This transcript is unedited

Department of Health and Human Services

National Committee on Vital and Health Statistics

November 17, 2005

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

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


  • Simon P. Cohn, MD, Chairman
  • Jeff S. Blair, MBA
  • Mark A. Rothstein, JD
  • Donald M. Steinwachs, PhD
  • John P. Houston, JD
  • Robert W. Hungate
  • Paul C. Tang, MD, MPH
  • Harry Reynolds
  • Judith Warren, PhD, RN
  • Dr. Dan Friedman
  • Carol J. McCall, FSA, MAAA
  • Kevin C. Vigilante, MD, MPH
  • A. Russell Localio, Esq., MA,MPH, MS
  • Justine M. Carr, MD
  • Audrey Burwell, OMH
  • Maria A. Friedman, DBA
  • Marjorie Greenberg, NCHS
  • James Scanlon, ASPE


P R O C E E D I N G S 10:10 AM

Agenda Item:Discussion of action items

DR. COHN: Good morning, everyone. I want to call this meeting to order.
This is the second day of meetings of the National Committee on Vital and
Health Statistics.

The National Committee is the main public advisory committee to the US
Department of Health and Human Services on national health information policy.
I am Simon Cohn. I am the Associate Executive Director for Health Information
Policy for Kaiser Permanente and Chair of the Committee.

I want to welcome the Committee members, HHS staff and others here in
person. I, also, want to welcome those listening in on the Internet.

Let us now have introductions around the table and then around the room.
For those on the National Committee I would ask if you have any conflicts of
interests related to any of the issues coming before us today would you so
publicly indicate during your introduction.

I want to begin by observing that I have no conflicts of interest.


MS. GREENBERG: I just got a memo saying that we are not on the Internet,
but hopefully we are by now, but this was about 10 minutes ago that it was sent
to me.

I am Marjorie Greenberg at the National Center for Health Statistics, CDC
and Executive Secretary for the Committee.

DR. WARREN; Judy Warren, University of Kansas, School of Nursing, member of
the Committee, and I have no conflicts.

DR. HOUSTON: I am John Houston, University of Pittsburgh Medical Center,
member of the Committee. I have no conflicts.

MR. REYNOLDS; Harry Reynolds, Blue Cross, Blue Shield, North Carolina,
member of the Committee, no conflicts.

DR.TANG: Paul Tang, Palo Alto Medical Foundation, member of the Committee,
no conflicts.

DR. VIGILANTE: Kevin Vigilante, Booz-Allen & Hamilton, member of the
Committee, no conflicts.

DR. STEINWACHS: Don Steinwachs, Johns Hopkins Bloomberg School of Public
Health, member of the Committee, no conflicts.

MR. LOCALIO: Russell Localio, University of Pennsylvania, School of
Medicine, member of the Committee, no conflicts.

MS. MC ANDREW: Sue McAndrew, Office for Civil Rights,Privacy Liaison to the
VA Privacy and Confidentiality Subcommittee.

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

MS. MC CALL: Carol McCall, Humana, member of the Committee, no known

DR. CARR: Justine Carr, Beth Israel Deaconess Medical Center, member of the
Committee, no conflicts.

MR. HUNGATE: Bob Hungate, Physician, Patient Partnerships for Health Care,
no conflicts.

DR. HUFF: Stan Huff with Intermountain Health Care and the University of
Utah, Salt Lake City, member of the Committee and no conflicts on issues that
are before the Committee today.

DR. STEINDEL: steve Steindel, Centers for Disease Control and Prevention,
liaison to the Committee.

MR. BLAIR: Jeff Blair, Medical Records Institute, member of the Committee.
I am not aware of any conflicts.

DR. ROTHSTEIN: Mark Rothstein, University of Louisville, School of
Medicine, member of the Committee, no conflicts.

MR. SCANLON: Jim Scanlon, HHS Office of Planning and Evaluation and
Executive Staff Director for the full Committee.

MS. BEDFORD: Carol Bedford, American Nurses Association.

DR. FRIEDMAN: Dan Friedman, Population and Public Health Information
Services and to quote John Lumpkin I have a teenage daughter. So, I have many


MR. WEINZIMMER: I am Rob Weinzimmer with the National Center for Health
Statistics. I am Acting Executive Secretary of the NCVHS Board of Scientific
Counsellors and just to mention that our board has a new liaison with your
group. Her name is Irma Ello. She is a new member of our board and she
apologizes for not being able to be here today. She wants very much to be at
future meetings.

MS. FRANKLIN: Angela Franklin, Blue Cross Blue Shield Association.

DR. HORLICK: Gail Horlick, Centers for Diseases Control and Prevention,
staff to the Subcommittee on Privacy and Confidentiality.

MS. JACKSON: Debbie Jackson, National Center for Health Statistics, CDC
Committee staff.

MS. JENKINS: Wanda Covan Jenkins, NCHS, CDC.

MS. FRIEDMAN: Maria Friedman, Centers for Medicare and Medicaid Services
and lead staff to the Subcommittee on Standards and Security.

MS. BURWELL: Audrey Burwell, Office of Minority Health, lead staff to
Populations Subcommittee.

DR. HUFF: Good morning, I am John Huff from CDC, NCHS.

DR. COHN: Good morning, everyone, and obviously w are pleased to hear that
we will have a new liaison from the Board of Scientific Counsellors.

Now, let us talk about the agenda for minute. We are going to be moving
things around just a little bit based on people’s departure times and such.

Currently the agenda talks about the first item being a general briefing
from Dan Friedman. Instead, what we are going to do is after we talk about the
agenda, we are going to move to the action items and we will have as we will
discuss in just a minute two action items that we will be taking up and then we
will turn this over to Dan Friedman who is I think as you know a former member
of the NCVHS and former Chair of the work group on health statistics for the
21st century. He is now a private consultant and a consultant to NCHS and has
been looking at national health information infrastructures and electronic
health records in other countries and obviously how they potentially contribute
to health statistics.

As you will remember he began a conversation with us back in June and this
is part two of that conversation. I think we all found it interesting and we
all recognized we didn’t have enough time to really go through all of the
information he had. So, this is a sort of a review of where we were as well as
a follow on, and we are very appreciative of having him here to join us.

After that we will probably take a short break and then go into general
subcommittee and work group reports to be followed by I think as we have been
doing recently a general discussion of Committee functioning and next steps.

I presume we will be adjourning certainly in the early afternoon and not
taking a whole lunch break we will take a very short 15-minute break which will
happen after Dan Friedman’s presentation.

So, having said all that we actually have two action items. The first one
is a letter that we discussed yesterday coming from the Subcommittee on
Standards and Security. You all have copies of it in front of you. We will ask
Harry Reynolds to sort of lead the Committee through the letter and the changes
based on our input and then we will consider it as an action item.

After that I will bring up an action item mostly around process for the
National Health Information Infrastructure Work Group and we will discuss that
after we are done with the letter, but hopefully it will be something that is
agreeable to the Committee members.


MR. REYNOLDS: Okay, we don’t make any changes until paragraph 4. Do you
want me to start there or do you want me to start from the whole letter again?

DR. COHN: You can start from paragraph 4.

MR. REYNOLDS; All right, starting with paragraph 4, NCVHS supports the
proposed standards for the electronic transmission of attachment information
for six types of claims attachments as set forth in the NPRM. We recommend
flexibility for adopting new claims attachments transmission and messaging
standards and additional types of attachments. In particular the NCVHS
recommends the development of a streamlined process for adding new standards
and attachment types and for modifying existing standards.

The Committee urges the Department to investigate other ways that adoptions
of new standards could be accomplished without the need for the lengthy and
cumbersome rule-making process.

On our part we will continue to investigate improvements to the standards

Any comments or changes?

DR. STEINWACHS: The sentence before last, the adoption of new standards or
new versions. I thought I heard you say, “New versions.” The
Committee urges the Department to investigate other ways that adoption of new
versions. Marjorie?

MS. GREENBERG: You got the answer?

DR. STEINWACHS: I thought I heard “standards,” and I thought
maybe I had the wrong version of the letter.

MR. REYNOLDS; No. I did say versions.

MS. GREENBERG: I remember there was some concern yesterday that the way it
is stated might indicate that the Committee actually had reviewed and supported
all the technical aspects of these standards but I know that last part was
deleted but then there was some concern that that might still imply that, you
know, all the details but I guess you decided that wasn’t a concern.

MR. REYNOLDS: We discussed this at length and felt that this is where we
stand. We are not making any further comment.

MS. GREENBERG: Because you are really supporting the standards for the
electronic transmission.

MR. REYNOLDS: That is correct.

MS. GREENBERG: Which doesn’t necessarily mean —

MR. REYNOLDS: The technical detail, that is correct and the six types that
they selected.

Okay, the next paragraph. We were interested to see that the development of
the NPRM was informed by a pilot project with Empire Medicare Services which
focused on the human decision variant for sending text or converting data to

We believe pilot testing is critical for both the human decision variant
and the computer decision variant in which data can be used in automated
fashion and read and understood by the computer. As clearinghouses and vendors
may not have experience with the loin(?) code sets we believe that pilots
should include testing of the full range of loin codes required by the clinical
and laboratory attachments along with any other untested claims attachment

NCVHS therefore recommends that pilot projects should be funded and
conducted using both the computer and human variants for the full suite of
claims attachments and attachment types that are proposed for adoption as NPRM
as well as the other attachments that are under development including home
health, durable medical equipment, periodontal services, and children’s
preventive health services.

The Committee recommends that the Department partner with private industry
in additional pilot projects in the area of claims attachments. Where it said,
“Pilot tests” in the last one to keep it consistent it is pilot

Any comments?

DR. HOUSTON: I would propose that in that sentence it was changed. Rather
than partner with industry in additional pilot tests to simply say,
“Partner with private industry to conduct additional pilot tests.”

MR. REYNOLDS: Agreement from the Committee? Okay

The last paragraph, finally the NCVHS recommends that the Department extend
the comment period on this NPRM for up to 90 days to allow the industry to take
the necessary time to comment on the business and technical implementation
issues associated with the standards proposed in this NPRM.

MR. BLAIR: I move that this letter, this recommendation letter be approved.


DR. COHN: Discussion?

So, we have had enough already.

All in favor?

(There was a chorus of ayes.)

DR. COHN: Opposed?

(No response.)

DR. COHN: Abstentions?

(No response.)

DR. COHN: Okay, it passes.

DR. REYNOLDS: The Subcommittee thanks you.

DR. COHN: Thank you very much.

The second action item has to do with process and I want to review with you
a proposed process and deliverable coming from the NHII Work Group and ask your
permission for this to move forward.

I think as you all know, we passed a personal health record letter and set
of recommendations in September. Since that time there has been work under way
by the lead staff and others to turn it from a letter into something that is a
more attractive, visually attractive and accessible actual report that now will
include an executive summary as well as a body of text and some graphics and
other things like this, in other words that we did work to develop the national
health information infrastructure report and one of the things I have learned
over the years is that I think it is valuable to make these things as
accessible to the public as possible.

Now, the NHI Work Group reviewed, I mean saw for the first time and began
to review this draft. Obviously the intent of the effort is to make sure that
A, the recommendations are unchanged as well as the intent of the document and
the substance of it are unchanged.

The NHI Work Group is recommending to the Committee that given that that is
the intent here and that there are going to be no new recommendations there
should be no new nuances to the report itself that the NHI Work Group will
review the draft over the next 2 weeks, provide revisions and comments back to
the staff who will prepare a document that then would go to the Executive
Subcommittee and that we would ask your approval to have the Executive
Subcommittee assuming that they agree that there are no changes in content
here, that they would approve it and allow it to be printed.

Obviously the view here would be if there were any content changes we would
defer that action and bring it back to the full Committee for action in

Now, this is obviously not necessarily the normal process for the document
we produce, but I wanted to review with everyone and I actually would like a
motion that this is okay and also for that matter if there are others of you,
and the NHII Work Group and the Executive Subcommittee, effectively most of the
members will have had a chance to review it, but if there is anyone else who
also wants to review this at the first stage we would obviously be happy to
send it out to you to have you review it also. So, anyway if this is an
acceptable process I would like to have a motion to that effect.



DR. COHN: Further discussion on this?

All in favor?

(There was a chorus of ayes.)

DR. COHN: Opposed?

(No response.)

DR. COHN: Abstentions?

(No response.)

DR. COHN: Thank you. Certainly if anyone who is not on either the NHII Work
Group or the Executive Subcommittee would like to review the document in the
draft form let us know and we will send you a copy as it is marked up right now
for comment.

Thank you. Those were the two action items.

Now, with that why don’t we ask Dan Friedman to come and join us for part
two of the discussion on national health information infrastructure in other
countries and impacts on health statistics.

Agenda Item: Health Statistics and the national health
information infrastructure – Dr. Dan Friedman

DR. FRIEDMAN: Thank you, Simon. When I was 55 I stripped off ties. I
decided that at that point daily conversations between my wife and my two
daughters about which tie went with what was just too much for me, and I am
turning 60 in a couple of days and I have almost entirely stripped off
PowerPoint as well partially because of conversations like the one yesterday
where there was almost as much conversation about the format of PowerPoint as
the content.

First of all, thank you, Simon for the opportunity to return to the
Committee and to continue the discussion that we started in June on the
potential contribution of national health information infrastructures, small
“n,” small “h,” small “i,” small “i” to
health statistics.

The conversation that we had in June and that we will have today relates
directly to several of the things that were discussed yesterday. It certainly
relates absolutely directly to Dr. Huff’s discussion of secondary uses of
clinical data with the difference being that it relates to it much more at a
societal level than at the level of an individual practice, an individual
health care institution or an individual network of institutions.

It relates directly to Mark Wellstein’s discussion of the privacy issues
and particularly the consent issues and in both the last year when I have been
looking at these issues in other countries the nature of consent and the
conceptualization of consent is one of the things that I focused on.

Since my June presentation I finished a draft report and I have sent it out
to roughly two dozen reviewers in five different countries and I received
feedback from roughly eight of those reviewers so far and more will be coming.
It is a lengthy report. It is around 140 pages of text so far and around 60
other assorted pages of references, tables, figures and so forth and conducting
a serious review which these have been is a real commitment and one that I very
much appreciate. Steve Steindel has been one of the reviewers. Many of the
reviews are very long and it has been gratifying to me to see people take it so
seriously .

Today I am going to do four things and I briefly discussed the presentation
with Simon a couple of times and I have urged him to interrupt me at any point
and maybe we can have hand signals or stop, really stop, go faster and repeat,
but what I am going to do is four things. I am going to recap a little bit of
the basics of the project, No. 1. No. 2, I am going to discuss my understanding
of the current situation in Australia and New Zealand as it relates to national
strategies for shared electronic health records and health statistics. Third, I
am going to discuss analytic issues in the relationship between national
strategies for shared electronic health records and health statistics.

I presented some of this material before but hopefully I can present it now
quickly and in a more structured fashion and then fourth, I am going to discuss
possible next steps for the Committee and I am going to mention three possible
next steps if there is an interest on the part of the Committee in continuing
this kind of work.

In terms of the recap as I said in June, this project is an outgrowth of
work several years ago from the NHII Work Group and from the Joint NCVHS-NCHS
Data Council Project on Health Statistics for the 21st Century, a direct
outgrowth and the work was commissioned by NCHS and I very much appreciated an
opportunity to do it.

The overall purpose of the project was to develop a more specific
assessment of the potential contribution of national health information
infrastructures and again especially shared electronic health records to health

Somewhat more specifically purposes include describing the current status
of national strategies for shared electronic health records as they relate to
health statistics in Australia, Canada, England and New Zealand summarizing key
themes that have emerged from interviews with roughly 80 informants in those
four countries, key things as they relate to national strategies for shared
electronic health records and health statistics, summarizing key themes
emerging from interviews with around 30 US informants and then delineating
major issues.

Terminological issues, let me just again briefly deal with those. It is
very essential to realize that the key terms are not self-defining including
the very most basic of terms including shared and sharable electronic health
records and health statistics and even population health.

The Committee’s September 2005 letter report on personal health records, I
am just going to quote two or three sentences here, pointed out that there is
no uniform definition of personal health record in industry or government and
the concept continues to evolve.

It is not possible or even desirable to attempt a unitary definition at
this time. However, the Committee believes that it is possible to characterize
them by their attributes.

Now, this applies equally as well to electronic health records and I would
like your focus here to focus not on the term but on the attributes as I am
using them in this report, and what I have used is a term that has something
resembling a common general meaning across as many of the countries that I
dealt with as possible and one of the reviewers of the report said something
very nicely and very helpfully that they were wondering if this was intended as
a criticism of current US strategies and it is not at all intended as a
criticism. It just happens to be the label that I am using for the attributes
that I am dealing with in this report and the attributes are longitudinal,
hopefully cradle to grave collection of patient centric identifiable data that
is cross provider and cross sector. It is not necessarily the desk-top record
that the clinician deals with or enters data into and it is not necessarily a
single record kept in a single location.

This is derived — yes?

DR. COHN: Could you say that one more time?

DR. FRIEDMAN: Sure, longitudinal, hopefully cradle-to-grave collection of
patient centric identifiable data that is cross provider and hopefully cross
sector,not necessarily the desk-top record and not necessarily data kept in a
single location.

This is a definition that has a lot in common with the National Health
Service definition in their seminal 1998 document on information for health as
well as the ISO Technical Committee 215 definition of integrated care EHRs. It
is not the same definition and the same attributes used in the IOM letter
report. It is not the same definition used in the July 2004, framework for
strategic action. I am sorry to belabor the point but it is important to
realize and it is over there, but there is, I think the mag is called
Government Health IT and in the latest journal there is an article. Yes, why
don’t you hold up the article on semantics and EHRs?

Let me go on. While she is looking for the article there was a very nice
picture of one of the panelists tomorrow in it.

Health statistics. I am defining health statistics as numerical data that
characterize the health of a population and the influences that affect its
health. I tend to use it synonymously with population health monitoring and
research because the latter tends to be used much more in other countries and
population health for the purposes of this report I am defining as the health
outcomes of a group of individuals including the distribution of such outcomes
with the group and the distribution and level of diseases, functional status
and well-being within a group.

It is an interesting article. I don’t particularly agree with all that it
says, but it is an interesting article.

Let me just mention that the final report which as I said, Steve has been
brave enough to read includes seven chapters, some on factors impacting on the
development of NHII, one on nation’s snapshots of the four countries including
locus of national responsibilities for shared EHRs, current status of plans,
EHR definition, NHII elements related to shared EHRs, EHR storage, patient and
provider participation, patient identification and uses for population health
monitoring and research and then I have got a couple of chapters on key themes
and then a chapter on analytic issues.

Australia and New Zealand, Simon, do you want me to spend a few minutes on
Australia and New Zealand?

DR. COHN: Sure, I think that was part of the reason we invited you. We do
want you to remind us a little bit about the other places you reviewed, also.

MS.MC CALL: A quick question. With respect to your working definition of
health statistics would you say that it is in common with the 21st century
vision in terms of how that is being defined or would you say that there is a
material difference?

DR. FRIEDMAN: I think it is the same word for word.

MS.MC CALL: Very good, thank you.

DR. FRIEDMAN: You are welcome. Australia provides really a terrific
illustration of the conceptual bureaucratic and organizational changes in this
area and if I had been reporting on Australia or New Zealand in June instead of
reporting on England and Canada it would have been a very different discussion
because in both countries even in the last 6 months there have been some real
developments and some real changes.

Now, the developments have been conceptual and bureaucratic rather than in
terms of data or information but I mean information about actual relationships
but still there have been major changes.

The locus of national responsibilities for national strategies for shared
EHRs in Australia has been the Health Connect Program Office within the Federal
Department of Health and Aging.

Now, starting in 2002, Health Connect Program Office launched five
different very carefully planned pilots relating to national strategies for
shared EHRs.

One dealt with preoperative hospital assessment. One dealt with chronic
disease management, another with hospital-based children’s health information
network, a fourth in services in remote areas and finally one with adults with
diabetes and their health care providers.

In November 2004, only a year ago the health connect business architecture
was public. I don’t know if any of you have seen that. It is a very detailed
document. It is extremely well written. I found it very clear. Six months later
in July 2005 the health connect web site contained a focus that health connect
will quote, no longer focus on health connect as a technical solution to
address health care reform in Australia, and starting in early 2005 there was,
I think of it as a quasi-governmental organization developed called the
National E-Health Transition Authority that would be taking over many of Health
Connect Program Office’s responsibilities. The board consists of the health
ministers of the federal government and the states and territories and their
charge is to develop a national approach to shared EHRs involving all
governments and involving both primary care.

Now, NEHTA, the National E-Health Transitional Authority has adopted
essentially a marker-driven approach in which NEHTA will take standards, not
make them, supply implementation guidelines, serve as a catalyst and commission
missing pieces that are necessary for implementing a national health electronic
health record strategy, but they are not going to do any implementation. The
initial basic vision laid out a year ago by Health Connect, it is not clear
whether or not just a year later that basic vision remains in place or what
parts of it remain in place.

According to the Health Connect business architecture EHRs would be defined
as a longitudinal collection of health information relating to a single
consumer that is stored within the Health Connect system itself and this would
be build around a series of event summaries.

Now, NEHTA is, part of the work plan is to develop templates for event
summaries. So, that part of it is continuing. However, this was not seen
explicitly under Health Connect. The shared EHR was not seen as replacing
provider’s own clinical records or own clinical information systems.

It is not clear to me what the current working definition of EHRs or shared
EHRs is, again, to me. NEHTA has a glossary. It contains multiple alternative
definitions of EHRs but as far as I can tell and I could certainly be missing
something it doesn’t clearly choose one single working definition.

EHR storage, the Health Connect business architecture included storage in
two locations. There would be national network of interoperable health record
systems that would operate at state, territorial and regional levels and that
national network would together constitute as I understand it an EHR
repository, a federated model that would allow provider and consumer access and
that would essentially be an operational data store. In addition to that there
would be a national data store that would maintain archival copies.

Now, again, it is not clear at this point whether that design is going to
continue. Patient participation and an important part of the Health Connect
pilot was testing out different formulations of consent models. The initial
health connect model, the November 2004 model included that patients must
provide informed consent before their EHR or other personal information can be
collected, accessed, used or disclosed by Health Connect.

It was as far as I could tell a clearly opt in model, purely voluntary and
purely voluntary again it seemed to be at the individual health event level, at
the diagnosis level, at the visit level, at the level of sharing of data with
other providers or with the national data store.

Now, the emphasis with the new national e-health transition authority seems
to have changed and their current statement is that they do not support an
emphasis on consent to the exclusion of other important privacy requirements
and they argue that consent and privacy requirements must be assessed against
specific initiatives or proposals.

DR.COHN: Please repeat that?

DR. FRIEDMAN: I am quoting. NEHTA does not support an emphasis on consent
to the exclusion of other important privacy requirements and argues that
consent and privacy requirements must be assessed against specific initiatives
or proposals, unquote.

Now, I have become a little bit of a kremlinologist and I think what they
are trying to do is essentially disaggregate the consent issue. My
interpretation is that they are trying to essentially disaggregate the consent
issues, move away from an all-encompassing discussion and the original
conception of consent, my understanding was based on several conversations was
very much, was self-consciously an attempt to defuse the possibility of public
opposition to shared electronic health records because of privacy issues.

So, I mean it was my understanding was it was really viewed as a trade off.

Simon, you look —

DR. COHN: I guess everybody can ask questions as we go along. I guess what
I am sort of hearing and correct me if I am wrong, but it sounds like you are
saying for certain use cases or business cases you might have to have full
consent but for others I mean one could imagine public health or public health
reporting or something like that , that wouldn’t be required; is that what you
are, is this sort of a model, I mean that you are suggesting?

DR. FRIEDMAN: I am just hypothesizing. I am not suggesting.

DR. COHN: Is that what you think is going on here?

DR. FRIEDMAN: Yes, I mean I think the original model that I saw seemed to
be very complicated and one of the people who I spoke to in Australia who is an
informatician wrote an article. I think I mentioned it when I was last here.
Enrico Coliera write an article in JAMA on how difficult it would be to
implement the kind of opt in model that Health Connect had put on the table. I
don’t know where the national e-health transition authority is going but they
seem to be moving away from this maximally flexible model.

DR. TANG: The other question I had is you made the statement about how they
opt in in the earlier model and you went on to say you could down to the lab
value decide whether to opt in or opt out. Is that your interpretation of this
statement or do you know for a fact that they intended the opt in to go that

DR. FRIEDMAN: My interpretation from reading that the original business
architecture, it seemed to be very granular, but I think that is no longer in
play. I think and I am sorry I can’t be more definitive. The documents
themselves are often not I mean this is a really good document and I have read
a lot of these things but still it is a little bit like you have got to use
your imagination, frankly, trying to wonder what they mean and now there is
even less there to —

MS.MC CALL: I think this is a good opportunity to understand which I think
is what you are trying to share with us here. So, this kind of all opt in all
the time, they have obviously veered away from that and it would be helpful to
know if they did it primarily for technical reasons or if they did it primarily
for public health reasons or if there were some other reasons that they did it
primarily for. What obstacle were they seeing out there that they were trying
to get around? Obviously they haven’t actually implemented anything, but I
think that just helps in how we think about it.

DR. FRIEDMAN: In all honesty I don’t know. My guess is it was probably
largely technical. That is my guess. Patient identification, there is presently
no national Health Connect patient identifier in Australia. There is a national
health insurance identifier. National identifiers in Australia has been a
sensitive issue flowing from the 1980s discussion around national ID cards,
something called the Australia card.

Having said this, the national e-health transition authority has said that
they consider an individual health care identifier as an essential building
block to shared electronic health records and that they believe an architecture
will require retention and maintenance of a core set of personal data.

MS.MC CALL: Read the sentence again.

DR. FRIEDMAN: The national e-health transition authority has essentially
said t hat they regard a national health identifier as an essential building
block and they also have said that they think that the architecture will
require the retention of core personal data about every person who uses
Australian health care services and at the current time what they are thinking
of doing is building off of the national health insurance identifier.

DR. HOUSTON: With regard to the core data, so regardless of whether
somebody decides to opt in, opt out, whatever in this environment, regardless
if they are a consumer of health services they are going to, some core data is
going to end up in the system is what you are saying, regardless or is that an

DR. FRIEDMAN: At this point based upon published material that is an
overstatement. It may not be an overstatement in 2 weeks or in a month or 6

DR. HOUSTON: Then I misinterpreted what you said. What is the —

DR. FRIEDMAN: Just to give you some sense of what is available on the one
hand you have got and this is not uncommon, you know in different places. You
have got a business architecture that is 100 or 200 pages long that seems to be
obsolescent a year after it was published and you have got two or three
paragraph squibs on a web site describing ongoing projects and right now there
isn’t much in between. So, one can make the statements but you can’t go too far

DR. HOUSTON: What you said was that there were some data elements
regardless that were going to end up in it.

DR. FRIEDMAN: What they have said is they envision that core data elements
will be necessary on every individual using Australian health care but there is
no definition publicly of what those —

DR. HOUSTON: It sounds like somebody could opt out of having their
information accessible through this.

DR. FRIEDMAN: At this point the new architecture, I mean I know this is a
frustrating conversation. Believe me it is frustrating for me, too, but at this
point the new architecture just doesn’t say because there isn’t a blessed new

DR. WARREN: To follow up on that when you were talking about this core data
that is retained you said the words “of everyone seen in the Australian
health care systems.” Does that include tourists who are seen for health

DR. FRIEDMAN: Again, all I can say and I know this is frustrating, all I
can do is report what is said and that was this is what was said. What that
means and how it plays out I don’t know and I don’t want to misinterpret it.

DR. COHN; Okay, Dan, thank you. I think we have a question from Jeff and
Kevin and then we will move on.

MR. BLAIR: I don’t know whether you want to save your response to this
question to later on in what you want to present to us or not but it sounds
like the information that you have gathered is not static. It is dynamic. These
are changing and they are changing for different reasons. So, I guess maybe
what I am looking for is less the specific things that they have agreed or not
agreed to in Australia right now but what are the lessons that we could learn
by the evolution they are going through?

DR. COHN: Jeff, your comments are very helpful. Kevin?

DR. VIGILANTE: I lived in Australia about a year and one-half ago and had
similar frustrating experience trying to do it from my living room. Of course,
one of the ways to gauge what people are doing or trying to do in terms of
function and vision and size is how much money they are putting into it and a
number I kept coming up for Health Connect for various sources is $128 million
which seemed really, really, really small to do anything of substance.

Are there new numbers out there for budgetary numbers against what their
vision might be that you stumbled across?

DR. FRIEDMAN: Not as far as I know. I thought it was a little bit more than
that but I don’t think it was a huge amount more than that. There was also a
very good report that came out about that same time from the Boston Consulting
Group basically criticizing the under investment.

Let me finish up. Let me move on.

DR. COHN: Marjorie just had a comment.

MS. GREENBERG: That is all right. I won’t make it.

DR. FRIEDMAN: Let me move from Australia to New Zealand.

DR. COHN: You might want to refer to what Jeff just asked you though now
that we are done with the questions. I mean is there anything here that you
think is lessons learned or is this more —

DR. FRIEDMAN: Absolutely and in some ways one take on the lessons learned
was reflected in the Australians for Health and Welfare, Australia’s Health
2004 which is the equivalent of Health US and in there there was a very
interesting paragraph and this is a government agency reflecting on the limits
of Health Connect for population health research and monitoring and they
pointed to three, one, voluntary participation; two, the nature of the health
event summaries and three, the lack of harmonized standards for clinical and
population health data and I heard this repeated in a variety of conversations
that I had with pretty senior people in my line of work in Australia where
basically they were saying voluntary participation will be a perhaps
insurmountable limit and I will come back to this later. Second, what is in
those health event summaries could be an insurmountable barrier and third, not
having harmonized standards.

MR. BLAIR: May I ask a question about that? Dan, would you characterize
those issues as issues which quote, derail the public commitment to the
e-health connect in that country?

DR. FRIEDMAN: No. I think there is still a commitment. I think there is a
very real commitment, but my impression is that how — but I think the nature,
the conception of what that commitment should consist of has changed because I
think that the Health Connect was doing implementation, albeit indirectly of
pilots. I think they wanted to get out of that business and move away from any
hint of actually taking responsibility for implementation, I think, but again
this is a little bit like reading tea leaves.

In terms of health statistics to the extent that health statistics were
seen as related to the shared electronic health record strategy it was going to
derive from the national data store which would apparently have contained both
identified and de-identified data but data would have been voluntarily
submitted to it. It is ont clear at this point whether that national data store
is still part of the strategy.

Let me just spend a very few minutes on New Zealand because I realize this
is taking a lot of time and New Zealand represents an interesting contrast
certainly to England that we discussed last time. The basic vision, in terms of
thinking about New Zealand one thing that is important to recognize it is a
very wired country. A couple of years ago an international survey indicated
that 70 percent of the population, adult population has used the Internet in
the last month and that was a couple of years ago. A 2005 survey from the New
Zealand College of General Practitioners indicated that almost 100 percent of
GPs used electronic patient management software. Ministry of Health estimates
that 100 percent of hospitals use electronic patient records.

The scale is totally different and the nature of the government is totally
different. It is a nation state and it is a completely different governmental
organization. Having said that I think there are some very interesting things
that are worth thinking about. The most recent iteration of the national
strategy in New Zealand has been in an August 2005 New Zealand health
information strategy and consistently over the last 10 years the New Zealand
Ministry of Health approach has been very light handed towards the idea of
developing a national strategy for shared EHRs and they have adopted what they
view as very self-consciously an incremental approach and I am going to read a
quote from somebody from the Ministry of Health. Quote, we cannot afford to
make large mistakes. So, let us make lots of small ones instead, and they talk
about building blocks, getting the basics right and there is also a very
integrative approach even from just reading the documents. They start with the
population health strategy. From that there is a health systems strategy
derived and then from that there is a health information technology strategy

The key documents around population health and the planning documents from
the Ministry of Health include mixed in priorities for population health, for
health systems and for health information technology. So, these things tend to
be viewed as really integrally connected in a way that is not always true in
other countries.

Yesterday one of you referred to the quote, Holy Grail of EHRs and in New
Zealand that term is used and it is used very disparagingly and the August 2005
report explicitly rejects, quote, the Holy Grail and the Holy Grail interpreted
by them as an EHR that holds all medical information about a patient is
contributed by every clinician involved in the patient care and is deployed for
every patient. That is explicitly rejected and instead what they are
emphasizing is the collection and use and retention of patient information,
quote, of what they call the coal face of patient care, coal as in c-o-a-l,
basically. I think what they are referring to is where the work is done in the
mine and where the work is done in the mine is in caring for individual
patients. That is the emphasis in the national strategy for EHRs and they have
explicitly; this is a quote from this August document, discounted a single
national repository for all of an individual’s identifiable health information.

They are thinking in terms of three levels of data storage, first of all
local systems that support the delivery of personalized care at the coal face
by service providers. These would be systems that are owned and operated by
individual service providers built for specific purposes and they would
obviously contain the most detail about individual provider interactions.

The second form of data storage would be regional systems that consolidate
specific clinical data at the regional level and New Zealand has I think it is
24 district health boards for their 4 to 5 million people in the population and
typically the regional systems would provide key event summaries that abstract
information from the encounters and then third what they refer to as national
system anchors which are core systems that provide shared data and consistent
processes throughout the health and disability sector and those would be owned
and operated by the Ministry of Health.

It includes the National Health Index which is the health identifier and a
national medical warning system that also includes information about

DR. VIGILANTE: A key event summary, that is something that somebody writes
and puts in there or is that abstracted from data and just mechanically sorted
in some way? Any insight as to what those words mean?

DR. FRIEDMAN: I think it is essentially an abstract of an encounter report.
Certainly in Australia they are deriving templates for different types of event
summaries, hospital discharges, etc.

DR. VIGILANTE: So, it is not something that somebody writes after the
doctor has seen somebody or an abstract or it is —

DR. FRIEDMAN: I believe you are correct but again it doesn’t have a single
self-defining meaning. So, for example, in the Australian context they
acknowledge the possibility of the shared electronic health record being
essential and not derived from auto extracts of desk-top medical, of electronic
patient records.

MS. MC CALL: I have first and observation and then really more a question
to Simon and to Jim. The observation is that they have obviously done a lot of
thinking around the concepts, what things are and more importantly or as
importantly what they are not. It is not a one size fits all. They reject the
silver bullet, what I call the silver bullet, what they call the Holy Grail,
but they have also done a lot of thinking about where certain activities need
to take place, local, regional, national and have also thought about the
governance structure for that and I think all of that is really, really
important and so I guess then my question for us and specifically to you and I
don’t know if you have the answer, in the work being done by AHEC in
certification are we anticipating, are we contemplating different types of
clinical systems, No 1? No. 2, is have we started to conceptualize what happens
at different levels and the governance of those? Is that part of AHEC? Is that
part of ONSHIP(?)?

DR. COHN: There are contracts that the Office of the National Coordinator
has let to deal with, they are starting formation system certification which is
going to be in draft form I believe in January and I was actually thinking
about asking the CCHIT to come and brief us in February. I think you are
potentially a little more sophisticated than where they are now meaning that
they are just starting and I think if you remember what David said yesterday
they are looking at very much the functionality to ensure potential
interoperability as opposed to slicing and dicing quite to the level I think
you had gotten and maybe I will ask Dan a question because I think that this is
a key question as to what you are asking us which is how is payment and
services organized in New Zealand.

MS. MC CALL: That wasn’t the question that I was —

DR. COHN: I know but that is what I am asking because I think that may
impact. Is it a National Health System?

MS. MC CALL: Yes. It is a public-private, but it has got a public base and
a private layer that is voluntary.

DR. COHN: Like the UK.


DR. COHN: Okay, because when I hear these things and I hear our thoughts
and all I do realize that there is always this relationship between —

MS. MC CALL: Absolutely, how you pay for a thing.

DR. COHN: Yes, exactly and I know that wasn’t your question but it becomes
part of the answer, I think, too.

MS. MC CALL: It does,and these concepts, again there is really no need for
us to reinvent the wheel if these concepts and findings can in fact find their
way to this work that is getting, you know the boat is pulling away from the
dock now and there is no reason why they can’t be carrying on board the cargo,
the findings that are here and they may be relevant. They may not, but they
could be considered. So, that could be an important link.

MR. SCANLON: Just quickly I think the US strategy, and it is evolving I
think you see, but it is primarily a, the US doesn’t have a national health
system in the sense that the government runs it. We have some programs like
Medicare and others but it is not a VA or a DOD for everyone and I think the
strategy you see emerging in the US is a strategy that tries to create some
market, tries to use the market for health IT and for health care and tries to
rely on that mechanism largely but with the national leadership level in terms
of standards, privacy protection research and convening and to some extent it
is not a top-down approach. It is going to be getting everybody to move ahead.

It certainly hasn’t gotten to the point where there is a, there are
concepts but it is not a governance issue just yet or even what exactly the
electronic health record would be. I think it is a focus more at this point on
functionality, what it could bring in its many manifestations.

So, doing this in Central European nationally or federally run health
systems is not necessarily, I mean you learn things from those but it is not
what we have in the US and I think that is what we have to be careful of, what
will work in the system we do have and I think that is much more complicated.

DR. COHN: And there certainly is lots of burning stuff.

Jeff and then we will get back to what Dan is talking about.

MR. BLAIR; Dan, could you help with a little bit of a level set here? I am
trying to make sure that I am interpreting correctly the fact that they have
rejected the quote, EHR as a Holy Grail. The EHR systems or what they call an
EHR system in New Zealand, my understanding is that that system has been
installed over the last 10 to 15 years and that a lot of the architecture for
that and the information base on that was what we considered to be, I don’t
know how to say this. A lot of the things that we want to accomplish with
electronic health records in terms of clinical decision support and outcomes
management and being able to transition to pay for performance and all of the
other really powerful transformative capabilities that an EHR would enable, my
understanding is that what they have implemented in New Zealand does not have
transformative capability. It is automating processes rather than transforming.
Is my understanding correct because if so then that may have caused them to
become disenchanted or disappointed with what they could achieve by just
automating. Am I on track or is that not the case?

DR. FRIEDMAN: Yes and no. I think you are largely on track, Jeff, in terms
of my understanding of what has occurred. I think that this 100 percent
penetration of patient management software doesn’t necessarily translate into
100 percent electronic patient records or into interoperable electronic patient

Having said that there are definitely some, again, my understanding is
there are some applications that are used there that are viewed, some of the
work of Enigma Publishing, Martin Entwhistle, which is decision support,
particularly around CVD and I think diabetes where it is really viewed as
decision support as well as collection of data that can be used for population
health monitoring in a transparent way to the individual provider. So, yes, I
mean I think yes, you are on track but I think there is also a real lesson
there in the sense of you know you can have a lot of, you can have really good
pipes and automated a lot of electronic data and it doesn’t necessarily
translate into the kind of payoff for the kind of narrow provincial interests
that I have in terms of population health monitoring and control.

Let me finish up in New Zealand and then discuss some analytic issues and
some next steps and there are a few things I want to say about New Zealand, one
of which is that the national system anchors, the national collection also
includes individual data collection streams and individual data collections,
mortality, inpatient discharges, cancer registry, etc.

At the present time my understanding is that these are not necessarily auto
extracted. You know they may be from some systems. They are not from others. It
is a set of individual data collections and New Zealand is going to be
continuing with those individual national data collections. There does not seem
to be an explicit strategy for moving from the desk-top record to automating
those collections. Patient and provider consent, in New Zealand de-identified
data can be used without individual consent, with normal approvals. There is a
National Health Index number that New Zealand has invested heavily in cleaning
up, invested heavily in de-duplicating. That also includes a set of core
personal data.

Let me move on to analytic issues and some of these I discussed last time
and I am looking at Simon here. I can sort of repeat and do it in a very
structured fashion and if I repeat what I am going to discuss it is numerator
and denominator issues. I am going to discuss over arching issues and then I am
going to discuss what I am calling, quote, success factors and if you want me
to do that I will do it and I am going to do it partially by reading it

As I said, health statistics we are defining as numerical data that
characterize the health of the population and influences on the health. In
order to do that we need three things. We need numerator data about a health
event, condition, disease, well-being, functional health status and so forth.
You also need denominator data describing the population in terms of its
numbers and basic characteristics and third, we need a basic match between the
numerator and the denominator with a known denominator typically defined at a
geographic level that either is the total population or representative of the
total population in known and quantifiable ways and in terms of the potential
contribution of shared electronic health records to health statistics this, the
most important concept is really the need for both the numerator and the known
denominator data.

As I said I loosely divided the issues into numerator and denominator
issues and over arching issues and I have defined I think it is seven numerator
and denominator issues.

The first is penetration of shared electronic health records. In order to
generate usable numerator data shared electronic health records must either
penetrate an entire geographically based population or a truly random subset of
that population with known characteristics or a non-random subset of that
population with known characteristics. If the shared electronic health records
have not penetrated an entirely geographically based population then that
subset of the population with shared electronic health records must be linked
with a known population denominator with known characteristics and so we need
both numerator data and denominator data.

Data quality is a second numerator and denominator issue and if shared
electronic health records are to generate numerator and denominator data then
those data have to match the same criteria for data quality as our currently
met by our current data collections and that includes the kinds of data quality
checks, the kind of field checks, the kind of field out of range checks, the
kind of consistency checks, etc., that are now used for such data sets as
births, cancer registries, hospital discharges as well as the same kind of
follow-up that now occurs both electronically as well as via telephone, e-mail,

A third numerator and denominator issue is obviously data completeness and
again, the numerator and denominator generated from shared EHRs have to meet
the same criteria for completeness as current data population health data
collections and the standards of both in terms of denominator completeness as
well as in terms of numerator completeness.

Yesterday Dr. Huff talked about maximizing data quality and completeness
and I am not going to repeat that unless people really want me to which I

Patient consent for the entry of data into shared electronic health
records, this is really one of probably the most basic issues and if there is
patient consent then it is going to affect the quality and the completeness of
both numerator and denominator data and there is no getting away from that. I
mean it is not that it is, I don’t know if it is a show stopper but it really
has to be recognized and dealt with.

Now, patient control, patient consent I think can be partially surmountable
if it is only over identifiable data and if de-identified data include
techniques for tracking unique patients such as encrypted IDs. Having said that
one of the things that there seems to be an assumption in some discussions that
public health and population health even for health statistics purposes only
use de-identified data, it is not true. Identified data are regularly used and
are used for very important purposes and they are regularly used in birth
certificate studies and regularly used in the cancer registries. Some of it is
because we don’t have health IDs and so they are used for linkage purposes but
some of it is also because there is a need for many studies with follow back,
with patient follow back and patient follow back obviously you need to be able
to contact the patient and you need to be able to contact the mother and you
need to be able to contact the father and you can’t do that with the identified
data. Unique personal identification, clearly some form of unique personal
identification is necessary because it enables a patient centric view of
population health, a person centric view and it also enables linkage over time
of data from cradle to grave and it also enables linkage across data sets and
how that patient identification occurs, I mean it can occur through a master
patient index. It can occur through a set of authenticating information or it
can occur through a unique health ID.

Finally, a seventh numerator-denominator issue is the need for known
denominator characteristics which can be derived if there is total population
coverage from shared EHRs, it could be derived matching population
characteristics via census. It could be derived from some form of a sample.

Over arching issues, I have identified five, several of which Dr. Huff
referred to yesterday. The first over arching issue is the population health is
obviously not equivalent to health care. So, there are inherent limits in what
share EHRs can produce in terms of population health monitoring and research.

That has both true of what is health as opposed to what is health care. It
is also true in terms of the kind of data that we collect such as survey data.
Second, structure data obviously EHRs are only going to be useful for health
statistics if they include the same variables and code sets or mapped code sets
to the data that we have now. Analysis is the third over arching issue and it
is really an unknown how EHRs, how a national data repository could be used for
analytic purposes. It hasn’t been done. Even in England it remains a real
question and clearly new methodologies will be necessary. Culture changes, you
know, clearly there need to be culture changes by the clinician in terms of
entering data for secondary purposes. It is not their job.

Culture changes by public health and also clearly culture changes by the
population in terms of consent issues, and finally a fifth over arching issue
and one that I really have not defined very well is the market issues and
clearly the market issues around collecting data for secondary purposes and
England and Canada, Australia, all define population health and public health
as a secondary purpose and the ISO defines it as a secondary use. Can we leave
that? Will the market respond to secondary uses and if it is a market strategy
how can secondary uses be built into that strategy?

If you would like I can move spend a few minutes just listing out what I
have called enabling threshold and tipping factors or I can move on to some
ideas where NCVHS might go.

DR. COHN: Give us the tipping factors.

DR. FRIEDMAN: These are really sort of meta level and I understand that.
They are not in any way and again one of the reviewers saw some of this
discussion as recommendations and they are not intended. I mean I tried to
separate out analysis from advocacy which in this area I think can be quite
difficult because there is so much advocacy going on right now. Obviously based
upon four countries and four countries’ experiences with very little
implementation identifying success factors is more, it is in some ways kind of
silly because it is totally speculative. We don’t have an information base. We
don’t have a database at this point and we probably won’t for many years in
terms of what works and what doesn’t work.

Having said that I will proceed. Enabling factors I am defining as factors
that —

DR. COHN: Dan, just to break in, so this is your opinion in other words?

DR. FRIEDMAN: Yes, absolutely. This is purely speculative. Enabling factors
I define as those that increase the likelihood of successful use of shared EHRs
for population health monitoring and research and health system enabling
factors and health information system enabling factors, greater funding of the
health care system by the government, a lower percentage of uninsured
individuals, higher ratio of GPs to specialists, greater central coordination
of the health system and greater control of the health care market by the
government, health information system enabling factors, closer relationship
between the provision of health care information from data sources and the
conduct of population health monitoring and second clinician incentives for
adopting and using shared EHRs especially for secondary purposes.

MS. GREENBERG: Could you repeat the first one?

DR. FRIEDMAN: Health system enabling factors?


DR. FRIEDMAN: Oh, health IT, closer relations, the first one really focuses
on is there a relationship between the provision of data from the health care
system for administrative purposes, for health insurance purposes, etc., and
population health monitoring. It is basically what was being discussed
yesterday in terms of one data collection, many uses and does that occur or

MR. BLAIR: Do we have these in our handout by any chance?


MS. GREENBERG: It will be in the transcript.

MR. BLAIR: Is it possible for us to get a copy?


MR. BLAIR: Of the enabling and the tipping?

DR. FRIEDMAN: Absolutely. Threshold factors, I define threshold factors as
those without which successful use of shared electronic health records for
population health monitoring and research may fail, now very carefully caged
language business threshold factors explicit inclusion of population health
monitoring and research as an integral component of the national strategy for
shared EHRs and the national mission for shared EHRs in terms of goals, plans
and pilot test implementation. System threshold factors, the national strategy
for shared EHRs must include integrated electronic provision of data and
integrated data flows from diverse health care sources for clinical
reimbursement, administrative and population health monitoring purposes, No. 2,
unique patient identification either through patient ID or some other form of
unique and stable identification algorithms. Third, I am going to skip that.
Okay, tipping factors which ultimately maximize the potential for successful
use of shared EHRs for population health monitoring and research, existence of
a single predominant payer, salary-based reimbursement for clinicians and
mandated use of shared EHRs with mandated standards.

Next steps for NCVHS, you know, I don’t know if there is interest on the
part of the Committee, I am obviously no longer a member of the Committee, in
this kind of sort of more meta level analysis. I do think that there are three
kinds of work that would be very helpful to see whether it is on the part of
the Committee or somebody else. One is essentially continuing to name the
problem and drilling down conceptually and analytically and drilling down
realistically and honestly, I mean even classifying and developing a taxonomy
of the kinds of issues that are involved.

Now,the problem that I addressed in the scheme of things, a very small and
very modest project, was one, you know, I tried to name one particular problem.
There are other problems such as the relationship of the desk top electronic
record to generating population health monitoring and research data that were
not addressed and that need to be named, that need to be classified, that need
to be thought through. A second next step I think is trying to develop and this
is obvious, a policy and a business case for maximizing the potential of shared
EHRs for population health monitoring and research and I don’t think that we
should assume, well, that needs to go beyond infectious diseases. It needs to
go beyond syndromic surveillance. It needs to go beyond bioterrorism and I
don’t think that it should assume positive answers and I think it really needs
to try to separate out the advocacy from the analytic elements which again I
think in this area right now given the amount of attention being focused on it
and the amount of money is very difficult to do and may be quite unpopular.

Third, building a research agenda. I see research agenda as including four
different elements, first of all identifying current gaps in research and
pilots and certainly in terms of the research. It is more what exists rather
than what doesn’t exist because there is so little empirical work that has been
done in this area. It is really almost nothing.

Second, ensuring that existing pilots and future pilots include a phased
and thoughtful plan for testing out elements of using shared electronic health
records for population health monitoring and research and personally I think
that is something that would be extremely valuable and it is a little bit like
a health impact assessment. Well, what does this pilot tell us about population
health monitoring research and what would a set of pilots look like that try to
focus on these issues.

Third, as was briefly discussed yesterday stimulating research into public
support for building EHRs and using them for population health monitoring and
control. There is certainly some work that has been done. I think Markell did
some work, and the California Health Care Foundation has done some work
recently that was very interesting, very, very interesting particularly in
terms of educational and racial differences in support but those only go so far
and I think it would be really helpful to build a more complete plan for that
kind of public health public opinion research and then finally you know I think
it is really important to try to learn from the experiences of other countries
in terms of what they are actually doing, what has actually been implemented
which is not always easy to find out, what the debates consist of and the
debates are really interesting and really instructive and what is going on with
implementation on an ongoing basis.

Thank you.


DR. COHN: Hear, hear.


DR. COHN: Dan, we don’t normally clap for people. This was very good. I
mean it is sort of a fascinating set of observations and issues. Of course I am
reminded that I felt that way when I read your health statistics and the 21st
century also though that was a little more upbeat than what you presented here.


DR. COHN: I guess when you peel the onion you peel the onion. I guess I
would ask other people for views and all this stuff. I think that certainly as
I am listening to all this especially having just been through a subcommittee
meeting that started at 5 a.m., Pacific time this morning I am reminded that
there is really actually a lot outside of the United States that might help us
understand better or some of the issues that we have and I think your last
point especially about the issues of monitoring what is happening in other
countries is really a critical issue. I mean in some ways there are other
pilots that we are talking about, knowing that of course there are different
payment systems and everything else but I think there is much to be reminded of
and learned and you are reminding us that this is not static out there that
they,like the United States are searching for sort of the right balance in how
this all is. So, I just want to remind everybody that this really is actually
part of our charge working sort of on that international level to understand
what is happening in other countries with HIP. So, I just wanted to make that
initial comment.

DR. FRIEDMAN: Could I just respond to one comment you made which is I don’t
— it is such a political area. I don’t intend to be discouraging or
discouraging about the prospects but I do think that there are some really
basic questions that have to be addressed in terms of how you move from an
implementation in a practice, in a hospital, in a network, in a part of a state
to the broader issues, the broader societal issues about getting data on
population health and I think it is important to really try to name those
issues and be honest about them.

DR. COHN: Sure, and I didn’t mean this in any way other than sobering but I
thought the previous report was upbeat.

Jeff and then Carol/

MR. BLAIR: Thank you, Dan, a lot to think about. Getting to the Australian
example here we had a country that had apparently worked for many,many years
thoughtfully to try to pull together a comprehensive strategy to come up with
some form of a national health information infrastructure and from what you
were indicating it looked as if they had really done a good job and then you
indicated that 6 to 9 months later it appeared as if the commitment to that
documented strategy was modified. From the way you described it it was like it
was decentralized and the word “transition” was focused on. In other
words, it seemed as if there was a mind set from here is the architecture for
what we are going to create to a change to say, “Here is what our
transition will be.”

So, my question is was this principally who is going to have control; was
it a political and control set of concerns that drove this change or was it
that there was a lack of confidence in the design, the technical design and
clinical design or was it both and if it was both which way does it lead? I am
trying to think in terms of again what lessons can we learn from the transition
that they have gone through.

DR. FRIEDMAN: Jeff, those are terrific questions and I really don’t know
the answers and frankly calling and talking it is really hard to get people to,
especially over the phone to air some of these issues especially as they are
going on.

I think for me one of the things that in particular what has happened in
Australia has reminded me of is the extent to which the architectural solutions
are political solutions as well and they make very basic statements about the
nature of the health system, the nature of governmental control, central
governmental control and the nature of sharing that control both with private
industry in the market as well as with individual governmental units such as
Australian states and territories.

DR. COHN: Thanks for trying to answer that one. I can imagine how difficult
it is to get to the bottom of some of these things.

Carol, you are next.

MS. MC CALL: A couple of areas, first an observation and then maybe an
opportunity, the observation around what may have been framed as sobering, just
the fact that as it rolls out whatever it is that we do in the specifics of
what we do, it will not be everywhere all the time, and it is going to be a
very uneven landscape in terms of what is there and that that fact materially
impacts and for a while severely cripples any sort of population health or
analytics that you want to do because your numerators and denominators are
suffering from different things, among other things. Because of that the
opportunity could be this, that there may be ways to kind of amplify or
expedite maybe going by area; so, it is kind of like this military strategy of
we are going to take an area by storm because otherwise if we just allow
whatever its natural progression is going to be without really trying to course
correct who knows when we will reach a tipping point with respect to some of
the secondary gains and tertiary gains that we think we can have in whatever
the domain and so I think that that is useful to think about the fact that the
reality of it is not flip a switch may lead to some recommendations around the
regional or some things that I think John Hollom could talk to us about. So,
that is opportunity No.1.

No. 2, with respect to analytics, nobody has ever dealt with this kind of
data before, just in terms of its size and scope. It will be highly
dimensioned. Conditional statistical methodologies will break down. They don’t
work necessarily in a very highly dimensioned domain. There are techniques that
are out there and yet they are not anything that are probably used today within
traditional health statistics. So, that both becomes an issue and an
opportunity, one that we are not going to have to deal with for a while because
there is not a lot coming out of these taps, because we are still running
pipes; however, there are areas that are doing work in dealing with both true
high volume, real big data and highly dimensioned data and they work on
different kinds of problems and it could be valuable now to learn what that
type of thing takes so that as architectures roll out you can say, “Look,
there are different ways to approach this,” and so that could be another
interesting thing to call on and I can send this out to the members of the
Committee. There is a model that may be worthwhile to pursue, and the CIA
actually pursued this if people are familiar with Incutel(?). The CIA actually
brought up a venture capital arm and it said, “Look, I need to know how to
do certain things but I don’t have the ability to go hire the people with the
skills and compete with essentially the folks who do pull them in which is
Silicon Valley. So, instead of trying to hire all that talent and learning how
to do those things, I am actually going to throw up a company that invites
people in to solve my problems. The asset that I have is the problems that I
have and allow these people then to commercialize whatever technique they find
wherever they can, not a problem,” and so there may be some interesting
business models again in the public-private partnership that help us really
launch forward to solve some problems that we haven’t even really experienced
yet because we have never had this much data before.

DR. FRIEDMAN: Just in response to one point there, it is interesting to me
that you say that. In Canada the responsible national organization which again
isn’t to implement it but still is kind of a health enfilade which is a crown
corporation, essentially depending how you look at it is either
quasi-government or private and the national e-health transition authority in
Australia is also a private company. It is quasi-governmental, but it is a
private company.

DR. COHN: Carol, maybe to turn this around a little bit only because I am
listening to you I really remind everyone that there is actually a lot of
information out there already. It may not be electronic health record
information but Medicare databases and all other sorts of things and the
question is not what do you do with EHR. It is what you do with the EHR with
everything else sort of all put together which is a very interesting issue.

The other piece of course is that there is also a lot of large
organizations that actually do have experience with electronic health records,
the Veterans Administration and we could certainly ask them to come in and talk
to us about how they deal with research and I suspect Paul even though Paul’s
organization is not quite as big as the VA is beginning to have to consider
that issue of how exactly you approach it.

I know my organization as we roll out electronic health records and so I
think there is, rather than us having to say, “Well, geez, we don’t know
anything and we have to start from scratch,” it is sort of the usual
American way that we really need to look around and identify sort of the bright
spots and sort of the sweet spots out there.

MS. MC CALL: Who is setting the pace and what do they know?

DR. COHN: Yes. So, it is just another way of looking at some of the issues
but I think you do bring up certainly a good issue around all of that. It is
going to be an interesting mixed environment for a while probably. I know that
we have got 8 years left in the President’s 10-year plan but it may extend a
little beyond that. I didn’t mean to try to answer your question here but I get
very engaged with your questions particularly.

Paul Tang?

DR. TANG: Actually that may be a good segue. I want to pick up on the
numerator-denominator question you talked about and I may have mentioned this
last time because you recapitulated a little bit of that numerator-denominator

One of my concerns actually is that we are reaching a tipping point in this
movement towards standardized reporting or pay for performance but I am
concerned about the direction of the measurement.

So, there was this DOQ project, Doctor’s Office Quality and the assumption
was hey, some people are already starting to implement EHRs or clinical
systems. Why don’t we try to get these clinical measures out of these clinical
systems which sounded very exciting until they handed me the claims-based
measures and definition. So, what we ended up doing is extracting claims-based
measures out of our clinical system or let us say it a little bit differently.
We extracted administrative data from our clinical system. Now, what was
alarming about that is the denominator, we have a clinical system. We have met
this in trying to achieve a high accuracy of our problem in Medlist(?). We can
actually reliably using both standards identify denominators.

Well, the claims-based method of identifying the denominator missed 30
percent of our coronary artery disease patients. It missed 25 percent of our
diabetics. Why? Because they had these highly developed ways of sort of trying
to get close to a clinical definition based only on administrative data that
are largely submitted by administrative people extracting charts. So, the
bottom line is that not only did we miss populations we were trying to measure
our performance on but you get different numbers. So, because of the biases,
interestingly the biases that were introduced by the ways that you designed
your administratively determined denominator you actually created a higher
performance than our clinical measures that we do very carefully ourselves.

The reason for that is the bias is you have to have two encountered
diagnoses on your claims for this condition under measure, let us say diabetes.
What happens is you selectively got the people who you are engaged with the
most on both sides.

So, for example, Marma Hinglonny once he measured we are at 97 percent.
That is totally ridiculous. Nobody can do that and we don’t when you consider a
real diabetic population denominator. So, the direction I am concerned about is
we have got this momentum, this tipping point going forward on performance
measures and I am worried that we are measuring the wrong thing. This is a huge
opportunity cost, and we are asking people to implement these symptoms to
measure and reward them based on administrative data, a major thing and so the
implication for NCVHS is it is possible that this is an issue we should take up
and it is health statistics; it is clinical systems; it is the goal that we are
after. Let us make sure that we are not going to measure the wrong goal after
all this.

DR. COHN: Paul, as you mentioned this I think I am glad to hear that you
joined the Work Group on Quality.


DR. COHN: And, Paul, I think we all agree with many of your statements.
Obviously I did not in any way try to explain some of the strategies around pay
for performance except I think there have been decisions made to reward pay for
performance in a more neutral fashion not requiring information technology to
support it and I think that is sort of what you are seeing but I do think it is
a conversation that the Work Group on Quality needs to have in terms of having
the discussion with people engaged in that direction.

Bill, you probably know a lot about this from Medpath(?).

DR. W. SCANLON: I mean I think that there has been a decision made but it
is more at the level of the concept of paying for performance not decisions
made in terms of exactly how we should do it and if we are stuck in a world
where we only can use administrative data there is a question of this may be
not a precise measure of care of diabetics but on a relative basis is it an
adequate measure and I could argue it is not in this case, but in other cases
there may be something that is not a precise measure of a concept that you
would like to be able to capture but it is good on a relative basis for a
pay-for-performance system. It is the kind of issue that needs to be resolved
because to say that you are behind pay for performance from a conceptual level
is no good if it ends up creating averse incentives and inappropriate payments.
We can have a backlash from it just the way we have had backlashes in the past
from ill-conceived ideas.

MS. MC CALL: Just to extend that a little bit farther I think that this
does need to go deeply into the design principles for P for P and there are
lots of different ways it could be handled. Bill actually just articulated at
least one which is if it is not good enough to get you closer then leave it

The other is to say that if it is in because it gets you closer but the
measure itself isn’t what you would really want it to be then why not pay
differentially, for example, to physicians that actually have taken the time to
do it right and say, “Look, I will give you credit because you jumped over
a low bar, but I am going to give the most credit to those physicians who take
the time to do it right,” and design that in so that it actually pulls
EHRs toward, so, you know, that is another idea but it needs to get baked in.

DR. COHN: Well said. Russ, how about if I let you comment?

MR. LOCALIO: Dan, I wanted to thank you again for coming. I just want to
say that I view your comments as encouraging and positive and here is the
reason. I think people’s expectations have to be reasonable and if they are not
reasonable after it goes into putting all of your eggs in a single basket and
to the exclusion of other baskets, for example, I would not like to see Ed
Sondik who is not sitting next to me, I would not like to see his valuable
enterprise disappear because somebody said that we don’t need that anymore. We
need to just press the button and it will all come to pass and so I think I am
just encouraged and I would just want to say that I also think we need to
follow what is going on in other countries even though they are different
because we may learn something.

DR. COHN: Russ, I am always impressed at how we see things differently
often but a very good comment.

Bob Hungate?

MR. HUNGATE: I wanted to pick up and thank Paul for articulating what I
think is the central challenge to the Quality Work Group but I wanted to take
that as a segue into coming back to Dan and asking a question in a little
different direction. The US enjoys the highest level of investment in health
care of any other geography. This has led to a demand for accountability, pay
for performance. The pressures that have evolved in this economy because of
that high cost I think are different than exist in New Zealand, the UK,

Now, maybe I have misjudged what is going on but I think it is different
and so I think the structure of change will be quite different in this economy
because of that fact and I think it affects, that somehow we have to, if we are
to be successful in improving population health measures from the tensions that
exist we have got to get the population health issues linked into the pay for
performance because that is the forcing function that is making it move. At
least that is my perception. You look puzzled.

We had a little discussion at the Population Subcommittee about the
evolving use of registries and it seems to me that that may be one of the core
interface functions between the clinical information which goes into the
registry and the tools which might be used to both assess population health and
guide individual judgments, that it might be the better place to generate
measures for pay for performance and that is a different piece than appears I
think in the other system.

Now, am I missing the boat or is there something there?

DR. FRIEDMAN: My impression and I am not expert is that England’s National
Health Service, I mean there is a lot of physician level measurement that goes
on and it is part of the new GP contract and as a matter of fact there are so
many different physician level measurement systems that it is really confusing
figuring out what each of them is supposed to do. One of the things that has
been interesting to me is that the secondary use service that I discussed in
June and I am sure is still is uppermost on your minds in the National Health
Service it is not clear to what extent those individual physician-level
measurement systems are going to be derived from the secondary use service and
that is the goal and to what extent they are going to be derived from the
electronic patient record, to what extent they are going to be derived from
physicians at the individual practice level culling the electronic patient
record and sending in aggregated data.

That is a long way of saying I think that there are some interesting things
to be learned there as well.

DR. COHN: I would like to finish off to allow people a break. Do you have a

MR. J. SCANLON: Just quickly, again you have to separate the cheer leading
from the reality and this has come up before where we thought we wouldn’t need
public health measures and monitoring systems or surveys because everything
would emerge from an electronic health record. That idea I hope the Committee
will at least understand that that is probably not going to be the case. Many
people don’t even interact with the health system for most of their lives.
There are still public health issues. In fact, surveys and other kinds of
monitoring systems for public health were developed because many people never
interact with the medical care system. So, again, I hope this theme that yes,
we use it for all it is worth to help the public health but the idea that it is
somehow going to replace, not that linking and new kinds of research and public
health measures may not be available but the idea that one will replace the
other and not only have I heard it by our budget folks, I have heard it by
former members of this Committee in fact. I hope everyone has more
sophisticated understanding than that.

DR. FRIEDMAN: May I just respond? In Australia for example, that has been a
real fear and one of the things that the person who was then their senior
governmental person in this area said to me is he had two goals with Health
Connect. This was several months ago and the first was making sure that they
don’t lose, they meaning what they have and the second goal being standards,
standards, standards, harmonizing standards, but there was a real fear and a
concern. I did hear this especially in Australia about people saying,
“Okay, we will take another 100 million away from health statistics. We
are going to have shared EHRs.”

DR. COHN: I think that the reality generally is that almost for anything
when you put these systems in there is a desire to get a return on the
investment and people will try to find it almost everywhere on this one.

Now, I guess I am going to hope that we can take about a 10-minute break
and thank you so much and obviously the Population Subcommittee is going to be
talking about populations and the NHII is one of their issues for next year,
and I think a lot of what you said sort of plays into that.

I know NHII will be having a conference call in January. I think maybe the
question is, I mean I think you said many very important things. I think the
central issue here is clearly at least in my view keeping our eye on the
international environment that you have reminded us about. There is a lot of
value but it is also that I think the realistic appraisal you know what can be
done versus needs augmentation in relationship to public health and how do we
bring everything together recognizing as I commented earlier we have lots of
data streams. I mean it isn’t for lack of data that we live in the United
States on all this stuff and the question is how do we put it together
recognizing the unique importance of each of the streams going forward.

So, I mean we will be calling on you and talking to you as we move forward
on that.

So, do you want to take a 10-minute break at this point and then we will go
in for our last session?

(Thereupon, at 12:05 p.m., a recess was taken for a working lunch until
12:18 p.m., the same day.)


Agenda Item: Committee Discussion – Dr. Cohn

DR. COHN: What we will do first of all is just basically go around and get
reports from the subcommittees and work groups. Then we will begin to talk
about obviously issues around the overall meeting planning and how the meeting
went, what worked well, what didn’t and then finally talk about possible agenda
items for the February meeting.

Agenda Item: Reports from Subcommittees and Work

So, why don’t we get started here. Why don’t we start out with the
Subcommittee on Standards and Security. Jeff or Harry, are you going to —

Agenda Item: Subcommittee on Standards and
Security – Mr. Blair and Mr. Reynolds

MR.REYNOLDS: Yes, I have it. With Jeff’s permission I have it again. We met
yesterday and obviously we thank the full Committee for approving our letter
today. That was a big one we had. We have a December hearing coming up where we
are going to focus on the return on finalizing our hearings on the return on
investment for HIPAA and we are going to hear from Wheaty(?) and possibly some
other testifiers.

We are going to have an update kind of on the whole gamut of e-prescribing.
We are going to hear again from NCPDP and hear about some of the pilot awards
and some of those things and I will say that NCPDP has made significant
progress in taking, you know, we talk about the free enterprise world. They
have really taken as an SDO, they have really taken some of the recommendations
from the group and are turning those into standards probably at a much more
rapid pace than they may have been done previously and that is really helpful
in aligning to the e-prescribing world.

We are going to hear an update on any items related to us from ONC(?) and
it will be right after one of the AHEC meetings and we will hear another
presentation on our continuing road. We have two future areas of interest we
are really focusing on. One you heard Stan cover yesterday on secondary uses of
clinical data and Judy has an assignment for us that she has taken as matching
records to patients. So, we will hear some more on that and then to show our
flexibility one of the things that came up yesterday and in our letter we just
sent was this whole idea of how do we simplify versioning and we will have a
half a day or of our day and one-half, half of it will be focused on having
people come in and present on how that might, what kind of approach that might
be. So, based on our letter that we sent to the Secretary saying that we would
continue to look at that we will have some of those types of presentations as
we go forward.

So, our next deliverables we would assume we would have some kind of an ROI
letter at some point and then we will be focusing on some kind of a letter at
some point for secondary uses of data and matching patient records. So, that
would be our input.

DR. COHN: Would the ROI letter be an action item for February or —

MR. REYNOLDS: We will have to see. That may be what it turns out to be
because we are going to hear our final testimony. We already had kind of
drafted our earlier testimony into four or five areas of situations. So, we
will see if we can’t start drafting something and have it for the summer
meeting to start looking at.

DR. COHN: That sounds great.

Paul, did you have a comment?

DR. TANG: Yes. There is obviously a privacy aspect for both the secondary
use and the matching and thankfully the Chair is also a member of the Privacy

DR. COHN: Actually also the Subcommittee on Standards and Security has
identified their 2006 meeting schedule. That will hopefully be posted on the
web in the near future.

Next one, Subcommittee on Populations, Russ, I think you are going to be —

Agenda Item: Subcommittee on Populations – Mr.

MR. LOCALIO: Don has asked me to report on our work to develop the committee
agenda for the coming year and we have two items that we are pursuing. The
first is the disaster response capacity of local community health systems to
respond to various disasters such as weather-related disasters that we have
experienced recently. It does not appear that data are available to assess the
adequacy of health care capacity to respond to the surge in demand that these
disasters affect. It is not clear that all the involved agencies are using
common metrics when they talk about capacity and it doesn’t appear that this
population capacity to meet these surges in demands are translated into
institutional capacity in communities and regions.

So, the next step is to have a conference call in December and then to
decide on a hearing in February and March on the questions that we might want
to pursue.

The second agenda item is barriers to linkage of health data. There are
some success stories such as NCI and Medicare data linkages. That is the CO(?)
Medicare data sets for example but we want to develop a hearing in the spring
2006 to explore barriers and opportunities for data linkages that could
strengthen the measurement of the following types of items: Socioeconomic
status or socioeconomic position at the individual level. That could include
income, as well as education and neighborhood SES. So, it is SES at two levels,
individual and neighborhood levels, measures of disability and then measures of
utilization and cost and again our next steps in this conference call in
December we are going to discuss specific questions to be addressed and ask how
data linkages might help evaluate health outcomes of persons not only overall
but persons affected by particular disasters.

Any questions?

DR. COHN: Firstly, Don isn’t here for us to sort of comment and discuss
with him. I think he had to teach as I understand. I was actually very
interested in some of the comments that Dan Friedman was making and I am
actually wondering and I don’t know whether this is an additional area of
investigation or discussion by the Population Subcommittee but certainly the
sort of basic issue relating to the fact that you know what electronic health
records and the NHI can do versus what it doesn’t do with population health is
I think a, I mean from my view it is probably not a 5-year project but may be a
relatively constrained issue that may be worthy of some sort of communication
to the Secretary.

Now, as I say that it may be more than I think it is but it might be
something that you all might want to talk about and see if indeed that is an
issue that might be of some value.

MR. LOCALIO: This was discussed this morning.

MS. GREENBERG: In the joint meeting and it is somewhat more in the purview
I think of the Quality Work Group but they are working together on it.

DR. COHN: Okay. I guess I am jumping the gun here.

Agenda Item:Workgroup on Quality – Mr. Hungate

MS. MC CALL: Actually I think it was discussed this morning. There are
elements that are going to be the purview of probably more in the line of
quality. There will be other elements that are clearly within populations and
we referenced and I will mention it again for everyone here, we made a lot of
reference to a frame or a model that is actually figure 2 in the 21st century
vision. So, you an go back and refer to it and it does a wonderful job of
laying out a model that helps you see that there are certain things that will
obviously come from an EHR or that type of individual rolled up environment and
then there will be things from a population health standpoint that cannot or
most likely will not ever come from an EHR and I think that is what Jim Scanlon
was talking about a little bit earlier and some of those types of things have
to do with, and they are very well framed in this document, the 21st century
document and some of them had to do with race, ethnicity, socioeconomic status.
There are some things also related to the topic of kind of disaster issues and
they have to do with the system itself and its capacity and can you articulate
what you have and how much you have of a thing with respect to health services.
There are a number of other dimensions in there as well and so I think that
part of it has been written and it may need to be taken to the next step to
essentially extend that concept that was really well laid out in the 21st
century vision and say now that we know more about the EHR it may be time to
begin to articulate what it will do and what it won’t do and where it
contributes and also where that contribution stops because otherwise I think we
tend to think of it as the Holy Grail, a term used this morning and we will
forget that there are some other things that must be done.

So, that was essentially the nature of the discussion and some things will
need to remain within population.

DR. COHN: Thank you. As you were talking I felt we shifted to the other
report. Mark, I apologize.

MR. HUNGATE: This is a privacy yield to the quality for the moment.
Friday’s hearing is really set up to try to help focus this discussion and
topic. The morning is set up with Dan Friedman there as a reactor to the panel
which includes John Lumpkin.

MS. GREENBERG: Just to prove that members of the Committee never really

MR. HUNGATE: You should know that these things are ongoing and David
Lansky, David Kitty from Academy of American Family Practice and I can’t
remember the name of the person —

MS. GREENBERG: Dr. Velagra.

MR. HUNGATE: — that I think you identified originally or Gail Horlich.

MS. GREENBERG: I think Gail Horlich identified.

MR. HUNGATE: And I thank you all for that assistance but the point there is
as we think about quality think about it in both the population and individual
sense and think about the limitations that occur in various places.

So, I think we have got the right body of content for discussion there to
start from that point because the afternoon then has EHR people including Stan
Huff picking up on his secondary uses description here which is perfectly timed
for our agenda and we thank Stan and his insecurity for your good judgment in
content selection and anticipation and timing. It is incredible. I tell you it
is just perfect.

MS. GREENBERG: And for joining the Quality Work Group

DR. HINGSON: We appreciate it. We will take all the help we can get and the
vice president for R&D from Seamons(?) is going to join that discussion and
the chief medical officer from the VA and so I think we have got enough
perspectives here that we can probably do a reasonable job of maybe thinking
about a letter that gets in that direction but it may be premature to expect
that until after we see what we end up with in the session.

I want to note because somehow I have been negligent in getting Carol
McCall’s name listed and Mr. Hungate and Ms McCall as Co-Chairs of the Quality
Work Group. I want to make sure everybody understands that we are in fact
operating as Co-Chairs.

DR. COHN: She is actually the Vice Chair.

MR. HUNGATE: Is it important that it be Vice Chair as opposed to Co-Chair?

MS. MC CALL: In the event you are not able to fulfill your duties as first
runner up, you know.

MR. HUNGATE: This afternoon we are meeting to talk about the rest of the
work plan for the next year. In other words tomorrow is pretty well set for
what we are going to do but what we are going to do after that is still subject
to a great deal of discussion. We are I think in a heavy learning mode about a
lot of things that we wish we knew more about. We have a highly articulate and
not always fully agreeing group and so getting a pattern that works well for us
synergistically is still a little bit of a challenge but we have allowed 3
hours of afternoon discussion. Stan is again going to join us which we
appreciate and we would welcome anyone else who can stand more time in this
room to talk about this.

The secondary uses of information is critical to the quality agenda and
meshing that effectively with the standards and security work, getting it
appropriately followed on this agenda with the full Committee I think is part
of our challenge in managing this content from the quality standpoint and so we
are going to try to link back and forth as well as we can and try to be as open
in inviting others to participate and everybody should understand that is the
mode in which we are operating.

MS. MC CALL: I think to extend that idea the links between the various
subcommittees and work efforts you had mentioned at the opening of yesterday’s
session that t here may be an opportunity for some strategic planning. This
could be one of those places where if we specifically called out those
important topics that essentially crossed some of the work streams for
different reasons, for example, standards will have, there is a huge impact on
harmonizing of taxonomies and quality in the work group and what the ultimate
goal is and so if there were a recognition of those topics and how they cross
and then if the agendas that we set out for hearings and all of that were made
to essentially synergize as opposed to either duplicate or miss an opportunity
that I think would be valuable to find some of those overlaps so that is just
for future reference.

DR. COHN: A very good comment. I guess a point well taken also.

Comments or questions? It looks like you are going to have quite an
exciting set of hearings, I guess this afternoon a meeting and then tomorrow.

MR. HUNGATE: This afternoon just a meeting of the work group and tomorrow
is the hearing.

DR. COHN: Great. We will look forward to hearing what the outcomes of those
conversations are.

MR. HUNGATE; We look forward to providing them.

Now, Mark, I think you are on next.

Agenda Item: Subcommittee on Privacy &
Confidentiality – Mr.Rothstein

DR. ROTHSTEIN: The Subcommittee on Privacy and Confidentiality met this
morning and decided to go full speed ahead with our research on the issue of
privacy and confidentiality of the NHIN and in particular we are going to focus
our efforts on the issue of patient control of health records and our goal is
to be able to reach some closure on this topic by the February meeting. We are
planning several conference calls as well as a meeting of the subcommittee the
day before the full Committee meeting in February, and our hope is to have at
least that part of the report or the document whatever shape it takes, have at
least that section completed.

The next section on our list of topics to complete is the one that deals
with such issues as role-based access restrictions. What we have decided is to
try to concentrate on those issues that would affect the design and
architecture of the NHIN first so that should we be asked to have some input
into the design of the system either in the department level or by the
contractors we will have that ready to go. We are not sure when or in what
exact form our ultimate work product will be distributed but it is important to
us and we think the full Committee that the substantive work be completed and
sort of ready to be rolled out on a short time frame when the need arises.

DR. COHN: Very good work and we are certainly informed and reminded of the
international learnings that may exist.

DR.ROTHSTEIN: It is amazing everybody has got the same issues to deal with.

Agenda Item: NHII Workgroup – Dr.Cohn

DR. COHN: Okay, the other two reports are obviously the NHII Work Group
where we had the action item today and I think as you heard we are trying to
come up with an actual report that contains the recommendations as well as
background relationship to personal health records.

It has obviously turned out to be quite a topical area and I think that the
letter itself was very valuable to help remind everybody about the variety of
things that are there that are called personal health records and may actually
help move us towards some better ways of characterizing and describing that.

So, obviously that is moving forward. The NHII Work Group is going to be
polled for a conference call in January to begin to talk some about next steps
for next year and we will hopefully be able to come back in February to be able
to report on exactly what we have decided in prioritizing and the work plan for
the coming year.

So, that is where we are on that one.

Now, the Executive Subcommittee I think we are polling for a meeting
towards the end of December to begin to —

MS. GREENBERG: For the nineteenth of December, no, seventeenth or
eighteenth, whatever, Monday or Tuesday before Christmas.

Agenda Item: Executive Subcommittee – Dr. Cohn

DR. COHN: For a conference call. We will do some agenda planning as well as
sort of discussing sort of the overall progress and I don’t think I have much
more to say than that at this point. We may very well also have a second call
shortly before the February meeting just to sort of see where things are and
what changes need to be made to the agenda at that point but that is sort of
the level of activity for the Executive Subcommittee at this point.

Agenda Item: Future Agendas for NCVHS Meetings – Dr.

Now, I actually will be representing the Committee at the upcoming AHEC
meetings. I think we identified that this was a valuable activity for the NCVHS
to be visibly engaged in. So, we will be there sort of going forward.

PARTICIPANT: Your voice is dropping.

DR. COHN: I am sorry. I was commenting that I will be planning on attending
the AHEC meetings in person at least for the future as my schedule will
accommodate that.

Now, beyond that obviously we have meetings. That was just sort of a point
of information.

John Paul, did you have a question?

DR. HOUSTON: Is it possible if you can’t audit that maybe it might be good
for one of the other subcommittee chairs to attend so that we always have, to
the extent possible we have somebody representing or at least you are from
NCVHS as the participant to hear what is going on?

DR. COHN: Sure. I think what we will be doing is monitoring this whole
thing, the environment as it evolves because clearly things are still new here
and I do think we have identified that it is important that we be working
collaboratively with them .

DR. HOUSTON: I think at least in the beginning it might be good to make
sure we have eyes and ears at the meetings to the greatest extent possible. I
don’t know whether that presents a problem from an NCVHS funding perspective or

MS. GREENBERG: No, I mean we are committed to certainly supporting Simon’s
participation and if he is not able to attend then we will identify someone

DR. COHN: Good point, and I think we all basically would agree.

Now, what I wanted to do obviously with the remaining sort of minutes and
there are always two issues as we end the meeting. One is your thoughts, what
worked well in the meeting and what didn’t; what can we improve, just sort of
in terms of the actual how we have structured it, what the flavor and the feel
of the meeting was and then the question of course is whether what we want to
put on the agenda for the next meeting and I have been keeping notes here of
what I thought were potential items.

I will run through those but the first question just sort of as an open
issue what did people like; what didn’t they like; what should we be aware of
as you plan the next meeting?


MR. BLAIR: Simon, when you decided this morning to go ahead and handle the
action items first while we still had everybody here, I think that was very
helpful. It reduced tension and anxiety in terms of time. I sort of felt as if
we were able to relax and listen to Dan much more attentively because we didn’t
have that concern about time pressure.

DR. COHN: Thank you. Do others feel that that should be done early on the
second day?

Okay, that is easy enough to change the agenda around to support that going
forward. That is a very good point.

MS. GREENBERG: The only thing I would say is I really would hope
particularly since we, I am not saying this to be critical of anyone but since
we really to try to end the meeting early in the afternoon at maybe 1 o’clock
or whatever that people — our concern has been in the past you put the action
items at 10 o’clock and people want to leave at eleven or something. I mean if
we are going to schedule speakers and we don’t usually schedule them for after
lunch but if we are going to schedule speakers on the second day then I really
just encourage everyone to try to be here until the meeting is over.

DR. COHN: I think you should say it a little stronger than that. I think it
is an expectation of membership that people attend the meetings and I think
people will have reasons to not be here and we understand there are unavoidable
issues. We all have day jobs as well as here but certainly to the extent
possible the expectation is we try to run these meetings in a way where they
provide people with the ability to make it home in a reasonable fashion. So, we
ask everybody to sort of honor that expectation.

MS. GREENBERG: Thank you.

DR. COHN: Justine?

DR. CARR; Simon, thank you again for the opportunity for the full Committee
to exchange ideas. I think that the agenda that is evolving on the EHR clearly
touches every subcommittee and we are struggling with trying to get everybody
represented and it is a challenge because you know the committees meet at the
same time but I think the more we can build in the opportunity for the entire
Committee to meet on certain topics the richer and more fruitful the
subcommittee work will be.

DR. COHN: So, does that mean you like the briefings and discussions that we

DR. CARR; Yes, I think I mean even discussing the letter I think we all
learned things. Not being in the Privacy Committee it gave me a different,
deeper respect and appreciation for all that that entails. I think the
secondary uses touched on a lot of what everyone does. I mean you know the real
challenge and maybe we need to think about this in terms of how we configure
our meeting time, but where we are all working on many related issues maybe I
don’t know, maybe we don’t have the subcommittees all meet at the same time.
Maybe they meet sequentially or the topics become sequential so that we can all
participate in them but I feel that with the cross fertilization we are moving
ahead much more quickly and getting to the most important issues and the
expertise on this Committee is fantastic and everybody is begging everybody to
join their committee but maybe that is a message. No, seriously though maybe we
ought to be configuring in a way that we go through agendas that take the work
of each subcommittee but that we all participate in it because it is like a
three-wheeled cart or wagon or whatever when you are trying to talk about
something and you are missing an element of expertise and then you find out at
another meeting and then you start again and I think we are very privileged to
have the diverse expertise that we have here and we should leverage it.

DR. COHN: And obviously, Justine I want to thank you for being willing to
join the Standards and Security Subcommittee.

DR. CARR: I want to join all the committees.

DR. COHN: As Justine was talking I was reminded of your comments about
strategic planning and how to deal with the issues where there is overlap.

MS. MC CALL: And I think it is very similar, the comments I would like to
make now are very similar to what Justine said. To draw an analogy to what I
see in industry it is that right now we are aligned by function. So, we have
the privacy and confidentiality function and the quality function and the NHII
function and when questions are very discrete and specific that can work very
well but it has changed a little bit and so a different configuration not to
wipe that out but to approach those in a different way may be valuable. So,
just as a food for thought, more a thought exercise for everyone is to say that
if there is a huge topic, secondary uses there are going to be things that
impact NHII and quality and privacy and confidentiality and standards and
populations and so that what we do is we take the really tall nails on the
board with respect to the issues, the most compelling things that need
influence right now and now I am looking at Jim Scanlon as well. So, what are
those and what comes out of AHEC and what is it that we see that nobody else
has seen and that we tackle them in a dare I say cross-functional to use that
paradigm frame? That is food for thought. There is work in the queue that must
be addressed but it could be something that we could migrate to for things that
are truly cross disciplinary.

DR. COHN: I guess I would jump in on that one and say that I think that we
are using a mixed model right now where we have subcommittees but we are
increasingly bringing issues for the full Committee to work on. We are going to
have to experiment and see how this works because I agree with what you are
describing and I am not sure that we are looking at all of the EHRs. I think we
are beginning to look at the NHII from all the various aspects but it is
important that whatever it is we are looking at here it is obviously more than
just EHRs. We are really seeing that we are getting much more close to that
NHII paradigm that we have been talking about.

Anyway we will continue to evolve this thing. I agree with you. It is a
real issue.


DR. TANG: I, also, really think the last few meetings were very productive
because of the discussion and the cross fertilization. So, I wonder if Carol’s
idea, you know the retreat she talked about for the full Committee, maybe we
need to have that sooner rather than later because I think trying to design how
we interact and derive synergy would be very, very important and can
significantly change our productivity. I think it was correct that we have
actually put out more things by sharing and being able to hear each others
discussion. I think that really enhanced our work. So, figuring out how to do
that would be a very useful exercise and pay off.

DR. COHN: Obviously Marjorie and I and Jim need to talk some about the
strategic planning session and we don’t want to start announcing dates or even
what form it will take because I would like if we are going to do it for there
to be a way where people can actually feel free to express their thoughts. So,
I think it will require some planning.

Other thoughts in terms of, I think I am sort of hearing that at least the
way we have been doing this meeting seemed to work pretty well. Probably we
will wind up I bet beginning to put more presentations in because we need to
achieve a balance there and there is always a balance that will be bouncing
back and forth but I just would expect that the way things are happening that
we will be engaging a little more with outside speakers at least for the next


MS. GREENBERG: This is really helpful feedback obviously to us, the
Executive Subcommittee and the Executive Secretary. I just wanted to add my
appreciation to Debbie Jackson.


MS. GREENBERG: Who really sort of puts together these agendas in a very
organic way and she is much more flexible than I am and so it is great
particularly when I am out of the country. I think it goes really well but I
mean I know I will get sort of attached to doing things one way but Debbie is
just so flexible and she just sees what you all want to do and what needs to be
done and she makes it work and she also just when I know at the last minute if
people would suggest new speakers to me I would say, “I can’t deal with
that.” She just finds them. She gets them here and I just think that she
is behind the scenes but I wanted to recognize that. That doesn’t mean that you
should think of all the possible ways to drive her crazy. We do need to
eventually put something up but also I want to say this to the subcommittees,
too. We really try to get agendas up on the Internet at least a month before
the meeting and then recognizing that they will change and we will put up new
versions of them but you don’t have to wait until you have every last speaker
or whatever and sometimes we may push you and you are not real comfortable with
that but we can always just put a topic and then change it but I think people
want to just even make a decision am I going to go to that meeting. I don’t
mean the members. You don’t have that choice or the staff and so they need to
know what are the topics that are being discussed. So, we do try to do that but
obviously we also try to remain flexible.

We are grateful to all of the staff, the lead staff, the other staff. It is
amazing how people get into it.

DR. COHN: Let me move just to talk about the notes that I made about the
next meeting. Obviously many of these are notes and some of them may be handled
with the full Committee and some of them may be handled by subcommittees or
work groups. Some of them may get done then or in June, and we will sort of see
how it plays out but the notes I made included an update from HHS on the
statistics work that the council was starting to undertake.

MR. J. SCANLON; Actually would you like a full discussion of the standards?

DR. COHN: Yes. I am not saying it very well but that is what I was
referencing because I think that was an area that I think we all thought was

I, also, heard that there was going to be sort of a compilation of the RFI
responses on personal health records from CMS and I have written down sort of a
question mark as to February but I think we would want to hear more about that
as a full Committee. I am not saying the NHII work group wants to hear about it
alone but I think it is potentially an interesting area that we would want to
all hear the report on about.

There is the HIPAA enforcement rule, final HIPAA enforcement rule that we
won’t want to spend hours on but we do need to be updated on it.

Now, I have a note here about, it says, “CHI update.” I am trying
to think of why I wrote that down there except that obviously that group is
doing work and once again it may be something that Standards and Security needs
to look at.

MR. BLAIR: I think we had had that on the agenda and I think it is combined
with CHI and health architecture together in terms of plans and directions.

PARTICIPANT: That could be even do you think the full Committee?

DR. COHN: I don’t know. I think we can hear from Jeff if he thinks maybe
Standards and Security. I had it written down here and without Steve Steindel
being here I was going —

MS. GREENBERG: CHI and what?

MR. BLAIR: FHA architecture.

MS. GREENBERG: And this is all under ONC?

DR. COHN: Yes.

MR. REYNOLDS: Simon, one possibility is whether or not the full Committee
is really attuned to the whole CHI. I mean this came through here at different
times, pieces of it did. So, we are looking at the new stuff that they are
coming out with in standards and security but the overall because you keep
hearing it more and more now, anytime you hear EHRs, anytime you hear anything
else. So, it may have been a significant enough change in the full Committee
that a kind of a restatement of what it is and what they are may possibly be
helpful to the full Committee and then we will continue to move forward with
the new stuff.

DR. COHN: But we actually had a presentation I think two times ago about
the FHA but I would I think defer to you for you and Jeff and Steve Steindel to
figure out whether there is something that needs to be described that we all
need to know about at the next meeting. Otherwise we will leave it for the

Bob, did you have a comment on that ?

MR. HUNGATE: A question and comment. I feel a need for some kind of a
metric to tell me how much progress we are making in real adoption of
standards. Now, we talk about standards and their importance but I don’t really
know where we are in terms of that adoption process as a percentage of how many
of them we need to have adopted. I have an uncertainty of where we are. I know
it is important but I don’t know what our real progress is and that is just an
uncertainty. I don’t know whether there is a metric that —

DR. COHN: I think I would say that later this year we will have a briefing
probably from the Harvard Group and do you remember this grant that was let by
the Office of the National Coordinator? I don’t know whether they are going to
be focusing on that piece versus the actual implementation but I don’t think we
know exactly all that they are going to include. I have been trying to figure
out exactly, you know how exactly to describe the standard universe and it may
be a tough one to approach.

MR. BLAIR: Simon, you and I wrote a chapter that was in that healthy people
book on standards and I pulled together a presentation for folks that are not
especially familiar with the standards pieces and we might talk about whether
the presentation that I pulled together would be appropriate or not for the
session on standards.

DR. COHN: Okay.

MR. BLAIR: This is in addition to CHI not in place of CHI and FHA. It is
just sort of an overview so somebody could understand the landscape of what has
been happening with health care IT standards.

MR. J. SCANLON: The other thing we could do as part of the same briefing I
think we could ask NLM to come brief the group on all of the standards we have
adopted somehow supported and who has actually implemented them is harder.

DR. COHN: Yes, that is the part I was trying to get at.

MR. J. SCANLON: And the mapping that actually interlinks the standards. I
am pretty sure somebody from NLM could actually give a nice overview of all of
that and then CHI could tell us what they are actually working on.

DR. TANG; NCHS is doing mapping with SNOMED and —

DR. COHN: Their view is described differently but it is really under the
aegis of NLM.

DR. TANG: There are probably half a dozen or more mapping activities at

DR. COHN: Okay, so, we will note that. Now, I have a note here about the
update from CCHIT and given I think the progress that they are making I
actually think that February would be a very good time to hear about where they
are. Given the success of our last conversation on privacy and confidentiality
obviously we will want to repeat that activity. So, we will make sure to
include that.

Now, this is a question for everybody. I don’t know whether it is for this
group or for standards and security or NHII. There was a report that was
recently released as originally funded by the Office of National Coordinator on
Fraud and Abuse which I thought was a rather interesting report. David
mentioned it very briefly. The question is whether there is any more that we
want to know about that. I noted it and I don’t know that I have an opinion
about whether it would be a value added for everybody or whether it is just
something we should send a copy of it out.

DR. TANG: It deals with data quality as a lot of fraud can come from data
that is not truly representative. I mean I think that does bear on it.

DR. COHN: Okay, the final piece I had here and I was writing down all these
things as we went along but the final piece was really the question about where
the NHNN piece will be at that point and there may be something that we ask
David Braylor to give an update on or it may be something that we would decide
that it deserves a presentation in its own right if we can sort of figure that
one out.

MS. GREENBERG: You mean the AHIC?

DR. COHN: No, I mean the NHIN. That is something that may be important.

MS. MC CALL: I would love for that to be full Committee and to the extent
they are ready for a full presentation that would be wonderful. If not that, an

DR. COHN: Okay, great. So, anyway that is what I have and obviously we will
be asking the Office of the National Coordinator to come and update and
everything else and that was what I had been noting as I wrote down the –what
are we missing, Marjorie?

MS. GREENBERG: Okay, well, I had written quite a few of those down, too,
but you added some additional ones. Did you want to have a presentation from
CSI on their report or just we send it out and I know we were interested
possibly for this meeting and Scott wasn’t available.

DR. COHN: That is right. You know, we will look at it as the Executive
Subcommittee and I would ask others. I mean my own view was let us send out the
executive summary and recommendations only because I think in my view the value
of the recommendations may be having the subcommittees and work groups see if
there are any items that they want to take and sort of move forward or is this
an issue that CSI has sort of started, but let us look at the agenda and see if
we have time and that would be great. We realize as important as this is it
will be 4 months after the release by the time —

MS. GREENBERG: Okay, also, at this meeting we had agreed at the Executive
Subcommittee or we had asked at the Executive Subcommittee for Dr. Sondik and
the liaison to provide an update or briefing on issues related to data release
and confidentiality particularly having to do with vital statistics and Dr.
Sondik was out of the country so we had agreed that we would defer it until
February, but I think that is an issue for February. We have heard we have a
new liaison now from the board and of course Bill is the liaison to the board
and I believe they are meeting in January. So, that would be timely also to get
an update from them. You had asked me at some point to provide an update on
what is happening with the international classifications and the WHO work. So,
just let me know when you want me to do that .

DR. COHN: Keep that on the list and if we have time we will do it in

MS. GREENBERG: Okay. Then we had also talked about establishing contact
with the new chief medical officer of the Department of Homeland Security and
thanks to Debbie, she keeps track of this stuff. So, she doesn’t let us forget
it and, Harry you said you knew him, Don Ringle?

MR. REYNOLDS: No, I didn’t say that.

MS. GREENBERG: Oh, okay, maybe not. I had that note here but in any event
either at a subcommittee or a full Committee level that would — well, that
fits in very much, too, with the population issues related to disaster
preparation and all of that.

MR. J. SCANLON: The major function if you are interested in public health
and medical responses that is not Homeland Security. That is HHS and he is the
medical officer at HHS or PHS but it is for their function there. I don’t know
that he would be able to talk about the medical and public health response.

MS. GREENBERG: I thought it was how the, Steve isn’t here but how the DHS
up until the naming of the chief medical officer there really wasn’t kind of a
focal point for these issues I guess but how they interface with the department

MR. BLAIR: Marjorie, about 6 months ago I had seen a list of standards that
the Department of Homeland Security was saying that everyone had to adhere to
including health care and they were not consistent with those that we have been
going through with the CHI standards and of course that caused great concern
and the thought that I don’t know whether your request that the chief medical
officer was in response to that but if it was we would like to have somebody
that could talk about what standards they were adopting for response to
bioterrorism and other health emergencies.

DR. COHN: Let us talk about this off line.

This is not a full Committee discussion.

MS. GREENBERG: But it was on our agenda.

DR. COHN: Other thoughts for the agenda?

DR. TANG: It is interesting we have been talking a lot about the direction
of pay for performance and performance measurement. I wonder if it would be
useful to get a briefing from CMS. I don’t know whether Mark would do that or
he would designate it. They are obviously going in the direction of a
demonstration project but from a data point what is their thought or even what
do they want us to do.

DR. COHN: We could get Terry Haywood talking about that.

MS. GREENBERG: I did have on here scope of work but that is different I

DR. COHN: Yes, that is accumulated.

MS. GREENBERG: It is related though. I worked for the PSRO program. So, I
haven’t caught up with all the new terminology but in any event okay. So, I did
have that on here as well and is there anything else? Data access policies,
remember we talked about that, also, about looking into the way investigating
and evaluating data access policies particularly related to small populations
across the department and other statistical agencies? There was even some talk
about maybe that you might have worked a contract in that area.

MR. LOCALIO: Let us wait until —

MR. J. SCANLON: We are going to do the practices and statistical programs
and that will lead to that.

MS. GREENBERG: Okay, so you are doing that, okay.

MS. MC CALL: Some of these things we have been deciding as we go kind of
where they belong and yet others we are not. So, is this something that you
will be talking about in the Executive Subcommittee?

DR. COHN: Yes, and this is sort of a master list. As I am looking through
the list some of them should be full Committee items. Other things I mean
especially as the agenda fills up which I think it has probably gotten pretty
full here one could imagine that you know the CHI stuff and all that unless
there is a determination made that there is really something that we all need
to know about that is very important we might ask the Standards and Security
Subcommittee to talk about that and then if there is something there we can
bring it up in June and that might e how we will do it. It is good to have a
master list of these issues so they don’t get sort of lost or whatever and so
it is useful to get a sense of some of the things we are going yes; others we
are going — your facial expression said it all.

MS. MC CALL: And so the only outstanding question is pay for performance. I
don’t know if everybody feels that that should be full Committee or if it is

MR. BLAIR: Full Committee.

DR. COHN: I actually think that the Quality Work Group will be taking a
more in-depth look at it but I think getting somebody to give us a broad
overview around the data issue would be useful.

MS. GREENBERG: The only thing I would say is we have heard that people
really benefit from the cross fertilization, from the time for discussion, etc.
A number of these issues seem to touch on several groups and we just may have
to think in terms of just let me go through all these topics having a 2-day
meeting rather than a 1-1/2 day meeting.

DR. COHN: That would work except we already have subcommittees front and
back to this next meeting.

MS. GREENBERG: No, I am talking about meeting the whole day the second day.

DR. COHN: Okay, and what I am saying is that I think other subcommittees
have already planned to meet the day before and others are planning to meet in
the afternoon on the second day of our meeting.

MS. GREENBERG: Who is planning to meet on the afternoon of the second day
of our meeting.


MR. REYNOLDS: For February Privacy is meeting the day before.

MS. GREENBERG: I didn’t catch that. I am sorry. You are meeting that

MS. MC CALL: There may be some specific instances where this would work.

MS. GREENBERG: I understand. I encourage that from our budgetary point of
view. Okay. I didn’t catch what Harry’s group or the Standards —

DR. COHN: But obviously also it is a piece of prioritization and making
sure that we are doing things that are important. There will be a lot of work
this year.

DR. CARR: I would just make the plea that even though we have all these
important things that if we just hear them consecutively and leave here without
speaking about them it is not a take.

DR. COHN: Yes and thank you for that comment. You are absolutely right. I
think that is why I do prioritization issues. It is so important and why some
of these we may say, “Geez, we need to hear about it but it can be held in
June or it can be in September or whatever or geez, that is something that the
Subcommittee or Work Group on Quality is going to be dealing with and they will
come back with a distillation of the information to the full Committee.”

There are lots of ways to handle these issues and not all of them need to
be in February for full vetting. So, I think we have put a list together and we
are getting a sense from you of what is important.

MR. BLAIR: I am not aware of this having been mentioned before but between
Maria Friedman and Marjorie, Marjorie keeps us apprised. Anytime there is an
HHS announcement we get an e-mail almost immediately and Maria does that for
any CMS announcements and there have been many many times when that has been
very helpful that we have received prompt announcements that the RFAs are
announced or an NPRM or the final rule and I just wanted to go on record to say
that that is very much appreciated.

MS. GREENBERG: Good because sometimes I think should I really send this to
everyone, but I say, well, you can always delete. So, you would rather I erred
sort of on that side, okay.

DR. COHN: Okay, I just want to take a moment and thank the members of the
Committee. I, as Chair obviously appreciate your support and help for this year
and obviously going forward. So, thank you.

We have already in one way sort of thanked all the staff but I just want
to, myself say that we all appreciate your help and support. We know that we
would not be able to do this without all of your help and I am sort of looking
360 degrees around the room for those of you who are here as well as obviously
all the support people that are sort of behind them enabling all this to
happen. So, we really want to thank you. We really appreciate you and thank you
so much.

Happy holidays.

I think with that the meeting is adjourned.

(Thereupon, at 1;20 p.m., the meeting was adjourned.)