try to give them some operational definitions,
and then to the extent that, again, time permitting, we can begin to lay out
what we believe the steps are to turn that into a more specific work plan.

So, keep that in mind as we go through, and it just kind of
lays out how we’ll be spending essentially our afternoon. So I wanted you to
know that you have those sheets and how we would be using them so that you can
begin to continue to think about that as we continue to hear from folks this

MS. GREENBERG: Now, it’s just the members who will be voting
or —

MS. McCALL: Yes.

MS. GREENBERG: You don’t want the speakers to — this is just
the members of the Workgroup?

MS. McCALL: Those people. It is decreed our work plan.


MR. HUNGATE: Yes, I think we’d like other people to be able to
comment, but it will speed the voting process if we narrow the number of actual
voters —

MS. McCALL: Yes.

MS. GREENBERG: The five of you.

MR. HUNGATE: — and that’ll be fine.

MS. GREENBERG: Anyone missing? Good.

MR. HUNGATE: Trying to think — are there any other little
issues that surface in that? Okay.

All right, moving forward, I want to welcome Dr. Loeb to our
discussion now. I have to precede that with two comments.

In my days in Washington, DC, working on health policy, I came
to get to know Dennis O’Leary reasonably well and ended up speaking to the
Board of Trustees at one time, which helped me understand the difference
between what the Joint Commission does and what I was trying to do and things
like that.

I also remember the book The Measurement Mandate put
out —

DR. LOEB: Oh, yes. It was our best seller —

MR. HUNGATE: Is it really, still?

DR. LOEB: — of all the books ever published by the Joint
Commission. Yes, indeed. We still sell that book.

MR. HUNGATE: And then there was a sequel to it or I don’t
remember whether it preceded or followed — Accountability in Health I
think was the other one.

DR. LOEB: It came later.

MR. HUNGATE: It came later.

And the other piece that I’d like to say is that in reading
all the testimony before the Quality Workgroup earlier, I was always impressed
by how the Measurement appeared in your testimony before the
Committee, so welcome, and we look forward to hearing about your observations.

Agenda Item: Perspectives on Prior Day’s
Subject Matter — Interactive Discussion – Dr. Jerod. Loeb

DR. LOEB: Measurement is my life, apparently.

Let me begin with two apologies. Apology number one is my
voice. I’ve been in about 25 different time zones in the last seven days. I was
in Italy, I was in Chicago, I was on the West Coast, I was in Denver yesterday,
so I caught a cold, too. I’m at the back end of it so I’m not contagious.
Still, my voice does have a bit of a strange sound, at least to my ear.

And secondly, in talking with Anna and Bob, I’ve done
something I traditionally don’t do for these remarks today, and that is I have
my computer with me but I have no slides. I’m doing this really as a sort of a
set of ruminations about performance measurement with the Joint Commission as a
vantage point. It’s almost like, what’s on our radar screen? And as I walked in
and looked at what’s on your flip chart, it looks like there’s a fair amount of
concordance in terms of what’s on our radar screen and what’s on yours.

So with that as a preamble, I’ve got about, oh, 10 or so
items, 10 to 12 items, that I’d like to at least tempt you with, and then
hopefully engage in some discussion as to what’s on the radar screen. And,
Steve, please jump in with this as well — I know you will.


DR. LOEB: I guess number one —

MR. HUNGATE: Everybody does know you, don’t they, Steve?

DR. LOEB: No, we know Steve very well.


DR. LOEB: He’s not saying anything!

The issue of who sets measurement priorities is an enormously
complicated issue, and how those priorities are set is an enormously
complicated issue.

At this point in time, as best I can tell, there are at least
about four or five, or perhaps more, players from a variety of vantage points,
all of whom believe that they’re in a position to set priorities.

The IOM has set measurement priorities.

The National Quality Forum has set measurement priorities.

The Joint Commission has set measurement priorities.

CMS has set measurement priorities.

Leapfrog has set them.

IHI in the context of its 100,000 Lives campaign, at least
indirectly, has set measurement priorities.

And the payers are setting measurement priorities.

And the question is: How do we get all of those various
priorities to align? And even if we can do so, how do we get congruence in
terms of the metrics?

Now, among the things that in my now 11 years at the Joint
Commission in the measurement world that I’m most proud of, and I have to walk
arm in arm with Steve on this, it’s the ability of the Joint Commission to
align its measures where we have common measures with CMS, and I think it’s in
large part because Steve has driven it at CMS and I’ve to a great extent driven
it at the Joint Commission, as has Dennis.

And from the field’s perspective, the ability to collect the
data once and meet multiple mandates —

regulatory on Steve’s side, and now payment as well with the
pay for performance piece, and accreditation on our side — has been enormously
helpful. And as I go out and about and talk about this, that is perhaps the
singular areas within the context of what the Joint Commission has done in the
measurement world in the last decade that we are getting enormously thanked

So I think that issue is a very important issue.

Right now, the measurement priorities are often set by who
yells loudest, by who lays money on the table — and this is the NQF process.
Because there’s no de minimus funding stream for the National Quality Forum,
NQF has to go where the money is.

And the question, of course, arises as to whether that’s an
appropriate way to be setting priorities. It’s the only way we play at this
point, but the question of its appropriateness is a good one.

And in the same context, as measurement moves outside the
hospital arena, we’re beginning to see analogs now of what has been formed in
the private sector on the hospital side in the name of the Hospital Quality
Alliance, organized originally by the American Hospital Association, the
Federation of American Hospitals, and the Council of Teaching Hospitals of the
AAMC, which is now posting data on the CMS website on Hospital Compare.

And we’re seeing an analog of that on the ambulatory side
called the Ambulatory Quality Alliance.

So now we have an HQA and an AQA. Now, that all sounds great
— as long as the measures are complementary; better yet, as long as the
measures are in fact identical, where you’re dealing with the same patient
moving into and out of different settings of care. The problem is, at least so
far, at least on the ambulatory side — this is a fledgling effort; it’s a
little bit more substantiated on the hospital side — I don’t see a lot of
congruence there.

And that worries me, because in the measurement world, clearly
the devil is in the details. And unless we can get congruence identity, if you
will, down at the level of individual data elements and inclusionary
characteristics and exclusionary characteristics and risk adjustment algorithms
and so on, it drives folks crazy.

And particularly as we begin to look at the continuum of care,
where I hope measurement will go ultimately as opposed to being in the various
silos that exist, we have got to create identity. So I think that is a very key
driver, from our perspective.

Next issue that really troubles me, and I spent a lot of
sleepless nights worrying about this one — it’s the issue of maintaining
measures and reconciling measures. As the evidence changes, it’s become clear
that there is a need to shepherd the measures through a process.

The problem is there is no standardized process by which to do
this. That’s a big problem.

We faced that problem in the last year and a half with respect
to the measures that looked at ACE inhibitor use in the acute MI set and
frankly in the heart failure set as well when the issues around the use of ACE
versus ARBs, angiotensin receptor blocking drugs, became paramount, and from
the hospital perspective we saw a diminution in hospital performance as it
relates to ACE use, which we became concerned about, but the hospitals in turn
explained to us, well, your measures didn’t keep up with the science. And our
cardiologists are practicing more contemporary medicine; we’re seeing a
drop-off in ACE use, we’re seeing an increase in ARB use, and you don’t have
any way to capture that. And that is a big issue.

Now, we at the Joint Commission and Steve and his folks at CMS
recognized it very early on and were engaged in discussion about how to fix
this. The problem that we faced, however, was that measures traditionally
follow guidelines, and the American Heart Association, the American College of
Cardiology were reticent to change the guidelines on the basis of what they
perceived to be a limited amount of clinical data, even though practice was
already changing.

So we then together, CMS and the Joint Commission, spoke with
an AHA, as in Heart Association, and ACC about the need to accelerate the
guideline process because we didn’t want to get out ahead of the guidelines.
And that really fell on deaf ears initially, and it was only when the National
Quality Forum, thanks to funding from Carolyn, got into the game and said
“you guys have to get your act together” that ultimately we were able
to accelerate the process of guideline change at AHA and ACC.

And all of this resulted in a summit meeting here in DC I
guess about 10 or so months ago now where CMS and the Joint Commission had
actually pre-arranged an agreement by which we would change the measures so as
to accommodate the changing clinical practice.

Now, that’s one example of a situation in which this timeline
between guidelines and metrics is a problem. The reconciliation of these
measures both within measure sets and across measure sets is an enormous issue
and it’s an issue that I can tell you for a fact is on the National Quality
Forum’s radar screen, but frankly — and I’ve had many discussions with Ken
about this at NQF — no one really knows how to handle it at this point. It’s a
black box and no one’s sure where the responsibility base lies.

The National Quality Forum has this exploding toolbox. It’s
getting bigger and bigger every day. But the measures in essence, while they’re
endorsed by NQF, are not NQF’s measures. They’re measures that belong to CMS,
to Joint Commission, and a variety of other entities.

And then the question of: How does NQF leverage these changes
that are necessary? And once the change has been made to a measure, the
question of whether it is a material change which requires NQF to go through
its Consensus Development Process all over again is a big problem. No one knows
what the definition of how changed a measure might be to require

I mean, you know, if you look, for example, at the measures in
the NQF toolbox now that pertain to acute MI heart failure and pneumonia, the
areas that we have in common with CMS, the measures that have been endorsed are
no longer the measures that are in use because those measures have been changed
over time in response to changing science.

Now, NQF has made a decision at this point that those changes
weren’t material, which may or may not be correct. But ultimately there needs
to be a process whereby the various silos of measures in the NQI toolbox are

I’ll give you one more example that I think really drives the
point home.

I was on the initial steering committee for the

Hospital Measure Set which resulted in 39 measures. In those
39 measures are two sets of cardiac measures, the acute MI and the heart

NQF empaneled another group, I guess it was about a year and a
half later, to come up with a set of CABG measures — coronary artery bypass
graft surgery

measures — and clearly the patient population is either close
or identical to the CABG measures as compared to the acute MI, certainly in the
acute MI, perhaps not as much in the heart failure set, but the data elements
are probably going to be the same. It turns out they’re defined differently.

So you sort of sit back and scratch your head and say, well,
what does the hospital do when it’s got a patient that potentially fits into a
denominator of population for the acute MI set and into a denominator
population for the CABG set but in fact they’re defined differently?

That’s a big problem, an enormous problem, and it’s a problem
that at least in my humble opinion at this point, I’m not sure that NQF knows
how to fix.

Now, we have proposed — we, the Joint Commission have
proposed to NQF that there needs to be a series of reconciliation activities
that take place again both across and within measure sets and they have to be
done to assuage

the political concerns at one level but you need the data
geeks like myself and others at another level who really need to be in the
trenches and understand the data elements and understand the way all of these
things are defined so that we can create a common dictionary and ultimately
allow the data to be collected once.

The problem, and certainly this is on your list, I think it’s
on everybody’s list, is in health care today we’ve got IT infrastructure over
here, for better or for worse, and we’ve got performance measurement over here,
and we haven’t connected the Ven Diagram. And it’s only when —

MS. McCALL: Could you do this?


MS. McCALL: Okay. We spent a lot of time —

DR. LOEB: I bet you did; everybody does.

It’s only when data collection becomes a byproduct of the care
delivery process that we really will have performance measurement at a point
that it can be used in all the contexts.

Next issue — again, these are airplane ruminations, I might
add — is the issue of labels. It’s funny, back home in Chicago I told Dennis
one of the things that has troubled me in the last couple of years, and the
analogy I made was to the world of pharmaceuticals, is off- labeled uses.

As you probably know, in cancer, particularly in pediatric
cancer, something like 80-plus percent of the drug use is off-labeled. And
that’s okay. Physicians are licensed to practice medicine; they can prescribe
the drugs any which way they desire.

And I sort of made the metaphor that we’ve got measures being
used in an off-labeled use and Dennis corrected me — he’s just a great guy, I
think as Bob alluded to. He said, “You’re wrong.” He said, “It’s
not that they’re off-labeled.” He said, “They’re unlabeled.” He
said, “We have never labeled the measures.”

And if you think about it, all of this began in terms of
performance measurement in the context of internal quality improvement and
longitudinal analyses over time. We didn’t have to label the measures; that’s
all they were used for.

But we’ve evolved from internal longitudinal analysis and
traditional QI measures into public accountability, transparency, public
reporting, if you will; we’re using the same measures. We’ve morphed again into
pay for performance — we’re using the same measures.

And we’ve morphed yet again, and I heard this as I walked in
the room, in terms of maintenance certification as Carolyn and Steve were
talking from the perspective of the boards of medicine.

And we had a meeting just in the last two weeks with the
American Board of Medical Specialties and several of its constituent boards
about the possibility of drilling down hospital data and tagging it at the
level of individual physicians.

Now, granted, there’s a whole host of problems which we can
talk about if you wish later on, that relate to trying to do that drill down,
not the least of which is the, as I call them, the tyranny of small numbers.
But the notion of using these measures in all of these contexts without a label
that says “yes, this measure should be used in this context,” what’s
the level of evidence required for use of a measure in the context of internal
QA or QI versus pay for performance versus literally one’s livelihood, when you
get into the perspective of maintenance or certification?

And is it just the level of evidence that really makes a
difference? I mean, is it an RAP — randomized control trial — that should be
used to judge, you know, what this level of evidence is? I don’t know the right
answer to that question.

So that’s another issue.

Next issue, the creation of composite measures from process

Now, that is something that is really beginning to be used in
the context of health care today. We use it in our quality reports that are out
on the website.

We actually take process measures, rate-based measures, and we
aggregate them, using what Harlan Krumholz from Yale calls an “opportunity
model.” And that is, there’s no waiting. The organization had the
opportunity to do the right thing x-number of times, and in the context of
determining the opportunity to do the right thing, you might add together
aspirin at arrival, aspirin at discharge, beta blocker at arrival, ACE use, et
cetera, and at all of those opportunities, how many times did you fulfill an
opportunity and how many times did you not, and come up with a grand total.

Now, “Is that correct?” is a key question. We’re
beginning to see it used certainly in the context of public reporting. CMS
hasn’t done it yet, but I know from discussions it’s being talked about
internally as a potential addition to Hospital Compare downstream.

But the question of how do you do this is a very key question,
and embroiled in this whole notion is the age-old question of process versus

And I can tell you, that argument is an argument that’s been
around since Donabedian and it’s still raging today. And I can tell you we had
a meeting of our Advisory

Council on Performance Measurement about two months ago where
I presented preliminary data to them on our two-year experience collecting
standardized core measures in acute MI heart failure and pneumonia, the data,
by the way, that will be, I’m pleased to say, published in the New England
probably late summer, but in the context of presenting those data,
one individual on the Council who happens to be from a purchaser, a large
purchaser organization, not the government, said, “Aha, finally you have
given me the ammunition I need to suggest that process measures are no
good” because in fact we are showing virtually a static acute MI in
hospital mortality rate across two years at roughly about 8-1/2 percent; yet
the process measures are showing improvement.

And he concluded from this: Mortality didn’t change, hospitals
got better in terms of processes of care. Therefore, what really matters is
outcome didn’t change; we ought to be looking more at outcomes. Throw those
process measures away — they’re useless.

My response to him, of course, was several-fold.

Firstly, a lot of these metrics look at processes of care
provided in the hospital that have huge impacts upon morbidity and mortality
post-discharge. He had forgotten that. I mean, that’s a huge problem.

And secondly, all we’re looking at in a crunch-down hospital
stay for acute MI, you know, you’re looking at basically a two-day length of
stay, and not a whole lot of people fortunately die in that two-day length of
stay. They die 30 days out, which is why CMS, the Joint Commission, the
National Quality Forum and others are looking to develop a 30-day
post-discharge mortality measure. Let’s risk adjust appropriately.

But also embroiled in this process outcome measure controversy
I guess I’ll call it is the notion of bundles.

Now, that really arose out of the IHI work in large part but
not exclusively. And what we’re beginning to see happening now is that
performance on the entire bundle, if you will — and the bundle is just a group
of measures that represent a like area; perhaps it’s ventilator-associated
pneumonia or surgical site infection, et cetera — ultimately, you’ve got to do
it all. You can’t do really well in one or two and really lousy in three and
four and expect a good outcome.

And in fact, one of the notions that’s emerging is maybe in
the creation of composite measures, or metrics, what really ought to be looked
at is not just an opportunity model but you ought to be looking at whether you
are fulfilling all of the aspects of care required in the context of a given

Now, this is a public reporting challenge, to say the least —
not to mention a measurement challenge.

Next area, standardization — I guess I touched on this a bit,
but I want to hit home with it one more time — and it’s standardization across
care settings.

And this really, from the context of NCVHS, I think is an
important issue because I’m afraid that we’re going to get double counting
taking place in patient populations if we don’t address the notion of creating
metrics that in fact are derived from the same data elements as the patient
traverses care settings.

This is clearly going to be more important downstream perhaps
than it is today. Certainly, it’ll be more important when we get an electronic
— if we ever get an electronic health record that folks can agree upon.

How should the data be reported? Whose report card is best?

When I do talks on this issue, I actually show — the first
report card I was ever able to find on the Web, not health care, mind you,
comes from education; it comes from Columbus, Ohio, in 1881. And it graded kids
on geography and arithmetic and spelling and so on.

Then I show my second grade report card from the New York City
school system — I hide my accent as best I can, but I grew up in New York —
and the grading system in second grade for me was a grading system that looks
at Works and Plays Well with Others, is Generally Cheerful and Friendly, He
Practices Good Health Habits. I mean — I show pictures — this is really
what’s on my report card.

And the grades were N, Needs Improvement; U, Unsatisfactory;
S, which stood for Satisfactory, and SO, which I got, by the way, in science —
I was a science geek, I guess, back then, too — which stood for supposedly
Superior and Outstanding. I had only one line of SOs and it was in science, and
all the rest of mine were Ss.

And then I looked at my daughter, my older daughter who’s now
ready to graduate from high school, but when she was in second grade, and I
compare her report card in a suburban school district, Chicago school district,
with mine.

The grading scheme has changed entirely now. From 1881 to 1956
when I was in second grade to my daughter’s second grade report card, the
grading scheme has changed. In fact, she was graded in elementary school in
three ways — whether a particular skill set, and one of those skill sets, I
might add, was called Measurement, interestingly enough — and whether a skill
set was considered to be Developing, Progressing or Consistently Demonstrated.

I’ve been on the medical school faculty at Northwestern now
for 26 years, believe it or not, and I sort of fancy myself as an educator, and
I’ve been involved in grading people for years, and I sort of fancy myself as
knowing a thing or two about how do you do that?

And I got this set of grades from my daughter, and Rebecca’s
grades in particular in one area, which was Engages in the Writing Process, was
checked off as Not Consistently Demonstrating but Progressing.

And my wife and I were horrified as parents.


DR. LOEB: Oh, my God! I mean, this is a big problem.

We went in and talked to the teacher — honest to God, this is
true — and said, you know, do we need remedial help? What can we do to help
this child?

The teacher looked at us like we were out of our minds because
she also gave us the Iowa test grades that

Rebecca had gotten, and the Iowa test grades as Low, Medium
and High,. It has Observed, it has Expected, and it has Rankings within the
context of the school, the school district, the state and national.

Now, for a data person like me, that was Nirvana because I was
able to see exactly —


DR. LOEB: — what her performance looks like longitudinally
over time in the various cohorts in which she ultimately participates.

Now, fast forward to health care: What do we have in health

We’ve got the CMS website, we’ve got the Joint Commission
website, you’ve got probably another several dozen websites that you can go to
that are proprietary and black box that contain purportedly information bearing
upon health care quality, oftentimes calculated in a way that is entirely
unknown to those who read it, containing a star system, check and minus system,
no check and minus system. How do we report this stuff ultimately for those
that have the need to use the data in a variety of contexts, be it payment, be
it actionability, you know, and choice of provider, provider organization?
There’s no agreement on whose report card is best.

So reporting, again, is a huge issue.

Currency of data — how current are the data? And without, you
know, pointing any fingers, if you look at mortality data, for example, that
you can obtain, it ain’t very current nowadays. And in the throes of trying to
do comparative analyses, for example, how do you match clinical data being
collected, to the extent you can do so in real time or close to real time, with
mortality data that’s two and three years old? It’s really difficult to do

Right now, within the context of where the Joint Commission
and CMS are in terms of joint data collection activities, I think we’re about
as good as we can get at the moment, and that is, we’re looking at data roughly
four months after the close of the quarter.

Now, can we get better than that? If we have an IT
infrastructure that everybody can agree upon, sure, I think we can. But that’s
about the best guess, or the best it is, nowadays, and I think that’s an issue
that we all ought to be thinking about in terms of the future, in terms of
trying to get this as close to real time as we can.

And lastly, it’s the issue of data quality.

I think it’s fair to say that the quality of the data being
collected today is quite variable, and as a guy that occupies a sort of a bully
pulpit, I guess, from the Chicago suburbs and looks at data from a whole
variety of entities out there, the quality of the data are widely variable. And
that’s very worrisome.

And the question of an audit process being put into place,
which of course requires someone to pay for it, is a very significant
challenge. Clearly, and I’m sure you’re all aware of this, or I know Steve is
aware of it, the GAO is doing a study right now that is looking particularly in
the context of the pay for performance world at the quality of the data being
collected in the context of the Hospital Quality Alliance.

And obviously when the government coffers are going to be used
ultimately to reward or perhaps even punish those who are not performing well,
the notion of data quality I think becomes paramount.

We still at the Joint Commission, even with all the attention
we pay, the audits that we do both to the vendor community which is interposed
between our accredited facility and ourselves as well as going right out to the
accredited facility, the quality of the data is quite variable. We see missing
data, we see data that is abstracted incorrectly, although we do have an AHRQ
grant — thank Carolyn; she’s not here at the moment — in which we’re looking
quite specifically at correlation coefficients when we go out and re-abstract

And I guess I probably should give you the good news story
here, too, along with the bad news story.

If you look at it on the aggregate, we’re seeing pretty strong
correlation coefficients, roughly at about .9. It varies by data element. Some
data elements are a heck of a lot easier to collect than other data elements.

But at the same time when you aggregate the experience on
high, it looks pretty good, as I jokingly said to Linda Cohen and the folks at
the GAO — we’ve done a series of interviews with them, and I’m sure there’s
more to come, about this whole notion of data quality — when you actually look
at the data that we are getting from the nation’s hospitals, we accredit about
80 percent of the hospitals representing roughly about 96 percent of the
hospital beds.

The hospitals that have measurement reporting requirements for
us is a bit smaller than the total number of hospitals that we accredit because
a lot of them at this point are psych hospitals or children’s hospitals that
are outside the requirement base because we don’t have measure sets yet that
can accommodate them, so we have a total of about 3,800 hospitals that are
reporting to us at the moment in a standardized manner.

And when we look at the aggregate experience across all of the
individual process measures and the few outcome measures that we have, but on
the process measure side in particular there’s only one measure where 90
percent of the hospitals are performing at 90 percent or better, and that
measure happens to be oxygenation at assessment.

Steve knows why because we were on a panel together where
Steve said, “Follow the money,” because there is a reimbursement
trail for oxygenation.

The second area that hospitals do very well at is aspirin at
arrival, aspirin at discharge. They are very close to 90 percent.

Following soon thereafter is beta blocker use both at arrival
and at discharge.

And then it falls off horribly. And you look at some of the
public health metrics like influenza immunization, pneumococcal immunization
and so on, performance is woeful.

And I joked to Linda at the GAO, when the question arose,
“How credible are the data and are the hospitals cooking the books?”
and I somewhat tongue in cheek said, “If they were cooking the books, this
is not what their data would look like.”


DR. LOEB: I mean, they’d be telling us they’re doing 100
percent in everything. And clearly we’re seeing a huge display — in essence a
normal curve is what we’re seeing. And we’re seeing significant outliers both
on the positive side as well as on the negative side.

I’ll stop there because from talking with Bob and Anna by
email, I think you want to engage in some conversation to the extent we can.


MR. HUNGATE: Thank you.

DR. LOEB: Thanks for indulging my ruminations.

MR. HUNGATE: Well, they’re very helpful.

Who would like to start the questions? Or are you as
overwhelmed as I am?

MR. SCANLON: I’m overwhelmed, and I wouldn’t disagree with any
of your characterizations of the problem. I guess I’m thinking in particular
about sort of the issue of maintaining or reconciling the measures, which I
think is very important because one of the concerns that we have is as we move
forward in this area that if part of the problem is the measures become
obsolete, then we have a backlash that’s generated by that.


MR. SCANLON: That could be as bad as if we have a backlash
generated by sort of inaccuracy or anything else.

The question would be, sort of: Do you have an idea of how
you’d go about — I mean, thinking about our making recommendations to the
Department — how can the Department play a role here other than creating an
endowment for NQF and —

DR. LOEB: Well, I don’t want to be a shill for NQF, but I
think funding is clearly of great importance here, and finding a disinterested
third party like NQF, and we certainly believe very strongly in the notion of
what NQF can do, finding a third party like that who’s willing to take this on
is great, but the issue that I brought up before that I worry a lot about is:
Does NQF really have the leverage to create the change?

I mean, if NQF has a measure in its toolbox that in its wisdom
for whatever reason it says needs to be changed, it doesn’t have the expertise
necessarily to do it. It’s the measure developer that has the expertise.

But then there’s a whole series of dominoes that fall
downstream because once that measure gets changed, all of the infrastructure
that’s been set up from the perspective of the hospital, at the data collection
end of it, to the vendor intermediary who’s collecting the data whether it be,
you know, a QIO data warehouse to which the hospital is transmitting, whether
it be one of the Joint Commission’s multitude of vendors with whom we have to
track the relationships, there’s infrastructure changes that are necessary at
that end. There’s reporting changes that are associated with this. And, you
know, the developer certainly can say, “We don’t have the resources to do

So how do you leverage that change I think is critical. What
are the trip wires to generate the need to change a measure?

I mean, NQF worries primarily, I think, about the notion of
what constitutes a material change, but I think that’s sort of only part of the
issue. The other part of the issue is, you know, how do you grade the evidence
to determine that it is time to change?

I mean, if we have measures that looked at open
cholecystectomies and we had those measures for years and now most of the
cholecystectomies are being done laparoscopically and we never changed our
measure to deal with laparoscopic cholecystectomy, that would be a big problem.

Your question is a good one, what can you suggest to the
Department to create that change? I’m not sure of a good answer beyond the one
I’ve given you, and I’m not sure that’s a good one.

DR. JENCKS: Well, if I could add something here. We’ve really
been working with Jerod and his folks. I have at least sort of a notion of how
it might work.

First of all, I think that if you submit a measure to the NQF,
you own it. It’s just like you send your child to school — it’s your child;
they come back at the end of the day. And people who submit it should take
accountability for keeping it up to date.

And that can be very helpful because it then gives NQF
somebody to turn to. NQF needs an internal structure which does something
fairly simple, which is it puts a change recommended by the owner, or if you
like, the

custodian for the foster parents if the original generator
loses their status, and you put it in one of two buckets. It’s either a
non-significant change, or one that you can just say, “Fine,” or it’s
a significant change — “This measure really isn’t the measure we had
before” and it’s got to go through processing here.

There are a couple of reasons why you want to do something
like this.

One is exactly the problem that Jerod described, which is you
get guidelines people who have different — well, sometimes they have a
different sense of the clock, but sometimes they have a different criteria.
Guideline writers want to know what the best treatment is.

For many of these measures, what we’re really asking is:
What’s a treatment that’s good enough so that people would say, “Yes,
that’s okay,” you know? And ARBs may still be not quite as good as ACEs.
Maybe they are.

But from the point of view of the measures people, you know,
we said, “Well, does anybody really think that somebody who gives an ARB
instead of an ACE is practicing bad medicine?” The answer is, they’re a
couple of purists who do, but the vast majority of people don’t.

It pushes the responsibility back down, and suddenly those
guideline managers begin to look at the issue in a very different way.

So that’s a way to do it. It’s not necessarily the best way,
but I wanted something to recommend to the Department.

DR. LOEB: Yes, and I think just to follow on what Steve has
just said, I think the American College of Cardiology and the American Heart
Association, have — how should I phrase this? — woken up into this notion in
that they are now trying to merge together the guideline process with the
measure development process.

Now, that’s a good thing as long as — and this is a really
key point, I think — you engage others outside of the American College of
Cardiology and the American Heart Association.

And toward that end, they have believed, to the extent they’ve
been looking at this so far, that they’re looking at primarily physician-level
measures and not necessarily organizational-level measures. So they’re wreaking
havoc with the world at large because while they merge the guidelines and the
measurement development process together, they haven’t accommodated the fact
that these measures need to get used somewhere and leveraged by some entity, be
it regulatory or accrediting, and hopefully they’re waking up to that.

Actually, three points. Point two is the notion of — how do I
phrase this? When I talk about this stuff

publicly, I’d say the measures came from three places. They
came from the measurement experts who know nothing about clinical medicine.
They came from the clinical experts who know nothing about measurement. And
they came from the third group, which are the entrepreneurs, who know nothing
about either and care about something else, which is making money.

And somehow we have to get all three of those types of folks
onto one track.

And the third point is the notion of the specialty societies.

It think it was Lyndon Johnson back a gazillion years ago who
said it’s better to have your enemies in the tent with you urinating out than
outside urinating in.


DR. LOEB: Well, the notion here is you really need to do this
as a consensus development process, and I think from a Department
recommendation perspective, I think that’s really important, to get all of the
entities in the room together so that the process gets done once and you don’t
have dueling expert panels. That has been an enormous problem for all of us.

You know, the American College of Cardiology and American
Heart Association pulled together a set of metrics that relate to X, Y, Z, and
the Joint Commission and CMS do it, and then the thoracic surgeons do it and so
on and so on, and you end up with a Tower of Babel that is absolutely
impossible to deal with.

So to the extent that you can recommend creating in these
unique clinical areas a singular mechanism by which all the stakeholders that
are appropriate can sit around the table and build on what each other are
saying. I think that would be an enormous boon.

And plus, from a cost perspective, it would be a heck of a lot
more cost effective than to have these redundant iterative processes under way
and they all collide at the end.

MS. McCALL: Right. Yes, and not agree.

Some things that you’ve said that struck me as just
particularly insightful and powerful — one, you started out by talking about
who sets measurement priorities —

DR. LOEB: Yes.

MS. McCALL: — okay? And I would link that — they’re not the
same, but what you’ve just talked about, it’s kind of the who and the what,
this maintaining and reconciling of measures, that when we talk about the who,
you listed off just a number of different players and how do we get them to
align and how do we get congruence?

We spent some time yesterday also talking about — and I think
you mentioned as well — different constituencies, that the same measure isn’t
really appropriate as you think about the different constituencies and what’s
the level of evidence that’s required? You know, how do you actually maintain
them? How do you morph them?

Whatever the mechanism is would probably have to align not
only who’s doing it but what they’re doing and what constituencies are

The other thing that you said that struck me was this gap
between guidelines and practice, and we chatted a little bit about that, which
is to say there’s value maybe in that gap, which has to do with learning, you
know, that it becomes the Catch-22 that people had talked about before —
what’s the ROI on more data?

DR. LOEB: Yes.

MS. McCALL: You know, or what’s the ROI on looking at
something in a different way?

It’s tough to know until you actually have a chance to look at
it in a different way. God forbid that we have to all reach consensus on
something with no evidence before we can actually move off our current

So it’s really kind of maintaining a creative tension in that
gap without letting it get too far that seems to be of value. I’d like your
thoughts on that.

DR. LOEB: Yes, I guess a couple of points.

And, you know, many years ago the AMA fought against
guidelines, and they fought against guidelines because — and this is words
from their argument — this is cookbook medicine, and, you know, physicians
should not be forced into practicing cookbook medicine; every patient is
different, et cetera.

You know, that’s fine and well. I believe that. I’d like my
physician to treat me as an individual. But at the same time, assuming I have
an indication for Drug X and no contraindication for Drug X, I’d like to know
that he knows about that and that he is going to prescribe that, and of course
I’m going to take it.

So I’m not sure that that necessarily makes me feel very
comfortable. In fact, I worry about that gap a lot when I look at the fact that
just about all of our measures that we’re using today are based on very strong,
sound clinical practice guidelines; they’re based on sound, randomized control
trials. I mean, it’s about as good as the evidence gets, and we’re seeing
compliance rates that are terrible.

And, you know, when hospitals call us, and I guess I’m the guy
that — how should I say this? — I tell them what I think when they say,
“What’s the benchmark?” you know, for aspirin arrival or for beta

And my answer that is: 100 percent. And that’s because the
measures are constructed in such a way as to permit the organization and its
component practitioners to exclude a patient for whom a given therapeutic
approach is improper. So if you’re aspirin allergic or you have a GI bleed, you
should not get an aspirin when you come into that emergency department with an
acute MI, and the hospital should exclude you from that population. That’s good

On the other hand, if you didn’t have a contraindication to
getting an aspirin, you should get it 100 percent of the time. That’s good

MS. McCALL: It’s not that situation. It’s more the ACE/ARB
situation —

DR. LOEB: Right.

MS. McCALL: — is what I’m talking about.

DR. LOEB: You’re crystal clear. I agree.

MS. McCALL: Okay.

DR. LOEB: The other point I wanted to make, and this I think
comes back to the first question relative to, you know, recommendations at the
Department level as to who sets priorities, we have been saying for about two
years now, and it’s really Dennis’s concept, that there really needs to be a
governmental entity probably out of the Office of the Secretary that is
responsible for setting priorities.

You know, the NQF doesn’t have the leverage to do this. The
Joint Commission and CMS alone, or even together, I don’t think, have the
leverage to do this. The IOM probably doesn’t have the leverage to do it.

We really need national priorities set, and probably set on a
regular, ongoing basis with the funding stream associated with setting those
priorities to make them real. And right now there is nowhere.

I mean, we call our metrics “National Quality Improvement
Goals.” It’s pretty bold of us to call them that because who deemed them
national quality improvement goals?

MS. McCALL: Right.

DR. LOEB: I mean, we did, but so what? We’re just an
accrediting body.

We really need a high-level entity, and our thought is that it
probably needs to be at the level of the Secretary to have the leverage that it
ultimately could and should have.

MR. HUNGATE: Look across the table.

DR. LOEB: Yes, exactly.

I mean, I think that’s a real key.

MS. McCALL: Okay.

MS. POKER: I wanted to address another issue that you talked
about, and that was about the bundles, of putting entire measures of like area.

DR. LOEB: Yes.

MS. POKER: And you were talking about it more from the
regulatory perspective.

DR. LOEB: Oh, no, no — from the outcome perspective. It’s
clear —

MS. POKER: Okay, yes.

DR. LOEB: — that if you’re looking at ventilator-associated
pneumonia, for example, there’s a number of things You can do to help
ventilator-associated pneumonia. You can prevent stress ulcer disease, you can,
you know, elevate the head of the bed 30 degrees, you could do a bunch of

And, you know, if a hospital’s doing one or two of them but
not the third one, the likelihood of being good at preventing
ventilator-associated pneumonia is pretty slim. Peter Pronovost at Hopkins has
shown this, as have others, but Peter has done yeoman’s work in the
ventilator-associated pneumonia area and this whole notion of bundles. Berwick
has been preaching it for years.

MS. POKER: Well, there’s bundles of performance that you could
put together.

DR. LOEB: Right.

MS. POKER: Or bundles that you could put together for any
workflow area, for example, for discharge. You want to do a number of things
there you want to put together, and that’s — almost like what I heard is also
kind of redesigning workflow.

And what I heard yesterday what somebody talked about is to
change the infrastructure to transfer evidence-based information. And my
thinking, with my informatics cap, is like decision support systems to help
those bundles.

DR. LOEB: Yes.

MS. POKER: How do you see it today currently, because one of
the problems is practitioners — can they do the entire bundle? At what point
do they drop the ball just because of their workflow?

So I guess the question is: How do we get there, because that,
I think, would make a really big impact, if people would do the entire bundle,
not portions of it?

DR. LOEB: No, I totally agree with you, but I think absent an
infrastructure that has the systems and processes in place — you know, they
don’t necessarily only need to be electronic. They can be other than electronic
as well, although electronic infrastructure is certainly going to help with
decision support aids and reminders and so on that precludes someone from
simply hitting the Enter key when, you know, the reminder comes up.

When I flew to Chicago this morning, it was pretty funny,
actually, on United. I had a paper upgrade that I wanted to use, and the agent
behind the counter, she flipped really fast through the various keys and there
was a screen that came up — she told me this — and said “Collect paper
upgrade.” And she was just an automaton, just going ahead pushing the
Enter key, Enter key, Enter key.

And then she said to me, “They told me to do something,
but I don’t know what it told me to do, so I’m going to have to cancel your
check-in and start it all over again.”

And she did. And in fact what it was — of course, I didn’t
want to give it to her because I would much prefer to use it on another flight,
but she had a decision support aid that said “collect that paper

Now, you know, how much of that exists in, you know, the
hospital infrastructure today? And, you know, well, close to zero. And if you
look at the complexity of systems and processes in hospitals, you know, it’s
not just ultimately the nurse dispensing that aspirin to the patient; there’s
about 95 processes that have to take place before that aspirin gets dispensed
by the nurse to the patient. And all of those are subject to failure.

And if you look at, you know, failure mode and effects
analysis and look at the possibility for the systems to fail — as a limited
aside, I mentioned this to Steve earlier — I spent one of the most fantastic
days I have in years yesterday, along with four of my Joint Commission
colleagues, out at the United Airlines Flight Center in Denver.

And we went out there specifically because as a chance
occurrence on a flight recently, I ran into a pilot who saw my briefcase, my
JCAHO tag, and he literally shook hands with me — stuck his hand out as I got
on the airplane. He said, “I want to thank you for what you’re doing to
make health care safer.” And I said, “Whoa! You even knew who JCAHO

And we got to talking. We talked in the cockpit before we took
off and then we traded business cards. He’s come out to the Joint Commission.
He’s one of four managing pilots in Chicago. And we talked about issues around
patient safety/aviation safety.

To make a long story short, we got into a very lengthy
discussion about what United calls its “FSAP,” its Flight Safety
Awareness Program, which is a reporting system different from the Aviation
Safety Reporting System, the traditional one that’s run by NASA.

This is a system that United has bought into with the Airline
Pilots Association and the FAA and the company. They’re getting 125 reports
every week, 125 weekly, and they invited us to Denver yesterday to sit through
a five-hour meeting, which they have every week, where the FAA is at the table,
the Airline Pilots Association and the company is at the table, and they go
through these 125 reports one by one and figure out:

What was the system in process that should have been in place?

Where were the redundancies that could have prevented this
situation from happening?

And what can we change in our systems and processes
downstream? This is a protected environment. It’s not subject to FOIA. And it’s
been, I guess, four and a half years now and the pilots have felt comfortable
with the reporting that’s going on and they feel comfortable because they’re
getting feedback and the processes are improving. It’s making the airline

Now, you know, fast forward that to health care, you know, my
God! You know, at the Joint Commission we’ve examined 3,000 crashes over 10
years. Now, that’s the tip of the iceberg. We think that’s probably one-tenth
of one percent of what’s happening. One-tenth of one percent.

You can’t prevent everything, but all of this could be
significantly improved — coming way back to your question about the systems
and processes. That’s the way to solve it. And by the way, they let us fly the
777 simulator yesterday.

MS. POKER: Oh, that must be good!

MR. HUNGATE: I’ve got Carol and Justine and Stan and —

MS. McCALL: Okay. I love that you were able to go out to
Denver and spend that time. I thought for the group there’s a couple of
analogies or analogous situations. We’ve heard about airlines. We’ve also heard
about education. You brought that up, Carolyn brought that up.

I think there are some opportunities and actually maybe a call
to action for us to look at some other analogous industries and to speak with
them to kind of bust through some paradigms and get some new thinking that
could be a lot of fun.

And, you know, education around measurement, I’m wondering if
there isn’t another one that we can search for in there.

And then the second was to ask you about these bundles, and I
find them fascinating. And I’m not sure I understand them right, so first a
question for you and then a comment. The bundle, you talked about it in

with process and outcome, and what I hear you saying is that
this choice between process and outcome is really a false choice and that a
bundle is really a combination; it a different kind of composite that actually
says that there’s a bundle of metrics that includes not only how you do
something but what it is that you try to achieve. Is that a fair representation
or do I have that wrong?

DR. LOEB: I’m not sure what the classic textbook definition
is, indeed if there even is one, for a bundle, but my concept is that it’s a
group of like measures the complement each other that address a single, well,
in some cases multiple, clinical areas.

There’s a bundle that looks at medication reconciliation
that’s in the IHI 100,000 Lives campaign, ventilator-associated pneumonia,
surgical site infection, and these are measures —

DR. CARR: Line infection.

DR. LOEB: I’m sorry?

DR. CARR: Line infection.

DR. LOEB: Yes, central line infection. There’s a bunch of

MS. McCALL: Right.

DR. LOEB: And they basically combine together now.
Importantly, they don’t create a composite metric, they don’t come up with a
single number.

MS. McCALL: Right.

DR. LOEB: But rather what they look at is: Do you perform
flawlessly with each of the aspects of this bundle?

MS. McCALL: Or the spider? I think of it as a spider.

DR. LOEB: Yes, you can think of it as a spider, with the
notion that the ultimate outcome, whether it be measured, you know, as in
hospital mortality, 30-day mortality, five-year mortality, whatever it might
be, the notion is that the ultimate outcome is going to be improved if you’ve
paid attention to all of these things as opposed to one or two or three of
these things.

MS. McCALL: Right, okay.

DR. LOEB: But it doesn’t really rest on the notion of
aggregating the metrics up to a single numeric.

MS. McCALL: Right. Okay, so that helps me understand a little

And I think when we get back to the who sets them and how do
we go about that, what I see is something that is — it’s turtles all the way
down! I mean —


MS. McCALL: — they’re nested, they’re subsumed. Some of these
things are very context-specific and they’re not generalizable to any other
thing and yet they must be

what they must be. And then you kind of go up to higher levels
and higher levels.

Trying to somehow prescribe all of that, or engineer all of
that, is quite daunting, and so it may be the wrong paradigm; we’ve got to try
to find a way to allow them to kind of emerge, and yet they can’t be just
completely unappended.

DR. LOEB: No, it’s got to be consensus driven, I think it’s
very clear.

MS. McCALL: Yes.

DR. LOEB: You know, you need some consensus to set priorities,
too, but priority setting I think in large part should be done on the basis of,
you know, where are the problems, where do we know there’s high-volume,
high-risk, problem-prone areas for which, as Wennberg has been saying for 25
years, you know, “In health care, geography is destiny.”

MS. McCALL: Right.

DR. LOEB: So we know we’ve got these problems; let’s set the
priorities around these problems and then let’s gain consensus about what to

MS. McCALL: You know what would be fascinating is you could
imagine a system — imagine what John talked about yesterday, okay, and into
that system which has some baseline data that, you know, is going to be common,

once consensus were reached — so I’m assuming I have a can
opener, okay? — and there’s some new set, that what you’re able to do is
you’re able to load, just like we have software patches and we have some other
things, you’re able to actually load into your system, just like a data
taxonomy, there’s actually a metrics piece it comes with — denominators and
numerators and I got, you know —

DR. LOEB: You’re a dreamer.

MS. McCALL: Yes.


MS. McCALL: But the thing is to visualize what these bodies
might create, you know, in addition to opinion, that could actually be executed
to help people —

DR. LOEB: You’re right.

MS. McCALL: — in the moment do what they do.

DR. CARR: Just maybe saying a similar kind of thing to Carol
and following up on what we heard yesterday, how you define quality. Actually,
we even had discussion about what’s quality and what’s value; should we be
looking at value or quality? Let’s just stay with what we call quality now.

I go back to what Don Detmer said, that, you know, we have the
IOM Dimensions of Care as one thing. A second thing is then how do you approach
it? And the approach has a lot to do with how it will be received, how it can
be defended.

So what you’ve done is really taken evidence-based — no
discussion about whether this is right —

DR. LOEB: Right.

DR. CARR: — because we have the weight of evidence with us,
and it’s a little bit maybe like Brent James said, “The light is shining
there.” We know this is an area that can be fixed and we can see it and we
can work on it.

But then there are the areas that are muddier. So you’re on
the effectiveness and really you’re being very effective in major diseases,
cardiac, pneumonia, but on the other side there are things like safety that are
not disease specific or condition specific; they’re going to be system
specific. And maybe these bundles are like that. We’re safer if we prevent
these complications.

And then, you know, there’s timely, and so on.

So let me just say, two things had broader dimensions
yesterday. One is, what’s the definition? And then the second is, what’s the

And I guess what I’m wondering is, as we’re reciting all of
the great work that’s been done by these different agencies — NQF is doing a
lot actually on safety, system safety —

DR. LOEB: Right.

DR. CARR: — and so on, you guys have done a lot on, you know,
evidence-based implementation — so one question is, or is this what you were
saying, that there’s a need to sort of set the priority, that, you know, in the
next five years we will be safe so we’re going to focus all on safety, or we
will be evidence-based.

Then the second thing is, and Brent James had brought this up,
and others, is the iterative process. Just as you found with ARBs, you know, we
thought ACE was the answer; now we know ARBs are the answer, whatever.
Actually, with the ’02 sets, maybe we don’t need to be measuring that because
everybody’s at 100 percent, we have that incentive.

So how do we go back and get the biggest bang for our buck,
take things out that either didn’t work or already done and then re-prioritize?
And it’s sort of this: It’s not enough to have the measures; it’s going back
and now using them and driving.

And then the final thing that is going to be great is to see
— well, I guess it’ll be great; I’ll have to see the article in the New
England Journal
— but this whole thing about we did all these processes
and how were we better?

DR. LOEB: Right.

DR. CARR: I think we really, really need to understand that so
that we can be better at what we do.

DR. LOEB: Boy, I put a couple notes down; I’m not sure I’m
going to remember all of this.

You know, you’re absolutely right in that we have pulled off
the low-hanging fruit at this point. I mean, that’s the areas in which there is
clear linkage between a given process of care and a given outcome of care. I
mean, the evidence is absolutely, you know, sound and strong and so on. These
are processes that are inextricably linked to good outcomes.

But that low-hanging fruit is gone now.

MS. McCALL: Yes.

DR. LOEB: There are some other measure sets that are in a
variety of states of evolution which are somewhat low-hanging fruit, like
children’s asthma care, for example, and so on, but now we’re getting into some
of the areas that are really kind of thorny, like surgical infection prevention
and in our case we have a set of metrics that relate to ICU care and we’ll
probably be looking at emergency department care, things like through-put, I
mean, stuff that is by no means low-hanging fruit at all. And how you measure
them is going to be an issue.

That’s, I guess, point one.

Second point. You know, one of the problems in measuring in
safety is that in safety you’re looking for the most part at errors of
commission. In quality, for the most part what you’re measures of omission. Not
exclusively in either case, but that’s pretty much what it comes down to. It’s
very hard to measure things that don’t happen.

I mean, when the initial To Err is Human report came out and
the Federal response to Quick Report and so on, everybody said, you know, John
Eisenberg, bless his heart, you know, we have to have a 50 percent reduction in
errors in five years. Fifty percent from what? And we don’t even know where we
are five years out on the IOM report now.

So to measure things in safety is very difficult, to say the

I guess the other point I would make, and I’m glad you made it
relative to the oxygenation measure, you’re absolutely right. There are some
things that we’ve been measuring for some time that probably no longer fit the
mold of the juice being worth the squeeze.

You know,, this is being done virtually 97, 98 percent of the
time at this juncture, and the question is: Is it worth bothering to keep
measuring it?

I would actually put that into this broad rubric I called
“reconciliation and measure maintenance” because the measure sets
have to change over time. They’ve got to get new measures in, old measures out.

But the problem is, when you have a responsibility and
accountability, if you will, as we do at the Joint Commission as an accrediting
body — and I can tell you our Board has a Strategic Issues Workgroup which I
staff and my staff work on that’s really grappling with this right now — it’s
can you blanket a set of rules that say, you know, in the acute MI set as an
example, they’re doing really well with the aspirin, they’re doing pretty well
with beta blocker; should we substitute in perhaps a look at management
measures, some other measures where we don’t know how well people are doing?

The problem is we’ve got hospitals performing all over the
map. And does there need to be a set of rules, if you will, established that
say “if you’re more than two standard deviations, three standard
deviations from the mean, no, you can’t stop doing this; you must continue to
do this?”

I don’t know what those rules should be. I don’t know who
should set those rules. I mean, we’ll have to set them ourselves initially as
an accrediting body to fulfill our responsible as an accountable entity to the
Federal government under the deemed status provisions of Medicare.

But, you know, as I sat through multiple discussions with our
Board over this, and they keep coming

back to us and asking us to model this using, you know, the
data that we’ve been gathering for some time and try to understand what would
happen if we do this or if we do that or if we do something else, your point is
exceedingly well taken: We have got to figure out what the rules of the game

And, you know, the push-back that we are going to get, I see
the handwriting on the wall here, is the hospitals are going to tell us we’ve
already got these systems and processes in place that you made us spend money
on — we spent capital to put in a system and process to do X, Y and Z and now
you’re telling me you don’t want to measure that anymore and now you want to
measure A, B and C? I mean, that’s what’s going to happen.

So we have to figure out how to deal with that problem.

DR. CARR: But I think, you know, that a little bit as we think
our 10-year plan of the electronic health record and think about flexible
fields, I think one underlying assumption is that it will be evolving and so
how we build the quality dimension of electronic health records might need to
be I mean even a binary yes/no —

DR. LOEB: Sure.

DR. CARR: — because as you were saying, do you need to know
99 percent, 92 percent? No.

DR. LOEB: Yes.

DR. CARR: You need to know yes/no.

DR. LOEB: Well, you know, the gradations in these indicators,
too, really are kind of fascinating because I don’t really know that we truly
have the ability to separate out in terms of fidelity a hospital that’s
performing at 94 percent versus one that’s performing at 96 percent, but I can
damn well tell you that I know the difference between a hospital that’s at 94
percent and one that’s at 44 percent.

DR. CARR: Sure. But P for P is separating out 99 percent —

DR. LOEB: It is.

DR. CARR: — and 93 percent and —

DR. LOEB: Well, it is, but that’s a problem.

DR. CARR: Yes.

DR. LOEB: What’s happening is, you know, there’s a finite tie
that’s being cut. You know, basing P for P on the notion of a zero-based budget
is a real problem because what you’re going to do is you’re going to squeeze
out those entities that probably are in the most need of investment to try to
make them better and give the money to the entities that are already, you know,
way at the head of the stream. And that’s a problem.

DR. CARR: Interesting, yes.

MR. HUNGATE: Stan, go ahead.

MR. ETTINGER: Having sat on all sides of the JCAHO, being
inspected by you and when I was in CMS I used to do some of your reports to
Congress and have to review them —

DR. LOEB: Yes.

MR. ETTINGER: — one problem that has always come up is — I
guess it’s part of the pay for performance argument, too — how many metrics do
you need to decide if somebody is equivalent in the case of the deemed status?

DR. LOEB: Yes.

MR. ETTINGER: In the case of paying for quality, how many
elephants can you fit on the head of a pin? How many measurements tell you —
you say like this bell-shaped curve — well, you can take the high end and
everybody’s 99 percent so everybody’s wonderful, you take the low end and
everybody looks terrible, and how do you integrate these so-called, having
looked at the survey data for God knows how many times in earlier lives, how
does that fit in with the performance measurement-type data? It’s very
different and probably very variable depending on who’s done it.

DR. LOEB: Right.

MR. ETTINGER: I mean, I’ve been in there behind some of your
people, state people, and they wouldn’t believe that all three of us were in
the same facility.

DR. LOEB: I hear you.

MR. ETTINGER: And just looking down the road, how would you
look at the issue of what to do in that case? What issues? How can we help in
addressing the issue of how to maybe standardize that or there’ll be some
metrics that would help analyze that kind of information on some sort of
coherent pattern?

DR. LOEB: Oh, it’s a tough question. I guess a couple of

Number one is the notion of, you know, a standards-based
accreditation process, or certification process, is complementary to
performance measurement. You know, you can’t have one without the other. You
need them both.

And so I sort of think it’s the Flat Earth Society to say,
well, you know, now we’re doing measurement; we don’t need to worry about those
standards anymore.

We need to deal with both. That’s, I guess, thought one.

Thought two is the ultimate answer to your question, and
you’ll, you know, chuckle, I’m sure, but the ultimate answer to the question is
an electronic infrastructure. You know, when measurement becomes a byproduct of
care delivery, it doesn’t matter how many metrics you have, it doesn’t matter
whether you’ve got one measure or 100 measures — you can calculate them by
collecting the data once and presumably doing so in an electronic manner.

Clearly, we’re not there yet. We don’t even have systems in
the same hospital that talk to each other. The billing system doesn’t talk to
the clinical system and the clinical system doesn’t talk to the pharmacy

Moreover, and when I testified before all of you and it’s
probably a year or so ago, one of the points that I made back then was the
notion of being able to transfer what today are clinically chart-abstracted
data elements into an administrative dataset is going to make an enormous
difference in terms of what the hospitals do with all of this.

And the challenge, of course, for all of us is to figure out
to be smart enough to know what are those data elements? Which are the ones
that we really need to pull out of the chart and make into electronically
captured administrative data elements so that we can ever so closely bring
together the IT side of this and the measurement care delivery side of this.

MR. ETTINGER: Well, in theory if you had electronic data, you
could almost do live-time monitoring.

DR. LOEB: Absolutely.

MR. ETTINGER: I mean, talk to Big Brother at one level —

DR. LOEB: Absolutely right.

MR. ETTINGER: — but it’s also live-time; you don’t have to
worry about if you’re going two years later, three years later or three weeks

DR. LOEB: You bet.

MR. ETTINGER: You’d have a live-time — sort of composite
monitoring you could actually do.

DR. LOEB: Totally agree with you.

MS. McCALL: Well, that’s really the only way that you’re
really going to learn.

You know, there’s a feedback loop in order to actually learn
from something.

DR. LOEB: That’s right.

MS. McCALL: It has to be fast enough to work. I mean, kids
learn because they go, “Hey, Mommy, do it again. Again, again, again,
again.” This repetition. And so the ability to do live-time kind of
feedback, it’s really I think going to be foundational to getting the kind of
change that you’re talking about.

MR. ETTINGER: I think it’s most educational even regulatory. I
mean, going into a Joint Commission facility and looking at some records from
three years ago doesn’t really tell you if something’s currently —

DR. LOEB: We don’t do that anymore.



MR. HUNGATE: All right, the point that measurement is a
byproduct of the care process is a critical observation that reinforces all
that Brent said yesterday as well.

DR. LOEB: Yes, I looked at his hand-out here.

MR. HUNGATE: It fits.

MS. McCALL: Right.

MR. HUNGATE: You know, it needs no further repetition, I
think, in terms of the absoluteness of — you know, that enables you to have
real-time measurement.

DR. LOEB: If you could make that happen —

MR. HUNGATE: It does so many things —

DR. LOEB: — I know —

MR. HUNGATE: — that, you know, it just changes the world.

DR. LOEB: It does.

MR. HUNGATE: And it’s a piece of the vision.

MS. McCALL: We’re going to work.

MR. HUNGATE: Now, we’re going to move on quickly. I’m going to
let Don have one more comment,

then we’re going to let Steve go.

DR. STEINWACHS: I too believe that measurement ought to be
part of the care process but I don’t know whether you mentioned it, or maybe it
was Carolyn or Steve, but, you know, we don’t have much of a research base that
talks to what ought to go into the medical record or what needs to be
documented in the care process that would drive the sort of idea that as a care
provider, this is the kind of thing that you’re doing.

Otherwise, very quickly becomes measurement for some other
purpose, and you’re putting it on top of the care process.

And I guess, you know, one of the opportunities for NCVHS
certainly is also to try and talk to what are research needs, since the
Department is in a situation of being able to think about where there are

And so I was interested just to get you to say something
about, you know, how do you try and move — the evidence part may be the
process, but how do you try and move this process indeed where health care
providers and clinicians would sit down and say, “Yes, these are what I
need to collect because this is part of what I need to have in order to do the
care process or to hand that care process off?”

DR. LOEB: Don, I’m not sure this answers totally the question,
but when I talked about the notion of having an entity at the highest levels of
the Department being involved in priority setting, it’s not just priority
setting for measurement.


DR. LOEB: An ancillary piece of that is clearly going to be
the linkage between the research needs to meet the demands of what those
priorities might have been. If a priority emerges that looks at — I don’t
know, depressive disorders, for example, is identified as an area for
measurement of prioritization, well, then there’s a whole series of steps that
need to fall into place underneath that which can be categorized in large part,
I think, as health services research and which I hope would lay out, you know,
a series of RFPs that will be needed downstream by AHR too or by whomever to be
able to meet the rigors of what this priority might be.

I totally, you know, support that notion, and as a guy that —
you know, one of the charges that I have in my job at the Joint Commission is
to grow our research infrastructure. And, you know, we’ve got something like, I
don’t know, 15 or 16 grants right now among my area.

So I resonate with what you say. I’d love to have, you know, a
mechanism by which to fulfill what those priorities might be.

So — absolutely. Please write that in the —


DR. STEINWACHS: All right. We don’t know that people always
listen to us —

DR. LOEB: I’m starting!

MR. HUNGATE: Very helpful. Steve, your turn to add to the —

DR. JENCKS: — recital of human knowledge and wastes.

MR. HUNGATE: Yes, right.

Agenda Item: Presentation: “Health
Statistics of the Future and Quality of Care: A CMS Perspective” –
Dr. Steven F. Jencks

DR. JENCKS: I figured that people were probably, after Carolyn
and Jerod, in some measure of PowerPoint withdrawal and so I’m going to dose
you —

DR. STEINWACHS: Oh, thank goodness, Steve.

DR. JENCKS: I do my best.

And this is going to be a little sort of a bit of this and a
bit of that, but I think where I ought to start is giving you an idea of how
we’re looking at some of these issues in the CMS, and Trent gave you some of
this yesterday, but I’m to go for a slightly larger picture.

This is the vision that we have adopted as an organization,
and I can only say that it’s a sad testimony about the health care system that
that’s a radical vision. The ideas, the definitions, are very familiar to you;
these are the same old IOM definitions.

We see this vision as requiring transformation. We’ve been
measuring the rates of incremental change and —

DR. STEINWACHS: Are they going in the right direction?

DR. JENCKS: They are, but perhaps not for long. And the
transformation, because of what we are, has to be the whole system. I mean, by
the time you’ve looked at Medicare and Medicaid, and we’re much too big to
selectively purchase.

And transforming the system means transforming the
infrastructure, and of course it means transforming CMS, which is its own

And I was thinking yesterday as Don was saying, you know,
“And what do we do while we wait for a health care system?” I
actually think that in many ways the health care reform business was very
valuable because it convinced a whole lot of us that we couldn’t wait for the
legislated solution, which was typically called national health insurance but
it could have had a dozen other names.

We’ve got a background kind of Internet contribution and
that’s an extraordinary sort of change in the way people relate to data and
systems. We’ve got emerging, I think, understandings of what patient-centered
care would like which really were not part of the vocabulary very much 10 years

And all of this brings me to the central, single thing, which
is, to use an analogy of Gandhi’s remark that you should be the change you wish
to see in the world, is we’ve got to figure out where we want to be and we’ve
got to figure out how we’re going to measure progress towards being there,
because if we believe that measurement determines behavior and we’re worried
about distortion because, you know, the things we’re measuring aren’t
important, the answer is: Let’s get a strategy, get the measures of the things
that are important in the places where we want to be.

And I come back a little bit more to what that might look
like, but let me just say this is what I’m going to assume, okay — Carol
assumed a can opener; I’m assuming quite a lot more than a can opener
[laughing]. But what “m saying is you have to have a sense of what this
might look like in 10 years.

And I think this is a not unreasonable estimate. I’m not
saying “every provider.” I’m not saying that all the systems will
have maximum capabilities. I’m not saying everybody’s going to be connected to
a RHIO or a grid or whatever you want to call it.

But I think we should assume that’s going to be

the dominant situation, and furthermore that if it might not
be, we should consider our job to do whatever we can to make sure that it is.

I also think that the payment system will be tightly coupled
to that electronic health record, to that whole grid system.

And what we’ll be talking about is efficiency of care. That
is, to what extent are we producing what we intended to produce as efficiently
as we can?

Third, I think we have transitioned from many purposes because
of the interconnectedness to patient-centered measures really moving toward
replacing provider-centered measures. And that doesn’t mean that every provider
will have managed that transition, but you can’t have everything.

And, finally, that there will be lots and lots and lots of
measures, because as the richness of the information system grows, we will no
longer be having to ask, can we afford to collect this measure?

Now, that’s just where I think we’re going.

I also think that this is a moment when we can hope to achieve
extraordinary things. I’ve been in this racket for a while and it’s that magic
moment when the ship has been built and it starts to move down the ways into
the water.

There are four major reasons that I identify.

The first is that I think we understand much better how large
the chasm is and we understand some things about how to fix it. Not everything
at all, but some.

Secondly, growing complexity in the system — I’ve learned
from Mark McClellan to take the positive view, so it makes the reward for
systems approaches much greater.


DR. JENCKS: The way I would have put this were I not being
tutored, and this got rewritten so I am being tutored [laughing], not on this
slide but — is that the growing complexity means we’re headed for a complete
disaster because human beings were never engineered to do what we’re asking
them to do in this system.

Thirdly, there’s really an unprecedented readiness of people
to work together, and I mentioned some alphabet soup of examples, and probably
you know some of those examples and you don’t know others, and from our point
of view it’s really interesting. We’re being asked to lead, the Department’s
being asked to lead. And it’s very interesting, you know, because this is not
necessarily the first response of a whole lot of the people who really do not
welcome government intervention in every forum, you know, as Brent clearly
doesn’t —

DR. STEINWACHS: Well, by “some,” is this an act of


DR. JENCKS: I think that’s part of it, and I think that part
of it is that they are beginning to see the difference between leadership and

MR. HUNGATE: A significant point.

MS. McCALL: It’s time has come, you know?

DR. JENCKS: Yes. And finally, which is for us important but I
think it’s important for others, solving the quality problem is essential to
the viability of Medicare or Medicaid, and S-Chip. It’s not an option.

And I think it’s not an option for the country in a different
way. I mean, it’s just sort of percolating through, and people see other
reasons and all that, but the idea that General Motors is facing bankruptcy
because of its health care costs is really earth-shaking in terms of people’s
sense, you know, that this isn’t someone else’s problem. [Laughs.]

So we see a business case which is fairly simple, as I said.
We believe that we can only keep the programs solvent and viable by focusing on
effective care and eliminating ineffective care. That’s a survival strategy.

I had a slide which seems to have gone to slide heaven.


DR. STEINWACHS: Do you recognize the other place, too?


DR. JENCKS: Well, since one can’t tell, one has to, I think,
have the positive approach, Don.


DR. STEINWACHS: Thank you, Steve. Thank you for being my

DR. JENCKS: But I think actually there is very strong evidence
that we can have major systems changes by addressing the quality issues. And I
won’t go into all the details on that because I think I’m preaching to the

A couple of perspectives.

One is, CMS is a public health agency. And Mark is very
straight and flat-out about this. And as he’s put it, that’s not a choice. We
have such an impact on the health of the public that our only choice is to
whether to be a public health agency thoughtfully or inadvertently. And we’re
trying to do it thoughtfully.

Second, pay for performance we see as absolutely critical, and
it’s not that it’s critical because we really think that we can, you know,
drive the bad ones out of business and make good ones rich; it’s because at
this point not to put a certain amount of resources on the table when we talk
about the importance of measuring things just belies our claims.

On the other hand, it might be that we’re not ready to do more
than one percent of the total payments, based on these measures. And that has a
lot to do with the concern, by the way, that I expressed earlier, that you’ll
run the places that are in trouble into even deeper trouble. This is enough
money so people will pay attention to it. Four-tenths of one percent was enough
money to persuade 98 percent of hospitals to submit data.

But it’s not, I think, enough that anybody is going to
legitimately claim that it’s going to run them out of business.

And, finally, I really want to just echo — first of all,
Jerod is absolutely right; we’ve got more applause from the hospital industry
which is who is affected by this for getting the measures to be the same
measures than we have for almost anything else we’ve done, you know?


DR. JENCKS: I’d like to say, you know, that — but it’s really

We don’t need to be encouraged, and we think that the
consensus as to how to do it is beginning to emerge.

One of the things that happened: Last September, all of a
sudden — it wasn’t on anybody’s radar screen —

the American College of Cardiology and the American Heart
Association produced a set of performance measures for cardiology and
cardiologic aspects of primary care. And they got more hate mail than I think
they’d ever imagined.

DR. LOEB: It was from me.


DR. JENCKS: No, sir! Yours was only a small piece of the pie.

And that was very instructive. I mean, the hospital industry
told them that this was unacceptable. J said it was unacceptable. And that was
very instructive.

I mean, the hospital industry told them that this was
unacceptable, J said it was unacceptable; we told them it was crazy.

And they very quickly sat down and said, okay, but we think
there are some things that are better about what we’ve done.

And we said, fine, let us all sit down together and
incorporate those things that are better. But don’t produce duplicate measures
with different specifications.

And by the way, out of that whole business, and out of the
work with the J, I would emphasize that alignment of measures is a phrase that
should not be used. We had aligned measures. They had the same names. They
appeared to be measuring the same thing. But the specifications weren’t the
same, and it drove the providers nuts.

So I think what you might think of in this, and I’m not sure
whether it hits with your mission, is the notion that the measures need to be
the same. And somebody said, you know, it should be like a software patch or a
module, you know? People can have many different systems but they should all be
able to just take the new version of the module and plug it in, you know?

I mean, one of the problems many of you, I suspect, know is
that people who write code in the face of something that isn’t quite right have
almost no self-control. They fix it. There can be a clear rule on the wall in
letters this high that say, “All system changes must go through the change
process.” You know, it’s uncontrollable.

So having the stuff published and having the software
standardized is, I think, a place we really do need to go. And I think we’re
all on the same page on this.

Now, we have five major strategies for transforming the health
care system — this is the way we’re going about it — and a whole bunch of
things that aren’t mentioned here. For example, an emphasis on prevention isn’t
mentioned here, obviously. The Part D benefit, which is really fairly
important, is not mentioned.

But working through partnership, and that means really working
in partnership with people, the traditional HCFA/now CMS partnership consisted
of saying to people, “We’re going to do the following. Would you like to
be our partners and do it, too?”


DR. JENCKS: So this is genuine partnership.

Measurement — and we’ve been talking so much about this, I
won’t reiterate it.

Paying for patient-centered care — we’re sort of trying to
get a little past performance. I mean, everybody performs, but what it is
exactly we’re trying to pay for.

The promotion of IT.

And an increasing process of creating and using effectiveness
data. Some of that may look a little exotic. It’s stuff like: When we cover
something, cover it with further effectiveness data required as part of the

But it’s also coming back and saying, all right; we now know a
bit more about what this is good for and what it isn’t good for. I think it’s
relatively unlikely that anything’s going to have its coverage removed as a
result of the data, but I sure do think the indications will change.

So the thing, though, that I would say, and I would really
emphasize this — I mean, Carolyn said IT is necessary but not sufficient —
none of these things is a magic bullet. And every year, or every couple of
years, we have a new magic bullet, you know? Four years ago at CMS, if we
publish performance data on everybody, the world would be okay. Now, it’s if we
pay for performance, the world’s going to be okay. And it takes nothing away by
doing this.

Now, you start off with a patient, and this obviously is
fictional because the idea that a system was built around patient is [laughing]
— you know, but nevertheless —

DR. STEINWACHS: We thought it was the provider, right? And
then the system —


PARTICIPANT: And the doctor’s name is Patti(?) and —


DR. JENCKS: Patti, V.M.


DR. JENCKS: But if you then say, okay, how does somebody, and
I’m thinking of CMS as an example, how does somebody like CMS influence this

And there are a series of things we can do. We can lead, and
that comes in a variety of packages. It is independent of whether we put money
on the table. If we articulate that this is where we’re going, it has a huge

We can afford standard methods. That includes IT standards, it
includes performance measures, it includes clinical guidelines.

We can promote partnerships. I’ve spoken about that a little
bit. It’s really central.

And we can provide technical assistance, which we do primarily
through the Quality Improvement organization.

We can provide public information, as we do by putting stuff
up on the Web and other ways.

We can structure the coverage and payment systems so that —
well, to take a very obvious sort of example, the decision to cover or not
cover email and phone contact could be a —

And we can reward desired performance. That means, you know,
pay for patient-centered care.

And, finally, which is what people always think of, you do
establish and enforce requirements, you know. You tell nursing homes that they
may not restrain a patient for the purposes of treatment.

So we don’t see a single magic bullet in this, and I only
emphasize this because I think it’s useful to constantly be saying, okay, how
might what we’re talking about right now fit in the context of other ways to
influence the system?

Oh, this is the sort of story about cost and quality and it’s
just — you won’t know this stuff; I’m not going to —

Now, let me talk about this Workgroup a little. I want to
thank you for letting me sit here over the last day and a half. It has been
really a pleasure.

You’re talking about the right things. You’re grappling with
the right issues. And you’ve made me think about some things in slightly
different ways and it’s worth the trip, to use the Michelin standard for a
three-star experience.


DR. JENCKS: I think if I understood the statement yesterday
morning, what we were being told was that the job was to provide actionable
recommendations that should take maximum advantages of the strengths of NCVHS
and should be, too, to have maximum impact on improving the system. Did I hear
that about right?

MR. HUNGATE: I think so.

DR. JENCKS: Okay. The big question I had as I listened to
that: Is this Workgroup focusing on the quality of the system or on making the
system such that quality improvement will constantly go on in it? I think
that’s a profound difference.

I would recommend focusing on the second.

I think, you know, the health informatics infrastructure
people and lots of other people are focusing on what make a system a good

Now, we might talk about measures. I said before I think you
want the measures that are based in the system you want to see. And I think
this particularly means that we have to think about how to measure two things
— we’re not very good at measuring at the moment — which are
patient-centering and efficiency.

You know, I mean we have a few trifling problems about price
of process of care measures, but these two are really real biggies.

And these things change rapidly. And what’s more, the ones we
choose are more likely to change.

It took me a while to figure out why we were having all this
happen when we had these wonderful measures which were based on rock-solid
agreement. Imagine, though, that we were to graft our move toward greater
certainty over time in some topic, let’s say the use of drugs for heart
failure, and so what we sort of like to think is — it goes like this: Now,
that thing might be a little more wiggly than that, but it’s nevertheless
envisioned as a monotonic, increasing function.

But the reality is not that. Reality is this: You may ask,
what are you talking about? What do you mean we’ve become less certain?

Well, somebody introduces ACE inhibitors, and suddenly we’ve
got — I’m sorry, ARBs — and suddenly we don’t know as much as we knew a few
months ago about ACE inhibitors.

Or, of a radically different problem, we have a list of drugs
for prophylaxis for colon surgery, and then we have a national shortage of one
of the drugs and some questions about some indications on another.

So it goes up and down.

Well, that’s wouldn’t be all that bad if it weren’t for this:
Do we actually select measures when we’re at this point? Uh-uh. That’s when we
say, we’ve got to unscramble this problem before we should ever measure it.
Select that, you know, select here.

And it’s very likely that having chosen something, but on this
opportunistic basis that we do for measures, and the opportunistic basis has
two features. One, what’s the data opportunity? And two, where is there really
strong professional consensus?

And what I’m saying is: Professional consensus doesn’t last as
well as it might, and it becomes subject to all sorts of controversy, you know?
Look at what’s going on with obesity.

So that means we need systems — I mean, this is just a way of
triply underlining what was said yesterday about the need for flexibility and
open loosely coupled architectures.

We also need, and I’m not sure that you folks would think this
was within scope, but I think you’ve really got to think about it, is figuring
out which things will self-organize. That is, out of the chaos you will get
self-organizing behavior, and what are the things that you need small or large
degrees of structure in order to assure that they organize?

And best of all, could we possibly have a little bit of a rule
or some guidelines as to which is which so we can tell up front instead of just
learning in retrospect?

The final thing about infrastructure, I want to just put it a
little differently, and I certainly agree that the data should come off of the
care system and off of the care process. But the basic rule of data quality is
lose it if you don’t use it.

Unused data rapidly deteriorates. The level of atrophy gets
very high.

And I’m just pointing that out because as you begin to use the
data, and particularly as you begin to feed it back, the quality goes up.

And I think that that is our most powerful tool for data
quality improvement. It’s better than audit.

DR. CARR: Can we have copies of these slides.

MS. GREENBERG: Yes, I’m sure.

DR. JENCKS: No, they’re mine. You can’t have them!


MS. GREENBERG: They’re in the public domain.

DR. JENCKS: Exactly. They are not copyrightable.

Let me urge you to think a little bit about the consumer role,
and it’s wonderful that Jerod comes back from visiting the United center,
because I think there are two models. One is what I’d call the “FAA
Model,” and the other is the “Consumer Reports Model.”

The Consumer Reports Model says that people are going to make
enlightened choices. The FAA Model says the system’s going to be safe and
effective, you know — you don’t decide between United and Southwest based on
whether you’re going to have a court action. And furthermore, if people started
to suggest that that would be a good idea, I think there’d be a good deal of
national push-back from people who have considerable political influence,
namely, passengers.

So then we have to say that as envisioned originally, the
selection of provider model has not really worked, and that’s what Bob was
saying yesterday.

And indeed this notion that you could refocus on the decision
to have the procedure rather than, you know, whether this was the best possible
person to cut on you is a possibility, and it is certainly also important that
we get advice which is past the denial of services model, and yet you look at
the work that Mully and Wennberg have done and it just hasn’t taken over the
world yet.

And we might think about, you know, whether it’s within scope
to consider how you could promote it over the world because clearly that joint
decision-making model is what a lot of us believe is not only going to save
money and produce more quality-adjusted light years; it’s also sort of an
ethical imperative.

And what I’ve come to think is that we face a very interesting
dilemma, which is that the consumer information model is really valid for only
a few consumers, and for them, that’s fine.

I mean, there are people who will go and look it up on the Web
and so on and, you know, we might think about the places that is most likely to
work, e.g., maybe when you’re choosing a nursing home for a member of your

and least likely to work, namely, choosing a hospital to go to
when you have a heart attack since, you know, the 911 people tend to make that
decision for you, raising interesting questions about what we’re publishing.

So then we have to face the reality, however, that this excuse
has produced a lot of very valuable change in the system. And I’m not talking
here about pushing the beta blocker rate from 45 percent to 75 percent. I’m
talking about the readiness of people to look at measures as having some
validity, to collect them, to report them, to begin to look at the systems that
underlie the numbers they have that they’re not as proud of as they hoped.

And we’ve got to work through, too, the problem that the
measures, although imperfect, have a lot of utility. And we clearly cannot
afford to wait for perfect measures. So what we have to do is be very committed
to the idea that: How are we going to improve them over time?

Now, what I haven’t heard anybody talking about here is the
importance of winning the hearts and minds of the people who play the game,
without whom this exercise is completely sterile. You know, it’s a reality that
physicians often just don’t understand what this is about. They over-estimate
how well they do things. They over-estimate their own rate as to change if
they’re not doing as well as they think they are. And besides, they’ve got a
lot of other irons in the fire.

It’s also true that CEOs — we just did a little survey on
this, reporting something in this to get out — think that the biggest obstacle
to quality improvement is the docs. The chief medical officers and the QI
officers have a very different perspective — they think the problem is a
system which doesn’t work very well.

And, finally, we have the problem of purchasers, and I’ll
start with CMS. You know, we’re not very good purchasers. The fact that we’re
purchasing from a broken system contributes to our not being good purchasers.
We’re desperately trying to figure out how to be better purchasers without
doing things that are politically unforgivable.

But the bottom line here is truly the bottom line, which is we
have to figure out how we’re going to make these changes pay off for the people
who invest, and I don’t just mean the people who invest money. Money is
important, but for physicians, the primary investment is not money — it’s a
money equivalent: Time.

I mean, who was telling us about what happened to —

DR. CARR: John.

DR. JENCKS: Was that John? Yes — anyway — and so there is a
huge purchaser issue here because at the moment there is very little mechanism
for gain sharing. I mean, we’ve got a coalition working on improving surgical
care. We think we can lower the rate of surgical complications by 25 percent.

When I suggested to various large purchaser that there needs
to be some gain sharing because some of this might cost some money and they
need to be at least able to cover their costs, the immediate response is:
Excuse me. We’re already paying too much. Now you’re telling me we’re paying
too much for bad care. And you want us to pay more?

It’s not a really interesting conversation, but we do have to
be thinking about it.

MR. HUNGATE: It is an important issue.

DR. JENCKS: So let me just conclude with a couple of comments
on systems thinking.

Again, don’t be timid. We’ve got to have the IT; it’s not
going to do it by itself, which means we’ve got to be fairly radical in our
thinking about how it’s going to be used.

We’re going to have to look across the board. This notion that
we’re going to have a measure here and a measure there and another measure just
isn’t going to get us where we need to go.

I didn’t believe 10 years ago that people could sub-optimize
by getting 20 measures to improve without improving their system, but they can.

Greg Meyer came up with this phrase; I like it very much:
“You people in A systems will always be A people in B systems.” We
need to sort of teach them that.

DR. STEINWACHS: We don’t believe that in health care, do we?

DR. JENCKS: Well, some of us do and some of us (Laughter).

DR. JENCKS: That’s the problem!

I think we have a major job to do, and I think, by the way,
it’s a job that you folks can really help with, in thinking about how to
reconcile systems thinking with scorecards and ranking. Scorecards and ranking
are not going away. And systems thinking is something we really want to have,
and we’ve got to define — and it’s one of those things where I think language
may prove to be a very important part of how we make it work.

Okay, and the final thing, which I think is, if you will, the
law of unintended consequences.

We’ve been doing some analyses of all the things — this goes
back, Carol, to your comment yesterday — that could really get screwed up by
pay for performance. You know, and how do you counter-balance that, because the
concerns are very legitimate?

We have to think about how we balance that stuff. That’s the
price of thinking radically.

Okay, and finally, now I’m just going to give some advice,
fully conscious that the biographical sketch of Socrates by an eight-year-old
back in the days when eight-year-olds knew something about history, which is
that “Socrates was a man in Greece. He gave advice. And they poisoned

MS. McCALL: Steve, can you talk into the mike?

We’re supposed to be recording all of this.

DR. JENCKS: Okay. I would urge you to look at this new
horizon, not at fixing gaps. And I’m saying this because that was a phrase, and
I can’t remember who used the phrase yesterday, but one of you did. That was
you? Or are you waving to Jared?

I can tell you my own experience, having worked in a lot of
organizations trying to do the kind of thing you’re trying to do, that if you
let yourself get involved in fixing the gaps, you will constantly get diverted
so completely from looking at the horizon that you’ll wind up just looking at
your feet.

MS. McCALL: Right.

DR. JENCKS: Secondly, I heard yesterday, and I absolutely
believe it to be true — that means, for purposes of those who are reading
notes that it is the systems quality interface that this group has an
opportunity to make a big contribution, and I don’t think there’s anybody else
about to do it.

I would argue —

DR. STEINWACHS: So, Steve, you don’t have the symbol up there,

DR. JENCKS: Well, all right — I’ll get it.

Actually, there’s a little problem with that symbol, which is
that there are some political sensitivities. That’s a lambda.


DR. STEINWACHS: It’s a good thing you came to counsel us.


DR. JENCKS: So the focus on patient-centering, because I think
we have little understanding of how well we’re going to be able to look at that
as regional, integrated information becomes available. At the moment, the
information problems in judging it are terrible.

The fourth bullet. If you want to promote the movement that we
want to see, one of the ways of doing it is the message: We think the present
system is in the process of going down for the third time. We’re not going to
invest in trying to make it better. And, you know, it wouldn’t be here by the
time we had reasonable things to —

That might not be true, but it might be a little

And, finally, that you really want to develop a vision in a
way which is complementary to the other people. And I emphasize that because I
haven’t heard it as much as I thought I might, you know. “Well, we don’t
need to do this because this is NQF’s job, and even if they aren’t doing it
well, the solution there would be to fix how they do it.” “We don’t
need to do this because there is an Office of the National Coordinator of
Health Information Technology and he’s working on it and we can provide advice
but we don’t have to do it.”

MS. McCALL: I think that’s spot on.

MR. HUNGATE: Yes, let’s talk about that for a couple of
minutes because it seems to me that if you’re yourself saying this is what we
think our role is, then you have to say what you think others’ roles are in
order for that to have coherence. Does that align with what you’re thinking?

DR. JENCKS: Yes, and I think you sort of have to have a rough
sketch and you need to be fairly sure that your sketch of somebody else’s role
is acceptable to them.

I mean, if you said that somebody was doing something that
they don’t think is their job, it’ll cause just unnecessary problems and won’t
help anyone.

MR. HUNGATE: Seems to me that that’s part of what we’re trying
to start working on here in terms of saying: How many visions do we have to get
an understanding of in order to get our own vision to fit, I think?

MS. McCALL: Yes. I also think it means —

MR. HUNGATE: There’s an iterative process there.

MS. McCALL: I also see it needs to be done not for this
Workgroup but for NCVHS, which just has an overarching purpose which has to be
complementary to the other parts, you know, kind of in the mall map of life?
And also has to go back to, you know, in your target practice where we had, you
know, Dr. Patti at the Center?


MS. McCALL: But can you go back there for just a second? Okay.
If that’s the toolkit, we also — that truly is a map. We have roles in some of
those areas, and so this can be kind of a visual to say, okay, where do we
play, you know, and what is our unique contribution to do things that won’t
self-organize? They will not happen naturally. You know, with a particular
focus on those.

So, yes, I think how we fit into this room here is critical.

MR. HUNGATE: Okay, floor’s open for full discussion.

MS. POKER: I just wanted to say really quick that another
roadmap that we have, that this group had, that we haven’t really talked about
is the IOM Patient Safety Report which also set a very specific roadmap. And
I’m not saying one’s better than another, but we do have a few roadmaps to kind
of select from. Just FYI.

DR. JENCKS: My comment on that is I wouldn’t judge that one
roadmap is a whole lot better than a roadmap from a different company or done
in a different way. It’s just how much more valuable it is than no roadmap.

And I think that if that is true in general for an advisory
group, it is just extraordinarily true because if you can lay out the people
and, you know, I mean we just took the IOM six aims not because we thought they
were the best possible statement of aims that anybody could imagine but because
we thought there’s a good degree of acceptance. If we use these and make
progress toward them, we’ve done good —

MS. McCALL: Right.

DR. JENCKS: — and people won’t saying, “Well, why
didn’t you use the IOM’s aims?

MS. McCALL: Right. Well, and there’s nothing that, you know,
creates success like success. So start where you are, get it moving, and it’ll
get there.


DR. STEINWACHS: I was impressed, Steve, that you made sort of
a center point here — patient-centeredness — even though we transformed that
into Dr. Patti, E.N.T.

And, you know, I took from that sort of the tension we have
and that, you know, we would like to think of a product like GM would like to
think it’s a car. We’d like to think a product is a person who is better off by
virtue of having been into and through specific health care processes, yet we
measure diseases, treatments for diseases, and outcomes that are generally
disease specific.

Could you talk a little bit more about how you think some next
steps might be that help us — you know, we’ll still stare at diseases and
metrics around those, but get back to the patient, because the patient doesn’t
necessarily experience what we think of in narrow diseases?

DR. JENCKS: Yes. I think there two kinds of issues that I
would focus on, Don.

The first is that I’m not sure that we, if we’re trying to
focus on patient, we do best to think about the outcome exclusively. The
process is really important to most patients.

I think of some work we’re currently doing on oncology care in
which the suggestion is that a huge amount of oncology care is directed at
patients who have failed the protocol treatment and now somebody is busy trying

rescue them. Well, they may produce on the average a bit of
life extension; it’s pretty small. They produce enough side effects so that
people’s last months are not a whole lot more fun.

And I think that we need to remember, too, and I’m going to
get a little philosophic here, but I think the philosophy is important, that
the word “clinical” comes from the role of the priest at the bedside
and that we are still, along with our many other roles, priests at the bedside
and that you have to then see that interaction as being a very important part
of what’s going on.

So that’s one piece. I would put a good deal of emphasis just
on their being a healthy relationship between the patient and the health care

And I use the word “patient.” Many people prefer,
and I understand exactly why, the word “person.” But
“patient” emphasizes to me a responsibility to consider a person who
is suffering, which is what the word “patient” means.

A second piece is that we have made, I think, a very
interesting mistake in our efforts to collect information from — and this
originally was beneficiaries, not patients, because it was started with managed
care in the CAPS surveys — which is we have used focus groups to ask other
people what they wanted to know.

In that process, we have often lost sight of the fact that the
patient knows things about the quality of care which we can’t get in any other

DR. STEINWACHS: And they put the pieces together.

DR. JENCKS: Yes. I mean, if you want to know whether somebody
was given enough education so that they understood their choices and so they
knew what they were supposed to do when they went home and whether they
understood that they had an appointment when they left the hospital, you’d
better ask the patient.

MS. McCALL: Right. Better ask them.

DR. JENCKS: The record is not the place to get this

And so I think a second part is to go back and ask the
patient. It’s a Francis Peabody thing. “Listen to the patient. They will
tell you what is wrong.”


DR. JENCKS: So those would be two pieces that I would really
focus on if we wish to become more patient-centered.

But I think the other part is the IT. I think the IT actually
is vital, because the notion that there is a patient record which is
independent of the place where you’re seeing the patient is really important.

I was in the Commission Corps for 33 years, and I got
accustomed to the proposition that I carried my record around with me.

DR. STEINWACHS: Not anymore?


DR. STEINWACHS: Not anymore?

DR. JENCKS: I still do. It requires some training of the
civilian physician. Anyway — but that’s another piece.

DR. STEINWACHS: Well said, Steve.

MR. HUNGATE: Bill, then Anna and —

MR. SCANLON: I was actually having the question before Don
asked it and you responded sort of like, exactly what is the patient-centered
focus going to involve in terms of a transformation? And your answer helps a
lot in terms of thinking in those dimensions.

But it also raises the question of whether we’re on dangerous
ground if we think that we’re going to make a complete substitution, because in
some respects, the patient-centered focus is so much more difficult to achieve.

When I first saw your toolkit, it seemed to me the tools were
a lot like the tools we’ve got today, in fact, if they’re not identical. But
you’ve given the re-definition of these tools that’s helpful.

But it’s going to be harder to get to trying to apply these
with a patient-centered focus all the time, and we talked yesterday about not
having the perfect, the enemy to the good, that we need to think about, in some
respects — this is a continuum — move in the direction, but we’re not going
to get there.

DR. JENCKS: I think that’s really well put. I mean, this is a
journey. And not only that, but we spend a fair amount of time actually
thrashing this back and forth because we were asking: What should CMS be doing
to push in this direction? And there are some analogies to the problems of
disparities, which is also a very patient-centered issue.

And what we concluded was that we wanted to make sure that we
were looking at policy changes and asking what their impact would be on whether
care was patient-centered. And for the moment, that would be a fairly powerful
place to start, you know, so that, for example, if you’re talking about pay for
performance, are you including CAPS-like data as a starting point in measuring

And, you know, rather than starting off and saying, well, the
way we’re going to fix this is we’re going to pay people to have happier
patients, instead saying, well, if we’re going to pay people for something
about how it was done, we are going to include this, aren’t we?

MR. SCANLON: And I think, you know, that bringing up CAPS kind
of raises a good sort of illustration of the difficulty we’re facing here. I
mean, we’re talking about the electronic health record as being an incredible
source of information that we’re going to be able to use. Now when we switch to
CAPS, we suddenly don’t have the electronic health record potentially.

And when we think about paying for performance using CAPS,
it’s much different to get information on a half a million physicians than it
is on 4,000 hospitals. That’s, I think, one of the challenges we have to think

DR. JENCKS: But in 10 years, what do we envision about the
feasibility of putting a CAPS instrument on somebody’s computer screen when
they do their email? I mean, I don’t know the answer to that question and I
don’t know that it’s necessarily the best way to do it, but I am saying we need
to think that the world we’re moving into is not the one we’re in right now.

DR. STEINWACHS: We’ll knock a dollar off your co-payment if
you answer the questionnaire, right?

DR. JENCKS: How about that one?

MR. HUNGATE: Yes, Anna, go ahead.

MS. POKER: I just had a clarification question, and I wasn’t
too sure that I understand. When you say you don’ want duplicate measures with
different specifications —


MS. POKER: — what are you saying exactly, Steve, with that?

DR. JENCKS: Well, let me give you an example from the work we
did reconciling with the Joint Commission, which was when we went in, for
example, there was a difference in the sequence in which you would look in the
record for a particular piece of information. So their specification said, if I
recollect, you look in the doctor’s order sheet; then you look in the progress
notes, and then you look in the nurse’s notes.

And the other specification said, first you look at the
progress notes, then you look at —

Well, you know, they looked at it and they said, “Give us
a break!” But when you actually went and audited, if somebody had done it
under this one and you audited under this one, they didn’t look so good.

So that’s the kind of thing I mean about specifications.

MS. POKER: Sequence, also.

DR. JENCKS: Sequence is an example, but —

MS. McCALL: There’s another, which is how you literally —
what’s in your numerator? What’s in your denominator? How do you calculate
them? How frequently do you do them? What is an outlier? What do you do with
missing data? All of those things that says, look, I may measure percent of
people that come out of the hospital, and yet there’s a lot detail that goes
into completely specifying that that can drive you nuts, and you will be apples
and oranges.

DR. JENCKS: If you can’t find a piece of data, does that mean
it wasn’t done? Or does that mean you exclude the case from both the numerator
and denominator?

MS. McCALL: What do you do?

DR. JENCKS: Both are highly defensible, but they’re not the

MR. HUNGATE: I had a couple of other questions of content. In
your graph on certainty, is that from the health care system view or the
patient view?

DR. JENCKS: It’s from the view of people writing measures.
It’s not even the system.

MR. HUNGATE: It’s just the measure certainty?

DR. JENCKS: Yes. The people who say, “I think we have to
re-evaluate this measure,” which looked like a very good idea six months


MS. McCALL: Back to that particular picture, I would say that
what we have on that picture is — whose point of view is it?

Sometimes we have what I’ll call a keyhole view, okay, because
I would say that that perspective is probably God’s view. You know, that’s the
only one that can step back far enough to kind of see that actually that’s
where we are. You know, we’re kind of going like this.

The other thing is that those time horizons, they’re so long
that I would bet you that sometimes what it’s going to feel like is zooming in
on kind of that curve right there, that sigmoid branch, and that what we will
feel are the G-forces of that acceleration at certain times over a very
compressed period of time. Our certainty is going to ramp up, all right, and
it’s going to be like [ahhhhh].

And then there are going to be times when it’s going to feel
like we’re falling right through the floor.

DR. STEINWACHS: Sounds like my investments in the stock market

MS. McCALL: Exactly.

DR. STEINWACHS: — and retirement accounts.


MS. McCALL: So I would submit to you that that time horizon’s
actually very long and that what we need to design mechanisms for is to keep
from falling into one of these stock market crashes and reacting to what is
going to feel like very fast acceleration or deceleration or, you know, kind of
climbing and falling, to get to the very point that you’re talking about, which
is where are the points that you set them? How do you react to what is going to
feel like sweeping change in a short period of time?

MR. HUNGATE: Another question. When you present your business
case, I have the feeling that maybe that’s a value proposition. Would you care
to comment on that? Is that structured in such a way that it starts to talk
about this value question that has come up?

DR. JENCKS: Well — now you’re talking about this. I really
went through that fast.

MR. HUNGATE: You had one that you called the business case per
se which — at least I think you did, yes. There it is. Focusing on effective
care, eliminating ineffective care. That’s kind of a value proposition, that
the value of effective care if far higher than ineffective care.

DR. JENCKS: It certainly is a value proposition, but I think
more value in the sense of value purchasing than in the sense of your values
are different from mine.

I don’t know very many people who think that delivering
ineffective care is desirable.

MS. McCALL: Yes, it’s true, but it’s a truism, so it’s not
terribly useful, you know, so to say that effective care is more valuable than
ineffective care.

DR. JENCKS: I don’t this is a big debate.


DR. JENCKS: The debate is how much money is in there?


DR. JENCKS: Is it enough to bring at least the growth rate
back under control? You know, and there would be different opinions on that.

MR. HUNGATE: Right. I have one last question before I
relinquish — we may be enamored with the need for a trusted advisor for
patients, that the complexity of the system we’re going to have is going to
mean that a patient is vulnerable and having a hard time grappling with it,
even if it’s patient-centered, and that we’re going to have to pay attention to
the trust factor in understanding how the conduit of information for the
patient is going to work, that that’s going to be a critical component of
achieving a patient-centered system. Does that make any sense?

DR. JENCKS: In two ways. First of all, I think you’re
reinforcing what I was saying about the basic model

of the priest at the bedside which I think is absolutely
central for most patients. And for those of us who have been sicker patients at
some time, it’s a very interesting experience how much it changes sort of how
you approach the world. So, yes, in that way.

There was a time, of course, when we thought that was the job
of the primary care physician. There is sometimes an effort to substitute a
nurse practitioner as somebody to whom people can at least talk and who has
time to listen as well as talk.

I think it’s absolutely true. It’s really one of the
malignancies of the current payment system that we have so emphasized. You
know, it’s like the lawyers talking about the tyranny of billable hours, the
tyranny of procedures.

MR. HUNGATE: I think it’s also interrelated with the certainty
of available information.


MR. HUNGATE: The information deficit impacts on the strength
that can be developed.

DR. JENCKS: Absolutely. There’s going to be a huge information
deficit. This is again one of the reasons why the role of the priest is so
important, you know.

In fact, our reliable information about what happens on the
other side of that great divide is very, very small.

MS. POKER: Steve, having chaperoned us through these two days
and having your vast experience — well, I mean, if you look at it with Steve
Jencks’s experience but maybe from a perspective of a potential patient or
historically you were a patient, what do you see? What would be like the
overarching thing that we have to make a selection agenda or issue that you
would wish for this group to take on for short or long term? Like what sticks
out for you?

I mean, you just kind of alluded to — did I hear
reimbursement? — that we haven’t really talked about, but, I mean, what would
be your wish, just to kind of, so we get the —

DR. JENCKS: Yes. No, I actually think that what I’ve been
hearing from the group is very close to what I would see as the right direction
to go, that I think that this is something which desperately needs to be done,
particularly if it can be done in what I would describe as a both highly
scientific and highly humane way and that this group is probably uniquely
positioned to do it and that there’s nobody else really doing it.

And so I would really encourage you to see if you can find
that as something, you know, over the next 18 months, let’s say, to really
develop a set of recommendations as to how we carry forward into this future in
a way that makes it more likely to work.

MR. HUNGATE: Related question. It’s a big task, in my
perception, that’s laid out there. Finite resources.

What resources do you think we’ll have to tap in order to
achieve that kind of a work product in a reasonable period of time? It’s the
doability question — you know, what have we got to bring that sort of thing —

DR. JENCKS: Let me put this two ways.

On one level, the need is sufficient and the current efforts
from others are sufficiently weak so that I don’t think I would say, well, it’s
only worth doing if you can bring X, Y, Z into alignment.

The other side is that I think there are a lot of people who
are really interested in this problem. They see a future coming. They think it
has a lot of potential, and they think we’re not planning very well for it.

That’s a major contrast to most other aspects of the future
where people think it’s a disaster coming and we have to do something to avoid
it. I think there’s a sense of hope and opportunity so that I think you can get
people to help you, that people will be very interested, and very varied

One of the things that’s fascinated me is — I’ve been working
in the last couple of weeks trying to get some aspects of the Surgical Care
Improvement Partnership ready for roll-out, and the interest of people in
participating, because they see that, you know, this is something with a
five-year time horizon; we’re not planning to do something tomorrow afternoon,
is really dramatic.

And I think if you said to people, you know, and the folks in
this Workgroup represent a variety of people that you could go back and say
this to: Look, we’re starting to try to think about how you plan the
informatics revolution and the quality revolution so that they support one
other. We’re not trying to plan the revolutions — we think they’re going to
happen. You know, we might think it could go a little faster, but we think
they’re going to happen, but how do we make them fit together? My bet is you’d
get a lot of people who wanted to help you in one way or another.

And then one of the limitations becomes, and I don’t know
exactly how you work this, you know — how can you organize the people who
would be willing to help? I mean, I know you’re able to do a little bit of
commissioning of papers, but I think it’s pretty —

MS. GREENBERG: Yes. Even — well, more than we used to be able
to, although, I mean, again we have finite resources. But one thing, I mean,
I’m wondering is if the Workgroup should engage — I mean, we have Susan

with us and sort of trying to pull this together for, you
know, work planning purposes, et cetera. And, you know, you might want to
continue to have a writer involved so that it — in fact —

MR. HUNGATE: Absolutely. It’s invaluable.

MS. GREENBERG: — so it comes out, it’s readable and all that.

But whether we would want to engage a real expert in this area
to kind of work with the Workgroup, I mean that’s one option.

And I’m not saying that we don’t have experts around the table
and that we’re not all dedicated, but someone for whom, you know, that’s a
piece of work for them and they’re committing 25 percent of their time or
something. I mean, it depends who it is and whether we could afford it, but —

The other thing I’m thinking — I mean, once you think this
through is — I don’t know that Steve had this in mind and I know that this is
not a time in which people are overflowing with resources, but it may be that
some of the agencies in the Department who are very interested in this and
have, you know, a lot invested in this might also be willing to put some
resources. Certainly, I think they will be willing to put some staff resources.
But if we needed more resources for, say, hearings or consultants or whatever,
they might be willing to put some money into supporting that. Or, the Office of
the Secretary, which already is the source of our funding for contractual work
as opposed to the care and feeding of the Committee, might find this
sufficiently worthwhile.

I mean, we’re not talking about millions of dollars,


MS. McCALL: I also think that part of the deliverable that we
should have in addition, as part of a specific working plan, a work plan, are
the resources and the mechanisms that we think we need in order to execute on


MS. McCALL: So, I think you’re right. I think that there’s a
lot of enthusiasm. I think we can tap into that vein. And I don’t think it’s a
lot of money. I think a lot of this is sweat equity on the part of people who
are going to be involved.

I also think that part of the work plan — there’s nothing
like creating your own future, and that when we think about some of the
mechanisms that we want to either create or to kind of create the who’s going
to do what that Jerod was talking about, that those entities will be impacted
in some way, and for better or for worse, I don’t know how, but, by God,
they’ll want to have a stake in that future. So there’s a natural, I would
hope, desire to work.

MS. GREENBERG: Yes. I mean, if you look at like the
e-prescribing effort which was just one area but it was big, and I mean it did
require having a lot more meetings than the subcommittees normally have, almost
every other month, most of the people came in and testified on their own dime.

Strategically, people who we’d need support, we support, but
generally you find that people rally around this, and so as long as you’re kind
of identifying what needs to be done and at a higher level and then not trying
to actually do a lot of the work, identifying who is doing it or could be doing
it, et cetera, I think it’s within the scope of the Committee, too.

MR. HUNGATE: Good. I think this morning has, again, been very
strong and very, very helpful in the range of what we need to grapple with. And
we’ve reached lunchtime, and the cafeteria is open, and we should come back at

[Lunch break from 12:33 p.m. to 1:22 p.m.]

MR. HUNGATE: Okay. We’re about ready to get on to the next
round of activity, and Steve’s dressing for the occasion, packing up, having
done his job admirably. And we are indebted to your help. Thank you very much.

MS. GREENBERG: Thank you very much.

MR. HUNGATE: How are we going to make it the rest of the way
without some chaperoning?

MS. McCALL: Oh, now we can really have some fun!


MR. HUNGATE: Thanks, Steve.

DR. JENCKS: I’ll remember that!

MS. GREENBERG: I told him he didn’t have a vote, so he’s
leaving, I guess!

MR. HUNGATE: Okay. Well, we’re doing very well, more good
content to add to the list, right?

MS. McCALL: This is great.

MS. GREENBERG: Yes, that may be one thing you want to decide
just before you do your ranking, I guess what you want to add from those last
two people.

Agenda Item: Perspectives on Morning’s Subject Matter
–Interactive Discussion – Ms. McCall

MS. McCALL: That’s exactly right. Just a little bit of a
process check. First, do we have everybody? Just kind of odd to actually not
have a discussion where we’re all kind of facing same direction and —

MR. HUNGATE: We can change the table framework.

[Workgroup members discuss, then realign the table for

MS. McCALL: So a little bit of a process check. It’s now,
what, 25 after? And we want to be done by, ideally, when?

MR. HUNGATE: Well, we’ve got to be done by four.

If we are able to finish before, but fine, but we’ll stop at

MS. McCALL: That’s a pay for performance!


MR. HUNGATE: That’s right. We’ll dock their pay if they don’t
get done on time, right?

MS. McCALL: That’s right. Nothin’ from nothin’ still leaves

Okay. And I think to Marjorie’s point, we have a couple of
things. And what we’ve said before is we kind of went into Jerod and Steve and
Carolyn’s. We have had some additional input. And I think like we did this
morning as we started, we want to see what we take away and what we would add,
so —

And that’s why you have these sheets here, okay?

So I’m going to make a recommendation in terms of process. You
guys give me some feedback; we’ll decide how to proceed.

One is to gather our thoughts from those speakers, much as we
did today, and essentially add them to this list, all right? And it could be
that we may find some redundancy with what is already here, that what we heard
just kind of confirmed what we’d already observed before, which is fine. And
another, there may be net new adds to the list.

So what you may want to do is just take a moment and kind of
reacquaint yourself with what’s here. It’s in a slightly different format, and
a lot of times memory is a very visual memory, so the way it looked up on the,
you know, flip charts may not be the same that’s here.

So I would recommend just take a couple of minutes. Read what
is here on these pages. Reacquaint yourself with them. And then we’ll go and we
will add our commentary to these, all right?

[Workgroup members spend several minutes reading the

MS. McCALL: Okay — how are you doing? Are you guys ready?

What we are going to do now — you may want to leave some room
on your pages so that you can almost mimic in a way that you’re comfortable
with. I’m going to put them up here, also on a flip chart, record the comments.
We’re going to put them all on the back wall because that’s actually where
we’re going to do this nominal group technique, and our voting.

But to actually enable that process, you’re going to want to
make little notes on your own sheet that kind of mimic what I’m going to do so
that you can do some private voting so that when you come up to the wall, you
know, you kind of know where you want to go.

Okay, so let’s just continue doing what we had done before. I
don’t know what sheet we’re on; I think maybe 10.

Think back to Carolyn and to Steve and to Jerod. What struck
you as —

MR. SCANLON: One of the things from Carolyn was the idea of
rewarding excellence, and the outliers. Truly the ultimate in quality, but it’s
not what we’ve been looking at. We’ve been looking at how you would treat the

MS. McCALL: So, the point being that we need to look at how to
reward excellence?

MR. SCANLON: Right. And for Jerod, I think the key thing for
me was the issue of maintenance process — how do get things current?

MS. GREENBERG: Maintaining and reconciling —


MS. GREENBERG: — he says, maintaining and reconciling. And
also, who sets the priorities?

MS. McCALL: So, how to maintain and reconcile metrics as one?
Another that I think you said, Marjorie, was some sort of forum for setting

MS. GREENBERG: Who sets the measurement priorities? Those were
the two main things —

MS. McCALL: Right.

MS. GREENBERG: — I took from him.

DR. STEINWACHS: Carolyn also raised —

MS. GREENBERG: And how are they set? I guess that’s sort of
“who,” but —

DR. STEINWACHS: — the distinction between what we do now is
looking at disease indicators versus a Baldridge kind of approach.

MS. McCALL: Can you speak up?

MS. GREENBERG: We can’t hear you.

MS. McCALL: We can’t hear you.

DR. STEINWACHS: You can’t hear me, oh — is the Baldridge
approach to quality versus indicator by indicator, disease by disease.

And the other thing she was very heavy on was prediction. It’s
not explanation —


DR. STEINWACHS: — but what are the predictive variables? What
it is that we are looking at that predicts performance, as different from
looking back and sort of disentangling.

MS. McCALL: Okay, so say that one more time. I want to make
sure that I catch it right.

Yes, she did talk about prediction, but the need is to —

DR. STEINWACHS: To have indicators that predict future

MS. GREENBERG: She said, do we need to learn more about
predictive power?

DR. STEINWACHS: That’s right. I think that was her point, was
that, you know, a lot of our measures may be better at sort of identifying
deviations than predicting what we’re looking for as what’s supposed to come
out of this system.

MS. GREENBERG: Do we have the educational role of NCVHS? Did
that come up after we did this, or is that already on here.

MR. SCANLON: Yes, we have a role on education.

MS. GREENBERG: At the end there? Oh, yes. We have here already
— we have a role in education. Then it says “translating successful
experiences.” But also I think explaining the value propositions, the
gaps, the needs, the vision — you know, it could be quite a broad educational
role, so I think it’s too limited here just talking about translating
successful experiences.

MS. McCALL: So, just —

MS. GREENBERG: The educational role. We already had on here we
have a role in education, “translating successful experiences,” but I
added to that explaining the vision, the value proposition, the need.

MS. McCALL: So, there’s a role in explaining and educating on
vision —

MS. GREENBERG: Vision, value. As Susan said, this is something
we actually talked about, and even brought in some marketers at one point to
talk with us about whether the Committee should undertake some kind of a
campaign on the value of information for research in public health et cetera
because of some of the privacy disconnects between the need for the data and
then some of the privacy concerns, but we didn’t pursue it, but anyway —

It’s not a new discussion, but I think it’s taken on new
relevance here.

MS. McCALL: Okay. What else? Yes?

DR. CARR: What struck me today and actually yesterday was that
we are all aware of the inadequacies of the current system, and I forget who
called for this — maybe it was Jerod — but if we cut to the chase of the next
step, we can resonate with the inadequacies of the system and maybe think of a
few, or integrate what people are saying.

But I’m wondering if our role isn’t to call for a national
coordinator of quality, and interest in sort of how that came about with NHII
or David Brailer’s thing. But was it Jerod who said it, that just to have a
final arbiter of what are the priorities, how are they measured, what are the
characteristics of measures so that we don’t have the growing little bit of
Tower of Babel in some ways, different words, different languages, different
goals, different metrics?

And I think actually it was Steve that said the volume of
factors are becoming unsustainable. And so, I mean, my take-away from this is
that there needs to be an organizing oversight of all of these agencies.
They’re doing great work but — and they need to be linked.

MS. GREENBERG: Can I — or are we just brainstorming now and
not —

MR. HUNGATE: We’re just getting the list.

MS. GREENBERG: I’d like to comment on that unless — okay. One
is that these would oversight — like Brailer, you could make the analogy
there, is really supposed to be a coordinator, not an oversight or an

DR. CARR: A coordinator is needed here, too, I think.

MS. GREENBERG: On the other hand, we have the

Agency for Healthcare Quality and Research and they
specifically put “quality” into its name a few years ago, and they’re
supposed to have the lead on quality where sort of nobody had the lead on HIT.

But he did say at the Office of the Secretary level; that was
his recommendation.

So I guess it’s a question of whether AHRQ should be further
empowered or whether it should be a separate.

DR. CARR: I’m just saying the concept that there is a growing
entropy and volume that is not sustainable and some entity —

MS. GREENBERG: On performance measures?

DR. CARR: Yes. And what we measure, why we measure it, how we
measure it, you know, and how we react to it. This is all of what we’ve heard
in these two days.

And there is no single person or entity. So I’m not saying it
has to be a new person or David Brailer or anything like that, but somebody has
to be accountable at the end of the day.

MS. McCALL: It’s kind of like you have to decide how we’re
going to decide, right?

MR. HUNGATE: That’s a thought, but it’s a debatable subject.

DR. CARR: Yes.

MS. McCALL: Okay, great. All right. What else?

DR. STEINWACHS: Like a group like us, right?


MR. HUNGATE: I have a couple of things. She made the
observation that the registry function is missing in EHRs, and I thought that
was a very important observation.

MS. GREENBERG: Was that Steve who said that?

DR. CARR: That was Carolyn.

MR. HUNGATE: Carolyn.


MR. HUNGATE: Steve also — or Jerod — made the comment,
“measurement is a byproduct of the care process.” I think that’s an
important thing which I think is aligned with Steve’s observation that we
should focus on quality improvement, not on quality per se. It was a clear
recommendation that he made, and it’s an important distinction. You know,
they’re interrelated.

MS. GREENBERG: I guess that relates to his statement that we
should reconcile a systems thinking with scorecards and ranking.

MS. POKER: You know, I’m just going to say something that —
Carolyn and Steve actually reacted to what we put on the boards for them. In
other words, we gave them a list of what was presented to us on the first day
and they reacted. I’m not sure if we would have asked them a different question
— we didn’t — what would they like? Well, Steve did get that question, of the
wish list.

I think Carolyn was specifically — I’m assuming — addressing
what we had addressed, you know, reacting to it. It’d be interesting to get her
comments without that list, what her wish list would have been.

MR. HUNGATE: Well, she added: What should I look for in a

MS. POKER: Which was in addition to?

MR. HUNGATE: Clearly in addition to. So I felt that she did
add the things that —

MS. McCALL: Okay. All right, we’re going to spend just a
little bit more time on this. I’m going to ask the question a slightly
different way now.

Think about what we’ve heard from these three people today,
and I want you to think back to what’s on our list so far. And I want you to
look for things that aren’t already there. What is brand new that you heard or
saw that we have not captured so far?

MS. POKER: I was fascinating with that bundles concept, and
that falls under the education piece, because I think that one of the things
that we’re missing is how to provide — how should I put this? — practitioners
with the right bundle, maybe right evidence-based data, so they do the right
things at the right time? It’s kind of hard to articulate, but —

MS. McCALL: Yes. I’m going to put down a couple of things. I
want to make sure I capture them right.

Within a bundles concept, it’s kind of process and outcomes.
There were some other things that were mentioned in there. It becomes a
knowledge management issue?


MS. POKER: Something that Kelly alluded to.

MR. HUNGATE: Integrated, self-reinforcing, synergistic.

DR. CARR: n, I’d like to sort of call the question of — I
mean, this is all stuff that’s going on very much in ICU care and the IHI and
all that. I mean, people who are doing this kind of care know what bundles are,
or the evidence, and so on.

And I just wonder — all of the things we heard today were
tremendous, with great value, but I don’t this Committee has a role in
adjudicating which of these techniques or data elements — I mean, again I go
back to just build the bridge with the electronic record and have someone in
charge of quality.

MS. McCALL: Right — okay.

MS. POKER: I was responding to her question which was what did
we hear?

MS. McCALL: And both points are very valid. And actually, as
soon as we’re wrapping up what we heard and what we saw, I actually — before
we go vote or anything like that — want to come back to that question
specifically about what our role is so we can vote properly.

MR. HUNGATE: Marjorie?

MS. GREENBERG: Well, in relationship to that, I guess, you
know, a question, and I guess what will be discussed, is to whether in fact the
Committee does feel it’s the role, kind of gotten all this input, to do what
Don Detmer suggested, and that is the kind of the keeper of the vision, which
might actually require kind of laying out the vision.

And so part of that vision could be, you know, not counting
things so much as looking more at these care — I mean, I could see the
clustering thing being part of that vision maybe but — or whether you just
want to make some very broad statements.

I did hear, I think universally, and actually did at the 2004
hearings, too, though they were more specific, but that there wasn’t anybody
who really said “we don’t really think is an area that the Committee
should be playing with.”

And not only that — I mean, they did say, look, there’s a lot
of people working in these areas, and you obviously don’t want to be
duplicative or you need to partner with people, and Steve made that point at
the end. But there did seem to be an overall appreciation for the fact that
there is kind of a void in pulling this all together, particularly the
systems/quality interface and the informatics/quality interface et cetera, and
that this Committee, there wasn’t a really major competitor for trying to
facilitate that, and that this Committee, you know, could very much be the
appropriate one.

So exactly what the “it” is not entirely clear, but
I think that’s reinforcing because I do think that’s a major thing we want
to get out of these two days — is there really a role for the Committee or is
everybody kind of, you know, on top of things?

MS. McCALL: Okay. Anything else?

MR. HUNGATE: Yes. Steve mentioned metrics for the


MR. HUNGATE: Metrics for the transformation. In other words —

MS. GREENBERG: Oh, right.

MR. HUNGATE: — if the visualizing, and in 10 years out it’s
going to be different, how are we going to know we’re making progress? And I
think that’s an important observation in content.

MS. GREENBERG: You asked what’s new that wasn’t already on
here —

MS. McCALL: Yes.

MS. GREENBERG: — that we thought that we’d mentioned? Because
I do think some of the things that Jerod said about how do we set measurement
priorities and what’s the process for maintaining and reconciling measures, I
don’t think we really talked about that much yesterday.

MS. McCALL: Okay. Yes, and I think we’ve got those captured.

MS. GREENBERG: I think those are definitely new ones.

MS. McCALL: Yes, they are new, absolutely. Anything else
that’s new?

MR. HUNGATE: In reading the list, I didn’t see the software
module idea, but it came back up again in conversation today.

MS. McCALL: Okay.

MS. GREENBERG: The what?

MR. HUNGATE: Software module. You know, once you learn how to
manage a set of detail, does it get implemented in a set of code which could be
put into various systems? It was a conception idea that —

MS. McCALL: Software, SW. So I’ll write down the idea of
metrics as a “software module.” I’ve got it as a companion to EHRs.

The one thing, the comment that I would make as a participant
here, is that this concept — Steve had talked about owning a metric, okay, and
owning a metric, I think, all the way down the bedrock, which is to say what it
is, why it is, it’s complete specification, can be done here, and you can also
assign ownership, who owns that particular piece that’s going to come in to
some sort patch or whatever it is, whatever module.

MS. POKER: Well, there’s something — this was sort of an
alluded topic, or an allusion to it, and actually I think it kind of came from
Justine. It was about cloning the New England group. And it was a kind of a

But I thought: Is that something —

DR. CARR: That was cloning John Halamka, imitating the
Northern New England group.

MS. POKER: That’s it. Right, but taking something that’s
excellent and replicating it or linking it up with people who are more

And I guess I heard it because this has been through my head,
but it was kind of referred to.

DR. CARR: I think it was Don, who’s very high on that. And I
think that group, you know, has created a model of collect data, analyze it,
and then modify behavior, and then collect more data.

But I would say, you know, what’s interesting in that group is
that when you get the data back — I think there’s seven hospitals in it — you
only know who your hospital is. They don’t tell you who everybody else is. That
was sort of interesting. But they are a collaborative and they work together.

It certainly has been a model. They were innovative, and the
concept, I think, is the one. It doesn’t have to be necessarily NNE.

MS. McCALL: Right.

MR. HUNGATE: I want to be specific in the semantics here
because I think the New England collaborative project is different from the
Mass RHIO, right?

MS. POKER: Yes, yes, it is.

MS. McCALL: Oh, I’m sorry. I thought you were talking about
Northern New England.

MS. POKER: That’s what I’m talking about, yes.

MR. HUNGATE: I believe we are.

DR. CARR: Oh, the RHIO, that’s the —

MS. McCALL: Northern New England Cardiovascular Study Group.

MS. POKER: I was talking about this one, yes.

Maybe one of the things we could do is take that model, and
how can we replicate it? Or can we kind of write maybe a recommendation for
short term, ways to replicate something that’s working?

DR. CARR: It’s interesting that it hasn’t been followed so
much, but the concept is that you refine, you measure something and you do
something with the information, and you measure it again. I think that’s really
the take-home message.

And where we are today is we have lots of measurement; we have
no idea what happens.

And the other thing with NNE is they link it to mortality.
They have five factors looking at mortality.

MS. POKER: But there has to be more to it, Justine, because
you know what? I think there’s something else they’re doing. They doing a good
organizational culture. They’re building partnerships. They’re doing other
things that work that obviously doesn’t work in other places.

So maybe a recommendation is to analyze that — not by us, of
course — and push it out there. I mean, just a thought. I don’t know —

MS. McCALL: A couple of thoughts that come up. You mentioned
the word “culture.” So there was some discussion earlier about kind
of the cultural readiness for measurement, particularly on the part of
physicians. So I think that there’s a need to look at what I’m going to call
here “cultural readiness” among physicians.

MR. HUNGATE: Or even to state it as “understand the
essentiality of cultural change.”

MS. POKER: Yes, and it’s not only limited to physicians, I
would hazard a guess.

MS. McCALL: Okay. There was another thing Steve mentioned
which I’d like to put up which is essentially “patient-centeredness”
and all that that translates into.

So, look at patient-centeredness and the impact on metrics et

There was one more, and it was they were using a lot of
analogies — airline industry, education — and I think there’s an opportunity
to look at outside ourselves for some wonderful analogies and bring those in.

DR. CARR: Well, it’s interesting. It didn’t come up today,
but, I mean, team training is one of the major safety initiatives, and very
tremendous involvement and partnership with United Airlines as well as other
members of the airline industry. And I think it’s being put forward by a couple
of national groups, maybe American College of Surgeons, I think, and —

MS. GREENBERG: What’s it called?

DR. CARR: No, it’s part of Don Berwick — isn’t that part of
the IHI thing, team training?

MR. HUNGATE: Probably.


DR. CARR: Institute for Healthcare Improvement. Finally, I
know an abbreviation that Marjorie doesn’t know!


MS. McCALL: Yes, put it on the list.

MR. HUNGATE: It’s Don Berwick.

DR. CARR: Don Berwick, Institute for Healthcare Improvement.

MS. GREENBERG: Oh, I know him. Institute for Healthcare

DR. CARR: Yes. There have been allusions to it. Maybe
everybody didn’t know this, but that at his annual meeting there’s always a
very thoughtful kind of call to arms, and this year’s call to arms was based on
the IOM report of 98,000 preventable deaths.

So he just roughed it up to 100,000 preventable deaths that
we’re going to prevent this year and that people were asked to pledge their
support of pursuing the five things that could reduce the unnecessary injury or
mortality, and they included line infections, ventilator-associated pneumonia
— what’s the other infection? — surgical site infection, then, let’s see,
rescue teams.

You know, somebody who’s getting bad that you have just a
S.W.A.T. team that comes in, all hands on deck. And maybe the other one —

MS. POKER: One more, I can’t remember.

MS. GREENBERG: Is it all for hospitals?

DR. CARR: Yes, it’s all hospital-based.

And Blue Cross in Massachusetts has given each hospital
$35,000 and you get $35,000 from your own matching funds to do this.

Interestingly, there is no metric — what the metric is: What
was your mortality last year and what’s it this year? And there’s no
consequence — like if you’re already doing four out of five things, you’re not
going to get that impact.

MR. HUNGATE: My suspicion is that we’re going to be thinking
of other things later on as we go through —

MS. McCALL: We will.

DR. CARR: We will.

MR. HUNGATE: — that we’ll add to this and —

MS. McCALL: Okay. All right, so I think we’ll round it out at
the lucky number 13. To me, I like prime numbers; they’re just great.

MR. HUNGATE: I agree with prime numbers but usually skip over

MS. McCALL: Oh, do you!


MS. McCALL: Okay, before we actually go through and try to
make some choices here, I think it would be important to go back to what
Justine brought up, and I think what we’ve been talking about throughout is our

Agenda Item: Organize Issues for Work Plan, Narrow
Choices — MS. McCALL

And so I think it’s important for us to think about not a
vision statement, not a charge statement, but just in particular: What are the
things that we can do, all right? What is it, our role, to do? What’s our role.

And so let’s just capture just fairly quickly some words that
we think describe what our role either is or could be, okay?

DR. STEINWACHS: One is providing a vision.

MS. McCALL: Okay.

MS. POKER: Oh, I have a good one.

MS. McCALL: What’s another?

MS. POKER: I love this one. It’s “brokers for
change.” Or maybe not brokers, but include for us to bring in change, you

MS. McCALL: Okay, so we are a catalyst?

MS. POKER: Okay. Catalyst for change.

MS. McCALL: What do we do?


MS. McCALL: Okay.

MR. SCANLON: Maybe related — my sense is we need to manage

MS. McCALL: Okay.

MS. POKER: What did you say? I didn’t hear you.

MR. SCANLON: You can manage expectations. It’s a key part of
this education because there is probably very unrealistic expectation that
exists on these sort of all parties’ sides, and that will be a great detriment
to making progress beyond the first steps.

MS. McCALL: What else do we do?

MS. POKER: I think we need to gather data. Before we educate,
we have to kind of collect information, or gather it.

MS. GREENBERG: Sort of — the word I’m thinking of — reaching
out to stakeholders, but, I mean, that’s part of gathering the information, but
sort of —

DR. STEINWACHS: Convening.

MS. GREENBERG: Convene — definitely convene.

MS. POKER: Convene.

MS. GREENBERG: See where there’s consensus. I’m not sure about


DR. STEINWACHS: Marjorie, really that’s you!

MS. POKER: Would you say identify major issues or identify
commonalities or —

MS. GREENBERG: Identify consensus and gaps.


MS. GREENBERG: Steve said don’t just identify gaps. He said,
“Don’t be timid.”

MS. POKER: Yes, but Don Detmer said —

MS. GREENBERG: Yes, so we’re not being timid, but just
starting with a vision.

MS. McCALL: Okay.

MS. POKER: — be the custodian of vision and gaps.

MS. GREENBERG: That’s right, he did.

MS. McCALL: Okay. What else? What else do we do? So let’s say
we do all this, like all the words on the page.

MS. GREENBERG: Well, advise, yes. Clearly, that’s what we’re
supposed to be doing.

MS. McCALL: Advise.

MR. HUNGATE: Advise the Secretary.

MS. McCALL: Advise. Okay, who do we advise?

MR. HUNGATE: The Secretary.

MS. GREENBERG: Secretary. But always it’s heard outside the —
I mean, there’s a long history of that.

MR. HUNGATE: And the public.

MS. McCALL: Okay.

MS. GREENBERG: But as for actionable items, there really do
need to be actionable by the Department, I mean some of them do, because that’s
whom the Committee is advising.


MS. McCALL: So, we advise the Secretary for action. We advise
the public for what? Education?

MR. HUNGATE: Yes, education.

MS. GREENBERG: Or, you know, action, too, because —

MR. HUNGATE: Catalyzing change. Most changes come from —

MS. GREENBERG: — as goes the Department, often so goes the

MR. HUNGATE: — the ground.

MS. McCALL: Okay. What else? Anything else?

MS. GREENBERG: Well, maybe a vision and a roadmap.

MS. POKER: That’s a good one.

DR. CARR: Yes. I just want to make sure that we’re very
concrete about the fact that there needs to be an intersection between quality
and the building of the electronic health record.

MS. GREENBERG: That’s the vision, I think, yes.

MS. McCALL: Yes.

MR. HUNGATE: How you feel about altering that term to
“quality improvement” and the electronic health record as opposed to
“quality” per so? You know, it was Steve’s suggestion.

DR. CARR: Are we ready to go into that?

MS. McCALL: I think we are. So let’s talk about why we did
this. All right, next we’re actually going to each of us individually and then
collectively are going to opine on all the things that are up on these sheets,
and they’re a little disparate. But we’re going to put some votes, some tick
marks, next to those things that we think are the most important.

Now, they can be incredibly important and yet it may not be
within our power. We may be concerned, but it’s not within our circle of
influence. We have to think about — again, we’re developing our own work plan
— what is within our circle of influence, as opposed to our circle of concern,
that we think that we can do, all right? So it being important is necessary but
not sufficient.

We start and say I think it’s important, I know it’s within my
circle of influence; I haven’t decided how yet. We’ll get there when we get the
specific work plan, you know? It could be important. It may be not articulated
on the page as something in a way that, say, we can influence it but in fact we
can because we’ll build a work plan around it that is about, you know,
convening stakeholders and finding consensus and gaps. So there could be a work
plan that is in fact within our line of sight.

But I think it’s important for us to understand the things
that we do so that we could sort of relate them to what needs to be done. Yes?

MS. GREENBERG: I’m not sure — just looking through my notes
to see if there’s anything we’ve forgotten — that this that Carolyn mentioned,
aligning the health record with the health research record, which was
interesting. She didn’t really expand that. And we’ve talked about identifying

But I don’t know if there’s anything explicitly up here about
identifying the need for research and advising on where research is needed, and
that’s partly what we know and what we don’t know.

But I think, you know, that kind of ties in with something
we’ve been talking about in the Executive Subcommittee, but —

MS. McCALL: Say it one more time, Margaret.

MS. GREENBERG: Well, identifying areas that need research and
advising on them. And it may be even suggesting priorities because we
don’t know everything.

MS. McCALL: Okay, at the bottom of the last page that we did I
am going to put just identifying areas that need research, okay, so that we
have it, so —

MS. POKER: A research agenda is really, I think —

MS. KANAAN: But isn’t a role, though?

MS. GREENBERG: Well, it is a role to identify gaps, but I
didn’t think the research piece maybe got picked up in the —

MS. McCALL: Right. And I’m going to put parenthetically, guys,
you can’t see it but it’s going to be an “ERR” — she talked about an
“electronic research record” as opposed to an EHR. Okay, and that may
be able to help trigger what it is, that whole dialogue.

MS. POKER: Yes, but I think also what Susan is saying that I
think is kind of important is that also falls within our roles. Isn’t one of
the things that we have to do as a Subcommittee is also feed into research
agenda information?

MS. GREENBERG: We’ve talked about that. I mean, I don’t know
if there’s a total buy-in, but —

MS. POKER: Yes, we’ve talked. I just want to put it on the

MS. McCALL: Okay. All right.

MS. GREENBERG: We kept hearing our experts saying, though,
there are these things we don’t know.

MS. McCALL: Okay, all right. So with our role in mind, and we
can just leave this up here, and with the priorities that you have on your
sheet already and the ones that we just did which, you know, if you’ve been
kind of taking notes or if you want to look — I think we started with the new
ones at Sheet 10. They have been numbered. So, 10, 11, 12, 13 are the brand new

We’re actually now going to vote, yes, before we start. You
had a question?

DR. CARR: Some of these are not voteable items. Some of these
are descriptive. Do you want to just see what’s on the list and what’s off the

MS. McCALL: Well, what I would do is I would just avoid them,
okay? I know, in an ideal world we would have actually been set up to do
something a little bit different, which is we would have gone through —

MS. GREENBERG: Grouped them.

MS. McCALL: — and grouped them using just what’s called an
“affinity process,” and then we would have done some nominal group
techniques off of that.

And in talking with Bob and looking at the clock —

MR. HUNGATE: We’ve run out of time.

MS. McCALL: — I think we probably would run out of time. So
you’re going to have to do some of that, take that into account as you go
through and vote. Avoid the ones that you think are redundant.

We will have some after the fact work to try pull other things
together that are subsumed in larger points. So as you go through, try to vote
for the —

MS. GREENBERG: The one that expresses it the best.

MS. McCALL: Yes.

MS. POKER: So is there a number of things —

MS. McCALL: How many votes do you get?

MR. HUNGATE: How many votes do we get?

MS. POKER: — everything that would be helpful?

MS. McCALL: It wouldn’t be helpful if you vote for everything.
So the question is: How large a number of votes are you going to get? And I
think you get 10.

MS. GREENBERG: This is like Chicago — you get 10 votes?


MS. McCALL: You get 10 votes. Vote early, vote often.

You can put all 10 on one. You can spread them around. It is
up to you. If you want to wait and hold back and you see somebody voting for
something that you don’t think is right, you can kind of, you know, use him to
kind of counterbalance that. It is all up to you.

MS. POKER: You know what I don’t have, though? I don’t have
the update of the new additions.

MS. McCALL: Understood, and that’s why you had the print-out,
so if you wanted to write them down, you can do that. They are on Sheets 10,
11, 12 and 13, okay?

MS. POKER: Yikes.

MS. McCALL: They are numbered. Ten and 11 are over here on
your left; 12 and 13 are on your right.

MS. GREENBERG: What, the new ones?

MS. McCALL: The new ones, correct.

MR. HUNGATE: And the time allowed is?

DR. STEINWACHS: Ten minutes — 10 votes.


MS. McCALL: Well, actually why don’t we take a little bit more
than that because there’s actually two distinct steps. So I’m going to say 20
minutes, okay?

So about 10 to go, make some decisions and look at what’s up
here. And then what I’d like you to do when you actually do vote, if you can,
pick a marker that is red, so you may have to share, or maybe we can get some
more. And I would like you to do it just with tick marks, all right, so that
they’re easy to see and easy to count.

MR. HUNGATE: All to the left of the label, right?

MS. McCALL: If at all possible.

MR. HUNGATE: If there’s a standard to be invoked —

MS. McCALL: Exactly.

MR. HUNGATE: — in this process.

MS. McCALL: Okay, any questions? Are people comfortable with
what to do next? I’m going to assume yes, great.

[Workgroup members cast votes.]

MS. McCALL: Okay, I guess starting here, these are the votes
that came in. What came up top? So what do you think? Does it agree? Do you
like it?

MR. HUNGATE: Are there any of those that are not a piece of
the vision per se? Is there any observation, anything, we’ve prioritized there
that is different from vision?

DR. CARR: I think the quality IT intersection is a very
concrete, tangible mandate. Yes, it’s part of the vision, but it’s really a
call to action that something happen. I see it as, you know, an important
separate entity. It needs to happen and no one’s doing it. So I would call that

MS. McCALL: Okay, all right.

DR. CARR: I mean, the vision — you’re saying, are these other
things — well, let’s see; what are the things we think go —

MS. McCALL: No, there are other ones that are distinct like

DR. CARR: I’m just trying to scroll down on myself.

MR. HUNGATE: Yes, I was just trying to do a kind of grouping

DR. CARR: Right.

MR. HUNGATE: — in my own mind.

PARTICIPANT: It would be a help to the Internet people to hear
what the list is.

MS. McCALL: Yes. Okay. Through this prioritization process,
what we’ve done is we’ve now voted, and we have 12 of a much larger number that
have surfaced as what we believe to be the highest priorities for our own work,
given the need that we heard about.

First one, going from top to bottom, it is the discussion
around quality and IT, the intersection between those two.

Second, kind of tied for second place, taking into
consideration the continuum and designing for the continuum from accountability
to learning that Brent talked about.

Another, also receiving five, the keeper of the vision.

Also receiving five, knowledge management as separate and
distinct from that infrastructure.

Receiving four was the whole dialogue around
patient-centeredness and how that is taken into account.

Also receiving four was the definition of value as opposed to
perhaps the definition of quality as a definition that we would want to work
with, define and then bring into the work.

Also receiving four was what we heard today about maintaining
and reconciling metrics, all that Jerod talked about.

He also talked about, which also received four, was who sets
the priorities and how is it done?

Receiving three votes, using IOM information to create a
balanced approach.

Also receiving three votes, that the vision should include
some sort of minimum. And again, these then become compressed, and there’s even
more full words over on the flip charts behind me and I’m struggling to kind of
see them here.

Also receiving three was cultural readiness among physicians.

Finally, receiving three, the role in explaining and educating
on vision, value and need.

So those are the 12 that received top votes.

There were others that received votes. They may have received
two, they may have received one; all of that information again is captured and
available. But these were those that received three or more.

So, summary done. Back to: What is a concrete deliverable? You
highlighted this one, Justine, and we’re starting to scan for other ones that
are concrete, you know, deliverables, things for us.

DR. CARR: I would set verification of who sets the priorities
and how.

DR. STEINWACHS: Which are more recommendations. I mean, that’s
a product from a vision and an implementation plan.

DR. CARR: Right.

MR. HUNGATE: I don’t think you can separate that from a
statement of a vision.

DR. CARR: Yes, you could. I think that the vision is that we
have a systematic progression, as opposed to a chaotic entropy.

MR. HUNGATE: Well, I could argue that point, that I think the
priorities will be set in a way from the ground where clinicians self-identify
the need.

DR. CARR: I’m just saying our vision can be about quality, but
a concrete deliverable is that there is a final arbiter, some place where the
priorities are set.

MS. McCALL: Right, okay.

MR. HUNGATE: Well, yes, but I’m saying that’s a decision that
we haven’t made as part of the vision yet, right?

MS. McCALL: No, understood. And what I hear you saying is that
that is actually putting something in place so that there is a who and there is
a how. That can be a concrete deliverable. It’s not ours to build, but to make
a recommendation around that.

DR. STEINWACHS: Around that piece of the vision.

MS. McCALL: So this is a concrete deliverable.

This has got some concreteness. This one’s got some
concreteness to it.

DR. STEINWACHS: Patient-centeredness give it a focus, too, as
it falls on the quality/IT intersection.

MS. McCALL: All right. Other things, other thoughts, as you
look through this?

DR. CARR: The educational role I think might be a separate

MS. McCALL: This one?

DR. CARR: I guess so. I don’t remember it being so quite like
that, but that apart, I think that’s a separate deliverable.

MS. McCALL: Okay, all right. Is there any one of these — and
we’re not trying to winnow them one more time; we’re just trying to wrap our
minds around what they are — are there any that you think you would eliminate
because there’s not a role that we have in there?

DR. CARR: Well, I think cultural readiness among docs is kind
of very — I’m not quite sure I understand. I think that’s sort of micro. I
think, in contrast, patient-centeredness, if in fact we’ve heard that and we
believe that, I think, you know, that makes sense to put that in the vision.

To speak to cultural readiness among docs, I don’t know that’s
ours to change. I don’t know what strategy we would put forward, what expertise
we’d have.

MS. McCALL: Okay. Yes, Don?

DR. STEINWACHS: Let me just talk on that because, you know,
part of the argument, I think, and I guess it was Steve who was making it, was
sort of there are two types of leadership — there’s transactional leadership
and there’s transformational leadership. And a lot of the things we do
incrementally are sometimes viewed as more of a transactional leader that’s
trying to get something done and out the end and so, you know, part of, I
think, that discussion about culture — it’s like the culture of safety — is
that is that part of a transformational process within organizations, within
health systems and society?

And so it depends on when you’d lay out a quality/IT
intersection. If this is some sort of transformational idea, does it require
certain things to come into place? And part of that may be like a culture of
safety for safety; there may need to be a culture of readiness to adopt. But it
talks to transformation in the way people think and function within health

DR. CARR: Well, I would then say “among clinicians,”
because there are nurse practitioners, nurses —

MR. HUNGATE: Well, we might want to even generalize it to
patients as well. You know, it could be the cultural readiness —

DR. CARR: Cultural readiness, yes.

MR. HUNGATE: — of a system for transformational change —

DR. CARR: I think that might be even more —

MR. HUNGATE: — might be the better way of articulating.

MS. GREENBERG: Do we relate it to the educational one?

MR. SCANLON: I think that’s part of the education. I mean, the
issue is, given our description of what our roles are, we’re not going to solve
any of these things, but we’re going to find out sort of how much need there is
for some of these things and then what might be the mechanisms to address it.

And so, I mean, and part of this idea of an education strategy
is in creating an environment where this is accepted.

MS. McCALL: It’s how we get at this.

MR. SCANLON: We need to think about all the different
stakeholders and how they’re going to view this, how they currently view it
that might need to change, and sort of think about strategies of how you can
change that, so —

MS. McCALL: Okay.

MS. POKER: Not just eliminating, but what would be short term
versus long term, and one of the things that comes into mind, this idea about
who shall set the priorities and how kind of falls in line with another one
that didn’t get up there, but appointing a national coordinator of something
like that.

But could be a short-term recommendation? Like do we want to
think that maybe making one of the short-term goals is to think about
suggesting to the Secretary who’s going to be — we can expand the role of an
agency or we can have one national coordinator or convener or whatever we
decide to call it. But that would be sort of a short term. That wouldn’t be the
long term, whereas the quality/IT intersection, that’s probably a longer term

MS. McCALL: Yes. Okay. And I don’t know. I think it’s a great
question. This is not a work plan yet. So, yes, and I think that that’s
something that we should definitely take into account.

What we’re saying is that we will take this information and
use it as a foundation to build a work plan, because this is what we want to
focus on. These become the focus elements of a plan; they’re not the plan yet.
And that plan has to have short term and longer term.

And each one of these may have short-term and long-term
components where we can make, you know, our own measured progress. We need to
also learn to exhibit that which we expound.

DR. STEINWACHS: You’re really raising the bar here.

MS. McCALL: I am. So I think it’s important for us to also
talk about, as a part of our own work plan, how we will gauge our own success,
how we will measure that, so that we can talk about that.

DR. CARR: I think Marjorie made a good point in sort of
saying, you know, we already have people who have accountability for quality
and so on, so I think maybe the one, the second from the bottom, that says
“who sets the priorities and how” would be more that someone, that
there is accountability and closure. I use “accountability” — well,
I’m not quite sure what the right word is, but there is a final word — that
there is someone who sets the priority, not who, but there is someone.

MS. GREENBERG: Right. Someone needs —

MR. HUNGATE: Well, related to that, I see missing from this —
well, maybe “maintaining and reconciling metrics” catches the
content, because there’s a very distinct interrelationship between that and the
priority aspect, it seems to me.

MS. McCALL: The other thing, I find myself wishing that — I
know that we worked with what we had in terms of materials and time and all
that — I find myself wanting to go back and pick up all these other points and
see which ones are actually subsumed in these, to kind of fill it out and flesh
it out. And each one of these, I think, if we take it now as a tip of an
iceberg, can be fleshed out not only with some of the points that are here,
which won’t be lost, but other things that actually make it richer, and I think
that those all become to-dos for us, so —

MR. HUNGATE: Let me ask Anna if it would be fair to ask you to
do that grouping of the next step of that because we probably can’t do it all
in this arena.

MS. POKER: I would take a stab at it.

MS. McCALL: Something for people to react to?

MR. HUNGATE: To react to, right, so that we have an iterative
back-and-forth. Does that make sense?

MS. McCALL: Well, depending on how have time, yes.

DR. STEINWACHS: Well, I always like to volunteer my friends
and colleagues. You know, it seems to me you’ve got a better sense than anyone
here maybe how to maybe take what we’ve done and do some clustering — or
essentially what you’re saying is take these —

MS. McCALL: Right, and cluster —

DR. STEINWACHS: — massage some of the others, and maybe with
Anna’s support. But it seems to me it’d be helpful if could sort of help guide
that and Anna work along with you —

MS. McCALL: Absolutely, okay.

DR. STEINWACHS: — because I agree, it’d be nice to come out
with some things that kind of lay the plan. And then I’ll owe you one!

MS. McCALL: I always love that capital. Okay, so I think that
brings us, agenda wise, to — I’m sorry?

MS. POKER: [Off microphone.]

MS. McCALL: Actually, we’re a little ahead of schedule.

MR. HUNGATE: Yes, you’re doing great.

DR. CARR: Like now do we have like Roman numerals because this
— I mean, Simon says we can have two, three, maybe four, that we put forward.
So what are they, because here he have how many, 10?

MS. McCALL: Actually, 12.

DR. CARR: Twelve. So we still have to get sort of the headline
for four of them.

MR. HUNGATE: Well, one of them is vision.

MS. GREENBERG: And I think several fit under that.

MR. HUNGATE: And most of those will fit.

DR. CARR: Right, absolutely right; I think so, too. I think
most of them fit under vision, and the question is what are the other ones that
we cull out?

MS. McCALL: Right. And so on that I think it’s important to
reach maybe not complete consensus but I’ve heard vision as one, which is kind
of like a Roman numeral.

MS. GREENBERG: Well, developing the vision.

MS. McCALL: Right.

MS. GREENBERG: Keeper of the vision I do think is a separate
thing, though you can’t keep it if you don’t have it.

MS. McCALL: We actually said our role was in providing a

MR. SCANLON: I guess I’m wondering if after you numbered the
first one, Quality/IT intersection, if everything else isn’t sort of a part of
the vision eventually.

And there’s really an issue which is: Shouldn’t we be working
on the first one and think of the rest as a menu that we will then make choices
from, as opposed to trying to pick a couple today and say, you know, this is
where we’re going to go for the next year?

DR. CARR: The only thing I would add is just the education
piece. I mean, if we believe that that part of what we should do is education
in addition to developing the vision. I mean, it’s not implicit that education
is part of the vision.

MR. SCANLON: Well, I mean, I think that in terms of trying to
implement the vision, there will be an education piece. I mean, and there’s
kind of various types of education, so — because I think that the discussion
where you and Bob were disagreeing a little bit is partly a question of where
you are. I mean, at 30,000 feet, I agree with both that — when we bring it
down to 15,000 feet, maybe then we end up with some conflicts, and so —

MS. McCALL: I’m going to make an argument for one more, for
actually a third thing to surface as something distinct, and I think there’s
some related pieces.

It has to do with “knowledge management versus
infrastructure,” but I think this is related to what I’m going to call
“maintaining and reconciling metrics,” which I see as related who
sets the priorities, because to me these are all about a mechanism to
perpetuate it forward. And I think that that mechanism is distinct from content

DR. CARR: And interface.

MS. McCALL: Right. So we have to have a vision and a vehicle
and a strategy — the vehicle being IT, the strategy being who prioritizes, and
a vision.

MR. HUNGATE: But the vision is of the knowledge management
issue, is it not?

MS. GREENBERG: Or of the quality/IT intersection.

MS. McCALL: Not totally.

MR. HUNGATE: Help me understand what’s different then. What’s
the separation?

MS. McCALL: I think the vision includes this —

DR. STEINWACHS: How quality and IT intersect.

MS. McCALL: — what this is. I think the vision includes the
definition of quality versus value. I think it includes concepts of

A vision is a picture that says “10 years from now,
what’s this thing going to look like?” And we’re going to say,
“There’s an EHR everywhere.” We’re going to say that it embeds, you
know, definitions of quality. And we’re going to say it has a mechanism for
keeping itself propelled and calibrated and all that kind of stuff.

So to say that everything comes in the vision is true but not
terribly useful, you know?

So we have to write one of these and create a mechanism to get
feedback. But these really are the two — you know, you always have to have
that. And so these become the two very specific things that we want to —

MR. HUNGATE: I’m comfortable with that.

DR. CARR: I was voting for three, to say that there’s a
designation of accountability. Right now, entropy is multiplying as we speak,
that the who is a separate and distinct kind of call for a mechanism and I
think we’re calling for, you know, the electronic health record as a vehicle
and an accountable party to prioritize what we’re doing because we have many,
many things happening at once now and it’s —

MS. GREENBERG: Well, it’s not just prioritized. I think it’s
to make sure that these things get standardized as the devil’s in the details.
You can’t have similar measures for the same thing. You really need to have —

DR. CARR: Right. But, I mean, what we heard from Jerod today
is no one is in charge —

MS. GREENBERG: Yes, nobody’s doing that.

DR. CARR: — and I think that was important enough to break
out of the vision.

MS. McCALL: Let me ask a quick question. So in your mind,
then, would you relate these three?

DR. CARR: Yes, could be.

MS. McCALL: Or would you just see the who as separate from
these other two?

DR. CARR: I don’t understand knowledge management versus
infrastructure. I mean, what does that mean? Can you use it in a sentence?


DR. CARR: And then I’ll spell it.

DR. STEINWACHS: It’s the trains and the trucks, the quality/IT

MS. McCALL: I think it’s what you said before, which is that
there’s a technology infrastructure and then there’s the knowledge management,
which includes the metrics and how you keep them maintained and —

DR. CARR: So I see that as part of the vision.

MS. McCALL: Okay.

DR. CARR: But an action item being absolutely that the
knowledge management has to have an owner and the infrastructure has to get

MS. McCALL: Okay.

MR. SCANLON: My one concern about taking on the
decision-maker, or the person who’s going to set priorities, or the entity
that’s going to set priorities, very early on is that it’s going to be a very
controversial area, because you know what we heard this morning from Steve was
that part of this is where there is a concern about sustainability of Medicare
and Medicaid from a cost perspective.

And, you know, we’ve got a history. I mean, the predecessor to
(?) in terms of whether they could be trusted — you look at effectiveness
within the Department; the Department is a funder or payer. And Steve suggested
that we need to get beyond that mentality about worrying about whether people
are making decisions based on the cost. It’s going to be hard to get beyond
that mentality.

And so this is something where I think we’re going to need to
get a lot of outside input in terms of —


MR. SCANLON: — writing a report and making a recommendation.

DR. CARR: But, I mean, wouldn’t that drive our hearings?

MR. SCANLON: Right, it will. But I’m thinking in terms of our
shortest-term product, it’s not going to be one that we’re going to be able to
say much about.

MS. GREENBERG: I would think at this point we could have
findings on that topic, the findings being that there is no one in charge in a
sense, that people with developed systems are saying, we don’t know exactly,
you know, where to put our emphasis now because there’s too much diversity;
that some measures are competing with each other.

You know, I think there are a lot of findings that we could
identify. I don’t think we’re ready at all to identify a solution, but I think
the hearings —

DR. CARR: But define the current state, yes, define the
problem. Anna?

MS. POKER: I was going to say also that one of the things that
comes out here is the value, and Carol rolls it up really nice into — I forgot
— with quality and IT, I think you’ve rolled into.

I’m not sure if we can’t think of value, the definition of
value, as being an important segue to what you’re involved with saying, in a
sense that the reason we need somebody as the keeper of the knowledge
management information is so people don’t have redundancies like Steve was
talking about, unknown to anybody, I forgot which organization came up with
sort of metrics and that caused a whole lot of havoc.

So maybe if we could have a business case for why somebody
should be overseeing that, that would be —

MS. GREENBERG: I have a feeling it has to be public/private,
too, although —


DR. CARR: Exactly the problem, it was public/private.

MR. HUNGATE: Yes, if you can define a process, then you can
assignment ownership of that process somehow in the system. Whether that’s a
single point or a multiple point is a secondary decision, it seems to me, and
that’s the part that I wanted to make sure we didn’t get into a corner on, that
it’s a process decision that’s the important thing, because as soon as you’d
name a single point of control, you’re into a heavy political battle on all

MS. McCALL: That may help — this is a process, okay.

MR. HUNGATE: The other place where I’m worried about that is
whenever we say “quality” and then we start to define it, we’re
saying that we’re going to reconcile quality definitions. And we can’t do it,
because quality is going to be dependent on the perspective of the measuree.

DR. CARR: Are we saying that, that we’re going to — what are
we saying?

MR. HUNGATE: Well, we said quality versus value —

MS. McCALL: We said quality versus value as —

MR. HUNGATE: We may have to be careful of that is all I’m
trying to express.

MS. McCALL: I’m going to make a recommendation because we, in
terms of use of definition, we get hamstrung there. As a guiding idea, again
not to try to define quality or even try to define, you know, kind of put it on
the page — that’s a rat hole that we’ll never get out of — but if I augment
that to say “quality versus value as a guiding idea” in how we go
through that —

MR. HUNGATE: Yes, but let me pick up a little bit on some of
our history. Peggy O’Kane from NCQA made the observation in our earlier
hearings that they have found that it’s better to talk about performance
measurement than quality, that it works better in the dialogue.

Performance measurement ties better to quality improvement,
and so I’d like to be as precise in our terms there as we can, because I think
we’ve got to try to link to the continuum that Brent first introduced for us
which puts the learning side, which is the quality improvement side, as the
core element. So partly I’m trying to say how we articulate it, the medium is
some of the message.

MS. McCALL: Okay.

MR. HUNGATE: Does that make any sense?

DR. CARR: Yes.

DR. STEINWACHS: Well, I guess all I would add, and I don’t
disagree, but it seems to me you do have to at least start out with a quality
framework and then move to performance measurement.


DR. STEINWACHS: And I would suggest the 1990 definition of the
IOM came out for quality, also brings in the patient’s expected and desired
outcomes. And so — whew (whistling) — too dangerous. She’s ticking!

The 1990 IOM definition brings the patient into that, so it’s
not just professional judgment; it’s also the patient’s expected — and so I
think that that could provide sort of the big umbrella and then you could move
to performance measurement.

MR. HUNGATE: I’m comfortable with that.

DR. STEINWACHS: I think dealing with performance sometimes you
usually think of it as only a process —

MS. McCALL: Yes. Stan?

MR. ETTINGER: Or maybe can’t you make it a role of quality
measurement in determining value, or something that’s — so it’s not
“versus” or “is” —

MS. McCALL: I’m sorry — say that one more time. “The
role of –“

MR. ETTINGER: Quality measurement in determining value, or
something along those lines; it’s not one versus the other or defining both of
them. It’s sort of the role leading to the other.

MR. SCANLON: I think value was introduced yesterday with the
idea that we are going to take into account cost.


DR. STEINWACHS: The outcomes.

MR. ETTINGER: And very different than if we just focus on

MS. McCALL: Right. So I think what I’ve done is added a couple
words here that say just change the definition on the page so we know when we
come back to it what we mean, quality measurement in determining value as the
definition, and then a couple of other words here. Just that language is
important as well, to kind of capture that idea.

DR. STEINWACHS: Maybe it’s one of the factors.

MR. SCANLON: Can we go back to it for a second, go back to
this issue —

MS. McCALL: A few more minutes here and then we’re going to
kind of go on to the next stage. Yes, go ahead.

MR. SCANLON: — because it’s a question of accepting value as
the objective, I mean, and whether or not we’re going to take costs into
account. I mean, this is a controversial issue and it may be critical, and if,
you know, General Motors is going bankrupt because of health care cost as we’ve
mentioned this morning, that brings attention to the cost, is a legitimate
dimension. But up to this point, it hasn’t been recognized as a legitimate
dimension in many contexts.

MR. ETTINGER: It is a CMS/AHRQ issue again.

MS. GREENBERG: I think it’s — well, it takes me back to the
ICD-10 discussions. But if you’re going to take cost into account, you have to
also find ways to quantify benefits, and that has to do with the education part
et cetera.

It is always easier to quantify the cost than the benefits, so
that’s why it’s like the value proposition. The value is not just how much does
this cost? I mean, it’s trying to weigh that against benefits that are much
harder to quantify. But there is scenario development and there’s some
examples, I think we heard a few — you know, we know Bradford Middleton has
done a little bit of that with IT or whatever — so I think that’s an area for
research, frankly.

But I think when you’re saying you’re taking cost into
account, because how can you not, but there are costs and benefits. And then I
think it’s sort of, you know, cost effectiveness.

But I actually wanted to say two other things. One is that I
think when we bring all these things in, it will clarify a lot of the things
that we maybe think are missing or won’t be or where there’s really lack of
clarity — that will become more obvious, also.

MS. McCALL: Something else that we need to spend a little bit
— and background.

MS. GREENBERG: And one thing that I’m not sure was even up
there, but, of course, as Anna said, you hear what you want to hear, one thing
that was really striking to me, particularly coming from the people that it
came from yesterday and today, was the focus on a population perspective and a
public health perspective in a very broad way.

Don Detmer, who didn’t start off there, came out with that
quite a bit yesterday, and Steve Jencks. I mean, this is profound in a way that
they’re saying CMS is a public health agency, because I was at a Data Council
meeting a number of years ago when a previous CMS administrator who actually I
would have expected to have this perspective said HIPAA has nothing to do with
public health. If HIPAA has nothing to do with public health, you know, does
quality have anything to do with it?

Clearly, we’ve gotten past that. But I think that we want to
make sure the vision has that perspective in it, and I’m not sure there’s
anything up here that says that — I mean, unless you don’t agree with it. But
I certainly heard it from people. It wasn’t public health people or population
health people who came forward and said that in the last two days; it was more
people on the provider side, payers, provider side, so —

MR. HUNGATE: We’re going to need to take a break.

MS. McCALL: Yes, okay. Before we do, and this will be an
incentive for us to do so — obviously there’s a lot of work to clean up and
bring together and all of that — I would like for us to end this part by being
able to come up with either two or three things that we believe are going to
form the foundation of our work plan. And I’d like them to come from this list,
and we have a couple of candidates here, all right?

One is the quality/IT intersection — I’ve heard one. And if
we were going to stick with two, I’ve also heard the second one to be kind of
who does this, and how, as a second part of our work plan, to try to go figure
that out and make recommendations on that.

So that’s what I’ve heard so far.

MR. HUNGATE: I’m not sure you can separate the who from the

MS. McCALL: Okay.

MR. HUNGATE: The knowledge management —

MS. McCALL: Okay, so that some of these things get bundled
together and that’s why.

MR. HUNGATE: I think so, yes.

MR. ETTINGER: It might be politically and strategically not to
make it look like we’re picking people in the Department or somebody. So it may
be nice to roll it in as combined with —

MR. HUNGATE: Yes, I think we’ve got to stay content-centered.

MS. McCALL: I think so, okay. So it’s really kind of a who and
how, with the understanding that it is about a knowledge management process?

MR. HUNGATE: Right. What are the components of a knowledge
management process?

MS. McCALL: Yes.

MR. HUNGATE: You know, we didn’t put decision support up
there, but it’s one of the pieces that ties into that, so —

MS. McCALL: It is.

MR. HUNGATE: — when we blow that up a little bit, it’s going
to get pretty good size.

MS. McCALL: It is. All right, so here’s two, and this one’s
really big — it’s got some sub-parts that include mechanisms and how. It’s
that intersection and then it’s basically how you get it defined and then how
you keep it going, okay. And those would be our two big.

MR. HUNGATE: You know, in the quality/IT intersection, the
observation that there was no provision for registries in the EMR is a pretty
big hole.

MS. McCALL: Oh, yes.

MR. HUNGATE: So, you know, that raised a red flag for me that
say, hey, we’ve got to get that on the agenda early, and which links to the

DR. CARR: Remarkably, I don’t agree.

MR. HUNGATE: Really?

DR. CARR: I mean, maybe it’s my concept of registries, but I
mean I think we’re sort of at the point of how can IT have quality data and
what kind of fields and flexibilities. But when you say “registry,” I
don’t know —

MR. HUNGATE: Let’s try to come to agreement on terms, because
it seems to me that I can argue that the Northern New England cooperative group
in effect has a registry which is called a database.

DR. CARR: Right, but they have people hired in each
institution with very specific definitions and the same person who’s in the
cardiac surgery registry might be in the CABG or the — I mean, the heart, you
know — and everybody might have a little bit of heart failure. I mean, this is

I guess it’s really what registries, what patients, toward
what end.

MR. HUNGATE: Knowledge management.

MR. SCANLON: Could I offer my confusion, which is the idea
that if the electronic health record has the data element, isn’t the registry a
software module?

DR. CARR: Right, a query.

MR. SCANLON: It extracts the elements that you need. And I
don’t know how you design an electronic health record that has everything else
but doesn’t have a registry, a pass-key to it. What are you leaving out?

DR. CARR: Well, you have data elements that then be queried,
and so you create fields that are flexible fields so that if a person’s
admitting diagnosis is this, these fields pop up. So maybe that’s what you’re
saying. But a registry to me is a static, unwieldy thing that you think is a
good thing and then you’re stuck with or you have to change.

But to have flexible fields that you can query, you know, in a
real-time basis —

MS. McCALL: One comment. Okay, this has been really, really

MR. HUNGATE: Semantics are important.

MS. McCALL: Yes, but they are important, and I think we’re
going to get there. I don’t think we’re going to solve this here.

I would offer the following comment, that they are so
important that when you said the word “registry,” what we got was
somebody else go, “Oh, my God.” And what you have is a mental model
of all the pain that the historic frame of registries have created.

And I think one of our biggest opportunities, as well as
challenges, lies in trying to break the frame of what we’ve walked around with
for so long when we talk about what this means.

So I’m going to recommend that we not continue to try to
define that right now but just recognize it as we’re going to stumble over that
at every single turn and we’ll have to kind of work through those.

I want to make sure that basically, Bob, you have what you
need when you go to this Executive meeting, which is at least a foundation for
a work plan.

MR. HUNGATE: I think we’re partly there.

MS. McCALL: We’ve got that.

MR. HUNGATE: We have a foundation for our work plan. I think
we can express a set of goals from that.

But a work plan is, okay, well, what are you going to do?

MS. McCALL: Right. Now we are now at a point where we can take
a break for, I guess, 10, 15 minutes?

MR. HUNGATE: I haven’t gotten anybody down to 10 yet, so let’s
go for 15.

MS. McCALL: Okay.

MR. SCANLON: Oh, the same for five.


DR. STEINWACHS: It’ll still be 15.

MS. McCALL: And then I think it’s all about next steps.


Agenda Item: Work Plan Development,
including Next Steps – Mr. Hungate

MR. HUNGATE: Okay, we’re on our way.

DR. STEINWACHS: Do you want me to say something about the
population quickly —

MR. HUNGATE: Yes. I think we’re on an excellent track that I
think is going to play out to our combined satisfaction. I applaud everyone’s
contribution to this dialogue at this stage.

DR. STEINWACHS: Thank you for our leadership and our


MR. HUNGATE: And I think we’ve got buy-in from CMS and AHRQ in
our endeavors, and I think that’s going to help us make this come true in a
very real way.

So Don and I have been talking back and forth about what we
try to do here and what we try to do in Populations. I think it’d be worth it
to take a few minutes now to talk about that because we’re going to talk about
it further at the retreat of the Executive Subcommittee, but, you know, we
ought to talk about it a bit here first, so —

DR. STEINWACHS: Well, you know, in the great wisdom of the
NCVHS, and Marjorie, no doubt, it was her guiding hand, there’s a lot of
overlap between the Populations Subcommittee and the Quality, and so early on
Bob and I had discussed that it seemed that if we were going to proceed, there
ought to be a lot of complementarity in the agendas of the Quality Workgroup
and the Populations with the kind of distinction, as you might expect, that you
might think of the Quality Workgroup as putting more emphasis on interactions
between individuals and medical care and the health system and the Populations
Subcommittee focusing more on population health or groups, and, you know,
there’s a strong interrelationship between those two, but both in terms of
metrics and terms of what you think of ERH, other things supporting the issues
in population health are different.

We are a little behind schedule at least from where I’d hoped
to be at one point in the Populations Subcommittee addressing the agenda, so I
see us as benefiting from this discussion going on here.

We are trying to put to bed, as you know, the report, racial
and ethnic, the measurements, and being able to have the capacity to look at
disparities, and so I’m expecting that that will be going — I’m hopeful if it
gets through the Executive Committee, we’ll be going for a vote and
presentation to the full Committee in June, end of June.

I thought at the Populations Subcommittee at the end of June
is we would be talking about the Populations Subcommittee agenda, and so I’d
love to say that build off of this discussion.

Also, Marjorie and I have been approached by an interagency
working group that would like to see the Populations Subcommittee maybe take on
functional status measurement around the area of disability, and so I thought
that would be on the agenda for discussion.

But I would like to see some complementarity because I don’t
think most of us as individuals will survive this process if, since we’re
working on the same things, unless there is some strong complementarity or

it’ll probably slow down both processes. So I’d welcome other
comments, but, you know, Bob thought and I agree that it’d be good just to try
and get us to think a little bit about how the two things fit together.

MR. HUNGATE: Observations, comments?

MR. SCANLON: I’d feel very positive about that kind of an
approach because my sense is we’re going have a vision and in some respects
we’ve already laid out a bit of the vision in the matrix and that, you know, we
didn’t identify population health as part of one of the dimensions.

And, frankly, once we’re beyond sort of the vision at 30,000
feet, we are going to have an incredible amount of work in dealing with each
one of the components. And the idea that our time on Populations and Health
Subcommittee, not that we’re doing sentences, but —


MR. HUNGATE: You are serving your time.

MR. SCANLON: We’re serving our time!


MR. SCANLON: And our time could be spent in a complementary
role. To try and work through some of the other details here I think is a very
positive thing because otherwise, I think, one of our next steps is going to be
a long list of areas that we could potentially investigate and think about what
our role is. And we’ll be able to say that we’re sharing some of that list
between the two groups.

DR. STEINWACHS: You know, I think a lot of people would be
interested, if we were willing to take it on, about what our vision is for the
intersection between EHR and population health. And it sort of talks to both
the potential and the limitations, and then that helps talk to where our
national health statistics, other things, fit in.

And so I could see, if we wanted to do it, sort of that
complement so we were building two things along the way that paralleled each
other but took a different sort of lens to this.

MS. POKER: Don, I was also going to emphasize — you weren’t
here yesterday, but Ernie Moy from AHRQ actually made a request for that, not
specifically that population, but he talked about including disparities data in
the EHR. And even though he said we’d probably be opening up a whole array of
other problems, that’s how important that is, and also customizing information
for different audiences.

MS. GREENBERG: Yes, he mentioned that disparities was part of
the quality equation, which of course it is.

DR. STEINWACHS: Well, you know, I think we sort of talked
briefly before that certainly the two reports that come out of AHRQ, the
national quality report and the disparities report, are in essence the effort
to do a population look at those issues that also can expect to be looked at
within organizations and within health plans and so on.

And there’s some real weaknesses in those reports because of
issues around data and, you know, how thick the numbers are when you get down
to the different subgroups and so on. So, again this idea of are there ways in
which EHR might help support that is one way to go. The other certainly is to
look at our national health statistics capture capacity and the fact that it is
failing to be able to fit in lots of pieces in that quality and disparities
equation as it addresses health status and utilization.

MR. HUNGATE: Okay. Any other comments, suggestions, there?

We’ve got a lot of “what” content in front of us and
almost no “how” at this point. And in my experience, a work plan has
a lot of hows.

It seems to me that our challenge now is to think about how we
get the content addressed by other interested parties in a topically related
series of information-gathering processes. And one of the first decisions is
where do we start, and how do we do that?

We’ve got a good start here in terms of the spectrum of
content of vision. One could say, okay, what are the parts of that vision which
are haziest to us? Can we describe what they are and can we think about what
people could help illuminate that part of it?

DR. CARR: Well, I’m thinking back to yesterday. I forget who
it was who said in terms of IT and of quality data elements that getting a
group together that included David Bates, Brent James — there are fewer than
10 — sort of thought leaders and to brainstorm with them and with John Halamka
of how do you take this information — I mean, I’m hesitating because I guess
we’re still wondering — well, I mean, perhaps just define the array of data
elements that would be achievable in an electronic health record. I mean, that
might help even being an organizing focus. You know, some things are probably
going to be out of scope because they’re too complicated but some things are
and what format.

I don’t know. I just think of that as a concrete step I heard
yesterday and I think it would be very informational and it would begin to
warrant thinking in the direction of how you structure that kind of area.

MS. GREENBERG: Can I just push that up one, to kind of define
the questions that you might want electronic

health records to answer or address, and then from that, I
guess, the data elements. And the idea being, you know, much as I love data
elements, when you start with the data elements, you sometimes lose sight of —

DR. CARR: Well — or maybe even using what Don Detmer
suggestion. Of course, including Don, you know, in terms of safe, effective,
efficient, IOM dimensions, using that because I guess it is a slippery slope. I
mean, we’re sort of struck by the fact that there are a million definitions and
permutations, and so if we wait to say “here’s going to be the one that’s
most important,” it’ll be a problem.

But if we think about what is the functionality, or might be
the functionality, of electronic health records and what kind of formats can
you collect data in, whether it’s yes/no or quantitative, whatever, we could at
least begin to define an architecture which could then be backfilled with
questions addressing maybe the dimensions of care or something.

MS. GREENBERG: I wonder if it would be good to — although
they really were pretty much at the 50,000 feet — but if it would be good to
include in that, or separately, to hear from the group at HL7 that was
responsible for developing the functional model for the EHR.

MR. RODE: There’s a supportive measure within the functional
model — I can show you the whole picture —

MR. HUNGATE: It looks pretty from here.

MS. POKER: Colorful.

MR. RODE: The pink stuff. But there is a group right now
working on this. John (?) from our staff is involved with this project and
maybe it’ll be better to talk to them sooner than later and have that dialogue
and maybe after you talk to this other group that you’ve mentioned but not to
do sooner — maybe you do it together.

MS. POKER: Also, if I could just suggest if you want airplane
time reading material, maybe the chapter that Brent James recommended, Chapter
8, from the Patient Safety — that’s the only one I know, so that’s what I’m
pushing forward — but that did happen to write that. And I think it also
answers some of the questions, Justine, you put forward. I mean, that’s just
also a thought.

DR. CARR: Well, from his perspective, too.

MS. POKER: Yes, it’s very first person. You’ve read the whole
thing? Oh, wow. You haven’t — I don’t know if you’ve read it.

MS. GREENBERG: Do we have that Patient Safety Report?

DR. STEINWACHS: I guess one sort of question. And, you know,
part of what Bob here is talking about is how do we lay out the landscape of —
but when you think of a quality/IT interface, it does talk to everything from
just the documentation function that a physician does, or other health
professional, of what is in the care process to does that drive into a decision
support kind of mechanism? So does what you put down there then gives you
feedback? Does that drive into reporting function that goes into either
organizational, other report cards? Does that drive into some of the things in
population health?

And so I guess it would help me a little bit to if we talked
about, you know, what’s the scope of this? We’re interested in the interface.
One, if it does talk about producing information useful or measuring quality
within organizations and within practices at a minimum. You know — does it go
further than that I guess is really what I’m asking. Does it get into
essentially decision support for the physician? Does it get into —

MS. McCALL: I think it would be valuable to actually take that
quality/IT intersection and talk about that interface and say, what are all the
different masters that it would need to serve? Everything that you’ve laid out
— population, decision support —

DR. STEINWACHS: You could generate the bill off of it.

MS. McCALL: — pay for performance — and talk about that from
a visionary perspective, that really it’s a vision maybe around that interface.
Then we can pull out the matrix again.

And so it’s really getting that, getting a deep conceptual
framework for that, so that it has some depth and specificity, and then I think
we’ll bring in various folks to talk with about that. We’ll understand, you
know, what can’t be done today, everything. But that seems to be a very
concrete, although broad, set of things that we could do.

MR. HUNGATE: A question related. The Northern New England
cardiovascular group has been used as a good example of a learning system that
somehow is using information technology in some way to self-improve. Would
using that group as an example, asking them to come and talk about how they
would see what they’re doing interfacing into these other domains?

DR. CARR: But I think actually didn’t Don mention that Jerry
O’Connor would be the right person to come and represent that group and, you
know, could talk about their model?

MR. HUNGATE: I need tangible stuff to understand the
abstraction, and it would help me a lot.

MS. McCALL: Yes. And they’re actually up here on the flip
chart, so it’s actually kind of what I’ll call

a lather-rinse-repeat model of getting some testimony,
creating a vision or a paper, and then, you know, getting feedback on what that
is. And so that process, we might be able to iterate through that, with: This
is our focus, all right? With the quality/IT interface as our focus, with very
specific audiences, people, things that we want to hear about, people we want
to hear from. And then we can write.

I would be very concerned if the first thing that we tried to
do would be sit down and write a vision.

MS. GREENBERG: That’d be premature.

MR. HUNGATE: Too early, too early.

MS. McCALL: Very premature. So that organizing these ideas,
these thoughts, and blowing out more detail, fleshing out what we mean by that,
and then literally creating some venues to gather some testimony on that
specific might be the next step.

MS. POKER: Didn’t he also say for us to do a field trip?

DR. CARR: I was just going to say that.

MS. POKER: Oh, yes.

MS. GREENBERG: A field trip — haven’t been to Boston for

MS. POKER: Yes. That would be the time.

DR. CARR: We could have dinner at my house.

MS. POKER: If it’s so different if we see it.

MS. GREENBERG: Wow — there’s the mother in you.

DR. CARR: It really would be good —


DR. CARR: — because it’s been learning for me to hear John
describe it and see people look surprised, because it’s the only system I’ve
ever known, so I don’t even recognize, you know, how novel it is compared to
other places. So it would be delightful. You will like it; it’s pretty cool.
And see the capabilities.

MS. GREENBERG: So there is that kind of a site visit but also
maybe to meet with some of these people who are up there —


MR. HUNGATE: We’d have to do the two together, right?

MS. GREENBERG: Yes, it would be like two days. One day, the
site, and the other day —

DR. CARR: Yes, that’s right. That would be terrific.

MR. HUNGATE: Now, how much advance, how much lead time do you
need in order to do something like that?

MS. GREENBERG: Well, you know, I think the first thing would
be to poll the members and key staff and see availability. But is it possible
there’s a meeting room at the hospital that we could meet in?

DR. CARR: Yes.

MS. GREENBERG: Otherwise, you know, if we have to find a hotel
or whatever, then you need more lead time for that. It would be nice actually
to have free meeting space, but it’s not required. But if it’s going to, you
know, not be a big public hearing but more —

DR. CARR: I’m sure we can work something out, you know, for a
conference room with a little lead time and have folks come over.


DR. CARR: I mean, John could host this, in a way.

MS. GREENBERG: So then the main issue would be, you know,
checking all your availability and the lead staff and then the ability of your
organization or to accommodate.

So I don’t think there’s a huge amount of lead time that’s

MS. McCALL: So who all do we want to be there, I mean outside
of our Working Group here? Dan, you had mentioned somebody.

DR. CARR: He wants to go.

MS. McCALL: You want to go?

MR. RODE: I’d like to go.

MS. McCALL: All right.

MS. GREENBERG: Well, I would have to say that — I mean, this
is like fact-finding.

DR. CARR: Yes.

MS. GREENBERG: So it’s not like we have to sort of invite the
world. But on the other hand, we don’t want it to be secretive, either.

MS. McCALL: No — I’m talking about people if we’re going to
have a couple of days; we’re obviously going to be on a field trip. But there
were some other people that we said we wanted to hear from.

MS. GREENBERG: Were you talking about Jerry O’Connor?

MS. McCALL: Yes, that’s who — well, I guess, all right, so
you’re structuring. Day one is field trip —


MS. McCALL: — and day two would be brainstorming with some
folks up there.

I was just saying to Don, you know, including Lisa —

MS. GREENBERG: I was just thinking of Lisa. We talked about
going up there and meeting with her.


MS. McCALL: So, Lisa — this would be a great time to have

MS. GREENBERG: Yes. And maybe even Dan Friedman from —

MS. McCALL: That’s what I was thinking about.

MS. GREENBERG: from that kind of population side. I told you
— don’t even think about serving your time, because there’s no end to the
service. Lisa —

DR. STEINWACHS: Well, Bill has come back once, you know, and
we expect him to come back over and over again.

MR. SCANLON: I was on probation but I —

MS. McCALL: He’s on reserve.

MS. GREENBERG: What about Barbara Stargill(?)? I think she
lasted longer on the Committee, until Simon, than anybody.

MR. ETTINGER: Oh, Marjorie, you might also want to ask Simon
if he’s available. He might be interested.


MR. ETTINGER: Simon Cohen.

MS. McCALL: No way!


MS. GREENBERG: Oh, well, obviously other members of the
Committee who are interested would be welcome.

MR. HUNGATE: Brent James was mentioned.

MS. GREENBERG: And the NHII group.

MS. McCALL: Well, I would ask that you take that

to the meeting next week and talk about alignment, talk about
intersections, talk about whatever. You know, reshuffling or juggling could
take place because there may be not only a desire but a real need to have some
key intersections here.

MS. POKER: What she just said?


MS. McCALL: With NHII in particular.

And if we develop the agenda, you know, on a trip to Boston
and there were folks that you wanted John to invite to sort of speak to some of
the issues that have come up, even the ROI and the HIPAA, you know, perhaps we
could have a more generic — I don’t know.

MR. ETTINGER: Marjorie, did you also want to take a look at
the VA here in DC because Edouardo probably could arrange something there. It
might not be that much of a big thing.

MS. GREENBERG: We talked about doing a site visit to them as
well and that is certainly something we could do. It’s good to see two systems.

DR. CARR: And, really, I think actually you’re right.
Understanding what went wrong — you know, we heard yesterday or today,
whenever, today, I guess, that with all of the automation of the VA system, the
data analysis had to take place on print hard copy.

MS. McCALL: And, yes, that was specifically the work that Beth
was trying to do, Beth McGlynn, in trying to go in and do that study and why it
was that so much had to get printed out.

MR. HUNGATE: That’s an interoperability infrastructure
question that, you know, is getting worked on.

MS. McCALL: She’s specifically trying to work in that
intersection and so we may want to actually hear from Beth —


MS. McCALL: — about, so what happened in there?

MS. GREENBERG: Maybe not when we go to Boston. Is she in

MS. McCALL: She’s in California but she’s all over the place.

DR. STEINWACHS: The reason I wasn’t here yesterday, and Kevin
Vigilante is part of that problem, is we put in a proposal to the VA to
evaluate nationally the quality of care for severely mentally ill in the VA
which had me dive in then to all those datasets. And essentially the VA runs an
EHR that is free text, and so there isn’t much you can do with a free text
system. And that’s what EHR traditionally is — it’s free text plus there may
be some structured lab fields or some other things, you know.

And I think part of the transformation you’re talking about
here is: What structure do you impose? What elements have to be there? And how
do they have to be recorded?

And so the VA has an elaborate system. They abstract 250,000
charts a year to support their quality reporting. I mean, so they have systems
in place that do it, but they do it what sort of feels like a little bit the
old way except that they can pull that record in across all sites, so the
record’s not a site specific.

MR. HUNGATE: I understand. But I think that issue is being
addressed elsewhere in the structure of the NCVHS. You know, we don’t need to
illuminate that problem.

DR. CARR: No, but I think as we think about the myriad
descriptions of quality that we heard today and at our hearings last year, that
knowing what kind of constraints we might be thinking about — you know, free
text, there’s always going to be a limiting factor.

MS. GREENBERG: How much of your system is free text and how
much of it is proprietary coding? How much of it is standardized coding?

DR. CARR: A lot of it is free text.

MS. McCALL: Well, and the thing is, this is going to get into
this idea of knowledge management, and the idea is one around a taxonomy. And
we can sit and debate taxonomies — all — yes, then it is plural — which ones
are the right ones? Do we have to come to consensus? If you come to consensus,
it becomes fairly slow-moving.

But I would like for us to investigate what the other
opportunities are. For example, it may be that there is: This is a taxonomy
that we’re going to use, these are the definitions, and on top of that to allow
people to play, to discover, that systems allow for the creation of what’s
commonly being called “tagging,” or “folksonomies,” which
is an emergent property that says people create their own taxonomies and they
can see what other people are creating and they can begin to use common
vocabularies and things like that.

And so that’s if I want to do something a little bit different
than, or more than, or more distinct, than what the formal and official
taxonomy is allowing me to do because I’m trying —

MS. GREENBERG: What is it, folksonomy?

MS. McCALL: Folksonomy. F-o-l-k —

MS. GREENBERG: That’s what I thought. Haven’t heard that one

MS. McCALL: But there’s just some new capabilities and ideas
that are emerging that if the infrastructures some of these things to
self-organize and people understand how to use them, they will self-organize.

And the question is, can it work? Can they co-exist together
so that you have the formal, top-down “this is the formal taxonomy; it’s
used to drive metrics and a lot of other associated things” and there’s
also a way for people to try something new that taxonomy doesn’t quite fit.

And if it actually produces research that’s valuable, then
maybe it does become official.

MS. GREENBERG: Or can feed into the formal technology —

MS. McCALL: Yes. It’s just an idea, but it’s to say that
there’s value. Just to kind of wave our hands over a free text system and say
somebody else is dealing with all that doesn’t do justice to what we have as
one of our key objectives as a Workgroup.

DR. CARR: And I think the other thing, I mean just raising a
question that Marjorie said, we have notes that are, you know, just regular
notes, but we also have fields that are free text but you can search on a term.
So chief complaint to the emergency room — you know, you can think of 10
different terms someone might say for a particular condition and you can pull
out those cases.

So some of it is just structuring and architecture so that at
least whether it’s free text, it’s a searchable field.

MR. ETTINGER: Actually, David Base(?) and I talked about this
because — [off microphone].

I’m sorry. David Base and I talked about this on other issues,
but there is a VA in Boston and I do see some common (?) between them. And one
of the problems is differences in the systems in transferring information. But
not getting into their operability. But it might be a good opportunity to see
maybe the Boston VA and one of your hospitals and look at the two systems

DR. CARR: That would be interesting.

MR. ETTINGER: We could discuss — there are some problems with
e-prescribing, even. Patients that come to the VA, they get their prescription
at your hospital and they have to pick it up at the VA. And there are certain
problems that arise from those situations.

And it might be a nice thing to kill multiple birds with one

MR. HUNGATE: In the sense that I’m kind of of the “just
do it” school in terms of charging in and getting it going, how soon could
we do something?

DR. CARR: You know John. It’s guaranteed he’ll [off

MR. HUNGATE: Yes, I understand. But I don’t know how soon
everyone’s calendar is clear enough so that we can all be in the same place at
the same time.

MS. GREENBERG: We’re looking for two days, folks.

MR. HUNGATE: We’ve got to look at two days. We’ve probably got
to start in July.

MS. POKER: Mid-June.

MS. GREENBERG: I can’t imagine it’d be — this is already

MS. McCALL: Well, if we didn’t have that full Committee

MR. HUNGATE: Well, you could try and restructure the agenda
and have all these people appear at the full Committee, have the full Committee
meeting in Boston.

MS. McCALL: I think we start looking in July.

MR. HUNGATE: Let’s look at the window between, say,
arbitrarily July 15th and August 15th. Is that okay for staff polling to see if
we can find two days that we could all make?

MS. McCALL: I’d actually look at the window before that —


MS. McCALL: — for the end date at August 15th, and look for
anything in that window.

MS. POKER: I would just look at the month of July. I think the
month of July could be —

MS. GREENBERG: What’s your availability?


MS. GREENBERG: We usually start with the Chair and work from
there. Let me look here.

DR. CARR: You’re going to have to email. I couldn’t tell you
mine, so —

MR. HUNGATE: Yes, I think it’s going to have to — I can give
you that, but —

MS. GREENBERG: But it’s a question of where do we start? I
thought maybe he was saying July 15th because — I personally know I’m not
available the week of July 15th. What we have right now in July is the NHII
Workgroup is meeting the 27th and the 28th of July.

MR. HUNGATE: Here, right?

MS. GREENBERG: And the Standards and Security is meeting the
26th and the 27th, which must that I don’t think they’re overlapping because
they have overlapping members, so it’s probably the 26th to the 28th that
Subcommittee and that Workgroup are meeting. Am I correct about that? I mean,
there’s so much overlap between NHII and Standards to think that they would be
meeting concurrently. So probably one is meeting for a day and a half and then
the other’s meeting the next half and day.

So I don’t think we’d want to be at that time.

MS. McCALL: I think we’re going to have to send out emails to


DR. STEINWACHS: Carol and I don’t handle our own calendars; I
can see that already.

MS. McCALL: Actually, I do.


MS. McCALL: I have no administrative assistant. What I lack
right now — and I mean none — is a computer. It’s waiting for me at home.

MS. GREENBERG: Okay. We’ll start with the week of — let’s
see, there’s July 4th and then maybe start with July 6th because if you don’t
want people to have to travel on July 4th — start with July 6th and poll up
until the 15th.

MR. HUNGATE: There’s a 6th and 7th. Try the 6th and 7th, which
is Wednesday and Thursday in that week.

MS. McCALL: Just start polling that week, or at that time, and
then we’ll figure it out.


MR. HUNGATE: I know I’m going to be wiped out a good bit of
that, but —

MS. GREENBERG: Okay. So let’s just poll for that.

MR. HUNGATE: Let’s find out where we are. Poll through the end
of August.

MS. GREENBERG: Through the end of August.

MR. HUNGATE: Through the end of August.

MS. McCALL: I’m also going to make a recommendation that we
have a conference call as a group between now and before that.

MS. GREENBERG: Oh, we’ll have to.

MR. HUNGATE: Yes, a couple of them.

MS. GREENBERG: Particularly if the second day is going to be
hearing from other people or whatever, that’s the biggest time constraint
really, getting on their calendar once we’ve agreed on dates.

MS. McCALL: I think we need two, then. One is to wrap up what
we’ve done here, and we need to be able to put a period at the end of the

And then I think the second one would be to plan for whatever
this July/August-ish thing is going to look like, okay?

MS. GREENBERG: Am I correct that you might want to do the
wrap-up thing before the June 28-29 meeting so that you’d have something to
report to that.

MS. McCALL: Oh, my!

MS. GREENBERG: Yes. I don’t mean the conference call. I mean
that you would like to —

What are the next steps here? You and Carol and Anna are going
to work on integrating all this.


MR. HUNGATE: There’s going to be all this, right?

MS. McCALL: Right. We’re going to integrate all this together,
and that includes the notes that you’ve seen on these pages; we now have
pictures of them, courtesy of Justine, and typed versions, so they’re going to
be kind of organized a little bit differently and some subsumed. We’ll bring
all these together.

We’ll also integrate that with what Susan is putting together
for actual notes of the meeting itself so that she can kind of —

MS. POKER: Can they be separate because I think that would be
too much reading?

MR. HUNGATE: Now, they’re going to need the notes of the

MS. POKER: Right. But shouldn’t we put it as two separate

MS. McCALL: I don’t know exactly how it’ll organize.

MS. POKER: Okay.

MR. HUNGATE: Yeah, it’ll settle down.

MS. McCALL: It’ll get organized in a way so that all of this
information doesn’t come out of context where somebody is trying to say, what
happened back there?

MS. POKER: That’s fine.

DR. CARR: Susan is doing that? Right.

MS. McCALL: Then I would like people to opine on that,
especially with respect to how some of these things are going to get integrated
back into these and because I think that that then becomes the basis on which
we add and expand. We go deeper and broader in some of the work that we’re

MR. HUNGATE: Is a week the right time frame for the pass that
comes out of this collective process, the first document?

MS. McCALL: You mean for the electronic pass?


MS. McCALL: Yes, I think that it should be out no later than a
week from today, electronically.

MS. POKER: Wait — that’s next week.

MS. McCALL: You’re not going to have any sort of —

MS. POKER: It couldn’t be like till evening, because a
conference is going on, so we have like evening stuff going on.

MS. McCALL: Okay.

MS. POKER: Can we just do it 10 days out? As soon as I get
back, that’s what I’ll start doing.

MS. McCALL: I think I’ll still take a straw man attempt and
then you can react to it.

MS. POKER: All right.

MR. HUNGATE: So, we’ll shoot for the 10th in whatever way we

MS. McCALL: You’ll still have a chance to react.

MS. POKER: Fine.

MS. McCALL: Shoot for the 10th, and then I’d love to have a
conference call.

MR. HUNGATE: Conference call in the window of the 13th to the

MS. McCALL: Anywhere in there.


MS. McCALL: June.

MS. GREENBERG: Okay, so you’ll poll for that? Okay, thank you.

MS. McCALL: Okay. Somewhere in that week. And then we need
something to plan our Boston.

MS. POKER: Can we discuss it also at this phone call? I’m
sorry, Stan. Between 13th and 15th, should we also discuss it or should we
start polling for that in addition to — how do you want to do it? Because we
could do two polls. We could do one poll for the phone conference and we can
also do simultaneously a poll for the site visit.

But first of all, Justine, could you find out with John, and
then based on that —

MS. McCALL: What I would do is I’d handle the

polling separately only because they’re contingent on
different things.

To wrap this up, all we need is ourselves, you know? We don’t
have to wait for John to find dates and facilities. Because we need two
discussions. One is right away. The other one is in prep for, you know, this
Boston trip.

MS. POKER: Site visit.

MR. HUNGATE: And I think the second discussion probably has to
occur about a week after the first one.

MS. McCALL: So we can poll for those at the same time?

MR. HUNGATE: Right. Those two phone calls can be polled for
the same.

MS. McCALL: Yes. It’s this other one that’s contingent on some
other planning and other people that —


MS. GREENBERG: You don’t want her to poll yet for this meeting
in Boston because first we obviously have to find out. There’s no point polling
for dates when John is going to be on vacation.


MS. POKER: Can I make a suggestion? You let me know when John
gives you the okay, what dates, and then I’ll take care of the polling with
Jeanine, if that’s fair?

MR. ETTINGER: One thing you might want to consider in the
dates — if you want to go see the VA, that’s another set of dates, another
date; you might need more time.

And you might want to ask him, because when I did it with
David, I just sat at his console as we went through it. It’s much nicer to do
it that way than have like a slide show. So if there’s too many people, it’s

MS. GREENBERG: Which is very good.

MR. ETTINGER: Yes, I’ve seem him do it.

MR. HUNGATE: Okay, I think the second polling is maybe between
the 21st and 24th?

MS. GREENBERG: What was that?

MS. POKER: That’s for the site visit. This polling is for

MS. GREENBERG: Second conference call, the week of the 21st
through the 24th.

MR. HUNGATE: Two-day. One-day site visit. Second day, panels.
Right? That’s what we talked about, isn’t it?

MS. GREENBERG: Yes, bringing in people.

MS. POKER: Right. But this time you’re talking about polling
for it between those times, or actually making the site visit between 22nd and
24th of June

MR. HUNGATE: No, no, that’s polling for the phone call to plan
the site visit.

MS. POKER: Got it.

MS. GREENBERG: We’re talking two phone calls.

MR. HUNGATE: Two phone calls. One to settle all this and
second to deal with the next session.

MS. POKER: Got it.

MR. HUNGATE: All right, have we done enough work?

MS. GREENBERG: Since you said we have to end in five minutes,
I hope so.

MR. HUNGATE: Anybody got any add-on thoughts before we let
this sit?

It’s been fun. Thank you all. We’re done for today.

[Whereupon, the meeting was adjourned at 3:55 p.m.]