[This Transcript is Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Subcommittee on Standards

November 15, 2012

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

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



Agenda Item: Call to Order, Welcome, Introductions

DR. SUAREZ: We are just going to go ahead and get started. Good morning everyone. It is really a great pleasure on behalf of the National Committee on Vital and Health Statistics, and the Subcommittee on Standards, to welcome you
all to this roundtable on the future of information exchanges for health care transformation. That is how we entitle this.

My name is Walter Suarez. I am a member of the National Committee, the
co-Chair of the Standards Subcommittee, and with my partner in crime here,
co-Chair. And with the members of the Subcommittee, we thought it would be very
important and timely to bring this topic to the table.

We are going to go through a few logistics in a minute, and we are going to
provide you with some instructions or rules of the road about how we are going
to proceed. And we are going to give all of you an opportunity, of course, to
introduce yourselves.

We have a number of people on the phone as well, and we have people in the
audience, which many of them are actually also interested and certainly will be
very welcome to engage in the discussions. So this is going to be a very
engaging, hopefully, and very important discussion to have.

Let me give you two minutes of overview before we start, and give you just a
brief background on the reason why we thought this would be very important to
have. I think we have gone through over 15 years already of HIPAA
administrative simplification standards and processes to improve the efficiency
of our health care system.

And now certainly with the evolution of the adoption of electronic health
records and health IT standards across clinical settings, and the start and the
move toward health information exchanges, and true interoperability as we move
into the future, it was important to begin to consider what we have been
referring to in the National Committee as the convergence of several forces,
several alignment of interests and needs, basically.

Among them, of course, there is the primary theme around health reform now,
moving along, that it is truly going to be transforming how we deliver care,
how care is paid for and reimbursed. We have all this pressing economic needs
on both federal and state governments, that are looking for making our health
care information and health care exchanges and health care in general, more

And we have a lot of standards really that we have been moving along with,
and adopting and implementing, both in the administrative processes as well as
in the clinical processes. And now we are seeing this convergence between them,
looking at more of the information that resides in electronic health records
certainly being used much more directly in the administrative processes, and
more of the administrative information being fed into the electronic health
record than clinical care processes.

And the same type of standards really beginning to become the theme of
exchanging information for administrative and clinical purposes — and not just
between providers but again, between providers and health plans and others in
the industry, including, certainly, public health, a major partner in this

So we thought it would be important. Last year, about a year ago, we
published and issued the 10th HIPAA report to Congress, a more comprehensive
view of the last 10 or so years, the journey that we have taken, the present,
with respect to administrative simplification. And then the future. And in that
future, we mentioned how this convergence of an alignment of various elements
were going to take us to a new way of thinking about information exchanges.

As we look at the changes in the demand for health information, the changes
in the need to exchange certain data, we needed to look at the standards that
will need to be adopted, and improved, and changed, and adjusted to meet those

And so that is in great respect what prompted this interest of saying, okay,
we are moving along with all the standards that are being called for, and they
are HIPAA, and they are the Affordable Care Act, and they are HITECH,
certainly, with meaningful use.

And now it is a great time to take a look more holistically about what is
the future going to look like, in terms of the data needs, the exchange needs,
and the standards that need to be thought about, to support these exchanges and
so we are going to do that during these four or five hours or so that we have

The other main message that we want to note here is that this is the
beginning of a dialogue really. We wanted to make this a roundtable rather than
a hearing, because we really wanted to open up the discussion and stimulate the
exchange of thoughts and perspectives.

And we wanted to make it the beginning of the dialogue rather than, as we do
with more traditional hearings, if you will, we do a hearing and we produce
some sort of a letter or report or recommendation to a secretary. We see this
again as a starting point.

And we are going to look at, as we close today’s first roundtable, we are
going to look at what are the next steps and what are going to be some of the
future opportunities to continue this dialogue, because we see this as a true
major priority, not just for the Standards Subcommittee but truly a priority
for the entire National Committee.

So you all should have received a document, hopefully, of the background in
which we lay out the perspectives of why we are bringing this forum and this
roundtable together. We identified a few questions.

Given the size and the interest, certainly, that this has generated and the
size of the group, both here present as well as on the phone, we are going to
try to limit the amount of questions that we are going to ask. We know that one
question could elicit discussion for four hours. So we are probably going to
keep it simple and high level in terms of the questions. We are really going to
avoid getting into the weeds, if you will, at this initial roundtable.

We have an incredible group of people helping us support this initiative. I
do want to acknowledge a couple of very important people that have helped us
put this together. We started thinking about this with our lead staff to the
Committee and Subcommittee, Lorraine Doo from CMS.

She couldn’t be here today, but we have partnered also with another very
close person to the Subcommittee, Michelle Williamson, who has been
instrumental in helping us coordinate this. She has been the one that has been
contacting you all to participate, so I want to acknowledge Michelle for all of
the support and assistance.

We also want to acknowledge Suzie Bebee, who is going to help us with taking
some notes in the back. And for those on the phone, we are going to be live,
typing these notes so that people on the phone and on the WebX can actually see
what we are noting and describing as thoughts and comments. And then I wanted
to acknowledge our facilitator for today, Kathy O’Connor, who will have a
chance to introduce herself and give you some background about how we are going
to proceed.

Also, I think for purposes of introducing people, I think we are going to do
that with your remarks, Kathy. Let me stop there and turn it to Ob for some
introductory remarks, if you have any. And then we will turn it to Kathy.

MR. SOONTHORNSIMA: I just want to echo some of the points that Walter made.
I think convergence is really the key theme here, so here is an opportunity for
us to think about, not just data, but information. What information is going to
be necessary for us to address all the opportunities, whether it is payment
reform, whether it is care delivery model changes, such as PCMH and ACO.

But I am constantly reminded by a colleague I met this morning, who said at
the end of the day, it is about the patient, it is about the person that we are
trying to care for. With that said, I just want to thank all of you for being
here, and thank Walter and staff for getting this off the ground for all of us.
So let’s get going.

DR. SUAREZ: Great. Thank you. Just one more thing before I turn it to Kathy.
I also wanted to acknowledge our host, certainly you are meeting today, we are
meeting today here at the Headquarters of the National Center for Health
Statistics, who has been clearly a very critical partner to — certainly the
executive support for the National Committee on Vital Health Statistics, but a
very important partner to the Standards Subcommittee.

We are very pleased and very glad to be able to meet here at the National
Center for Health Statistics. Also, just to mention, Kathy, who will be
introducing herself in a minute, is a service statistician at NCHS, the
Division of Health Interview Survey and Interview Statistics. And she is going
to help us go through some of the rule of process here, and how we are going to

You also should have a copy of the Agenda, I believe. As you see, we have
sort of time boxed some of these discussion points. We are going to be talking
about the ground rules until about 9:00 and then we will spend about an hour
talking about the framing issues, and then talk about the policy level
questions and considerations. We will take a break around 11:30 and then we
will talk a little bit about the high level technical questions and

We are going to try to avoid getting into the weeds of the elements of the
standards and all that, but we are going to try to at least highlight some of
the key technical considerations about the future of these information
exchanges. So with that, I am going to turn it to Kathy for her introduction.

Agenda Item: Facilitation and Ground Rules

DR. O’CONNER: Thank you. Again, I am Kathy O’Connor. I am a Survey
Statistician here at NCHS and I work in the Division of Health Interview
Surveys as well as working on the state and local area integrated telephone
survey. I am sure you have all heard of the National Health Interview Survey.
That is the division that I work in.

So first I want to thank you all for coming and I want to welcome you all to
NCHS. My responsibility today is to make sure that the meeting flows well, that
it is value added. And I am here to ensure participation by all members. So if
you are not speaking up, I will kindly point you out and ask your opinions
throughout the morning.

We have some ground rules. First, if you have anything that makes noise like
cell phones, et cetera, please mute those. And if you receive a call during the
meeting, just feel free to go out in the hallway. That would be great, so we
don’t disrupt the meeting.

We are going to have one 15-minute break at 11:30. And I have a xylophone up
there that I will use to make sounds so that if you are out in the lobby or in
the restroom or whatever, you will be able to hear, just like you see at
meetings. (Housekeeping details)

We also have a few special ground rules because we have a lot of people here
today. I didn’t count, but there are quite a few, plus the people on the phone
as well. I can’t reiterate this enough. We want to hear from all of you and we
anticipate that we are going to have a rigorous discussion and a robust
discussion, and that can only be accomplished if I get to be the heavy. So I
will tell you how that is going to happen.

For the first discussion on framing the issues, each person will have about
three minutes to talk. So at three minutes, if you use your whole time at once,
then I will at three minutes politely encourage you to wrap up your comments.
Katherine will be holding up a red piece of paper that I will see, so that is
how I am going to know that she is timing the participants.

We have both in room and phone participants. So we need to pay special
attention to the phone participants so that they get a chance to talk as well,
and give their input. For the phone participants I would like to mention that
for each time that you speak please say your name for the sake of the
transcriptionist, and also for the benefit of those who are in the room,
because we may not recognize your voice.

Roundtable participants, you should all have tents. If you have questions or
comments, if you want to speak, you can turn it over on the side. I understand
that has been the routine, you just turn it over on the side, and then that
will be a cue for me to know that you want to say something. Phone
participants, it looks like everyone has a tent. Phone participants, each time
you speak please say your name. Michelle sent instructions this morning on how
to enter the queue for questions or for comments. And if you are in the room,
it is pretty obvious. You can raise your hand, or tip your tent over.

If you are on the phone you have one of three methods. If you are using the
live meeting link you can type in a question. (Housekeeping details) That is to
raise your hand, and to ask a question in that same pane, yes, there is a box
there and you can type it and then click ask. Michelle will be monitoring those
throughout the meeting.

We are going to be cueing you in, both the people in the room as well as the
phone participants. If you are on the phone and you are not using the live
meeting link, your only option is to say something. So you will have to just at
the appropriate time say something, and we will accommodate you.

Because time is so precious this morning, please stay on topic, because we
do have a lot to cover. And you don’t need to repeat points that have already
been made. I am going to try to stand in this room because I don’t like
standing behind lecterns or podiums, but if I am blocking the view of anyone
just let me know and I can move.

As Dr. Suarez mentioned, Suzie will help us capture the important points, up
there with the white paper. She is going to be at the flip charts, so please
help us capture those points accurately. If you notice that she is writing
something down that is not to your liking, we can accommodate that later on.

This morning there is no such thing as a too-basic question. We want to hear
from everyone. And if you need clarification about a question or a comment that
is being made, please ask. Let’s go around the room now. We will start with the
people who are in the room and then we will go to the phone. If you could just
say your name as we go around.

PARTICIPANT: Just as a reminder for everybody to please speak clearly into
the mike, because we are recording, and also there is a free-standing mike for
the audience.

MS. SHEPPARD: I am Cathy Sheppard. I am here with ASC X12.

MS. MURPHY: Judy Murphy. I am Deputy National Coordinator for Programs and
Policy at the Office of the National Coordinator.

DR. CONRAD: I am Dr. Diane Conrad. I am a family nurse practitioner in
Cadillac, Michigan, and I am also Assistant Professor at Grand Valley State
University in Grand Rapids.

MR. DANIELS: John Daniels, Vice President of HIMSS.

MR. RODE: Dan Rode, I am with the American Health Information Management
Association, AHIMA.

MS. LEITER: I am Alice Leiter, policy counsel at the Center for Democracy
and Technology.

MS. DARST: I am Laurie Darst. I am representing WEDI.

MR. TENNANT: Rob Tennant, with the Medical Group Management Association.

DR. FRIDSMA: I am Doug Fridsma, Chief Science Officer from the Office of the
National Coordinator.

MS. GREENBERG: Good morning. I am Marjorie Greenberg from here at the
National Center for Health Statistics, CDC, and I am the Executive Secretary to
the National Committee. And welcome to NCHS.

MS. JONES: Good morning, I am Katherine Jones, CDC and NCVHS staff.

MS. WILLIAMSON: Michelle Williamson, Standards staff, NCHS.

DR. SUAREZ: Walter Suarez with Kaiser Permanente, from the National
Committee on Vital Health Statistics.

MR. SOONTHORNSIMA: Ob Soonthornsima, Blue Cross Blue Shield Louisiana and
co-chair of the Committee.

DR. SCANLON: Bill Scanlon, National Health Policy Forum and a member of the

DR. CHANDERRAJ: Raj Chanderraj, a practicing physician and a member of the
National Committee.

MS. KLOSS: Linda Kloss, Health Information Management Consultant and member
of the National Committee.

DR. JAFFE: Chuck Jaffe, CEO of HL7.

DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Research and
Quality, liaison to the Full Committee.

DR. CARR: Justine Carr, Chief Medical Officer, Steward Health Care.

MS. BROWN: I am Clarice Brown, Director of the Division of Healthcare
Statistics here at NCHS.

DR. KENNEDY: Good morning, Rosemary Kennedy, Vice President for Health
Information Technology at the National Quality Forum.

MR. SORACE: Jim Sorace, ASPE, Staff to the Committee.

MR. ALBRIGHT: Matthew Albright, I am sitting in. Christine Stahlecker is
going to sit here right now. We are with the Office of eHealth Standards and
Services, the Administrative Simplification Group in there, as part of the
Center for Medicare and Medicaid Services.

DR. POSTMA: I am Terri Postma, a Medical Officer and Senior Advisor at the
Center for Medicare and Medicaid Services and the Center for Medicare.

MR. KLIMEK: Good morning, John Klimek from the National Council for
Prescription Drug Programs.

MS. THOMASHAUER: Good morning, Robin Thomashauer, Executive Director of

MR. QUINN: And John Quinn, CTO of HL7 and Senior Executive at Accenture.

DR. O’CONNER: For the participants on the phone I will allow you to take
your coat off before you introduce yourself.

MS. MEISNER: Debbie Meisner, with Emdeon

MR. ST. CLAIR: Jim St. Clair, Senior Director of Interoperability and
Standards at HIMSS.

DR. KENNEDY: George Kennedy, CEO, Aetna Accountable Care Solutions.

MR. ARGES: George Arges, American Hospital Association.

MR. COYNE: Frank Coyne, Vice President, Chief Transformation Office of Blue
Cross Blue Shield Association.

MR. GEDDES: And Nick Geddes, a Medical Officer of our market facing clinical
organization and Chief Medical Officer for our regional account division with
CIGNA Health Care.

DR. CASALINO: Larry Casalino, Weill-Cornell Medical College.

MS. AMATAYAKUL: Margret Amatayakul, MargretA Consulting.

DR. CONRAD: Alan Conrad, a practicing family physician in Cadillac,
Michigan, President of our local physician hospital organization.

MS. WEICHER: Margaret Weicher, ASC X12.

DR. O’CONNER: Okay, great. I think we have heard from all the phone
participants and then we had one person join us, if you could just tell us your
name and affiliation please.

DR. STAHLECKER: Certainly. Chris Stahlecker. I am with CMS. I am the
Administrative Simplifications Group Acting Director.

DR. O’CONNER: Wonderful, thank you, welcome.

DR. ANDREWS: On the phone, Roxanne Andrews from the Agency for Healthcare
Research and Quality.

DR. O’CONNER: Thank you.

(Introductions around the room)

DR. O’CONNER: Great. We will go ahead and get started. As has been
mentioned, today is all about starting the dialogue. This is a kick-off
meeting. There will be follow up meetings as well, and we are emphasizing
vision. We spend most of our time at a very high level with this meeting. We
don’t want to get into the weeds. So we don’t plan to go through each one of
the questions.

There was a document that Michelle sent out that had the topics we are going
to talk about with a lot of different questions underneath that. We are not
going to discuss all of those questions by any means. Those are the background
material. However, we welcome your input on any of those questions as we cover
the general topic areas, of which there are three: framing the issues, policy
considerations, and technical considerations. Any questions before we start?

Agenda Item: Framing the Issues – Introductory Remarks

DR. O’CONNER: Let’s begin. The first of our three broad topics is on
framing. Ideally what will information exchange between providers and payers
look like in five to 10 years? I will restate the question. For framing,
ideally what will information exchange between providers and payers look like
in five to 10 years.

MR. ST. CLAIR: This is Jim Sinclair from HIMSS. I would like to offer that I
think in answering that question we first want to address what we think ideal
information exchange is. Obviously it is driven by business purpose. And I
think that we have already hit upon key themes.

Not only in the Affordable Care Act, but if you also look at publications
such as of course the Triple Aim and the efforts by Dr. Berwick, to start to
encompass ideas around how the entire body of data, knowledge and analysis from
a clinical and a non-clinical perspective could help you analyze and understand
not only how effective care is, but of course measures of that effectiveness
and the economic investment around that care and be able to make cost-based
decisions and analysis around how that care is delivered for patients or groups
in an area.

DR. CARR: Justine Carr. Steward Healthcare is one of the 32 initial pioneers
in the Affordable Care Act. And in our first coming up to one year in this
program our focus now, not just in Pioneer but across all payers is about
covered lives. It is no longer siloed.

And so as we are accountable for the care that is delivered, the
cost-effectiveness and the quality, I would like to put out there the question
of what will be the role of the payer as more and more organizations move into
ownership of the total medical expense and the quality of care of the
individuals under their care.

DR. O’CONNER: Anyone else?

MR. TENNANT: This is Rob Tennant. We understand there are a lot of new
payment models that are being explored, but I think from our perspective, I
suspect things aren’t going to look that much different in five to 10 years.
The same information that is needed today is going to be needed then, meaning
everything from credentialing data that falls between providers and payers,
eligibility for patient services.

So I think my point with that, it is exciting to look at new payment models,
but we have to go back and make sure that that information flow that is so
critical to make the system run is done in an efficient way.

We have operating rules that are cashing in in January, but there is no
notice. And there is no excitement in the industry because the software can’t
handle it yet. So we are developing the standards moving forward, but the
software isn’t keeping up. And just back on credentialing, that is a huge
burden administratively for physician practices and hospitals.

If we can streamline that by moving towards a centralized industry based
solution, get away from the silos, get away from the proprietary approaches,
whether it is through CMS or the states, I think we are going to save a lot of

DR. CONRAD: This is Dr. Alan Conrad in Cadillac, Michigan. Just to speak to
that point, there was an article in today’s New England Journal of Medicine
regarding reducing administrative costs and improving health care. And they
identified six areas where standardization could reduce costs and their
estimates where there is standardization, one of those was on credentialing.

But those six areas, they estimated would save an average of $29,000 per
physician per year in administrative burden, if a standardized process was

PARTICIPANT: I think if we look at information exchange five to 10 years
out, there are probably three characteristics that should be taken into
consideration. One is the national quality strategy related to the triple aims
and the characteristics of that strategy. That really is guiding what we are
doing at a national level.

And that leads to the second component, building a common data
infrastructure. And that data infrastructure will be used for care delivery,
measuring the quality of the care, quality improvement, and could also be used
for administrative and financial function as well.

And then those two components then really lead toward patient-centered data
collection, whereas the information is collected once and then re-used for
multiple purposes. And that is where the data infrastructure will help us get
there, even though I agree that the software maybe needs to catch up with that.

MR. GEDDES: This is Nick Geddes from CIGNA. What I would add to the
discussion — and I certainly agree with many of the points that have been
raised already. What I would add to the discussion is that the exchange of
information quite frankly I believe needs to move.

Not only to include claims-based information, but also information around
outcomes, that information that is holistic, so that the scope of the
information is changed from administrative to administrative and clinical. And
in addition to that, from a timeliness perspective, it needs to be much more
real time, or quite frankly real time versus the delay that occurs today.

I think we expect the premise that in fact in the future what we are looking
at is an enhanced partnership between all levels of the delivery system
including the payer group, and we certainly believe that.

MS. MURPHY: Judy Murphy. I want to go back to the first comment Jim St.
Clair from HIMSS made. I think a good way to frame this — and when we think
about five to 10 years out, is that there are two major areas that we think
about with exchange. One is that concurrent or the real time. What does it take
to manage this patient right here right now? And so whether that is looking at
best practice. He mentioned the Triple Aim. I think that is one whole goal.

But the second one is this sort of retrospective, or the aggregate, where we
are going to look back in time, and look across care encounters either for an
individual patient or for groups of patients, and pulling that together,
looking at the practice patterns or the costs over time, or how is a particular
type of patient being managed by a particular organization. And that is of
course where more of the payment model things get in. I really like framing it
in the concurrent and the retrospective or aggregate.

DR. O’CONNER: Michelle, you have a question?

MS. WILLIAMS: We have three in the queue: Charles Kennedy, George Arges and
then Frank Coyne.

DR. O’CONNER: And after that, we have a question over here as well.

MS. WILLIAMS: Charles Kennedy?

MR. KENNEDY: This is Chuck Kennedy from Aetna. I believe — that’s going
back to the point that the person from Steward, I believe, made around what is
the role of the payer, because technology such as Health Information Exchange
creates value through its ability to support underlying business processes.

We believe that the role of the payer has to evolve from one of traditional
financial and administrative support to one that includes support for clinical
decision making as well as population based analytics. That evolution and role
requires a different type of health information exchange, not just traditional
electronic clearinghouses for claims processing.

And not even just traditional, I guess now a traditional Health Information
Exchange, but rather using all the transactions that are moving back and forth
in the clinical and administrative environment to create a human understanding
of the patient.

We believe that the foundation for this is taking advantage of semantic
interoperability techniques so that an understanding of the patient is created
that can be shared across the care team. As well as be used for clinical
oncology which will, for lack of a better word, create a data model which can
then be used and leveraged both in real time as well as on a population basis
to optimize care and achieve the Triple Aim.

DR. ARGES: This is George Arges with the American Hospital Association. In
many ways I agree with many of the comments that have been made. But we almost
have to step back and take a look at this as a mathematical expression to some
extent where everyone here is part of that front end of that mathematical

And we need to look at what our expected outcome is, the end result, and how
do we get there, what are the cost drivers, what are the roles, what type of
coordination do we need. And how do standards basically fit into that equation?

I would say today that while we talk about standards, not everyone has fully
embraced the standards in a way that is meaningful, whether it is being able to
handle all the diagnosis codes that are reported, let’s say, on an
administrative transaction, those type of things need to be understood because
it gives us a clearer picture really of what is taking place within the

But all of us really are part of that equation. And we just need to figure
out how we basically carve out our role to basically get to that end result. If
the end result is a more efficient, more effective quality outcome then we need
to be sure that we define all the variables.

MR. COYNE: This is Frank Coyne with Blue Cross Blue Shield Association. And
again, like the other speakers, in many ways agreeing with what I heard. Just
looking at the information ecosystem that we need going forward, what strikes
us is that the kinds of data that we are going to need to be interoperable and
available in real time going forward are probably going to expand significantly
to meet the ultimate goal that we see as improving consumer health and safety,
and in doing that engaging consumers.

Sometimes when we look at this and take a step back from the ultimate goal
of improving consumer health and patient safety, what strikes us is that there
are certain datasets from consumers, for example, including biometric data,
social media data, and information on what engages different segments of the
consumer population, that we don’t spend a lot of time talking about.

But that are nevertheless really critical to our ability to achieve the end
goal of this information ecosystem that we are trying to create. And that is,
driving better consumer health and patient safety.

DR. O’CONNER: We have six participants in the room who would like to chime
in now. We will start over here with Mr. Rode.

MR. RODE: Thank you. Dan Rode with AHIMA. I agree with a number of things
that have been said, but I think the Committee needs to look beyond the payer
community needs. And I think we have already heard it expressed at the table.
There are so many other needs that impact the data we collect, the data that we
put into our various electronic health record systems, the standards we use,
the code sets we use, the nomenclature, and so forth.

And I think we have to go back and especially in the Committee’s role of
advising HHS, looking at a need to consolidate the roadmap that we are going to
look at in the next 10 years. We have got to incorporate the needs that we are
hearing to determine the data. Is the data there or not?

Rob may be correct that the data is already there, but are we using the same
language? Are we using the ability to transmit it? And in addition we need to
take our bow to standards and actually do something with it. The closest we are
coming to right now is the Meaningful Use Program, which sets standard criteria
for certain products to determine meaningful use.

But there is so much out there that is not covered in those standards. There
is so much that we have not consented to as a community. We have standards, but
they are not necessarily in the electronic health record systems we have today,
unless the systems tried to meet a meaningful use criteria.

We have various nomenclatures. We were talking this morning 11 different
terminology systems with just nursing. How do we incorporate those into the
system, and how do we determine what it is we need so that we know the
terminology that best suits the community need, not just payers, to deal with
the cost picture, but to deal with the patient centered care and to deal with
the quality outcomes.

So I think that we need to take a larger view. The Committee has a history
of over 60 years of looking at data. And let’s not just look at HIPAA or the
work that we are doing with ACA. Let’s look at this as a community, and attempt
to let HHS lead some of this discussion through, but everybody participates.

MS. DARST: I just want to make a comment in conjunction with what Rob had
indicated about the data. One of the things that WEDI has been looking at is
the whole bundled payment ACO concept. As we were looking at actually
communicating that administrative data and as these new concepts are coming
forward, the ability to communicate without having a lot of manual intervention
is very important.

We need to keep our standards, keep our communication vehicles going. As we
look at patient eligibility, as we look at claims, as we look at remits, right
now there is no way to know, is this patient in a bundle. How is that being
communicated from the payer community? How is this being communicated from the
provider community, that it is a bundled payment? And is this one where
everything has been consolidated?

There are no indicators to be able to communicate this back and forth across
trading partners. And so as we look at all these new concepts, we have to make
sure that we have the tools to be able to stay efficient. And that is one of
the things that WEDI is looking at in this ACO bundled payment field.

DR. FRIDSMA: There are a lot of really smart people in this room. I don’t
profess to be able to predict the future, so I am not going to be able to
answer the question as framed. However, there are a few things that I think we
can say.

I think we are going to have an increasingly technically savvy patient
population and providers that will demand far more of us than we currently
deliver. They are going to have their iPhones and their iPads and all of their
different technology and they are going to wonder why we are still using paper
charts and sending things with fax machines.

We know it is going to be dynamic and connected because that is where the
world is going. And health care is going to have to be the same way. And I also
know it is going to change, because we are going to measure things and we are
going to find out what we do right and what we do wrong, and we are going to
have to fix the things that we are doing wrong and make them right.

It is not going to be a one size fits all and there is not going to be a
single solution. So there is going to be heterogeneity out there, and people
are going to do things in different ways to locally optimize what actually
works. So when I think about the work that we do around standards, I don’t know
whether data will be seen as a common good or whether it will be a competitive
weapon that people will use to compete against other folks. And I am not sure
what is the right way to do that.

Standards can either help that. Standards and policies can either help that,
or it can hurt it. And I think when we think about what it is that we want in
that ecosystem, we have to make sure that we are selectively engaged in
standardizing the right things so that we create an innovation environment and
we don’t stifle where it needs to go.

So our approach needs to be dynamic and responsive. We have to do it
iteratively, incrementally. We have to figure out how to make our standards,
not we are going to create them and they should be good for 15 years, but we
are going to have to iteratively update them and have new data as we have new
things that we want to do.

We have to have substitutability, so that if we get it wrong we can swap out
a bad solution with the good solution and not have to take the whole thing down
and start over again. So I don’t know. I didn’t know five years ago I would
have to summarize my life in 140 characters. And so we can anticipate that
there are things that are going to happen that we haven’t even thought of.

And that is going to be good, because it is probably going to be better than
anything we come up with right now. But I think we have to be humble about what
the future holds, and we have to be aggressive in managing that risk in how we
deploy standards.

DR. STAHLECKER: Echoing some of the things from Doug, I would try to advance
the notion of this future view. We have a very collaborative, cooperative
industry for embracing all of the changes that folks have talked about around
the table so far, that we have a protocol for how we would address that similar
to what Doug was saying, how we can embrace the new changes along the way as we
discover things that maybe didn’t go quite so right, how we can, in an agile
environment, address them more readily.

And in a lack of any other rallying point, I would suggest we think of
something like Carnegie Mellon’s Capability Maturity Model integration tool as
an industry-wide approach for how we address these changes that we know need to
come forward. That we don’t have a strong infrastructure for how as an
industry, we embrace and adopt and try to introduce change.

So we should have a process that we can all embrace as our collective change
agents from our various interested perspectives, how we can move forward
cooperatively and address all of our needs, so we are not disadvantaging

DR. POSTMA: Hi, it’s Terri Postma from the Center for Medicare. Just to go
back to some of the themes that we have been hearing and maybe reframe it in a
little bit different way. As we are implementing these various Medicare
value-based purchasing initiatives, I think especially the ones that are
Accountable Care Organizations that are built on a fee for service platform,
one of the things that Dr. Berwick always talked about was creating journeys
for the patients, so that the patients’ care is no longer fragmented. And as
they transition from care setting to care setting, that the patient’s
information travels with them.

And so I don’t know where we are going to be in five to 10 years, but I
think one of our goals should be to create data journeys or seamless transition
of data from care setting to care setting. One of the things that we are
hearing in terms of feedback from some of the folks that are participating in
the Medicare Short Savings program and other ACO initiatives, is that there
seem to be sort of gaps.

So that the patient transitions from setting A to setting Z, and along the
way there has to be manual input of data from some source, whether that is
administrative data or especially clinical data. And I think that is where we
are seeing the biggest gap right now, is being able to extract quality
information, that information that largely depends on information in the
patient’s medical record.

A lot of systems seem to struggle with getting information from the lab into
the medical chart, from the imaging center to the medical chart. So I think a
goal of addressing how those pieces of clinical information that are so
critical to patient care, and also to evaluating the patient care, how we can
make those transitions more seamless, I think is becoming more and more

MS. THOMASHAUER: This is Robin Thomashauer from CAQH. I am really struck by
the patterns that we are hearing. I think there is an awful lot of consistency
across a lot of these comments. I was encouraged to hear that.

Building on something Rob said earlier I think that one of the things we
have to grapple with is, how do we encourage the market and still move away
from a proprietary point of view around what we do? There is a lot that we can
do, if we can consolidate and cut down the silos and break down the
fragmentation that we see, in order to get to where we need to be.

And in doing that, I think one of the things we really need to look at are
the roles, particularly of the private sector and the government. And how do we
allocate those responsibilities in a way that is meaningful and can support an
infrastructure that gets us to where we want to go. And in light of that
infrastructure, what is the funding mechanism?

We talk about a lot of things. But the point that often gets left out is how
do we fund those efforts going forward? So the funding needs to be thought
about as well. In addition to the impact, we put a lot of things in place but
don’t often allocate the time or the resource to measure the impact, the
return. And I think we have a lot stronger case and a lot stronger story if we
can do that in a way that will be meaningful to the people that actually have
to engage and implement.

And that brings me to my last point, and that is around the implementers.
There are a lot of familiar faces in this room. And when we reach out beyond
the familiar faces, there is not a depth of understanding in a lot of cases
about why or what we are doing. And so we have to spend time figuring out who
is not at the table that needs to be at the table as an example of employers
that are really going to be a part, going forward, of what we need to get done.

MR. QUINN: John Quinn from HL 7. A few points, and some of them build on
what Doug just talked about. The future holds an opportunity to exchange a huge
amount of information that is not available for exchange today. It is available
in the computer systems. It could easily be put there, but it is not available
for exchange today.

Meaningful Use Stage One, and the upcoming Meaningful Use Stage Two is just
scratching the surface of what the potential is. So we are looking at a
mountain of information that is suddenly going to become available for moving
it. Before it was stuck on paper in an unparsable form by a computer. It was
scanned at best, or faxed.

The future market demand will be ahead of our ability to deliver that
information, guaranteed. The odd thing right now, we are in a strange position
right now which is just the start-up, which is, we are ahead of the market.
That is going to change, and when it tips over, we will know that the avalanche
is coming down on our heads.

We will know when things have really kicked off, when new information starts
to come from the market. And we haven’t even thought of ourselves what the
market is going to demand. No matter how much we try, the market is going to
surprise us.

Why? Because it has surprised everybody in every other industry as the
demand picked up. How many people predicted smart phones 30 years ago, or 20
years ago? The technology wasn’t even invented then. If we had all predicted
it, we would all be rich, and doing something else rather than sitting around
this table, right?

So it is important to predict demand, because the ability of the specific
standards implementation specifications that we need and the delivery from the
vendors will always lag the demand. And so I guarantee frustration, because
unless we figure out how to solve that — and I have only been working 25, 30
years and I haven’t seen it really come down a whole lot — it has gotten a lot
more complex. But the amount of time it takes to do it has not really

I am encouraged today when I meet and work with practicing physicians who
are excited about their EHR systems and are rushing to write and present papers
in their medical community about new problems that they have that can now be
solved through the use of their EHR systems. That is happening.

I spend a lot of time in front of a lot of physicians for my own clinical
reasons, and I seek them out to find them. Folks that are my age that don’t
want to touch the system and let their nurses update the system, that is their
choice. But they are planning to retire, so their point is why invest the
intellectual capital or the money.

Number five — today is likely the only time where there is a slight time
gap in the favor of the information that is just beginning to be available and
hasn’t found the demand yet because it is not uniformly available. And more
important, processes have yet to be invented throughout the market to use that

MR. GEDDES: This is Nick Geddes. I am just jumping in for a minute. I have a
request. Could you ask folks who are on the phone maybe to mute their phone if
they are not speaking? There is a fair amount of background noise.

DR. O’CONNER: All phone participants, if you are not speaking at that moment
please make sure that your phones are muted because we do hear some kind of

DR. CONRAD: I am Dr. Conrad and I am a family nurse practitioner. But I
spend a lot of time in front of patients. And I think what we need to really
look at here is that when we are looking at technology, remember that it is
garbage in, garbage out.

And until we really address who is putting that data into the system and how
well they are, what kind of resources they have, how well they use their EHR,
and how well that data is collected, reflecting the processes of patient care,
then all the data we collect doesn’t mean anything unless it is correct and
accurately describing that patient and the patient care experience.

And so I think we need to start back where the rubber meets the road a
little bit and realize how much variation there is in usability of EHRs. So it
is one thing to say that yes, there is EHR adoption. But does that mean that
somebody just has a computer sitting on their desk and has somebody entering
the basic data?

Or is that data really reflecting that patient care experience? And are the
quality measures being entered? And can we actually retrieve them in order to
continue to report on those quality outcomes?

So meaningful use is one, scratching the surface of the resources that are
needed to implement EHR on a provider basis where the patients are actually
being seen and cared for. In our practice we have five family physicians and
myself practicing. We started our EHR early in 2005, 2006.

Since then we have found that it has cost us — and I had our staff look at
what it cost us in hardware, software, IT support, ongoing staff training,
including provider training, and ongoing management of those records — and
since 2006 it has cost us $853,000 to do that in our little tiny practice.

Now Meaningful Use is saying we have achieved stage one. But that is only so
far a pittance on what it cost us to adopt and maintain those records. And the
variability in each provider’s use of those records is even evident in our

So when we are looking at the future, if we don’t provide the infrastructure
and the training and get people on board with how they are using this tool,
this EHR to provide data that is accurate, then all of our outcomes and things
that we want to have in the future are not going to be very representative of
what is happening with that patient care experience.

Because that is where health care happens, is between the patient and the
provider. And if we don’t have this tool that accurately represents that, then
we are going to miss a lot of information in the future.

DR. JAFFE: Chuck Jaffe, HL7. I think we have the challenge of using the
information at hand to both improve the quality of patient care and reduce
costs. In many industries that is not the issue at hand. I believe that there
are numerous standards available to make these changes happen. Our challenge is
to convert all of the available standards into usable form, so that
implementation is easier and the end result more effective.

When we face this, we have to come to the realization that by and large
policy trumps technology and implementation is often the challenge, not only
for the industry but also for the caregivers and the patients who are the end
product of our work.

DR. KENNEDY: Rosemary Kennedy from NQF. I think one of the challenges, and
it was indirectly stated through many of the participants, is redefining the
source of information that we are looking at beyond the electronic health
record, and how do we tactically move with EHR standards but also take into
consideration other sources of information.

Infusion pumps, ventilators, a lot of that information is redundantly
entered into the electronic health record and it is a rich source of
information. So I think it will be a challenging area. And in some respects we
are probably redefining what the electronic health record really is, and need
to embrace those other sources and devices.

DR. O’CONNER: Michelle, you have some phone questions?

MS. WILLIAMS: Frank Coyne — a question on the phone?

DR. COYNE: Just following up on some of the earlier comments, I couldn’t
agree more with the comment that was made earlier about the challenge that we
have inasmuch as the market demands, including consumer assumptions and
consumer demands, are going to far outstrip the ability of this information
ecosystem that we are trying to create, to deliver.

So at some point in this discussion it might be helpful — and this is also
reflective, I think, of some of Robin’s comments earlier, to have a discussion
about what we could do differently, or what we could change, to create a much
more interoperable information ecosystem that could at least anticipate some of
the needs in the market and be there in order to deliver them so we are not
always playing catch up to such a great extent.

And I agree totally with some of the comments that were made about adding
more information into that ecosystem, looking again at the standards. And real
time is a really critical challenge for us. But at the same time I am really
struck by the comments on innovation, that we don’t know what we don’t know at
this point. We don’t know what the future information demands are going to be.

And so what we are challenged with is creating that information ecosystem
that can be flexible enough and real time enough, and be able to be agile
enough to change, to meet emerging market demands. And so whatever we say on
specific issues it would be helpful to see if there are some principles we can
agree to on how we work together to make sure that foundational information
system is there.

MS. LEITER: I wanted to return to what Dr. Conrad said about garbage in,
garbage out. All of these information flows depend on accuracy of information
and that depends on the patient being comfortable submitting accurate
information, whether it be to his or her provider or his or her self, in some
of these more advanced electronic health records.

So it is really more of a policy issue that I was going to wait until the
next segment to bring up. But there needs to be a focus on baseline trust when
it comes to health information technology for patients, and that is, the
privacy issues here are crucial because if there is a widespread distrust in
health information technology it leads to privacy protective behaviors which
ultimately decrease the accuracy and value of clinical information. So I just
want to add the concept of privacy and trust into this discussion.

DR. SCANLON: Bill Scanlon with the National Committee. The comments have
been incredibly interesting and I think very reflective of what is happening
with respect to health care. This reform that we are talking about is a
multi-faceted, multi-headed sort of phenomenon with all kinds of strains that
are going on.

I wanted to, though, say something that in some respects, to not disappoint
you as the Committee moves forward because I think it is important to think
about the Committee’s charge and how we have taken that charge and tried to
expand its sum to deal with the change that is underway.

The Committee’s first responsibility is with respect to administrative
simplification. It has come up today in terms of the high cost being borne
because of the fact that we don’t have administrative simplification, and the
need to try to improve on that. That involves the communication between payers
and providers. That is all it really involves.

It is not about the internal operations of providers and their dealings with
the patients directly. Those kinds of things are very, very important in terms
of the transformation that we would like to have to happen in health care.

But in some respects those are not going to be solved by the federal
government setting standards. They are going to be resolved by the providers
themselves, the provider communities themselves coming up with best practices.
This is the way any industry works.

The thing that is being transformational at the federal level and also at
the payer level is, we are changing in some respects how the health care market
works. It has been very, very different in virtually every other product that
you buy.

And when you need health care, you have a sense of the need. And you
generally go and get some service which you weren’t really sure that was what
you needed, and then you are given a bill. That is the way it has been.

And what has happened over the last, say, eight to 10 years is the sense
that we really need to think about changing that. One is, when we get a service
we should actually be sensitive about what was the quality of that service that
we have got. And should we have information about that?

That has created sort of another administrative problem, which is that we
have asked providers to offer or to give information about quality in a variety
of different forms – which creates a big burden for providers. There is the
question of how do we short-circuit that and make it a more efficient process
in terms of being able to measure the quality of care being provided.

The second thing that is going on, which is somewhat more recent in some
ways but not totally is this notion that we have to stop paying fee for
service, we have to stop paying for individual services and we need to pay for
bundles. Well we have had a bundling experience since 1983 with hospital DRGs,
and it has worked out reasonably well.

But we actually found that we needed to have more information to refine it.
That is where we are today. We need to think about how we refine information,
how do we get that information, to refine it in an efficient way? Those are the
challenges we have got. That is where we are going forward. Hopefully we won’t
disappoint you in the future.

DR. SUAREZ: This is Walter Suarez. I think the start of the discussion was
great. I think the framing that Bill just mentioned is now going to take us
hopefully the next 30 minutes or so, into getting a little more in that
particular area. There are a lot of things that are being mentioned through
this introductory framing discussion.

I think now we need to hone in a little bit more into this aspect that I
think Bill is bringing up. Because I think that is what we really want to get
to as we move forward into the next part of the discussion.

DR. O’CONNER: Thank you. Miss. Sheppard?

MS. SHEPPARD: Cathy Sheppard from ASC X12. I think that it is really
important for us to remember, especially as we listen around the table today,
that there are an infinite number of great ideas and improvements and things
that we can do better, more data that we can collect, more things we can do
with it when we collect it. But there is a finite number of resources available
across the spectrum of the industry.

And we need to ensure going forward that we learn from the last 10 years
every time in that rolling frame. We cannot do everything that is good and
worthy at one time. We need to make sure that 10 years from now we have a
different system in place where we can prioritize a reasonable amount of work
that the industry can support across the spectrum, everywhere.

And that we manage that so that we can do things methodically, accurately,
and effectively, so we don’t have to do them over and we can move onto the
next. If we try to do everything at once, we are going to do a poor job of all
of them. We need to find the right number of things that we can support and do

I think part of that is coordination of the different federal programs. Part
of that is coordination amongst the voluntary things that are behind those. And
we need to move toward an industry where we do things because there is real and
meaningful value, not because somebody has got to hammer the mandate on top of

If we can get to those places, then I think we will be in a much healthier
situation. We will be able to move in a more agile way. We will be able to
adjust more quickly to needs that are presented to us.

DR. CHANDERRAJ: Raj Chanderraj, member of the Subcommittee. I am a
practicing physician. People have introduced simplify and reduce costs. Over
the years it has taken on a different tone now, and says now quality is also
important. I think this is placing a huge burden on the provider, the
physicians. As we heard the cost of doing this is immense and not adequately

What is going to happen down the road in five years, yes, the infrastructure
is still being developed. But it is only at the basic levels. We have to rise
to a higher altitude, as Bill said yesterday. And it will take an enormous cost
to get there. It is not going to simplify the costs or simplify the procedures.

What we have to do is to have a buy-in by the stakeholders. Everybody is
talking about the industry and the payers and the patient. Nobody is talking
about the provider. What is it taking for the provider to do this? Nobody in
this group, or nobody in the stakeholders except the physician, is suffering
the consequences of this. The penalty is being imposed on physicians only, not
anybody else.

Meaningful Use has been started on January, but all of the RACs are
conducting audits and penalizing physicians for doing what they are doing, what
they are supposed to do. They don’t know what they — they are all in fear.

So unless this factor is taken into the buying of the stakeholders, the
stake, and completely into the discussion, I think all the policies will lead
into more heavier cost. Producing quality is scaring physicians. We get reports
from several payers in the industry every month saying this is the cost of you
providing care.

But they don’t realize that attach any mortality, morbidity benefits, but
they increase costs. They completely ignore that aspect, and they are just
showing the cost is providing. And that is one factor that has to be taken into
account. Thank you.

DR. O’CONNER: Thank you. We will go to the comments on the phone. I would
like to remind everyone we have 20 minutes to discuss framing of the question,
and Dr. Suarez would like more focused comments on that area.

MR. ARGES: Thank you. This is George again, and one of the comments that I
would like to make is the fact that one thing that seems to be a barrier in the
way we are looking at this is the ability to basically tie sites of care

So a patient who goes to a doctor’s office or who goes to an acute care
facility or goes to a post-acute care facility, all of those events are very
separate and distinct in how they are registered, how they are captured, how
that medical record information resides, is unique within many of those areas.

And what we need really to some extent is a way to tie that all together,
whether it is the unique patient identifier or a unique ID for the patient is
something that has to happen. Otherwise, I think it becomes very difficult to
really look at how we can bundle payments down the road.

And bundling really should have the idea of providing all the pieces that
are necessary for the patient’s care in the best site possible, and tying it
all together in a more cost-effective way. And until we have at least that
piece I am not sure how we can do it accurately or efficiently.

MS. BROWN: I am Clarice Brown. I am director of the Division of Health Care
Statistics. I sort of wanted to tack onto what Kathy was talking about, the
providers. We are having a very, very difficult time recruiting hospitals for
our new hospital care survey because of all of the demands that they are
currently going through, changing from ICD-9 to ICD-10, changing the UBO-4 from
one standard to another.

We have never experienced this kind of resistance to participation in a
voluntary national survey before. And I think it goes to the point that
providers have to be considered in all of these decisions and standards that we
make because otherwise they are just overwhelmed, they are overburdened.

I just wanted to mention that in five years I am hoping, in five to 10
years, I think that was the question, I am hoping that we will be able to
integrate these surveys, be able to get a picture of health care delivery
across dividers. We will be able to do that in a non-burdensome way, and
accurate, and be able to provide accurate and objective statistics that will
inform health care policy, as is our mission.

But right now our mission is sort of in jeopardy in some circumstances
because of participation rates. So I just want to mention that challenge.

DR. CARR: Justine Carr, Steward Healthcare. I wanted to go back to what Dr.
Scanlon said regarding the task at hand. I think what we are hearing is that we
have got to have harmonization of this data stream. And even though our task is
administrative simplification, claims attachments, if we don’t now begin to
create that harmonization we will continue in this overwhelming fashion.

And I wanted to just follow on a couple of points that were made. Because as
we think about data, there is some data that is a one-to-one, a potassium level
is a potassium level and there doesn’t need to be any middleman. As was pointed
out, in the EHR we are putting information in without any coding clinics or any
guidance of what is the level of specificity and all that.

And then even when we put in coded administrative data in the hospitals we
have a group of people who are well versed in exactly how to apply the codes.
In the offices we have the spouse, the daughter, the part-time per diem, the
physician himself or herself, who are making choices about the information that
is there. And then we are moving into patient-generated data which is, as we
said in the beginning, it is about the patient.

So that is probably the most unstructured but in many ways the most highly
valuable. And so I think as we think about the stream of data, we have to begin
to think about have we addressed what data and how you are supposed to use it.

And then we get to the issue about can it be exchanged. And I think what
Doug said is so important, about the flexibility. We are so hamstrung. If we
have to wait five years for these standards to go through and be vetted by
everyone, we have lost our way. We are already overwhelmed with that.

And then finally, thinking about the end user, while payers, yes, but we
have talked about public health and providers themselves who are accountable
for the care of this patient. So I go back to my point about the fact that we
break down those four elements that are critical to getting data that can be
generated once and used many times and be credible.

DR. O’CONNER: Before we go around the room and go to the nametags that are
up, I would like to ask Mr. Klimek and Dr. Sorace if you have any comments. You
have been kind of quiet, but I want to make sure you have the opportunity to
speak up as well, if you have anything to add.

MR. KLIMEK: John Klimek from National Council for Prescription Drug
Programs. Actually I have been taking some really good notes. It is kind of
unusual in the fact that I sometimes, being from pharmacy, I feel like the
red-headed stepchild in the group. But pharmacy has been doing claim
transmission and information exchanges between payers for over 20 years.

We tend to get the right people in the room to talk about what needs to be
done for industry. We get a very good consensus group that says this is the
right thing. Sometimes it is a burden. It is technically a challenge for a lot
of payers and providers to be able to put that information into good use and
make those system changes. But it is the good for the patient. And that is the
way we look at it many times.

What I look at a group like this and trying to do what I think pharmacy
tried to do 20 years ago. I think it is a much larger task, obviously. But I
think eventually that is what needs to happen. Maybe the right people in the
right room, and this is exactly the right people in the right room. So sort of
describe what the challenges are.

And I have heard that $800,000 cost to a small group, I go to a physician
and he has made the changes, but he was on the fence. He said maybe in five
years I will be retired. I am sort of afraid that you are going to start to see
a lot more physicians doing that, where they are going to come up and say it is
not worth the cost any more, it is not worth the cost to me to make these
changes, I am just going to fade away. And what is that going to leave us with?
And that is my biggest concern right there.

So sitting here taking these notes, I am sort of correlating what pharmacy
has done over the last 20 years and how we try to get onto the right path in
taking care of the patient. Medication and therapy management — I was a
pharmacist. I worked in practice for over 15 years. I did medication therapy
management. I got paid nothing for it.

But now we are starting to see more and more patients coming in with 12, 15
medications that they need that kind of service. So that is what pharmacies are
out there trying to provide that service. What are they getting paid for it?
Sometimes nothing.

So I think that is something that also has to be put on the table. Are we
actually looking at the right providers, getting paid the right fees for what
they are providing? Me being a pharmacist and seeing that happening on a day to
day basis, I think that is what needs to be put on the table as well.

DR. SORACE: A couple of thoughts. In terms of the garbage in, garbage out
question, you actually go to the literature on intra and inter-observer
variability of coding, it is very high. And there are some papers out there. It
is a difficult field to study, actually, but it is something which we need to
give more attention to, and which we need a lot more formal training on.

If you start thinking in terms of clinical code sets, and you start having
fairly granular clinical code sets, one thing you will find is that patients
become unique very, very rapidly. So it is not just a question of implementing
finely granular clinical code sets which you hope will more accurately describe
a patient’s current clinical state for the purposes of direct care.

But you are also going to have to think very carefully about how those codes
are rolled up into courser units for other purposes like quality management.
And that is actually a combinatorial question that is very interesting, and
touches on a large area of computer science which we don’t go into here that
much. But you get involved in some fairly interesting combinatorial mathematics
that you have to start to grapple with.

In terms of the future, I think one thing which we don’t think enough about
is actual communication. And it turns out that I think HIT systems will be
needed, more so to support communication among disparate caregivers, and that
that is a very valuable thing in addition to exchange of structured data. I am
not sure they are the same things exactly. I think you can sometimes do one and
not the other.

A challenge case which I will throw down because somebody mentioned labs and
imaging earlier, is communications between pathologists and radiologists for
diagnosing a stage in cancer. And these tend to use imaging systems and
laboratory information systems that aren’t currently under our meaningful use
EHR criteria formally. They may be in the bigger groups like hospitals. And
they may grow out of that.

But there you have two specialist groups that aren’t often thought of as
providers but really are. I hope pathologists for full disclosure here. They
are doing a thing that is very valuable for a patient, and that is telling you
what type of cancer, and what is the degree of spread that will drive therapy.

And they live with systems that are more isolated from talking to one
another, as isolated as anybody else, and they come together at tumor boards
and tumor registries. So I am just going to suggest that as a challenge for
those people who want to, it is a place to start.

DR. O’CONNER: Thank you. I would like to go back in this corner because I
don’t think you have spoken yet, Ms. Kloss.

MS. KLOSS: Linda Kloss from the National Committee, and I also serve as
co-Chair of the Privacy, Security and Confidentiality Committee, so I am
interested in the discussion that we had about provider identification. My
comment is really related to this issue of vision for information exchange in
five years.

I know what I would like to see the industry having accomplished is a smooth
kind of end to end process of starting with eligibility and right through
claims payment that is uniform across the industry. And we begin to reap the
kind of savings that we know are there if we squeeze out the variability in
that administrative process.

I certainly agree that we are going to need to focus and invest all of our
energy and innovation in the care process side. But there isn’t any reason why
the industry can’t get around the issue of really driving toward
standardization on all things administrative.

We started out, I think the first comment was on credentialing. And we have
got standard solutions for credentialing through CAQH CORE and standards for
many of these processes moving through the system. So I always think what would
it take for us to operate as a SWAT team, just really to drive that goal home
over the next five years and then free up the resources and the hassle and
start addressing all of the pieces that we have in place to support the
variability, to overcome that variability.

I did have the opportunity to be part of a conference recently on RACs and
ZPICs and really understand the huge investment there that providers are
making. But it is all a symptom of the lack of standardization in that
administrative underpinning of health care.

DR. O’CONNER: Thank you. We only have five minutes left for this question
and I know that the three of you have spoken before so if you could just wrap
up your comments in about a minute each so that we can hear from all of you.

DR. FRIDSMA: I will try to do 30 seconds. These are really big problems and
this Committee is not going to solve them all. So one of the things we have got
to do is figure out who do we partner with and what do we expect them to do and
what do we expect us to do.

I think part of the challenge we have with physicians is you have five or
six different organizations all doing quality measures and they don’t
coordinate. Now if one group said we need you to do our quality measures for
us, maybe that would help, I don’t know.

But I think part of the framing is, we have got to understand what our role
is in this ongoing standards ecosystem and then just knock it out of the park
in terms of what we do, and not try to do everything that we have listed.

MR. TENNANT: Two quick points. Rob Tennant with MGMA. Back to Dr. Conrad’s
point, I am not worried about Laurie at Mayo. They are going to do everything.
I am worried about the practices that provide the vast majority of care to this
nation. And that is the small physician practice.

She mentioned $853,000. That is a huge investment. And if you talk to
physicians they say that comes right out of my child’s college fund. So how do
we build the ROI for them to move forward? Why has there been such a spike in
EHR use since 2006? The answer is two-fold. One is certification. It took away
some of the fear factor.

Now you know, if you buy that product it will do certain things. Also, via
incentives. But why hasn’t that happened on the administrative side?
Certification is not there. We need certification so a provider can say if I
buy this practice management system software, it will do the following things
and I will take advantage.

One last point to Justine, claim attachments are going to be 20 years in the
making. We cannot take 20 years to implement a standard.

MR. RODE: I would like to reflect the last two comments and challenge Bill.
I think the full Committee of NCVHS has got to deal with data beyond the
administrative functions under HIPAA. We are merging these. The data has to be
the same whether it is the data being used for a HIPAA transaction or it is the
data being used in the clinical exchange of information.

If it is not the same, if we do not develop the standards for terminologies
and classifications in transactions, and the other code sets that we need for
all sorts of purposes, then our practices, our hospitals, are going to continue
to have these large amounts of money that have to be put out because they have
to modify the standards system to meet the needs of each of those
organizations, including the National Center for Health Statistics, the payer,
the provider, the public health agency.

You have got to be working maybe with Doug to see that everybody works the
same. We can’t have you silo the answers.

DR. O’CONNER: Thank you Mr. Rode. That is the end of our framing discussion,
which was 65 minutes.

Agenda Item: Policy Questions and Considerations

DR. O’CONNER: Now we are going to move onto the next question. We are going
to have 90 minutes for this question. We are going to open the floor for
feedback from you. It won’t be as strict as three minutes but again, we do want
to hear from everyone in the room as well as on the phone.

We are looking at policy questions and considerations and we are thinking in
terms of three types of hurdles to the ideal that we talked about earlier —
structural considerations, business considerations and policy considerations.
And some of those crept in during our framing discussion.

So the question to start this second session is, what are the major changes
coming to information exchange between providers and payers? What are some of
the major policy, business and structural drivers that are changing and will
change over the next five to 10 years? The information exchange needs between
providers and payers?

Examples could be changes in reimbursements, changes in enrollment and
eligibility processes and other types of changes. Certainly it can refer to the
first discussion but we would like to have a value-added discussion, so if you
could focus on things that haven’t quite been discussed.

Dr. Suarez and Ob, do you have anything to add before I open up the floor?

DR. SUAREZ: Just a thought, maybe a way to connect to this next discussion.
We all have lived through 16 or so years of HIPAA and in some respects maybe
the best thing that could have happened to HIPAA was meaningful use because in
reality meaningful use and the entire push in the industry to adopt electronic
health records is beginning to turn upside down the way we think about all
these data exchanges really.

Because in the end, it is certainly about the patient, but it is about
making sure that we have the information to deliver the best care to the
patient. And we have the right processes to ensure the appropriate coverage and
the appropriate administrative and business processes are done in the

But in reality, ultimately what we are seeing is that EHRs are turning this
around. And then on top of that, we are seeing the transformation of the health
care system through health reform in all those things. So I think, going back
to the point that Bill made but also considering the other comments that people
have made, certainly, we are getting to that point of opportunity of we know we
need to.

And we see that we will continue to do things in many respects over the next
several months to few years, probably, the way we have been doing it in terms
of transaction based exchanges for enrollments and eligibilities and claims and
claim payments and all those things. And we are trying to move those to become
more interoperable ultimately and efficient.

But now again with EHRs, things are making these processes be looked at
differently, and with health reforms, again, those major forces that we talked
about. So I think that is sort of maybe a connection to go back to these policy
questions that we are going to get to.

DR. O’CONNER: Thank you. I would like to open up the floor.

MS. THOMASHAUER: This is Robin Thomashauer. Thinking about something you
referenced, if we are talking about the integration downstream and the
importance of clinical and administrative data, maybe what we need to do is
think about the interplay between the HIPAA requirements going forward coming
out of ACA and meaningful use.

Today they are totally siloed, and their only incentive is really on the
meaningful use side. There are some penalties on the HIPAA side but truthfully
not for all stakeholders. And so if we are talking about how these converge
downstream, I think we need to think about how these two mechanisms can be used
to incent the industry to look at them as an integrated whole rather than
having meaningful use down here and the HIPAA requirements over here.

MR. ARGES: Yes. Thank you. I had a few comments with respect to some of the
changes that are happening that have already begun. We have had changes that
may ding hospital providers with respect to the number of readmissions that
occur or the adverse events that may happen within health care facilities as

But all of this really points out to the fact that there needs to be a new
paradigm with respect to the way we look at care that is rendered, not just
within the acute care setting but as it moves from acute care setting, let’s
say to a home setting or to another post-acute care area. And that is the role
of each participant to this process.

Many providers are stepping up and basically trying to make certain that the
patient understands their discharge notes and takes the medicine that they are
supposed to take, and many begin to follow up with calls to the patient at
home. But there also should be another role with respect to the role of the
health plan. Are the health plans basically doing that sort of follow up as

Are there instances where they are looking at helping the patient deal with
their obesity? Today we have one in four patients who come in with a
co-morbidity of diabetes. All of these add strains to the cost of care being
provided, but we are not really doing this in a collective manner.

And it gets back to what we discussed previously in terms of the roles and
how that might be changing. I do agree that — and Dan Rode mentioned this
about data has to be the same irrespective of whether it is gathered for
clinical or whether it is gathered for administrative data.

To me the billing data is just an abstract of the clinical data that is
there. And people need to understand it and need to have that sort of
application built into their systems.

But we need to really redefine our role in a way that looks at a more
collective, coordinated approach that has the wellbeing of that patient at the
heart so that when acute care is provided and the patient goes home, they do
take their medicine, there is somebody there to help support them. There is a
safety net there in terms of social fabric.

And it means more than just the health plans as well. It may mean employers
or other folks that we haven’t brought into this equation.

DR. COYNE: Once again, this is Frank Coyne of Blue Cross. Just to follow up
on the previous comment, one of the things that we are going to see —

DR. O’CONNER: You are breaking up a bit, Frank. It is hard for us to hear
you. We can’t understand what you are saying.

(The call is lost.)

DR. O’CONNER: Hopefully he will call back in. Mr. Tennant?

MR. TENNANT: Just a couple of points, and I will frame it around the idea of
details and logistics. One thing we have seen, through CMS we have seen a lot
of incentive programs, ePrescribing, PQRS, Meaningful Use, all driving
physicians toward adopting technology and reporting quality. But what we found
from our guys that are involved in this is the details are difficult, and the
programs aren’t harmonized.

And so it makes it extra challenging to get to where we need to go. So I
think as we develop standards and processes, we have to keep in mind the end
user has to be able to do it. And I will be the only one probably around the
table to use a prop, but I am going to use this prop. We have United Healthcare
through MGMA.

And I got a new card in the mail and lo and behold it had a bar code on the
back of it. And I was so excited. I went into my physician’s office and I said
look, I have a new card. It has got a bar code. And they said wonderful, and
they took it and they photocopied it. That is where health care is today.

It is those simple things. What other industry — imagine going to a
restaurant and they take your credit card and they go in the back and they
photocopy it and maybe a couple of days later they decide to submit the charge.

That doesn’t happen in any other industry. It starts with the patient and it
starts at the time they walk into the practice or hospital. We have to automate
to drive out the costs.

MS. GREENBERG: As I often will do at a National Committee meeting, I will
say I agree with everybody, but lots of good comments, and lots of thoughtful
comments. Doug mentioned that the National Committee obviously can’t solve all
these problems, even the Department of Health and Human Services can’t solve
all these problems. That’s why we brought you all together here.

As Walter mentioned, this is not a hearing. Typically the Committee has some
specific questions it holds a hearing to get input, it deliberates and it makes
recommendations. This is not in that sort of mode. This is a roundtable
discussion in which the Committee comes into this knowing it can’t solve all of
these problems. But it does want to work as a convener, as it has over its
history, a facilitator, a sort of a listening post.

And as Bill mentioned, obviously the Committee when it was re-authorized in
1996 it was in the HIPAA legislation so it has a very strong responsibility in
the administrative simplification area. At the same time across the hall, we
have our Population Health Subcommittee, which is addressing a different sort
of side of this, but very consistent, and that is how to empower communities
which includes individuals and families to improve their health.

So we are trying to work at it on both ends. What I would appreciate as the
Executive Secretary of the Committee is some feedback on where you feel the
Committee could be most useful in recognizing that, of course, the Committee
can only do a piece of this. Where, for that matter, you feel ONC fits into
that, and CMS, and so I am really speaking more to the non-governmental folks
at this point.

But one thing that we have heard loud and clear both back at the June
meeting, today, and every time in between, is this need for, as was just
mentioned, harmonization. Other people refer to it as a roadmap. So is that
where you feel that the Committee should focus its efforts? Or are there
particular standards areas where you feel the Committee could be most useful?

Possibly in the — there is a long history working in vocabularies, code
sets, I have heard a lot about that and the need to — ontology’s, all of that.
We have been meeting for the last two days and all of these things came up. Or
the convergence idea of population health and payer and provider data, if you
remember those concentric circles back in the NHII report.

So I think among other things it would be helpful to the Committee to know,
as Harry Reynolds used to say, what you think the Committee’s sweet spot is, or
where you feel the Committee can be most useful.

You don’t have to answer that right now, but as you are providing feedback I
certainly would find that helpful and I think the Subcommittee would as well.

DR. O’CONNER: Michelle, did he come back on?

MS. WILLIAMS: Yes. Frank, do you want to try again?

DR. COYNE: Yes, let me try again. Sorry I got cut off. Just very quickly, in
the context of the comments that were just made, when I look at some of these
questions that you are leading with to try and look at them from maybe 75,000
feet, from a business perspective, and then ask myself what information
infrastructure is needed to facilitate and enable the business needs that are
emerging very, very quickly?

And in that context what would be just useful from my point of view? Not
fully understanding the roles of the different committees that you talked
about, but believing that what is needed here is a roadmap across all of these
groups looking at this question of information exchange, that enables us to
create an interoffice system that meets all of the business needs that are

And then secondly, the business needs that I was just going to put on the
table — and they may have been mentioned already while I was trying to
reconnect — at least on the payment innovation side that was mentioned at some
of the pre-materials.

What we are seeing is a very fast movement, at least within the providers we
contract with, toward patient centered medical homes, toward ACO-related
services and a new model for providing input into providers, and for measuring

And then secondly, the big change that we see coming in 2014 and sooner is
just a need to engage payers and providers on this question of risk adjustment
because payers are not getting what they need on the claims and providers hold
the diagnostic information that is going to need to be supplemented with the
claims data in order for payers to adequately justify the risk of the members
they have.

And that is going to very quickly drive a need for more information
exchange, very quickly, simply because of the amount of dollars that are
attached to that. So I just wanted to put those two issues on the table.

DR. O’CONNER: Thank you.

MS. LEITER: My comment is a little out of order now, but I wanted to follow
up on something Robin said about meaningful use and the HIPAA’s integration.
Just note that in the Health IT’s Policy Committee discussions in writing
meaningful use, there is some discussion of how to link HIPAA.

And especially with respect to the privacy and security components of
meaningful use, there is an explicit and deliberate decision to not link them,
that meaningful use was seen as its own program and that it wasn’t the
appropriate vehicle for a HIPAA enforcement.

And a lot of people, the organization I was with at the time, the National
Partnership for Women and Families and CDT opposed that vehemently. That is how
it went. So I guess I would just say that the good news is that meaningful use
as a separate program is going to end. So there is an opportunity I think for
us to take the spirit and the substance of meaningful use and the association
criteria and standards that are linked to it.

But once meaningful use ends, there is a whole new opportunity to integrate
the spirit with some of the more robust parts of HIPAA that we don’t feel got
integrated and linked with the Meaningful Use program.

MR. RODE: A couple points that have been made and maybe I will re-make them.
The business is changing. And one of the areas that we were discussing before
this morning is the whole area of risk and the data that is being required now
by the payer community for risk management as well as for clinical management.

Especially as we are seeing the coordination and collaboration of various
providers throughout the spectrum and not in silos of hospitals and physicians
but also incorporating medical home programs, programs for long term care, and
so on. So we are looking at the full care of the patient.

But we are also looking at the continuity of data that has to cross a number
of providers and is coordinated with the payers. So I think that the
transformation of care that George talked about definitely fits into that
process. Both the HIPAA rule and the HITECH rule talk about coordination.

If anyone goes back and looks at the 1996 rule you’ll see that the Secretary
can designate other standards, not necessarily just specifically to
administration but to improve the administrative simplification, whether it be
financial or clinical. And this is an area that has not been explored. HITECH
came on and went through the same process.

I would argue that HHS cannot resolve all the problems. But I think a single
MAP policy within the department that coordinates the needs of CMS, that
coordinates the needs of the NCVHS and the ONC and the statistics, is something
that we are desperately crying for. There really needs to be that coordination,
and how this Committee and how the HIT committees work together is going to be
extremely important.

I come from a very small staff. Yesterday there was a standards meeting. We
can’t attend the standards meeting. We are at the NCVHS meeting. We around this
room represent a very large constituency within health care. We are very
anxious to work to resolve these problems. We have been trying to work with
them, in my case, for 20 years.

But we need to see some coordination on the part of the Department to help
us work with you to resolve these problems. So if there is a policy change, I
think it is to begin to look at this as a whole. And I also think it is a
question of recognizing that in our business, our health plans and our
providers are becoming very much the same animal and we are becoming parts of
each other.

The data we exchange is parts of each other. So we need to be looking at
this as a coordinated process to render decisions and not one that is just

DR. O’CONNER: I am going to go to Dr. Conrad and then over to this corner.
And by the way, when I first started this discussion I said it would be more
free-flowing, but I know a lot of you have comments. So please try to keep to
the three minutes. I will remind you politely.

DR. CONRAD: I think from a provider standpoint, one of the key things that
can happen at the national level is standardization of data as far as
interoperability. That has to be the first priority on a national standpoint,
because if we cannot talk to each other, if our systems cannot communicate with
each other, then we cannot provide the care coordination that leads to quality
care because we are all in our own silos and all of those different systems do
not talk to each other.

So one of the things that Meaningful Use helped with is finally giving us
some standards that we can have a national conversation instead of an
individual conversation, depending on what your priorities are.

So as a provider, one of the things that has been helpful is the ability to
use the EHR to coordinate care. We are a patient centered medical home. We are
a level three patient centered medical home. It took a lot of resources to get
there. But one of the tools that we used was the EHR.

However, if we don’t have the interoperability to be able to communicate
between the hospital, the home health care agency, the pharmacy and everywhere
else, we can’t provide the level of care coordination that is needed to smooth
out those transitions of care and prevent the errors and the costs that happen
when we cannot communicate back and forth.

So, on a national level, on a standards level, if we can come up with some
way to say that we have all got to talk to each other, and that systems need to
talk to each other, that will help save money and lives and prevent errors.

MS. THOMASHAUER: This is Robin Thomashauer. First, I would just like to echo
Dan’s plea for coordination, because it is the same people and it is hard to
figure out priorities. But my point is to respond to Marjorie’s question
earlier. And maybe this is better kept for next steps.

But I would suggest that an important thing the Committee can do because it
can’t do everything is identify those most important goals where you can
influence. And create the roadmap specifically around those goals so that we
can achieve something real. Built into that roadmap needs to be ongoing
tracking and measuring the return for that investment, so that the next steps
and the next goals can build on those.

So I wanted to pass that along in response to Marjorie’s question.

DR. O’CONNER: I think that is a great question, thank you. Dr. Stahlecker?

DR. STAHLECKER: I really appreciate the promotion and the credentialing, but
simply Chris Stahlecker. I did want to try to knit some points together, CMS
from our administrative simplification group and what we do there.

Obviously we are within the Office of Enterprise Management and Office of
eHealth Standards and Services, looking to promote regulatory text that
includes not only interpreting the legislation but putting forward a framework,
some guidelines, in the regulations. But that is not where our responsibility

We then do some oversight of the components within CMS and their
implementation of those requirements. And then finally all of that leads up to
enforcement. And I am trying to link it to the point our good doctor at the end
of the table made that only providers are being penalized right now. ACA did
put forward a couple of new requirements.

One will be a compliance certification requirement for health plans. So with
that, there will be a requirement that does bring penalties, if they do not
comply or they are not in compliance with the standards.

It also puts forward another identifier, the health plan identifier, and
another entity identifier. It puts forward the operating rules around the
transactions. And then we know the current operating rules or eligibility ERA,
we talked about that claims status. And then the future ones, with claims and
attachments and referral authorizations.

But within that framework, then, how do we get to an industry-wide virtual,
interoperable, smoothly exchanged, uninterrupted electronic health environment
without some oversight and guidance? We have heard repeatedly that industry
would like a roadmap.

And to Marjorie’s question then, perhaps the overview of how that roadmap
and the individual components and what responsibilities they have and how we
orchestrate the working environments to come up with the standard CARCs and
RARCs within the remittances, within the operating rules.

If we had a program that would line up with the statutorily dictated
deadlines that we are all facing, our industry may be much better served by our
collaborative efforts — not to keep honing in on the same point — but we do
have an opportunity with meaningful use stage two.

We have linked the ICD-10 codes within the criteria, with SNOMED codes, and
so we would expect that clinical content in the EMR to include not only the
required SNOMED and LOINCs, but also integrate interoperably with ICD-10. We
know industry efforts are underway to link those code values, but we need a
method of championing them.

And so I do think that we would be best served if we could find a way, and
perhaps this Committee could help lead us in that.

DR. FRIDSMA: I just wanted to make crystal clear, because there was a
comment made that when Meaningful Use ends. What is important to recognize is
that ARRA, through the stimulus, through the HITECH Act, provided a whole
series of stimulus money that could be used as incentives.

But one of the things that was unique about HITECH is that it has extended
the executive order that George Bush put in place for ONC, and gave ONC
legislative authority to establish the standard certification criteria and
implementation guides that could be used across the country to provide

That is not tied to incentive money, and it is not tied to ARRA. And it will
persist beyond even these first three cycles, if you will, of the meaningful
use program. And so I think it is important to recognize that the ability to
establish standards, either through executive order 13410, in which the
Secretary could adopt standards as well as the legislative authority given to
ONC to establish those through a regulatory framework, persist well beyond what
the HITECH Act is.

And so we need to remember that. And that becomes a policy lever that we can
use if we provide that level of coordination.

DR. O’CONNER: Thank you for the clarification. I would like to go to Mr.
Quinn and then we will go to Dr. Jaffe and then Clarice as well. And again, I
would like to ask people to remember Dr. Suarez’s comments as well as
Marjorie’s, that they frame this discussion with.

MR. QUINN: John Quinn from HL7. Following closely onto what Doug just said,
now that we have established there will be a Meaningful Use stage and going
forward, what really bothered me about the introduction to this was, it became
very clear to me suddenly that when we are talking in the context of claims
attachments we are talking about a level of granularity that is very specific
to what the payer needs in order to be able to adjudicate a claim, that really
isn’t the overall conversation that needs to happen about the clinical care of
the patient.

Specifically looking at Meaningful Use Stage One and Stage Two, we have
automated the things that are in a standard way across the country that are
either easily done because we are already doing them a different way or easily
can be seen need to be done. And there is a tremendous value in doing them from
the clinical side.

My concern is, computers normally don’t have ad hoc conversations amongst
each other without some human thinking ahead of time what is that conversation
going to look like. So if we think that we can move forward with claims
attachments and figure out how to do that to the 9th degree that is perfect for
what claims attachments does, even though we are using the same clinical
information that is being used for meaningful use stage two, it will neither be
sufficient in detail nor will it support the processes that need to be
supported if we don’t think about those things ahead of time. So that is it.

DR. JAFFE: I just wanted to shift the focus ever so slightly on the policy
issue, as we debate the merits and possibilities and even the standards
requirements around claims attachments and risk management and so forth. We
forget that if we were able to provide evidence-based medicine at the point of
care with clinical decision support we wouldn’t be talking as much about risk
management and administrative simplification.

DR. BROWN: I don’t know about that. One thing I wanted to remind us of,
earlier, in the first discussion we heard a lot of people asking for collect
the data once. And this is what we hear from our providers in our hospitals as
well when we go in to collect data from our surveys.

They want to know, if we are launching a new effort, they want to know why
haven’t I already reported this? Why can’t you sort of harmonize these data
elements? And so I think that collecting the data once or actually accumulating
the data once is kind of a good idea here, especially this clinical data.

DR. KENNEDY: Rosemary Kennedy, National Quality Forum. And in response to
what the Committee could do, we talked a lot about data standardization, which
is very important. But what is equally important in order for harmonization to
occur so we can use data that are collected once for multiple purposes is
getting all of the stakeholders around the table to discuss why they need the
data and what they are going to do with the data.

And I think it sounds like a simple statement, but I think we make gross
assumptions in terms of what the needs are. And I think the Committee could
maybe do an inventory of what is currently going on related to meaningful use,
what is working in terms of bringing all stakeholders to the table.

One concrete example is the clinical quality measures that are being rolled
out from the meaningful use perspective. The purpose is to use data that are
collected for care delivery, also for purposes of quality measurement. It
brings us into the payer world a little bit because historically those measures
were developed to get the information from claims data. So when all the
stakeholders got around the table, measure developers, providers of care, we
grossly over-assumed uses of the data.

We thought that because the data were in spreadsheets, there were so many
codes, there were all these codes and it was good to go. But when people got
around the table and started to talk about what they were doing, the
information, and why they needed it, changes and modifications were made.

I think it is the first time at a national level where we had these key
stakeholders coming to the table. What is probably missing is the payer
perspective, engaging in that dialog. So maybe an inventory of what has worked
from a policy perspective, and how we could leverage that moving forward to get
insights, greater insights into what payers need in terms of data that are
captured as a byproduct of care delivery.

DR. CHANDERRAJ: I think that is a policy making decision. I think one of the
key factors is cost. Sure, I like to drive a Mercedes S500, but I can only
afford a Ford Explorer. I think we are moving away from recognizing this single
fact and wanting to impose all these restrictions and penalties and rules on
people that are important stakeholders.

I think there is a dilution of trade delivery in America. I see that
happening across the board. This sacrosanct relationship between the patient
and the physician is being eroded. It is being eroded by business decisions.
And this is what is affecting the quality of care.

America was one of the leading edges in longevity, pediatric care and
everything. Now it has gone down to the bottom. Why is this happening? It is
happening because of the dilution of care. Now recently the government
increased the payment for physician assistants and physician practitioners. I
don’t want to offend anybody, but they increased their pay by 30 percent.

And every year the physicians have to go and do a dance before the Congress
to offset the effects of SGR. Why is this happening? It is directly related to
payment. And unless you realize the cost involved and what we are all trying to
do, I don’t think any of these will be successful.

MS. MURPHY: Thank you. Judy Murphy. Two quick points. First of all, I think
that Chuck and Rosemary are onto something in terms of thinking about it is not
about clinical data and then it is about payer data. It is about clinical data
that becomes payer data, and especially when we think about our changes in
payment models.

That is dramatically going to change, I think, the way we look at the data
that is needed for payment. And so I think that is an interesting concept when
we think of policy issues or structural issues that NCVHS could tackle.

The second point is — and I don’t know if this is an elephant in the room
or not. I started talking about it a little bit before the meeting — patient

If we are going to do concurrent information about a patient where when I am
seeing a patient as a provider and they are in front of me and I get the data
that I need immediately and not once the patient is matched and tagged and
maybe then that clinical encounter from a month ago can get pulled in hours
after I actually needed it, if we could actually do that up front

So I really think that NCVHS could do some things around thinking about
either locking and loading a patient matching routine that we could all use, or
actually looking at resurrecting the idea of a national patient identifier.

DR. O’CONNER: Next we are going to go to Mr. Rode. But before I do so, after
his remarks we will go to Michelle for questions from the phone. But I want to
check in with Dr. Suarez and Ob as well as Marjorie to make sure that you are
getting the information that you need.

DR. SUAREZ: I think this has been a great discussion so we should continue

MR. RODE: I will go to the last comment first, because we have been trying
to work for a couple years now in getting Senate approval to look into the
whole idea of patient identification, since the appropriations bill each year
comes up with language that says that HHS shouldn’t touch that subject, and it
is a desperate thing.

This Committee actually did go around the rule kind of a couple of years ago
and did one of the first discussions about it. So I think that is great. To the
issue of data and exchange and the use of data wants, I think I have to just
remind the Committee, the question of governance of the terminologies and
classifications, the harmonization of those, which are going to be so necessary
across the clinical and administrative terminologies.

We have raised this issue with both ONC and this Committee since about 2006.
And I think it is one that the Committee really needs to work out with ONC
jointly. And Walter, certainly you are a person that sits on both committees.
So that is an opportunity that I think can happen.

But I want to also remind us that we have a new need for metadata, which is
going to have to again permeate across administrative and clinical specters. As
we heard yesterday, how do I identify the information that came from the
patient, came from another source, which again is being used by both providers
as well as plans.

And then finally I wanted to just raise the issue that as we look at this
data, and as we look at the merger of this data, we consider how we also
address the vendors that are very crucial to this. We have talked about
Meaningful Use just scratching the surface.

But it seems to me that as we see the payer community coming together and
recognizing the need for data, perhaps we have a way that we could be working
with the vendor community as well because they are not hearing the call for
independent providers who purchase their services. We need to bring them into
the equation so that we begin to see these standards implemented, maybe even
quicker than doing it through meaningful use.

DR. COYNE: Three points really quickly. One, on the patient ID issue, this
is something that I think we all consider critical to deal with some of the
churn we are going to expect on exchange business among different health plans
on an off exchange as well as for patient attribution and an ACO or patient
centered medical home setting.

So that is something that from our perspective is very critical, and one of
the risks that I think the industry runs among all stakeholders is that if
there is not a standard out there, payers are going to have to invent one. And
that is just going to increase the costs later on.

On the issue of cost in general, I really sympathize with the comments that
were made earlier about all of this having a huge cost impact on providers on
both sides, both in terms of potential savings but in terms of investment.

And one of the things that I think is going to be important for all
stakeholders to do as we decide how to move forward without just trying to
blindly boil the ocean, is to focus on use cases that are coming out of these
market changes that we expect very quickly. And be sure that we have a very
good ROI on the use cases tied to market needs. So that the issue of investment
is there, but the issue of payoff is there, too.

I just wanted to finally, thirdly, support the comment that was just made
about bringing vendors to the table. Because so many of the stakeholders,
including payers, are reliant on vendors in this space to get the market
requirements met. And if the vendors aren’t plugged into an interoperable
information ecosystem that they buy into, their costs only go up as well and
they are much less effective. So thank you.

DR. O’CONNER: Thank you. We have about 50 more minutes to discuss this
question so keep your thinking caps on. Ms. Sheppard?

MS. SHEPPARD: I just want to take a step back, I think. We keep talking
about policies related to provider data, payer data, clinical data,
administrative data, collecting the data once, using the data repeatedly. But
we are not really acknowledging the fact that it is the patients’ data.

The patients in this country are uncomfortable with the kind of sharing that
we are talking about because at some level we are talking about a national
repository of data. And that is clearly out of the comfort zone of the average
patient in this country.

So before we get too far towards developing policies that require that level
of data sharing we had better figure out how we are going to make that
palatable to the American public. If we can’t do that, then we might as well
not spend the limited time that we have trying to devise a plan to share data
at that level. And we had better figure out what level the population will
tolerate before we go too far down the road.

DR. JAFFE: I hear the objection raised that our patients are opposed to
exchanging data electronically, sharing data, using data for other purposes. I
am not sure of the evidence of that. It is largely anecdotal and before we make
any policy decisions based on this notion, I would like to see evidence that
this is the prevailing mood of the patient population.

DR. FRIDSMA: I just wanted to comment. I am not sure because I haven’t heard
it but maybe I missed it, that what we are talking about is a ginormous
database in the sky that contains all the patient data. I don’t think that is
what is being proposed. What I think we are saying is we want population level

So the question is, can we do that in a distributed way that makes patients
feel comfortable but still gives us the value of what we want to do. Now
standards are going to be really helpful for that. But it is not going to be
just data standards. It is going to be APIs and query methods and things like

So I think we have to be very, very careful that we don’t create a message
that says our goal is to create a ginormous database in the sky. I think we
have to be very, very clear that patient privacy, security are important, and
we can use technology to help advance that, to get the analytics without having
those things compromised.

DR. O’CONNER: Goodness, it seems like everyone’s flag went up at one time. I
am going to go to Michelle for a phone question and make sure they get asked.

MR. ARGES: Thank you. Actually, I wanted to pick up exactly on what was just
said. I think it is critically important to understand the data analytics
because that is really how we basically look at the cost drivers that are
impacting the delivery of health care in the US.

And that really should be our concern, is really how can we use data to
basically improve the quality, improve the outcome, and basically make also the
patient aware of the choice that they have in front of them. And it may mean
more education even on healthier lifestyles or follow up with drug regimen or
follow up care and the like.

But the important thing is that we understand populations and how they have
a particular need for certain types of services, and making certain that the
communities that serve that population have the ability to deliver that. And we
can talk about the risk in how we divvy that up.

But really it all comes down to understanding the data, having routines that
efficiently collect that data, really giving the caregiver the tools to ask
this medical records for their approach to delivery of care so that they are
not repeating tests and you are driving costs down on that basis. So that is my
fundamental comment, and I just think it is so important to understand the data

DR. O’CONNER: I would like to focus on some folks we haven’t heard from,
recently anyway, for this question. Miss Kloss and then we will have Miss

MS. KLOSS: Thank you. I guess I would like to ask a question of the group.
At yesterday’s meeting of the NCVHS the Committee approved a letter to the
Secretary outlining some fair information practice guidance in sort of a
stewardship framework for new uses, new emerging uses of health care data that
really are outside the framework of the HIPAA approach that we are familiar

It seems to me — and I am speaking as a personal matter — that one of the
areas that will enable interoperability is a better understanding of what the
ground rules are — not necessarily new regulation regarding privacy and
accountability and really stewardship practices.

This is an area that ONC looked at from an information exchange perspective,
but really chose not to go down a regulatory route. I guess my question is, is
there a setting some voluntary framework or guidance materials or educational
framework around the rules of the road with regard to best practices and
stewardship that could be enabling and help us move forward in a way that is
not rigid.

MS. DARST: This is Laurie Darst, on behalf of WEDI. I think Kathy’s comment
is really spot on. That was one of the issues that we identified at WEDI as we
looked at some of these questions, is what was the patient’s perception? As
payers get more information would they allow that release of information? But I
think it really does come down to perception.

Chuck, you asked the question is this really a problem? Do patients — and
again, outside of our discussions that we had where we are having this in depth
discussion — what is the patient perception of a payer getting more of their
medical information if their perception is they just pay my bills? So I think
we need to dive into that a little bit, too.

MR. ST. CLAIR: Thank you. I just wanted to take a minute to reiterate and
reinforce what Doug’s comment was, Dr. Fridsma. Within the standards
organization and within HIMSS, I think what we have been talking about more in
my personal experience is the concept of democratization of data. And all of
Doug’s points were germane.

I would add to it that the standards aren’t perfect, but what we see is that
standards offer interoperability that drives that democratization, and that the
big database in the sky and the concept of big data and big analytics comes
about in some cases as in other industries where you don’t have standards

And the big database in the sky becomes the repository for a multitude of
data from different sources that organizations then use and process for
analytics to give you an answer. And in health care, I think the immediate
example of this, which I believe in my personal experience everyone should look
to, is Watson, and what natural language processing is going to mean in the
future for the concepts of big data and analytics being centralized to an
extent that someone may or may not feel comfortable with it.

The greater extent to which information is made interoperable through
international standards and consensus or nationally accepted standards, means
that democratization allows individuals to have control of their data and be
able to share in a means that doesn’t always require one large source of
analytical capability. Thank you.

MR. QUINN: John Quinn, HL7. In thinking over this concept of today we get
quality and public health metrics, cross-patient metrics, we pull them out of
the claim. We have in this country for years. Let me put it this way, they come
out of either the claim directly or more importantly they come out of the claim

I am talking here to vendors. And so my point and piece of advice is about
vendor systems. I found when I went over and spent a year in England looking at
the NHS’s environment, that here they had a GP environment that in fact did not
generate a claim. But it did certainly generate a transaction for every
encounter that was used primarily for perspective payment contract negotiations
for the following year.

Before I became a consultant I ran development for a company that did
patient accounting systems. In this country we tend to have either stand alone
patient accounting and quality database systems and then the clinical systems
are separate. Even vendors that do have integrated environments, the fact is
they have integrated two separate applications.

That is not a criticism. The point is that when I looked at what happened
when US vendors went over to England and started trying to address that
country’s needs, they all had serious problems with being able to produce that
reporting information that went from GPs to England’s public health recording

And literally there are 80 databases that get fed from this stuff, that I
figured out. And so you might want to have a serious conversation with the
vendors when you talk to them, because when they are going to be combining
information from both their clinical side and their claims side, there is going
to be issues that some of them addressed in England and other European
countries where the payment system is much different from here.

DR. O’CONNER: Before we come around to this side of the table, Mr. Daniels,
you have been quiet. Do you have anything to add? I want to make sure we hear
from some other folks, too.

MR. DANIELS: I think Jim gave a great comment to Dr. Fridsma’s remarks as
well, so I will leave that at that. The one thing that I would add at some
point is a comment from our business centered systems group who is focused on
the medical banking area. They have addressed this question that is in the
paper here, one of the policy drivers that will define the type of information
required and the way in which providers and payers share information.

So if you will allow me, I want to read his remarks in here. I think you
will appreciate that. We are already experiencing profound changes in this
arena. ACA, Section 1104, has required the adoption of new operating rules that
will further this area by standardizing how data is exchanged. This in turn
will reduce costs for administration, which is a key objective in health care

Yet it is another portion of ACA. The option of health insurance exchanges
that may bring wide scale change as consumers start making decisions around
their health care. Health information exchanges is likely only going to be for
those who have no insurance coverage today, like the uninsured.

As a matter of fact, large employers are starting to understand these
exchanges and embracing this formula. For example, Sears recently announced it
is closing its traditional health plan menu for employees in favor of giving
them funds to select a health plan on private health exchange. Other employers
are watching them closely.

So as consumers interact more with their plans, the information bridges
between health plans and providers will evolve and transform. For instance, one
very large health care provider is now planning to open its own health plan,
using a very large health plan as its third party administrator.

So imagine how this could transform the process and the types of data
exchange that will be flowing between the provider and the payer. Clinical and
business data will be used to develop business intelligence that will markedly
improve care.

And then he goes on to say increasing granularity of clinical diagnosis and
procedure data that not only contains additional information such as payload
but also the data will need some sort of tracking such that it is certain to
eliminate duplicates. It follows a logical history and diagnosis of treatment
across multiple providers and payers in order for claims to be expedient,
accurate and efficient. So how is this going to be conducted?

A system that receives needed clinical data into patient accounting systems
that rate the procedure and assign codes that are granular enough for claims
processors to not have to ask for additional data or clarification of the
workflow history of the patient.

So what is going to be exchanged? It will look much like a bill of lading or
an auto repair bill where the amount of time spent, the materials used, and the
reason for the time and materials such as a diagnosis code or some sort of
tracking episode or identifier so that the payer can assure that it is not
duplicative in any way. It is the same x-ray being ordered by two different
treatment providers.

He also answered another question in here about what are the major changes
that you see coming with respect to the information that will be needed to be
exchanged between providers and payers in support of health care
transformation. And he says the walls between the two groups will need to break

DR. O’CONNER: I have to cut you off because your three minutes are up, but
when you say he, can I ask who you are referring to?

MR. DANIELS: John Casillas, the medical banking project.

MR. TENNANT: We have been asking questions about the patient, about what the
patient wants and doesn’t want. I think we know what they don’t want, and that
is, their information going to people that shouldn’t get it and shouldn’t be
looking at it. But what they do want, and frankly they expect, is the
information is shared between their physicians and their care settings.

All of us around the table are also patients and we know how frustrating it
is to go in and find out that the referral didn’t get there, the lab notes
didn’t arrive. It slows the process down as needless cost. I think what
physicians don’t want is data that they can’t use. And they need it at the time
of service.

They can’t wait two weeks, and they can’t get 14 year old immunization
records. That’s not going to help them. And they also want a system that is
simple and inexpensive. And if we look at a lot of the HIEs, they are
complicated, they are subscription fees, it is not easy. We need a simple,
simple process. And if you look back a few years ago, it used to be if you had
an AOL or CompuServe account you could only email to those folks that were on
AOL or CompuServe.

We solve that problem through interoperability. We need the same solution in
health care, where a primary care physician can send a secure email and get
that information from the specialist, the lab, the hospital discharge, whatever
they need at the time of service.

DR. O’CONNER: I would like to turn to Miss Murphy, and then we will go back
to the corner, and then Mr. Rode.

MS. MURPHY: Judy Murphy from ONC. We have been talking about exchange
between providers. We have been talking about exchange with payers. We just
brought up the issue of exchange with employees. I guess I want to put it forth
that concept that many of us are aware of and maybe thinking about, and that is
exchange with the patient themselves. And so a couple of thoughts around that,
and how we would build that in structurally or using policy levers.

Certainly in stage two we have stepped up the idea that consumers are
partners in their care and in fact need to have access to their data. That is a
little bit different than maybe entering data. So consumer generated data, if
you will, I think we could spend some time thinking about how that would work.

It is always interesting — I know I was talking to a provider and I said
medication lists, we could get that from the patient. And they are like, well
how do we know that the patient has the right list? And I am thinking, well
because they are the one taking it. It is an untapped resource and maybe they
are not smart about absolutely everything, but they are smart about a lot of
things. And thinking about how that should weigh in.

The other area is consumer mediated exchange, and how patients for years
have served that role in a paper world where they get copies of their records
and then they manually tote them over to the other provider in inches, not in
bits and bytes. So the idea of how we can leverage them, when in fact we
haven’t yet developed the exchange, either standards or the ability to do that.

And could we think about — and the medical banking got me thinking about
that — where you might be able to use the consumer to download it and then
upload it.

MS. KLOSS: I would just add to Rob’s comments about what the patient
expects. I think what we heard in testimony is that patients also want to know
how their data is being used. Even in the aggregate, even if they are not
necessarily identified. So I think our obligation to be more inclusive with
patients with regard to all the range of uses of data needs to be stepped up.

MR. RODE: A number of points on the information that we are discussing right
now. One of the other business changes that hasn’t come up is just comparisons.
And one of the things that I am reminding a lot of folks right now is that CMS
and others are putting comparisons of physicians, of hospitals, of nursing
homes up on the web for consumer information.

How that information gets there, and how the data integrity of that
information is maintained across a number of systems I think becomes another
challenge that we have to look at as we are dealing with quality from the
perspective of a consumer selection. And so the information again goes back to
both administrative and clinical pieces.

A second point that we have not spent a lot of time with is operating rules.
We are beginning I think and will see some advantage of the operating rules. It
will give us the benefits we have been seeking for HIPAA for the last 15 years.
But we need to look again at operating rules as it goes to the use of data and
the use of standards.

I had a discussion with an individual yesterday. There is a quality hearing
at ONC on the 30th, and she was telling me how in their large payer information
that was taken from the claim was re-coded into a proprietary system within
that organization. And that went into the database. It wasn’t a code that was
originally transmitted by the provider.

So if we are looking at end uses of data we now have to look at and I think
establish some consensus operating rules about how that data transfers from the
point where we collect the data to the various uses. And that is not always
necessarily done with standards. We do have to look at the operating rules and
I think expand our thinking to that extension. I think that is the comments I
have at this point.

DR. SORACE: Back to Mr. Tennant’s comment about more scalable solutions. And
also, many of us have had to care for an elder relative. And one of the real
challenges sometimes, even if you have been a patient, and if you have had a
complicated enough history, is what providers have information on me.

It is not always intuitive because information gets squirreled away in
pharmacy systems, imaging and lab systems that may be associated with a claim
that are often just different. So administrative data, and Blue Button plays
off of this, does offer you a history of who you have contacted in the health
care system.

And if it were to contain links to where their data is stored electronically
it is actually a fairly good, straightforward roll up for you to use it as sort
of an NHIM of one. There are of course going to be some privacy implications in
this. It does, however, sort of skirt around the issue of actually forming a
centralized national database of clinical data, because it will tell you where
it is reposited.

MS. BROWN: I just wanted to follow up one of the comments that Linda had
about patients want to know how their data are being used. In our experience
with recruiting hospitals, I know you all were probably from the Centers of
Excellence in hospitals that can really use all of the data that they have. But
many of the hospitals that we are recruiting will report data to us.

And we are offering to report their data back to them, and they find that
that might be, we are hoping that that is a valuable incentive. Because these
hospitals, they don’t have the experience analyzing the data, or they have the
experience and the need to report to CMS or to their payers and so forth, but
they don’t necessarily have the experience of looking at the data and analyzing
it for themselves.

And so one of the things that we are hoping will be an incentive will be for
us to provide the data back to them. Now because of confidentiality concerns,
we are not putting it on the web, we are not ranking them, we are not doing the
comparisons. But I think that it is kind of our obligation as a data collector
to report back to the providers.

DR. SUAREZ: It has been fascinating. I know I have been trying to catch as
much notes as possible and I know Suzie is doing it too. We are going to run
out of walls pretty quickly here. But I wanted to see — we have about 25
minutes, so here is one question that I would hope we can get feedback from all
of you.

We have heard a lot about different exchanges and different areas where we
should consider focusing on. And so to try to bring it all back from all you
have heard and all the things that you also know about the National Committee,
what would be your number one, if you had one thing that you would suggest the
Committee should try to address in terms of the policy.

We are going to get into the technical area a little later, but in terms of
the policy, what would be one policy area that you would suggest, would
recommend that the Committee consider with respect, again, to this future
exchanges of information between providers and payers in support of these
changes that are happening.

I really want to salvage this as the probably most significant one we can
work on, and that is something that Judy and others have begun to mention,
which is patient identifiers. And certainly it is something that in light of
not just what we are today going through because of the lack of that, but more
importantly to the future, with integrated care organizations and patient
medical homes and things like that, we are really going to need something like

So that is just one example of an area. But if you could quickly say in very
few words what would be one policy issue that you would be recommending that
the Committee begin to look at and address, that would be very helpful.

DR. O’CONNER: Any immediate feedback? Dr. Jaffe.

DR. JAFFE: I was thinking about this before you asked the question, Walter,
so we are connected. And the answer is, data quality. At Columbia they did a
rather extensive study and 20 percent of the data entry had major errors. I
don’t want to call out anything specific, but I was amused at a data entry
point on this chart here, which said delusion of care.

I assume that means care that is not grounded in reality. And I believe the
term was dilution of care. And not to pick on anyone, but this repeats itself
when we are doing quality measures, when we are doing patient outcomes, when we
are doing evidence reporting. It is pervasive. So that would be my one hope,

DR. O’CONNER: Thank you. Dr. Postma, then we will go over to Mr. Tennant.
Again, your one policy issue that the Committee can work on.

DR. POSTMA: Thanks. There are a number of exchanges that are so important in
the initiatives that are moving forward from CMS, diabetes purchasing
initiatives involving quality of care and efficiency of care delivery,
including coordination of care and care transitions.

But since you asked the question, I am going to focus on one of the biggest
needs that I see in these value-based purchasing initiatives from a Medicare
perspective is standardizing the interface for reporting of quality metrics and
the information that goes into the calculation of those metrics.

I think there are a number of clinical measures that are used to calculate
quality metrics, whether that is through PQRS or bundling or ACOs, and having a
seamless exchange of that information from the provider setting and many
different settings to Medicare would be very helpful, anything that the
Committee can do to look into that would be great.

MR. TENNANT: The Committee has looked at HIPAA admin simp, it has looked at
the ACA section 1104, and 10109. It has looked at ICD-10. All of those require
software in the practices and hospitals to achieve. If we want to achieve true
administrative simplification it starts with the software.

So I would say we have to get the vendors engaged in this process. We did an
impromptu survey of our guys. The vast majority of practices check eligibility
on websites, a very inefficient and costly way. Why? Because their software not
only can’t do the operating rules, they can’t do the 27271 transactions.

So if we could move toward certification, as we have done on the clinical
side, we would start to reap the benefits and more and more physicians could
take advantage of these standards.

DR. O’CONNER: Do we have any more immediate feedback to Dr. Suarez’s

MS. WILLIAMSON: We have one on the phone. Frank, you were in the queue
before Walter stated his question so I don’t know if you want to respond to him
or provide a different comment.

DR. COYNE: This is Frank Coyne. I actually wanted to make one last comment
around the issue of member protections or consumer protections around the data,
and just suggest that one way in which we could reframe that question is to be
sure that we make the case that this is a patient safety issue as much as a
privacy issue.

And that for consumers who expect their data to be available when they need
it and where they need it, sharing that data ensures that their safety is being
looked over by the various stakeholders in the health care system. It is not
just an issue of privacy but it is an issue of patient safety so that their
records can follow them wherever they go, so that a doctor can have access to
an x-ray or a series of tests another doctor has done.

I think if we can try and reframe that issue as a patient safety issue as
much as a privacy issue, I think it helps us all. My answer to the question was
actually focused on the answer that was given when the question was asked.

And that is, I think the patient identifier is critical simply because a
patient’s data can’t go anywhere with them. It can’t be accessible by different
stakeholders in the system without the patient identifiers. Thank you.

DR. O’CONNER: Dr. Carr, do you have an answer for Dr. Suarez?

DR. CARR: Yes. I agree with the four ideas already put out, but I would add
harmonization of the definition of data elements.

DR. CHANDERRAJ: I agree with Justine that harmonization, I think, like Don
Rode has pointed out and Steve Lazarus pointed out yesterday, the codification,
the exact quality of data being entered, is missing in this whole piece.
Physicians don’t care about the billing aspect of the business. They only care
about what they are doing to the patient.

What goes into the charge ticket is all being done by MAs or billing people.
Nothing is being entered by 90 percent of the practices except in academic
centers where there is more time to see a patient. I think most of the work is
being done by ancillary people. Unless this is standardized I don’t think we
will get anywhere.

So the policy should be — to answer Dr. Suarez’s question, is to
standardize or codify every element that is being entered into the electronic
health record.

MS. MURPHY: At the risk of being redundant, I would like to make a vote for
patient identification.

MR. TENNANT: I would pick another topic, and that would be smart card use in
health care. I think it is already being used around the world. It is being
used by the DOD. There is no reason why we can’t adopt that technology in
health care.

MS. WILLIAMS: Dr. Nick Geddes on the phone.

DR. GEDDES: Yes, thank you, I have a couple comments I would like to make
and then perhaps take a crack at the actual question around policy, or priority
on policy. My suggestion is we kind of take a step back for a second. Here is
my commentary.

Number one, I don’t think I have met any health care professional that wakes
up in the morning and doesn’t want to do the very best thing for their patient
that they are seeing on that day. Yet I am quite sure that every one of us on
the phone is acutely aware of what some of the stats indicate around medical
errors, decision making, outcomes, unnecessary procedures, et cetera.

So the question has to be, why does all this happen within a delivery system
that very clearly every single professional from administrators to
practitioners all want the very best for their people and their patients? I
think it boils down to information. Not data points, information, actionable
information. And actionable information comes from data.

I will tell you also that we have close to 50 what I would call accountable
care relationships up and running at the moment. I don’t think there is one of
those relationships where the health care professionals do not turn to us and
say we need information from you. What we need primarily from you is not data,
although some will ask for data, but actionable information.

So what I believe physicians are looking for, in addition to all the things
we have talked about, is assistance at actionizing. The decisions that
physicians make today may be the best decisions they can make with the
information that they have, which really says the information is flawed. That’s
what I would tell you. That is my gut sense.

Now from a solution perspective. Obviously the relationships we have, they
ask us a lot more things than just that. But that is a key, that is a real key.
The solutions are multi-fold and require a lot of work from a lot of different
folks. I am not sure you could say that one is more important than the other.

First of all, very clearly we have to have the ability to share information
within the relationships, so that today to some degree are impeded because of
either the way the systems are running, the interface between the two that we
have talked about.

But more importantly policy statements from a national perspective that
preclude full sharing of information within the clinical relationships, quite
frankly, that the physicians have with the hospital systems they may work with,
and/or with the carriers’ payers that they are working with as well, amongst
other parties. And that includes behavioral information.

The second thing quite frankly is then the ability to take that information
and transpose it, if you like, from system to system. Because what is very
quickly developing are relationships that are preferential with some, and not
necessarily working for others, but at the end of the day a patient is going to
be transportable. That information has to be transportable.

So if you think about it, I probably have talked about at least three or
four broad policy issues already. Every single one of those things has to be
tackled. Now can they all be tackled by one committee at one work team? Maybe
not. So what I would tell you is, there is no lack of priority on a whole bunch
of things that need to happen all at one time.

I am not too sure that you can say that one takes precedence. But very
clearly, standardization has to occur. Very clearly, the federal regulatory
environment around sharing of information clinically, holistically amongst
individual organizations that are empowered to look after that patient, has to

Very clearly the portability of that information and the transportability of
that information to subsequent individuals or entities has to occur.

DR. O’CONNER: I am going to cut you off here so that we can get some more
comments in room please. I’m sorry.

MS. THOMASHAUER: This is Robin Thomashauer. In terms specifically on the
admin side, we are giving an awful lot of support to the clinicians as they
implement their EMRs. On the administrative side what we see is that a lot of
those less sophisticated organizations we were talking about check the box off.
It is a burden, and they have to do these things and they check the box off.

How do we educate and assist them so that they can leverage what they have
to do to move them along the continuum and help them, for lack of a better
word, drive more sophistication in their systems taking advantage of what they
have to do, rather than saying we have to do that and kind of cordoning it off
and not integrating it into their strategy to help them become more

I don’t know if I said that very clearly, but I do think that there is a
large world out there that doesn’t know how to leverage what they have to do.

DR. O’CONNER: Mr. Rode, what is your answer to the question? What one policy
issue would you address?

MR. RODE: It is hard to come up with one, but I think if I listen around the
table, the one that I would propose is that the Committee look at the process
to establish a governance of and harmonization of clinical terms, terminology,
classification, metadata, to answer some of the questions for exchange and for
data integrity.

I don’t think you could answer those questions, but I think coming up with
what the process should be to approach that and ensure governance and a place
for stakeholders to be involved in that is what the Committee could do, and
could do in a relatively short period of time.

DR. O’CONNER: Michelle, do we have any comments from the phone with any
answers? This phone is quiet. Let’s see, who hasn’t spoken recently? Dr.
Fitzmaurice, what are your comments?

DR. FITZMAURICE: I would guess I would encourage the Committee to think more
broadly. We have a health care system. I would encourage the Committee to think
of how do the pieces fit together? How do you want them to fit together? I have
heard Doug said that we don’t want a big database in the sky.

But if you were to ask any health plan, any large medical practice group,
they would want a large database, not in the sky but in their own data
repository vault. Over the time I think we are going to see more consolidation,
more mergers in the health care area. I think that is going to reduce
administrative costs, it is going to increase the risk pooling ability, large
numbers, and they get more diversity of the people in their risk pool.

And it also gives them revenue growth. So we have got forces in the economy
leading to more consolidation and more mergers, larger entities. So if you were
the head, if you were responsible for that large entity, call it a health plan,
call it a large medical delivery system, call it a combination of both, maybe
like a Kaiser, a Geisinger, what data would you want?

You would want longitudinal patron data. You would probably want to have it
provider supplied, because you want to get the data quality that Chuck was
referring to. You would want cost and payment data pulled together, you would
want to ask what standards do you want, what standards are needed, and where
are the gaps.

We do a lot of that thinking, and that is good. You would want to think
about what national architecture should lead the country in pulling the
information together, what national reference vocabularies should pull the data
models together, what are the privacy and security protections we should have.

And we have some very strict privacy and security protections. What patient
outcome measures and process measures are effective, weigh the burden against
the value that they produce, and what research would lead us to improved
patient outcomes with this. So essentially, make the health care data more
uniform, accurate, valid, computerized, and protected.

And then use it to improve efficiency and effectiveness of this whole health
care system — not just the parts, but look at how they fit together, look at
what the incentives are. How do we change the incentives? Because that is to
me, I have learned, more important than standards, although I think standards
is high on the list. There is only one thing higher and that is the right
incentive to do the right thing.

DR. O’CONNER: We have about eight minutes left to answer this question so I
would like to go to Mr. Daniels because he hasn’t had a chance to answer this
question. And then we will go to Michelle.

MR. DANIELS: John Daniels from HIMSS. First of all, let me say that I can’t
answer that question because it is a very tough question. But what I would like
to share with you is a conversation that I had yesterday with a group of senior
executives from community health centers. And the idea of wanting access to
information is on the top of their minds.

But what they are concerned about is being able to get access to that
information. They are spending what little resources they have now just to
implement the technology to be able to collect the data and to get to the data.
But then when they ask for access to the information to help them with their
decision making, they are being asked to pay even more money.

And so what they are realizing is that there is this new added layer of cost
that is starting to bubble up for them, and they just can’t afford it. And so I
don’t know if that would play into any policy discussions with the Committee,
but I wanted to share that with you because that was something that I thought
was very important to bring out.

MR. ARGES: One of the comments I would like to make is really the idea about
trying to simplify the current process. It is too complicated the way it is
right now. It is hard to come to an agreement on just simply a coarse set of
data that should be routinely collected, that could be built by vendors and
others, and that providers understand what to collect, when to collect, and how
to report it.

And also to make certain that once you define the course of the data you
improve on its quality and reliability in terms of information. Because you
can’t do anything in terms of the analytics until you have that ability to
simplify and make that routine a more streamlined process.

But is also imposes a burden, I think, on many people who offer benefit
plans to consumers. And that is, making certain that you don’t create packages
that are so complicated that it requires a nuance of data that is not typically
collected today and it causes all sorts of hurdles for providers and others to
go through.

So that is another dimension to some of these discussions that I think need
to be added. I do agree with many of the other points here about vocabularies
and architecture. And I do think it is vitally important, as I said earlier,
about being able to create a unique patient identifier so that you can create
information from a longitudinal point of view at different sites of care, and
be able to look at that information so that the quality of care is improved

DR. O’CONNER: Thank you. I am going to ask Mr. Klimek if he has any
comments, or what his one policy issue would be. Do you have an answer? You
don’t have to, but we would love to hear it.

MR. KLIMEK: I sort of hesitate, because from the pharmacy standpoint we
always hesitate to ask for more policy and more regulations. So be careful what
you ask for. But anyway, the one thing obviously is patient ID. I can remember
working in the real world of practice and dealing with Social Security numbers
as your ID, and everybody slapped your hands and said no, that’s not good.

So everybody moved away from Social Security, everybody went to their own
unique patient ID. While in today’s world we have got patients that are moving
from health plan to health plan faster than you can catch a bus. So that is
part of the dilemma the pharmacy runs into is how do you track that patient?
Again, as I mentioned earlier, pharmacies are used to a real time world, real
time processing of claims, real time access to information.

So if we can’t get stuff real time, we have got a patient standing in front
of us trying to get access to care, and we can’t provide that. We participated
in meeting with Medicare back seven years ago when Medicare Part D was first
coming up, and we all sat around a table in Baltimore on several occasions
trying to come up with solutions to try to administer the Medicare Part D

We brought all the right people to the table to identify eligibility, how we
are going to keep track of those patients, if they do move from pharmacy to
pharmacy. So again, it is getting the right people around the table trying to
identify what the issues are and how you can resolve those issues is going to
solve the problem.

Again, I look at patient ID as being a key component of that, and then also
being able to identify those patients as they move from environment to
environment, and that is always a big challenge for us.

DR. O’CONNER: We are about a minute and a half away from the break, so I
will give the final word to Dr. Conrad and then we will break at 10:30.

DR. CONRAD: I agree with all of my esteemed colleagues. You have really put
forth some wonderful ideas. If I have a wish list, though, as a provider, I
would really like to have not only the patient ID on the smart card that they
carry with them, but I would also like to have a face sheet attached to that.

So if every patient who came into my office or saw any provider today had an
accurate list of their medications, their allergies, their family history and
their diagnosis codes, what errors could be prevented just with that minimal
dataset that they carry with them no matter where they go. And it is updated,
and we have a process that we can update it, if they see you or you or you or
you. And that is updated.

Can you imagine just that simple sharing of simple data, actionable data,
besides the identifier that could make a huge change in our system? So perhaps
maybe we need to turn it right back again to the patient, and what data does a
patient carry with them that allows them to have the best care possible by all
the providers?

DR. O’CONNER: Thank you very much. It is almost 11:30. I have about 30
seconds until then. We are going to go for a break right now. We have 15
minutes, and you will hear chimes at the end of the 15 minute period.

(Brief recess)

Agenda Item: Technical Questions and

DR. O’CONNER: Thanks. I know some people had to leave at the break to catch
flights, et cetera, so it looks like we still have a critical mass. Our next
topic is going to, if you look on the agenda at 11:45, it is technical
questions and considerations. It is listed for 60 minutes. And so we have had a
slight change. We are going to talk about the technical questions and
considerations for 45 minutes.

And then for the last 15 minutes we are going to answer Dr. Suarez’s
question about the one technological priority. So before you talked about one
policy priority and then for the last 15 minutes of this meeting we will talk
about one technological priority. It looks like everyone is back. We have a few
people changing seats, which is totally fine.

Before we get started, Michelle, Dr. Suarez, Katherine, do you all have
anything to say before we start?

DR. SUAREZ: The only thing is, so here we are getting to the really — I
don’t want to say sexy question, but the really interesting question for the
Standards Subcommittee. The others I mentioned for many years on the
administrative transaction standards. We continue to do so. We continue to
depend in this country and this industry on those standards, and will continue
to see that happening.

But in reality, and some of the reason why this conversation really started,
came around the next generation of standards and particularly one specific one
that we mentioned in the background, which is claims attachments. When we
started to talk about claim attachments, then the whole world of clinical
information, medical information to support claims came to sort of the table,
our table.

And we started to think, well we have been all hearing about all these
standards that are happening in the electronic health record world, so it is
really important from this technical side to begin to think about what are the
new ways in which we need to think about transactions.

And the other very important aspect is the transformation following the
health care reform of, again, both the care delivery and the payment reform
side, and the formation of all these view structures, ACOs and HRS exchanges
and all that. And how that information is going to begin to flow, what are the
transactions that are going to be needed to support those.

There is enrollment and eligibility processes that are changing, there are
standards that are being changed to support those, and we have representatives
from the standard development organizations that are helping shape those. So
now we are thinking five years down the road, and how is the — maybe it is not
the right term at that point, but how is the claim of the future going to look
like? Or is there going to be a claim in the future?

Probably there will be in some form. So that is the frame of this next round
of questions.

DR. O’CONNER: Thank you. We will have our full 45 minutes of discussion for
this first question: what are some of the transformative changes needed in
transactions and standards coming in health IT? I will repeat the question.
What are some of the transformative changes needed and transactions and
standards coming in health IT?

There is a second part of the question which I will also read: how is the
adoption of EHRs changing the information exchange opportunities between
providers and payers? Some of that has already been discussed. But again, how
is the adoption of EHRs changing the information exchange opportunities between
providers and payers?

We are going to have a 45 minute discussion on those questions and then the
last 15 minutes we will have a discussion of Dr. Suarez’s question. We tweaked
it, and we want to hear your one technological priority that you would offer to
the Committee. So we have 45 minutes. Discuss.

MS. DARST: Laurie Darst from WEDI. As I said I think when we were talking
about the framing piece of it, WEDI has recently created an ACL bundled payment
workgroup. As we looked at doing this process, it is completely a manual
process. And a lot of the transactions and our processes don’t really support
the communication of bundled payments very well, so we are looking at that.

But one comment I just wanted to make, this is not just something new. As we
have been looking at this, this has been going on for quite awhile with
transplant billing, and that is like 20, 25 years where it has been a total
manual process for payers and providers to process this. And so it is really
time for us to take a look at making these changes.

MR. QUINN: John Quinn, HL7. Two areas. One, the current Meaningful Use
requirements in Stage One and Stage Two don’t really provide the
non-transaction specific — I know it is easy to look at a claim and get
information about what happened with this lab test, what happened with this

Getting an overall picture of the patient’s health doesn’t really — if you
took all the Meaningful Use transactions possible in Stage One and Stage Two I
am not sure you would end up with what is the progress of the patient on the
treatment of this disease, chronic or otherwise, as of their last appointment
last Friday? I don’t see how you would find it.

In Meaningful Use Stage Three, the proposed changes, in fact, you start to
see information like that, like Progress Notes, et cetera, becoming available.
I am not sure we have a definition yet of how we would combine all those things
to provide to the physician who is interested in the patient’s current health
or even the care payer’s interest. But that clearly, we have to get to at least
that stage.

The second piece that we have to get to is adoption of the terminologies
like SNOMED that actually give us the granularity necessary. I just spent a
week at an IHTSDO meeting in Europe two weeks ago. And they are making a heck
of a lot of progress, and there are a lot of other countries that are much
further along at using it than we are.

And that is not a statement against us. It just basically says that somebody
has already at least put a small dent in the grass that we have to go through,
to figure out how to use some of this stuff. And the tools are coming along
nicely for using it, and with a lot of American participation.

And NLM was there in force. So that is a big hurdle, because most
implementations of EHR systems today, A, don’t require it, and B, we don’t have
the user interfaces yet that I have seen that would actually make it palatable
for a caregiver to take the time to document a visit at the level that you
might be doing with SNOMED coding. And that is a challenge to the vendors and
to the folks that are really good at doing user interfaces, to figure out how
to bridge that gap. That gap has to be bridged or we are not going to get
adoption by the people that need to adopt it.

MR. ARGES: One of the items that struck me when I was looking at the
transformative issues with respect to the administrative transactions, it
really has to do with the operating rules. And for us the operating rules
really will make a standard much better in terms of how they are used, and an
expectation that organizations are geared up to basically use a transaction
standard with certain pieces as core components of functionality.

But the one thing that struck me, at least from the billing perspective,
because I chair the NUBC and UBO4 dataset, is that not everyone really has the
ability to use the full array of data components that are part of the claim.
And so you have information that is on the 837 institutional that isn’t fully

And the idea of an attachment transaction standard to basically spoon feed
an answer that may already be on the claim that is codified is something that
to me is very troublesome. And what we don’t want to see happen is really that
sort of spoon feeding of the end result.

And hopefully I think as operating rules get developed for the other
transactions, such as the claim, that organizations really are building the
type of edit logic that they need to build from the codes that already
contained on the UB.

And in a lot of ways, it is extremely important that that functionality be
part of that process. And so that to me has to be transformed. It has to be a
part of what I had mentioned earlier, basically working with a core set of data
trying to simplify that process and that understanding.

DR. FRIDSMA: I have just a couple of things. One is that I think it is going
to be really important that we don’t try to solve it all, and that we identify
within NCVHS where our sweet spot is, and where people are turning to us —
speaking collectively, I am not officially part of the group but I feel a sense
of ownership. But that they identify what NCVHS is going to be good at.

I think in a dyadic transaction based system, as we move to accountable care
organizations and shared risk and things like that, this is a tremendous
opportunity to do a refresh on the administrative transactions. Having worked
with CMS on some of the insurance exchange activities and all of the kind of
X12, 270, 271 transactions on eligibility and things like that, it was really
complicated to use those standards.

And I am not sure that they were necessarily envisioned to have that degree
of interdependency in determining eligibility. And so it seems to me that there
is an opportunity for NCVHS to say we own the administrative transactions and
we will make them not be the barrier to new policy and new payment
opportunities going forward.

Because if you have the technology it isn’t going to support the policy,
people are going to sort of pull back from that ability to push forward with
that. Don’t let the technology be the barrier. I also think one thing to think
about is, we talk a lot about standards and specifications, but as you get an
increasingly connected and process-driven set of interconnected machines we
need to think not just in terms of static and declarative information that gets
passed between machines, we need to think about how those machines orchestrate
the work that they do.

And so we may need to start thinking about things like APIs and services.
And I think it is a reflection of the need to get sort of business
harmonization around the business operating rules. Those things have to be
translated into the technology. And oftentimes that means not just having a
static, declarative set of information that gets passed, but actually have the
ability to proceduralize that in some way by having APIs that would be able to
do that.

And then the last thing is to say there are going to be parts of this
problem where NCVHS is going to be dependent on others to solve. We should go
to the HIT policy committee or the HIT standards committee and we should say we
have to do something with claims attachment, you guys are doing a whole bunch
of stuff on clinical information. Here are our requirements for what we need.
You guys need to help us solve this problem.

I think that is better than having lots and lots of other people sort of
taking their piece of the puzzle and their perspective, and then getting out
there with all sorts of different standards that are there. We see this in
quality all the time.

We have a prescription drug monitoring program that isn’t particularly well
integrated. It would be far better for NCVHS to sort of identify a bellybutton
(?) 00:13:40 and say you guys fix the clinical claims attachment piece and we
will use it if you meet our requirements.

MR. RODE: The Subcommittee was set up in part to look at administrative
simplification. I think in many cases the transactions as they apply in the
primary provider site are viewed strictly as an administrative transaction, and
fail to recognize that the information that is being generated has other uses.

As John reflected, we have been using the UB for years for quality
measurement, for personal health records, for a variety of other things. And
now we are looking at the collection of data that we have already discussed
this morning as not only a reimbursement perspective, but has a perspective
related to public health, to quality measurement, to other primary care

The IOM has talked about the fact that we have the technology but we haven’t
necessarily educated people how to use the technology. We have operating rules
but have we taught the end user how to use those operating rules?

Having served on the original X12 committee even before it became the X12-N,
one of the things that was very clear is, we saw eligibility as one of the
primary transactions, and yet the community made claims at the first
transaction. So we put the cart before the horse because that is where the most
bang for the buck was.

But all of a sudden we had a community of providers who didn’t understand
what the eligibility process was all about and how it could be used, and the
value it had, not only in just a simple transaction to determine the
eligibility but some of the managed care activity as well.

So I think as we look at technology, as this Committee looks at it, look at
the standards, look at some of the revisions that Doug was talking about,
George, and others. We need to look at also how we get an understanding of the
use of all of this at the primary site so that it is used effectively and we
actually achieve the original goals of administrative simplification.

DR. KLIMEK: I want to comment on something that Doug just mentioned on
prescription drug monitoring, because that has actually been a hot topic for us
at NCPDP. As I mentioned earlier, pharmacies had the luxury of being in real
time, real time eligibility, real time drug information between payers and

The one thing that they were left with is to try to comply with some of the
prescription drug monitoring programs that were being put in place that was
using a product that was not real time. Now the problem with that is you have a
pharmacist that is taking care of a patient, and most of these drug monitoring
programs are obviously geared towards narcotic use.

You have a patient who is trying to get a medication and they are using a
device that is not real time. Now you have got sometimes 24 hours, sometimes a
couple of days, sometimes a couple of weeks, before that information is
updated. I am sorry, in the pharmacy world that patient is long gone, and they
have probably hit about a dozen pharmacies all on one location.

So to me the product that the pharmacies are using is not meeting the
necessity that is out there in the real world. So with that said, NCPDP
actually held a focus group not too long ago to talk about this and bring all
the right industry people to the table, to try to figure out how we need to fix

That is high on our schedule right now, to look at putting together a task
group and a workgroup to try to fix that kind of a problem. Again, come up with
a real time environment world so that the pharmacists can take care of those
patients and get the right information in their hands, as clinical information
is needed in doctors’ hands real time.

I kept on hearing over and over from my notes earlier this morning, real
time, real time, real time. In a pharmacy’s world, we can’t live without real
time. So I just want to make that comment.

DR. O’CONNER: Ms. Thomashauer, do you have another comment?

MS. THOMASHAUER: Yes, just two quick points. One thing is that I think we
need to do more looking outside of health care for industry standards that
support processes that may be similar or related that we can build on and learn
from. I don’t know that we do that enough and often enough. That is one point.

The other point is, as we look at new approaches and at standards that are
going to support what we need going forward, the timeframes, our timeframes are
different than they were when we first created these standards 15, 16 years

And so we really need to see how we can build in — I know we have talked
about this at other Subcommittee meetings — build in a maintenance cycle that
respects the timing that the industry needs for refresh and reconsideration in
a way that we haven’t historically.

DR. O’CONNER: Any comments from the phone?

DR. COYNE: Actually, following up on Robin’s comments and the comments prior
to that on real time, I am always struck when I think about transformational
questions like this at how the extent to which we really don’t know what the
future is going to bring.

Except I think what we can assume here is that business needs for data in
real time that is interoperable and that lends itself, i.e., high quality data,
to good analytics, is only going to increase. And so I just wanted to second
the comments that were made about, one, the need for real time information
exchange that is interoperable, and the need for a really agile development of
new standards.

And the only other thing I would add is that going back to where we started
the conversation this morning, understanding that NCVHS and all of the groups
involved need to have, as Harry Reynolds said, a sweet spot.

Is there a common vision among all of these groups that could be put
together about what an interoperable information ecosystem would be in order to
meet the needs of consumers for better health and patient safety?

So without getting specific here, it does seem to me that the real time
information exchange and the agile development of new standards to meet the
business needs is going to be critical. Because if the business needs start to
outstrip the standards too much, businesses then invent their own standards and
we are left with a bigger mess at the back end. Thank you.

DR. O’CONNER: Thank you. Dr. Sorace and then we will come over to Mr.
Tennant and Dr. Conrad.

DR. SORACE: Complexity is always the enemy. And so as we try to implement
this stuff nationally I think it sort of rears its head in two ways. The first
one is, when you actually have a reasonable set of standards that you want
people to go ahead and implement, and whether they have enough support and
enough health sites and enough consultants actually available to them so that
if they are not domain experts they can do it.

I think there has been some substantial progress in that in the last little
bit of time. But I think it is still an issue that we have to think of in
parallel as we are doing this.

The second way of looking at complexities is perhaps a little more
challenging. As I have gone along I have watched what works and what hasn’t
worked. I have developed the philosophy of a complexity trap. And that is where
the scope of the solution you are proposing, or the complexity of that solution
blows out really fast as you try to increase the scope.

And bluntly, it is not sustainable from a mathematical point of view. It
sounds sort of abstract but I think we might actually want to sit back a bit
and look at some of these more computational issues as we chart the path ahead.
Because I think otherwise you can dig yourself into a corner, which you can’t
then abstract yourself, even if you get what you think is the amount of
resources you want.

MR. TENNANT: This industry doesn’t have a particularly stellar record at
implementing standards, to say the least. Laws get passed in ’96, and laws come
out in 2010 saying oh by the way you have got to actually implement what we
told you to do back in ’96. But one thing we did do well one time was, we had a
pilot. We actually piloted the claim attachment standard in 2005 between a
practice up in New York and a Medicaid contractor.

And the strangest thing happened with that pilot. It was actually
successful. Both sides found value in the transaction, to the point where they
would go around the conference circuit talking about the success that they were
able to exchange data. Each side was saving money.

Typically with standards it is one side that benefits over the other. But
this particular one was benefit on both sides. So what of course did we do?
Nothing. We didn’t do anything with the standard until of course ACA had to
come forward and demanded, by when? 2016. So literally 20 years after HIPAA was

I think one lesson learned is, let’s not rush into things. Let’s understand
what the business need is. And Robin will correct me if I am wrong, but look at
other industries, like what we did with the Operating Rules. We brought in the
financial community to tell us how they did it. We can learn from other folks.

And John alluded to other countries. God forbid we look at how other
countries deal with some of these issues. Taiwan has a national ID card.
Germany moves data much more efficiently than we do here. So learning from
other folks would be a wonderful opportunity for NCVHS to get a better sense of
what works and what doesn’t and pilot test these standards before we move

DR. CONRAD: I think that one of the things they have to look at is the fact
that we are moving from a fee for service payment system to a value-based
payment system. So therefore, the old ways don’t work. Currently when I do a
CMS 1500 form I have to prioritize my first four diagnoses when I see somebody
in the office. Now that doesn’t reflect the complexity of the care that needs
for my patient who has 14 diagnoses.

And so therefore, if we are looking at moving to a value base, we have to
find out some way to capture that data of the care that is delivered to these
complex patients, and not only that, but the care coordination that it takes to
do that. Right now I am not reimbursed one penny for coordinating the care for
those 14 diagnoses that that patient needs to have addressed.

So therefore, if you can make it simple for me, and in my EMR when I
document the care that is given and the time that it takes to coordinate that
care and all the different things that I need to do to care for that patient
with that 14 diagnosis, and my EMR is smart enough o pull that data out and
transmit it to somebody to tell you how well I am doing that care, that would
be very helpful.

And it wouldn’t add one more thing to my day other documenting the care that
I am doing. So I have to think there is a good way. When I do my ENM code right
now, when I make my note, it tells me that I met all the requirements for this
level of code out of my document that I have to do anyway.

And why can’t then some smart EMR and the data coding be tied to that so
that when I document once that data can be extracted to reflect not only the
complexity of the care of the patient but the care coordination and the health
care delivery that went around making the best possible care delivered for that

DR. O’CONNER: DO we have any questions on the phone? (None) We still have
about 20 minutes to discuss this question. We have talked a little bit about
real time data. We have talked about looking at other industries for support.
So I will focus on the second question that I asked, which is how is the
adoption of EHRs changing the information exchange opportunities between
providers and payers?

DR. GEDDES: This is Nick Geddes on the phone. Can I make one comment on the
previous? I just wanted to agree with many of the things the last speaker said,
number one. Number two, what I would urge is consideration of flexibility. The
purpose for my comment is that correct, the world is evolving, we are going
more toward value. That may mean more risk payments, capitation payments,
bundled payments, group payments, whatever. So whatever system we have, though,
it has to take all that into account.

But at the same time you can’t throw out what you have. The reason for that
is, as we ramp up one process or system or methodology, the other one has to
exist while it is ramped down. So, flexibility.

MR. DANIELS: John Daniels from HIMSS. One of the things that we do at HIMSS,
one of the things that we have developed is a capability maturity model that we
are using to track EMR adoption trends across the industry. So we collect data
on every single hospital across the country. The N is about 5,303 right now.

We track their adoption of EMR technology, starting at state zero where
there is basically a paper-based organization all the way up to state seven
where they are paper less organization. And at Stage Seven, that is when we
start looking at their HIE capability. And right now, at Stage Seven, we have
about 1.7 percent of the hospitals in the country at Sage Seven. Validated by
us through an on-site visit where we actually go and look at the capabilities.

But we talk about HIE, and what is interesting is the different HIE
capabilities from the state’s seven hospitals. One in particular hospital,
Tucson Medical Center out in Arizona, they have the capability to exchange
information, but they have no one to exchange it with.

And then you go and look at Adventist Health System. There are 27 hospitals.
They have a very robust HIE capability. They can exchange between all of their
hospitals, and they are working quite aggressively on the ability to be able to
exchange outside their organization as well. And they do have organizations
that they can exchange information with.

There is a huge gap between those two organizations and they both have the
capability to exchange. So I thought that is very interesting. The other
interesting note that we pull out of that data is that currently, in 2012, only
about 25 percent of the hospitals in the country are participating or report
that they are participating in health information exchange.

Five years ago that was about 11 percent. So it has taken five years to get
from 11 percent to about 25 percent, and we still have a long ways to go. So I
just wanted to share that information for the discussion.

MR. RODE: Thinking about technology and the Committee, I think two areas
that I have heard so far this morning. One is the technology on data capture
and how do we get the data into the system in the first place. There is really
a need for innovation in this particular area. We are using systems that I
don’t think have been significantly improved in at least 10 years.

And again, the question of whether the users know how to use the systems
that are out there. I know I have to use a visual audio system myself and it
does some very strange things with the information that it pulls into the
system. I am listening on my earphones and I can’t believe it.

I think one of the things is getting that information into the system, which
impacts the physician’s ability. So I appreciated the ability to collect the
data, you might say once, and ensure that in putting the information down it is
in the system and then came come out of the system.

I think the second one that Robin raised that is very much in this
Committee’s lap is taking the ACA requirement to improve how we update our
standards, especially standards identified under HIPAA. We have just finished,
or maybe not, implementing 5010. We know that there is a 6010 or 6020 out there

But if we don’t come up with a process that is linked with all the other
changes that have to be made in the industry for other requirements, we are
going to still be playing some of the same problems off that we saw in the last
go-around. So we need to have an ability to maintain and upgrade our standards
on a regular basis, whether they are transactional standards, clinical
terminologies, vocabularies, what have you, and sync them up.

This is an area that I think is definitely within the role of the Committee,
and HIPAA’s charges.

DR. JAFFE: The bottom line is what is in it for me? I sat recently at a
California HIE meeting between two CEOs. That was an accident and a bad
mistake. They had spent the last 20 years competing. Each of them cared for
millions of patients and they had no notion what the business case was to
exchange data.

As we developed as business cases and answer the question what is in it for
me, the standards part becomes a whole lot easier. For example, we can’t
continue to have one health care system use M and F for male and female and the
other use one and two. That is not an issue of technology. That is an issue of
stubbornness. And I am not sure how to reconcile that.

The bottom line is that we have to achieve a greater sense of what’s in it
for me, and then I believe the standards part will be easier to establish.

DR. O’CONNER: Clarice, I saw you shaking your head earlier. Do you have
anything to add to this discussion? If you don’t that’s okay.

DR. BROWN: I was just wondering what is it in it for the CEO? Can you make
that business case for exchange of health information, for the two CEOs sitting
on either side of you?

DR. JAFFE: Well, the irony of course is that it is better care for patients.
I would never broach that one. In a larger sense if you look at the mission
statement of corporations it says deliver value for stakeholders and provide a
great future. It doesn’t say patients deserve better care. I haven’t seen one
that says that. And I apologize for all the ones out there that I have

So that’s the business case, provide better care for our patients. But Doug
has an answer.

DR. FRIDSMA: I don’t have an answer. I just have more and more questions.
But I do think we talked about this notion of data and analytics and trying to
provide better quality and we have got pay for performance.

If what we do is get away from the notion of send us the data and we will
tell you whether you are good or not, to the notion of we will provide you the
tools and resources in a standardized fashion that will allow you to do those
analytics on a continuing basis, we actually start to drive a value proposition
for the folks that have the data. Because it is about having it in a standard
format, being able to aggregate it and being able to do analytics within their
own institution.

So I think one of the things that we have to do is, if what we really want
is a continuous improvement process in how we take care of patients, we need to
equip those people in the periphery with the tools and the analytics so that
they feel empowered to understand how to do improvement.

And rather than sort of send their stuff to some central database and then
find out nine months later that they weren’t doing so well on their diabetic
care, it would be far easier if they could do that on a weekly or a daily or
whatever basis to know, again, to the real time question, the ability to do
real time analytics.

And so I think standards and the ability to empower providers to do that,
gives us some of that value proposition and it is going to be part of what we
have to do anyway.

DR. O’CONNER: We have about seven minutes left to discuss this question and
after that I am going to ask everyone for their one technological priority that
they would like the Committee to consider. So think of that answer. Before we
get there, I want to hear from Dr. Scanlon as well as Dr. Fitzmaurice.

DR. SCANLON: I just wanted to comment on this issue of a business case,
because I think that one of the things that has struck me continuously about
these discussions with respect to IT and other transformations within health
care, is how the question has come up repeatedly, whereas in another industry
the question would be relatively easy, which is to say, my customers want this
and I am not going to have any customers if I don’t provide it.

The business case is not so much that I can increase my revenue because of
this, but in part because I can maintain my revenue because of this. And I
think that is what we are talking about here in part. We are talking about a
change in terms of what the expectations are on the part of patients as
consumers and as payers of health care.

And that is, I think, very important because this notion that everything has
to be a business case from a perspective of more revenue or more profit is not
necessarily going to be sustained. There is a need to make this change, to keep
health care viable for the future.

DR. FITZMAURICE: I want to continue on in the same vein. If information
technology allows a provider to reduce office visits, reduce tests, reduce
hospitalizations at the margin, maybe because of better monitoring of the
patient, better current information, who gains from it? Or, as Chuck said, what
is in it for me if I am the provider?

And the answer is, well, it is a savings of fewer services. Health plans pay
for the services. I get back to incentives, which I raised earlier. If there is
some way to incentivize the health care providers to supply the data, that
makes the system get more efficient, then we would have a system that
continually improves itself.

But if the information is taken to a bottom line or is used to expand the
services in some other area, then there is no reward for doing good. I mean, no
reward for doing the best. There is always a reward for doing good for the

So that is a thorny problem, how do we incentivize providers to do the best
thing for the patient and for the system if, when they give information that
they are mandated to by health plans, by the government, that they don’t get
the immediate payoff? Doug brought up one payoff. You get information about how
you are doing. Is that sufficient to drive this?

DR. O’CONNER: Any more comments on this question?

MS. THOMASHAUER: Just a point — and I agree with everything that has been
said, but I think that in the endgame you have to pay for this somehow. And so
we do need to be — I think it is incumbent on this when we look at what we are
going to be taken on, to make sure that there is a mechanism in there, we can
demonstrate the business case and the value of it, both financial and
non-financial because in the end, there is limited resource. And somehow we do
have to make sure that we pay for this responsibly.

DR. O’CONNER: While, technically, we have four minutes left to answer this
question, but if no one has any comments I would like to move onto the one
technological — I’m sorry, Ms. Sheppard?

MS. SHEPPARD: Go ahead, I will be first next.

DR. O’CONNER: Okay, we will start our discussion then, to segue from what
Dr. Suarez said earlier this morning when he had us answer the one priority
that you would have for the Committee in terms of policy. So now the question
is what is your one technological priority?

MS. SHEPPARD: I couldn’t decide which segment my comment belonged in, so
this is fine. I think while we are doing this section we need to remember that
we have kind of used transformative change to standards and transformative
change to technology interchangeably in the last little bit, and they are not.
Transformative change to standards is different than transformative change to
technology. I believe we need both, but they are not the same thing. So we
should keep that in mind.

DR. O’CONNER: Any other comments?

MR. DANIELS: John Daniels from HIMSS. My background is as a CIO. And one of
the things in the previous discussion that might get to maybe answering the
question on the table is the struggle with trying to figure out a return on
investment calculation that CEOs could use to determine whether or not an
investment in a technology would give them the biggest bang for their buck, not
only from a financial metrics perspective but also from the clinical quality

The problem that we have is that there are so many different ways you can
measure that, that there is no standard way to be able to use to determine
whether or not an investment in a particular information technology system or
application could truly answer the question in the same way that it would
answer a question for another CEO in another system, perhaps, considering the
same technology.

But because their business objectives and their strategies are different,
there is no single model that they could use to really calculate the true
return on investment, again, including financial metrics and the clinical
quality metrics. So, that has always been a struggle for CIOs, if you will,
trying to pull that information together for their boss.

So perhaps to answer the question, it might be a way to, if there is a way
we could come up with some sort of methodology, standardized methodology, to be
able to measure real return on investment, that includes both financial metrics
and business metrics, I think that might be helpful.

DR. O’CONNER: We have a comment on the phone and then we will go to Dr.
Fitzmaurice and then Mr. Quinn.

DR. COYNE: This is Frank Coyne with Blue Cross. Just two comments. One, on
that ROI question and the previous comment, I agree totally. One of the
struggles I run into is that ROI on some of these investments needs to consider
not just the dollars saved against the dollars invested, but some of the
qualitative improvements to the system that are a little harder to translate
into dollars.

And those would include improvements in patient safety, improvements in
consumer health that are proactive, and finally better outcomes. It is a little
hard sometimes to translate those into solid dollars and cents. They are
nevertheless a critical part of the equation, as I think quite a number of us
were saying earlier.

On the question of transformative change to technology, I just want to go
back to something we had said earlier about staying away from the concept of
this great big database in the sky which kind of works against, I think, some
of the arguments for making data more accessible in real time, and more
available in the interests of patient safety and health.

Some of the other capabilities that are out there include Cloud services,
and include standard APIs which were mentioned earlier in another context, that
have potential to provide access to data in a highly distributed model, but
that nevertheless ensures and can ensure that the right data is in the right
place at the right time.

So that openness to those innovations and awareness of what other companies
are doing to create information ecosystems that are distributed but also
available in the Cloud so that they can be pulled together at the right time
and the right place, is really critical for us, I think, as we try to think
through the vision of what we are trying to accomplish and how we get there. So
thank you for that.

DR. O’CONNER: Thank you. Dr. Fitzmaurice, then Mr. Quinn, and Dr. Jaffe.

DR. FITZMAURICE: Currently, we face a national goal of reducing the rate of
increase in our deficit. And we know what that means. If I am doing something,
you can bribe me to do the best thing by giving me $50. You can achieve
probably the same effect by penalizing me $50 if I don’t do it. Or you can
regulate me to do it, otherwise I will have to get out of that business.

So those are strong levers, and if you do any of those things to me I am
going to go to the politicians and say look what they are doing to me, you have
got to fix it. So ultimately the economics and the politics have to align with
improving the efficiency and effectiveness of the health care system so that we
can maintain our quality and still achieve other national goals. And it is
going to take good information to do that.

MR. QUINN: Since the question is regarding technology I am going to sink to
that level for a minute. It goes to a combination of things that John Klimek
said about real time, real time, real time. And a comment that Doug Fridsma
made in the first half about we need to go to an API services architecture.

Look, if we are going to really pull all the data together from multiple
sources at the same time we are going to end up having to use some sort of a
remote distributive processing model for this. While that may sound complicated
here, it is quite common outside of health care. And so this is a
well-developed set of science and computer science.

We are going to have to do that. The real time response capability for most
of these systems using the typical way of either pushing a message or even I
will call it primitive query response capabilities that are available in it,
isn’t sufficient. We have done a lot of experimenting within HL7 over the last,
I am going to say, four or five years on services-oriented architecture. We
work with OMG on it, which is basically a non health care group that does UML,
that writes UML.

And that is the model, in terms of an enabling technology. How is that going
to happen? It is only going to happen if the architecture is defined to do
that. And the architecture is defined primarily at this point within ONC, so
tonight I am bringing this up. Nevertheless, there are other people from ONC
here as well. If that is what we are going to do, then we have to figure out
how to embrace that kind of technology.

The data standards, whether it be terminology standards like SNOMED or
whether it be stuff like HL7, actually the content, the payload, remains
largely the same. It is how do we interoperate with that payload that has to
change to give you real time, real time, real time.

DR. JAFFE: Two examples. One is that Wal-Mart enables it efficiency by
getting real time data. One of the business requirements if you want to do any
degree of business with Wal-Mart is to have bar coding and RFID.

It was absolutely transformative for the pharmaceutical industry because lo
and behold they wanted to sell something to Wal-Mart, and bar codes and RFIDs
appeared on everything. Clearly the customer defined the need to the purveyor.

Early in my career I was in a genetics department and we had two
well-defined ethnic groups, one of whom we paid $25 if they would give us their
blood. The other we charged $50 in order to do their test. We just understood
our audience.

The issue as we move forward is, we need the ability to turn the standards
into actionable innovation in our industry. And so I think we have to know the

MR. TENNANT: One thing that physicians and practices need and want is the
data to compare. They want to know how they are comparing with their peers,
with their competition. And to Dr. Fitzmaurice’s point, you can use carrots and
sticks, but you can also showcase those entitles, organizations, that are on
the cutting edge, that are leading the pack.

It is one of the things the Committee might consider, to showcase some of
these organizations that are a little ahead of the curve, that are using the
data in innovative ways to get to the point of how do you convince the CEOs of
groups to do it. Well you do it because you show the value that their
competitor is doing across the street.

And that is the way things can grow. But we have to showcase it. We have to
broadcast it out to show that this can work, there is ROI, and again —

MR. ALBRIGHT: Matthew Albright. I would just like to echo some of the things
that are being said here and frame it in the concept of, in terms of
incentivizing towards that administrative simplification Nirvana.

There is a role for government, but I would say that role for government
probably won’t answer the question of what is the most innovative technology
that is needed or what is the transformation. Hopefully that will come from the

I think when we talk about policies, or even standards, some of those should
come not from the government, because I think the analogy was made earlier that
once you get to the government, that’s a hammer. And so we talk about NACHA,
and even Wal-Mart, in the pharmaceutical, a lot of those were self-regulated.

A lot of those came up through self-regulation, either everybody getting
together and coming up with standards which then never have to be adopted by
the government, or self-regulation in terms of contracts. And maybe that is
where the question of how to handle vendors, certification of vendors and

So I would just like to think about that, too. And maybe in terms of NCVHS,
I think it has been kind of a body that makes recommendations to the government
to adopt standards. But perhaps it can also be a body that sends those
recommendations to other bodies which don’t necessarily come back in the form
of a regulation.

MS. DURST: I just want to make a comment about real time. There has been a
lot of discussion about that. WEDI has been working quite a bit in that field.
We did some work with real time adjudication workflows and looked at what that
would take to move the industry in that direction.

Right now we have a workgroup in the dental world trying to replicate what
is happening with the pharmacy in the dental arena. So we strongly support that
real time process also.

MS. THOMASHAUER: Just to piggyback on Matt’s point, one of the initiatives,
I think Linda Kloss mentioned it earlier, that CAQH is involved in has to do
with a provider database that is being used mostly for credentialing. It is
voluntary. We really feel strongly about voluntary issues.

It has taken us 10 years to get that to 1,075,000 providers. And we are
still growing at about 7,000 a month. Nevertheless, 10 years to get to that
place. This industry doesn’t move on a voluntary basis very well. And so I
think that is a great idea, to see if the Committee could do something to
accelerate voluntary adoption as well as looking at the regulatory process.

There is a lot that is going on and a lot that can be done. But because
there are so many requirements, it is really hard to push voluntary efforts in
this industry. It is a great point, Matt.

DR. CHANDERRAJ: I just wanted to enter a couple of responses to some of the
statements made. Yes, government is the hammer. But unless there is a hammer
this will not progress. The reason we have such complexity involved in this,
every industry developed their own standards, and their own thing. Now we are
finding the problem of convergence of all these different elements, and that is
where the stumbling block is.

Unless you have the government introduce certain regulations and certain
criteria, for all the industries to accomplish in a uniform manner, the task is
not going to be done. The reason why Europe and other countries are way ahead
of us is because of government enforcement, not because of the industry. If you
limited the industry, they would develop their own specification to their own
revenue generations, not to the goodwill of the society. I think the government
has to take a role in this.

The second thing is, what is required for the standards, to make the
technology simple for the end user. It is so complex and so unwieldy at this
time, that it takes more time for the physician to provide care to his patient
with the existing health record than what he was doing manually.

If I have 30 patients in three hours time, I have 180 minutes to take care,
and each patient would get six minutes. The manual system used to take five
minutes to provide care. Now it is taking 12 minutes. I don’t have this extra
time to provide care. Make it simple. Make it deliverable. And then you will
see the end result.

DR. O’CONNER: Speaking of minutes, we have less than three minutes left. So
Dr. Carr and Dr. Conrad, and you can throw in a comment too. We have less than
three minutes.

DR. CARR: I will just add my voice to real time technology.

DR. CONRAD: I just want to echo those comments about making it simple for
the user. But I also think don’t reinvent the wheel. We had some really good
models out there, like patient centered medical homes, that is demonstrating
quality and cost savings as well as improving the quality of care delivered.
Use those.

And use incentives. That is why our practice made that investment, because
we said we can get the incentives for being a PCMH, because we are getting an
uplift in those payments. So that is the reason why we justified our return on
investment, by saying that if we can capture X amount of incentives.

Not just from CMS but also from the Blues, from priority health, all the
different payers for quality. We want to do that anyway. But if we get the
incentives to do so and the tools to be able to report that data, then you are
helping us do what we want to do anyway.

DR. O’CONNER: We have one minute and 30 seconds to wrap up. Any closing
comments? Dr. Suarez? Do we have anyone on the phone?


DR. O’CONNER: I am certainly not going to start another discussion, so I
will turn the mike over to Dr. Suarez and to Ob as well.

Agenda Item: Next Steps

DR. SUAREZ: Thank you very much. I am going to turn it to Ob. He has agreed
to take the brave role of trying to summarize what we just heard through the
entire morning. I will turn it to him and then I will make a couple of comments
and wrap up.

MR. SOONTHORNSIMA: First of all, this has been a very rich dialogue. What I
attempted to capture, I hope, pretty much sort of summarize most if not all the
comments you made. And whatever I say, do not shoot the messenger. This is what
I heard. Obviously you can read that on the wall. It is very hard to read, so
here we go.

Here are some of the common themes. And I will explain each one, expand on
each one a little bit more. One is around provider engagement. You guys talked
about the need to have the provider better understand the intended value of all
the capabilities that over the years we as an industry have introduced, and are
continuing to roll out more capabilities into the future. So the point here is,
definition of value and making sure that the provider community really
understands those things.

Second I heard the provider engagement is around decision support. What is
some of the actionable information that can be provided at the point of care,
and how information can be captured more effectively from the appropriate
diagnoses? Again, capturing the data out front seems to be a common theme in
the provider setting, in order for proper decision support to take place.

Another area, another theme, is provider-payer engagement. An effective data
exchange with the right set of information, what I heard is this is no longer
about claims. This is about outcomes, about clinical data being shared between
the payer and the providers. Second, I heard this more than once, of course —
patient identification. I heard it about 10 times I think. So we will move on.

The third one is data analytics. How do we harmonize the datasets and
standards? Perhaps not make a database in disguise, but more distributed ways
in a more agile fashion to help integrate and aggregate data information and
make them, again, actionable for the providers, the physicians. These things
talk about the provider and payer engagement.

Third theme is around patient and consumer engagement. I think we heard also
that the consumers are actually moving way ahead of us in terms of what they
are demanding, whether it is their preferences, what their values are, but more
importantly what I heard also is that they demand more information for their
own decision support, to access appropriate care, and what quality care means.

The second thing I heard also is around why not treat consumers as a
partner? Oftentimes we come together as a community of enabler and standard
organizations and representatives of different segments of our industry. But we
need to bring the consumers to the table.

And perhaps help reframe the value proposition of all these changes that we
have been talking about, because they are kind of outside of the loop, as you
indicated. Just like what we are trying to educate or explain to our provider
community why some of these capabilities are important or may be important, the
same thing has to be done with consumers.

I heard a lot — this is a fourth theme. I heard a lot around business case
for change. We heard roadmap, the term roadmap, at least four or five times.
And what then is that quote, unquote roadmap for the industry changes and
mandates that are taking place? And how do we ensure that we have the right
value definitions that have been explained, and how the industry will
implement, and whether or not we will achieve these benefits?

The next theme is around vendor engagement. Just like what we talked about
with the consumer, the vendors seem to be having to catch up, as we are trying
to make all these changes happen as rapidly as we can. But we can engage our
vendor community more effectively.

Perhaps more effective certifications to help accelerate two things — one,
the alignment of the data needs that basically these systems are the sources of
the record, but also the usability of these systems. We heard loud and clear
how some of these systems aren’t necessary, not only hard to use, putting the
workflow, but perhaps not the right set of data is being captured.

Then another theme is kind of — they all go hand in hand — standards
terminologies, common definitions. So how do we harmonize and improve the
terminologies, that is one thing we heard. Coding of data from using the
correct data definition and standards, and to make sure that not only those
standards, because they are really hard to understand to begin with.

I think I heard one comment that a more granular dataset or more granular
standards isn’t necessarily going to translate to effective data capturing
either. So how do we make sure that practice in the workflow changes occur
effectively, as all these data standards are being rolled out?

We also heard the process of standards development and how we need to
harmonize them across the industry. So that is it focused on value. They are
properly vetted, tested, and appropriately maintained. We certainly heard that
considering the pace of change that is taking place today, that the process of
making standards and harmonizing these standards have to be more timely.

Another theme is around coordination and collaboration across an industry.
Alignment of policies, alignment of mandates and initiatives across the
industry with the appropriate timeline, and this kind of gets back to the value
proposition earlier, that way the industry can meaningfully achieve these goals
and results and drive the improvements around cost and quality. That is the
last theme.

Here is the laundry list of one thing, and I combined both policy and
technical one things. Data quality, standardizing the interface between quality
metrics, and having a seamless exchange between all the entities.

Engagement with the vendors and certification, patient identifier,
harmonizing of data elements. I believe this is how we codify the data
standards definition at the point of care, in the EHR system. I believe that
was the context.

Smart card — and I think the smart card, really the context is around
better engagement with, or make it easier for the consumer. And if we have the
right set of actionable information at the point of care, whether it is going
to be on that smart card or not, that would be a nice one thing as well.

Educating constituents on the value of what they have to implement. That is
another one thing. Governance and stakeholders need to be aligned. That’s what
I heard. Minimal dataset. Incentives. And the last one I heard was around
voluntary versus mandatory steps to drive the right change. Walter?

DR. SUAREZ: I was typing as fast as I could. That was amazing. So okay,
thank you so much, Ob, for that. I think what we wanted to do in the last few
minutes here is to describe some of the next steps that the Subcommittee will
be taking.

And first of all I want to add my thank you to Ob’s note about that. I think
it has been just amazing to hear all these perspectives. Again, the goal that
we had was to start the dialog. And I think it has started with an incredible
force. We clearly see that there is some role that the Committee and the
Subcommittee can take.

There is a need of a lot of coordination with others that are working on
this space. There are some subjects, some topics that we have to really focus
on. Ob summarized a number of those. There are some areas where we are
responsible for the administrative standards. And there are some links of those
with the work that is being done by other committees, like the HIT standards
committee, the policy committee, and even others.

We didn’t get a chance to talk a little more about public health and
population health data exchanges, and I think that is another major activity
that I know the Committee is going to be working on through Standards and
through the Population Health Subcommittee.

So over the next couple of months, the Subcommittee is going to be meeting
to discuss basically all these points, and comments, and ideas for directions
and topics and recommendations for priorities, and coming out with a summary,
if you will, that we will be I expect presenting to the full Committee at the
February meeting.

We expect that, as I mentioned, this being the initial dialog, to be able to
bring together this discussion into the future. Probably in virtual ways, as
well as in person ways. And once we begin to define some of the priorities that
we are going to be looking at, now bringing the groups back again to talk about
those priorities and how to move them forward.

I think this concept of the roadmap that we heard quite a bit is very
critical for the Subcommittee and for the Committee as a whole, and I know
there is expressed interest in many agencies, including ONC, CMS and others, to
really create that roadmap, to draw a map of where things are going and align

And finally, alignments that we haven’t yet even discovered really, truly,
with respect to all this work. So I think that is going to be a very important
element of the work that we do. And then how the current standards and the
current work that we are doing with respect to HIPAA and Affordable Care Act
aligns with those elements in the roadmap.

And so that is, I think, a little bit of what we are going to be doing next.
We don’t expect to produce a letter report, recommendations, or anything like
that coming out of this. This is the beginning of a work item that we have as a
Subcommittee over the next year. And so we very much appreciate your time, your
commitment to participate.

I think we have your contact information. We know how to find you. And if
you haven’t yet, if you can sign on your way out, there is a signature document
that you can just provide us, if you haven’t yet provided us with that. We will
be communicating with you by email. We will process this information through
our Subcommittee and present this to the full Committee in February.

And with that, I only want to highlight a couple of thank you notes as well.
First of all thank you to Marjorie an NCHS for hosting us here at NCHS. Thank
you very much to Michelle for helping coordinate this first roundtable. I think
it is an amazing work, to be able to bring together so many people. So thank
you so much.

MS. WILLIAMSON: Thank you to Suzie for scribing away, Katherine for keeping
our time, Marietta and Jeannine and Nicole for pulling it together in the
backside where people don’t see what is going on, and especially to Kathy for
coming in and helping us as a facilitator. (applause)

DR. SUAREZ: Well, I think we are done. We are going to adjourn, so thank you
again. Have a great rest of the week and happy holidays.

(Whereupon, at 1:00 p.m., the meeting was adjourned.)