[This Transcript is Unedited]




September 15, 2010

Embassy Suites Crystal City Hotel
1300 Jefferson Davis Highway
Arlington, VA 22202

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


DR. TANG: We started out looking at quality measures as part of the Quality Work Group, and we also grabbed onto what we called meaningful measures, thinking that one of the things we’ve heard about in our whole Quality series is that people aren’t necessarily getting what they wanted out of so-called “quality measures”. A lot of reasons for that – part of it is what’s available, how they’re defined, what’s currently in NQF, et cetera – there’s a lot of reasons. So we tried to move toward – well gosh, if we had to reinvent the world, could we come up with measures that were meaningful to people? And that’s how we coined the term “Meaningful Measures”.

And we found that well, actually, of all the groups working on things, not necessarily – we couldn’t find anybody that was actually working in that direction. So that moved us towards thinking about a strategy for going toward Meaningful Measures.

Now in parallel is a rather intensive activity that tried to either retool or create some new measures in fulfillment of the Meaningful Use program. And so in fact, there is the retooling effort, which is essentially taking existing concepts for measures, and redefining them so that they draw on data available in EHRs. So that’s the retooling. Take what exists and make the data come out of EHRs. After doing that exercise, which is sort of done for Stage 1, there’s still a need and a desire to strive more toward meaningful measures, in stages at least three, if not try to be two. So there is a new work group of the HIT policy committee, that’s charged to work on quality measures for Stage Two, in a sense.

We still have our original goal of trying to go toward the goal and work backward, rather than sort of a bottoms-up approach, which by necessity ONC and HIT policy committees have to do.

So that’s where we came up with the idea of let’s think of a strategy and a road map of getting towards the real quality measures that would satisfy a lot of the needs that we already had but couldn’t fulfill, whether it is for patient care, population assessment, public health, et cetera. Is that a fair summary, Justine?

DR. CARR: Yes.

DR. TANG: So that’s our charge. So we came up with the idea of well, you know what, that’s such a new topic, we need to have more information; i.e., a hearing, to talk about that subject deliberately. Part of that is to do an environmental scan and had a conversation with Booz Allen folks, who contracted to help us, and to make sure that the environmental scan doesn’t inadvertently – because obviously, what’s out there already is reporting on the stuff that we said isn’t good enough, so learning what’s not good enough isn’t what we truly wanted to know.

It is first, where are organizations accomplishing the goals we want to accomplish, which is to improve the quality and health status and quality of health status of individuals, then find out what they used to get there, and probably they had to measure something, so they knew if they got better at it, and what are the attributes of those measures?

So that we may find in the literature, not by looking at what people are doing with the existing quality measures. Does that make sense? So we had this discussion at Booz Allen, and that was a very – what I just reported to you is, I think, the ah-ha moment there, is that it’s a different kind of environmental scan. It’s a look for not where the light is, but a look over there where some of the benefits accrue.

Okay, so we’re going to have the benefit of the results of the Booz Allen assessment by September the 24th. And by the way, let me introduce them. Kathryn Schulke and Hayley Anne Severance, and Christine Martin Anderson, are working with us on this project, and they’ll be with us through the report.

So with that as a background, maybe what we should do is look at the – well maybe give a little bit of time with you all to go over the plan of the environmental scanner, whatever we want to call it.

MS. SCHULKE: I’m Kathryn Schulke, with Booz Allen Hamilton, and I’m working with both Christine Martin Anderson and Hayley Severance on this environmental scan and literature review. Hayley will talk you through kind of the methodology and our approach of how we’re capturing and searching for the relevant information, but I do just want to make a couple of points.

We have framed our environmental scan based upon the original four research questions that were given to us by the committee, as well as an additional research question that was identified on conversations with both Dr. Middleton as well as Dr. Tang. And that is, really, to add a research question around also looking at what providers need in their ability to measure either the improvement of care and/or accountability.

So that is a research question that has been really added in the last 48 hours, I think, and we are moving forward on our scan.

And I also just want to confirm what Dr. Tang said, in that when we’re doing our scan, we really are looking for future needs; what do you need as either a consumer or a payer or a purchaser or a provider? What do you need in the future to be able to measure the care that’s being provided, and in addition to that, we’re also looking to see if you’ve had successes, and if you’ve identified either a best practice or a lesson learned in terms of really, truly improving the quality of care that’s provided. How can we also capture that and help align that or analyze that with the future needs.

So that’s kind of the focus and the approach that we’re taking in terms of conducting the environmental scan, and Hayley can talk you through the actual methodology and approach that we’re using.

MS. SEVERANCE: So the first stop in our work plan would be to define research questions. We really wanted to focus on who the stakeholders were in each of the 60 ; 60 ; 60 ; questions that were posed, and so we broke down the questions in terms of the terms and phrases used and identified definitions with them that we would use in our research efforts. So that was our first step, and I think after our conversations with Dr. Tang and Dr. Middleton, we really came to a consensus on who were the actual stakeholders.

So right now we’re in Step 2, which is identifying and collecting the information, and this is basically best illustrated through our Table 2, which is on page four, and so we outlined, according to each research question, some example stakeholders who we’re looking at a little bit about their mission and initiatives, and within each of these initiatives we’ll identify the ones that are the most successful and the lessons that we can take from the successful initiatives.

And then future needs would be the second to last column. We are identifying through mostly literature, what their future needs are.

MS. SCHULKE: If I could just add something to that, on Table 2, for the stakeholders, those are really representative stakeholders. It’s just a small sample of the stakeholders that we’re looking at for each of those research questions. There’s a much more exhaustive list of actual stakeholders that we’re looking at for each of the questions.

MS. SEVERANCE: So you think the synthesis of this information that we’re gaining, you think our research capabilities then will synthesize the information and identify the most important future needs in each of the stakeholder groups according to each research question?

DR. TANG: On stakeholders, for the second topic of providers, you said – what is HRET?

MS. SCHULKE: Health, Research, Education and Trust – It’s a not for profit quality division of the American Hospital Association.

DR. TANG: So you might expand – I know that is not exhaustive, but maybe people like ACP, American College of Physicians, you know, one of the large provider groups, but other, much closer to the front line, and the people who use the measures to improve themselves rather than aggregates of providers at a high level.

A lot of work is going to come out of, let’s say, Brigham and Women’s Hospital, it will come out of Regenstrief, it will come out of Kaiser – I mean, there’s a lot of places where they do the actual care – how they improve the care.

MS. SCHULKE: So looking at Geisinger, and Premier –

MR. QUINN: Primarily hospital based or more broadly?

DR. TANG: Definitely more broadly, and my only hesitation was primarily out of the hospital, because that’s where the care and health happens. So if there’s a bias, it’s certainly not in the hospital.

MS. SCHULKE: Okay. So for the provider research question, that’s one of the things we did want to clarify; we are looking at inpatient-outpatient institutionalized care, clinical practice –

DR. TANG: Let me check out whether other people agree. I think it’s more out of hospital. Hospital is such a confined piece of anyone’s life, and to improve, certainly, the health status of the population is way going to be in the out-of-hospital experience. I want to ask other people what they feel.

DR. SCANLON: There is an intensity of experience – that if –

DR. TANG: Not to be ignored.

DR. SCANLON: – a little bit wrong and it’s dramatically –

DR. TANG: That’s right.

DR. SCANLON: So that’s important, and there has been – I mean, you can think about some of the things like Geisinger’s and their initiatives on proven care. Their hospital focus is kind of like, if we’re going to have this encounter, it’s a serious situation, we need to think about how do we maximize the value?

And there have also been the efforts like thoracic surgeons and their registries, sort of cardiac surgery New York State reporting, so I think these events are so big, and even though they are low incidence, they are important to have.

DR. CARR: The medical home experience, out of group health, you did mention that, I’m sorry, I got a little bit sidetracked, but they just published their two-year experience, that gave patient satisfaction, outcomes, physician satisfaction and cost, all favorable.

DR. TANG: And that raises another bias. So the current bias is the quality of process, like care, but I think we want to get closer to the outcome, always had an orientation toward outcomes. In outcomes we’ve done these survey things, but in the new world we can certainly go directly to the patient on a more continuous basis, so whatever literature probably not going to be as encompassing as the new emerging is? Just don’t want to confine ourselves again quality measures.

MS. SCHULKE: So the question I would have is in terms of the role of the hospital or the institution in terms of care coordination and transitioning of care between provider studies, I think that that would be an important aspect to look at, particularly around measurement.

So I think what I’m hearing is that when we’re looking at hospitals, not just to look at inpatient hospital stays but more as it is relevant to the patient moving in and out of the system.

DR. TANG: So when I just phrase it the other way, which is when you’re looking at population of individuals’ health, then do you not consider not only the ambulatory but the times that they also have to spend in the hospital or other institutional setting? It’s just a different bias.

DR. CARR: Do we want to do anything with the Oasis home care data? I think it’s called Oasis.

DR. TANG: I think they’re moving to something different, but –

DR. CARR: They just did. It’s actually very interesting. So it’s something that we’ve not paid a lot of attention to, yet as we think about continuity of care, it’s to me, becoming a critical piece.

DR. TANG: Mike?

DR. FITZMAURICE: Let’s suppose there was a program for meaningful use of personal health records. There isn’t one now, but let’s suppose there were, and there had to be meaningful use measures, performance measures. The personal health record might note some things like exercise, weight, eating, so to get a payment for meaningful use of your personal health record, you would have to click this information and submit it somewhere, maybe submit it to your own physician, to be set up and analyzed, but it could follow the same kind of program, same quality type measures, numerators, denominators for a population and a center for payment for use of personal health records.

DR. CARR: I think there are some like that, are there not?

DR. FITZMAURICE: I think there are some benefits for if you’re in this exercise program at the company’s office and you get something, but I’m thinking in terms of if there were to be an expansion of meaningful use and of incentive payments, it could reach down to individuals and you could then measure, do these quality measures line up with better health, which may be less use of hospital and physician services, or it may be higher rankings on a health status measure of some kind for individuals that, when aggregated over the population, you get some benefit for these incentive payments to the population?

DR. TANG: I think the summary is the bias is to look for the novel thing, innovative measures, rather than things that we actually know, either consumers or providers, already have that data. So let’s go for the new data, and what makes them powerful – that’s the road map we want to go. Can’t we make us all Geisinger, you know.

DR. CARR: You know, we heard – well, when we had our medical home hearings, we had great presentations from Geisinger – I’m mixing this up – we didn’t have Tony Rogers there, that was meaningful use, but who did we have in the – oh, it was in North Carolina, the Medicaid program. I mean, if you weren’t looking at those presentations and even, perhaps, revisiting, to say what measures are they using. They had a really robust Medicaid program, and actually, Tony Rogers we heard a similar thing, and also Farzad(?), looks like if you have a great program, you get promoted.

DR. GREEN: Allen Dobson is the contact for that. Allen Dobson in North Carolina. Another set of measures is the National Demonstration Project that TransforMED did that came out in June. They have a robust appendix, the set of measures that included practices as iterative analysis, also individuals iterative analysis and reached across these settings.

DR. CARR: Right. I know we’ve talked a lot about American Board of Internal Medicine, or American Board of Medical Specialties. Is there something that we would look to – is there measurement of that program in terms of outcomes of patients?

DR. GREEN: There’s more than one program that sits there. One of them was the IPIP initiative that RWJ funded that was done by the three primary care specialties, pediatricians, internists and family physicians. Then another thing that’s going on there, though, is the Big Lever, following Paul’s leadership here, to think about the novel and future ways of doing this. The Big Lever is called maintenance certification, and the American Board of Medical Specialties is all over looking for measures and metrics that can be deployed all across the country, and to every community, that can be used reliably to determine whether or not the care being rendered is proper and whether or not it’s having desired effects. It’s a very big future opportunity.

DR. CARR: We don’t have them as a speaker.

DR. TANG: So where’s the good stuff happening, what do they use and then your analysis is really, and what are the attributes of those things that engage the folks who are trying to change and the folks couldn’t change, that’s why the providers are such an important group. What are the attributes that make it convincing, compelling and that changes it for those folks, then we can figure out, then we can put together strategy I think. I mean, that’s the past. Any more on the work plan for the environmental scan?

Next we turn to our hearing schedule, and that’s a two-pager everybody has. This is what we thought at the time, and so this is our chance, it is our last chance, to update these, since we’re going to invite people in about a month.

So with that caveat, let’s look at the titles we have and see if we’ve missed something. So, the first one was, we say the traditional consumers of these measures, which has traditionally been the payers, sort of surrogates for the patients and consumers. And we know that they don’t get paid attention to at this point, so something’s wrong. We’re either measuring the wrong thing or we’re not making it understandable.

So anyway, those traditional consumers, what’s their perspective on quality measures?

The second topic, I think this is where it might have been worded a little different, but the goal here, I think, was supposed to be what do the providers find, what quality measures would providers find useful to them to include in their care and improve the health status of the folks that they serve? That’s not exactly what this says, I don’t think, and so we may have – What do people think about that topic as I restated it? Is it more on track?

DR. CARR: Say that again.

DR. TANG: It’s really, we’re looking at it from the provider’s perspective – If I had these measures in a standardized way and I could compare myself against others, what would those be? I would love to know that, because if they believe they had that, our experience has been that they improve.

PARTICIPANT: To change those who create measures –

DR. TANG: Yes, not worried about who creates measures, because I don’t think they’ve been delivering the stuff that we need. I’m more interested in from the provider’s perspective, what do they think we need?

MS. SCHULKE: So if I could just clarify. I think that the second portion here from 1:00 to 2:30 is really going to take on our new research question, number 2, correct?

DR. TANG: Yes.

So in some sense, we’re trying to discover what the attributes are of a good measure so that we can communicate that to the measure developer, rather than have measure developers tell us what they have been doing.

DR. SCANLON: Can I raise a question about that. I mean, I’m thinking about this from a provider perspective. I guess it’s not just a question of a measure, but it’s also my confidence in the measure, because if I get a bad report, my immediate reaction was you didn’t risk adjust properly, because I have sicker patients and they should have.

And then this is something that’s come up years ago in a quality hearing when AHRQ, we had a presentation about mortality and hospital mortality predictions and how when you add explanatory variables you change the quality of the risk assessment. Mark, at the meeting in June, raised the issue of he’s in a position, with data flowing to him from all types of providers, to get a very different measure of an individual provider’s performance because he’s got information about that person’s patients from other providers.

So there is this question of what is it going to take to create the measures that people have confidence in. I think that’s a very important thing, because at this point, there’s still a lot of focus on when we talk about getting information on EHR, getting it out of a single EHR. And we need to think about how do we – besides the Marks of the world, which are – they’re not going to be cloned tomorrow – how do we get to the point where we’re going to be able to put more information together to create confidence in the measures we have?

DR. TANG: I think that’s an important point. Maybe that’s the difference between your column of initiatives versus future needs? So, most of these measures that have been affected have been occurring in integrative delivery systems for multiple reasons.

One is they have the money and the expertise, the other is they have the data, most of it. So we can certainly learn from them what kind of data, how is it defined to know what is credible to the people we’re trying to change?

And then our future goal is in the next millennia, when information is truly interoperable, we really want to know from every patient-centered measure, no matter where they go. So we can understand what happens to an individual, no matter who touches them, but it’s a bit future but that is the end goal.

DR. CARR: As you say it, that really is a critically important thing. We’re starting with the assumption that the registry that’s developed from your EHR is going to be sufficient, and if Marc Overhage had stayed on that of EHR free standing versus a continuum of care and how that affects the outcome, I actually think that’s hugely important.

DR. SCANLON: Well he did demonstrate an example in June – He’s not sitting there anymore – but he did give us an example in June, saying that there was a group that was rated extremely high when you look at their data alone versus when you combined their data with others, they were ranked incredibly low.

DR. TANG: Do you know who we are talking about – Marc Overhage? So clearly, it’s probably unpublished, but if you can get whatever he –

DR. SCANLON: It’s in a transcript.

DR. TANG: So if we can get pointed to wherever you can get that kind of stuff.

Okay. The next panel was on looking at the professional organizations, accredited regulators. Those kinds of folks who do with this data some other things, whether they’re accredited or regulate or pay, that is their perspective. So that was the third panel. Any modifications to that?

MR. QUINN: The numbers, I had asked for Christine Martin Anderson’s to assess the rank and give some feedback, numbers 1, 2, 3 and 4 are in order of preference.

DR. TANG: Okay, actually I’m going to probably – you know what, we don’t have – well maybe the MOC comes in here somehow, and that needs to be then the professional association. ACP is an example, AAFP is another example, where we’re looking at how do professions like those two predominant ones, for primary care.

Kevin Weiss, that’s true, would do the MOC piece. And that’s fine if he can represent the whole thing.

DR. GREEN: I think he can do that and I draw a distinction, Paul, between the certifying boards, VMS, and ACPA, AFB and AAP. I think we’d be more interested in the boards for these purposes. They collaborate, they talk to each other, and they may show up to hear what their board has to say. So ACPA may show up to listen to what Kevin says about APIM.

DR. CARR: I’m not sure, HIMA – trying to figure out how that fits with the others.

DR. TANG: I’m not sure that fits.

DR. CARR: I think it’s not the same.

DR. TANG: Let’s see, the fourth panel on the following day, is how do you measure value and use it for decisions about coverage? Certainly have people there that are addressing that.

DR. CARR: Do we have Leapfrog here anywhere, and do we need them?

PARTICIPANT: We don’t have Leapfrog as a staple for interview, but not as a proposed speaker in one of the panels, but we could clearly add it at this time.

DR. TANG: We can go through the panels now and look for suggestions. So the first one is the consumer perspective and everybody fixes on the same names, but we’re trying to – we ended up with Consumer Union and National Partnership. Other suggestions in terms of trying to represent the consumer who have to understand, one, what consumers – ideally what consumers need, also know what they are doing now and why or why not they’re doing what they’re doing.

DR. CARR: I’m thinking about caBIG and some connection there. There aren’t really measures that come out of caBIG, I guess.

DR. TANG: I don’t know, yes.

DR. CARR: Patients that are empowered. I’m trying to think of other people besides the usual.

DR. TANG: That’s right. And actually it almost – you’d like to have infinity groups, because if I were someone with this condition, what would I seek out?

DR. CARR: Yes. I mean, caBIG, I think, is like that. That people contribute –

DR. TANG: Is that true?

DR. CARR: Is it like Patients Like Me?

But I think understanding the psychology of those empowered patient groups, that’s what we’re looking for.

DR. TANG: What’s another example?

MR. QUINN: There’s one called Diabetes Mind, there’s a cancer group –

DR. TANG: Well now, those groups are self-forming and they exchange information among themselves. We are looking for a group that can comment on what would information from my provider group do for me? How would it influence my choices? And I don’t know.

MR. QUINN: I went to the Interagency Committee for Disability Research Meeting yesterday. Certainly it would be interesting to hear from one of the disability groups, whether it be the deaf or the blind, or one of those groups, to talk about the sort of information that they need, and that would be an affinity group, but it would also cut across not just their own research, but it would cut across measurement, domains, so chronic disease and other things. It might be interesting.

DR. CARR: What about Cincinnati Children’s parents’ group? You know, the parents’ group that were asking about the outcome for their cystic fibrosis kids and then they became empowered and they worked with the institution to improve the outcomes?

DR. TANG: So you know that story?

DR. CARR: Yes.

DR. TANG: That’s the kind of story – Well, let’s see, so how did they use quality measures, or did they?

DR. CARR. So the kids were being cared for there, and they learned from publicly reported measures that their care and their life expectancy of kids at Cincinnati Childrens’ was not good compared to other places, and instead of leaving to go to the other places, they partnered with the leadership.

DR. TANG: That’s perfect. That would be a neat story.

DR. SCHULKE: And just to add a little more information around that, it was also as the Cystic Fibrosis Foundation was starting to compile the data by each of the cystic fibrosis centers and publicly report on the Cystic Fibrosis Foundation.

DR. CARR: I think it’s a great story because of the outcome is exactly –

DR. SCHULKE: And they are very clear outcomes – FEV-1s, body mass, and they were very clear outcomes that are clinical indicators of care.

DR. TANG: We need that kind of scenario to describe what it is we’re looking for in the future.

DR. CARR: Right. So there has to be, if we have one that was a step toward an outcome we desire, I think that’s the best.

MR. QUINN: Another – Ontario Hospital Association in Canada, publishes quality measures, not just quality measures, but characteristic measures of all the hospitals. They do it in the newspaper, and they actually – in a previous life with GE, we pitched them and said wouldn’t it be great if your hospitals knew what their measures were going to be before they came out in the paper, and that they could do something about fixing them? And I haven’t checked in on it in a couple of years, but it was really a powerful program, because it was so accessible to people through the newspaper.

DR. TANG: So it would be nice to distinguish between the publication making people change versus the measure being that powerful. I heard things like FEV-1, which is a measure that’s very relevant, and the providers believe – do you see what I’m saying? It sounded like it had some of the attributes of what’s very relevant to this population, and if that’s true of the Ontario Hospital, that would be good too.

MR. QUINN: They changed the measures over time based on what was relevant or not relevant.

DR. CARR: Consumer Reports has just taken STS data from cardiac surgery and they’re now making that available and getting 1, 2 or 3 stars based on your SCS outcomes. Again, it’s just come out – it’s kind of like health grades, I guess, but remarkable that they got that registry data.

DR. TANG: There are some caveats that are important, like the STS has editorial control over what Consumer Reports publishes.

DR. SCHULKE: But my thought on what might be interesting about that, just looking into the future for the consumers, is the different ways that consumers are going to be able to start understanding the care at their provider level. The people who really are used to going to Consumer Reports to look at their cars and their tires and their dishwashers, it might be of relevance just to see if that is a place that the information is going to stick with consumers, despite all of its potential kind of flaws.

DR. TANG: So what you’re saying is, what are the attributes of the assessor and reporter that make it more useful?

DR. SCHULKE: Exactly.

DR. TANG: Consumer Reports has defined itself and has a track record for quote, unbiased and no conflict of interest stuff, which is why this other caveat is a bit of importance because it’s an anomaly.

DR. GREEN: Well, I like these examples. I’m sitting here thinking about others. The cystic fibrosis thing is so nice because it brings a child and a family into the story, and I like your example of Ontario where it takes more of a community-wide perspective. So much of the money is in Medicare. Maybe AARP?

DR. SCHULKE: Actually, one of the suggestions we had was Joyce Devoy? I’m not sure I’m pronouncing her last name correctly – from AARP, as kind of a Medicare consumer voice. That was one thought we had.

DR. GREEN: Do they have a story to tell about what their members are looking for?

DR. SCHULKE: I would hope, but I don’t know that they have kind of the same –

DR. CARR: You know, what about the Commonwealth Fund, it has this website “Why Not The Best”, where they take the hospital, compare data and you can slice and dice and compare them.

DR. TANG: That’s a good idea, because they have essentially a product line about comparison, particularly global comparison, and they could inform us on what –

DR. GREEN: About thirteen countries are doing – at least six or eight.

And they have both a consumer and a provider – They have a broader perspective. I like that idea better than AARP.

MR. QUINN: One thing CMS has been doing for a while is around the long-term care reporting, I don’t know if there’s any stories of track record or changes since they launched that. That was their first toe in the water about five years ago.

DR. TANG: Which is helpful – how credible it is.

DR. CARR: I mean, what we’re looking for in a way is when the data were made available and who looked at them, and what changed with that? So if, I mean, Flowers Hospital in Alabama is always at the top of the list, so I always go through this, Why Not The Best? I’d be interested in going and seeing what’s going on there. It is that kind of thing. It would be interesting to know what happens with that.

DR. TANG: So let’s start summarizing in our minimal time left. So for an hour and a half, I’ll tell you one of the models we’ve used in HIT Policy Committee, and I think we’ve used here, is very small presentations, and what we mean by small is five to seven minutes, leaving most of the time for discussions. So in an hour and a half block, I think we’re going to have lots of discussion, because this is so probing and merging – for an hour and a half block, four is good, is the best probably, and five is the most, if we end up there. So we’ve mentioned so far the Consumer Union – I love this cystic fibrosis story, that’s the Cincinnati Hospital. Then you talked about Ontario, and you talked about the Commonwealth Fund, and then you talked about the Alabama Hospital.

DR. CARR: Yes, I mean, one would know that they had the highest scores because I could testify that I use “Why Not The Best” and I’m very interested in Flowers Hospital.

DR. TANG: So maybe, almost in that order.

Okay. The next one was the provider’s perspective. So Marc Overhage stands out because he got a bunch of competing hospitals to go participate and go do these things and so on and so forth, so he’s an example. Anybody else want to start speaking for some of these other folks on this list?

MR. QUINN: You mean do we want the guy from North Carolina and this one or another one? Larry had mentioned his name. Allen Dobson, I’m sorry.

DR. CARR: And what about Group Health? Or is that a background?

DR. TANG: Even though they’re background doesn’t mean they can’t testify. People who can be articulate about the true needs.

DR. CARR: Right. But I think where Group Health has already published their data, they’ve put a lot of thought into what they needed and how you get what you need.

DR. TANG: The same as the Geisinger story.

DR. CARR: Yes.

DR. GREEN: Allen Dodson might belong better in the October 19th

MS. SCHULKE: How you measure value?

DR. GREEN: I detect a need to reduce the size of this?

DR. TANG: Yes, we have to reduce the size of this.

MS. SCHULKE: And are you thinking for this panel the same sort of construct in terms of five to seven minutes, four to five members?

DR. CARR: Maybe let’s just go through what is the story line – this isn’t the right question, is it?

What do providers want/need? Okay, so Laura Adams is the President of the Rhode Island Quality Institute.

DR. TANG: Do they have a big story? Not a very big state but still a relative story.

DR. TANG: Mark is standing out and what about –

DR. CARR: Advocate Partners, again a system of care – I don’t know, do you know anything about Advocate Partners? Another group I follow, but I don’t – I mean, they have a very systematic approach of measuring, setting a work plan, doing it, measuring it, reporting back.

DR. TANG: What is it, a physicians’ group?

DR. CARR: Yes, it’s a physicians’ group.

DR. TANG: And they got good results?

DR. CARR: And they’re very systematic, and here’s what we’re doing this year, and then they do it, and here’s what we’re doing next year.

DR. TANG: Do they make their own measures, so is it the measures that are –

MS. SCHULKE: Let me just pull up their – my thing, you can take a look at it and see.

MR. QUINN: If we’re going to look at accountability here, do we want to have somebody who is like a California IPA type representative? Closest thing to accountable care organization-type structure.

DR. TANG: I think the main thrust is – influencing physician behavior. Whoever can do that really well.

MS. SCHULKE: Dr. Tang, if I can just say, I was handed a note from Christine that said, in this particular panel, she would suggest that we look at one person who has worked with a mature HIE, and her recommendation was Laura Adams, that we work with one government leader such as Terry Collen(?) or Yale Harris, and that we have one measure creator such as Barb Rudolph or someone from STS, and then a health systems person who is creating measures on the ground in order to advance quality improvement.

DR. TANG: But I think our bias is more toward what the providers use.

MR. QUINN: Terry Collen could be a good person. DR. TANG: They have done some good stuff in their system, as has the VA.

PARTICIPANT: We have Steven Andre(?), he can speak to that.

DR. TANG: It would be nice to have groups that are more representative, because clearly the VA and the Indian Health Services, they’re a good example of what can be done. We need examples of what other – like the group that Christine was talking about, I think.

MR. QUINN: I think I put this one in there – Fred Rockman is an AHRQ grantee that has done a lot of quality improvement efforts in community health center type settings. He is the CEO of a group of those really underserved communities in Chicago, and is a brilliant speaker.

DR. TANG: He did that driving with quality measures? Do we know what kind of quality measures he used?

DR. CARR: We can find out.

MS. SCHULKE: We can find out. Would it be useful if we took those five or six names and did a little more research in terms of actually looking at the measures, looking at their improvement, looking at their success and then communicating back before we confirm?

MR. QUINN: You know something, that if we want to do two hours on this too, and have a few more speakers, we could do that, and then just take 15 or 20 minutes from the closing time.

DR. TANG: So let’s give one more name, let’s say.

By the way, do both these Chicago groups have EHRs?

MS. SCHULKE: One of the other groups that we had brought up, I don’t know if there’s interest or not, is looking to the quality improvement organizations in terms of the measure work that they’re doing in the Medicare/Medicaid population across settings of care, where they clearly have defined scopes of work and measures that they’re moving toward improving.

If you’re interested in that, my recommendation would be Dr. Mark Bennett, from Utah, who has just done a lot of work in his state, and was the past President for the American Health Quality Association, and I think would be able to speak to the use of measurements driving improvement across provider groups.

MR. QUINN: Is there any example that jumps to mind of groups that are able to bridge the gap, other than an integrated delivery organization, to where some of the responsibility is for the discharge and the hospitalization, and some of it is for the post-discharge period, and some of it is for the follow-up?

DR. SCHULKE: I think Colorado is probably moved to the farthest in terms of leading in care coordination across settings of care when you’re not in an integrated health system, where the system is driving the coordination as opposed to the providers driving the coordination, and the processes driving it.

DR. TANG: Have they gotten measures?


DR. TANG: That’s a bit more like what Bill was saying.


DR. TANG: If we had an example of that, that would be great.

DR. SCHULKE: And that would be R. J. Adair is the CEO or QIO for Colorado.

MR. QUINN: It’s been acceptable and palatable for all involved in divvying up responsibility and properly assessing accountability.

MS. SCHULKE: And they’re also looking, they’re tracking hospitalization measures based on the care coordination effort, because that’s the ultimate goal, is to reduce rehospitalization. So we could again, just add them into our group and provide some additional research for you in terms of whether they’re appropriate for the panel.

DR. TANG: Unfortunately we have two more panels of this group. So I think we actually had – this one, we had some good names. I think we dropped the HIMA for this particular panel. We had Mark Chasin and Kevin Weiss. Tony Rogers would be great. David Lansing from PPH, so I think we have enough to draw on.

MR. QUINN: We lost, from GE, you know he’s a Blackstone partner.

DR. TANG: Bob Calvin(?).

MR. QUINN: Do we want to try him?

DR. TANG: He was a lawyer – that might be in the last one, right?


DR. TANG: Okay. So let’s move to the last one. It would be terrific to get Mark McClellan or Elliott Fisher – Karen Kapetic, if anything, could be possibly in the accreditor, is that right? I don’t think – we have had her, that’s true, we did, for the Meaningful Measures, and I don’t know that she’s doing thing about coverage. Kevin Fitzgerald – who is –

DR. GREEN: Kevin Fitzgerald is – I would be even more enthusiastic about him now than before, with the designation of Grand Junction, Colorado as a beacon community. This is a mature community, 20 to 25 years of working together across centers. He will say something we’ll be glad to hear.

DR. TANG: And then Jim Muld?

DR. GREEN: He doesn’t really fit here.

DR. TANG: We might want to put one more name then – I don’t know that we could get Mark or Elliott or both. Bob Galvin would be good in this.

MR. QUINN: As much as I’d like to think that we could get Mark McClelland – If he’s available to call in, would that be acceptable?

DR. TANG: Yes, absolutely. Well you know what, maybe one from the plans.

DR. GREEN: How about someone from the Blue Cross/Blue Shield Association?

DR. TANG: Someone we used to know? (Laughter)

DR. GREEN: Jumping away from that line of thinking, what are your reactions to thinking about getting Paul Gurney.

DR. CARR: I don’t know Paul Gurney.


DR. GREEN: Paul Grundy. You know who I am talking about. Here is a guy that makes decisions about coverage in about 35 countries.

DR. TANG: That was the Bob Galvin type – right? They could be interchangeable – is that right or not?

MR. QUINN: Paul Grundy has been very involved in the medical homes – he has a big role in PC PECC, as well. Bob Galvin has been more quality improvement.

DR. CARR: They both sound good.

DR. TANG: Okay, we might be done. What do you think? Sounds like a good line up.

MR. QUINN: We just have to get them. We set aside two hours after lunch to begin writing the paper.

DR. TANG: Catherine talked about between the environmental scan and the hearing, they would help us prepare essentially the outline of the report, which was a technique that was used in another setting, and that sounded like a good idea.

(Whereupon, the subcommittee adjourned.)