[This Transcript is Unedited]




SEPTEMBER 13, 2006

Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington , DC 20001

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

R O C E E D I N G S [4:39 p.m.]

DR. COHN: As soon as Steve and Jeff get in the room what I really want to do is spend a little time talking about process and next steps sort of from here through mid-October because I’d like to be able to have this agreement about what needs to be done so we can share it with the full committee tomorrow when we talk about it.

DR. TANG: As an overview I’m not sure how far off the report is. So what’s the, so there’s no harm in the delay and is there any benefit to coming out tomorrow with an approval?

DR. COHN: For this report?

DR. TANG: Yes.

DR. COHN: Well, I’ll tell you and maybe this is part of the process, I don’t think, I think what we would like to do is to get some public input on the report, you have to realize that we’ve had one public open session and that was not on this report, it was on some of the appendices, at which point everybody was complaining that they didn’t have an overall framework upon which to even consider the appendices. And so I think we would like to at least have one and even maybe more then one open call with the industry, with consortia, with other interested parties, not just with the industry, to elicit public comment.

I was sort of reminded as we were going through the document today with many of Mike’s questions realizing that Mike hadn’t even seen the document before today. And I agree with you, I think it’s probably 85 percent good but I guess I’m hoping that out of some additional comment we’ll actually wind up with some revision or changes, maybe not to the main recommendations but maybe some of the supporting pieces, maybe there will be some of the functional requirements will become richer as a result of it, and I certainly don’t think it will hurt us at all doing that because we’ve been in really a very quick process and given that we have a little additional time I think we should take it.

Jeff and Steve since you’re back in the room let me just tell you, what I want to do is talk a little bit about process and about how we get from here to a successful report later on in the month. Paul Tang was sort of bringing up the issue of well maybe we should just vote on it tomorrow which some of us, I know looking at Margret, I think she thinks that maybe we need a little more time to further refine this.

But we have been given some additional time, which is good, and I think we need to think about how best to utilize it. I think from my view A, we need I think at least one open call with the public and the industry to get further input recognizing that we obviously had a call with them back in the end of August, A, everybody complained that they didn’t have enough time to evaluate it, B, they didn’t have a context upon which to evaluate the appendices at that point, and so I think we should redistribute whatever it is we come out of as a revised document from these sessions today and tomorrow to a wider, once again to a larger group and try to do as much as we can to get public comment.

And I’m thinking basically we’d be respectful to people that are going to be wanting, that we will want them to review, we probably should give them a couple of weeks to do it so maybe we’ll want to do one call in the very early part of October potentially. And I guess I’m almost thinking that I would just hold this out as an option, that maybe we’ll want to follow that up with another call shortly before the ONC Forum.

Now that second one we can think of for a minute but I will tell you, and I guess we also need to think about this, is we’re obviously being offered, we’re being asked to participate actively in the Forum both in terms of presenting this as well as hopefully helping to moderate some of the reactor panels. Now John Loonsk has been describing that this session maybe a little fuller with various topics than the last ONC Forum which they had and so one of the questions will be is whether or not there will be a breakout on this. And one of the questions I want to bring up to everybody, that at least from my view there’s pros and cons of having a breakout on this at the Forum versus just taking comments from people in the audience after we present. I mean the pro obviously would be that, let me think of the pro, the pro would be is that we have two weeks to finalize it after that session and it obviously would not just completely open up all the public comment. The con obviously would be that we would not get that additional public comment in as structured a fashion and we would have to come up with ways before the ONC Forum to get that public comment.


DR. STEINDEL: Simon, when you say breakout session, would it be a formal NCVHS meeting?

DR. COHN: I don’t believe that we were planning having a full NCVHS hearing —

DR. STEINDEL: I would be in favor of having an open NCVHS meeting in the context of the time they allow us for a breakout session, but I would not be interested in having a breakout session like you just said.

MR. REYNOLDS: I guess I’m a bit alarmed that none of the key players in this arena are here today. Look at the audience that was here today, nobody. I’m trying to figure out, I’m talking about the players that were at the last conference, the players that are at the table, the players that are saying they didn’t have enough time or anything else, nobody is here and this was a public meeting. And so I’m really struggling trying to figure out what this all means because obviously as much as they are ingrained in this and as much as they have put into this the fact that, and this is obviously what’s going forward, so I think as we look at what we do in this Forum and where we fit in this Forum, I’m struggling to reconcile that to be quite honest with you.

DR. COHN: Well let me give a different frame on that one that maybe doesn’t sound quite as dire as you’re presenting, we have to realize that there were a whole lot of people who were commenting and talking to us during our open conference call, that would be people that you would normally expect to be here commenting on this. They have no knowledge that we did anything other then to take their comments and it’s exactly the same document that they saw a couple of weeks ago. And so given that I think that, I mean we obviously did not make a big point of having them come.

Now I think the interesting question about whether or not we ought to do some sort of an open hearing after we present, maybe at the same time as the ONC Forum where we elicit public comment is actually sort of an intriguing one, I had initially told Marjorie that we weren’t going to do that but maybe that really is the way to get additional comment that we may need.

Now it does put Margret and the rest of us in a bit of a quandary if we get stuff that really requires some significant revision to the document or at least requires some thought around that, trying to do that within two weeks, but once again that’s why we’re talking about process, I wanted to bring this up to everybody to help think through what it is we think makes the most sense.

Now I’m obviously happy to talk to John Loonsk and others to represent whatever we think is the best idea going forward. Mary Jo?

DR. DEERING: It was Marjorie who insisted I sit here when she leaves so I’ll ask maybe a Marjorie question, maybe she’s already answered it but is there a precedent for the NCVHS just participating in a breakout session to formally present for comment on these work products?

DR. COHN: Well actually we would be presenting at the full committee, at the full session, and then the question is whether we would take comments at a breakout session or participate in getting additional comments in a breakout session.

DR. DEERING: I’m just wondering protocol and legal issues about the kind of a format we needed to be in in order to formally present and it sounded like when you said a breakout session that it was going to be just a —

DR. COHN: No, I mean the document would be presented to the full Forum, and I actually don’t know that there’s a requirement that, I mean it’s a question of how formally we want to go out and get additional input in addition to the open conference calls. I don’t have an opinion on this right now, I’m sort of bringing up the issues.

Jeff and then Steve.

MR. BLAIR: The feeling I have right now in terms of where we need additional comment, I’m a little less concerned at this point about getting additional comment on the substance of it from the four consortia or from the folks that have worked with us by being at the testimony the last week in July or on the call on August 31st. In terms of substantive omissions, I think we’ve probably gotten most of those gaps and omissions and the basic content in this document. The piece that is of concern to me is that we get some additional refinement in readability especially from folks that haven’t been active in giving us feedback so far. I’m almost wondering whether if we had a directed mailing to like the leaders at HTSPI or CCHIT or other folks that may not have been involved that may be affected by this and solicit feedback not only for content but for the areas that they may not understand or be confused so that we get this document so where it’s much more easy to read. That’s where I think we should focus our next efforts.

DR. COHN: Steve, I’ll let you comment though I do think that that’s a poor use of the resources you’re describing to test readability, I mean if we want readability we can get an editor to work on making sentences shorter and reducing the complexity of the words. I think if we’re talking about content those are exactly the people that we ought to be asking.

MR. BLAIR: I agree with your statement, Simon, and maybe I would wind up taking you up on that idea that maybe we should also get someone on readability as an editor to —

DR. COHN: Let’s think about whether that’s really the issue or not, Steve?

DR. STEINDEL: I wanted to make two comments, first of all the only reason I felt that an open meeting might be a good idea is that it really, I don’t think it does much for us one way or the other, we’ll get the information coming in but it may make the people who want to make comment to NCVHS feel like they’re in a more significant situation, that was the only reason I suggested it.

And in terms of what Mary Jo was mentioning, we’ve gone ahead multiple times in the past presenting outside of the context of meetings on types of work that we’re doing so we’re not prohibited, the committee is not prohibited in doing it, we are as staff.

I’m not as concerned as Harry about the, I am a little concerned but not the dire concern that Harry expressed about people like from the consortia not being present at this meeting because I think in one sense it’s a compliment to the work that we’ve done so far because I don’t think the document that we have today has really directed anything in new areas, areas that they haven’t thought of or areas that they discussed, but what we’ve done is codified it and consolidated it in a fashion that is understandable and that they all can grasp for it and they can see the areas where differences are and that’s the service to the public. But that doesn’t do the consortia that much good because they’ve got to deliver a product which is much more detailed than what we’re producing.

So I’m not concerned about that, I’m concerned that we do produce a very good readable understandable document that explains the initial sets of requirements that are needed for an NHIN and we did that with the NHII report, without going through a massive set of public hearings and stuff like that, we had a limited amount of that, we did get an editor in to help us with the wording but that’s been an amazingly long lasting document.

DR. COHN: Harry?

MR. REYNOLDS: Still not convincing me, I’m holding steady here. When you go to an NHIN conference that’s got 1300 people, and you’re going to go to another that will probably have 1300 people, and we come out of there, we’ll go with your 500, the point is it was all segments of all industry represented there. I’m totally confident in our document, I’m not totally confident in this process yet. We are treading on new process, yes, we are doing what NCVHS does and I am totally behind that and I am totally comfortable with it.

However, we are playing in somebody else’s yard too and so consequently I just want to make sure that we air this enough so that if for any reason this were to be challenged through other arenas with people that aren’t necessarily coming here but would go somewhere else, that we at least have made it visible enough that we could clearly say that we gave every bit of the public and every bit of everybody else that’s been involved in this an ample shot at it. That’s all I’m saying because a lot of these people might not know our process, there is another very visible process going on, I’m just trying to be careful.

DR. COHN: Harry, I’m buying what you’re saying but based on what all that you’re saying tell me what you’re recommending.

MR. REYNOLDS: I think we definitely need to present at that conference and ask for comments, I’m not at all voting necessarily for a separate breakout session but just like any presenter we would present this, take any questions or comments from the environment, say we were there, could say we did it in front of this many people, could say we got the input and we go on and do what we do. That would be where I’m going.

MR. HOUSTON: Call me cynical but having been through a number of these forums, if you’re going to ask for public comment, I hate to say this, what ends up happening is you get comments from people that this is the first time they’ve ever seen it, so people that are very immature in their thoughts on it, there’s an enormous amount of, there’s a lot of noise that you end up hearing, I’m not sure what the value at times is in doing that just simply because of that. I mean I’ve been through these and even the last one it seemed like there were people in the room that just, they’d never even been in the room before, at the table before, and they’re making comments that when you listened to them they were absolutely simplistic and off base as to what really where I thought, really where the discussion had matured to I guess is my point.

DR. COHN: I’m just trying to think of which hearing you’re describing, the one in July?

MR. HOUSTON: Yeah, the one up at Bethesda —

DR. WARREN: The gal that was talking about end of life —

MR. HOUSTON: There was an enormous amount of discussion about, I mean Judith and I were sitting in the room thinking boy these people have never been at the table before and I’m sorry for, I don’t know how to say it any more gracefully other then you sit there and you listen to 45 minutes of people talking about things that really were —

DR. WARREN: They had their own agendas but it wasn’t ours.

MR. HOUSTON: It wasn’t furthering the discussion or it was very simplistic overall.

DR. COHN: Okay, Steve and then Mary Jo and then Judith.

DR. STEINDEL: I agree with John from his comments about the value of what we would hear at a meeting like this, if we do a presentation and then just ask for people to comment on what they just heard we’re going to get a random set of comments, some of them are going to be off topic, some of them are going to be from the people we’ve heard from multiple times before saying the same thing in a new forum, and if we’re going to go in front of people and say we presented in front of N people, we asked for comments, we got some, we responded, and therefore this has been vetted, Harry, I don’t think that answers your question.

MR. REYNOLDS: Steve, yours is but one opinion.

DR. STEINDEL: And if we really want a cross section of opinion let’s do an NCVHS hearing on this and invite people, we send them the document and we invite them to comment on it, from various segments of the industry, and we send them the document that we have either today or two weeks from today, we hold a hearing two weeks after that and then we have our normal type of vetting on that document. That I think would better address your concern about getting wide industry input.

DR. COHN: Mary Jo.

DR. DEERING: Well I’m just going to lend my voice to more input, both acknowledging what John says and certainly not wanting to look to any NHIN Forum as a sole source of input. Even there I think that given who we are and what we represent in the process that to fail to present would be a mistake. I also agree it’s not going to gather the substantive input that we’re looking for.

MR. HOUSTON: There’s a difference between presenting and being there and talking about an open dialogue and soliciting input. Unless I misunderstand the nuance between the two, presenting versus —

DR. DEERING: There could be different variations, at a minimum it could be like any typical presentation in a plenary session, there’s not a whole lot of time for Q&A but people have seen the document, especially if it’s available beforehand, there’s only maybe five or ten minutes for Q&A at the end and you hear those who get to the mics first and other people say hey I want to catch you in the aisles afterward and you’ve done it, you’ve been there, you’ve done it and everybody got to hear about it. And then for your substantive input you have another process.

MR. HOUSTON: And I could accept something like that, I just think that otherwise to have an open forum for the express purpose or really the intention of people giving you input I just don’t think is going to be worthwhile.

DR. COHN: Judy.

DR. WARREN: I guess I agree with Harry, I was concerned when I walked in today that I did not see representatives from the consortia and I didn’t see some of the others and I guess part of that is colored by our experience with e-prescribing, that as people got into that effort they were deeply committed into the process. And I think back, I wasn’t on the last phone call but I was on the other phone calls that we’ve had throughout the summer and one of the consistent messages we kept hearing was that people did not have time enough to evaluate the materials and to give them thoughtful reviews and get back to us. Now I know we’ve gotten some more comments but those have been written comments that were not within a synergistic meeting where you could get, ask questions, respond to those questions and gain input.

I agree with John from our experience at Bethesda, you’re going to have a lot of people that like to get up and make a public comment, that may or may not be helpful or relevant to what we’re trying to do and may not provide any more consensus, but you’ll also get those people who do have a chance to do relevant comments and stuff to do that. So I would hate to cut them off and I guess I just feel a need for some validation in some sort of public forum from the consortia members who had a lot of concern and from some of the other organizations that were attending the phone call and stuff like that to get back to us.

DR. COHN: Let’s move from the high level input into sort of what we’re going to do and I basically want to throw out a couple of options.

Now I agree with everybody that we need more input and the real question is how we do it in a way that feels right for the NCVHS and feels right for our process and probably gives John Houston some additional input of the types that are helpful.

MR. HOUSTON: Not just me but everyone.

DR. COHN: Everyone, okay. Now, we obviously have a month and a half, we have an ONC Forum that’s going to occur —

MR. BLAIR: What is the dates of that?

DR. COHN: That’s the 16th and 17th. Now at a minimum I would suggest to you that we are going to present there and take questions from the audience as part of the presentation, and it can be anywhere from a full hearing to as part of that, it could be just a breakout where we get input, I mean all of those are possibilities.

Now before that, which is the next month or whatever, we can obviously send things out, we can do open calls, we could actually do a hearing before the ONC meeting knowing that we have a meeting of the Subcommittee on Standards and Security the week before we could actually extend that potentially a day or reorganize it, as I say that I don’t know who else is around and going to have a heart attack for that comment. But we could tack it onto that and therefore not, and have that be a public forum if we want to do that, and that’s sort of an and/or with the open call, certainly the open call can be very useful but we could do both or one or the other. We have a number of options at our disposal knowing that whatever we do we need to get this done by the 31st and we don’t want to open up so many new cans of worms that we find ourselves in a position where we can’t complete this in a reasonable fashion.

Now having said that I agree with most people that I think this is like an 80 percent document at this point, maybe it’s 85 percent, I don’t think it’s so good that I’d vote on it tomorrow but I’m delighted that Paul thought so. But I guess the question is, I’m just throwing out a range of possibilities and the question is what feels right to people in terms of what we ought to do.

DR. WARREN: Can I ask, do we have a budget for any of this stuff?

DR. COHN: Yes, we actually have additional, we did not sign up for this until we got some additional money from ONC so we do have some flexibility, we don’t have unlimited flexibility, I’m not suggesting, we have enough for an open conference call, we probably have enough if we wanted to extend the subcommittee meeting one day to do something, I’m sure I could probably bend or twist Marjorie’s arm a little bit with the budget we have. This was not done without some agreement for additional funding from ONC. Steve.

DR. STEINDEL: Simon, just as a quick logistics point, I was checking with Judy very quickly, there’s a SNOMED meeting scheduled the same time as our Standards and Security meeting and the last time there were simultaneously scheduled I came to NCVHS so I’m going to go to the SNOMED meeting so I probably most likely will not be at the October meeting and I just checked with Judy and it turns out she probably will not be at SNOMED but she’s indicated she had another meeting so she’s going to be catch as catch can with the NCVHS meeting.

DR. WARREN: But I can dial in for most of the meeting, I just can’t physically be in D.C.

DR. STEINDEL: So that’s just a logistics thing for you to consider.

MR. BLAIR: You’re talking about the Subcommittee on Standards and Security —

DR. STEINDEL: The October meeting.

DR. COHN: Okay, Harry.

MR. REYNOLDS: My recommendation is that we have an open call prior to the ONC meeting, we could then state clearly that we have had hearings, we have had open calls, and we are presenting to that group our document. I agree with Mary Jo you take your ten minutes worth of questions or comments or whatever you have like most people that present do, but then, and I say this gracefully having adjudicated this while you were out of the country, there was a lot of concern around this table about this whole process and who had the ball and who had what and who had everything and where it was going. So I’m just making sure that we are smart enough to make sure that we have covered all the bases and dotted all the I’s. So if this goes forward, if anything else shows up anywhere else in any other way we have clearly made ourselves available in every possible way.

So I think if we have that open call first, offer it again because we’ve already had an open call, that’s two open calls, that’s hearings, and then we step forward and present in an open forum in front of all those people, then I have absolutely zero concern politically, emotionally or anything that we have not been as visible as necessary and that nobody could question that visibility and nobody could question anything about it. That’s where I’m trying to go.

DR. COHN: John Paul it looks like you had a comment, then Steve, and I know Steve is trying to get out the door.

MR. HOUSTON: Two things. I agree with Harry’s position, I also think that you also have to look at what we can do in light of the timeframes we’re asked to complete this work, and we have in addition to hearings and the like I know this has been distributed, so it’s not as though this has been a black project for which there has been no opportunities to see the work product, and in fact everybody who is here today had an opportunity to get a copy of this and look at it. Judith I know made comments, she’s sitting in the back of the room now, Carol, I’m sorry Carol, I don’t know why I called you Judith, I’m sorry, Carol Bickford, so people are making some comments so I think we have done what we can in the timeframe being asked to develop a document so I agree with Harry.

DR. COHN: Steve.

DR. STEINDEL: Yeah, I liked Harry’s schedule, that we have an open conference call before the Forum, that we participate in the Forum, my only suggestion, it would make me feel a little bit more comfortable with the process, is I would suggest a hearing of the NCVHS the morning after the ONC Forum with invited commenters, because they probably will be in town. And that would make me feel comfortable that we’ve gone through the traditional NCVHS process.

DR. WARREN: On the 18th?

DR. STEINDEL: Half day.

DR. WARREN: Do we know what the ONC schedule for their Forum is? I mean do they have time the afternoon of the 17th for the same thing?

DR. STEINDEL: If they did, I’m just trying to slip it in what I considered to be an open time.

DR. DEERING: I just had a logistic, I happened to remember NIST has a conference that follows the next two days on interoperability with a lot of high level CEOs so I wonder whether some of the people who are coming in town for the first two days of the Forum would go right over there so that may preclude that.

MR. BLAIR: I feel fine with Harry’s suggestion and I am okay with Steve’s suggestions too if we are able to work that out as well. The area of concern that I have, because I really feel like this is a good solid document in terms of the content, and I think it’s readable from the standpoint of those of us who have been working on it, we understand it. The piece that concerns me is the new readers, whether they are IT people —

DR. COHN: Jeff, were you going to comment beyond the issue of readability?

MR. BLAIR: Yeah, what I was going to suggest is that in the past when we’ve distributed the document there’s been such a short time for people to review it that, people commented that they didn’t have enough time, so what I’d like to suggest is that we hire, I don’t know if we even need to hire, I mean on Marjorie’s staff she’s got some really good writers that could work with, because I really want to make sure, Simon, that you’re hearing these remarks —

What I’d like to see is maybe, there could be some good writers from Marjorie’s staff that could work with Margret because I don’t think we want to hand this over to somebody who’s starting to make changes in this from an editorial standpoint and doesn’t understand the intricacies of the discussion so I think it’s got to be somebody who’s working directly with Margret to bring it to the next higher level of readability, and that that be done soon enough that the changes from this meeting and those readability changes could be done soon enough so that when this letter gets electronically distributed to people to comment they have a good ten days before we solicit their comments and then I think we’re more likely to get good useful comments on the flow, on areas that maybe we haven’t been able to get before.

DR. STEINDEL: To my knowledge there’s no writers on Marjorie’s staff.

MR. BLAIR: Isn’t Susan Kanaan —

DR. STEINDEL: No, she’s a contractor. Anytime we’ve used an outside writer it’s been a contractor.

MR. BLAIR: I’m sorry, somebody like Susan.

DR. COHN: Judy?

DR. WARREN: I guess I’m questioning the need for readability, if that’s something that we can do as we take a look at comments from today and upgrade the document. I almost had a knee jerk response, Simon, when you mentioned well we can make it more readable by making the sentences shorter, and I have a real hard time with people who are going to be building an NHIN that can only figure it out with short sentences.

MR. BLAIR: Judith, that is something where, then I’m in your same bucket with Simon that I struggle, sometimes I have to reread the sentence two to three times and wind up getting, find that the last part of the sentence is the critical piece, so I very much agree with Simon that this finishing item of readability is helpful for a new reader.

DR. COHN: I guess I’m struggling here and I’m listening to this particular discussion and I think we sort of just need to figure out what we want to do about this one. Now I’m more than happy to talk to Marjorie about having Susan Kanaan take a look at it, I am well aware though that every word, you just think about all the conversations about the difference between evaluate and test and all of this that we had as being the types of things that we talk about, so this isn’t, this is not just sort of editing to edit. I also am not certain, I mean when I think about readability I was actually thinking about what Justine as asking about which is more examples as we move into the recommendations which is like a whole different set of processes of coming up with for examples in each of the recommendations, which I think would really would help readability assuming we could get them right. But I’m once again not sure that we can do that in, I mean we are at the 15th right now I believe and there isn’t much time between now and when we would need comments from people.

Mary Jo and Justine and Margret and as I say if we can come up with a solution to this one I’m happy to do it.

DR. DEERING: I would point out that the letter report on personal health records and I believe even on, definitely the one on the personal health records began life as just a letter report and then we went back afterward believing as we did that it was the type of document that was going to have a wider audience and we after submission very consciously went back and without changing the subject, we were very careful, you all got to see it and I think you were comfortable with what came out but it was a highly more readable document so I would suggest that we just bifurcate the process and say we’ll assess our funds available but if we’re going to do it and I agree, this may be that level of document that does deserve a hard cover publication, I mean this is the sort of thing that you want to take out of this letter form eventually and ship out there as a pretty PDF with pull out boxes and everything.

The other thing I wanted to say is that people keep saying how many times people have had a chance to look at this without time, go back to what Simon says, nobody outside of us has seen this document. This document that we are about to send to the Secretary, we did not send this out for ay external comment, ever, all they have seen is one, maybe two, of our appendices. So I think that in terms of getting any substantive comment we really haven’t had that yet, they haven’t seen the letter —

DR. COHN: They haven’t seen the recommendations, they haven’t seen the letter, they saw appendices.

DR. DEERING: None of this document.

DR. COHN: I don’t know if that changes everybody’s views. Justine.

DR. CARR: I like Harry’s idea of, I want to say a couple things, one is I think lots of it reads really well, I think the things we stumbled over today had some ambiguity in it and I think there were only two or three areas, I think a lot of it reads terrifically and the examples are great and that’s what we made me think the more we have the examples the more readable it is. So I don’t think it’s, I think it’s sort of content/concept and the words are getting in the way of getting that across, so it’s not just an editing thing it’s really a thinking through thing.

But I think that with all the work that’s already been done that we would want to have, to your point we want to disseminate, but we want to have meaningful input so the idea of a call where people who are familiar with this and have had a chance to review it call in, that will give us enough time to incorporate the changes. I think to have sort of a hurry up fire drill ten days before it’s due, whatever, go to that hearing and then rush, rush to try to get things in, I think that would be too late. And I think it’s such a great document we ought to just keep going in the way that we go, have the open call, and then present it at the meeting and we may hear some other things but I think the value of the input would come more from the open call then from the open meeting as you said.

DR. COHN: Margret and then John Paul.

MARGRET: Both Karen Trudel and John Loonsk talked to me during break about a couple of suggestions they had and it might be helpful for you, I did try to enumerate them, I don’t know whether you want to do all of them or not but it might be something to help you kind of think through this.

They suggested, particularly Karen, that we list the recommendations alone without the full set of 11 functional requirements and see if they can stand alone. So I think the process here is to refine the recommendations and take whatever other steps we need to do and then separate them out and see in fact if they stand alone and look for dups and so forth.

The other thing Karen suggested was to list the 11 functional requirements separately in a text box whether we incorporate each of the recommendations and observations within the body of the letter, like we have it today, but in addition have a text box that separates out just those 11 so they see the whole structure at once. I think we stumbled on that with the global recommendation at the beginning.

Karen asked to explain what an observation was, she felt that the observations, and I think because I’ve done with this before with you I was comfortable, I knew what observations were, but maybe the regular reader doesn’t know what an observation really is and so she asked for some explanation.

And then both John and Karen wanted further description about how the 112 became the 11 and that is there a possibility, and this is where I don’t know whether you want this done or not, but is there a possibility to then map the 112 to the 11 as a check point and not that that would be necessarily in the body of the letter but could again be in the appendix.

So those were some things that I thought were pretty good recommendations.

DR. COHN: It sounds like a lot of good recommendations and given that I I think at one point asked for that mapping the 112 to this to make sure we weren’t missing anything, although of course you commented that some of them go to, this is a complex mapping. I think all of those were very reasonable recommendations though you can play around with the boxes.

MARGRET: And I think the last one probably needs to be in an appendix as a check and maybe doesn’t have to go out with the initial refined letter.

DR. COHN: Yeah, exactly. John Paul?

MR. HOUSTON: Back to the prior topic for a few seconds, we’ve obviously got an extension for a month and it seems to be odd that we would, if we got an extension through the end of October present something at this upcoming Forum without, and then as Justine indicated, not really have enough time to react to comments. And I guess what if we have as a goal to complete the letter by the time the Forum has occurred with the intent that it be officially released at the Forum, that way it’s an opportunity to present it, it’s an opportunity to, if people want to say something about that’s great but it having been released then precludes us from really, we wouldn’t go back and make modifications to it, it would have already have been released so therefore we wouldn’t feel any obligation to go back and take any input back and modify it. I think it also gives us sufficient time to allow it to go out for further review, which we said hadn’t been done yet, gives time for it to be refined, and obviously in this forum here we’ve had an opportunity for people to make comments about it so I think that may be a way to bridge the gap.

DR. COHN: I’m always really god that I work with committees and with such smart committees, because I think you’re solving a conceptual problem that I’ve had, I mean I should look to everybody to see if this makes some sense but certainly there is an issue, there’s some discomfort bringing it up to a full forum for discussion and then what do you do at that point if there’s comments as opposed to, especially if there’s some major comments, what exactly do you do. Certainly one option you’re bringing up and let’s try it on for size, I mean that we send it out for comments, we have an open call of stakeholders to get input in say early October and that we try to arrange a call of the full committee say maybe the week before the full Forum to consider it and see if it’s ready for approval, and then we basically can present it as a document that is sort of hot of the press at that point.

MR. HOUSTON: I think John Loonsk, you probably want to talk to John about these points but I can’t imagine him not being in favor of it because it gets it out the door quicker, which is something I’m sure he wants.

DR. COHN: Well what do people think? Is that a reasonable proposal? Does that cause problems?

MARGRET: Would you still want to have an open call —

DR. COHN: We need to get some more input.

DR. WARREN: I would feel much more comfortable if the consortia saw our recommendations before we finalized it.

DR. COHN: We definitely need to open up the process, it needs to be more then us today and then having a conference call in the second week of October —

MR. HOUSTON: I’m not talking about precluding anything, all I’m trying to do is take out of the equation the possibility of getting a lot of input that we have to try to respond to at the Forum by simply, that’s the only thing I was trying to resolve.

DR. COHN: I think we could actually almost leave it, I mean it becomes an issue for John, I mean it’s either we need a little more time after the Forum to be able to deal with any comments or this is the other approach.

Harry and then Jeff.

MR. REYNOLDS: I’m great with it if you will ask John one question and that would be if we presented that letter at the Forum and afterwards ONC got a flood of comments about it, what would be —

MR. HOUSTON: What would happen?

MR. REYNOLDS: There you go, that’s all I’m trying to deal with through this whole thing is there is a forum right now that people can go to, that is ONC, we are on parallel paths with the Secretary, all I want to make sure is that whatever we do we have had a chance to respond, otherwise the response will go in through there and then what does that do to our letter. We have never been in a situation, tended to be in a situation before since I’ve been involved.

MR. HOUSTON: Two things, the first being is that by the fact that this meeting today was an open meeting, we have provided an opportunity for people to be able to hear and to respond. Secondly, the original deadline was extended by a month so the deadline was the end of September, correct? So it is not as though we are fundamentally changing the original, what we’re really effectively doing is extending it by two weeks rather then a month, the deadline, from the original. And I think it might be viewed as and accepted differently at the Forum if it is presented as a final product rather something for which you’re asking for comments on.

DR. COHN: We don’t need to decide this right this minute. Jeff? It’s a worthy idea.

MR. BLAIR: Simon? I feel very comfortable with your proposal, just a note of clarification, does your proposal include that we do that refinement of the document in terms of readability?

DR. COHN: The readability would be on a separate track, we could certainly have Susan Kanaan read it over and if there’s something that she can do on that but I think that I’m, I would sort of think that Mary Jo’s comment about if we’re going to turn this into a full fledged report in the way that we’re describing we probably need to do it in a thoughtful way after the report is passed. Are you okay with that, Jeff?

MR. BLAIR: Okay, the only other piece on that is that if Susan does review that I don’t, I’d be uncomfortable if she starts to make modifications without working very closely with Margret because Margret really understands why the sentences have the things they do, so I sort of feel like whoever it is that’s looking at readability needs to work closely with Margret.

DR. COHN: It sounds like you’re convincing me that maybe we do that as a separate process after the main document is finished. I mean we can’t have everything, something is going to have to get dealt with in a different fashion here and to me public input is the most important here.

MR. BLAIR: Maybe it was my thinking was that a lot of the concerns that might be expressed in public would go away if we just finished that readability portion of it so I was thinking of it from that standpoint.

DR. DEERING: I was going to say that, Jeff, I think we can make a commitment to do everything possible and to make it readable, the question of Susan I’ll leave to Simon to handle otherwise but I think Margret certainly is experienced in writing good prose, I’m happy to take another look at it, so I think we could certainly, and we’d want to make a commitment there.

But in terms of the deadline I wanted to just hold out the prospect of something that fudges just a little bit because getting this document literally into final, final, final, final form to hand out to people by Monday the 16th of October is really all but impossible I think. I’m just going to put it on the table, I just don’t think that we’re going to do it.

On the other hand there are things called pre-publication versions which I think the first IOM letter report on functions of the EHR was, I mean you put out, labeled all across the front, pre-publication version, you have the right to go back and make a few little tweaks that enables you if you hear anything that’s a real non-starter, if there is anything that really hits the fan, I mean you haven’t solicited it but on the other hand haven’t you hedged, haven’t you sort of like reserved the right, so anyway, so I’m just holding out that the fact that what is presented is presented as if it were —

MR. HOUSTON: I don’t see a problem with doing something like that, I think if we need to we do that, I mean I think we should still work as aggressively as we reasonably can getting a final product out, if we hold that in the bag of tricks if we need to. I would think you might want to still even if you are done stamp it that way just in case as you said totally glaring comes out but I think we’re going to avoid that, or I hope we can avoid that.

DR. COHN: Margret, did you have a comment?

MARGRET: I was just thinking of the timeframe and I was thinking about this mapping of the 112 to the 11 and I guess what I was sort of thinking and maybe we have some mental telepathy here or something that if we could get the document, the report part, really final, final and not get that appendix done, if we couldn’t get that appendix done there may be a little bit of tweaking needed in terms of what we find from that mapping. That is my major concern in the timeframe because that mapping I think will take a little bit of time.

DR. COHN: It seems to me like we have a couple of options, I do like the idea of having it finalized if we can but I’m also the more I hear I think we can do this in a couple of different ways and I think some of it we’ll want input from John Loonsk just to see what his thought is on all of this, so I don’t think we want to do this as a surprise to anybody.

MR. HOUSTON: We can ask him tomorrow, I think it’s our best opportunity to try to get this done in an efficient manner. I think the likelihood of churn if we don’t do this, how it will actually impact the final product will be negligible, I suspect that’s the case, end up going through a lot of gyrations and end up with a very similar product anyway, so I think this is a way to present that and give some concreteness to people who are actually attending the Forum that this is where things are going.

DR. COHN: The bad news is I may all surprise you tomorrow with what we decide but hopefully it will give the flexibility to work with John and others to try to figure out what’s the best pieces here. But I think regardless, I mean one of the key pieces here is an open conference call and I’m actually thinking early October, which Jeff is why I’m trying to push a little bit recognizing that we are, what is it the 14th, 13th of September, if we’re doing something say as early as the 3rd of October that’s basically two and a half weeks from now, it’s three weeks and by the time we get done with our meetings and can get something cleaned up and out to people, I think they’d probably appreciate a little bit of time to look at it especially if they’re looking at this in the context of the 12 and the 977, which we’d want to basically give them the opportunity to look at the entire piece even if we don’t have the mappings between the 112 and the smaller group of functional requirements. So I think we really do want to try to get this stuff out to people relatively quickly to get secondary comment. Mary Jo?

DR. DEERING: I wanted to clarify exactly what you meant by that because, I guess the question would go to Margret too, I’m trying to work the timetable back. Let’s say we do have the open call about the 2ndor 3rd of October, we heard before that giving people four days wasn’t enough to comment so we have to work back, what is a reasonable amount of time before the 2nd of October to get out what is our penultimate product to them. Because they’re going to want two weeks —

DR. COHN: Which is next Monday.

DR. DEERING: Which is next Monday, so just wanted to put on the table what those timetables were.

DR. COHN: That’s why I was trying to move this forward in a way that didn’t —

MARGRET: How much time do you also have to give the committee if you’re going to approve it before the Forum?

DR. COHN: That’s another good point.

MR. HOUSTON: Why can’t you, we tell the committee tomorrow, assuming that everything John Loonsk is okay with it, when we send it out to the contractors we send it out to the committee and then we send out a redline based upon what might change and say committee members here’s what has changed since the version you got and allow them, so hopefully they read the first version and they can distill down the changes from the second version and say okay, I see what’s changed. I think that works, maybe we should sleep on it and caucus tomorrow morning briefly before meeting, again, it was just a proposal, if you guys think it’s not workable —

DR. COHN: I think we’ll think about it, I don’t think there’s anything impossible here that we’re describing, certainly I think, I’m reminded about Paul Tang’s comment that he wanted to vote on it. And indeed —

MR. HOUSTON: Let’s vote on it, all in favor?

— [Laughter.] —

DR. COHN: But I think the reality is I think we all think it’s a pretty good document at this point.

Now having said all of that and as I said I think we’ve put in some elements, I guess from my own view I would propose that we try on for size October 3rd as an open call if that works for people knowing that for example, not that I notice but October 2nd is actually a high holiday for at least one religion that I happen to be a member of, I mean regardless of what path we take, it’s a Tuesday, I guess I would propose that we begin to think of that as something that needs to be happening regardless. Margret is asking how many hours?

MARGRET: Would the 4th be possible? Wednesday the 4th? No. Morning okay?

DR. COHN: Which time zone.

MARGRET: Central. I have calls all afternoon, I would have to reschedule those.

DR. COHN: So if we started at 9:00 Central time and went to 1:00 or something like that, would that work?

MARGRET: I’d have to reschedule one call at 11:00 but I can do that.

DR. DEERING: 9:00 to 1:00 Central, so it’d be 10:00 to 2:00?

MARGRET: 10:00 to 2:00 Eastern.

DR. DEERING: On Wednesday, on Tuesday, 10:00 to 2:00.

DR. COHN: And the rest of this we may play around with but I think that’s something that needs to happen regardless. Are people okay with that? With the idea being that we will get out a revised but probably not all that revised version for people for comment by Monday.

DR. WARREN: I think it’s pretty close right now.

DR. COHN: And I think we can reflect, I mean I’m very sensitive to Jeff’s comments in terms of readability so we just need to think about, especially if there’s things that are sort of not clear which is different then I would almost review as readability issues, and Jeff, you may be observing, I haven’t looked at your redline version.

MR. BLAIR: I think I pointed out maybe most of them, and I agree really, when I’m saying readability this is a very, very good document, I’m talking about polishing, refining, finishing it especially for new readers, that’s what I’m focusing on, so that people don’t get tripped up, that’s all.

DR. COHN: Now the other piece is as we begin to put all this together, I think that there needs to be, once again we have not really thought beyond today in terms of getting this document finished because we didn’t know whether we were going to have additional time to work on things or not. I’m suggesting that there probably needs to be some conference calls, at least one between now and that open call, to see sort of where we are. John Paul.

MR. HOUSTON: I think that the people, there’s a core group of people I think that need to be educated on this or hear their issues and I think a lot of this committee is probably already happy so if you’re talking about a conference call of this workgroup we’re not the ones we need to sit down and have a conference call with.

DR. COHN: You think it’s the full committee?

MR. HOUSTON: I think it’s the full committee or an opportunity like we did with the privacy letter, for the full committee members and others to have the opportunity to call in and ask questions, again we ain’t the ones that are having the problems, or should have the questions at this point. So I think we hold an hour or two conference call and hear what we hear and if people don’t voice concerns, don’t voice questions that we need to react to, I think we short circuit the process again. This is a letter with a tight deadline on it and the endless consensus building can’t go on, we have to tell people this is your opportunity.

DR. DEERING: Were you thinking that this would take place after the document already goes out to everybody else for comment but before the open call?

DR. COHN: Well that was what I was mulling about, I mean we could, and I guess I’m looking that if we don’t watch out things are going to get busy after that and we obviously would want to get everybody’s input before we start looking towards the NHIN Forum or anything like that, so maybe the last week of September for committee members.

DR. WARREN: Simon, do you see the committee members going to the open forum or just a select few that would be involved in the presentation?

DR. COHN: You mean workgroup or you mean full committee?

DR. WARREN: I mean our workgroup.

DR. COHN: Well, one of the things that I need to know from people is whether, and this is something that I need to provide to John is who wants to participate in what fashion, I mean I’m certainly expecting the chair and the vice chairs, Jeff, to be there, but whether or not they’re able to be there for both days, I already know that Harry is going to be able to be there on the second day and I’m not sure that I can myself.

But I think the question is is if, I mean this is an opportunity where I’m happy to provide John with a list of people that are willing for example to play reactor roles, moderator roles, that sort of thing, which I think he’d like to have us involved in. Obviously part of the question got to be is whether or not we were going to be trying to get more input at that session and I’m hearing that at least as of this moment unless we change our minds that this may not be an occasion for an open session with everyone. I was going in thinking we would have a two or three hour session even if it wasn’t an official NCVHS meeting to be able to hear people’s concerns, comments, answer questions and all of that, and I’m thinking that maybe that isn’t what we do at this point.

So I think it’s really a question of what role you want to play and how we play that if that make sense, so maybe you can leave me little notes before the meeting ends tomorrow with your interest and availability if that’s okay with everybody, or you can send me an email if you want to the next day but it would actually be better the sooner the better on that one.

Now it is 15 minutes to 6:00, have we had enough? Okay, well with that knowing that there’s more to talk about the meeting is adjourned.

[Whereupon at 5:45 p.m. the breakout session was adjourned.]