[This Transcript is Unedited]




June 30, 2005

Hubert H. Humphrey Building
Room 305A
200 Independence Avenue, S.W.
Washington, D.C. 20001

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


  • Robert H. Hungate, Chairman
  • Justine M. Carr, MD
  • Carol J. McCall, FSA, MAAA
  • William J. Scanlon, PhD
  • Donald Steinwachs, PhD
  • Anna Poker
  • Trent Haywood, MD, JD, CMS
  • Marjorie Greenberg, NCHS


  • Welcome – Bob Hungate, Chair
  • Finalize the work plan topics from the retreat – Carol J. McCall, Donald Steinwachs, Justine M. Carr, William J. Scanlon 6

P R O C E E D I N G S 8:00 AM

MR. HUNGATE: Introduce yourself and spend a little time telling these people what you do.

DR. HAYWOOD: Okay, I am brand new to CMS. I have a clinical background in nursing and kind of an eclectic background. I head strategic planning at Johns Hopkins School of Public Health, research at the school of medicine, about 7 years managed care on the commercial side and 5 years managed care on the Medicaid side and just joined —

MS. GREENBERG: You are too young to have all this experience.

DR. HAYWOOD: Thank you. I am brand new to CMS as I said and I actually just joined a new division called the Division of Quality, Evaluation and Health Outcomes which currently falls under the Family and Children’s Health Programs Group but we are actually servicing all of the Center for Medicaid and State Operations and we are in the final stages of finalizing the quality strategy so that the timing is perfect.

DR. SCANLON: We are glad you are here.

MS. MC CALL: Carol McCall from Humana.

MS. POKER: Anna Poker from AHRQ.

MR. HUNGATE: Bob Hungate, Physician Patient Partnerships for Health.

DR. STEINWACHS: Don Steinwachs, Johns Hopkins.

DR. CARR: Justine Carr from Beth Israel Deaconess Medical Center in Boston.

MS. GREENBERG: I am Marjorie Greenberg from NCHS, CDC.

MR. HUNGATE: Just a couple of housekeeping details. I want to spend most of the time on the content. Carol raised a question how could we screw up. Things drop through the cracks. I am not going to accept for responsibility. There are two things. We missed the conference call. That slowed us down a little bit. We have got a tight agenda and if we try to do this mission thing if you will in a year we can’t miss too many steps or we will have trouble and so I want to also welcome Cynthia Sidney and she is replacing Jeanine Christiani as support for this group who was really just filling in as a contractor after I guess Gracie retired.

So, that is a touch point for scheduling and I have asked her to hold your meeting days on either side of the NCVHS meetings so we can find out what availability is because I would like to do our hearings here on either side of the Committee meetings. I think it will work better.

MS. GREENBERG: That is fine to poll. I know I am not available on that seventh but if the rest of you are that is fine. I did note that I think the fourteenth and fifteenth which are the dates before our, or whatever the dates are before our full Committee meeting, I believe are the dates of the Board of Scientific Counselors which wold create a conflict for Bill.

DR. SCANLON: You mean in September?

MS. GREENBERG: Maybe you should put out some other options.

MR. HUNGATE: Let us take a first pass.

MS. MC CALL: I think that is ideal, and I think in addition what we can do is poll for other dates that either may be really good or that also we could say are absolutely can’t do because there are known conflicts way in advance and that what we really need is almost like a bullpen or a stable if you will of potential dates that we can lock down, that and some conference call times, and I think once we get that we will just start using them.

MR. HUNGATE: You see what the need is, Marjorie?

MS. GREENBERG: Yes, I will work on it.

MR. HUNGATE: You work it out.

MS. GREENBERG: And generally what we do is we check the schedules with the Chair and the lead staff and then we go from there. I mean we don’t want to start with dates if you —

MR. HUNGATE: But if everybody else can make it and I can’t, I am not indispensable. Somebody else can pick up.

MS. GREENBERG: One option is for you to have a Co-Chair or a Vice Chair.

MR. HUNGATE: That is Don.

MS. GREENBERG: Oh, Don is your Vice Chair?

MR. HUNGATE: He and I kind of agreed to back each other up. I think that it is tight and we had trouble probably because I was slow in responding.


DR. CARR: What will we talk about and what will we hold hearings about? I just want to compliment Carol again for the great summary that she did and the great organization of topics and I think it is a great segue into focusing our thinking in terms of these category themes. I found that extremely helpful.

MR. MC CALL: I would, also, like this to be on the record for really an incredible job that Susan did. It was delightful working with her. It was absolutely exquisite.

MS. GREENBERG: And she is very interested in this work and I would love it if she could continue.

PARTICIPANT: We will keep her engaged. She is very interested.

MR. HUNGATE: Could she always be involved with content either by phone or by presence?

MS. GREENBERG: If you want her to and she is available.

MS. MC CALL: It is the combination of her personal passion, her skill and talent and understanding the full context. It will be compelling and really valuable to us.

MS. GREENBERG: Great. She will be very pleased to get that feedback, but I know that she is agreeable.

MR. HUNGATE: I still need a couple of minutes on where we can screw up. It is in not getting enough linkage into the functions and government. We have got to get that done right away and it seems to me that we should have somebody from ONKIT(?) we should have somebody from ONKIT involved in this.

MS. GREENBERG: We can certainly ask that.

I will talk to Jim about that and mention it today when you make your report.

DR. CARR: I think it would be good, yes, if we can have an articulation of the two biggest things on our plate. It will then be a matter of record so that other people will understand why we would be asking them to be —

MR. HUNGATE: I would encourage Committee members to think about people that they know in other functions that are related to this that they may respect and say that that person has good talent because I don’t see why we couldn’t seek out.

MS. GREENBERG: We should try to get VA.

MS. POKER: Isn’t Eduardo VA?

MR. HUNGATE: His job is not sufficiently related to this issue. His interest is but his job isn’t, and the job has to be aligned with what we are working on in order for hands-on work and so there are some specifics there that have to happen soon.

MS. MC CALL: I think just as a next action on that I would like for us to put that as a topic on our first call where it says, “Everybody come back with a list of potential areas, that it would be really critical or very helpful to link into,” and then we decide how to do that.

MS. POKER: Or else if you want I could collect other names and then kind of compile a list. You could all mail it to me and I could just bring it forward or hand it out or something.

DR. CARR: Okay, just e-mail us.

MS. GREENBERG: If there are any organizations and they can’t be official staff but that you want to reach out and say, you know, if you can send a representative when we meet that would be great.

MS. MC CALL: And the flip side not unlike what Justine is going to do, is it possible for the ones that we think are real hubs of activity to have a liaison into them as opposed to them to us, so, again all things I think that we can talk about.

MR. HUNGATE: I think NQF might be one of those. Bill might be the natural contact point for the National Quality Forum.

MS. GREENBERG: Actually you know there is this recent finding that we can actually include non-members in work groups. I mean we don’t need money.

MR. HUNGATE: Let us pursue that.

MS. GREENBERG: Anyway it is a possibility.

MR. HUNGATE: Part of our job is linkage and you have got to do it up front so that people that are links are involved in the development process.

MS. MC CALL: I would also ask that when we send this information to Anna that there needs to be a one-or-two-line blurb, something we can discuss about why we believe; what is our theory of the case as to why that is a critical link.

What is it that they are doing, why it is vital to us? Are they making decisions, setting policy; what is it that we seek to get because time which is our first need is a scarce and irreplaceable commodity and we have to spend it wisely?

MS. POKER: So, you want AQF and you said, “The National Advisory Council for AHRQ you wanted to link?

MR. HUNGATE: I think so.

MS. POKER: And Don, you are going to be the Vice President of this or Vice Chair?

DR. STEINWACHS: I almost prefer the term “Co-Chair.” I think anyone else here is sufficiently involved in this content and active enough in discussion.

MS. POKER: Yes, but I am going to be calling him is I can’t get you.

MR. HUNGATE: Okay, let us go to content. How will we use what we have got so far?

MS. MC CALL: I guess I would love to just get people’s specific thoughts and reactions and visions and we haven’t had an opportunity just to hear people’s thoughts around all of this. We haven’t been together since the third.

DR. CARR: I think your categories are very helpful to sort of focus this in different areas and I think that the overlay has to be achievable and actionable and, also, a time line.

I think when we last met we talked about having the long-term goal or contribution, so maybe a lot like the vision but also a short-term deliverable and we have been talking about the quality IT interface. We heard more yesterday that sort of changed it a bit but that would be my thought.

As I read this over I also saw the things that I think although we heard a lot about we would be setting ourselves up for more than we could take in terms of defining quality or some of the challenges that are in front of people.

I think that we can make a difference in terms of kind of moving ahead the infrastructure, the building blocks so that it is not for us to say what process measures or how often or whether they get revisited every year.

I mean there are still other great minds thinking about that, but I think it is for us to help explore whether the electronic health record is going to in some way facilitate fields that are retrievable so that as we move forward with whatever the quality question is there is a mechanism, a content, a yes/no or you know some way that electronically information might be housed.

Again, hearing what David Brailer said yesterday about the architecture gave me pause. If only I understood the architecture presentation, I would be a little more articulate but I am still studying those slides, but I mean his point was interesting yesterday as we said, “Should the electronic health record have the capacity to address quality issues?” he said, “Also, think about is it really the architecture for storage and that?”

So, I think having a representative from ONCHIT was very important.

MS. MC CALL: Yes. I am left coming out of the announcement that they made and then after the discussion yesterday with two thoughts, and one of them is what are the implications for the work and the opportunity that we see in front of us in terms of how it changes it and the second is all that much more passionate about the opportunity because he knows it is there but I, also, heard him say indirectly that they are not addressing it and they need help and so that much more passionate about doing it and doing it now and being more than aligned with that work, being involved in it because if these don’t come up like this at the same time, whatever is going to be the symbol —

DR. STEINWACHS: We have a secret symbol.

DR. CARR: I think that is right. I mean every day in every way underscores the importance of this interface and the fact that it doesn’t belong to any of the designated areas at the moment.

MS. MC CALL: If there were one link, it is there. How do we affect that?

MS. POKER: You only link up, align with that effort. Do you also want to align with other Subcommittee efforts like Subcommittee subappointing? In other words can we do, should we, do we want to do that to align? We can align with it, whatever it is or are we going to try to align with other Subcommittees?

MS. MC CALL: When you say, “Other Subcommittees,” other Subcommittees of what?

MS. POKER: Of NCVHS, like Population.

MS. MC CALL: I don’t know. Tell me how those are going to be impacted.

DR. CARR: I think let us stay on this topic. We have identified a gap that there is no crosswalk from the electronic health record to collection or capture of quality.

MR. HUNGATE: You have got to be careful there because people who work in the details of this believe the point of attachment is the mechanism for communicating secondary views.

MS. MC CALL: No way. I didn’t hear that.

DR. CARR: Oh, that was the point. I wanted to amend our report that goes into the thing to say that all the work that we did last year was a tremendous amount of work and one of the observations that came from that work was learning that the claims model was being, you know, will be replaced by the electronic model.

All the hearings that we had although we say that we had seven presentations and I mean seven recommendations and we came up with one, I think that just leaving it like that under serves the learning experience that happened because one went forward but the others were then repackaged into thinking about the new world of electronic health records and maybe as Marjorie pointed out at the last meeting the claims will suffice.

I mean the claims world could sort of accommodate what we wanted but pushing for that was not the direction we wanted to go into. The capacity was there if people had no alternative.

The measure of those hearings should not be one of seven recommendations went forward. That was one outcome but the real measure of those meetings was the information that was put forward that the menu of quality that we are looking for exceeded the capacity of those recommendations and therefore we return with renewed vigor.

MR. HUNGATE: It seemed to me that Brent’s slide which had the accountability side and the learning side that that articulated the problems that we saw in our hearings, our early hearings. That is a decent recap of the problem of what is going on.

MS. POKER: That is Chapter 8.

MR. HUNGATE: And we could take our hearing process in that content and say that this segues to Brent which then segues to Don. So, there is a sequence there of information that is rational and fixable.

MS. MC CALL: It is a nice framework.

DR. CARR: So, how does that get involved with what we are going to see in September? Is it the Executive Committee or would it be, how do we get that content into the summary that we heard yesterday from Simon of the work of 2003 and 2004?

MS. MC CALL: You mean the hearings?

DR. CARR: Yes, I am saying that as we describe and the Quality Committee did this and passed one recommendation I think we should say, “And we learned that” —

MR. HUNGATE: I guess you and I don’t agree completely on what we learned, but that is okay. We don’t want to discuss that now.

MS. GREENBERG: Is it in 2005 or 2004? Calendar for four? We had the hearings in June and September and then we put forward the recommendation at the —

DR. CARR: Okay, and that is what the annual report says. I have to look at that again. So, what you are saying is it needs to also say —

MS. MC CALL: Yes, here is what we recommended but his is what we learned and what we had an opportunity to learn was this big and the recommendation was that big.

MS. GREENBERG: And the fact is that what we recommended was really something that the current mechanisms couldn’t accommodate.

We, also, learned that the current mechanisms could one way or another accommodate the rest but that really the bigger picture was the electronic health record. I mean that is the way I would cast it and that is where we needed to push that agenda.

MS. MC CALL: So, there is a “to do” there in terms of trying to bring that out.

MS. POKER: I was going to make a suggestion for that.

MR. HUNGATE: That is my task, probably.

MS. POKER: I suggest if you want, would you want me to add about two or three sentences based on what Justine said and send it around for everybody to tweak? Is that okay?

MS. GREENBERG: What are you suggesting?

MS. POKER: What I am suggesting is I will add two or three sentences saying what Justine just said basically which I understood her to say a little bit differently than what you just said but —

MS. GREENBERG: We don’t see it the same way.

MS. POKER: It is not so much administrative data. What is really important is we decided to go with the EHR because we are going to get more bang for the buck there. That is what is coming down the pike and it just makes better sense to invest our energy there.

DR. CARR: It says, “Also, highlighted the importance of functional outcomes, a topic likely to receive further attention in the future.”

MR. HUNGATE: David Brailer raised the question of whether it is EHR that is going to be —

MS. MC CALL: Yes, let us go back. Let us separate these out.

MR. HUNGATE: You have got to separate them because they are two different issues.

MS. MC CALL: I want to separate out these two topics. So, I want to hold that one because that one is huge but I want to go back to just how we wrap up, how we want to foreshadow what we are about to do through the 2003 and 2005 wrap-up. So, you are going to put a straw dog out there?


MS. MC CALL: Okay, and again it is not meant to summarize all of this work. It is just to foreshadow it, right?

MR. HUNGATE: I am going to try in my summary of our meeting today tomorrow to put some words that relate to that into my report.

MS. MC CALL: Back to your other point, I will tell you his bringing that up there is such a huge difference not in degree but in kind in my mind between the EHR and the supporting architecture and where the work that we would like to pursue happens and for people to think that somehow it would be somehow contained within the EHR I think is a huge mistake.

I don’t think it can happen there. I, also, don’t think that it is going to be taking it out of the architecture kind of a la sort of the old world or even today’s world analytics, taking it off, banging it up and shoving it back in. It is going to look a little bit different than that, and now I feel like I am stuck with what David said yesterday which is that every time somebody starts talking about architecture it goes off into these highly theoretical conversations and we are going to be stuck there, too.

MR. HUNGATE: Not if we work on it carefully. If we think about, you used the word “mechanisms” also. There is an issue of the framework. A vision is like a painting if you will. You are trying to get something that people can understand and relate to and actuate themselves.

We are trying to trigger action and that means getting a framework visible that people can work on. We are not going to answer all the pieces of it. We would like to articulate the framework in which answers have to be derived.

MS. MC CALL: Let me toss something out as an idea and I have no idea whether this is going to work but one of the themes running through all of this that I saw once you get kind of past vision, when I look at the other categories, knowledge management, the huge section of education’s role, a lot of those have to do about us being a mechanism for people coming together both formal and informal and I was wondering I know that we are going to have hearings. Is it possible for us to have a conference?

MS. GREENBERG: Absolutely.

MS. MC CALL: So, I was thinking about what we are talking about is learning about how people learn. We are talking about knowledge transfer and knowledge creation. We are talking about doing it in a very unusual architecture and so I started thinking about lists of people that maybe are not necessarily of this game today but people like Peter Sange, John Sidney Brown, Don Burwick, Michael Crow, Howard Gardner, Douglas Hofstetter, Timothy Wilson, anybody who can come in Ester Dyson and talk more broadly about IT, more broadly about how people learn, more broadly about cultured cognitive process and then also inviting people.

So, these would be people that would speak, but then you would invite people from all over, CMS, AHRQ, NCQA, NIH, IOM, RIOs, Markell(?) Foundation you know; so, it is a party and so there is a lot of cross-pollination and I just started thinking about that as one way that we could learn as well and facilitate.

So, I don’t know quite what to do with that.

MS. GREENBERG: There are resource issues but we did it for the 21st century vision about statistics. We partnered with IOM and I think NCHS. I wouldn’t recommend doing that, but NCHS actually gave some money to IOM.

MR. HUNGATE: ARHQ is the right partner.

MS. GREENBERG: AHRQ has a small conference grant capability that I don’t know that the National Committee could apply, but it is worth pursuing. I think it is a good idea. The National Academy of IOM often does that. They will have a conference out of which the produce a report or something which is kind of what you are talking about I think.

MS. MC CALL: Yes, that somehow and you would have to say, “What is success? What is the goal of the conference?” and I suppose there would be a couple. If education facilitation is a key role for us then this would be one mechanism to do that. There may be some specific content that we would want to get out of that./

MS. GREENBERG: You could commission papers for it, also.

MS. MC CALL: Yes, we could actually have kind of a speaker session where these guys would present new ideas that we don’t traditionally think about and then there may be some other sessions where people can actually get together and talk about a specific topic. It is almost like having simultaneous hearings going. We just take a fire hose of information but it has all been seeded with very provocative ideas and different ways to think about things.

MS. GREENBERG: I think it is a great idea.

MR. HUNGATE: Let me ask a couple of questions? When you think about your categories here to me these are all categories of a big vision.

MS. MC CALL: Big tent stuff.

MR. HUNGATE: What we are laying out is a big tent framework and so that obviates the ability to do very much detail because you can’t keep up with things. You can do some detailing of examples that help illuminate the framework, the stories that Brailer was talking about. You could find ways to make it visible and you could do the learning in the process piece that you are talking about.

It seems to me we have to take what we heard in our session which was exciting I think for all of us and put that in a solid enough framework using this kind of structure so that we can begin to communicate, so that we have a consistent communication of the framework and then what we are doing in the hearing process is trying to put a little more detail in pieces of it.

DR. CARR: The only thing I would say, I like that idea, but the challenge of the hearing assumes a certain kind of finite sort of question and as Carol was pointing out, that really struck a note that this is really uncharted territory.

So, what we are doing beyond the hearing is bringing together content and experts.

MS. MC CALL: We might follow on with hearings if we had a more —

MS. GREENBERG: We are also trying to advance the science.

MR. HUNGATE: Let us talk about that a little bit. I think you are going to have to do some work in content development before you can go to that step.

MS. MC CALL: I would agree and it looks something like this. Imagine the following, that what we are able to do is put together two things and we would either share it with either speakers or we would actually have it as an opening presentation that says, “Guys, we have a dream, and here is what it looks like,” and we also see there is a lot going on, and we also see a gap, and here is what that looks like, and so, here is broadly, 100,000 feet, here is where we think the need is and in order to meet that need it is going to need new paradigms, new ways of thinking and welcome to our speakers that have actually been asked and invited to talk about some of those ideas, but actually have it framed up so that we say, “Look, here is a very high picture of a vision,” and it won’t all be ours. You know we are going to beg, borrow, steal from Levitt and Brailer and all these guys and then kind of wrap it with what we learned when people came in.

DR. CARR: What I see with this, I mean the two huge things that sort of take stepping back from this and remembering is just all the dialogue around quality, you know, are we at the accountability end or are we at the dynamic end; you know, how do we measure? Do these measurements equate with quality? What about value? I mean that whole discussion was critical to the full momentum of this. There is lots of activity, You know we are all going but we are not quite sure where we are going.

So, I think that that is a huge thing that this Committee couldn’t take on but sponsoring the conference —

MS. MC CALL: And to talk about it.

DR. CARR: That then helps us keep you know putting together here is our current state and here are the challenges going forward and we have to choose a path and then the second part is as we do this to facilitate this how do we leverage the electronic environment which is so vast but more concrete, but the kind of you know what is true thing, what is quality is big but it would be well served I think by a big conference because I think —

MS. GREENBERG: I wouldn’t say too big but —

DR. CARR: A kind of big conference.

MS. MC CALL: Invitation only.

MS. GREENBERG: The problem is that when the National Committee directly sponsors something it is under FACA. So, everybody, the Federal Advisory Committee Act, and everybody has to be, it has to be open to anybody and so that is the part we have to work around.

MS. MC CALL: It is what 60, 75 grand tops.

MS. GREENBERG: But I think there is a marriage here between what Bob is saying and what you are saying. Bob is saying that we need to pull together what we have learned which was a tremendous amount, and I think not only information but we kind of advanced our thinking to some degree but it is still kind of amorphous at those 2 days.

Maybe we hear folks and maybe bounce that off against the people who were there, do some more work and then before we would go ahead with such a conference, and I don’t think there is a disagreement really on that —

MS. POKER: Is there any kind of desire at this point to look at other disciplines other than, because we are looking within the Federal Government in health care, but there are other disciplines that are doing quality and managing it much better than health care is doing it. Is there any kind of desire on the part of the group to bring in people from the aviation discipline, from nuclear, etc., how they are managing it and maybe kind of finding out what they are doing right or how they feel? Did you guys hear Polly and Itholder? He gave a business case for the EHR which I thought was unbelievably good. That was at NHII.

MR. HUNGATE: My impression was totally different.

DR. CARR: Your point is team framing is one of the national safety things and all of that.

MS. POKER: It is cultural.

DR. CARR: I think the challenge for us is to size it so that we don’t have to bring all of Washington and I would say stay in, you know try to take the unclear areas and make them clear.

I think the airline, I mean I have been to so many of those things.

DR. SCANLON: i wonder about our role here. I kind of focused on this idea of coming out of the retreat of a bridge and that really are an incredible number of people and groups working on the quality side and quite a number of people working on the electronic health record side and that for us to kind of try to do what they do is probably counterproductive and we may not do it as well, but the question is is there a linkage. I mean the electronic health record is a record in some respects. I mean it is just a set of data elements and it is not doing anything for anybody but the issue is the potential and that is where we may play a role, but I think we have got to figure out sort of which element.

There are many sort of lanes in this bridge. Which lane do we want to be on? Do we want to be on the performance measurement side? Do we want to be on sort of the surveillance side? Do we want to be on the payment side?

MR. HUNGATE: If you want to talk about a framework for performance measurement you have to have a framework that has a lane for each of those.

We may not choose to work in a lane but you had better define them.

DR. SCANLON: All right, where do we want to be at the end of a year in the sense of could we have a relatively kind of broad framework that we could come up with by September but then at the end of a year we have got recommendations that tell the world, okay, if you are focused on performance measurement for a variety of different purposes here are important things to think about and then next year you go on to lane two and you deal with that.

MR. HUNGATE: I am not sure how long we should spend on broad conceptual discussion before we get into what is — I am not sure the second part of it going to be our agenda. I think if we do the first part really well, the vision thing that people can hang their hats on and say, “That is where we need to go.”

MS. MC CALL: Yes, if I had to define success after a year I would love for us to be able to make a recommendation to the powers that be on what sort of ongoing mechanism must exist as part of the EHR architecture suite in order to both usher in and continue to evolve quality, whatever that is going to be defined as, and I would love to be able to be specific enough to be able to say how that should work and the types of skills and entities and knowledge that need to come to bear and one more thing.

On the P for P because I think that that is going to be a need I honestly, if we work for a year making specific recommendations on things to care about when people go into P for P it is needed and yet I don’t think anybody will pay attention to it because when I think about health plans and all other entities that may do P for P they are not going to wait for a recommendation and even if there were one they may not take it and so I am looking for bang for our buck.

MR. HUNGATE: I am not sure what you are thinking about in terms of what we would do in P for P because I guess again I am thinking of this bridge and this question of if this is your model of P for P how do you get to the electronic health record in a way that actually supports that, and I agree with you that everybody is moving forward. They are not waiting for that but the future you know what is the way that we could enhance the capacity to do P for P because of the electronic health record that is kind of where I see again the bridge.

DR. CARR: I share your thoughts because as I read this over defining quality is huge. On the other hand, and creating building blocks was my idea that if we can say, “Here is how you could pull up a process measure or begin to capture it and so on,” I think the challenge that we heard that day was the sort of Brent James iterative, you know this is good today but next week we want to exclude the midwives, and next week we want to exclude the CSEC(?) and whatever and that iterative part versus some of the other things and I guess building the bridge you have to also understand what it is.

If we build, I mean again the claims data is not going to be enough to get the information. We could repeat that and build something that was finite kind of process measures and that would be good for that but many people already know as Brent James said, “We are moving away from that onto the next thing.

So, what I liked about Carol’s idea although I share your, you know we don’t want to get into too big of a thing, but we need to know building a bridge to what. What is the ideal and then what could we put in place that would get us closer to the ideal and I think without that vision we could build something that was outdated before we were done.

MS. MC CALL: Although I would say I think that these building blocks are the mechanisms that we have to somehow say that in order to make this happen we need three of these and they need to be connected up like this.

I think that we are talking in such theory that all we have are these small concepts to work with, but one of those could be as we learn more what it is how to embed P for P.

Even if we tried to take on the question today, you know, EHR and P for P links I am not even sure that I would know how because I don’t see the link between, I don’t see the necessary link as being one between EHR and P for P. I think the necessary link is between quality and P for P and data and metrics are not at all the same.

MS. GREENBERG: To me the most compelling statement that was made in these 2 days was John Lunka saying, “I have got all the connectivity. I even have the content, etc. I don’t have a road map for quality,” and if he hadn’t said that I might question whether we even had a role, but that is what convinced me that we did and then of course, Don Detmer at the higher level about the, you know, nobody was building this vision, but I would even say, “Well, yes, that is nice,” but if John hadn’t said that, but I think we need to and maybe you can do it, Justine just because you see him probably all the time but I think we need to really pursue with him what he meant by that.

MS. MC CALL: That is another action item that we want.

MS. GREENBERG: What would he need in order, I mean what does he mean is missing.

DR. CARR: The reason it is not being built is that no one, you know the IT folks don’t live in a quality world and the quality folks don’t understand the constraints of the IT world, and so no one knows what to begin building.

MR. ROTHSTEIN: I think it relates to the testimony we heard about there is nobody in charge. Nobody is saying that is how we are going to measure this. So, you don’t know what to build in because it could be —

DR. SCANLON: Part of that is because the quality hasn’t finished their job. The question is which physician is responsible for what.

MS. GREENBERG: There are so many issues but —

DR. SCANLON: That goes to how you organize the electronic health record and how you retrieve information.

MR. HUNGATE: I think we are going to have to get something down on paper from — go ahead?

MS. GREENBERG: Let me just add what I wanted to say and that is that I think this is a combination of content and that is one of the reasons that I think the work that we did over all these months and years is still really relevant because we did identify some real critical content where we couldn’t agree or where we couldn’t reach closure where the content should come from, but nobody was saying that this is the wrong content.

So, it is a question of content It is a question of processes and it is a question of metrics and it is a question of a combination of connectivity and how you get data from here to there.

There are lots of issues but it bothered me in recent years that we focused, the Committee has focused much more on things like message standards and gotten away from its long-term contributions to the content area you know with the uniform data sets and all that and I mean that is its history and I was very interested to see that the PHR, most of you who were on the NHII, the PHR report tentatively comes out for agreeing on some core content and so I do think that is a role for the Committee and it is a very important one where the Populations Committee comes in, too.

So, I think there are lots of different pieces but I also feel we do need to understand better what John meant by that.

MS. MC CALL: We have got about 3 minutes.

MR. HUNGATE: I think we have got to take what we gained from the retreat and try to summarize it with appropriate graphics drawing in the content as summarized here with priorities set, content-wise based on these so that there is some rough framework that we then say, “Okay, we need to change this. We need some models.”

MS. GREENBERG: And Carol’s summary is a start of that.

MR. HUNGATE: It is a start but you have got to add in some of the specific graphics that were there. You have got to sequence it. You have got to add the history of the earlier hearings.

MS. GREENBERG: How do we get to that next step?

DR. CARR: Boston? What was the reason we had to cancel that?

MS. GREENBERG: We have fairly serious financial constraints.

MR. HUNGATE: After October 1, you can spend. We have got to get the Washington community, the rest of the functions.

MS. MC CALL: No, we are just talking about a field trip because where I think you are going is if I could go out and hear and see John’s work before we finish that up that would be valuable to actually writing it up and finishing it up because it would add more oomph to and more vision behind his statement that struck us all and because what we are trying to do is make the case. It is almost like a protovision(?) but we are trying to make a case for the gap that we see and the need that we see and that would be valuable.

MS. GREENBERG: Are you talking about a site visit or a hearing? We were talking about a combination site visit and hearing. We have serious constraints on travel money at the moment and our entire budget is under serious constraint this fiscal year or until we get our next budget. I mean it is just a fact.

So, now, interestingly enough the standards and security was going to have a 3-day meeting next month which they have now canceled.

Of course, my budget people say, “Phew, that saves us some money,” but I mean if there is some low-budget way that we could accomplish this.

MS. MC CALL: Sure, I will pay for myself.

MS. GREENBERG: No, you don’t have to pay for yourself. If you think it is really critical I might be able to get you —

DR. CARR: What about this idea? If you could get me a setup on screen I could take you through you know 2 hours’ worth of this is how we live our life in terms of all the electronic things that we do and we do everything electronically and I could demo that in a moment.

MS. GREENBERG: Are you talking about in a web way if everyone is there or —

DR. CARR: No, here.

MS. GREENBERG: Is there some way we could do it through a web?

DR. CARR: We can do that. I am just saying, yes, I can get into the web.

MS. GREENBERG: Without going to Boston.

DR. CARR: Yes, I could do that. So, we could set up a screen in a room like this and I will just take you through a day. Here are all the different elements and components.

MS. MC CALL: On top of that what we would need because that would be valuable to get the full context, would John be available to join you to say that now, given that we know what it is, what the “it” is, tell me more about why —

DR. CARR: You know there is actually another physician that builds all this.

MR. HUNGATE: I don’t know what we are going to get out of that. I am sorry.

DR. CARR: This is what Don Detmer recommended. He said that before you try to build a vision you can’t envision what this world is like.

MR. HUNGATE: He talked about the Northern New England group not what John was talking about.

DR. CARR: No, he was the one who said,”You guys need to take a visit to Boston and see John’s set up because as you talk about it here unless you have seen it you can’t envision it.” It took me by surprise because I realized, yes, I see it but —

MR. HUNGATE: I didn’t hear that.

MS. MC CALL: I really want to be, I know back to web cast, we have got to get out in the jungle. I want to experience it. I want to try to go somewhere and see how the whole process is affected. I don’t want to see a software application. I want to be immersed in the world of what it is like.

MS. GREENBERG: There are two of you who are in Boston, Don and Bill and Russ. We need a work group to travel to Boston which is not a big deal. Russ, I don’t even see you here under Workgroup on Quality but is the entire Subcommittee on Populations — well, we welcome you because we are talking about metrics and Russ is an expert in metrics. So, would you be interested in the site visit?


MS. GREENBERG: You would be a great addition.

MR. LOCALIO: Until I see numbers it is very difficult for me to figure out what is good or not good.

MS. GREENBERG: And essentially the staff would have to figure out a way to figure out a way to get there on their own I guess. I mean if we are not talking about a situation where we have a hearing and we have to rent space and we need audiovisual and we have to tape it and all that, that adds up to a lot of money. If we are just talking about a site visit we could probably pull it off.

MS. MC CALL: I would also recommend that while that information would be great to add into what this paper is I think that we could start it and get a first draft before we go and see how it amplifies it.

MS. GREENBERG: And we do want to meet with John. I think it should be done in person and because this is like investigative or whatever on your part it is not covered by FACA anyway. So, that is fine.

MR. HUNGATE: What you will see there is an electronic health record in use, right? You won’t see connectivity.

MS. GREENBERG: We will. We will see how is it connected to the lab; how is it connected to the pharmacy, to this, that and the other I assume.

DR. CARR: Actually we have it across multiple hospitals. Patients have universal ID and you can when you look up data you could say, “This hospital, that hospital or the other hospital.”

DR. SCANLON: And is it now or in the future that you are going to have a history of their contacts with other providers?

DR. CARR: We have that now.

DR. SCANLON: I thought it was the contact but not the record.

DR. CARR: No, we have an electronic health record but it is a narrative.

DR. SCANLON: Right, but I mean I thought at some point you were going to be able to know that they went to somebody who was outside of your system but you wouldn’t know what exactly happened but you would know it.

DR. CARR: Right. That may be the kind of thing.

MS. GREENBERG: That is the other thing.


MS. MC CALL: I don’t know anything about that.

MS. GREENBERG: He has got 2-1/2 million people carrying 100 terabytes(?) of data in a RIO. That is what we want to see and how that interacts with the EHR because the RIO is what passes for an architecture in David’s vocabulary and —

MR. HUNGATE: I thought the RIO was a mass e-health collaborative.

MS. MC CALL: It is.

MR. HUNGATE: But it is on paper.

MS. MC CALL: No, it exists. You can’t carry 100 terabytes of data. It is not a world that I live in. I know that —

MR. HUNGATE: It is on paper.

DR. STEINWACHS: We had better site visit and find out.

MR. HUNGATE: I have been to the meetings that are forming this. I think the VA is farther along in some of these things.

DR. SCANLON: The pertinent one is the health record and you can demo that.

MS. GREENBERG: Okay, so first we need the dates from you.

DR. CARR: I am in touch with John’s office because there is no point in putting me in the middle. You are in touch with them and they gave you some dates in May.

MS. POKER: Wait a second. There are no dates right now because I told them that we are not budgeted for it.

MS. JACKSON: We still need something to justify it to have something we can all fall back on so we can see just what we are trying to accomplish.

MR. HUNGATE: Let us verify a date.

MS. GREENBERG: But I mean we are not talking about a hearing and so we are really just taking about travel.

MS. POKER: Just to clarify I don’t get to go, right, because I am staff?

MS. GREENBERG: I would think that AHRQ would think it was worthwhile to send you.

MS. POKER: No, we went through this. Right now their budget is they are not — I talked to Carolyn personally also about the site visit and she is not — if you want I could take it off line with you, but —

MS. GREENBERG: We will have to talk about that off line. I would say that if you are lead staff you probably need to be there but we will have to deal with that but the maximum staff that we could send would be the lead staff. Others would have to find a way to get there.

MS. POKER: The question is we are going to go by first Bob’s availability.

MS. GREENBERG: We need John. I think we begin with John’s availability.

MS. MC CALL: There is a lot of date polling.

MS. GREENBERG: It would be really good if Susan Kanaan could be there.

MS. POKER: Are we going to need to have a summary of it?

MS. GREENBERG: She is going to be working with us it sounds like on all the writing.

MS. POKER: What kind of writing do you want from this kind of for a site visit?


MR. HUNGATE: I will work with Susan and Marjorie.

MS. GREENBERG: Susan may not be able to come because of funding.

MR. HUNGATE: What I am talking about right now is getting a piece of framework down that tries to take what we heard in our retreat and organize it in what I would call a summarized semi-vision with some context that we can all critique so we are talking about something specific. Our discussions have been extracted. We have some differences. You know the things that we are troubled with make it hard to make progress in short times, but I think if we could get a hard piece to look at and say that this helps or doesn’t help and change the pieces so we would build the picture a little bigger it would help us.

I think we all took little different things out of what we heard and heard and understood different things because of our own backgrounds. We have got to have something that we can consistently look at that fits or we are going to have trouble and because this is such a big abstraction.

MS. GREENBERG: Where we don’t agree we have to rectify what those issues are.

MR. HUNGATE: We have to say what the questions are that lead to the uncertainties in those areas and that is part of our content that we have to go through.

MS. MC CALL: I think it goes something like this. We are going to write up this paper or PowerPoint or whatever it is and we are going to take a field trip and then we are going to come back and we are going to finish that paper. Then we are going to see if we are going to hold a conference.

MS. GREENBERG: That is why the question is whether we need Susan at the site visit or whether you could just feed her information from what you have learned.

MS. MC CALL: What I would do is if she can be there I think it would be wonderful. If she can’t then we do it anyway.

MR. HUNGATE: Is the site visit going to happen before the Executive Committee retreat? It would have to really be quick.

MS. MC CALL: Probably not.

MS. POKER: What are the black-out dates? What are the dates that everybody knows we can’t do?

DR. CARR: Do we want to do that September 6, date as a work you know come in early or something so that we can continue to work.

MR. HUNGATE: Fine by me.

MS. MC CALL: As a point of order I just heard that Cynthia is not going to be able to call everybody to set it up.

MS. POKER: Obviously she just started. Why don’t we feed it to her like what are the black-out dates?

MR. HUNGATE: Is September 7, clear for everyone?

MS. GREENBERG: Maybe not for John. I don’t know.

MS. POKER: We are not talking about Boston.

DR. CARR: I think what we need is sort of what we are looking for and then some traces of dates and the sequence.

MS. MC CALL: So, Cynthia is going to do that. Send out e-mail, looking for dates for and then she needs a list of what she has actually accomplished calling face-to-face and field trip, right?

MS. GREENBERG: Why not provide Cynthia with what the parameters are and Cynthia can follow it?

DR. CARR: I think we need to keep refining our thinking and brainstorming in a time frame more than an hour. Around the time of that September meeting we ought to carve out some time that we can really keep refining where we are going.

MS. GREENBERG: Do you want to try to get to Boston before the September meeting?

DR. CARR: Yes.

MS. MC CALL: And I would love to also have, we are going to need a call at least one. I would just like to sprinkle this even prior to the field trip.

MS. GREENBERG: Within the next 2 weeks I think.

MS. POKER: Are there some black-out dates that you know that you all, that is what I am trying to figure out because the retreat is —

MS. GREENBERG: I wish I had them. I just don’t have them.

MR. HUNGATE: Okay, we are adjourned.

(Thereupon, at 9 a.m., the meeting was adjourned.)