[This Transcript is Unedited]

National Committee on Vital and Health Statistics

Subcommittee on Standards

E-Health Vision and Standards Roadmap Roundtable

September 18, 2013

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



Agenda Item: Welcome and Review of the Agenda

DR. SUAREZ: Good morning everyone. Welcome to the National Committee on
Vital and Health Statistics Roundtable on E-Health standards. We are very
excited about today’s event. This is our second roundtable on this topic. The
first roundtable we had back in November of last year, and it was an opening
roundtable to talk about road mapping and the future of information exchange
and data needs.

I think we are going to go ahead and do some introductions first, and then
we will make some remarks. We want to of course, first of all thank our host,
the National Center for Health Statistics, for having us here today. We are
going to go around and do introductions. I should start. My name is Walter
Suarez. I am with Kaiser Permanente. I am a member of the National Committee on
Vital and Health Statistics and co-chair of the Subcommittee on Standards. The
Subcommittee on Standards is the subcommittee that is convening this
roundtable. We are very appreciative of your attending today.

If you could just tell us your name and your organization that would be

MR. SOONTHORNSIMA: Hi. Good morning. My name is Ob Soonthornsima, Blue Cross
Blue Shield of Louisiana. I co-chair the Subcommittee on Standards. Thank you
for being here this morning.

MS. KLOSS: Good morning. I am Linda Kloss. I am a health information
management consultant. I am a member of the Full Committee and co-chair of the
Privacy Subcommittee and member of the Standards Subcommittee.

MS. GREENBERG: I would ask that the members just identify if they have any

DR. SUAREZ: I do not have any conflicts. This is Walter.

MR. SOONTHORNSIMA: No conflicts.

MS. KLOSS: No conflicts.

MS. GREENBERG: Thank you. I am Marjorie Greenberg. Welcome to NCHS. I am
here at NCHS, CDC, and am the executive secretary to the Committee.

MS. WILLIAMSON: Hi. I am Michelle Williamson. I work for the National Center
for Health Statistics. I am a senior health informatics scientist.

DR. CHANDERRAJ: Hi. I am Dr. Raj Chanderraj. I am a practicing cardiologist,
member of the National Committee of Health Statistics and also member of the
Subcommittee of the Standards. No conflicts.

MR. DALEY: Jim Daley, Blue Cross Blue Shield of South Carolina. I am also
here as a chairman of Workgroup for Electronic Data Interchange. I understand
Tim McMullen will here in a couple of minutes.

MS. MULLINS: Amy Mullins, medical director of quality improvement and
American Academy of Family Physicians.

MS. SAVICKIS: Mari Savickis, American Medical Association.

MR. WILDER: Good morning. Tom Wilder with America’s Health Insurance Plans.

DR. FRIDSMA: I am Doug Fridsma, the chief science officer from the Office of
the National Coordinator for Health IT and direct the Office of Science and

MS. LOHSE: Gwen Lohse with CAQH CORE.

DR. TENNANT: Rob Tennant, Medical Group Management Association.

MR. CULLEN: Rich Cullen from Blue Cross Blue Shield Association.

MS. DUBOW: Joyce Dubow, AARP.

MS. MOORE: Rebecca Moore, Professional Association of Health Care Office

MR. TAGALICOD: Good morning. Robert Tagalicod, director of Office of
E-Health Standards and Services at CMS and the senior agency official for

MS. BUENNING: Denise Buenning, deputy director of Office of E-Health
Standards and Services, CMS.

MS. GOSS: Alexandra Goss. I am the program director for the Pennsylvania
eHealth Partnership Authority as well as being the Pennsylvania health IT
coordinator and a member of the Full Committee and a member of the Standard
Subcommittee and I have no conflicts.

MS. FARRAR: Good morning. Thank you for being here. My name is
Kamahanahokulani. Nice to meet you all in person. I am with CMS and the staff
person to the Standards Subcommittee. Thank you.

MS. COOPER: Nicole Cooper, staff to the committee.

MS. JONES: Catherine Jones, staff to the committee.

MS. DEUTSCH: Terry Deutsch, CMS.

MS. GREEN: Denesecia Green, CMS.

MS. JACKSON: Debbie Jackson, NCVHS, CDC, committee staff.

MS. JONES: Diane Jones, American Hospital Association.

MR. RODE: Dan Rode, independent consultant and auditor.

MR. ALFANO: Bill Alfano, Blue Cross Blue Shield Association.

MR. LAZARUS: Steve Lazarus, Boundary Information Group representing CAQH

DR. FORESTER: Rachel Forester, Boundary Information Group representing CAQH

MS. DOO: Lorraine Doo, Office of E-Health Standards and Services at CMS.

DR. JAMOOM: Eric Jamoom, National Center for Health Statistics.

PARTICIPANT: We have others on the phone.

DR. SUAREZ: Yes, I was going to ask if Jim and Jean if you could introduce

DR. NARCISI: Hi. I am Jean Narcisi from the American Dental Association.

DR. SORACE: I am Jim Sorace, staff from ASPE.

DR. SUAREZ: Thanks. Do we have some people on the phone? If you could
introduce yourselves and your organization please.

MS. WEIKER: Margaret Weiker, ASC X12.

MS. BROWN: Deborah Brown, ASC X12.

MS. GILBERTSON: Lynn Gilbertson, National Council for Prescription Drug

MR. FINERFROCK: Bill Finerfrock, HBMA.

DR. SUAREZ: Anybody else on the phone? Okay. I think we have actually one
more person joining us. Suzie, do you want to introduce yourself?

MS. BEBEE: Suzie Bebee, Assistant Secretary for Planning and Evaluations,
staff to the subcommittee.

Agenda Item: Purpose, Goals and Outcomes of

DR. SUAREZ: Okay. Thanks everyone again for joining us today. I know a few
other people are going to be coming in as well. We have a full agenda. I hope
you all have received a copy of pages that had our introductory statements of
this roundtable defining the purpose of our roundtable, the objectives, the
expected outcome, and then our agenda. What we did with respect to the agenda
was to organize it in certain themes that we would be working through during
the day. We time box some of those.

We want to start just very quickly by saying a couple of important
statements about this roundtable. I think the main message and the most
important aspect of this is that we are in the midst of a number of
transformative changes in health care. I think that is the first element that
really comes across. We are seeing changes as we speak. Basically, we are about
to launch the largest health reform initiative since Medicare was created. We
are transforming the way health care is structured, health care is delivered,
health care is paid. We are changing how patients relate to the care system,
how they interact with the care system, the responsibilities that we expect and
that patients expect from us. We are transforming the way literally, public
health and population health management is done in the country by virtue of how
we are seeing all these transformations going on.

In the midst of all these changes, the National Committee of Vital and
Health Statistics, which is the committee advising the secretary on health
information policy, including various domains and dimensions of health
information policy such as standards, privacy, population health, quality,
governments and stewardship of health information. Really the need to begin to
organize and have a view of how all these changes are going to transform the
way we exchange data, the way we relate to each other across and through the
exchange of information, and in that respect the way we use standards to
exchange that information.

A lot of things have happened since the last roundtable actually. Besides
health reform, we have seen the updates to the National HHS Health Strategy
across the entire spectrum of health domains. We have international quality
strategy come out, national IT strategy, a strategy for national patient
safety. We have seen the progression of meaningful use of HIPAA. We have seen a
lot of things happening just in the last 12 months or so. The opportunity here
for us today is to really move us forward with development of this vision and
roadmap for the future with respect to health information and particularly with
respect to the standards.

We will be talking a lot more about the roadmap itself. We have a lot of
time during the day to discuss those elements of the vision for E-Health, any
health standards, and the roadmap concept. And ultimately I think the goal in
many respects even if we describe it in our document the main outcomes is going
to be give us the core elements that will help us frame as a national committee
what we see as a vision for E-Health standards into the future and then
creating a roadmap for the industry that ultimately will in our view help us
all understand not just what is happening today with respect to requirements on
when do we have to do certain things related to standards in general, but also
and perhaps more importantly be able to have that as a reference point for any
future requirements in which we are going to see the need to plot new
requirements within this significant number of existing requirements and
identify the most appropriate, more effective sequencing and timing really of
the new requirement.

This conceptual roadmap that we are expected to be able to develop as a
national committee, again, is going to help us and help the industry have a
reference point for future adoption of requirements. Again, it will serve us as
a national committee, to advise the Secretary with respect to the adoption of
new standards and the sequence, the timing, the pace, the size of those

There is a lot of interactivity and interdependency between what happens
with the adoption of one particular requirement and all the other ones and that
is one of the other goals that we have today to be able to identify some of
those interdependencies of the various existing requirements as we look at the
vision for how things are going to be happening. We establish some ways of
monitoring how health reform is going to be shaping the new relationship
between providers and payers and between other elements of the system and be
able to define new ways of exchanging this information that is the blood of our
health system. I think it is going to help the national committee frame this
vision and this roadmap.

Today is also not about ultimately completing a roadmap or completing a
vision. We are very pleased to see that we can progress this work through the
convening of this roundtable. We expect to see this happening as we go along.
Today it is more about refining the components and the elements of this vision
and this roadmap.

The other thing important to note is this is a roundtable. This is not a
hearing. NCVHS conducts a lot of hearings. Through the hearings, NCVHS receives
input from the industry frames, a series of recommendations to the secretary
with respect to specific topics. That is not the goal today. We are not
conducting a hearing and we are not going to formulate recommendations to the
secretary out of this roundtable. We are formulating our own, again, vision as
a committee and our own way of describing the roadmap that will help us as a
committee and hopefully of course the industry to understand how things are
evolving through a timeline with respect to requirements and again help us put
it as a reference for future requirements.

And the other important thing I want to note and we will talk a little more
about what is a roadmap ultimately as we get to the discussion later today on
the roadmap itself. But there are many roadmaps out there already. That is good
actually. That helps us build from some reference materials and some important
perspectives. I know CMS has developed an E-Health strategy and a roadmap. We
have been able to actually leverage some of that information. ONC has developed
also a series of roadmaps in different areas. And other agencies and
organizations have established their own roadmaps on different topics. The good
thing is we have different roadmaps. The value, I think, the opportunity that
we have is to really create the connection between those and help again define
a larger scope roadmap that will help us into the future.

Today is really about that. It is about discussion. We do not have
presentations except for a couple of framing slides. We are here to discuss
openly and to listen and to identify certain very core elements for this vision
and this roadmap.

We are very fortunate that we have a facilitator that is going to join us
and help facilitate the discussion. We are grateful to NCHS. We are lending as
the expertise of Eric who is going to serve as our facilitators in this
discussion. I think one of his most important roles is going to be to help us
be on time in terms of our discussion and move the discussion forward on the
very significant topics that we have.

With that, I think we are going to launch into this. I am going to pass it
to Ob who I think will have some introductory remarks as well and then move
ahead. Thank you.

MR. SOONTHORNSIMA: Thank you, Walter, for framing up the conversation and
thank you all for being here today. As Walter talked about a year ago when we
got together, some of us were around this table in the very same room, and we
discussed back in November of last year I believe, the concept of convergence.
We were talking about clinical and administrative data and processes and see
how those things can come together and provide some strategic capabilities for
the industry. In those conversations, you may recall this concept of we have a
lot of things going on. While we got into very tactical conversation, very rich
conversation I recall and some very substantive things came out. But one theme
came out loud and clear was this concept of roadmap because of all of these
different aspects of things that we are having to do.

You may recall some of these things from that conversation back in November.
We continue to hear over and over again things like we have implementation
fatigue as an industry. So many things going on at the same time and pulling on
a lot of resources across the stakeholders.

Another thing is every change, every initiative is quite costly to all the
entities, large or small. And oftentimes more often than not unfortunately lots
of these initiatives are either unfinished or are delayed.

And of course, the questions kept coming up surrounding how are we going to
get some pay back. What are some of the benefits if we can have immediate
benefits on some of these initiatives or at some point will we ever receive
some benefit from these initiatives? You may recall those conversations. A lot
of people in this room contributed to these themes.

At the same time, I remember everybody recognize that convergence is going
to take place. We should look at all these opportunities as a real opportunity,
a genesis for us to make some real change to the “system”.

But more importantly, everybody also said we have lots and lots of data. Can
we make good use of the data? This concept of big data for the greater good.
What is that greater good? At the end of the day, everybody agrees around the
table that it is a triple aim. I see a lot of nodding around the table and I
can hear people nodding on the phone as well.

With that said, this is the second slide if you have it. What we attempted
to do here is if you look at all the entities in the circle, primarily you have
the providers on the upper part of the circle and in the lower half of the
circle, you have really the payers, the employers, the commercial and
government payers. This slide attempts to talk about all the activities. This
is not an exhaustive list of activities by the way. These are some of the
initiatives and mandates that we are all working on. The first one talks about
the meaningful use. This is the HITECH Act. You have stage 1, stage 2, and 3
and hopefully beyond that. And there are significant goals and objectives with
huge promise of payback. But obviously, this set of activities impact primarily
our provider community, large or small.

The second major set of activities of course is ICD-10. This is going to
take place in October of 2014, just about a year from now. That impacts
practically everybody in the industry both on the upper part of that circle,
the providers, as well as the bottom part of that circle, the payers.

The third set of activities has to do with HIPAA standards. 5010 is in place
now. At some point, we will have 6020 or 70X. I should not put any sort of
number version out there. But we can expect something beyond 2017. And of
course, we have HIPAA Admin Simplification where plan ID is supposed to come
live effective next year in 2014, this time next year.

And a major lift as we are going through right now and this impacts — right
now, it seems like it impacts primarily the payers. But in fact, this really
impacts providers in significant ways as well. This is really the health
insurance exchanges or the market places that are supposed to go live that will
go live I hear on October 1, less than two weeks from now.

There are different stars if you look at the slide next to the market
places. October 1 is the enrollment. And then January 1, 2014, as most of you
already know, is the effective date. A year after that in 2015, we will begin
to do risk adjustment across the market places to offset some of the risks
among the participants or the issuers on the exchanges.

The next part is operating rules. You know about the two operating rules
that went live in early part of 2013. And now we have 2014. The next set of
operating rules coming out and the future operating rules as well. And then we
also have some standards around attachments and so forth. Again, this slide is
not meant to depict absolutely every activity and all the details behind each
and every one of these mandates. But the devil is in the details. More
important, as we all heard and we all are witnessing, every single star, every
single milestone, there has what I call a long tail sometimes. In other words,
it is unfinished business, incomplete adoption. Without complicating the
graphics so much and if you start drawing a line after each and every one of
the implementation, you begin to see some of these things stack up on top of
each other quite heavily. And not just that, but this is meant to demonstrate
the impacts, absolutely every entity, every stakeholder in our ecosystem.

Thus, the cry for some sort of a “roadmap”. We do not know what
that roadmap is going to look like. That was just a backdrop. That is not meant
to say this is what the roadmap looks like. Why do we need these roadmaps? This
came out from folks around this table and on the phone. One is we want to
understand key mandates, purpose, and goals, but more importantly, all the
milestones and timelines. And what can we do to make sure that we can
effectively execute on these important mandates and initiatives. How do we make
sure that we get the effective adoption and account for the value proposition
regardless of what that long tail may or may not look like?

Secondly, we want to identify any challenges, issues, opportunities for all
of our HHS units or agencies and industry, private sector to achieve the goals.

Lastly and this is probably what we are trying to tease more out of from
this group today is can we envision, anticipate any strategic shift in the
industry. This is a very similar conversation we had last year, but this time
it is a little bit more concrete on what do you see as the activities, not the
activities we are currently doing, but activities that we will be doing in the
future that we can begin to shape or influence the future direction. We cannot
look back. Well, we did 5010. We cannot go back and change that. It is done.
But we might be able to influence. We, as a group, can influence perhaps things
in the future, the next set of operating rules, the next set of X, Y, Z. That
is why we are here today.

Walter, with that said, I will leave it up to our facilitator.

DR. SUAREZ: Yes. Now we are going to turn it to our facilitator for some
remarks as well. We are going to do some additional introductions of people
that have joined us. And then we are going to go to our first topic really,
which is the vision and goals. Eric, do you want to say a few words?

Agenda Item: Vision and Roadmap for E-Health

DR. JAMOOM: Thank you for the opportunity to help facilitate this session on
E-Health and communicating what you vision. Each of you represents many
different industry and interests. Having all of you participate will really
help further the objectives of this group.

During the time that Walter and Ob were speaking, I think some new folks
joined us and especially on the phone. If you can just introduce yourself and
say where you are from. On the phone, anybody? Nobody new on the phone. If you
just joined us.

MR. ARGES: My name is George Arges. I am with the American Hospital

DR. BLOOMROSEN: Good morning. Meryl Bloomrosen with the American Health
Information Management Association.

MR. MCMULLEN: Good morning everybody. I am Tim McMullen with Cooperative
Exchange, the association for the clearinghouse industry.

MR. GLICKMAN: Good morning. I am Michael Glickman representing HIMSS and
Computer Network Architects.

DR. JAMOOM: Now, what we would like to do is go a little bit deeper. If you
can just succinctly say what your role is at your organization and then
communicate to us in two or three lines, I know that is going to be tough, what
your vision of E-Health is. And if you can speak to some of the changes you are
hoping to see, some of the specific alignment issues that Ob presented just
recently. That should help facilitate our further discussion.

DR. SUAREZ: Eric, one step that I failed to mention. As a start of this
discussion, we wanted to ask Rob to help us frame this vision. We did not note
that in the agenda. But to open up really the discussion about the vision and
the goals, I think it would be helpful to here from Rob some of his
perspectives. He can tee us up on the next step, which Eric already explained.

MR. TAGALICOD: Thank you. I would like to just keep my comments brief, maybe
not more than ten minutes rather the 30 minutes allowed me because I think
there is going to be a rich discussion. Indeed, a lot of things have happened
in the last 12 months that I think frame a couple of things. I will put out the
copy here. It is a particular point of view. It is not the point of view and it
is not necessarily the point of view of the secretary of the administrator of
CMS from where I am. But it is a perspective of what I hear. I know that
several of you have been privy to at least the draft of our plan. But I think
it captures some of the things based on our conversations that I have had with
many of you around the table or your staff are kind of if I can use the phrase
no brainer. But again, I will leave that up for your judgment and not to close
the conversation, but here are a few context or framing things that we are
thinking about.

I usually start in a different place than I usually start with this. The one
thing that we started off this week was the health IT week. Farzad Mostashari
and Patrick Conway from CMS states upfront in the great hall in the Hubert
Humphrey Building we are misfits. It was interesting. What do you mean by they
are misfits? We have forgotten and they used the universal. We have forgotten
the patient in all this. We have been focusing on the other piece, the
provider, the plans, and other folks. And what we have forgotten is the patient
and the consumer. If we could reclaim that, that would be a great step forward.
This is consistent with a lot of the things that we have been talking about. It
is about patient-centered care.

I think of it a little bit differently. I started in public health. I think
that is normal. As far as I was talking about, let’s renormalize it. I do not
think we are necessarily the misfits, but maybe I am just a little bit
egocentric. I think we need to bring everybody back and reclaim the patient in
this. When we have that as the frame, then we can see where data fits into
this. We have been talking about here is the data in terms of financials or
payment or claims, but what about the patient data other than clinical data.
What about the patient self-reported data? Those are the kinds of things first
off that I want to remind folks of why we are here.

When we talk about E-Health — I was interviewed yesterday and two of the
interviewers in two different settings said Rob, isn’t E-Health really about
health. I stepped back and I said absolutely. It is. To have E-Health or
standards as the end all and be all is to miss the point. It is about the
triple aim. It is about better care, better health or the individual and
populations at lower cost without compromising the quality or of the safety of
that care. Again, it goes back to patient-centered, consumer-centered care.

The other piece to this — yes, I just wanted to reiterate. It is about
transformation of health care both in terms of delivery and the payment. The
administrative part is important. And when we talk about that, aren’t we
talking about big data? I know that we introduced it. But the one thing I would
like to reiterate is and the patients are important to this, but again what is
CMS and HHS and a lot of us are sitting on. Claims and payment data. One big
set. How do we share that? That is a question mark. Because sometimes we have
to look back at least for CMS and HHS what are our authorities to share that
data and why we collected it in the first place. What are our dissemination
strategies or even again our authorities first?

The other piece to this is of course the clinical data that we are acquiring
through EHRs. As I have said in the previous setting, EHRs are seen and PHRs,
the extension of it, are seen as the backbone of health care transformation.
How do we get that in a standardized way? Again, I would argue it is more than
just clinical data. There is other quality data that is nonclinical in that we
need to attend to and kind of opening up in terms of a framework and a kind of
standardization that we need to talk about and the interoperability I am going
to be talking about shortly.

The other piece to this is when we talk about health. E-Health is equivalent
to health, but what do we mean by health. From our perspective, a lot of people
have been mentioning the fiscal year is only two weeks ago, actually less than
two weeks away. For us at CMS, we are talking about health care coverage. That
is part of our strategic goal as well as accessing care. What kind of care are
we talking about? It is more than just primary care. We are also talking about
labs. We are talking about ancillary care. We are talking about mental health.
We are talking about the whole kit and kaboodle of health care as well as post
care. It is not simply in the institutions.

As we know in this mobile age, it is moving to communities and it is moving
to people’s homes because they have access to whether it is tele-medicine or
whether it is their mobile device in which I can take a blood draw and transmit
that somewhere to give me my blood values in which I need to do health
interventions for myself or preventive measures for myself based on the
information that I get at my fingertips. Where we get it is being transformed
as well. It is not just simply institutional. And then the question is how do
we account for it and how we pay for it. That is another question.

The other thing that I want to reiterate is that this is partnership. At
least at CMS, we use the phrase and the whole creation of the Office of
Enterprise Management, which our office, the Office of E-Health Standards and
Services are part of, is that is a big fancy word of partnerships. We see it in
four ways. One, we recognize that we within CMS need to work better together
because we have a lot of payment policies, quality policies, all these policies
that in a different day, 10 years ago, 20 years ago it made sense. There is
Medicaid. There is Medicare. Within Medicare, there may be A, B, C, and D. And
all of them are separate with their separate authorities. But with ACA and the
reality of health care and about the integration of health care, it cannot be
seen again as three, four, five, six separate things even with CMS. We need to
talk with each other. That is the first level.

The second level is really talking with our other federal partners and not
the usual suspects. Sure, we can talk about everybody else within HHS. But we
are also talking about FDC, FCC. When we are talking about mobile health care,
we are going is there a spectrum, is there a broad band, is there a capacity in
different places including the rural areas and underserved urban areas where
there is no infrastructure. It is amazing when you go from one block to another
and all of a sudden I do not have connection, connectivity on AT&T or
whatever. And then in another block further down I do. It is amazing the
difference even within an urban area.

And then I heard the word convergence. We talk about alignment. Let me tell
you. I have heard this. This will get to the issue of priorities. In 2014,
there are a lot of things happening. It is the market places. It is meaningful
use 2. It is ICD-10. The D word is coming up. Can we delay this or that? For
many partners around the table, we have received your letters. Believe me. We
have received your letters.

But the one thing that I pointed out and you will have to help me in terms
of our partnerships because that is the other part of the partnerships, our
partnership with industry. And quite frankly, isn’t the government really part
of the industry if CMS, for example, is one of the largest health plans in this
country. We are part of industry.

The question is for us. I have a specific example, meaningful use 2, and
whether or not industry whether they are vendors, providers and therefore the
ultimate beneficiary is the consumer themselves will be negatively impacted
because we do not have the ability to do that. Can we somehow look at delaying?
Again, I am not saying that — I am not getting ahead of the secretary or the
administrator that we are going to delay. But I heard the D word. But at the
same time, it has an impact on other things.

One of the things that is important to the folks around the table is the
alignment of quality measures across all the CMS programs. There is a negative
effect. The question is which poison do we want to take in this, but getting to
the greater good. That is a big question mark. I would like to have the
conversation with each one of you at this table and separately as to what that
is and how can we accomplish what we actually need to do. What do we need to do
is really about our focus, which was about meaningful use 2. Intraoperability.

Again, I go back to the data sets. The four big data sets. I actually did
not touch on the last two. Claims and payment, clinical data, patient behavior,
and patient sentiment data. For those who do not realize, CMS does collect that
information because of mymedicare.gov. But our world has expanded and so has
HHS’ and so has yours by virtue of that. Because a lot of you are representing
the plans or interact with the plans as well as providers as well as with
government entities. Those are the kinds of things we are looking at.

The other piece to this and quite frankly I am borrowing from a white paper
that I read, but it is also about clinical trials information and
pharmaceuticals and how so. Well, our payment policies, local coverage
decision, national coverage decisions are based on the information that has
gotten from those clinical trials. But wouldn’t it be great rather than wait
for three or five or six or seven or maybe even ten years because I have seen
some of the papers on it. What if it took less than a year or maybe a couple of
years in order to get to the payment coverage because we saw the efficacy of
certain trials and the behaviors and interventions that were related to it?
That is the kind of big world that we are talking about, but again wow. How do
we standardize this? What is our priority?

I will just go through eight of the pieces that, again, as a level setting
and something that we have already shared with this committee. Again, here is a
caveat. We have not published the plan yet. It is still going through
clearance. But some of the ideas, again, are not something weird or strange or
even that cutting. I would say it is cross cutting. It is at the edge. Because
some of the things that we talked about two years that was in the plan was
probably at the edge. It is no longer. Two years past. A lot of things have
happened. What are the couple of things that we are talking about?

The first thing is about normalization of data whether it is socioeconomic
data, whether it is clinical data. The question becomes for us and several of
you have used this phrase. For example, we will try ICD-10 because it is right
around the corner. There are scads of codes. But what are the codes that matter
that we should be focusing on right now that mean a lot more to you folks
around the table than a lot of the other codes? There is a lot that has been
said about the codes that do not make sense or they are kind of outliers. We
are not talking about that. What are the codes that matter? What are the
clinical metrics that matter? And therefore, we need to normalize across all
the quality reporting programs and therefore the payments and the payment
adjustments admittedly. What are those?

The other thing too is again about the interoperability standards
themselves. What platform are we going to talk about? Sure, we see the White
House talking about meta-data and how we structure data. But I think, again,
what are the central things in 2014, 2015, and 2016 that we need to focus on
now. And again, vis-a-vis the resources that we currently have. I do have a
particularly bias. I will offer it for those who have written the letters to
the secretary and the administrator. What will be a heavy lift for us in the
next three years? The strategy is what authorities that we currently have so
that we can actually get the changes that we need.

The other piece to this is really about health equity. Again, most people
may not see CMS as part of isn’t that AHRQ’s thing or CDC’s thing or HRSA’s
thing. No because of our payment authorities. The question for us is not only
collecting the data, but how do we address the disparities that the Secretary
has identified as her priorities and this administration has identified as its
priority. Yes, it has been focused on race and ethnicity. Someone who has been
in public health for almost three decades and I have said this to this
committee, just getting Asians to be included and then even the breakout to
this day where we were considered other in information gathering about 30 years
ago is amazing. But imagine all the other data sets that we need to — all the
other data I should say that needs to be collected. Those are the kinds of
things that we are focusing on.

But to get a little bit even more tactical and I think I kind of introduced
it, ICD-10 is around the corner. The date is certain. The question is what do
we need to do in order to get all providers, urban, rural, big, and small to
get to be successful in ICD-10. Moving from strategy to tactics is the
immediate for us. For meaningful use 2 that is immediate because it is about

When we talk about outcomes and yes, we are going to be doing rule making
for stage 3. If we do not have the kind of intraoperability or at least the
base intraoperability that we need, how can we even compare data? I did have a
conversation with some of the CIOs and a couple of other folks this week. It
has been jam packed because of health IT week. But I said let me put my data
geek hat on. I know for a fact that some folks just on birth date say at 12
o’clock midnight, this is when your birth date is. It starts here. For some, it
is structured where it has to be 12:01. For some, it is another time. From a
national level, from a population level, when you start seeing the
discrepancies in terms of numerator and denominator, they are not comparable
data. How are we going to do population health if we do not get those kinds of
standards? I beg to differ with some perhaps. Well, Rob — CMS’ ability to do
more regulation.

Well, the question is what authorities do we have and what can we leverage
rather than go through more regulation. What are the things that we can come to
agreement in partnership in order to say these are the standards.

And the one thing that I do before I became a public health person was a
banker. Yes, this was before interstate banking. But there are two events that
happen in order to get us to where we are in terms of international banking and
interstate banking. It basically is all the partners and the CEOs, by the way,
of the largest providers to get to an agreement to say without necessarily
government intervention or additional regulation, which was what are the
essential standards that we need to agree to, not a whole slew of standards.
That will come later. What are the essential standards today, tomorrow in order
to do that? In order to get to one, the standardization of ATMs. That was the
first in the ’80s. And two, in the 1990s or there abouts, was where we got from
interstate to international to online banking. All those things had happened
because the partners got together in a room like this and all agreed that it is
time to agree to certain standards.

Again, I think I am putting a little bit more of my tactical hat on, which
is great. But again, not to lose the focus on the consumer. I think part of it
is how do we also standardize. And maybe it is not a priority in 2014, but it
needs to be a priority soon, which is how can they share their own data because
the evidence is there. The evidence is emerging in which people engage in their
health care are actually transforming the way health care is, one, delivered,
and the outcomes that are seen. Again, still broad enough. I did not want to
squelch the conversation because other people around the table have different
points of view.

DR. JAMOOM: Thank you, Rob. I think that Rob threw a lot of really good
information at outlining the environment we are in right now and what we hope
to achieve here at this roundtable and discuss more about what E-Health means
to all of the different interests here. Certainly, what E-Health means to CMS
has been quite articulated well by Rob.

At this time, let’s go around the table and talk a little bit just
succinctly for the sake of time what you do, what your E-vision is for this.

MS. MULLINS: Again, I am Amy Mullins, medical director of Quality
Improvement at the American Academy of Family Physicians. I have had this job
for about six weeks. I am kind of trying to figure out what I am supposed to

But the interesting thing is eight weeks ago, I was a practicing family
physician in Texas doing E-visits in my office and trying to juggle all the
things a family physician is supposed to do and think about ICD-10, meaningful
use, documentation, contracting, quality, and then oh by the way we have to see
patients too. I really appreciated what you said about don’t forget the patient
and don’t forget that is what we are here for and what we do. When you have all
these other things going on in your head, you have to remember every 15 minutes
or every 10 minutes or shorter you have somebody else walking in the door that
you have to see and you have to take care of and you have to solve all of their
problems too while you are trying to remember to do all of these other things
and remember all of these standards. I never really thought that I was a
writer, but you have to become a novelist and you have to write a short story
every 10 to 15 minutes and make sure your documentation is right. You really
have to become a very good writer to be a physician these days.

Those are the kinds of things that family physicians and physicians really
all over the country are dealing with in addition to all of these other things
going on behind the scenes. We need to remember what a day in the life of a
physician really looks like. That is my perspective.

The AAFP really wants people to remember that we want the physician and the
patient or the provider and the patient to have a relationship. We want
patients and a PCP to have a relationship. We think E-Health is a good
extension of that. We do not necessarily want that to be the only relationship
that a patient and a provider have. But we think that is a great way to extend
and to facilitate in a new way the provider-patient relationship.

As I said, I have been doing this in my clinic in a limited way with online
office visits since 2006. I do bring some experience to that. I have not done
tele-health or Skype visits or anything like that. I think that it is a great
way to offer increased access and to really reach out to patients that cannot
necessarily come to your office because they do not have insurance or they
cannot take off of work for a variety of reasons. It is a great service to

DR. JAMOOM: Thank you, Amy. Let’s continue.

MS. BLOOMROSEN: Good morning. This is a coincidence, Amy, since I have been
at the American Health Information Management Association for about eight
weeks. This is a nice opportunity. Currently, I am the vice president for
thought leadership, practice excellence, and public policy at AHIMA. I am
delighted to be here and thank you for the invitation. Before joining AHIMA, I
was a vice president of public policy at AMIA. I interacted with many of you in
that capacity.

I think if we need to be succinct, my opportunity to suggest a vision is as
follows. Assuming we all have a common understanding or we agree upon some
definition or definitions of E-Health because I am not sure that that is
exactly easy. I do not think it is easy. We may need to spend some time
confirming that there is some words that we would agree upon, at least some
core words that we might agree upon in terms of the definition for E-Health so
we do not assume that we all have the same understanding. I guess we could have
optional definitions if we wanted to.

From our perspective, it is complicated. It includes the following types of
words. It is the appropriate availability and access to health data, high
quality health data for multitude purposes across the care continuum. It is
health and health care data. I think, Rob, that is what you are getting at. If
we are going to be talking about the triple aim, it seems to us that preventive
health care or needing health care what services that keep us healthy is

I do not know if this fits into the vision, but I think we need to be
mindful. AHIMA thinks we must be mindful of things like consumer-mediated data
as part of that.

DR. JAMOOM: Remember, it is your vision. Your E-Health vision. It is okay.
Definitions at this point I think like you were saying.

MS. BLOOMROSEN: Consumer-mediated data. That is if we are going to be
providing in the future more transparency to the patient then our regulations
are probably going to need and our vision needs to be mindful of what that
means are we going to and how are we going to allow patients, not just to view
their data, but possibly to make it more accurate. Is the clinical data going
to be continued to be seen as hierarchical that that is the data that is
accurate and what the patient may provide through implanted devices or devices
in the home or because the patient recalls his or her history differently than
it was recorded? I do not know if we have given enough attention to that
thinking across the care continuum, which will not be in a facility
necessarily. It probably will be in our home or I guess Ford might think it is
going to be in the car. I think we have to really be thinking beyond our — I
think the vision needs to be very futuristic in how to get there.

MR. DALEY: This is Jim for those on the phone. I have been at WEDI for
longer than eight weeks, many years. I am currently the chairman.

Our vision is the seamless and secure flow of information among stakeholders
including the consumer so that the right information is at the right place at
the right time. That is kind of a very broad brushed statement.

One thing that concerns me is the talk about a goal of getting to standards.
Standards should never be a goal. They are a tool. If we wanted standards, we
could say great. Let’s implement eight-track tapes and we would have a
standard. But that is not really what people want. They want to have their
music available when they need it and those kinds of things. We really have to
look at the underlying business objective. What are we trying to accomplish?
Then look at the available tools of which standards are a tool to the point
that they facilitate reaching that goal then great. But we have to make sure
they are not an inhibitor to reaching that goal.

Whatever we implement in terms of a standard, we also have to make sure we
have the flexibility to evolve as the world evolves, as new business models,
new consumer requirements, new health care methods evolve and new technology
occurs so we are not locked into something that does not serve our purposes for
that point or the future.

With that in mind, one of the things I would like to raise — many maybe are
aware of this already, but WEDI is working on an update to their 1993 report.
It is 2013 update. We have looked at four basic areas that we feel are very
critical for the future. The first one is patient enablement. It is not
necessarily the health care. In other words, they are sick. Now let’s take care
of them. But how do you keep them well? That is important. Who is the best
person to monitor a consumer 24 hours a day? It is the consumer themselves. How
do you get them involved in that?

Payment models. We had one work group that identified about 90 different
payment models. When we talk about standards and moving information, you have
90 different models. What is the right standard for that? We need to determine
what models are going to evolve. What is the type of information needed and how
can we potentially have the flexibility to move the right information so that
whatever models end up surviving or becoming most dominant that they will be
able to be supported?

Third one is data harmonization and exchange. When you send something across
to somebody else, do they really know what you mean? Everybody interprets
things E-Health. We are all interpreting it right now saying what do we mean by
E-Health. We need to make sure that we can transmit it and once it reaches the
destination, it is usable at that destination.

And lastly, innovative encounter models. I was very impressed when I saw
someone give them an EKG in a big auditorium using an iPhone. Everybody could
look at the person’s heart beating. New things are there all the time. We also
have to look at the technology is changing. Certainly, for many years to come,
we will have the administrative stuff, the HIPAA transactions and that kind of
thing. But there is a lot more out there in the market place. And we have to
make sure that we can take advantage of this new technology as it moves along.
Those are just some of my thoughts. I will have more as the day goes on.

MS. NARCISI: Hi. I am Jean Narcisi from the American Dental Association. I
am also a chair-elective of WEDI and I agree with everything that Jim said.

I just wanted to share with you a little bit about what the ADA believes. We
are actually a standards developing organization. We are accredited by ANSI. We
have a couple of different standards committee, the Standards Committee on
Dental Informatics, which is working on standards such as electronic health
record things and we are working with HL7 and so on. Also, we have a standard
committee on dental products, which has been around for a very long time and
has been very successful.

But one of the things I think that we are a little bit concerned about is
the whole thing with the meaningful use. There is a very small percentage of
dentists that are participating in that program because of the benefits. There
is a percentage that if dentists are treating 30 percent of their population is
children in Medicaid then they can participate in the meaningful use program.
That is probably less than 10 percent of all dentists out there. When we are
talking about trying to standardize an interoperability, which we think is
wonderful. We are very supportive of implementing SNOMED CT in electronic
health records, but that is not going to get into a lot of dental offices
unless we think about maybe some benefit coverage.

There is a very big problem with adults being covered. They are not seeking
dental care. Somewhere along the way, everybody forgot that the mouth was part
of the body. A lot of the diseases are systemic. Medicare of course, there is
no dental coverage. We are seeing the coverage in even working Americans
decrease because of benefit coverage and those that have had benefit coverage
for years and years, it has not changed in 30 years. We are concerned about

We believe that yes there is an access problem. An access problem is not
because of the lack of dentists. It is probably because of the lack of benefits
in being able to seek care. But we are definitely very supportive of all the
standards that are being proposed by HHS.

MR. MCMULLEN: Again, my name is Tim McMullen. I am the executive director of
the Cooperative Exchange, which is the association for the clearinghouse

From our perspective, which we have a unique perspective being between the
providers and the payer so we can see both sides of the coin. Similar to what
Jim and the other folks have said so far, it is for us the seamless exchange of
information of electronic data specifically among all stakeholders putting the
patient at the beginning of that list of stakeholders and going to the
providers and the payers and the clearinghouses. And then even thinking about
folks that are non-covered entities. I think that is really important because
you have players like some vendors. You have property and casualty out there
that is not covered. For instance, with ICD-10 coming up, property and casualty
is still in the ICD-9 world. There is going to be dual coding as far as we can

And what I mean by seamless is the normalized semantic interoperability. We
were talking about definitions with an automated end-to-end workflow. You do
not even know it is happening. For instance, as you were saying, you need to
have it. It is going to go mobile. You have to have that seamless exchange of
data so that the consumer can pull it up on their computer, not having to go
through all the different steps to get the data in a format that they can

MR. GLICKMAN: Good morning. I am Mike Glickman. I am a consultant with a
firm Computer Network Architects, but I am here representing HIMSS today. I am
also involved in a number of standards development organizations.

In any event, just a couple of thoughts to share in terms of E-Health and
definitions and kind of coming up with a roadmap. If you look at it from HIMSS’
perspective in the trenches if you will trying to make these things work. I
have worked in probably a little over 30 different health information exchanges
since the ’90s. When you sit down and try to develop and maintain 300 or 400
interfaces that will tell you something right there about the expediential
nature of complexity.

A roadmap has to recognize — we have to break this up into manageable
pieces. I hear everybody talk about big data. I kind of smile about big data
because big data is raw and not very processable. The real notion is to come up
with meaningful information, not big data. We have invested a lot in meaningful
use and now we want to move the ball forward and the bar upward. I always think
about meaningful reuse, the real payback in all of these systems, the real
reason we have E-Health information and we share data among and between people
is because of the meaningful reuse of data. That is where you get the return on
investment where you collect it for one purpose. It is data. It is normalizable
and can be used for another purpose. We look at it in HIMSS and my practice.

Those other purposes are kind of in two different domains if you will. One
is clinical, financial, population-based, and research. If you look at data in
all those different domains then you look about EHR and PHRs. Personally, I
think they need to be kept separate because their reliability is different and
granularity is different. The terminology is different. We kind of see it as
breaking it up into pieces and parts kind of the old Peter Drucker approach of
breaking it into pieces.

If you look at the other pieces, there are standards that revolve around
transport, payload, and vocabulary. When you put those all together, you can
get to the holy grail of semantic or commutative interoperability.

HIMSS has done a lot of work in testing and testing for the interoperability
showcase. Just all the work that goes into all of that. The connect-a-thons in
January where 400 or 500 engineers get together from 200 companies and try to
make all these different standards work.

The key is to have a lot of testing. The key is to have tools to simplify
that testing. The key is to be able to come to the table with some pretesting
already done, self-certified or run through tools or whatever, again, because
of that expediential nature of complexity. I will leave it at that for now.

DR. SORACE: HI. I am Jim Sorace. I am a medical officer at ASPE. I am here
to listen to tremendous amount of very interesting input. I have very few
thoughts coming into the room and now I am simply going to echo what has been
said to my right with maybe a little more detail.

If you look at the real basic mission of the health care system, it is to
diagnose patients hopefully before they have symptoms even, but prevention. But
at some point, diagnose their diseases, refer them for therapy and hopefully
obtained a benefit.

I think that one thing I would like to see is much more thought given to
diagnostic work flows especially early in that process because when patients
prevent — they do not have an ICD-9 or 10 or some code on their forehead.
There is a process that involves laboratory or imaging testing, history taking
that leads to hopefully one of those codes. Many patients walk around with
symptoms that may never be coded or take years to get to a code. I think we
might want to think about that process in more detail and how it should work.
At the moment, we have people going to coding perhaps prematurely. They should
be at a higher level and actually trying to work through a differential

The second thing, which we have also heard I think, is a bit about the reuse
of data. The goal of data is to support true discovery. As you collect more and
more of it, you will find that there are for statistical reasons you also will
see other patterns reemerging in the data that are actually false discoveries
for another reason.

I think we might want to go back and look at issues of data stewardship
including how data is studied. What processes were used in the study? What
statistical measurements were put in outcome? What ICD-9 codes were not
included, for example, and how they estimated the mortality and expenditures
that might be associated with diseases that were not part of a study and how
that might have influenced the thing.

The third thing that Michael also drove home a few minutes ago is that there
is sort of an expediential complexity in many of the things that we try to do
here. Things will tend to blow out. And that is actually something that we
might want to look at to avoid either as how we structure standards so that
they do not undergo the sort of expediential complexity or to manage and also
to look critically at the support that the various stakeholders need so that
that does not become a burden for them. I am here to listen broadly
particularly interested in going into it on those three areas. Thank you.

DR. CHANDERRAJ: Hi. I will give my comments after I listen to all the panel.

MS. WILLIAMSON: Hi. Michelle Williamson with NCHS. I guess there are three
areas when I think of E-Health that I think are very essential. One, I have
heard a lot of talk about reuse of information. I have been focused at NCHS on
a project for vital registration. I see some of the complexities of trying to
get information that we want to get from electronic health records and reuse
that for vital records purposes. Being able to look early in the game to see
what are we capturing in an EHR system. Are we capturing it in a way that is
also going to be conducive to reuse? That needs to be thought out early in the

The other is the issue of partnership. I know Rob mentioned some things on
partnership. One key partner that I do not think is often mentioned is the
vendor. We develop these standards and we have things that we expect to
implement and the vendors are not necessarily engaged in the process early in
the game to make sure that, one, it is on their plate for part of the process.
I think meaningful use is a great example. We are using meaningful use and with
this the vendors are very much engaged. Now, those who are not focused on
programs that are meaningful use related are having a challenge of getting them
to invest. They need to be part of the process early.

And then finally is education. In talking with those who are collecting the
information, it is great if we come up with standards and ways to do it, but if
those who are putting the information in the system do not understand there is
not semantic interoperability to support that, then we still do not have any
good data.

MS. GREENBERG: Thank you. In contrast to some of the new kids on the block,
I have been with the committee 31 years. Everything that people have said
certainly resonates with me and I think resonates well with the committee,
which is as some of you know, you have been here all week the way I have, but
that the committee was meeting the last two days in this room. About a year and
a half ago, the committee made one of its main themes convergence. Everything
Rob said and we have been partners in this process for a long time also
certainly resonates.

We talked a lot about clinical and administrative data, but remember the
convergence also if you are going to start with the patient, if you are going
to start with people, it also includes population health and public health
data, which has kind of been scrambling to keep up in this whole process both
looking for its role in meaningful use and it does have a role, but not front
and center necessarily. And also its role in health reform. It will change as
more people get coverage and as access changes, et cetera. I think yesterday
one of our members talked about this continuum, which starts at population
health and goes all the way to individual health.

I always think of John Lumpkin, one of our former chairs, who used to quote
Chris Gebbie in well-known public health. It is not that the health care and
public health used different data. They just use it differently or look at it
differently. As Michelle just said, that has never been more important as we
look to harness and leverage electronic health record data for population
health purposes both to lessen the burden hopefully on those who are reporting
this information and also to improve the quality. But it is a hard sell all the
way around.

And just one other thing that I think Bill Scanlon at the committee said
yesterday that in some ways, roadmap might not quite be the right term because
you might be — a roadmap is sort of getting all the model T cars maybe all
going in the same direction of your last year’s model at least. As Walter said,
we are really talking about transformation. If we are, then it is a more
dynamic and more — not linear and we all know that this is not really a linear
process. I think Bill talk about an architectural framework that will perhaps
layer and integrate things in a way that a linear roadmap would not.

The committee, I know, is extremely interested in getting the feedback from
this meeting and from all of you. You all have been very supportive as I look
around the room of the committee and of this work. I look forward to continuing
to work with you.

MS. KLOSS: Thank you. I am going to put my hat on as co-chair of the
committees of Privacy, Confidentiality and Security Subcommittee and just share
or put on the table that one of the issues we have been wrestling with is the
need for new stewardship models for data that really falls outside of the
framework of HIPAA, which now as we know is almost 20 years old. And it was
developed with the assumption that if we dealt with treatment payment and
health care operations and put the right controls about it, that would take
care of the issue. We certainly do not have that fully operational and working
smoothly as we know from either a privacy or a security standpoint. But we have
vastly new challenges when we think about new uses and we have come against
this as we look at community uses of data, some of which is deidentified, but
also runs the risk of reidentification as we mash up data sets.

The committee has developed a framework for stewardship practices that fall
outside of the traditional HIPAA view. But I think we have to see that as one
of the infrastructure areas that undergird all of our E-Health discussions and
certainly the work on this is really just very much in its beginning stages.
But I add that to the conversation.

MS. GOSS: I am going to pass most of my comments because I really want to
hear from the participants at the roundtable. There is one theme here that is
underpinning a lot of the discussion, which is the shift in our culture and our
society in how we view the partnerships and how we leverage the human
interactions and the data acquisition from those in a variety of care settings.
I think that there is a lot of opportunity here and it will take all of us
being willing to look at the bigger picture and think about a framework, which
will balance the extreme diversity and the challenges that we have within the
health care continuum.

MS. BUENNING: I have a unique position in that not only do I deal with all
of these issues, regulations, standards, interoperability, enforcement, et
cetera, but I am also a health care consumer, a heavily invested health care
consumer. I have chronic conditions. My parents have chronic conditions. My
daughter. You name it. We are probably Blue Cross Blue Shield’s worst
nightmare. Something that Alex just mentioned really set off an alarm. It is
the shift. It is the cultural shift. It is the technology chasm that exists.
Every two weeks there is another iPhone coming out. People are using apps in
stores. You go through the mall and there is a car parked and it says shoot
this thing and you can get all the information that you want about this
particular model of car.

The technology that our children are just taking for granted is indirect
opposition to my 88-year-old mother who I am a caregiver for who has no idea. I
just kind of steer her through the paces. It is like you need to be here at
this particular time. You need to take this particular drug. She basically does
what I tell her because obviously there is some trust there.

I am a consumer. I want to go into my doctor’s office having made an
appointment online. When I get there, I want them to say this is going to be
your co-pay and it is accurate. I want the doctor to be able to pull up all of
my drug interactions, my conditions. I want her to be able to shoot out an
order, get it to the lab, have her get the lab results electronically, have her
contact me with what I need to do next, et cetera. I want it to be seamless. I
want it to be accurate. I want it to be private. I do not have a problem with
sharing my health information. But I probably feel more comfortable with it
being in the aggregate as opposed to my PHI. When I was diagnosed a number of
years ago with a chronic disease, all of a sudden it was amazing. I never got
solicited for life insurance anymore. I know that was because my information,
my personal health information was shared.

I still believe in the Star Trek vision and I know people are working on
this. They used to have bones. Get the guy on the thing and they used to scan
it and say here is what is wrong with you. I know people are actually working
on this and I think that is fascinating.

I want this group and I want the industry at large to not only provide the
leadership to make this happen, to make this a reality, but I also want to
leave this legacy for my children because I know they are the ones that are
going to be taking care of me. I have a vested interest in this. I agreed with
everything that Rob said.

MS. BURKE-BEBEE: Jumping off of what Rob said earlier about patient
centeredness, what I would add to think about going forward and thinking in the
future is we do a lot about capturing the care that we give to patients. But we
need to start thinking about capturing their preferences of care.

We have a lot of research that has been done on unwarranted care, which is
really based on the supply of the providers, the hospitals, whatever setting it
is. But we need to begin to shift with health reform to think about the demand
and the patient preference so that we can begin to capture this. And meaningful
use is trying to do this, getting to interoperability and looking at what we
give to the patient, but we need to look at not just the summaries of what we
give, but what we bring to the electronic world and the electronic record from
the patient and document, begin to think about how we would document patient

MR. ARGES: I am George Arges. I am with the American Hospital Association. I
have been there nearly 25 years. I am one of several individuals who work in
the policy shop on IT. Actually, one of my colleagues is out in the audience as
well, Diane. But AHA’s vision and I have heard several folks here talk about a
new stewardship model, a new framework as well. Our vision too is one that
looks at that as a way of us stepping back a little bit because we heard Rob
talk a little bit earlier about what is out there. We have gone through 5010.
We have ICD-10. There is meaningful use. There are a whole host of other
activities that are taking shape.

But one of the things that we would like to see really is a new framework
that basically adds a discussion point around the E-Health process as kind of a
way of corralling, if you will, the different ways of setting the priorities
and work plans.

The data needs really for providers, health plans, the patient and public
policy makers are different. There is a cost to the collection of data and
managing that data. It is important for us to step back a little bit and really
create a process that is very transparent in the way we look at and discuss the
priorities and work plans, one that basically looks at the normalization of
data because it is important that we get the data right the first time. Once
you implement something and it is wrong, it is harder to undo in many cases.

The important thing here is that there is that discussion that does take
place where there is the group of stakeholders who are part of that process,
one that has the appropriate stakeholder that is proportionate in the way it is
structured as part of that process. That is our overarching vision in terms of
what we would like to see as part of the process going forward.

MS. MOORE: I am Rebecca Moore and I have been a practice administrator for
over 30 years. PAHCOM’s goal is to keep the small medical practice informed and
involved with respect to E-Health. Our problems are very different than a large
medical practice. We are hoping to work with CMS so that we are a voice for the
small medical practice.

MS. DUBOW: I am Joyce Dubow from AARP. I think I am one of the few consumer
representatives here. Our members are 50 and over. They certainly have a horse
in this race.

I cannot help but — if you will forgive me. I just want to make an
observation about one of the earlier slides that talked about implementation
fatigue and how costly it was to do all this in the ORI. If you think about
implementation fatigue, just consider how a patient feels when she has no
access to data. When there is a capacity of information, when you cannot make
an informed decision because you just do not know what is when you get push
back because you want to see something in your medical chart. I do understand
the challenges.

But I think that it is really important to have an appreciation for the
urgency that you hear from the consumer community about the slow pace that
health care has had to date. The reason there is such pressure now is that we
are finally paying attention to what many other industries have attended to for
so many years earlier.

HIT, E-Health represent enabling tools to improve quality. We have known
recognized quality deficits in this country. There is ample evidence to
demonstrate that E-Health may be a mechanism, a tool to help us out of this
enormous problem. It has to do with wasted resources for care that is not
needed. I do not have to go into all of that. I know you appreciate it.

At this point, E-Health probably should be considered as the cost of doing
business. And ultimately remember who pays for it. It is consumers who pay in
their premiums. We think this has value. We think that the investment in IT
that is productive and meaningful will improve health care. It is something we
ultimately will pay for. I think we need to have it in that context.

Lots of people have talked about the importance of sharing information and
the seamlessness of sharing information. I just want to mention a few things.
First, policy goals have to drive the standards. We have to remember not to let
the cart before the horse. We have to have good policies. Linda, thank you for
mentioning privacy. It is on my list. We certainly do not want to see privacy
to be an impediment to the use of data, but we need to acknowledge that the
public is wary and we need to create a sense of confidence that their data will
be addressed, handled, shared respectfully in accordance with their wishes. And
policy has to guide the standards that address that. That is the first thing.

The second thing is I think we have to remember who consumers are. It is not
a monolithic group. We are all people of different capacities, different
preferences, and different circumstances. We need to have mechanisms that
enable all of us to access data in however we need to access it. We need to
take into account cultural competency. We need to take into account
decision-making skills, literacy skills, and cognitive issues. We need to
remember that it is not only the patient, but also a family caregiver who may
be involved. We have to figure out how to weave that into the system as well.

I guess I will leave it at that. I think you hear my perspective.

MR. CULLEN: Rich Cullen from the Blue Cross Blue Shield Association. I am an
executive director in our national program’s division. I lead a lot of our
national initiatives related to product network and consumer. It includes a lot
of our industry interaction and standard-setting organizations and other fun
meetings I see you all in.

Listening to this, I have been torn in coming up with one vision. I have
two, but I will still keep it succinct. One is the more longer term. I think
E-Health will enable a safer, higher quality, more equitable, and sustainable
health system for all.

But second, I think we need a shorter-term vision for the next two to three
years that really balances the industry’s strategic priorities with the
tactical. I think we have had a mixture of those through the discussion so far

I am not sure we can do them in parallel or if we can do them in parallel
maybe not in the same meeting. I am kind of choosing to focus on more the
shorter-term vision for the two to three years. And what that would look like
for me is really identifying the comprehensive roadmap with the appropriate
sequencing and timing of mandates and non-mandates. I think NCVHS has been
successful providing guidance in the past like for 5010 and ICD-10, test the
standard, test it in products and applications and do end testing and the
sequencing from level one, level two. I think that was a great roadmap for the
industry to work on those two initiatives alone when we are still implementing
of course. Obviously, the regulatory mandate landscape is much more complex
today. It is going to be harder to determine that roadmap and that sequencing.

But in addition to mandates, we have a lot of non-mandates that I think we
need to look to identify those interdependencies and make sure we have the
touch points with those roadmaps as well and make sure those connections. Just
one example. SNI’s electronics submission of medical records. Does that have
interdependencies or connection to X12 claims attachments with HL7 payload? It
is a little more tactical.

Rob threw out another example that they are looking at regarding mobile and
on their roadmap and things to look at. How do we ensure we have transparency
and coordination across all those initiatives across the industry both the
mandatory and the non-mandatory because definitely we see a convergence there?

DR. JAMOOM: Thanks, Rich. I think you raised a really good point about this
concept of timing. The short-term versus the long-term planning for this
E-Health goal.

MR. TENNANT: Rob Tennant. I am with the Medical Group Management Association
where I help to lead the association’s HIT policy and help implement all these
standards and regulations in small, medium, and large-sized group practices.

Obviously, a lot of great comments. It would be easy to say I agree with
everybody. I want to just add maybe a little bit different twist on a few
things and really building on what Rich said. I think there are really two
roadmaps and maybe it is a different way of saying exactly what Rich said. We
have a macro-roadmap where we are looking at all the various standards and
requirements being pushed out onto the industry. In that area, we really have
to be careful with, for example, the operational impact on the end user.

I think a prime example is the federal quality reporting requirements. The
fact that somebody who attested to being a meaningful user would still be
required to go into a government website to announce that they were getting a
hardship exemption to avoid a penalty even though they are doing exactly what
they had to do in the meaningful use programs. The redundancy in reporting is
something that has been well documented obviously by a lot of folks. But it
persists I think possibly because we have different silos within the government
developing these programs.

I think it sends a bad message to the end user. It makes physicians and
their administrators very frustrated in having to go through these steps simply
to achieve something that could have been done through a convergence of a

I think when you look at meaningful use, for example, another level of
frustration comes from specialists asked to do tasks that are really designed
for primary care. A fine example of again jumping through the hoops to avoid
penalties and perhaps get a bonus, but at the same time adding to the
frustration level.

I think when we talk about Rob’s use of the D word, which is interesting.
When you look at all of the admin sim provisions that have come down the pike,
every one of them has had the D word attached to it whether it is the
transaction standards, which have been delayed forever officially, whether it
is 5010 and its enforcement delay, the NPI, the easiest of all standards —
four years to implement. The question is do we continue to do that or do we
work ourselves backwards and say what caused the delay and what can we change
in the process so we do not have to go through this delay. And delay is fine
when it is needed. But if it is caused because of things that we can solve,
then it is an issue.

I talked about the macro-roadmap. But I would argue that there is a
micro-roadmap as well. Each of the standards should have its own roadmap. It
has to be different than what it is today. I am vice chair of WEDI so of course
I agree with everything Jim said. In particular, Jim talked about the business
need for the standard. I think sometimes we create a standard and then try to
find a problem for it to solve. A great example of that is of course the
accounting of disclosures access report where there is absolutely no evidence
that there is any need for the standard yet it is going to be pushed out on the

I think we have to be nimble and we have to establish a distinct ROI. That
is used a lot. But we do not really employ it the way we should. I think a
prime example is this own committee, which based its recommendation back in the
early 2000s to move to ICD-10 on an ROI report developed by the RAND
Corporation. When you go back and read that, it is very interesting because the
number that they attached to the cost is now going to be assumed by one health
plan. One health plan essentially is going to use up all of the money that they
said the entire industry would use. To get to Jim’s point, you have to
establish a true ROI. What is the benefit to somebody and what is the actual
cost before we go ahead and mandate it?

The other piece is the provider responsibility. I think we have to have some
direct input not just after the fact so we react to a standard, but we have to
be brought into the process before, during, and after. I think one of the
things we have avoided very successfully is pilots. We did one pilot for one
HIPAA standard, which was the 275 transaction, which was a resounding success.
It showed ROI for both providers and health plans. We promptly never released
the final regulation. Maybe it is a bad thing to do a pilot because we may
never see the regulations. But at a minimum, it educates the industry. It
identifies problems before they happen.

Steve Lazarus and I were talking beforehand. The idea that you could have
put on two code areas on 5010 to be able to do a code ICD-9 and 10 perhaps for
six months a year to understand the differences that would have solve a lot of
angst in the industry. Thinking about it from a strategic point of view is very

MS. LOHSE: Gwen Lohse. I am the deputy director for CAQH. CAQH does a lot of
industry utilities nonprofit that are not necessarily part of the regulatory
process. And then the managing director for CAQH CORE, which is working on the
operating roles. Within those two roles and providing this framework.

We are working with especially with the CAQH CORE board, which is
multi-stakeholder, primarily providers and health plans. Having to communicate
out an E-vision that the patients understand. All of us in this room are
“insiders” up to a point. What is our vision for those that are not
part of the process? We had looked at it as a trusted system across all those
that are participating. Whether it be the consumers, the home health agency, be
the nonprofit or the for-profit health plan, the large hospital, the small
hospital, a trusted system that everyone wants to participate in, feels secure
about, and that the data definitions are the same. There is truly an
interoperable system and we can reuse data. Obviously, the public agencies are
part of that. That is the vision.

That vision is not necessarily what we all communicate out. How do we as
more insiders look at the governance of this and what is going to drive the
governance, that E-vision from those that are potentially more on the inside
developing the framework? And that governance includes sustainability. We all
talk about ROI. What is going to really drive the ROI? Were we going to get to
the woman that spoke about the consumer viewpoint? What is going to drive each
of the pieces and how do we evaluate them? What do we do with funding and
bringing public and private together because it is not all about regulated
aspects? It is bringing the resources we have to the table.

And then additionally, really driving through on quality assurance and
checking that we are making sure that we have quality. Beyond communicating the
viewpoint on the vision that the layman can understand, our vision on the
internal side, the governance issues. Then there is a timeframe issue here.
What are our goals for each of the phases? It is probably a different vision
every three years. How far as we going to lay that out?

MR. FRIDSMA: Thanks. I think ultimately we will be judged on our ability to
support the triple aim. Our ability to improve the health care system, our
ability to improve health of the citizens, and to improve efficiencies in the
systems that are out there.

If you take a look at the triple aim, improving the health care system is
about really just trying to improve the quality and the outcomes that we see.
When it talks about engaging or improving health, it is about engaging
consumers because we are talking about outside of the health care system.

When we think about efficiency, we are really talking about reduction of
extra tests and improving quality because we believe that I think better care
is probably going to be more cost effective in the end.

But this group is focused on health IT and it is focused on how can we use
health information technology to achieve those triple aims. We talked a lot
about interoperability. I would suspect that if we polled the people around the
room, everybody would have a different definition of what interoperability is.
I am going to propose an interoperability definition based on the IEEE, a bunch
of geeks that do this across the world, which says interoperability has two
principal components. The first is the ability of two systems to exchange
information. That goes to Jim in this notion of the seamless flow of
information. But that is a necessary, but not sufficient part of

The second part of interoperability is the ability of the systems to use the
information that has been exchanged. I think that is where we differ in our
definitions of interoperability because we all have different uses for which we
want to have that information. It is really important that as we think about
health information technology and we think about standards and the like that we
move beyond what we build to what we enable. Because if we move beyond what we
build to what we enable, we start to talk about use and that is where we really
get to interoperability.

I would say that when it comes to use, the big thing that I would like to
see in terms of a vision is we have talked a lot about big data. I really could
care less about big data. What is the definition of big data? It is more data
than you are really used to. We talk about big data, but then you talk about
the folks that have petabytes worth of data and they are like that is big data.
That is what we care about.

What I care about is lazy data, data that we collect once and it just sits
there. It is never reused. We spend hundreds of millions of dollars collecting
this information and then we never use it. To me, it is not about big data. It
is about lazy data. It means that we need to be able to support small data
analytics for the primary care providers as well as big data for the people
that want to mine that. Because if what we do is release this data to all the
big companies and they do all the analytics and our small practices are
spending all their ten minutes gathering data and not seeing any benefit from
it, they are going to shut off the pipe and they should because they are not
seeing the value of the work that they are putting into the system.

When we think about use of this lazy data, we have to think about how we
apply it to our current situation. We have to talk about how we measure its
use. We have to learn from the experience and then we have to feed it back so
we improve. There is an apply, a measure, a learn, and improve, when we think
about the use of that data.

The thing is we talk a lot about a learning health care system. We talk
about we want to get this system that is going to learn. Again, I probably am
being kind of churning up the apple cart for a bunch of these things because I
did not care about big data and I am going to tell that I do not care about the
learning health care system either.

What I care about is a system of health care learners who use the data to
learn. We do not want the system to learn. We want the people to learn. We need
to create a way that this data can be applied to the decisions that people are
making in real time. That it needs to then measure in terms of quality and our
outcomes. We have to learn from that information and then we have to use
clinical decision support and process reengineering and change management to
improve what we are doing. At the end of the day, that is what we need to do.
We want a self-sustaining system.

The last thing is how do you scope all of this? How do you figure out to
make this a self-sustaining system? I think you have to go back to what our
triple aim is. Quite frankly, if we create standards and nobody uses them, do
they make a noise? I do not think so. I think what we have to do is we have to
make the property of the system, the emerging property system should be
interoperability driven by our needs to use the information to improve health
care and all the triple aim. It needs to be driven by business drivers. It
needs to be driven by our desire to improve quality and to improve payment.

And then if we can focus on those and people see a need to exchange
information and to use it in useful ways, then interoperability both the
exchange and use becomes an emerging property of the system, not the thing that
we focus on.

That is my vision. Focus on the triple aims. Realize that it is exchange and
use. Make sure that we get use down because if we use it effectively,
interoperability will be an emerging property of the system.

The last thing that I will say is that a roadmap is really useful. But if we
have multiple roadmaps across multiple agencies all doing different things, it
is not going to help us. The roadmap should be used as a way of getting
agencies and organizations to work collectively towards those common goals, not
an end in itself. If what we do is never come out with a roadmap, but we have
the agencies actually talking with one another and beginning to merge things
together, that would be success.

MR. WILDER: I am Tom Wilder. I am senior council at America’s Health
Insurance Plans. Some of you have heard me say this in the past. I am not a
technical expert. I do not really understand the intricacies of information
systems or standards. I am a lawyer and a lobbyist. For my view of E-Health, it
is really at the end of the day, what are you making my members do and how much
time are you giving them to do whatever you are making them do and what are
they going to get out it?

I think Jim Daley actually had a very succinct definition of E-Health that I
would agree with, which is the right information, right place, and right time.
I would add to it at the right cost and value to the end user.

I will give you a personal example. My primary care physician uses paper
records because he sees no value whatsoever out of electronic records. I have
had discussions with him about that. At the end of the day, he has made the
decision that it is just too much hassle and too much cost.

When you are laying out this vision of E-Health, I think you have some great
and lofty and I think very agreeable goals. If it provides no value to the
consumer or to the provider or to a payer or to a clearinghouse or vendor, it
really is not going to get any traction.

The analogy. Doug, I think, gave us the analogy of the banking system and
the banks coming together to develop their electronic exchange standards and
standards for mobile banking and standards for swipe cards and the like. I
think in some respects that is a false analogy because if you think about the
number of players and the complexity of the data and the number of exchange
points, it is pretty simple compared to the health care system. I think in
another sense it is the right approach, which it was the stakeholders coming
together and deciding what was best in their interest and not having it imposed
on them from a government agency or from someplace else.

I think it is a very tough thing to do, but in terms of laying out a vision
for E-Health, I think again we really need at the end of the day think about
who is using this information, what are we asking them to do, what value are
they getting out of it so that they would actually want to take part.

I will just finish. The one thing that Doug just said, which is about the
roadmap. I do think one of the values is not so much laying out a specific set
of goals and deliverables, it is actually getting people together in a room to
talk and to share perspectives and to share information so that we have a much
better understanding of where everybody else is coming from.

MS. SAVICKIS: Saving the best for last. I am Mari Savickis, AMA. I did try
to take a few notes last week to put down some thoughts on this. But I will
start with I think some little known facts about the AMA, which I wish they
were better known, but our moniker is helping doctors help patients. The
physician-patient relationship is always at the heart of what we do. Also, we
went through a realignment recently and we have three new focus areas, which
may be of interest to everyone, which is improving health outcomes. We are
going to be focusing initially on pre-diabetes and cardiovascular disease. GME,
which is Graduate Medical Education and physician satisfaction in their
workplace. Just a little bit of things to think about as we are focused again
always on the patient.

My back of the envelope or back of my iPad notes were as I am bouncing my
son on my knee trying to get through Friday evening. What I had written down
and after listening to everyone I know it is definitely not hitting every
single thing, but I had written down and no, I swear I did not compare notes
with Rob Tennant. A thoughtful implementation that takes into consideration
better communication and coordination between CMS, ONC, and OCR, which has made
in my opinion great strides in the past few years, but I think it is something
that we have to continue to work at and it is hard and I get it. Clinical
administrative health IT deadlines like HITECH and ACA. Other federal HHS
mandates like Medicare contracting reform changes, non-E-Health ACA changes, et
cetera. A meaningful use program that is more flexible, less rigid, and less

Maximizing the ROI. ROI should take into consideration ways that truly help
maximize physician’s ability to deliver better care and outcomes, but is also
weighted against costs associated with each mandate. For example, there a
number of mandates and meaningful use that when taken together represent costs
that exceed the maximum incentives available to physicians like the cost of an
interface to a lab and patient portals.

CMS should also undertake a comprehensive assessment of each E-Health
mandate and the estimated ROI and financial impact on the industry and
prioritize the changes that are at the very least can be made without
regulation and look for ways to offset identified pain points.

Another thing would be to take a step back and break down the workflow of
information from the provider to the payer and back and everyone in between to
address how all the pieces fit together. The clinical pieces cannot be achieved
without the administrative and vice versa. Those were some things.

I do like the ATM analogy. A lot of things everyone said totally on message
about — we use this analogy about having the right information at the point of
care for the physician so they can help the patient. I totally agree with that
and what you said also.

This RAND report. Having come from CMS and ONC and being there on the ground
in 2005 when all the cost savings were predicated on the true
“interoperability”. I am kind of starting to hate that word. It is so
inside the beltway word, but so annoying. When I have to break it down into
plain English, I would just say one EHR talking to another just in plain
English. There is a lot of stuff in between and not quite as succinct and
detailed as you are. I am not an informaticist.

But there is this quote in the more RAND report that came out. I think it
was earlier this year or last year. I do like the ATM analogy. It is just
saying it is more like everyone can relate to the ATM. I am just visiting from
Kansas or San Francisco and I just want my $100. I just got to get a cab. They
do not care what happens behind the scenes. They just want your $100.

Right now, the analogy that was made in this more recent RAND report was
things do not operate like that in health care. They operate more like a
frequent flyer program. How annoying are those? I have to compile all my US air
points. They are not going to help me in Southwest. It is just not. I think
that that resonates more with the plain English speakers of the world and I
think we can all relate to that.

I know I have not hit a number of things. Things that keep me up at night
would be privacy and security mobile devices. Holy cow. I do not even know what
to say about that other than doctors are not technologists by and large and do
not really know how to encrypt their PDAs and laptops in a manner that they
probably should without getting too in the weeds. These are things that do
worry me. Payment delivery form. We can go on and on about all these things.

I will give a patient example. I have a son who has some health problems.
Without naming names of medical institutions, I am in the DC area, I have to
get information from my doctor’s office that was a three-physician location
practice that has an EHR. I won’t name names. I love my doctor. But now I need
to go to the pulmonologist who is in a health care system that is inside the DC
area. The summary care. We get a lot of pushback on the summary care. It is a
meaningful use requirement. Again, I am looking at the patient advocate here.
If you spit out something from your EHR that looks like gobbly gook, how
helpful is that? You know what I have in my file for my kid is I have this
written summary that every year I take out during flu season and I put it in on
the refrigerator in case he gets sick, do this. One, two, three. And I know
exactly what I have to do. But and I know they have an EHR. She did not print
it out. Also that I need to go another institution in the relatively same area.
They do not talk to one another and they all have EHRs.

What would be great is if my doctor got all that stuff, the pediatrician got
everything pulled in from. But you know what it is going to happen. I am going
to be the one who brings that over, scans into the PDF in my spare time and
shoots it off through unsecure email because I am going to dispose HIPAA and
just say it is okay. And then they will send me back a secure email. I totally
get it.

At the end of the day, when the doctors call me and they ask me am I going
to be able to talk to another EHR across town and do this. I am like no. Then
the ROI becomes but I have a patient form for meaningful use. Yes. Well, what
about the lab interface? It kind of goes on and on.

My last comment would be doctors are not technology phobes. So many of them
are using things that work really well like iPads, iPhones, PDAs. They are
emailing me and texting me. Trust me. They are wired. It is just that they want
to use well-developed tools that makes sense and that are going to be something
impactful that will drive outcomes of care and help them help their patients.

DR. JAMOOM: Let’s check the folks on the phone. Is there anyone on the

MR. FINERFROCK: This is Bill Finerfrock with HBMA. I think at this point
pretty much everything has been said. I think to recap from our perspective,
what Tim from the Cooperative Exchange and Jim on behalf WEDI said in terms of
a seamless system, we would certainly associate ourselves with that.

We, for a long time, have been talking about trying to emphasize or point
out or demonstrate the ROI. If we cannot demonstrate an ROI, I think we have to
seriously ask why we are doing certain things.

And then finally to Mari’s last points with regard to interoperability, I
think that that is perhaps one of the more frustrating aspects of the financial
investments that may with regard to EHR and the need to really make that a
reality. After millions of dollars, billions of dollars being invested and
still not seeing the improvements there that we had hoped for is very
frustrating. As part of the vision moving forward shortening that up and making
sure that those things actually work as promised.

MS. WEICKER: This is Margaret Weicker with ASC X12. We are a standards
development organization. You all have heard people throw 5010, et cetera.
Those would be our X12 standards or implementation guides. A lot of what has
been said I would agree with. I think we do need to define what we are talking
about. I do think there are short-term and long-term goals as well as visions.
It is like a developing a product or your strategic plan. You have a short-term
and then a long-term goal.

One thing and Gwen touched upon it and several people and it would be
included in any kind of ROI calculation is resources. From an X12 perspective,
our resources are all volunteers. The member company of ASC X12 brings
volunteers to do the work. As we lay out the plan, the roadmap, somebody called
it implementation fatigue, and I think we need to be mindful of there is just a
limited set of volunteers that for the most part do the bulk of this work. Any
kind of plan that comes out I think that has to be taken into consideration as
well as then from the consumer, the patient point of view because we can never
lose sight of why we are here and why we do what we do and that is because of
the patient or the consumer.

DR. JAMOOM: Do we have anyone else on the phone?

MS. GILBERTSON: This is Lynn Gilbertson with the National Council for
Prescription Drug Programs. We are one of the other SDOs, Standards Development
Organizations, that is named in HIPAA as well as Medicare Modernization Act and
meaningful use and other things.

I do not want to reiterate some of the points that others have said because
I think they were spot on. But some of the things that we have been dealing
with in the fatigue as I think there will probably be a couple of smiles around
the room is the regulatory process and trying to make sure that the processes
are consistent across all the different kinds of standards and all the
different kinds of regulations that have been named or to be named out there.

We are dealing with different process requirements based on interpretations.
We are dealing with different timeframes. We are dealing with situations where
the industry is requesting a modification and the regulatory folks are trying
their darndest to facilitate the timing of the enhancements and getting their
hands tied. We need to be nimble with our regulatory process so that we can
when the industry needs to move forward, we are showing that support so that it
is not the kind of thing where if the industry has decided they need something
in a year, it can be done in a year. There are other things that may take two
to five years or whatever. But continue the nimble and the consistent process
so that those activities can move forward as needed.

DR. JAMOOM: Do we have anyone else on the phone? I think that is it. We have
Cathy. Tell us where you are from and then share with us your vision.

MS. SHEPPARD: I am Cathy Sheppard. I am the chair of ASC X12. Not
surprisingly, Margaret and I have many of the same views. I do not think we
need to repeat everything so obviously I agree with a great majority of what
has been said.

I think it is important that we roll out something that is clearly well
thought out and coordinated because we have set a huge precedence that that is
not what gets rolled out. We say we are going to make Jell-O and we boil the
water and then we put it into the refrigerator, but we do not put the Jell-O
in. We start over. We say forget that. And we get the boiling water and the
Jell-O, but we forget to put it in the refrigerator. We need to make a plan
that is doable. While we are doing that, we need to make a plan that is both
flexible and adaptive. What we think of today is that is just out of the realm
of possibility is going to be commonplace five years from now. Whatever we
build, it cannot be stuck in any one particular implementation view or one
presentation. It has to be adaptive.

I think it is really important for us to remember something that there is an
infinite number of great ideas, but there is a finite number of resources and
that includes people, that includes money, and that includes time. We cannot do
everything that is a good idea. We need to decide to set a standard or set a
policy for things that matter, but not for things that don’t. If we are going
to talk about writing checks, we want everybody to sign their check. But do we
really care whether they write it in blue ink or black? We need to set those
priorities right so that we are controlling what is important and letting the
other stuff work itself out.

DR. JAMOOM: Easier said than done. We hear a lot of similar themes
throughout the group. I appreciate everyone sharing. I think it is very
important for the experts to have the time to share what their vision is, what
their interests are. Let’s take a break because I think we have really spent a
lot of time this morning. We have one more person who wants to —

DR. CHANDERRAJ: Raj Chanderraj. I am a practicing physician and a member of
the committee. Two things. One thing is money, money, money. The second thing
is square peg in round hole. The whole idea of this information started from
CMS because they are tight with the budget and they want to make reform so that
they can save money. Unfortunately, health care does not fit into a model.
Businesses have only a few things whereas individual’s health care is a wide
entity. There are only 155,000 diagnoses in ICD-10. When I am seeing a patient,
I have to figure out what hole am I going to fit this patient in. It does not
fit sometimes. It takes so much time for me to put in this number. And that is
why most physicians are totally ignorant of what the coding is. They just put
what they feel is. And the billing girls spend a lot of time trying to read my
notes and trying to figure out and trying to put the square peg in this round
hole and send it to the billing.

The data collection, which we are all interested in it. The business part
and the clinical part. The business part is very clear. You get clear coding.
You get clear claim. You have reimbursement. You can analyze that data. But
health care, which is so clinical, is so difficult to categorize into a data.
And that data you are trying to convert this to and that is a problem.

There are so many difficulties for the clinicians and the end user to
convert this data. Unless there is a payment reform addressing this issue,
unless you take the physician’s part in putting this current data into the
system, you will get garbage out. Garbage in. Garbage out. You cannot balance
these two unless there is a — it is all right into the money.

The only reason meaningful use became accepted is because $55,000 per
physician. That is not even enough to cover the expenses. Now you are adding on
all these mandates and there is no return of investment for this physician. He
is spinning his wheels for uncompensated care. Now you have this portal and the
patient emails all these things. There is no time in the day for a physician to
attend to all these emails. It is all uncompensated care. For a business man or
a lawyer, a telephone call, you bill for that. But physicians have to do all
these things and it is uncompensated. Unless there is a compensation model and
then you will see total integration. That is a delay.

DR. JAMOOM: Thanks Raj. Let’s take a 15-minute break and we will back and
pick up from there with the industry.


DR. JAMOOM: Let’s get back into it. We have some folks in the audience. Does
anybody have any comments they would like to make on their vision of E-Health
and what you have heard today?

DR. RODE: This is Dan Rode. I used to work independent so I
will leave it that way. I am not a member of an assoication like most of you
are. If I had a second eye, it might be idealist. But I just wanted to share an
observation. I started in this arena over 20 years ago. At the time, the
question was can we possibly cut a check to people to pay for their health care
claims and what data would we need to exchange. A few years later, we were
kicked out of the finance committee for the X12 beause nobody would send that
much data in an electronic tranmission. That was the comment.

A few years later, we looked for a way to come together and
to resolve many of the issues you are still talking about today. Eventually,
that became pat of HIPAA 1996 and this committee became the overseers of HIPAA.
Of course, now, with HITECH, we have other committees.

My observation today is not the vision of what we are going
through whether it is the three stages for the government or it is better
quality or it is better communication between consumers and physicians or what
have you. I think my vision and what I hope this group might think about is how
do we sit down representing these various entities and actually address these
questions with the goal of actually coming to completion. Jim said that
standards were a tool. And yet what we did is we built the standards without
really having a complete goal of how did it fit with the clinical and
administrative work that we did.

We have problems because many of our caregivers are not one
with the goals and objectives that we look at when we think of electronic
exchange of data. There are frustrations with how it is done, when it is done,
does it fit in with the vision of payment for health care. We have a lot of
questions and most of you addressed those this morning.

We have built a regulatory system that is a start and go
system. We come up with a law and then we go with regulations and then we go to
the next piece and then we go to the next piece and then we go back three
steps. If there is something that could be done to work with the federal
government, which has a big piece of this that can be done with various groups
like CORE, that can be done with our standards organizations so we can come
together not in hearings, but do what the financial system did, which is
actually sit down as a group and say how are we going to address this problem.
How are we going to address this goal? What standards do we need? What policies
do we need? What education do we need? How do we be buy in?

I have been to meetings like this for most of my last 20
years. I guess today what I would say is each of you from your perspective, how
can your organization and the people you represent actually sit at a table or
send some folks to a table that actually can make these decisions so when we
leave that table, we each know what our parts is going to be and move forward.
Otherwise, I am affraid that as we have approached this over the years, we are
going to go back and do it again piecemeal. That is my concern as someone that
has been very much wed to this process. I hope you will think about that. I
know there are hurdles to overcome to do that. I know those hurdles exist. But
there has to be some way that we can actually take into account what you are
talking about from your constituency and address that in a group that actually
can move beyond just the discussion. Thank you.

MS. FORESTER: Rachel Forester. I am going to express some personal thoughts,
not as representing CAQH CORE here nor Boundary Information Group. I have heard
some greater visionary concepts here. I think that we really need to focus on
the vision. If Denise had a magic wand, what would she want her life to be in
dealing with her family’s health and health care and so forth? We have to set
that conceptual vision. And then we have to say how are we going to get there.
And I do not want anyone to say we cannot do that because we do not have this
standard. We cannot do that because we do not have this tool. Take the
obstacles, break them down, go around them, pulverize them, whatever you have
to do, but set that vision so that the AARP people, I am one, Denise’s family,
and the gal from the AMA when she talked so that we can address those things
and how do we want it to be. It is not a regulation. It is not a technology
tool. It is breaking down the barriers to getting to where you want to go.

DR. LAZARUS: Steve Lazarus, Boundary Information Group, taking off his CAQH
CORE hat for a minute. I want to bring two points up. One is yesterday in the
committee’s discussion, there was an observation that is very significant as we
talked about here and that is the train has left the station. Change is
occurring whether we like it or not or we participated in the change or not.
Technology and data and consumer demand for information, how it is being used
is all changing. We cannot keep going the same way we did things at the same
pace we did things because it is already ahead of us. Keep that in mind in
thinking about this vision on how we move forward.

The second thing is that I want to speak on behalf of the consumer and the
provider for a minute. I am also an AARP member for a long time as Rachel is.
This impacts us because we are the experts among our peers about how this is
supposed to work or do we deal with these problems. Boundary Information Group
is commissioned by Citibank to conduct a study based on 50 executives and
revenue cycle management and financial management and provider organizations
about what is changing and what the future is likely to be in our revenue cycle
management process over the next two to three years both because of what is
going to happen with health care reform and what is already happening as
insurance-like products, health plan products are changing in the market place.
That research report is available on our website. And Citi has presented this
to HFMA. It will be presenting it to MGMA in October and to the WEDI meeting in

But the big insight, the big take away, which you want to put on the table
as you are thinking is there is already a big shift underway of moving from a
largely health plan payment process reimbursement for providers environment to
a consumer largely responsible for payment environment. And all of our systems,
products and work flows on the provider side in particular are focused on the
health plan payment picture because that is where 70, 80, 90 percent of the
money comes from. And that is already shifting and likely to accelerate. We
have to be thinking about what is the system going to look like, what are the
workflows, what are the tools we need to help the provider refocus on
collecting their earned money from the consumer and educating the consumer by
giving them the information about what they are going to actually owe and the
options they have for paying for it.

DR. JAMOOM: Anybody else from the gallery?

Let’s talk about some common themes to E-Health. If you have any corrective
comments that is dynamic that you feel free to engage. We know that the
definition is in flux. What is E-Health? That was something that we need to
come up with some common definitions for talking about E-Health.

Also, we know that the patient is at the center of E-Health. We understand
that there is a consumer demand aspect to E-Health. What does that mean? That
means the consumer is engaged that they have to be able to use this information
and hopefully it improves their health care. We also know this consumer choice
or patient preference that was mentioned by quite a few of you. It has to be
personalized to the patient.

The data usefulness and the reusability of data. It is not just data for the
sake of data. That it has to be usable to the physician or the provider and
even to researchers for that reusability piece of it. Data stewardship. With
difference to privacy and security making sure that data are secure.

Also, we heard from some of you about this need for short-term and long-term
vision for this E-Health roadmap.

There is also the issue of the regulatory process and how we can make that
work for furthering our cause and then leading with sound policies. Having
policies to drive that change that is needed. Sense of urgency. It is now. If
we need to adjust things as we go that the E-Health roadmap is flexible.

And then stakeholder communication and engagement that there is
communication among all stakeholders and that there is a way to engage. Are
there other things, other themes that I have missed that you would like to

We will do the NCVHS. Put your card on the side and I will acknowledge you.

DR. BLOOMROSEN: I think this is terrific and you did a great job of herding
cats. This is always the case with a group like this. We all have been around
the beltway representing all kinds of different perspectives. But I think some
things are missing that I heard. One is that we are facing multiple and
potentially conflicting expectations and perceptions that we all may believe or
I think I thought I heard that we all believe there are going to be reasons to
balance priorities with resources. I think that may not be up there. But I do
not think we are all going to be able to necessarily or at least not yet sing
off the same song sheet. That is just the nature of the complexity of our
health care system. I do not know how we will balance that, but there might
have to be an underlying agreement that there is a baseline framework upon
which we all can agree. And then maybe there are options or shifting priorities
depending on a stakeholder view. We all have different needs for data.

The other thing that I think I intended to convey, but maybe I did not in my
marks is I think the common denominator are the data themselves, not the tool,
not the device, not the setting, and that we have to be thinking moving forward
to even back to basics. That it is the data integrity and the data quality as
well as the data definitions and their implicit meaning that we all have to
think about.

My worry is that we should be thinking through the data capture and data
collection and documentation practices and principles in spite of the fact that
we are implementing electronic health records or envision mobile devices, et
cetera. My worry is that there is a perception that because data are automated,
they are accurate. They are complete. They are timely. They are appropriate.
That we agree on their definitions. I worry about that we understood when data
were manually kept and maintained and records were only on paper that there
probably were nuances. But I think we should be respectful of the ideas that
there might be differences and those subtle differences might be impactful as
some people talked about with respect to the second or other uses that are made
of the data.

DR. JAMOOM: That is an interesting perspective. I think it is okay that we
have differences of opinion. Everyone has different priorities that they
represent. I think that is an excellent point. Finding that commonality that we
can have agreements on is an excellent point and then focusing more on data.
How can we tailor this vision around the agreed areas with data use?

Who is next? Raj, you initially were speaking.

DR. CHANDERRAJ: Just on return investment. I think all the stakeholders’
concern is on return of investment. Nobody is paying attention to the end user
and return of investment. Everybody is all so focused on the patient care, but
nobody is paying attention to that.

DR. JAMOOM: The return on investment and the end user of these data. I will
pose a question to you for more clarification. When you say end user, whom are
you referring to?

DR. CHANDERRAJ: End user is a patient and the physician.

DR. JAMOOM: Patient and physician.

PARTICIPANT: ROI had come up quite a bit so I want to make sure we capture

DR. JAMOOM: Let’s just continue.

MR. GLICKMAN: What I don’t like is ROI. It is too simple. One of the big
problems we have in health care is that the people that make the I, are not the
ones that get the R. If we are going to talk about data and the reuse of data
and how we all need different data. The fact is that data is raw. It is a
normalized data that becomes information that combined with our experience
becomes knowledge. That is kind of what we are losing here because without that
knowledge — the physicians use the data differently than the payers who use it
differently than the insurers that use it differently than everybody. The
question is you have raw data. Data has to be normalizable. Then it has to be
normalized. Then it gets combined with experience to become knowledge.

The problem is that doing ROIs — it has always been a difficult thing to
quantify as we saw with the example that was given earlier of that RAND report.
What happens is that if you — I am trying to figure out how to describe this
simple. It is that collecting of the data in a way that we know it can be used
in multiple ways. There are times for these different uses when the individual
identifiable information can be stripped away. If you look at those four
domains, we talked about people and clinical administrative population and
research. When you get into genome, there is no way to anonymize genomic data.
It cannot be anonymized. And it cannot be pseudonymized. I do not want to get
into the technical differences. There are times when you have to pseudonymize
data where you can return it back. That speaks back the whole notion of
governance and stewardship and privacy and security.

We talk about data. We would like to be able to go to sleep at night and say
I got my data problems solved. That is just the beginning. We should remain

DR. GROSS: Building on Meryl’s and Michael’s comments, I would like to
applaud their remarks. I would also like to call out that my concern about this
ROI business. We really need to be thinking about the fact that this is for the
patient. I am a patient. I have a similar scenario to Denise’s situation. I am
frustrated because as a patient, I am paying for my premiums and I am paying
for tax dollars to invest in the private sector’s ability to comply with
standards and regulations to do what they really should be doing in this brave
new world of technology.

DR. FINERFROCK: ROI is about patients. If you are asking physicians to
invest direct dollars in terms of purchasing technology, indirect dollars in
terms of sufficiency and operation of the practice to the point where they are
no longer financially viable and the practice cannot sustain itself, then you
have no access to care and that affects quality. You cannot think of ROI is
simply a business proposition. It directly impacts on access of care. It is
what has been missing from the debate thus far is that we keep imposing more
and more requirements on the providers, expectations on the providers in terms
of investment and time and there is no way for them to pay for it.

I do not know who it was earlier pointed out that you are doing all of this
time and you are not being compensated for it, but yet all this money is going
out of practice and you are financially bankrupting the medical practice. You
cannot ignore it.

MR. TAGALICOD: Similar to that, again, I will refer back to how we started
in HIT, Health Information Technology week at HHS. It was very clear that it
was both the patient and the provider were part of the equation. The focus on
consumer health did not mean to jettison the provider in that or that it was
anti-provider. It was very clear. I think that is what we need to understand.
There are different perspectives in terms of ROI or the value of the data.

I want to reiterate I think Michael and other folks about the data. It is
really about information. It is about actionable information regardless of who
you are because we are different consumers of the data because I, myself, am a
patient and I am a consumer, but I am also a regulator. I use the data in a
different way in my different respective roles. In the same person, I have
different uses of the data. But again, I need to use the data that is sensible
and whether we get it through standardization or normalization or whatever we
call it. I think that is what we need to get to. For us, what are the
priorities? Yes, based on the resources. For us, in terms of a regulator, the

Now, there are several people around the table who will say by the way, you
do have the authority. I am going great. I just need to make sure in my OJC in
my Office of Legislation agree with us that we do have this authority. But
again, not to create an additional burden, regulatory burden. Maybe that is a
bias that I am introducing here. I will say that is my particular bias. But I
think it is something that I have heard.

DR. JAMOOM: I think the issue of biases that we all bring is something that
as a facilitator in any process everyone has their own interest. I think that
is okay. But I think what we are trying to do here is identify common themes
and issues. Those are valid. All of those concerns I think that you raised are

MR. ARGES: I think process is so important. I think governance is really the
key as part of this process in a sense of a roadmap is really a way of defining
how we are going to move forward on a certain set of activities or goals. I do
not like the term ROI because I think that is missing what needs to happen.
There has to be measurable value and outcome. That ultimately has to improve
patient care as part of that process. I think that is a key part of this.

Our hospital members over the last several years have spent a considerable
amount of money and capital investment in IT. It is probably the number one
capital investment over the last several years. I think what we need really is
a way where they can provide input to say that the following types of data
activities are being demanded upon us. But we think the following are the most
important because we cannot do it all within the given dollar amount that we

Having a forum, a discussion place, where that can take place I think is
critically important because I think it really lays the groundwork in terms of
developing something that is feasible and defining a timeline that is practical
and getting us to where it ultimately improves patient care and quality of
care, something that would I think benefit the patient as part of that process.

DR. JAMOOM: Having more value and maybe taking this conversation about what
that ROI would look like.

MR. ARGES: Measurable value. You have to have a measurable expectation of
what do you hope to see come out of the change. I think it could be better
patient outcomes. That could be an important item or metric that you want to
establish and achieve. Maybe the dollar cost is not necessarily there, but the
investment is there. It has a human cost that has to be taken care of and

That is where you need just to have that dialogue to talk about that. To me,
it is a new process and new governance model that has to be looked at.

MS. DUBOW: We talked earlier. A lot of people talked about harmonization and
we use lots of different words that we are talking about trying to achieve
consistency. I think that the issue of ROI or finding value has to be decided
upfront and then there is no do over. There has to be consensus at the get go
and not again at the time of implementation. What we have is push back at every
single stage of the process, which is not productive. We have a contentious

The ACA created the measure application partnership that was designed to
advise the secretary on 28 programs and soon to be expanded. Now the exchanges.
And these were specifically — the legislation specifically provided for
guidance on the measures that were to be used in these various federal
programs. That happens through the National Quality Forum, which is a consensus
body, where all of the stakeholders are at the table. This is an opportunity to
forget harmonization if there is agreement at the get go. I do not think that
having multiple bodies to achieve different types of consensus is productive
because we will have this disagreement at every stage. We need to have a
rational process here.

The ACA provided for a mechanism to achieve consensus around the
measurement. If the measurement represents what people think are scientifically
valid or important to measure, are consumer focused, are usable, there is a
whole slew of evaluation criteria. Then we need to accept that. Every one of
these groups here today is represented at that table.

I just think we cannot have so many do overs. That goes for ROI. If all of
the stakeholders at the table believe that this is a direction we ought to move
in then that is where we ought to go and figure out how to get there.

DR. JAMOOM: There are a few points that you raised. One is consensus about
the purpose of this group and what can be taken as agreement from the get go
starting with certain commonalities and moving forward from there. The second
thing that you mention that kind of was interesting was once you have
agreement, you do not necessarily go back. You do not go backwards.

MS. DUBOW: We can have room for mid-course correction. I do not think we can
be rigid. What I am saying is that we would not be duplicating processes and
agreements and consensus that have been forged with great difficulty. This is
not an easy process. Consensus is really hard because we all come from
different perspective. But I think we need to accept the consensus of
recognized bodies when it is achieved.

DR. JAMOOM: Hopefully, we can figure out what those areas we can agree on
and move forward with. It takes, as you said, a lot of effort to obtain

MS. DUBOW: I just wanted to make one more point. The issue about burden. I
think when you think about burden and the effort it requires to move in the
direction we want to go in, we need to think about the fact that we are trying
to transform the system. It means that status quo is not necessarily what we
ought to be maintaining. It means change. That means shifting resources to
perhaps more appropriate things to achieve greater value. I think we have to
have a mental map that allows us to think in the direction of transformation as
opposed to status quo. That is the second thing.

DR. JAMOOM: And I think something that Walter mentioned earlier on is this
concept of transformation. I think it is a theme that is going to permeate
throughout this entire day. I think what you raised is absolutely right. The
status quo. When you are talking about this, it is okay to give ourselves
permission to extend beyond the status quo. We have to. It is vision. It is
E-Health vision.

DR. TENNANT: I agree with everything that Joyce said with the exception of
her use of rational process in the same sentence as health care. I want to talk
about ROI a little bit because we have to remember that there is sometimes an
ROI that goes beyond economic. Rob and I were talking on the break. We laughed
and we said 20 years ago would you have said to somebody you would have a $700
phone in your pocket somebody and we would have laughed. Times change and
standards of care changes. To get to Tom’s case study of his provider mired in
paper, that physician has done the ROI calculation and determined it is not
worth it. Not just for the money, but probably because they believe their
providing high-quality care.

The challenge for us is to convince that physician that yes, it is
expensive, but there are value points beyond economic ROI. It is better quality
care, but also retention and recruitment of physicians becomes more and more
challenging for practices that have not moved to electronic. As new physicians
come through the system, they are not going to want to go back to the
clipboard. We have to sell more than just the standard. We have to sell the
concept of why we are trying to do this.

And the other point is the only person that really has highlighted the issue
of vendors was Michelle. Physicians do not get the data. Physicians are not
interoperable. The data flows into their system and they are not here at the
table. The vendors that are responsible for making all this happen are really
outside of the system. They are not covered entities under HIPAA. The only
thing we have is meaningful use certification. That is the only lever that the
government has. Other than that, it is all market place driven. Vendors have a
vested interest in developing a proprietary approach and it may or may not be
interoperable with their competitors.

We have to step back and say how can we make vendors part of the process
whether it is deeming them covered entity status like some folks have suggested
moving into a more aggressive certification realm, which we have suggested. How
else can we convince them to support the physicians other than just say market
forces will prevail?

MS. LOHSE: I am going to go on the ROI theme for a minute. There is a way to
think about the advancement of the system. As Rob had said, it may not be
financial. The return for the system as a whole to advance it. We are talking
about making a better system. That is not sustainability. We are not staying
where we are. It is not a financial word. It is advancement of the system.

And then really what is the sustainable case for each of the stakeholders
because we have models for the — maybe we have models for the systems, but we
do not have models for the different stakeholders and what their financial
impact is going to be. That is a missing piece.

DR. JAMOOM: Let me just ask a clarification question. When you were talking
about advancement of the system, tell me more about when you say system. You
are talking about the entire breadth of the health system. Define system for

MS. LOHSE: This goes back to my second point. We almost go through a process
of asset allocation or an asset assessment. We have all these different assets
that all of us have different pieces. What are we going to call the assets we
need to build the vision? Back to your point. The system. Any one that is going
to make the vision happen, this E-Health vision, is part of the system. If we
are going to have a shared role in that, then you need to consider the system
as a whole. I think it is the health care system, quality, delivery, and the
nonfinancial pieces. But if the financial underpinnings are not there for each
of the stakeholders, the E-Health vision is not going to be sustainable. You
really have the advancement of the system and the sustainability of the
stakeholders underneath it because the system does not exist without the

My second piece is I do think there is almost like an asset assessment we
need to do. A lot of people are talking about different components. Joyce just
mentioned NQF. There are all these different assets we have and maybe we
underestimate the value of how they work together. An asset assessment.

MR. WILDER: I want to react to one thing that you had said. You mentioned
the regulatory process and you said how to use the regulatory process.
Actually, I am more interested in how you avoid the regulatory process. I am
not anti-government. I think the agencies here provide great value and bring a
great perspective and can help push the process. But at the end of the day, if
I had to choose between CAQH or X12 and ONC and CMS, I am going to go with CAQH
and X12. I think they can do a much more effective job of not straight
jacketing the process and bringing people together to do what they need to do.

MS. LOHSE: I am going to build on a point Tom made. I do not know if my
asset assessment got clearer. CAQH, for instance, has a database of 1,300,000
providers. It is growing by 5000 to 6000 providers per month. That is mostly
ancillary providers. All the providers that we are going to need to help make
this system improved. We have this asset. It is actually owned by the 1,300,000
providers. It is growing. How can we use that asset? It is not a regulated
asset. But how can it help the process? I guess back to Tom’s point and my
point about assets and how the public and private work together.

MS. MULLINS: I want to be the voice of the small family practitioner in
America. Every week at the AAFP, we get phone calls from people that are going
to have to close their practice because the cost of doing business is getting
to be too high. Not everyone is a Kaiser or a Mayo or has a huge support behind
them to buy all this infrastructure that is needed to fulfill all these
regulations that we come up that they need to do to make all this work.

As more primary care physicians leave primary care, at the same time there
is more people that are about to be insured that are going to need primary
care. There is about to be a huge imbalance in the country of people that need
health care and that will want health care that can now get health care and
there is not going to be people around to give them health care.

As we make regulations and we make standards, we need to make sure they are
affordable for our primary care physicians especially those that are running
small practices to carry them out or they are going to shut their doors and
there is not going to be people there to deliver health care.

DR. DALEY: This is Jim again. I would like to also look at not just ROI in
terms of dollars, but we have to look at time. First, before I even get into
that, I want to say, what is a provider. We keep talking about providers. I had
a physical recently and had a learning experience there. I actually did see a
clinician, an MD. That was great. But that provider also consisted of all the
other people sitting around in the office. When we talk about the provider, we
really need to be clear about that.

One of the situations that occurred during the physical is I said show me
your EHI and what is going on. And the doctor called it up. He was cursing it
out right and left. I won’t mention which brand it was. And all the things he
had to do to get the right information in there and then certify it. My office
staff used to be able to do this. Now, I am having to do this. We
“automated” the work and yet that physician had less time to deal
with the patient than before.

To what Amy just said about not having enough doctors to go around, we
really need to look at making that process simpler to use so the physician can
do what they do best, which is treating patients and not working on the admin
side of it.

One other related item in here. Way back when my wife worked at an
organization, which was a large provider organization, she said it is really
interesting. We are starting to get rid some of the clinical staff because we
need to make room to hire all the admin staff for the office due to all the
things we need to do. Isn’t the thing we need to do is to treat patients? And
yet it was going in the other direction. We really need to look at that is how
we are enabling the people who treat the consumer to do that better, quicker,
cheaper, et cetera without over burdening them with all this other stuff.

DR. JAMOOM: Again, it comes down to patient-centered care.

DR. DALEY: Patient-centered care and provider’s time, physician’s time.

DR. JAMOOM: Efficiency of the clinician’s time and what is a provider.

MR. GLICKMAN: I wanted to comment about what was said on the other side and
just to reinforce it. If we talk about meaningfully reusable data, we should
also take advantage of the consensus that has been reached with meaningfully
reusable process and the work that came out of ACA and the measured guidelines
and the National Quality Forum. There is an awful lot of rigor that went into
all of that. And to reinvent all that would make little sense. We should look
at that as a meta-process and say this is how quality is measured and we get
the people to help us out with data integrity and completeness.

One of the big problems you have with data quality is when something that
you think — you do not know that something is there. People would say it
sounds like a quick way to take role. If you are not here, raise your hand. It
does not work. If you think that all the data is there and it is not, that is
almost worst than not having it all. That gets you to a critical mess.

If we are going to talk about ROI as measurable value that improves quality,
we should, but measurable value should be part of what the National Quality
Forum and others are focused on that we should —

DR. JAMOOM: Let’s use agreement that exists and not necessarily reinvent the

MR. GLICKMAN: That exists and we should look at it as a superset and say
which pieces of that. Certainly, quality, consistency, completeness, knowing
that something is missing. There are going to be attributes of that.

But really, I had put my card back up about the whole notion with the
vendors. To put my HIMSS’ hat on, the vendors are involved. There are 1400 or
1700 chapel vendors that have gone through testing. I am an assessor for the
laboratories. I asses the labs so they can go test vendors. I am a technical
assessor. They are there. The problem is they are not hearing a common voice
from the buyers. We are all here for all of our —

I want to give an example and I hate to do this, but it is a good one from
the ’80s. You have heard of ACR-NEMA, the American College of Radiologists and
National Electrical Manufacturers’ Association. In ’82, we had meetings. I
guess I am dating myself. But we sat around the table and there were lawyers
present because we had every vendor in the world in the room. By the way, that
became DICA. But the radiologists said just because I buy a magnet from you,
GE, Phillips, Fuji, et cetera, I am not going to buy everything from you. You
better come up with some interoperable standards. Thirty years later, it is
3500 pages of standards. New ones come out every month. It does not happen
overnight. But you can still buy a $50,000 tube that now has 3D. The price has
stayed the same.

But the point is that you can buy these things like pencils.
Interoperability is not unachievable. You have to start out with that clear
goal that says what am I trying to do. They said just because I buy one thing
from you, I am not going to buy everything from you. There isn’t a vendor out
there today that — a diagnostic quality imaging vendor that is not DICA

There is light at the end of the tunnel and I think that if we work through
this process with that handful of goals that we are looking for it is not going
to happen overnight.

MS. KLOSS: We have talked about the stakeholders and we have been talking a
lot about provider patient. I think when we get to scoping out this vision, we
need to return to an essential question of how holistically are we looking at
this. Don’t we really need to look at this as a continuum from public health
through patient care and not get channeled into thinking this is provider
patient and the same domain as we are looking at with system certification and
meaningful use. I think what we are looking at is a broader perspective that
really takes in so much of what the national committee has been dealing with
lately, which is community and population health.

I think to answer the question about the value of those discrete quality
measures, they have value in some sectors. But they are not going to meet the
needs for population health more broadly.

I think this will be a challenge for us to think about what is the scope or
frame for our vision. I would hope that we are keeping it pretty broad.

DR. JAMOOM: Reflecting on that continuum in terms of public health to the
individual and hearing a lot of what we are discussing. It sounds like because
everyone has so many different interests to just be respectful that there might
be broader purpose for certain measures. It might be applicative to your area
or may not be applicative to your area and that is okay.

MR. SOONTHORNSIMA: That is a great segue to what I was about to comment.
When I listened to several folks around the table and try to figure out at the
end of today, what are we hoping to get out of this. You kind of framed it for
us. Think broader and all that. But maybe three things to think about to help
think a little bit higher and broader because it is hard to come from different
sectors or areas, the specialties that you represent, groups that you

One is when we talk both about vision at high level and what we heard at the
beginning of this, we also heard several comments around the current
experiences from the various stakeholders like day-to-day, the grunt work, and
the challenges. Those are the today experiences that I think everybody is
trying to change. With that said, what we think our desired experience would be
for those different stakeholders, not to say that those desired experiences are
going to happen over night whether it is from consumer experience. Again, Joyce
said it best. There are so many different consumers and there are different
types of providers, different types of health providers and so forth. What do
we think those desired experiences would be at a much higher level? That is one
way to frame this.

DR. JAMOOM: With respect to the higher level part because we have heard from
some folks about that need for seamless interaction with the system that if you
are interesting with the system that it is simple to just obtain information.

MR. SOONTHORNSIMA: So describe those experiences a little bit more. That
means from the various stakeholders what would those experiences be like.

Second, we also talked about leveraging opportunities. Again, Joyce’s
comment about we do not want to restart, redo, and reconvene because every time
trying to get a consensus is extremely difficult. Use what we got. That is
exactly why we are here today to look at why we have that slide that shows all
the activities and mandates. Which of these mandates already have decide
already stuff or things that are already — like the quality measures and so
forth whether it is legislative or otherwise. There are some common
capabilities, common agreements that exists. That is a second point of using
what we have today, using what has already been decided and shape our future.
That is the last point that we started talking about. There is so much
diversity across the table today from the various stakeholder groups.

Therefore, what we are trying to tease out is some commonality. We cannot
solve everybody’s problem. But let’s identify what commonality, what areas we
can create sort of common set of vision and guidance. What this is going to
allow us to do as a committee, I believe, again, this is just one person
speaking is we can tease out guiding principles or how we frame up the concept
of ROI. How do we frame up the concept of short-term and long-term? How do we
frame up these concepts collectively, not completely representing every single
stakeholder in this room and on the phone? That is it. We are trying to tease
up. That is the only practical way for us to create using the common grounds
for us to create a glide path, roadmap, or whatever you want to call it. I will
pause right there just as a reflection of what we have been doing so far this

DR. JAMOOM: I know we are getting close to lunchtime.

DR. SUAREZ: My comments were going to be very similar to Ob’s. I was going
to just reflect on a couple of points. A couple of really interesting and I
think significant perspectives that I heard. One of the most valuable things we
can have is a tool, a mechanism that allows both the regulators as well as the
industry to see that as soon as there is an intent to go in a particular
direction with a requirement, what are the opportunities for building on
existing requirements. And what are the opportunities to avoid duplication and
to utilize some of the existing mechanisms rather than creating yet another
round of requirements that in many cases end up duplicating things that happen
or are happening already?

I think that is one of the interests that I see we have with this concept of
whatever we call it. We are referring to it as a roadmap or a framework. But it
is really a mechanism to help begin — it is a tool really to help begin to
plot and to identify situations where if these regulations were to be put in
place, what is the right timing? What is the right sequencing? And more
importantly what are the existing regulations that this might either overlap
with, replace, build on, those kinds of things? It comes out of a comment that
was made about — it actually happens in other settings as well where
regulators — in common opportunities and things like that. What other
regulations do you think we can eliminate out of this?

Vince said already how much regulation is out there and how challenging it
is to map all this. And organizations like ours like Kaiser and pretty much
every organization has to really analyze and understand it and to create the
mechanisms to resolve it. That is one comment.

The other one I wanted to really make is — I think we are facing a new data
paradigm in the following sense. I think the old concept of gathering data for
purposes of whether it is treating patients the traditional way or seeking
payment a traditional way is changing. It is turning us around.

In the near future, we are going to see the need to number one have to
collect better and more granular data to allow it to understand better more
granularly the conditions of a patient. And more importantly, as we look at
payment, we are going to change the way in which we probably seek and receive
payment by virtual of saying it is not anymore an encounter-based payment
mechanism. It is more of a truly outcomes-based reimbursement. That includes
things like do whatever you need to do as a provider to care for this
population and don’t bill me by the email and by the hour. Bill me and I will
pay by the outcome of that population by the fact that you did not have any
readmissions or complications with infections or things like that, which are
the current ones.

I think that new data paradigm is the one that is going to in many respects
drive the new data purposes that we are going to see. It is going to change. We
are seeing it already. It is going to change the way we establish the quality
measures that we are going to be reflecting on, establish the standards, the
electronic standards that are going to allow us to extract the data that is
needed in order to calculate those quality measures and report it and
electronically transmit that data on quality and reporting and communicate

And then on the other end to finish the interoperability cycle is not just
being able to put out and send it and transmit it. It is really being able for
the other end to executive on it and act on it. I think that new data paradigm
is the one that is in my mind going to drive significantly this new roadmap.

DR. JAMOOM: I think at this point it might be a natural place to stop. I
know we have some questions left.

PARTICIPANT: Were you going to take any comments from the phone?

DR. JAMOOM: Yes, we will. My question though is the following. At this time,
let’s take the questions from the phone. Go ahead.

MS. SAVAGE: This is Lucia Savage at UnitedHealthcare. I just had two
comments. One, I was struck by the speaker who asked about an asset assessment.
I think that we all have a pretty good idea of what the assets are. But what we
do not know is that whether the assets are synchronized. That would be my
suggested friendly amendment, which is that we figure out if the assets are
synchronized, not what they are. There are thousands of lists of what the
assets and the groups are, but the question is whether they are all working
towards the same end in a way that can be leveraged and built off synchronized.

The second comment I had was going back to the ROI. One thread that comes
out of the conversations particularly people who have been working on this for
now more than 30 years is it is all evolutionary. The cycle time on the
evolution is increasing. Whatever results have to be able to accommodate a
rapid cycle time evolution. Those are my two comments.

DR. JAMOOM: Thank you. Are there any other comments from folks on the phone?
Hearing none unless you are on mute. Are there any comments from people in the

MS. BUENNING: In the cycle of things, I think we have probably beaten this
dead horse, but I want to come back to ROI because this is a term that I have a
problem with because I think that when people talk about ROI or is suggested,
it is always in a financial mode. It is always, what dollars am I getting back
for the investment? I think based on George’s comments and I think that maybe
perhaps Jim made some comments as well alluding to this. Maybe we should call
it more value for investment because it is not always a financial return. It
could be patient convenience. If you have a standard for prior authorization
for Part B drug and you are not waiting for two hours for someone to get back
and you are saying it is okay to get that shot, that is patient convenience.
That is consideration. We need to build that into it as well.

DR. JAMOOM: Again, what the ROI so it is not just financial. There is a huge
quality piece to it too that comes back to the patient and to the system.

DR. BLOOMROSEN: At the risk of keeping us between conversation and lunch, I
recently heard a provocative presentation. Unfortunately, I do not remember the
author who said this, but I will get the quote if you would like me to share
it. The paradigm he used was old story, new story. I kind of feel like we are
stuck on our old story in our conversations a little bit. I would like to
encourage us, myself included, to really start thinking in terms of the new
story meaning the future. I keep hearing words like provider and patient and
consumer. I think we all agree that we want to be proactive visioning what the
future of health and health care will be. But I think we are still stuck in the
old story, which is provider, patient, payment, not that these are not
critically important and factors in today’s day and age.

As an example, once upon a time not too long ago I was speaking to a group
of school health nurses about the benefits of electronic health records. During
the break, one of the nurses took me aside and said Meryl. It is not that we
disagree about the benefits of electronic health records. But we do not even
have fax machines in our inner city schools to send information back and forth.
We are not about to with the budget cuts in these cities and communities have
any ideas. Maybe eventually on a cell phone or other opportunities, but they
were going to be doing it themselves.

I bring that up because we are thinking about health disparities, but we
probably need to also think about technology disparities and the technologies
down in the future. And to bring it back to Linda’s earlier point of thinking
at the higher level of what we think the vision will be for the future and to
be thinking along the lines of other points of touch points where people either
seek or need to seek preventive health services as well as care delivery. I
think we need to be thinking more broadly if we really truly want to be

And probably from a government perspective thinking in terms of broader
agencies like the Department of Education. Something tells me there are
requirements. If I recall correctly as a parent of young children, you have to
still prove your kids were immunized before they could go to school. In terms
of regulations and requirements, I think we have to be thinking more broadly.
Shame on us if we don’t. I think the brain trust is available at this table and
elsewhere. Maybe there are a few other stakeholders we need to think about
including in this discussion going forward.

DR. DUBOW: If I could just add. We also need to be able to share information
with community resources outside of the medical space because health care is
really burgeoning. It is not necessarily only in the health care arena.

DR. JAMOOM: I think that is an excellent point for us to break and then pick
up in about an hour from now.

(Lunch Break)


Agenda Item: E-Health Vision and Goals

DR. JAMOOM: I hope everyone had a nice lunch and had some really good
communication about E-Health. This morning we started talking about what is
your vision of E-Health. But we kind of kept it very open to just hear what
your industry and your expertise, what you valued from your personal interest.

At this point, we have heard a lot of different themes around E-Health. But
now let’s look at 2020. What is your vision of E-Health in 2020 given this
morning’s discussion? I want you to take the next five minutes or so and write
down three succinct sentences if you can about what your E-Health vision is for

DR. SUAREZ: While you are thinking and writing your notes, just a couple of
logistic notes. One is we are going to be passing around a piece of paper for
you to note. If you need a taxi, just make a notation of the time and the
direction you need the taxi for. And then as you leave if you have a visitor’s
pass, you can just leave them on your way out at the guard desk. Please do not
leave your phones on top of the table because they will start vibrating or
creating some interference with the people on the phone.

DR. JAMOOM: For the folks on the phone, you are writing your vision of
E-Health in 2020 given this morning’s discussion. You are limiting your
statement to three sentences. Four sentences will not be allowed.

We will begin with the folks on the phone. People on the home, who would
like to begin?

MS. SAVAGE: This is Lucia Savage. My first sentence says, professionals in
the health care system think about what the patient is trying to get out of
E-Health and facilitate that. My second sentence is, fear is overcome so that
it is no longer an excuse not to make this as easy as online banking. My third
sentence is patients who want to do it without technology are free to do so
without reduced quality or higher prices.

DR. FINERFROCK: This is Bill Finerfrock. I only actually have two. A
seamless system that allows clinical and business data to flow efficiently
between all parties in a system that is nimble enough to embrace new technology
as it emerges.

DR. JAMOOM: Do we have anyone else on the phone?

MS. WEICKER: This is Margaret Weicker. What I wrote was that all
stakeholders have all of the right information at the right time in order to
make informed decisions regarding health care and that the method of
reimbursement account for that and that the regulatory processes are modified
to allow more fluidity with the standards.

DR. JAMOOM: I think that is all from our phone folks. Is that correct?

DR. FRIDSMA: I do not have three sentences. I have four words: seamless,
intuitive, ubiquitous and indispensable.

MS. MULLINS: An informed and streamlined exchange of information between the
patient and provider that provides for an accurate, timely, and efficient
health care and data flow to providers that is meaningful, accurate, and

DR. SHEPPARD: Represented by base info, which is standard plus with the
amount of plus driven by users of health care functionality with no regulatory
mandates available to everyone and available on multiple platforms without
degradation between and shareable and non-shareable data can exist within each

DR. BLOOMROSEN: A framework that enables seamless exchange of accurate,
reliable, and consistent health and health care data for multiple purposes
across the care continuum including population health and research. The
framework is supported by underlying practices and principles of data
integrity, data and information governance and data stewardship.

DR. DALEY: Physicians and other stakeholders can collect, consolidate and be
able to use all pertinent information as needed and it must be correct. The
consumer has access to care 24/7 anywhere. The consumer is 100 percent
satisfied with their health care experience and feels better and is healthier
as a result.

DR. NARCISI: Seamless, granular data sharing with privacy and security
between all health care providers. Identification of patients will be seamless
whether that is through biometrics or an individual identifier. And then access
to my own health care data, all my data, and to my health care providers
through secured devices.

MR. MCMULLEN: The seamless and secure exchange of standardized electronic
data to promote efficiency, accessibility, and quality of care.

MR. GLICKMAN: E-Health 2020 as a mechanism for improved quality of care and
improved patient health will involve the domains of clinical, financial, public
health and research data in a setting of acute ambulatory and homes in multiple
platforms 24/7. It will involve personalized medicine due to the integration of
the domains in genomic research. It will employ a continuous feedback process
of health care standards, development, conformance criteria measures, testing
feedback use and maintenance.

DR. SORACE: There exists an interoperable diagnostic medicine system that
unifies pathology, radiology, and imaging. There exists a method to query and
find similar patients nationally to the patients that you are trying to care
for so that you can exchange ideas with providers who have identical concerns.
And there exists statistical methods that enable you to determine true
discovery from false discovery and just random patterns in data.

DR. CHANDERRAJ: Ease up on the legal framework that has taught reform for
providers to deliver care with guideline management and mandate performance.
Facilitate accurate, clinical data entry by increasing provider reimbursement
for extra time that is presently uncompensated and also have transparency in
the payment reform. Lastly, enforce regulation after due time for processes to

MS. WILLIAMSON: It would address the needs of the full spectrum of the
health care team such as for referrals, care coordination and on to enable
improvement in population health. It would include the development of EHR and
other HIT systems that are designed to be patient centric, but include upon
initial early planning, population health and other program needs. An E-Health
vision for 2020 would support advances in technology and in design to support
the evolution of health care.

MS. GREENBERG: Consumers, communities, health care providers and plans are
truly functioning in a learning health system where there is timely, accurate,
and secure exchange of standards-based information that is needed to improve
and manage population health, one’s own health and that of one’s family. I
might get the prize for the most words in one sentence. That information will
take into account a person’s health conditions, functional status, test
results, recommended interventions, preferences, and goals and the environment
in which he or she lives. Health outcomes for individuals and populations will
be the focus and will be rewarded.

MS. KLOSS: In 2020, the US will have demonstrated the value of an integrated
approach to population health improvement guided by evidence-based research and
ongoing quality management. Interoperable standards-based IT and analytics are
deployed by providers and public health and used by patients. Incentives and
payments are aligned for providers and incentives are in place for patients and

MR. SOONTHORNSIMA: A significantly improved patient and consumer health care
experience that is easy to navigate with specificity around care scenarios with
informed decision around care options, cost, quality, and understanding of
financial impact. There is a specificity around how new and existing
administrative clinical data and other non-traditional data are used to
facilitate care coordination, informing patients and measuring specific set of
care quality. Lastly, effective and efficient administrative processes are
measured and tracked for incremental changes in improvement with specific and
prioritized business processes in mind.

DR. SUAREZ: I wrote one sentence so long I have to take a sip. In my mind,
E-health and you will see a lot of the themes actually come across I hope. In
my mind, the vision for E-Health in 2020 is a true seamless, interoperable,
secure, efficient and sustainable system of technology infrastructure,
application tools, and devices that supports anytime, anywhere access to and
delivery of high quality, patient centered, health care services at the lowest
cost possible with the goal of achieving better health and wellness for
individuals and populations.

MS. BUENNING: By 2020, consumers will experience a health care delivery
system that is swift, transparent, accurate, accessible, and patient centric
and also secure. Providers will have the electronic, administrative, and
clinical tools and information necessary to render comprehensive care across
all settings with information exchanges seamlessly across patient, provider,
plans, labs, public health entities, et cetera.

MR. TAGALICOD: By 2020, we envision all health care consumers in the United
States to be empowered by meaningful, actionable knowledge via standardized
electronically enabled media that ensures access to the right care at the right
time at the time place at the right cost in a safe, secure, and seamless

MR. ARGES: I thought it was ironic that you use E-Health vision in 2020
because I felt as though I was at my optometrist. In any case, it is important
and I think the NCVHS can play a pivotal role really in creating a framework
that is inclusive, establishes a process of making certain the relevant
stakeholders are there, but one that clearly lays out the key components, the
common vocabulary, standardized data content, messaging structures and secure
routines for exchange of data.

MS. MOORE: Interoperability and exchange of patient information in a timely
manner. Providing physicians with the means to practice medicine that is
financially viable for them. And refine patient access to care.

MS. DOO: Trying to beat out Marjorie on the number of words in my sentence,
but I do not know if I succeeded. In 2020, we will probably have two versions
of X12 standards. Interoperable system of health care and health information to
which patients including their advocates, physicians, researchers and public
health agencies share appropriate access to information. The exchange of the
data is managed by a set of appropriate standards that are updated and adopted
in a flexible schedule that accommodates industry needs based on technology

MR. CULLEN: 2020 E-Health will enable a safer, higher quality, more
efficient and sustainable health system for all. And pertinent information is
available at the time it is needed to easily engage consumers, empower
providers to holistically manage patient care and enable population health.

MR. HICKEY: An interconnected health care ecosystem that is proactive,
transparent, patient centered, and delivers high quality care where, when, and
how the patient needs it at an affordable cost. And the patient’s medical
record follows them as they navigate the health care system irrespective of
what health care facility or vendor a provider is using.

DR. TENNANT: I am hopeful that in 2020 there will be enhanced consumer
engagement in their own health care through deployment of E-Health tools such
as Smart Chip and web-based technology. There will be employment of a standards
development and implementation process that fully engages providers and other
stakeholders that is business driven and operationally actionable by all those
impacted. There will be abstraction of all claims and quality data directly
from the EHR.

MS. LOHSE: I like the way you started out. I am hopeful that an impactful,
clinical, and administrative interoperable system that is trusted by its
multiple and aligned users, a shared public-private governance structure that
manages the trusted system assuring training needs, quality, security, privacy.
And sustainable models or model designed to evolve the system targeted
resources and incentives based on tract impact.

MR. WILDER: This actually repeats what a number of folks have said, but a
structure enabling the right information at the right time and the right place
for the right cost and value.

MS. SAVICKIS: A place where providers have access to the information they
need to treat their patients and where they need it in a manner that helps them
improve the patient care and does so taking into account the patient
preferences and helps the provider be more efficient. For providers, this would
mean less red tape, less focus on screen work and paperwork and more focus on
what doctors are trained to do, that is, to treat patients while keeping up
with the cost of delivering good care.

DR. JAMOOM: Let’s come back to the folks that we skipped.

MS. FARRAR: Could I ask everyone to either email me? If you are on the
phone, it would have been the same email address from the invitation. It is for
people in the room it is kamahanahokulani.farrar@cms.hhs.gov or I could just
pick up your papers. Just waive your papers and I will come dancing by.

DR. SUAREZ: I think we probably have the transcript. But the other thing I
want to make sure we know that this will be anonymized of course.

DR. JAMOOM: At this point, you probably heard a lot of similar themes in a
lot of your statements.

DR. SUAREZ: One reaction and I guess maybe others can share their reactions
or perspectives on what you have heard. Clearly, there are a lot of
commonalities. What is interesting is a lot of it is something that does not
have to be 2020 necessarily even though we said 2020. It seems like these are
goals that are probably even achievable hopefully sooner. But any way, I just
thought as I was hearing and I was drafting my own, these are things that I
think we are already moving in the direction of achieving by virtue of all the
things that are happening. We might not have necessarily the inter-integration
or the appropriate alignment or interrelationship between the various programs
that are aimed at taking us in that vision in that direction. But I think we
have a lot of the infrastructure elements through all the programs that we are
seeing implemented.

DR. JAMOOM: At this point, I do want to just let everyone know. We are going
to change a little bit of the rules in the afternoon as far as the facilitation
process last time. You put your nametags to indicate you wanted to speak. This
time we want it to be a little more fluid to be more conversational and
dynamic. If there is a specific part that someone’s vision really resonated
with you, does anybody feel strongly about something they have heard or that
surprised them about that vision in 2020?

MR. CULLEN: I am not sure about surprising, but obviously, a common theme is
access to pertinent information.

DR. JAMOOM: Access to information that is relevant to what in particular.
Are we talking for the patient, for —

MR. CULLEN: Yes, yes, and yes.

DR. JAMOOM: Did anyone think of any challenges that would — this is the
vision for 2020. Were there any challenges to any of the ideals that were
described that you could think of to obtaining that vision whether it is
regulatory processes? I heard some comments actually involved circumventing or
given regulation did not exist or what not. Is there some sort of block to
obtaining that vision?

MS. MULLINS: I think one thing people need to know about physicians if you
all do not know already and you probably do is we are a little bit afraid of
data when it comes to data about our own patients and getting data from
insurers and from anyone really especially claims data and things like that. We
get data. And the first thing we do is we say it is not accurate because that
obviously cannot be our data because all of our patients are extremely healthy.
If you say that half of my diabetics have not been in the last year to get
their A1C done, well, obviously that is wrong because of course all my patients
come in to be seen. Getting over the roadblock of giving data to physicians and
having them believe it is a real roadblock for a lot of people to get over.

The other side to that coin is I have been given a lot of data as a
physician and as I go through it, I realize that a lot of the data is incorrect
and inaccurate. If we are going to start giving data and flowing data to
physicians, we need to make sure it is the most accurate data we can come up
with because the minute you give a physician a bunch of data that is wrong is
the minute they are going to quit paying attention to it.

DR. JAMOOM: Really, trust that information that is being received and used.

MS. MULLINS: Like she said, it takes once that they get a bunch of
inaccurate data that they are just going to throw it all out and not look at it

DR. FINERFROCK: Can I add to that? I think it is also important that
physicians believe that that data is relevant. I think what we are hearing from
some of the physicians and providers is that right now what they are going
through is that data collection, data reporting effort and it is not clear to
them how that translates into improved patient care. I think having accurate
data, but also being able to demonstrate why that data is relevant.

DR. TENNANT: Just to build on Amy’s point. There is also the issue of legal
liability. If you are trusting the data that is coming to you, you act on it.
There is a bad outcome. There are some liability issues. We have to remember
that if you do not use it, there is a liability issue and if you do use it and
it is wrong.

It also gets to another theme I heard a lot and that is engaging the
consumer more in their own health care. That is wonderful except the reality is
a lot of times and we talked about diabetics. If they do not be aggressive
themselves then they are going to fall into that category perhaps going to the
ER. It has the issue — there has to be some accountability on the side of the
patient as well. We can arm them with the tools, but they have to use those
tools. How can we educate and incentivize them? I think one of the ways is
through the private sector. Businesses are actually giving their employees
money to participate in a PHR and things like that. We need new models of
engaging the consumer.

DR. JAMOOM: We have this issue of consumer engagement and how that plays a
role in this. What about compliance requirements that exist currently or that
are going to be underway? Are there certain things that you can see 2020
presenting those requirements?

MS. SAVICKIS: Encryption. Big privacy data breach security requirements
coming up for the industry next week. Traditionally, doctors do not really know
much about encryption. I am trying to make a full throttle effort to talk to
everyone who will listen that we need more help educating the physicians who
make up the vast majority of providers out there to try and help them
understand what it takes to make sure that their patient information is
protected. At a very basic level, our feeling is that the physicians want to
protect patient information. They find to be a very sacrosanct relationship.
But we are in a new digital world and increasingly we are going to become more
digitalized. We need some basic building blocks to help them get over this and
just have a greater understanding of do not leave your PDA unprotected or your
laptop in the back seat of your car while you run into the store. Like a how

We have some of that stuff and will continue to do the outreach but we
really need a lot of help from the industry to help educate physicians in a
plain English approach of what this means. Maybe it needs to be in — pieces in
not a scare the crap out of them kind of way. Even though it is technically not
required, it is for all intents purposes if you want to avoid reputational harm
to your practice and an awful harm to your patients, you really need to do
this. I am looking to CMS to help and ONC.

MS. DOO: I am looking to X12 to solve everything. I actually have now two
and a half things to add to that. Because I have kids who do not care a whit
about privacy, I actually thought privacy was dead. My apologies, Linda. But I
think it is not dead.

There was a New York Times’ article that I was sharing with someone else
this weekend. I think it was a university in Pennsylvania about their incentive
for the health insurance plan that they had purchased from one of the health
plans and WebMD where they were given an incentive for signing up for the
program. It was a health assessment.

The professors basically have mutant against it because it was so invasive
that the university purchased it without really looking at what the questions
were because it was about are they having trouble with the supervisor. Are they
having marital problems at home? The questions were so intense that they felt
it was a real privacy breach and they were going to be penalized $100 a month
or a pay if they did not do the questionnaire. It was a good health assessment
according to WebMD, but it was so invasive according to the staff that they
said we are not going to do it. It might be a good assessment of our
well-being, but you are going to have way too much information about us so we
are not going to do it. We are talking about a health assessment, which there
is an opportunity there, but from a privacy perspective, it was not cutting it.
Here is this bifurcation of an effort to do something good, but it cuts across
the privacy issue.

The other thing about physicians’ understanding privacy and people
understanding privacy is someone just showed me how vulnerable we are when we
go to Starbuck’s or we go anywhere else and we take our computers and we use
the free WiFi and free software program that anybody can download and look at
every single thing on your computer, all of your email, and all of your
passwords that you keep on an Excel spreadsheet or anything else that you do
with great ease. Both physicians and people really need to understand exactly
how vulnerable they are all the time.

DR. SHEPPARD: Since the SDOs live to please Lorraine, I will try to speak. I
think that I can speak for all of the SDOs when I say going back to your
question about what needs to happen to the standard. The SDOs can continue to
standardize the standard content, but we need to be free to present that
standardized content in different presentations, in different syntaxes for
different users and all of that still be recognized as the standard. If we
define the standard and we say I can show it to you in XML, I can show it to
you in EDI, I can show it to you in PDQ whatever comes next, that is very
powerful compared to what we have now.

DR. DALEY: First of all, in terms of looking at barriers to going where we
want to go, the WEDI report actually has documented a bunch of those. They will
be published shortly. We are in a process of compiling all those things out

There are a couple of items though that I think are significant. Not to
totally pick on regulations, but it is really the overall workload. People have
so much to do that they have to do because it is in law or it is in regulation
or whatever it is that they do not have time to do the things they think they
really want to do. You really have to balance that of should we still be
progressing down all the paths that have been set before us or should we alter
them and look at the things that will get us to where we envision the future to
being. Important thing to look at there. I am not just talking national level
or state level regs that people have to do that have to be looked at.

The other thing that came out very clearly in our work is we need a way to
make sure the person we are dealing with, the patient we are dealing with is
the right one. I know we do not have a unique individual identifier, but still
when you go and get care, you want to make sure all the records consolidated
are for you and not for somebody else and they get all the stuff they need to
know about you, maybe things that will kill you if they give you that medicine.
Finding a way to uniquely make sure that is the right person and we have all
the stuff for that person is critical and it does not necessarily need a unique
identifier. We just need to be able to make that happen.

DR. JAMOOM: The patient as a common thread across the entire continuum of
the health care system.

DR. FORESTER: Rachel Forester again with Boundary Information Group. I am
going to ask Steve to come up and join me because we had an interesting
conversation last night about this. I think that everybody is thinking inside
the box of health care instead of looking out to see what else is happening in
the world around us that we could go to school on. We were talking about the
Amazon and the way they deal with their customers and how they do it in a
seamless, easy, customized, on the fly almost way to do it. Why aren’t we
thinking about that kind of approach and the three or four key words that Doug
Fridsma used and look to outside of our industry to see how we can do something
now? Amazon did this a long time ago. They did not wait for standards. They did
not wait for regulation. They did not wait. They knew how they needed to serve
their customer.

DR. LAZARUS: I do not know what to add to that, but I do want to make a
comment about regulation. And I, like many of you believe, we should not be
overly regulated. The federal government has a role. I have to share with you a
story. My internist started doing E-prescribing 18 months ago. He has erred on
E-prescribing eight times in those last 18 months. And the reason why he errors
is that he does not do the E-prescribing. He just gets the incentive money. He
tells his receptionist what he wants e-prescribed. It is almost always the
right drug, the wrong dose, or goes to the wrong place. I stay with him because
he is a good diagnostician. But we have to get the right regulations in place
to ensure the quality of the data and all the trust issues we are talking
about. And patients do need to be very aware of what is going on with their own
health care and be attuned to the doctor may not be doing it correctly. He
never made a mistake when he was doing paper.

DR. FRIDSMA: When I bring my dog to the vet, I get an email 48 hours later
asking me how my visit was and whether my dog was doing any better. When I
bring my daughter to the pediatrician — we are pretty health care specific. It
is the reason I had four words basically. Seamless means that the information
flows and it just sort of moves around.

Intuitive means that the user interface is a good one that people know how
to use. It is not going to require six weeks of training and a huge hit to your
productivity to start using this particular technology. Nobody has to take a
class on how to use an iPad.

Ubiquitous means I go to my coffee shop and there is a USB port there that I
can charge my phone with. I do not have to worry about because it is just
there. It is kind of like wireless and things. It just needs to be accessible.

Indispensible is about the business driver. If it is indispensible, we will
make sure it is important part of what we do and we will essentially build it
around our work processes rather than the other way around. I think that is an
important piece of what we need to do.

I will totally echo outside the box. There is this huge push to get quality
assessment and try to understand. I look at how our doctors are educated. It is
the subjective, objective assessment and plan. There is no place in there where
we document outcomes. Then we go through conniptions to try to create quality
measures because nobody actually asks the patients 48 hours whether the
medicine for their allergies is actually making a different or not. I think we
have to think about using the technology to do a better job rather than seeing
this as a huge burden that the doctor has to do everything. If we just send a
little reminder and say is this medicine working or not and they say yes, you
can just document that. You now can actually start to get outcomes with what it
is that we do. I just want to echo the whole notion of let’s blow this open so
that the doctors operate within the patient’s lives to make their life better
rather than the other way around.

MR. CULLEN: Hearing a couple of themes and definitely a strategic, probably
seismic shifts on a couple of fronts including our delivery system moving away
from fee for service, but definitely on the consumer engagement with new
generations and cell phones and new benefit designs, new relationships with
their physicians, new way to purchase insurance. It is moving at a fast clip.
Back to Kathy solving all of Lorraine’s problem. When we look at standards and
operating rules, I think into the future you have to have some flexibility to
accommodate new business as it comes along.

MR. TAGALICOD: I think the role of organizational culture could be also a
barrier and maybe it is being addressed in the WEDI report and other places. It
was rather interesting when I had a discussion with folks and this is within
the federal sector. We said, what do you mean, Rob, that we are going to
achieve interoperability in real time in five to ten years. Look at the trends.
We are already doing real time and we are talking about interoperability so the
time is now. But the refrain back was but that is not our traditional way of
looking at things. It can cast that attitude. It can cast a pall on whether to
think about things new. This is inside and outside government, by the way. It
is across settings. And to get people used to the idea when we talk about new
and all these things. That is why I try to couch it and not use the word
interoperable because they seem to be — or things like that because people go
we do not do that. It is amazing that these same people are the people who make
decisions in terms of resources. It is something that we need to educate folks.

MR. MCMULLEN: Again, on the vision, I kept on hearing the consumer, putting
the consumer first. I do not mean to throw a wet blanket on anything, but we
also have to realize that adoption rate of something is not 100 percent. We
know that there are 4010 files still being transferred to clearinghouses along
with a flat file. When they get to ICD-10, they are going to have to have some
sort of flat file, put it together. And the physician may think that is a
cheaper way to go than to upgrade their system to 5010. We are seeing that
eligibility going through the eligibility process people just are not doing it.
They are referring them to their websites and that sort of thing.

As we are talking about a roadmap and looking forward and looking at vision
that we also take into account looking backward and doing a metrics of some
sort. CAQH is doing a great job on this. There are problems that arise and so
forth, but looking at adoption rate. I am not saying if it is not 50 percent
adoption then we should scrap it. I am just saying that we need to make sure
that what we are doing is being used and if it is not being used, why not?

MR. SOONTHORNSIMA: Just listening to everybody talk about regulation, I
agree. I think regulations can hurt. It can actually help as well. I think we
just have to be careful in what areas that we are trying to do too much and
what areas we are not doing enough of. That is really what we are trying to do
is balancing this thing.

I am going to take off my co-chair hat. I am just going to speak as an
individual person who is trying to implement the insurance exchange, for
example. I think we are just throwing too much along with the kitchen sink.
When I think overall ideally this can work. This could work and think about the
adoption, think about the complexity of it. If we can ease into this, I think
this would be a much better experience for everybody because the goal is
already there. Again, regulations can work as long as we do not do too much.

DR. SORACE: A lot of complicated things have to work for anything to work it
tends not to work. I think you have to start thinking in terms of what simple
queries can we support nationally that people will find of value. There are
other consumer outward facing organizations like PatientsLikeMe that are more
or less trying to negotiate finding people with similar problems. They are not
offering hard-wired solutions, but they are offering communication as what you
get from it. I think you have to start look at simpler systems that can ask
simpler questions across a more diverse set of diseases and that put people
with communication than being a follow up.

DR. JAMOOM: We are at this point now I think —

DR. FRIDSMA: I was just going to make a comment about the pace and all the
stuff that is going on. Project Management 101 tells us that there are three
variables we have to work with. It is timing, scope, and resources. We can talk
about timing, but frankly patients need this stuff out there and we need to
start moving forward. I feel reluctant to say we need to just take a lot more
time to get this work done because I think that is probably a disservice to the
patients that we are trying to serve.

Then we have scope and resources. I think we are already maxed out in a lot
of the resources that are not there. That tells us that probably what we need
to do is we need to focus on scope. And what that means is it is not to change
our vision for 2020 that we want to do less when we get to that point. I think
what it means is that we need to take smaller bites of the apple and do this in
an iterative, incremental approach that is focused on the things that provide
the most value to providers and the most value to the patients.

Part of what that does in an iterative approach is it means that you have to
plan for additions and changes to your infrastructure as you go forward. And
frankly, the systems that we implement today will be the legacy systems of
tomorrow. We need to understand that this is not something that we are going to
fix on one fell swoop.

I think it is really important if we think about timing, scope, and
resources that our focus should be on what are the small bites of the apple,
iterative approaches to getting this done, build it in so that we know that we
can expand and update as we go because that way if we do not get it right and
there are parts of this that we will not get right that we have a mechanism and
a way that we can swap that out and we can keep going forward and not let that
be a barrier to us getting to that better place. To me the discussion about how
we are going to do this is not so much that 2020 changes where we want to go,
but it says what are we going to do in the next six months because we are not
going to try to create a two-year plan for this.

DR. JAMOOM: And building on what Doug is saying really this part now is the
time when we are looking at priorities. I think the scope, the resources, and
the timing that we are trying to hone in is based on coalescing around what are
feasible priorities that we can go from point A to point B in an incremental
way. What sort of priorities, as Doug said, bites of the apple would you think
are feasible?

MS. SAVICKIS: Since I am such a shrinking violet, we need guardrails for
meaningful use desperately. I know that the deadline for stage two to start is
weeks away for the hospitals and it is a few more months away, January 1, for
the providers. I think there is over reach here where we are desperate to get
some wiggle room. If we do not get that wiggle room, they are going to go off
the road. This is a very imminent timeframe for us. I think that if we are able
to get some wiggle room that you are going to see a greater success rate. But
if we do not, the trajectory that we are on right now is we are seeing some
dropouts and it is going to get more pronounced.

I can tell you that the providers we were talking to who do want to do this,
but they are missing some of the requirements and it is not always by a
substantial amount. It might be by a fraction and they are in danger of getting
penalties. That means less money to invest in the things that they need to
invest in starting next year if you do not participate. I will be frank. I
would like to see NCVHS put a recommendation forward to ask for more
flexibility and meaning use for stage two ASAP. We need guardrails.

DR. JAMOOM: I could actually build on some of what you were saying because
some of the work that we did here at NCHS of surveying physicians and asking
them whether or not they meet as a proxy. Do you meet the meaningful use
criteria? And if you look at the capabilities these physicians report having,
there is a gap among those who claimed they meet meaningful use. Forty-two or
forty-three percent of them do not have all the capabilities associated with
stage one CORE meaningful use. I could completely understand that there is this
perception gap of what is meaningful use and are they ready for it.

MS. SAVICKIS: I totally get that some people think that the bar has not been
set high enough. But speaking from the provider’s perspectives, I know that
they are trying. If you are not able to meet even a fraction of a requirement,
not only do you not get the money, you are going to get danged. I have already
talked to them. We know where the pinpoints are for stage one. But I think they
are going to become even more pronounced for stage two. Again, we are hitting a
lot of the stuff, but some will reach a conclusion at some point that it is
cheaper to take a penalty than it is to invest in a costly lab interface or a
patient portal when you know that the cost benefit is not going to be there.
That is bad for the taxpayer. It is bad for the provider and it is bad for the
patient. I could go on forever so I just have to be quiet.

MS. LOHSE: I think we all talked about a trusted system that involves all
the different stakeholders. There are some gaps in the system right now whether
it is long-term care, it is property and casualty. We all know the gaps. Some
of the practice management systems. In order for us to have this system that we
are talking about, we have to get most of the players on a level-playing field.
How do we engage those that are not under the regulatory framework whether we
are going to do it through contracting as a unified group? There is a lot of
different ways we can approach this, but getting those players to the table.
Those are essential, key segments of the market that are not moving along like
everyone else. Do we change the regulation? I know no one wants to even talk
about that. Then if we do not change the regulation, is a more innovative way
to do that? Medicaid has very strong contracting authority. Medicare has strong
contracting. There is public/private and innovation means looking at things

I think the concept of the integrated model we have definitely played off of
that within CORE develop test, early adopters, retract. We need to see more
case studies and a framework for people delivering the case studies so the
early adopters are able to bring along the tail that Pete is talking about. We
are doing some hand holding and bringing everyone along. Again, both of those
pieces are thinking about the critical mass moving forward.

MS. DOO: Which regulation were you talking about?

MS. LOHSE: For one, I know some of the providers are challenged with the
non-HIPAA covered vendors that they may rely on that do not have to do the
adoption. Then we have certain products that are not covered under HIPAA. I
think we all know what they are. I think both the vendor systems that are not
covered under whether it is meaningful use or HIPAA, they are sitting out there
and they are not in the framework. And then there are the covered lives with
certain insurance that are not in the framework either. How do we engage them
in a different way? Lorraine, does that seem clear?

DR. TENNANT: I just want to build on Mari’s concept of the guardrails. You
are 100 percent right. That is one silo. If you broaden out that silo then you
have to talk about ICD-10. If you can believe, we are already messaging out to
our members about contingencies. This is well over a year in advance because it
is inevitable that certain trading partners are not going to be ready whether
it is — EHR vendor, clearinghouse or health plans. As Tim said, we have 20
percent of providers still using 4010. That is an immediate group that is in
dire straits.

What do we have to do? If we take Rob at his word, we are not going to get
that D word applied to ICD-10. But the reality is health care cannot come to a
crashing halt a year from now so we are going to have to do something. We have
not learned from the previous implementation. We know where the problems are
and for providers, it is absolutely critical to test, test internally, and test
externally with their trading partners. Again, not to beat a drum, but for
Medicare to step up and say we do not plan to test, we just plan to flip the
switch is irresponsible. They should be leading the way. It is an easy thing to
do for them to lead.

DR. JAMOOM: We can see some potential benefits from existing groups like
Medicare where perhaps they can help lead policy, innovation in terms of
bridging the gap.

MS. LOHSE: I do think the ONC term beacon communities where we have beacons
within all of this framework and having the public agencies be some of the
beacons really do speak to the market.

MR. MCMULLEN: I wanted to make sure I understood very correctly. When Eric
is talking about priorities and meaningful use is on our doorstep in a couple
of months, I just wanted to make sure I was clear. You are saying that is not
the priority right now and that is something that —

MS. SAVICKIS: No, just the opposite. It is a huge priority. It is coming
right up for us. We are the January start date, but the programs are tied
together with the hospital. A hospital starts stage two in two weeks. I know
this does not affect everyone around the table, but it does affect the
providers substantially. It is a huge rub point.

I guess our experience and Rob can speak for himself. Our experience has
been that stage one has actually been hard. I have talked to the doctors who
are missing the mark. They are getting audited and being found to have been
incompliant for a measure or two measures or missed it. I will give for an
example. I talked to a physician who missed for 2011 one of the data exchange
requirements. It is no longer a requirement. It does not really matter because
they took the requirement away for 2013, but he did not get the incentive for
2011. His EHR system — he thought he was moving data in an electronic manner,
but it was spitting out as a fax at the other end. That is not meeting the
requirement that was established for that point in time. He missed out on the
$18,000. That is just one example. Again, that requirement is gone, but I could
give you other examples.

We are just trying to figure out a way. Are you really going to say a
patient that your doctor is using an EHR? They are doing X, Y, and Z, but they
are not doing G. Are they not a meaningful user of health IT? They are actually
using their EHR and meaningful manner. It is just not meaningful to the
government. Again, if you mix a fraction of a measure, you are risking starting
in 2014 a penalty.

MS. LOHSE: I think Mari had said it might not affect us all.

MS. SAVICKIS: We are competing with all these other things that really are
important to everyone else around the table like ICD-10, the exchanges. The
list goes on and on. But we are talking right out of the gate in two weeks.
That is pretty pressing.

DR. LOSHE: I just wanted to make the point. If we are all sitting around
this table talking about an E-vision. Ob, you put up the slide and Walter about
the different components that are out in the market. It actually does affect us
all. If you have a communication out of one of the biggest things we are
rolling out as a system and the messaging should be the whole system because
each of those things are going to be impacted about how people perceive each of
the pieces.

As you all think about the scope of this, it all really — I just wanted to
make a point.

MS. SAVICKIS: Their ability to make these other deadlines that are all
intertwined with what other stakeholders have here at the table is severely
dependent on meaningful use if you are providing care to Medicare beneficiary.
Just for example, an ICD-10. Stage one. Providers realistically. If you are
even doing meaningful use, will enter into the program if they are going to do
it the last quarter because you only have to 90 days in 2014. What is the last
quarter? October 1. When is ICD-10? Mid-October. The systems are supposed to be
certified and they are still not even all in the marketplace yet. You can see a
perfect storm brewing for claims processing disruptions, consumers calling the
help. We have down this road before with all of you. I know it is going to be a
really rough road like the last quarter of 2014. We want to stave off some of
these problems.

I do not know even the guardrails will help with the ICD-10 issue because we
have not tested the certified systems. You could be using a product the
government says is fine, but then you might not be able to get your claims
through. Again, that is maybe something less that ONC would be focusing on so
much as it would Medicare. It is an OESS requirement. They all kind of tie in

MR. MCMULLEN: I just wanted to finish up. When you were talking about
priorities, I think two very low hanging fruit right now is what Gwen and
Robert were alluding to. One is that these non-covered entities is we have to
figure out some way to bring them into the system because that is causing some
issues. Not everybody is at the table.

The second one about testing. I know Lorraine has said this before where if
there was a testing model that we could use time and time again. So we are
going through ICD-10. We know that this is going to happen on this day and
everybody is going to do this on this day and so on. I do not know honestly
what is going on with the NGS testing. I would like to maybe talk to you about
that. Anyway, I think those are two things that are probably needed to be
thought about and worked out. Like I said, I think those are going to be low
hanging fruit to where the rest of the stuff will be easier. If we do not have
the covered entities at the table and people are still doing the testing
because we are going to have to test for all this stuff, it is going to be a
nightmare if we do not have a platform to work off of.

MS. SAVAGE: This is Lucia Savage. Can I make a comment from the phone? That
was a really passionate discussion about the complexities of converting from a
paper system to an interoperable electronic system from the provider’s
perspective. I do not want to downplay those complexities. But I want to get
back to the idea that the reason we are doing this is to keep the patients
healthier and to improve the patient’s health. I want to get back to the idea
that it really is the fierce urgency of now for the patients. We have a
population that is increasingly older and sicker than it ever was before. If we
do not figure out how to do this, they are going to get even more sick than
they were before. Yes, we have to empower the patients, but it is the
professionals who understand how their bodies work who can help those patients
become empowered.

I just do not want to lose sight of the fact that this really is an
important thing for the patients. It is true that in almost every system of
carrots and sticks, there is a point at which you get a stick instead of a
carrot and it just is. There might be political discussion about whether it
should be at one point or another point. Decisions were made by the federal
government about what you had to do to qualify for stage one and what you have
to do to qualify for stage two and they are discussing stage three. We live in
a competitive entrepreneurial society and people pass and people fail. It is
unfortunate. If you fail, but you really want to pass, you have to go back and
do it again just like people who have to take their licensing exams for any
number of professions.

We should not get too wrapped up in the problem of pass-fail in a way that
we lose sight of the fact that what we are really doing this for are the

DR. JAMOOM: Michael, you are up.

MR. GLICKMAN: I want to change the focus just a little bit. It is a theme
that has come up a few times in this discussion and that is about testing. I
think the next step if we want to look at what are our priorities. A big
priority is to stop thinking about standards development as being done by one
group in a static environment. I think the notion is that standards development
is an iterative and incremental process just like Doug was talking about it. It
is not an all in proposition. You cannot get it right out of the blocks. You
sit around the table and you can think you have it right. I remember HL7
version one in ’87. It was not even legible let alone implementable. We had
mixed up all kinds of stuff.

The point is that standards development is more than just development. There
is development and maintenance at the ends of that continuum. In between that,
there is the development. There is coming up with conformance criteria. Then
there is testing which involves tools. If there were tools and you knew I can
test them individually and that gets you a step further. There are also pilots,
which let you know that those notions you came up with do not work. That should
immediately feed back to the development process. We should not have to wait
for ballots or a year or three years.

When we get some field experience that says this does not work be it back to
the government or back the SDO or back to the regulators or whomever that needs
to be handled stat. That cannot go through a regular process. We thought we
were right. We did some testing. When a tool does not work, you get the people
together and you say all the people using that tool. This tool did not work. We
need to fix X, Y, Z. We will be back to you next week.

After testing becomes use and that feeds back as well because testing is not
the same as actually using it in the environment. All the works that HIMSS has
done with the connect-a-thons is for the HIMSS show in March. That has nothing
to do with production systems. A lot of work is done there, but production
systems are used over and over again.

And then the last part of that, but it still is not the last, it wraps back
around, is maintenance. At the maintenance, that is another point. You have
development and conformance. At each level, testing feeds back to the
developers. Use feeds back to the developers. Maintenance feeds back to the
developers. We can tackle a couple of things that would be helpful in the area
of trust and that would be if we are going to look at data for a clinician and
we are going to look at data for public health, we have to be able to reliably
anonymize that data. We can just come up with some acceptable ways where we all
agree that this is reasonably anonymized data. Let’s just call it anonymized
data. We would be able to use it in that other dimension of public health.

The notion that we look at is testing is important and the idea is that
standards development is a continuous process, a continuous improvement process
that involves development, conformance testing, use maintenance, and then it
wraps back around.

MS. GREEN: My name is Denesecia Green with CMS. It has been a lively
discussion today. I have been listening in from the background. Just getting
back to the 2020 vision here, which is the big picture. It is where we want to
be at that time. How do we want to shape health care between now and then? I
heard someone say pass-fail and some implementation issues and testing needs to
be done and those sorts of things and absolutely. All of those things play a

I also agree with Gwen when I heard her say do we have everyone at the
table. Is everyone invested? How do we all come together to get this done?

Looking at where we want to be, I think Doug really did shape it up a little
bit earlier for us looking at that emerging technology. Where is it going
outside of the health care system?

One of the things I would say is we need to step back and figure out where
we want to go before we determine how we get there. It sounds like right now we
are talking about what is the how. What are the implementation steps? What do
we actually need to put in place when we have not really shaped up the vision
yet? We need everyone around the table having their own perspectives,
individual perspectives, all of the stakeholder to say this is what I can bring
to the table to ensure that implementation goes well.

Here is my suggestion for testing and here are the best practices that we
have used that have worked well with our implementation. It is knowledge
exchange. It is sharing. It is ensuring that everyone has a stake in a full
implementation or implementations of various programs to really get us to the
end goal. I think that continuing these discussions will help us to get there.

DR. SUAREZ: I just want to jump in with just one quick comment on this very
important point. I think it shows how critical to know where we are going. In
reality, we have a lot of requirements that we have to comply today that takes
us in a direction presumably. The requirements for HIPAA is taking us in one
direction or hopefully in the same direction or towards the same kind of area
that meaningful use is taking and that health reform is going to take us that
quality measurement ultimately is going to take us. There are all these things
that are in place today that we have to comply with in the industry.

When you take all those and look at where is each of them as a program
taking us, are those visions of each of those in the general ballpark, in the
general area so that we can frame a common vision across all those? As you
pointed out, we are here talking about the steps that we are taking or the
regulations are making us to take us to some place. We have not defined
concretely where we want to be really. When you heard visioning process that we
have here, a lot of commonalities came across.

But in reality, there are a lot of visions out there. That is what is
creating some of the challenges of having trajectories already defined that we
have to meet and where they are taking us.

DR. JAMOOM: Let’s try something real quick.

MS. GREEN: If I could just add one comment really quickly to that. Looking
at the existing levers that we have in place, the existing programs that we
have in place, how can we shape those to get us where we want to be?

DR. JAMOOM: I think that is an excellent question and meeting this group
here. Why don’t we pose to this very diverse group of experts? How many think
that all of the regulations that are currently on the books, the compliance
requirements are actively taking us to a shared vision of what you heard going
around the room? Do you think that there is a shared vision by all of the
requirements, MU, ICD-10, all the different regulation components that Walter
was just talking about? I see no hands.

MS. GREEN: And separately from that, not just regulations, but what else is
bubbling up with an industry that could also bring about that change? It is a

DR. JAMOOM: I think we are hearing a lot of things. One thing that we heard
Gwen talk about was long-term care. They are not necessarily at the table with
the meaningful use. There are lots of pieces here that are not necessarily at
the table and they maybe should for that shared.

MR. SOONTHORNSIMA: May I answer that question earlier? The question was if
anybody believes that all the required activities, mandates will get us to that
vision? Again, speaking as an individual participant here. When you look at the
whole thing all together, it is very tough to see. But if you really focus on
each and every one of the initiative or the mandates, goals and objectives, you
can definitely tease out the triple aim component, the patient centric.

The challenge, I think, is for us to tease out how we actually implement
those things because we cannot change the past, but we might be able to
influence the implementation and how we go about doing it. I think, Doug, you
were saying earlier eloquently. Scope, scale, and timing and resources. We are
not going to change the vision. That is exactly the point. We are not going to
change the objectives and all these initiatives. But how can we tease out those
things that are much more practical and pragmatic for us to do in order to get
to some measurable results? It is a different way of answering that question.

MS. LOHSE: To build off of what Ob just said too, it may look tactical, but
it is actually very strategic because how do you implement on a national basis
and really bring along that tail and have everyone feel like they are at the
same tail and the tail is important and sharing the best practice is important.
I think it is strategic and not just tactical. We are talking about a strategic
plan. I thought those were great points.

DR. JAMOOM: We are going to take a 15-minute break. We end at three so we
have about a half an hour. We will not forget those who have something say and
hopefully you will not forget. Keep going. Just go right through. We will

DR. DALEY: We keep talking about regulations. One of the things we need to
not forget is there are state variations and regulations. Here is the
government. Great. We can do our stuff. But if every state has 50 ways to do
what you want to do, that really affects the national players, the big
providers. We are talking about tele-medicine except some people cannot
practice across the lines with HIEs. You cannot move it because of the regs.
You have to do the regs 50 ways. That is a significant thing that we do not
actually have to implement. We can actually remove some of the implementation
requirements if you address some of those variations and that may free up some
of the resources to address some of the things we really want to do.

DR. SAVAGE: Bloomberg carried a story earlier this week about a group of
academics and lawyers who are trying to figure out if the whole set of rule
system should be federalized, meaning have one set that applies to everyone. I
do not think those people are hearing this conversation today with a few of us
who pay attention at the fringes.

MR. CULLEN: I am taking a lesson from Gwen and Jim and just keeping my name
up the rest of the day. We will see how that works out. Just a couple of quick
comments. I think if you ask the question the opposite way, are all the
regulations taking us in the wrong direction, but you will probably get a
response that no, no one really thinks that. Maybe to Walter’s point that is in
the area of how on target I think is a bit of the open question.

I do think on the scope and I agree with Doug managing the scope, but I
think what I hear from some of the conversation is we do not really have a good
sense of a current scope. And as new things come up, you need to look at the
current work and you fit it in, the typical project management. There are other
things coming that are unknown like 820 for exchanges, for example, expecting
some rules on that. Even some of the knowns we do not really know.

Just finish on Mari and Rob. I agree with them. If we have a multi-year
roadmap, it is really only as good as the roadmap to get us through ICD-10
because that has some risks of having a tail that could be very disruptive.

DR. BLOOMROSEN: I am not exactly sure if what I am going to say makes any
sense to me let alone to anyone else. But I am struggling with our efforts
today to try to articulate an E-Health vision. I am thinking that there are
other efforts on the books so to speak or underway such as Healthy People 2020,
such as the Health IT Strategic Plan that ONC helps put together, such as the
Health Disparities Report and others.

I wonder if at all those should or could be looked at, considered, and
leveraged. Those things have goals and objectives and there are efforts
underway whether they are regulatory or programmatic that I am certainly not
well versed in, but I suspect that we should take a look to see how consistent
or inconsistent those directions are from a nationwide perspective and from a
strategic perspective an overlay or look at what directions we are heading in
due to other incentive type and things that have been articulated through other
agencies and other efforts that is at the federal level.

Then I echo my colleagues’ concern about or the observation that no matter
how well we might articulate what is happening at the federal level, what goes
on within each state let alone within each community particularly from a public
health perspective probably needs to be factored in as much as the small versus
large provider and the tail and what tails are we talking about I think depends
on the exact focus that we are thinking about. I think free clinics and public
health clinics might be a different kind of tail from a public health
perspective as opposed to large academic medical centers who may or may not be
well positioned to implement I-10 or meaningful use two or three.

The other thing I believe we need to look at is what is happening in the
ecosystem around us and that would include the life sciences industry and those
vendors as much as the EHR-type technology and the mobile health type
technologies as we think this through.

I think this is very complicated and I think I sympathize the most with the
fact that we should focus our efforts or we will not be successful. It is the
little bits at a time with the idea that we have a destination in mind and
recognize, however, that maybe there is a straight path there, but it is
probably crooked. There are probably places in the road where we are going to
need to or want to have the nimbleness to make left or right turns.

My other observation is while I heard about testing from standards
development processes, I am not really sure I understand once some of these
things are implemented whether it is meaningful use two, three, four, five,
ten. Do we take a pause and take lessons learned from that implementation? Not
at the standards development per se, but after we have implemented and how to
redirect ourselves if we feel pain points or see pain points that we did not
anticipate initially.

DR. JAMOOM: I think those are all valid.

MR. WILDER: Two quick points. One is a bit of a disagreement. I think
actually the stakeholders that need to be involved are actually mostly
involved. Long-term care insurance actually is a HIPAA covered entity. But the
HIPAA transactions have nothing to do with their business model. As a matter of
fact, they are not here because it has no relevance to them. Vendors are not a
covered entity and they are here because it is relevant to them. I am not
saying everybody is engaged that needs to be engaged, but I would actually say
I think for the most part those people that need to be involved in the process

I agree with the comments that have been made that really what we are
talking about is the development of standards, a set of requirements and that
is a process. You actually talked very good about what the stages of that
process are. Rob talked a little bit about it too. We have done this on a
number of occasions and yet we still have not quite figured it out. If I was
going to list as a priority, I think part of that priority would be figuring
out how the process works and what are the different stages and where do you
build in the feedback and when do you do testing. I have been engaged now since
HIPAA first came on the books. It is the same thing over and over again about
12 to 18 months before the implementation deadline, the level of angst just
starts ratcheting up. It is going to be a train wreck. It is going to be the
end of the world. Nobody is going to get paid. Patients will be thrown out on
the streets. Then we delay for a year and things kind of happen. And then we
come to the next deadline. In 12 to 18 months, it is going to be a train wreck.
I am hearing that now with ICD-10. It is going to be a train wreck.

MS. LOHSE: Just one comment to add with what Tom said. I think he is right.
The B to B — a lot of the entities are involved, but the B to C is an area
that if you really look at B to C versus B to B, it may not have a home. Just
as a comment, we are talking a lot about the patient.

MS. KLOSS: I have three comments. Like Tom, I have been at this a long time.
I have a glass half full perspective because think of where we were just ten
years ago. That is a long time, but we have made remarkable progress as painful
as it has been.

A couple of things that I have heard today that I have to really chew on. I
think we right now do lack that mechanism or that structure to have the kind of
dialogues, public-private that we had in fact in the run up to HITECH and when
we kind of made that really big push to stop talking and start implementing.

I think what we have been so eager to have this dialogue about is that we
are marching forward with all the ACA and we kind of see almost a light at the
end of the tunnel where we actually have standards to support all of these
critical administrative processes. We are not fully implemented, but that is
happening. And then things are happening on the meaningful use and in other
perspectives. It is like a fabric where we are all going in our own directions
rather than weaving it into one integrated process.

Maybe one of the short-term needs is a mechanism to bring these at least
core groups that are doing great work together to make sure we are really
aligning. I think that is not happening as easily as it did perhaps before

DR. CHANDERRAJ: I think we are putting the cart before the horse. We do not
have resources, but we were talking about lofty visions. To achieve lofty
visions, you need to have lofty resources. I want to drive a Mercedes, but I
have money only for a mini car Ford Cooper. I do not go buy a Mercedes and say
I will pay you three months later or ten months later. The payment is required
now. The lady does not go to a salon and have her hair done and say I will pay
you in three months. Physicians’ practices are the only places where you do not

I understand consumer’s concern of getting this, but they do not pay. They
pay the insurance companies. They are not paying the physicians. Three months
later, we getting the payment, maybe a fraction of what we bill. We do not have
resources to support these people who are essential in this wheel. There are
spokes, but the hub is the physician, physician-patient relationship. You are
not paying any attention to the provider and providing the resources to them to
make this happen. Unless you have the resources, the timeliness, and the scope
cannot be realized.

MS. MULLINS: My comment is going to build on that. It was initially building
off what Mari said about having guardrails for meaningful use. Yes, that is how
long my card has been up. I was going to say what is our goal for Meaningful
Use. Is it to help further health IT in our country? We have to go back and
look and say, why are we doing Meaningful Use. What is the purpose? Is it to
make people pass and fail or is it to help further a community of health IT in
our country? I do not think it is to make people pass and fail.

But what is going to happen out of this is those that fail are not going to
go back and do it again. They are going to say I am done. I will take the
penalty. I am not going back through the standard again. They are going to
cease and desist doing any IT innovation in their office. That is going to put
a halt to any furtherment of health IT at that site. We have to know what our
purpose and our goal is and then equip people for success to make that happen.
I think that we need to not lose sight of that.

DR. FRIDSMA: We are talking about glass half full, glass half empty. I am
the standards guy. I just wish everybody would use the same sized glass. A
couple of things. If we think about this iterative and incremental approach,
one of the things that is really important is we take the path of least regret.
I think a lot of times and I worry about this with some of the stuff that is
happening that I see in the environment around portals. What we want is
patients have access to their information. What they are going to end up with
is 12 different portals, none of which talk with one another. We have to think
about how can we get to that end state that we would like to see and not create
situations in which we end up taking an expeditious, but kind of side tracked
way of getting to where we want to go.

I think the second thing is we also have to think about risk management.
They say culture trumps strategy every day. And what is happening out there in
the world. I order my tickets on my phone. I never actually print them out. I
can go through security without ever having to touch a piece of paper. I can
take a picture of my check and I can send it to the bank and they will actually
cash it. People are going to start expecting that from health care. If they
don’t, they should.

I think we have to think. We could have the best strategy out there, but
frankly, we need to also pay attention to what is going out in the rest of the
world. If we are not responsive to what patients are seeing in the rest of
their lives, then we have missed the boat with that.

But I think part of it is with risk management in an iterative approach. If
I had been able to predict the future, I would have invested in Wal-Mart 25
years ago and we would not be having this conversation, but we don’t. The way
we manage our finances is that we create a portfolio of investments knowing
some that will do well and some that won’t and that we can swap things out and
not worry about it. But over the average, we are going to get to our retirement
goals even though we have not created the one investment that hits big.

When I think about the way in which we have approached the goals that we
have within health IT and HITECH is that we have tried to create a portfolio of
standards knowing full well that some of them are going to take off and some of
them are not. But if I can take the building blocks, which are vocabularies,
structures, transports, security, and services, if I can take those building
blocks and I can use those to solve lots of problems, if I get one of them
wrong, it is going to be that I throw everything away. It means that I just get
a new building block that I put into place.

It also allows us to change each of those things at different rates. The
things that are going to go into a clinical document will change in
relationship to our understanding of health care. But the way in which
transport and security changes is going to change in response to what is going
on in technology. We have to separate those two otherwise, we get ourselves
into trouble.

We need to take a path of least regret. We need to make sure we do this in
an iterative fashion. We need to create reusable building blocks that are part
of our risk management strategies because nobody here can predict the future.
The last thing we want to do is create a huge system that we have to rip and
replace two or three years from now.

I think the final thought that I would like to say is that interoperability
is not created in committee despite our very best efforts to make that happen.
We have lots of smart people who sit around a table and they try to predict all
of the possible scenarios. But we know in health care that even with drug
development, who knew that COX-2 inhibitors were going to have problems with
the heart. We did all the clinical trials. We did all the stuff in controlled
settings, but it is not until you get it out there in the wild that you really
understand whether it works or not. We have to build that into the system. We
have to understand that everything that we put out whether it is in regulation
or not is a draft standard for testing and use. We are going to have to figure
out ways to make sure that we create systems that allow us to iteratively and
incrementally improve them.

Glass half full. Glass half empty. I do not know. I just think that
everybody should use the same size glass.

MR. ARGES: One thing I wanted to mention, however, and I do not think —
skirted around it. To me, you have legislation that basically lays out certain
things that have to be done. Maybe a timeline has to be done. What I am hearing
happen is that there is a lot of overlapping, a lot of competing priorities.
There is no way to basically adjust that timeline unless somebody is going to
be out of compliance or somehow you do not enforce something, but you are still
technically out of compliance. But there really is not a process where the
stakeholder is basically influence the date so that you can say that I
understand the intent of meaningful use. I am working towards it. I may miss
the mark, but I am still striving to meet that intent at least recognize that
effort. Let me stay focused on it. But let me basically identify what is the
best way of dealing with handling the smaller bites approach.

To me what is missing I think is the ability of the stakeholders to
basically influence the timing, scope, and resources to deliver on what
Congress and others may have laid out and to introduce other things that they
believe might be important as part of that process.

DR. JAMOOM: I think that is a really interesting point. Letting the
stakeholders define what is feasible in terms of the scope, the resources, and
the timing as it pertains to their interests and then trying to find
commonalities among all of the stakeholders that is getting at that apple.

MR. ARGES: Right. Sometimes the scope of work may be very costly. I may not
have the resources to do it all within a one-year time. If you were to tell me
it is three years, I might be able to do it in that period of time. I am still
meeting the intent of what maybe Congress and others may have decided. Building
upon the building blocks that might be necessary to develop what has to be part
of an EHR.

DR. TENNANT: I wanted to build on what Amy had said and Tom as well. They
are interrelated though they may not seem to be at first. What Amy said was
that what we do not want to do is disincentivize providers from moving ahead
with HIT. I think once the penalties start to kick in 2050, we will do exactly

If the ROI is such that the providers are going to say it is not worth my
while to move to stage two, I will take the penalty. It is not as simple as
that. Providers have a choice. A lot of specialties are at the point where they
can say I have open slots. I can open it up for Medicare patients or I can open
up for fee for service. If I am going to get penalized, well I am going to have
less slots for my Medicare patients. There is a negative impact on patient

To Tom, I agree 100 percent about the train wreck concept. We use that at
MGMA and AMA. We use that concept not to say the sky is falling because that is
one technique we have to try to convince members to do something, to get
moving, to contact their vendors, to do an impact analysis, all these things.
If we do not stir the pot a little bit, they will not move at all. They do not
move much anyway. But at least when we start to talk about implications to cash
flow, they start to listen a little bit.

But what the difference is and I agree that we have used the train wreck
analogy many times. The difference with this particular train wreck, ICD-10,
really relates to Tim. And that is, a provider could take a claim on a cocktail
napkin, jot it out, send it to a clearinghouse and they would magically convert
it to 5010. That is one of the services they provide. As we know, folks have
not moved to 5010. A huge chunk. ICD-10 does not fall into that category. A
clearinghouse cannot magically come up with the right ICD-10 code. The train
wreck is an appropriate analogy for next October, which is why we are messaging
on this more and more.

DR. JAMOOM: So I just want to check with anyone on the phone. Does anyone on
the phone have any comments?

MS. GREEN: I was just going to mention that this would be a good opportunity
for us to work with your organization, Rob, to identify those groups that are
still on 4010 and to get that message more broadly out into the industry. We
are working on that, but we would love to be able to broadcast that more along
with your organization.

DR. TENNANT: Just real quick on that. Unfortunately, the vast majority of
those folks are not going to MGMA members. They are going to be the smallest
rural. They are going to be community health center folks. They are going to be
folks that have very little technology in the practices that probably are not a
member of a professional organization. They are the most difficult providers to
reach quite frankly.

DR. JAMOOM: We only have now probably another five minutes left. I am going
to give you this time. I do not know if there is more room we can cover. Is
there a specific area that any of the chairs would like covered at this point?
Interdependencies. Anything.

PARTICIPANT: Maybe we could go over next steps.

DR. SUAREZ: This is Walter Suarez. I was just going to make a note about the
next steps. But as I am making the note about next steps, one thing I would ask
is if everybody can just in one word. Now we are down to one word. If you can
say in one word your vision if you will or what you see needs to happen next
more importantly, I think that will be very helpful for the committee — you
are collecting your thoughts about the one word about what we need to really
prioritize as a committee and work on it.

I will mention a few next steps. This is our second roundtable as I
mentioned at the beginning. We, as a subcommittee, will be certainly reviewing
all the incredible feedback and the statements and the vision and the elements
of the roadmap that we talked about today. We will be developing a picture, a
document at this point, but a picture of what we think represents and reflects
the elements that we talked about today. We hope to be able to do that. We will
be summarizing all these and presenting it to the full committee in November,
again, as a very high level picture. We do not expect that by November we will
have the roadmap replaced or defined and the final vision. But I think it will
be very helpful to establish that. We will share that document with you all as
we formulate those.

What I expect to see also happen is that after we meet with the full
committee in November, there will be probably an opportunity to work in
finalizing really the vision and the roadmap in a third roundtable yet to be
defined when exactly. But it probably will not happen before the end of the
year. It will be before 2020. Those are some of the most significant next steps
that I think I want to point out.

Now we can maybe go around and say the one word. It could be multiple

DR. FRIDSMA: Out of the box.

DR. SHEPARD: My one word is also hyphenated and it is about the same because
I said open minded.

DR. BLOOMROSEN: I, actually Walter, wanted to use the word you said, which
was prioritize. That is what I think is needed.

DR. NARCISI: I would say seamless.

MR. MCMULLEN: Process.

MR. GLICKMAN: I am going to cheat a little because I have been thinking
about either trust or accuracy. In thinking of the two, I came up with

DR. CHANDERRAJ: Resources/vision.


PARTICIPANT: Collaboration.



PARTICIPANT: I think transformation is still my word.

PARTICIPANT: Multidimensional.

PARTICIPANT: Shared goals.

PARTICIPANT: Patient centered.

PARTICIPANT: Streamlined.


PARTICIPANT: Defining the destination.

PARTICIPANT: If Rob were still here, I would say delay. I will say


PARTICIPANT: My word was already said by Marjorie. Collaborate or

DR. JAMOOM: And if I can participate, I would say partnerships. I think it
is very interesting. Folks on the phones.

PARTICIPANT: Convergence.

DR. JAMOOM: Anyone else on the phone?

PARTICIPANT: Ever evolving.

DR. JAMOOM: Is there anyone else? Is there anyone else on the phone who has
their one word? With that, we can conclude. Thank you.

DR. SUAREZ: The subcommittee will be holding a follow-up session right after
the break. If you want to stay along, please do so.


Agenda Item: Subcommittee Discussion

DR. SUAREZ: I think we are going to start our meeting as a subcommittee. We
will go around and do a quick roll call for the record. Eric, if you are
available, you are very welcome to stay. We will just spend probably about an
hour or so, I don’t know if we are going to take all the time there to 4:45, as
we have scheduled. We will take enough time talk about some of the outcomes
from our second roundtable and some of the themes and probably more
importantly, some of the next steps, as I was mentioning at the end of the

Let’s start with introductions. My name is Walter Suarez, I am with Kaiser
Permanente, and one of the co-chairs of the Standards Subcommittee of the
National Committee on Vital and Health Statistics. I do not have any conflicts.

MR. SOONTHORNSIMA: Ob Soonthornsima, Blue Cross and Blue Shield of
Louisiana, co-chair, member of the Full Committee, no conflict.

MS. KLOSS: Linda Kloss. Member of the Full Committee, co-chair of Privacy
Subcommittee, and member of the Standards Subcommittee. No conflicts.

MS. GREENBERG: Marjorie Greenberg, NCHS, CDC, Executive Secretary to the

MS. WILLIAMSON: Michelle Williamson, CDC’s National Center for Health
Statistics and staff to the subcommittee.

DR. CHANDERRAJ: Raj Chanderraj, member of the Full Committee and member of
the Subcommittee on Standards. No conflicts.

MS. DOO: Lorraine Doo, CMS.

DR. JAMOOM: Eric Jamoom, NCHS.

MS. BEBEE: Suzie Bebee, ASPE.

MS. GOSS: Alix Goss, Pennsylvania E-Health Partnership Authority, member of
the Full Committee, member of the Subcommittee, no conflicts.

MS. FARRAR: Kamahanahokulan Farrar, CMS.

(Public introductions)

DR. SUAREZ: Okay, this was just an incredible Roundtable. I think we
achieved a lot of the objectives that we had in mind.

MS. WEICKER: Margaret Weiker, ASC X12.

DR. SUAREZ: So as I was saying this was just an incredible second
roundtable. This really built quite nicely, as I was looking at my notes, from
the first roundtable back almost a year ago now with some of the original
discussion. It was a lot more fluid.

This one I think was really nicely focused around the vision truly and I
think the process for going first through the discussion and people just
stating just their first thoughts about E-Health visioning and then refining
that with having, after everybody has talked, asking people to spend 5 minutes
to write a couple of sentences.

I think that was very effective in reaching us to a point where we had quite
a bit of commonalities and very good statements about what people think is a
vision for E-Health 2020. I think that’s maybe not something that necessarily
has been done in the industry. A lot of people probably have their visions of
course of what they believe is going to happen but I think it was very, very
helpful and useful for us as we frame this vision.

I think the opportunity to share some of the sort of original perspectives
and having Rob introduce sort of the vision was also very, very effective.

I don’t think we are going to be able, of course, to summarize all the
things that we heard. I have more than 14 pages of notes here. And I think
that’s going to be one of the actions we’re going to take over the next several
days in extracting some of this.

But the most significant and most salient messages in my mind was number
one, this is really an important activity that we must conduct and complete.
And they are looking at the National Committee as truly a vehicle to achieve
this and to set sort of the visionary statement and have it there.

I think the other thing that I noticed truly was as we were – and I was
trying to take as much notes as I could when people were saying their two or
three sentences – was the consistency really in the messages. I heard the words
patient centered and we identify those common themes there but in the
statements we heard them again, patient centeredness, seamlessness and sort of
interoperability and all this key expectations that people have that by 2020 we
would realize that we had achieved these goals. So I think there’s a lot more
commonalities than differences.

I also heard a lot of concerns certainly about the more immediate issues. So
yes, we can talk about the vision for 2020 and we can kind of converge that
vision of all the different things that are happening but the reality is in the
next 2 months, in the next 2 weeks, we’re going to have health reform and
meaningful use too. And in the next several months we’re going to have ICD10
and all these other changes that we’re going to see and so there is concern
about the immediacy of some of these activities.

And so there’s clear statements about those concerns, not new necessarily
because they’ve been expressed by the same type of organizations representing
the same groups in other venues but they were emphasized today as well with
respect to issues like meaningful use stage two and concerns about the ability
to really meet some of those requirements and sort of the evolution of the next
round of requirements and concerns about how we’re going to achieve that and
the risk of actually seeing people drop rather than join programs like
meaningful use. I think that was quite an important point – is really
meaningful use should be the incentive not the barrier to get to effective use
of health IT and I think it’s important to point those concerns.

I think we also heard the idea of trying to align things and converge. I
think alignment was also a very common theme and in that respect I think this
concept of a roadmap that we’ve been talking about, however we call it into the
next stage of our work. This concept of really identifying and documenting and
plotting into a picture all these different elements that allow someone to just
see in a picture and say look at all the things I have to do or our
organization has to do and what are some of the connections between them. Many
organizations have already done a lot of those connections and can share those.

My own organization, Kaiser, has looked at those that way and align some of
the commonalities of, for example, ICD10 with meaningful use with some of the
other requirements and try to certainly take advantage of those opportunities
for finding common ground for changing processes internally and for adjusting
technology. So I think alignment and I think that is the opportunity for this
roadmap provide us.

Prioritizing was another big message. I think identifying the most immediate
set of low-hanging fruit. I think the concept of staging and progressively
moving towards the goal and that ultimately division is really a critical
concept. At the same time, I think a lot of people and Doug Fridsma from ONC
was pointing to that, we should find the small pieces and take small bites at a
time and progressively move forward. But at the same time people are talking
about flexibility in terms of everybody taking the same size of bite to the
apple. How much can we – some organization might be able to take a bigger bite
and we don’t want to disincentivize them from taking the bigger bit because we
want everybody to take the exact same bit in the exact same size of the apple.
So those kind of flexibility in the progression I think was valuable in my own

I’ll stop there and see if Ob and maybe others have additional points.

MR. SOONTHORNSIMA: Maybe another way to look at this is our – I’m going to
think about what our next steps might look like. Obviously, we heard a lot
around the themes. There are some different organizations have different
visions, which is great. I’m glad we took the time to write out, tease out
those three sentences because they are rich with content and context. And it’s
very powerful to hear that from the various organizations. So that’s a second
piece beyond the initial themes that we heard on the board here.

And the third thing we heard were some of the obstacles which it’s almost
even in specific because they are not just talking about all the current
experiences but also what we heard was a lot more specific. If we do this, than
we could ease our way to achieve that vision. So it’s not just regurgitating,
if you will, of those problems and current experiences but let’s pick out on
those specific areas that could make a difference.

And the last one that we heard also, is, what are the priorities? So that’s
a very powerful set of information. One is the themes that we heard, granted
it’s about a page long or so. Second we heard disparate visions. Third we
heard, what are some obstacles that we have to overcome and lastly what are our

Now, we didn’t achieve absolutely everything we set out to do but those are
pretty darn good set of information. What are we going to do with it? I think
from those four things what we’d like to do is frame up, glide path, roadmap,
whatever it is. But maybe we can tease out some common set of guiding
principles perhaps where we see common visions, the elements of the visions.

Keep in mind – let me just sidetrack for a little bit. What I try to do when
I was listening to all the various visions, tried to look for those, not only
the context but specific operative words, action, actionable and deliberate
operative words. And I think those are very good sort of vision statements, if
you will, because those are things that we can look for in our common vision,
whether there is some consistency across the board.

And it’s going to be – I think it’s impossible to absolutely address every
single vision, we had about 22 of them out there today. But if we can tease out
some of those common actionable visions that would be great. So that’s how we
would perhaps use as a starting point.

And the third thing – so coming up with a – repeating just a little bit –
coming up with a common themes, common set of visions, we might be able to draw
up some guiding principles. What are the guiding principles use for, and I
think this is one of the things we discussed yesterday as a committee.

We talked about how we can use this roadmap guiding principles, gliding
path, whatever it is because we’re not going to change so much the activities
what we do today but we might be able to shape the future deliverables of what
is required of us as a National Committee. We definitely could use these
guiding principles and the common vision as the means to deliberate on up and
coming work that we have to do and not only just for standards. It’s for the
entire committee – on public health and privacy and security because there’s a
lot of crosscutting themes. So that’s what I’m thinking of in terms of how we
can make good use out of a very rich set of information today, put into context
something that usable, not only for the Standard Committee and our routine work
but also for National Committee in a crosscutting way.

MS. KLOSS: I would like to suggest that we – well, step one is to get the
transcript. I think we need to capture everything we heard as part of the
record even if it ends up as an attachment to a refined piece. And then it
seems to me that what we need to do is develop a strawman vision. Pull in the
concepts that really resonate with the work of the committee and what we set
out to do here. And we’ll probably leave some things behind but there was
enough consistency, as you say, that if we could get a half page vision, no
more than that, a paragraph or two, that would be really helpful.

And then it seems to me a lot of the recommendations could be boiled down in
to some categories. There were – the structural imperatives are
recommendations. What are the mechanisms that need to be in place to allow this
to be pretty much an ongoing dialogue? I think that was a really interesting
set of comments.

And I think this is one of the things that the NCVHS has done well, and
particularly this subcommittee has done well, is provided that forum. And I
think what we were hearing is some formalization of that so that periodically
the committee is really leading this kind of dialogue – that’s why I picked
dialogue – with the industry to update this document.

So I think taking some of the advice of iterative incremental, let’s not try
to boil the ocean, let’s get something down that is a good reflection of where
we think we need to go over the next couple of years and then expect it’s going
to updated all the time.

So we heard recommendations regarding needing to formalize this process for
dialogue. Certainly address some of the process deficits, like the regulatory
process and kind of those issues. And bring in more perspectives. We had some
consumer perspectives but we didn’t have any employer perspective. So there
were some groups that weren’t part of the dialogue.

And I think part of the process would be thinking out of the box in terms of
how we refresh this vision and maybe this becomes one of the issues that tied
to the website revision and other kinds of mechanism. Because I just came away
with the need for a pretty dynamic process, not see this as a report but the
beginning of a pretty dynamic process. So I think we got everything we need to
do that.

MS. GOSS: Can I just comment – we need a dynamic process because, as someone
commented to me, this is not the first roundtable we’ve done but we’re
repeating the process but we don’t seem to be getting anywhere. And one of the
things I think you heard me say early on when I came back to participating in
this forum was I felt like I was having flashbacks from 10 years ago having the
same conversations and we need to break the cycle and create a new healthy life

MS. GREENBERG: I agree. I had a professor in graduate school who published a
lot of books. And what he did when he was starting to work on a new book was he
surrounded himself with all of his previous books and I sort of do that in my
head, figuratively, thinking about products of the National Committee. And as I
think about some of the observations that were made, some of the things you all
have said and how these kind of are different aspects of things we’ve been

So let me just – and I’m not saying we’ve already done it – I do think that
the fact that now we’ve held two of these, it’s been about 10 months or
something. It will be very interesting once we’ve processed and summarized this
one to look at the previous one and to just see a lot of it – there was a lot
of same old, same old, but it wasn’t just that. None of us felt that way, I
don’t think. We all felt there was a new – and to some degree I think there was
more acceptance of all being in this together, which I felt less of in the
past. It really was nothing acrimonious about it.

There were people who said things that I didn’t agree with and I could have
said things that they wouldn’t have agreed with and, you’re right. There were
differing views but that was my word, why my word ended up being collaboration
and the other I would have chosen was partnerships and so we were definitely on
the same wavelength there, Eric.

And that is clearly what we need and what is sort of lacking in the industry
right now in the sense of people feeling beleaguered, knowing that they have to
do certain things but not being able to give up on complaining about it or
saying there’s going to be a train wreck or what have you. Almost like
halfheartedly because I think – obviously, my favorite subject, but ICD10. How
many more times does it have to be said that this deadline isn’t going to
change and I certainly don’t see any benefit if it were changed.

I mean it would kill a lot of organizations to now delay it. And those who
want it delayed wouldn’t do it either. So it’s a just a question of sort of
getting people to say, look it, there’s a lot on our plates but we have to sort
of help each other and we have to figure out ways to get from here to this
shared vision which was pretty strong I thought, the shared vision.

So you said a word, you said something about the elements of a vision. And
what that made me think about, Ob, was the elements of a stewardship framework
which we’ve been pretty good at defining but we want to update and needs work.
But I think if we keep that idea of the elements of a vision and the common
elements that people share and then aspects that aren’t necessarily shared but
have a lot of potential, at least the committee thinks, than I think that will
be good. We don’t want to just put out another vision, another mission
statement, but this idea of the elements.

Then you talked about the guiding principles. Well, I don’t have them with
me and Debbie Jackson’s in the room, she always has everything with her that I
say I don’t have with me, but I do know – and I’m putting you on the spot, it’s
okay if you don’t have it right now – but I do know that at the August 2012
Executive Subcommittee Retreat, we did come up with guiding principles. So we
need to go back and look at those. So I guess I’m saying we don’t want to
reinvent the wheel. So we want to look at those guiding principles. Those were
for the Committee but they relate to this and so – we can change them.

Really the other word I could have said is iterative. Because I thought – I
was really pleased that Doug stayed the whole time and I thought he really was
spot on with a lot of what he said. I was struck by this tension between we’re
moving too fast and a lot of this is long overdue. And some people almost said
both things. But we certainly heard both of those and I think from the point of
view of the woman who was here before lunch and she didn’t stay but the
consumer point of view, yes – and for a lot people, the providers, et cetera,
given the way they’re structured and their resources and everything, we
probably are moving too fast.

But for other parts of the stakeholders group, this is so long overdue that
it’s ridiculous that you can’t exchange information and you can’t get access to
information and that mistakes are being made and errors that – it may be a
train wreck would be bad but people losing their lives is not so good either so
– so somehow we’ve got to pull it – we’ve got to hear both of those.

And I do think we need to add some people to this conversation. We need to
add more consumer and public health voices. I’m probably almost the only person
who said public health but maybe one other person did. All right, the committee
is almost the only people who said it, let me put it that way.

And we need – because some of these constituencies could be helping each
other and there could be partnerships and there could be collaboration. Doug
made a comment about it’s iterative but we have to at least get the foundation
in place. And he kept saying vocabulary.

Well, that gets me back to the issue that if meaningful use and electronic
health records and the implementation of SNOMED CT isn’t helping anybody move
to ICD10 than there’s a real problem. Really, if we could think of one thing,
and not just the committee but the Department, that would help us make that
transition better, it might reverberate. At least I hope it’s going to happen.
Part of me worries, I’ll retire, not because I’m responsible for any but I’ll
retire and I’ll pick up the Washington Post one morning and see that they’ve
delayed ICD10 but – I don’t think that’s going to happen.

But is there something, is there one thing that can be done by CMS, by the
department. Is there one thing we can recommend that you haven’t already
recommended or is there one partnership we can create or one group of, type of
technical assistance, one something that will make this happen in a better way
and definitely avoid a train wreck.

And, is there some way not to make the system so punitive. We here in the
federal government, we work for a very big organization, the federal
government, and organizations within that. And time and time again I see that
rather than trying to solve a particular problem, there’s just a punitive
solution so that everyone will just get swept up in it. And it just doesn’t

So is there some way that we can address real problems rather than just
punishing people, I don’t know. But that resonated with me too, the feeling
that this system, whether it be meaningful use or ICD10 or any of the
standards, whatever, it’s just dinging people and yet there’s a common vision –
all right.

DR. SUAREZ: Thanks Marjorie, thanks.

MS. GREEN: First of all, I’m so glad to hear the word public health. I have
a public health background as well and I do see the significance of that,
especially with some of the programs we’ve been talking about today, ICD10 in
particular. There are many HHS agencies and beyond that use ICD10 for public
health reporting for disease outbreaks, for surveillance, for disaster recovery
and other opportunities at the state and local levels as well.

MS. GREENBERG: If it’s mortality data they are using ICD10. They will use
ICD10 going down the road and there are population health advantages to it. But
that wasn’t the voice that we heard today.

MS. GREEN: Sure, sure. And that goes back to looking around the room and
introducing that public health voice at the table.

The other piece of that I heard a lot about the technical assistance piece
and we are offering technical assistance and training. We’re actually expanding
the program to reach rural health community health centers. We’ve trained
behavioral health communities as well as specialties. So all of that is being
developed and, as a matter of fact, we’ve held several stakeholder groups
partnership meetings with the groups and some of the groups around the table,
but we’re working hand in hand with those groups very closely. Thank you.

DR. JAMOOM: The one thing I want to make sure is that, with Joyce from AARP
who left, if you can get her vision as well for the 2020 – so if you can make
sure that any of those folks who didn’t stay for the second half –

MS. BURKE-BEBEE: I am looking at this slide and trying to keep it simple. I
think there’s a lot of what we do right that we don’t need to waste time on and
there’s a lot of things that are already in place, regulations that we can’t
change. We talked about that.

But I think the vision going forward should emphasize, and we should think
about 2017 to 2020, that’s not on this, with the change in reimbursement. So we
heard about incentivizing. Raj, you talk about money, money, money as being an
issue, and payment, and providers, physicians not having enough time in the day
to do the work that they do plus they’re not incentivized to do it. So I think
the emphasis of going from fee for service to value based care needs to be a
theme across the environment.

Also cultural cohesiveness, because this is a culture change, going from fee
for service to value based care. If we can’t get buy-in, it’s not going to
happen. So I’m thinking our discussion about forward thinking is to think about
what terms those providers on and not only will they do it but they can’t wait
to do it. They don’t want to be left out. I don’t know how that would happen
but I think we need to think about that because I’ve been around 10 years,
working either predating HITECH or now I’m in it, and then we have the ACA
which also adds to electronic adoption and meaningful use. But our adoption
rate is still low. We’re still not reaching the people that we need to reach,
like Amy said. And if we don’t get it right early on, not only are we not going
to get them than we’re never going to get them.

DR. SUAREZ: This is which entities?

MS. BURKE-BEBEE: AAFP. Family practice. Small group. So I would say to some
of those issues about getting them on board E-Health wise, but also the ACA
piece coming, we need to broaden our thinking beyond physician centric. Also
think of other advance practice providers so that we’re touching more than just
this physician centric topic incentivizing the physicians. And we talked about
the dentists. There was someone at the table that said you don’t have a big
turnout because it’s not aligned, which we’re talking about alignment.

MS. DOO: We are talking about suggesting incentives for the meaningful use
program whereas really we should be thinking about just the incentive of using
health IT across the whole physician medical perspective, whoever you are, so
not just a Medicare and Medicaid issue. It’s just across the whole spectrum.

And I have one physician who is a complete medical IT maven who showed me
how to do things on my own iPhone and then another physician who is probably
just in his 40s who is completely paper based and would not touch electronic
medical record. He says see those paper records there, that’s what I’m using
until I die. That’s just the way it is. But these smaller providers, the
vendors don’t have time for them. So that’s one of the big challenges right now
is they can’t even get an electronic medical record even if they wanted to. So
part of it is just a problem of supply and demand. They can’t even get the
attention of –

DR. SUAREZ: It is a large transformative, talking about transformation,
transformative process for a provider to go from whatever small,
computer-based, simple system they might have to a full-fledged certified HER
to achieve all the goals.

MS. KLOSS: But if we had some of the medical practices that are perhaps part
of AMGA at this table, we would hear some stories of transformation happening
rapidly well. So I think we just always have to acknowledge we’ve got a
spectrum. I see tremendous innovation in some of the medical practices who
understand this transition from volume to value and are using data very
effectively and getting ahead of the path. And so I think we need to create
those kind of case studies that show this light at the end of the tunnel.

DR. JAMOOM: I think there’s a few things that I heard and I just wanted to
talk a little bit about – scope. When you have specific specialists who may or
may not be able to participate because whether there are templates, whether or
not the system meets their needs – I think of optometrists, I think of mental
health – I think of certain specialties that are not able to have a seat at the
table and truly to integrate patient care as it pertains to those specialties
is a challenge.

The second thing relating to mental health in particular, Larry mentioned
that yesterday as part of the things he wanted considered. And I think mental
health is an area that hasn’t been able – maybe it’s the data stewardship, the
confidentiality piece, security piece of it, but those were two areas I wanted
to mention – the scope aspect as well as the mental health –

And I’ll add a third – long-term care is something that is also – I don’t
necessarily agree that there might be some fringe kind of things with Medicare
but I think long-term care is something also not really being put into this
E-Health and maybe finding some more participants would be helpful.

MS. FARRAR: The folks that attended didn’t include everybody who was
invited. So the three groups that you mentioned were all folks on the
invitation list and for different reasons, they weren’t in attendance today. So
we do have them in mind.

MS. GOSS: Two comments to add to the really good thoughts and remarks by my
fellow teammates. The first one is in regard to partnerships and the
efficiencies of collaboration and the reality of the time, interest, and more
especially, the politics within the marketplace – and I don’t mean the
insurance exchange – I mean the health care community, the standards community,
the business players, the associations, and the reality of trying to bring them
together having played in this space for 25 years and participated in
collaborative groups, informing collaborative groups in trying to improve the

This is going to be a tough nut to crack. And for us as a set of leaders who
need to really help advance to the end-game vision that we want to define,
we’re going to have to seriously think outside the box and try to break down
the turfs and start to really – we’ve been spending a lot of money under HITECH
and HIPAA to modernize our systems in health care as many other industries
chose to do on their own because they had the incentive to do it whereas we
needed to force it within the health care world. There’s a reason we had to
force it. And as part of our glide path discussions we need to factor in how do
we really continue the positive vibration related to collaboration and
partnership, which we’re seeing. It’s gotten better but there are some still
strong underpinning issues.

The other thing that struck me and I thank you, Susie, for one of your
comments when you talked about innovation, it struck me that I needed to sort
of pull in another comment related to the states. And a number of states have
received innovation grants to look at the pay for volume to pay for performance
shift that needs to happen. And there’s a lot of input that we’re not getting
because we’re not necessarily talking to state leaders. I’m coming bringing
Pennsylvania’s voice and am participating in our innovation efforts and
participating in our state dialogue for improving health care but we’re just
one state.

And although there are common problems, there’s a diversity that we need to
hear, a diversity of problems that we really need to recognize. And there are
important nuances in those. So maybe something we could also do is maybe do a
solicitation to sort of state leaders to sort of get some thoughts from them on
our healthy vision or our 2020 vision and figure out how we can then also
leverage the innovation efforts within CMS, some of the things they are doing.

MR. SOONTHORNSIMA: Again going back, I like Susie’s point about how do we
motivate the providers regardless of size of the practices. And it’s not just
the providers, it’s all the stakeholders as well. For example, fee for service,
moving from fee for service to value based, and that might just spur a
different conversation all together because all along we’re focusing on
E-Health, HIT focus, or even public health sort of focus, I think there are
different foci for different audiences.

Now maybe there’s an opportunity for us to try to harmonize those different
motivations, to again try to tease out – there are some common capabilities,
common set of needs that would address all of those different areas. For
example, to move from fee for service to value based, yes, at the heart of that
there’s enabler called data, and some of it, even some of the small practices
may not actually get there through EMR alone or right away. They are already
getting data from health plans, for example, just to achieve some of these
value –

So there’s different degree of movement if you will for different size
practices but ultimately they can get there with E-Health and get there with
data but at a different pace. I think we just have to acknowledge and recognize
that. Does that make sense?

DR. CHANDERRAJ: I think this is a very productive day and I think there are
several vision statements made but I think we need to streamline that vision
and bring it down to one page or something, maybe five or six bullet points.

And the second thing is, once we encapsulated the vision, we need to see how
to achieve that vision by overcoming the obstacles that we face. I think we
talk more of the time of how to implement but we don’t talk about the obstacles
that we encounter in enforcing – trying to enable the vision to take place.

The main focus of this committee and the National Health Vital Statistics
data collection, I think when you enforce people, you get junk data. They try
to accomplish the task, that’s a human tendency. But when you incentivize
people, you get more better data. When you enforce, you’re forcing people to
produce data but that data we don’t know if that’s accurate or not. Today in a
typical office visit, 90 percent of the time is spent on data entry and very
little time is focused on the patient and the diagnosis and how to deal with
it. Patients go out of the office saying that he didn’t spend any time looking
at me. And I’ll tell you, 95 percent of the patients come to the office and
never get undressed. Their physicians talk to them and just simply keep sitting
at the computer away from the patient and enter the data. They’re fulfilling
all the requirements that our agencies require. They’re not meeting the needs
of the patient.

But once you change that focus from incentivizing rather than enforcing and
penalties, then I think you will get better data, you’ll have physicians
spending more time with the patients and getting more meaningful use of
achieving the goals and vision.

MS. BURKE-BEBEE: Something else I was thinking of. We talked a lot about the
different initiatives that are out and the timeline reflected in this one
slide. And we’ve talked about HITECH, we’ve talked about the EHR incentive
program, meaningful use, but there’s a whole bunch of providers out there that
are ineligible.

So we haven’t incentivized them in a formal way that we have – I’m talking
about all the ineligibles – and so, for instance, long-term care.

So, way back when 10 years ago, when we were getting on this path to
meaningful use, we had legislation called the Stark law and anti-kickback and
just to let you know that this is being revised, it’s in the process of
clearance in the department now and there has been discussion about modifying
it to be inclusive, more inclusive of the ineligibles, which would be breaking
up a logjam for those ineligibles to be recognized and therefore able to be
incentivized in a non-threatening way.

So I think we need to be adding those providers to the list explicitly and
knowing that there are levers that are going on as we speak that will help
improve their eligibility status, that transition through the 2017 and picking
them up as doctors and meaningful users.

MS. WILLIAMSON: In just looking at my notes, Doug Fridsma made a comment
that everything really is a draft standard for testing and use, and Mike Litman
talked about the IHE connect upon process for testing and I really think we’ll
be remiss if we talk about E-Health and we don’t talk more about the testing
component of it, interacting with vendors. There has to be an opportunity for
people to understand the process. I know because I’m knee deep in it.

We develop standards and people think, okay the standard is developed, now
use it. And that is far from the case. You have to put the standard there.
There needs to be some process to assess whether this really works, what we
develop and then you retest, you modify, and there has to be pilots to support

DR. SUAREZ: It is interesting, as I listening to that I was realizing that
the true challenge, that there is a cycle, a cycle of standards from
development to full implementation, going through refinement and testing and
piloting and all that. At what point do you create a regulation nationally that
says this is the national standard.

There is now – and I can give you examples of standards they have adopted
after they passed three cycles of the ESTU and became normative. I can give you
examples of standards that are one cycle of the ESTU and became the national
standard. And I can give you examples of standards that were approved yesterday
and are being already written into regulations.

So there is a big issue around – what happened to the evaluation of a
standard with respect to maturity, adoptability and the reality that because of
this interest of moving us forward, and it is a good intent and a good
direction – we might be adopting standards that we’re going to find out – and
we all heard about the sense that we are going to do all the time, trial and
error and we’ll have to adjust and all that but in some cases it’s risky to
adjust, to adopt a standard nationally that we find out, oh, it’s immature and
we need to adjust it accordingly.

It’s a case of what happened, in some respect, it was the only thing we had
at that point but with 4010. And a little bit of 5010. But 4010 was a – even
though it was a standard at ESTU, a formalized, tested, it had a lot of things
in place – and it was the only thing we had at that point, it was something
that needed improvement – right at the get-go we knew it was something that
needed improvement. So that’s an interesting challenging.

The other one is really the balance of regulations. Not only when
regulations should adopt a standard nationally because there is a major issue
around that and challenge. As an organization to really do that and now to
configure systems to meet this standard and what if someone says a year later,
oops, we need to change —

But the other one is just a balance of regulations and I’ll give you this
example. We are in meaningful use two required to do things like a lot more
access to patient information. No question of the need and benefit for that.
But what everybody is interpreting that to be is I need to create a portal for
consumers. So now as a provider I’m going to have to hire web designers, create
a portal, have people be able to see the data from the portal. Have a little
blue button to be clicked and bring down the data.

And now it seems to me that there is a lot of granularity to not use the
other way, which is over-regulation in some respects, of over-detailing – the
color of the website has to be this way in this side of the corner of the
screen so that consumers don’t – when you are doing usability studies and
applying certain concepts, yes, there is value certainly of doing certain
colors of the screen in certain ways, but you’re now getting into a level of
regulatory position that is creating some questions or challenges by trying to
make it better. So there is that question of the balance but I know Alix had
her card, well, Linda has her card.

MS. GOSS: Thank you, Walter. My question builds on the dialogue that you had
on top of Michelle’s comments. When we’re talking about standards, are we – I’m
not sure the full breadth of that and I know that may sound kind of silly
coming from me but I want to understand when we think standards are we going to
the level of thinking about the frontline people and what they do in
interacting with the patients – so the registration, the eligibility, not just
the framework for the operating rules I want, this payload content,
constrainment on the adopted standard of the HIPAA standard.

I’m talking about how registration desk Amy interfaces with patient Susie Q
and that commonality of experience and people not having to reinvent the wheel
on how do I use this piece of technology in a tool for accomplishing a business
function and do that in a way that can be delivered within my own business
model. Are we including that?

That’s something like the regional extension center kind of thought process
we’ve been having at the full committee. And I think that that’s been a really
major part missing from today’s dialogue because it’s where the real people in
the trenches have to deliver on all of this and there’s a disconnect on the
intent sort of regulations, the standards, transport protocol, payload content,
et cetera, to the actual end-user that has to make it work in regards to
delivering care for the patient.

MS. KLOSS: I think that is certainly part of the whole milieu but one would
hope that over time in a standards-driven industry that organizations develop
competencies with how to implement standards. And that’s what you’re talking
about. It isn’t a competency that a lot of organizations have so you’re
pointing out a deficit that is a real issue I think.

MS. GOSS: I am not sure who should be taking that on. And I’m wondering also
that there’s this academic impact that could help us in preparing end-users,
whether that be a patient, whether that be a doctor, a nurse, a technologist, a
software developer, et cetera, starting to create this cultural aspect of how
we look at some of these and figuring out how to start to get people’s
expectations to be set to sort of more of that common principle framework.

MS. KLOSS: Again that exchange you had about standards. That seems to me to
be an exchange that would really benefit from some national committee work on
guiding principles because what you were talking about was the variety of
approaches and I would think that there could be some good consensus around
guiding principles for standards development, dissemination, adoption.

MS. GOSS: These have been done. In 2009 we presented a paper on regulatory
reform –

MS. KLOSS: Where are they?

MS. GOSS: Well X12, NCPDP, and HL7 all work together and I was a part of
that team. Actually, I asked Lynn Gilbertson for it today so I can send a

DR. SUAREZ: I don’t know if a lot of people know this but there are
principles in the 2003 regulation that established HIPAA, that established the
HIPAA standards of 4010. There are specific principles and basic kind of
general requirements of what a good standard is to adoption.

MS. GOSS: And we’ve been talking about including those in our subcommittee.

DR. SUAREZ: So have that. We also have the HIT Standards Committee developed
a series of evaluation criteria really more than principles but specific about
which criteria looking at adoptability and maturity of standards. So actually
there’s quite a bit of work around that. What I have noted, because I actually
work on that sort of principles and those evaluation criteria, and then also in
implementing them. And what I realize is that when we try to evaluate the
standards to the degree of those principles, not a lot of standards meet the
adoptability, the maturity, the marketability, at the point of when we need a
standard to be adopted because otherwise we won’t be having something to do
with meaningful use two, for example, or three. So it is a challenge.

DR. JAMOOM: Something I was wrestling with was with what Susie was talking
about with incentivizing those physicians or providers that are not necessarily
in MU and something that occurred to me is, okay, well what is the common
denominator across the entire health care system, it’s the patient. Is there
any way to incentivize from patient’s perspective to get them engaged in some
way that could then translate back to the system. Just because of how
fragmented it is. Is there some – whether it’s a PHR of some sort.

MR. SOONTHORNSIMA: Excellent segue. This is one of the questions that we
raised today. It’s what experiences do we want to change? And I think one
perspective is what about the patient or the consumer experience and that was
one of three points that I talked about. And I’ll get back to the standards in
a second.

It’s not necessary what we should do with the standards in harmonizing them
in getting adoption. I think at the end of the day we start on the other end of
that – is the end-user experience. She doesn’t care as a consumer – a consumer
doesn’t care what standards you use as long as I know when I have an episode,
when I have a crisis, I need to know what information do – and what options do
I have and how do I pay for this. Those are basic questions that – just to
answer those questions is very difficult today and I think that’s what we’re
trying to solve with some – what are the capabilities and business processes
that are needed to be harmonized and then what data and standards would have to
come to play.

I think that’s sort of peeling the onion if you will. But at some point we
stop as a government, federal government, because that’s where we need the
industry to innovate. And we don’t want these things to get in the way.

DR. JAMOOM: Although the market failure concept to patients in using these –
there’s this need for – I think there’s a space for what would be the patient
across the country. If you can somehow develop what that looks like and from
that point, innovate that.

MR. SOONTHORNSIMA: I’m not sure we need to develop that as a role of the
government or as a National Committee, I think we need to acknowledge and
anticipate potentially this different modality, there’s different venues and
accepting that this can be very diverse. It could be on paper, it could be
telephone calls or it could be on the phone, iPhone and whatnot. So different
modes. At the end of the day, I like to peel it back to say for the role of the
committee these are specific areas that we need to acknowledge that there’s so
much diversity out there because the consumers themselves have varying segments
of consumers. At the same time, same thing with the providers, we talked about

So where can we tease out – again this is getting back internally now –
where can we tease out those common ground that really would make a difference
because we’re not the ones nor it to be the role of HHS to figure out what that
engagement model would look like. I think that’s a role of the private sector,
the consumers and things are evolving, we’re actually trying to catch up. Does
that make sense?

MS. DOO: I agree 100 percent with what Michelle said about standards and
testing. We’ve been talking about that for years, it could be our middle name I
think. And we’ve gotten to do the pilot of the testing, thank God.

And now we’ll have a review committee, which I think you all are doing a
letter on or will be doing a letter on of how the standards could be or should
be tested and vetted. Whether it’s through the DSTU, through a pilot, through
some mechanism that before they are recommended, there is some kind of a test
to say this works for the purpose for which it’s intended so that it comes to
you then it gets recommended to the Secretary so that there is some proof in
the pudding, if you will, before it gets put forward, whether it’s an X12 or an
HL7 or an NCPDP. And that then there is also again for the committee some way
when there is a maintenance or a modification change – and I think Lynn was
alluding to this earlier for NCPDP, when there’s a change that the industry
needs that there’s also another way of being able to put that forward for an
expedited way that it can be used by the industry rather than having it have to
go through a lengthy regulatory process. So I agree with that and now it sounds
like there will be process by which that kind of thing can happen – that
something that’s good can be used and maybe you don’t have to wait until 2017.

MS. GREENBERG: What is happening with the review committee? We didn’t talk
about it all this week.

DR. SUAREZ: We didn’t talk about it during the committee meeting. We had
discussed it during our conference calls with the subcommittee. I think what we
are looking at is – the expectation is that the review committee will be
identified and then the first round of hearings actually would need to be
scheduled by April 2014 and then no less than 2 years from that –

MS. GREENBERG: Who is going to be named as the review committee?

DR. SUAREZ: Well, that’s part of what we have discussed, is really the idea
would be that the NCVHS would offer to become that review committee and offer
to provide some of the –

MS. GREENBERG: But the last time that was discussed – at least the last
teleconference or whatever I was on – it was felt that really there was an
issue of resources. There was an issue of needing some expertise that the
committee didn’t really have and –

DR. SUAREZ: But that doesn’t mean that the committee can’t acquire –
subcommittee you mean –

MS. GREENBERG: I don’t think we have gone anywhere with that is what I’m
saying. And I thought we were kind of looking to CMS for some guidance on that,
the committee, as to because – when is this supposed to be established?

DR. SUAREZ: Well by April 2014.

MS. GREENBERG: Okay, so what is the process if the committee is –

DR. SUAREZ: Well, there are two options. One is the committee offers to
become that based on the current structure and then if there is a need for
further like more refined detail analysis and evaluation, the subcommittee can
work on mechanisms to achieve that – whether it’s through contractors or
through – that are supported by someone – like CMS or something like that, that
could be worked. So that’s one option.

And the other option is that the committee decides not to do it and then CMS
needs to identify –

MS. GREENBERG: What I am saying is this needs to be on the agenda for
November. We can’t wait until the February meeting to –

DR. SUAREZ: It is expected to be.

MS. GREENBERG: It was never mentioned over the last 2 days and I forgot
about it.

DR. SUAREZ: I have it on the agenda for – I don’t know what we will achieve

MS. GREENBERG: We need a plan for thinking this through and seeing what role
the committee wants or is able –

DR. SUAREZ: There is a plan for moving in that direction of discussing and
deciding about it during this period between now and November and then by
November we will come back to the full committee with a formal recommendation.
And the idea is that between now and November we will also have discussions
with CMS to define that.

MS. GREENBERG: All that needs to happen. Because when we talked about well
what are the action items that we’re going to have in November the only one
that came up I think was the HIPAA report. So this may be another one.

DR. SUAREZ: Let’s wrap up I think as we probably want to – I think it’s
already 4:30. So I just want to point out, I think that clearly we talked about
at the beginning next steps of what we are going to do with respect to this,
not the review committee, but this.

So with respect to this activity, I think we’re going to get some
documentation, transcripts, we all have notes and our own kind of themes and we
have this – and it will be helpful if we can transcribe those as well if that’s
possible and have it on a document.

I do think that we have enough with all the information to define a draft of
a vision, a clear statement of a vision with additional supportive bullets or
sub-statements if you want to. That’s one piece that I think we can come out
with. We can call it elements of a vision or – but I think we have enough to
really say this is a draft of a vision, a single statement or a statement with
some supportive bullets under that. That I think we can probably do out of all
the information that we got.

What we can do also is define the elements of the – whatever word we use,
roadmap or glide path – I think that is the real next picture. Because by
November my thinking is we bring back to the committee a draft of the vision
and a couple of slides that show a picture of a glide path or roadmap, in terms
of picture of elements in it.

And I think with that we move into the discussion with the full committee
about what will be the next step from that point on.

We have supportive documentation besides those two major things, the vision
and the elements of the roadmap. We have the transcripts themselves. We have
the themes.

And then the last item I think we can begin to tease out is really the
priorities because I think that’s what we would need to really help define, is
the priorities.

Linda mentioned recommendations and used the word recommendations and we’ve
been careful in discussing recommendations when it comes to a roundtable format
because a roundtable is a little different from a process of NCVHS in gathering
feedback than the true hearing where we invite testifiers and we document that.
So I don’t necessarily see that we would have recommendations in terms of
recommendations to the industry.

I think Linda was suggesting some recommendations for us as a process, like
establishing an ongoing dialogue as in these roundtables and we can continue
helping convene that – not a recommendation to the Secretary. So those are the
kind of things that we would be able to do over the next couple of months and
bring back to the full committee.

In fact, I think, not to bring that back, but I think the whole concept of a
review committee is sort of embedded in this dialogue.

MS. GREENBERG: Do you want those typed up?


MR. SOONTHORNSIMA: To augment that a little bit, maybe you didn’t mean to
say this but it’s not – I’m not sure it’s a vision of the committee as
subcommittee. I think we’re also trying to bring in the value of the collective
elements or vision of the group that provided those points, okay good, thank

DR. SUAREZ: It is a collective of what we heard but it’s really kind of the
representation of what we as a subcommittee heard and present as the vision.

MR. SOONTHORNSIMA: We do want to also acknowledge that some of the things
may not be included, some of the things we’ve heard today may not be included,
just to be mindful of that. We will try to come up with as much as we can the
common set of elements.

MS. GOSS: That certainly works with the need to prioritize, we need to go
for the low-hanging fruit. We need to accomplish some success.

DR. SUAREZ: So it is four things. It’s the vision, the elements of the
roadmap or glide path, the priorities and these recommendations for the
committee or for us. I think those are the four major pieces of what we’re
going to do.

MS. BURKE-BEBEE: So going back – that’s the way I am, the organized piece of
me – going back and looking at the purpose of this roundtable. There were six
different points on page one. To me, and I could be wrong but I didn’t really
hear anything different from one to five. So there’s nothing new. And so we’re
really sticking with six and trying to do the things Walter that you just said
– the vision, the elements of the roadmap, prioritize and then possibly any

And I think what you said Ob is that we can’t do everything and that’s why
the prioritizing and I would guess with the process that we’ll run it back by
those that participated.

DR. SUAREZ: Yes, that’s the other thing that we would do certainly as we
document this –

MS. GOSS: I would suggest that we don’t want to go just back to the
roundtable participants. I think we want to produce a document and we want to
get very broad input on it, especially from the folks who are not the usual

MS. BURKE-BEBEE: And I guess what I was meaning, just to make sure that we
got it right, what we’re representing in this report, that we didn’t
misrepresent something that somebody said.

And one last thing, I didn’t hear you mention, Walter, the guiding
principles, were we still going to look for those?

MS. GOSS: Because when you said elements of the glide path I got lost
because I was thinking that second thing was really the elements –

MR. SOONTHORNSIMA: It is really an elements – when I talked about elements
earlier, I was talking about when you tease out every vision that we heard
today. Some of them were really good because they were actionable and so forth.
So those are the things that we want to tease out. Others have some common
themes, I think, and that’s what we meant and those would form and shape
guiding principles in addition to the guiding principles you’d talked about
that we came up with in August 2012.

DR. SUAREZ: An important distinction – when we look at guiding principle,
I’m not sure we’re looking at principles of a vision. I think we’re thinking of
guiding principles of how to plot things into a roadmap –

MR. SOONTHORNSIMA: That is one thing but it can also shape the next piece of
work that we have to do. For example, if we have deliberate on something, we
would want to use these guiding principles, okay, do they pass the test, if you
will? These are the requirements and –

DR. SUAREZ: I just wanted to not maybe confuse the things in my mind that we
were writing guiding principles of a vision so that wouldn’t make sense –

MS. GREENBERG: We’re talking about how the committee – if you’re talking
about that we should go back and look at those other guiding principles. If
we’re talking about different ones they’re not relevant.

MR. SOONTHORNSIMA: And then we come up with the next set of – the next
deliverable for the subcommittee would be the next set of operating rules, for
example. Because we can’t change what’s required of us to do but we would apply
these guiding principles to help shape our recommendation to the Secretary.
That’s how I would use this from the practical and pragmatic perspective
because we did take in the industry feedback.

MS. GREENBERG: Well, I know Bill Scanlon would say, yes, if we are supposed
to do something by X date or the industry is than it makes no sense or it’s
impossible than we should say something. Be that as it may. I’m just trying to
understand –

MR. SOONTHORNSIMA: We’re not going to use the word D – the D word, excuse me
but we might use the word determination.

MS. GREENBERG: I’m sorry to interrupt you but that was something I needed
clarification on. I know what the subcommittee’s going to do but my thinking
was, but I don’t know if that’s what you described and maybe I’m not right
about it but – before we, the subcommittee, takes these elements of a vision or
these common themes or whatever to the National Committee to deliberate, I
think we would want to push them out to everyone who is here and to those who
weren’t here but were – at least who we invited and weren’t able to come.

DR. SUAREZ: I think that would be the right order. First have a development
of the draft, have sort of us internally within the subcommittee kind of refine
it and then push it out to the members who participated plus others before we
go to the committee.

MS. GREENBERG: So it may be challenging to get this to the point – to get
this all done by the November meeting which is November 13th, 14th or

DR. SUAREZ: So one thing before we adjourn, any comments from the public.
Let’s just give an opportunity, Steve?

MR. LAZARUS: Steve Lazarus, Boundary Information Group. I am going to say
some of the things I was going to say when the roundtable was convened, but we
ran out of time, which I understand, and also respond to one of Alix’s comments
in this discussion. Doug Fridsma made a number of very valuable comments today
which may have gone by the understanding of several people here.

One of them was when he talked about ubiquity this morning and this
afternoon he talked about standard vocabulary and other infrastructure
standards, which also include things like – I’ll use the interoperable word –
inoperable security and connectivity issues. And let’s take that standard
vocabulary and apply standard definitions with xml tags that are standard.

Once we do that, and it may take us a new structure, two or three years to
build that, then the innovation of the private sector will be tiered loose to
do whatever it needs to do to create any kind of consumer app, provider app,
payer app or anybody else’s app, at very low cost and very quickly, based on
that standard data and be able to get at it with the proper security in a
standard way.

And these barriers of these interfaces that cost the doctor, we heard too
much money, maybe cost $5 or $10,000 for a lab interface become $300 and
instead of taking 6 months to test, it’ll take 3 days or less. That’s how we
get to 2020 and accelerate this process in a very dynamic way.

Doug also said, and he’s correct, we will have failures. Some of them will
be private sector failures that invest in the wrong thing. Some will be
decisions made by the government or jointly that we went down this wrong path,
but if things are modular and their plug-and-play ubiquitous, it just means one
thing out of 20 failed, it doesn’t mean the whole thing failed. So the whole
concept of testing and so on changes.

In your thinking about how we move forward, we have to create these pillars
of the infrastructure and make it a priority and do it probably in the next 3
years. Otherwise you won’t have any of this done in time for 2020.

DR. SUAREZ: Absolutely. The only thing about failure that is important to
have in mind is that hopefully the failures are not going to be – have
unintended patient safety consequences.

MR. LAZARUS: I understand. There’s all kinds of infrastructure issues we
have to build into this.

DR. SUAREZ: Well, on the standard issue, if we forward certain standards to
be done and the standard wasn’t really –

MR. LAZARUS: If I could speak – the standards become the data and the way
the data are defined and what datasets are used. It’s not something that is
fixed in its format and fixed in a number of different ways and let the world
out there, if it has the authority to access it, create an application that’s
useful to the public or the providers at will. If something like – Alix was
sort of getting at this I think as part of what you were talking about – not
only will be there be application failures, there will be provider and health
plan failures from all of this. There are every week anyway.

And there are other models to accommodate the small business, whether it’s a
provider or a smaller health plan, of sharing resources, just like you’re
talking about. There are examples all over this country where the solo
practitioner doesn’t have to stand on their own as the only way of doing this
and still be a solo practitioner. And we’re not going to regulate how that

We have to put the ideas and the case studies out there through – maybe it’s
ACOs, maybe it’s collaboration, we’ve used that word a lot today. I know of
five community health centers in Washington State that collaborated on their
EHR and the investment and the resources. I know in Michigan there’s a
nonprofit organization that supports the IT infrastructures of 25 or 30
community health centers. There are all these models out there where the solo
doc may have to think about how they do business a different way and still be a
solo doc.

MS. GREENBERG: Thank you. I’m glad you said that Steve.

One last process thing and that is would it be helpful to turn around the
transcript more quickly and I only want to say yes, let’s do that because there
is a resource component if somebody’s actually going to use it. Would members
and staff find it helpful to get it –

MS. GOSS: I think it could be very helpful from the perspective of we took
good notes but there was so much that was said, the transcript will help us
start to see the patterns of the words and the under-meaning philosophies.

MS. GREENBERG: I think it would be but I don’t want to do it and then
nobody’s really looking at it –

DR. SUAREZ: But one important that’s not going to be on the notes or even on
what we accumulated is the 30 or so, or 20 whatever number, statements that
they made about their vision. That we don’t have. We even asked for emails to
send –

MS. GREENBERG: But that will be in the transcript.

DR. SUAREZ: That’s the part that I’m really more interested in.

MS. GREENBURG: Okay. Thank you.

DR. SUAREZ: All right, lastly I think we should thank first of all our host
NCHS for having us here. Thank you very much. And our staff and all the staff.

And well, we have a lot of work to do so let’s go and do it. Thank you very
much everyone. Thanks to those who joined us on the phone, thanks.

(Whereupon, the meeting adjourned at 4:45 p.m.)