[This Transcript is Unedited]


National Committee on Vital and Health Statistics

The Subcommittee on Standards

September 20, 2012

Hubert H. Humphrey Building
200 Independence Ave., SW
Washington, D.C.

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

P R O C E E D I N G S (3:38 p.m.)

Agenda Item: Welcome

DR. SUAREZ: We should go ahead and get started, so we’ll call the meeting to order and we’ll go around very quickly and do introductions first of all.


DR. SUAREZ: So basically we have two main agenda items in today’s meeting. The first one is to finish up the letter that we will bring back tomorrow to the full committee for approval for action; and then the second one is really a discussion about the work that we are going to be doing.

So following on the discussion about the Executive Committee retreat outcome and the larger picture of where we want to be with the Standards Subcommittee, and then lining up some activities over the next few months and then at least talk a little bit about some of the things for 2013. So those are the two main agenda items. I don’t actually have them in front of me but I hope those are the two.

So the first part is to go through the letter and make the revisions that were suggested. And I think the first one was, probably even before getting to the recommendation, was the insertion in section A on page two, a point about mitigating tax flow issues. And maybe it’s not necessary on just A, but it’s more of an overarching theme we can include.

DR. WARREN: I’m sorry, which issues?

MR. SOONTHORNSIMA: The issue I think the person from AMA raised about cash, some sort of advanced payment in mitigating cashflow issues. This is where we can try to craft in such a way without giving a single bullet to her point in advancing the cash payment.

Perhaps we can say something to the effect that the overarching goal is about preventing or minimizing disruption to healthcare delivery.

SPEAKER: It is going to be under C for ICD-10?

MR. SOONTHORNSIMA: Yes, I’m sorry. I didn’t answer that question. So instead of saying we’re providing advanced payment or whatnot, if we can say something to that effect. And it’s not a bullet, I think it’s somewhere —

DR. SUAREZ: Maybe it is across the board.

MR. SOONTHORNSIMA: Across the board, yes.

DR. SUAREZ: Just that section we add a foruth numnber.

MR. SOONTHORNSIMA: The ultimate goal is to minimize disruption.

DR. SUAREZ: Yes. Overall the ultimate goal is to minimize disruption.

MR. SOONTHORNSIMA: And provide a practice.


DR. WARREN: Is it minimize disruption in care delivery? Patient care delivery?

DR. CHANDERRAJ: This is a business of running.

DR. WARREN: But we want to be really careful about business disruption. I mean, we’re here about patients.

DR. CHANDERRAJ: No, we are about patients care but the business end –

DR. WARREN: Care delivery includes the business.

DR. CHANDERRAJ: That is my point. If a business cannot survive –

DR. WARREN: Cannot get outside delivery.

MR. SOONTHORNSIMA: Because it’s a business of delivery.


MR. SOONTHORNSIMA: That’s the concern.

DR. CARR: I see what Judy is saying, that it is care delivery, but I think we heard very clearly that people ran out of money, and in at least one case closed down.

DR. WARREN: So maybe minimize disruptions in the business of care delivery.

DR. SUAREZ: Well, it could even be more like minimize disruptions in care delivery and mitigate cashflow issues. Without getting into advance payment – we’re not going to get into that – I’m not using the word advanced payment, I’m just using the word mitigate –

DR. CARR: We’re recognizing the impact of disruptions of cashflow.

MR. SOONTHORNSIMA: I like what Raj said earlier, business. That’s all-inclusive enough, wouldn’t you think? Instead of just saying specifically cashflow.

DR. WARREN: We don’t want to create a lightning rod that everybody who reads the letter says those greedy people are at it again in wanting more money. I don’t want to create that kind of lightning rod with this letter. But the business of care delivery I think then it captures all.

MR. SOONTOHRNSMA: Does that read well, Raj?

DR. CHANDERRAJ: I think that should be made as a recommendation rather than –

DR. WARREN: The business of –

MR. SOONTHORNSMA: Of delivering care.

DR. WARREN: Of delivering care, I think is even better.

DR. CHANDERRAJ: Deliver health care, as well as business.

DR. WARREN: That just feels better to me, I mean we’re still in the right space.

DR. CHANDERRAJ: Do you want to make that disruption as a recommendation? Because that becomes a big issue rather than as a bullet point or somewhere buried in the whole paragraph.

MR. SOONTHORNSIMA: That is why we outline what we want to emphasize. Stay the course, to maintain momentum, three, minimize the disruptions of business of delivering care.

DR. SUAREZ: Here we are not dealing with recommendations, here we are just providing the testimony of what we heard. If we wanted to add something about that in a recommendation –

DR. CARR: If we heard, and we did, we did hear that at least one office had to close down. I mean, that was very powerful that the disruption in funds flow had dire consequences. I mean, that’s what we heard. What we recommend we have to be circumspect, but what we heard is what we heard.

DR. SCANLON: What we heard is very selective testimony. We have no evidence about incidents. The issue about taking this to a recommendation, again we’re making a recommendation about government. This is worded okay because it’s talking about what the industry and DHHS should take into account. The industry can take it into account as it wishes, okay? Medicare has sort of rules about payment speed. I mean it’s in law about what they’re supposed to do. So I think we have to make this distinction. This is getting the lot expressed but I don’t think we want to take it as far as a recommendation.

DR. CARR: I would say this in term of rules. Rules are timeliness of payment, but are they rules about when you change out a whole system and one end of the end-to-end process doesn’t work, then you don’t get paid for legitimate reasons except for the fact that this is all new and mistakes will be made.

DR. SCANLON: I can talk maybe about this more. Medicare contractors have been known to turn off things to make the payments flow, because there’s a strong emphasis put in payment flowing as much as there is on meeting other sort of requirements that are in place.

MR. SOONTHORNSIMA: There are provisions that they would do, plans would do, to mitigate that by doing advance payments, for example. When they pay the claims and so forth, they can do that, in light of emergency and whatnot. And that’s happened.

DR. WARREN: I guess I would like to keep it global, the way he was talking about it, because even in the testimony we heard we don’t know all the facts around that particular instance. I mean there could have been a lot of things going on.

DR. SUAREZ: I think this is keeping it tight enough.

MR. SOONTHORNSIMA: When Jim later on said in our recommendation talking about outreach and education, that’s where we might want to be a little more specific. When Jim suggested having more of an outreach and target it to small practitioners and whatnot, I think that’s where you can be a little bit more specific.

DR. SUAREZ: So the other comment I had in this particular section was from Linda about innovative and highlighting something about the – it was on recommendation 3 of 12, but do we want to include a bullet here to link it back to the recommendation?

In other words we did hear some of the bullets. One of the bullets, an additional bullet, could be “promote the establishment of test databases and scenarios and testing areas”.

MS. KLOSS: I think the other thought that came out in the testimony was additional guidance. Guidance on testing methods, and –-

DR: SUAREZ: And innovative testing.

MS. KLOSS: — and innovative.

DR. WARREN: Provide guidance —

MS. KLOSS: You probably could combine the two.

DR. WARREN: — on test methods including exploring innovative testing through test databases.

MR. SOONTHORNSIMA: I am not sure what that, test databases, means.

DR. WARREN: It’s maybe too specific.

MS. DOO: Sample test data?

MS. KLOSS: Yes. The idea that there would be test data sets that could seed certain clinical data in, whether the ICD-10 codes are coming out accurately.

MR. SOONTHORNSIMA: This we talked about in testing in a clinical context, I think that was one of the testimonies we heard, right? And that was really to not test absolutely everything but to pass through from provider all the way through the plan.

Maybe be a little more specific. What do you think about promoting the establishment of test scenarios, test methods including sample test data to ensure clinical- oh, you’re doing that? Okay.

DR. SUAREZ: I think what Ob is getting to is really the two main messages of ensuring that once we switch there is clinical concordance as well as financial neutrality. In other words, including validating it for use by industry, to ensure clinical concordance or consistency I guess, to ensure clinical consistency and financial neutrality.

MS. KLOSS: I think that is good. Under number four up above, are you going to take that comma out if confirmed? Emphasize that the additional year will provide, since it has been confirmed now?

MS. DOO: We did catch it up above, but yes.

DR. SUAREZ: The next one is on recommendation three. Now I’ll just skip it.

DR. WARREN: Can we just back up on the dental code sets? Before Jim left, Jim was concerned that the tone of the D paragraph was that NCVHS had the authority to tell the ADA what to do. And looking at that Ob and I were wondering if we could change the tone merely by in the very last paragraph where it says furthermore — in the very last paragraph of D. With the sentence that starts furthermore. It was suggested, and then between the suggested and the that, we put by testifiers that NCVHS look into the maintenance process, and then that puts it into the whole DSMO domain instead of the ABA domain.

DR. FITZMAURICE: Lorraine, I think there is missing an “and” in front of financial.

MS. DOO: Yes, that’s why I went back to that sentence. Thank you. I thought something looked awkward.

DR. SUAREZ: Hold on. So now we can go to recommendation three, and in there I think we —

DR. WARREN: Walter, I was wondering, could we make recommendation 3A and then a recommendation 3B? So A would stay pretty much like it is and B would speak to the test bed and the urgency that Linda was trying to capture.

DR. SUAREZ: Yes, I think that would be good. Otherwise it becomes too convoluted.

DR. WARREN: Yes, way too long and convoluted and you get lost. So if you take that and make that A, and then where you’ve got “NCVHS looks forward to” —-

DR. SUAREZ: Just do a hard return there?

DR. WARREN: — just do a hard return there and do a 3B.

DR. SUAREZ: So we said three things, I think. We said about the urgency, about the prioritizing to small organizations, and about receiving specific reports.

DR. WARREN: Right. It’s specific around ICD-10. 3B is specifically around ICD-10 where 3A is about all of the future and everything that testing is important in.

DR. SUAREZ: Included specifically in ICD-10.

DR. WARREN: Right. And that should probably be the last – “NCVHS looks forward to” should probably be the last sentence in the recommendation. But the recommendation is to actually create these test beds to look at performance of implementation of ICD-10.

MS. KLOSS: I have just looked back at my notes from that and it was Blue Cross Blue Shield of Michigan that made that testimony and suggested medical scenario-based testing. I don’t know if we like that phrase better than the more general way we’ve used it, but that was the term.

MR. SOONTHORNSIMA: The focus of that medical scenario-based is really to achieve what we talked about early on, conserve the clinical concurrence as he used the word and then it’s all financial neutrality. So do you want to repeat that here or no?

DR. SUAREZ: Well I think we could just say here, specific to ICD-10, CMS should –

MS. KLOSS: Should encourage ongoing testing during the implementation.

DR. SUAREZ: Well, we can say foster the creation of test scenarios, and test data. We might not want to call it medical, there might be some other pieces that need to be –

DR. CHANDERRAJ: Most of the testing scenarios are based on a clinical situation anyway.

DR. SUAREZ: Specific to ICD-10, CMS should create or make available test scenarios and test data. Well, right up to “Specific to ICD-10,” we insert there the test scenario test data. You probably want to copy it in before NCVHS, that should be the last sentence as you already mentioned. So copy that, promote, before the word NCVHS. And then period right after neutrality.

MR. SOONTHORNSIMA: Take out the other bullet point, or do we leave it there? From the previous section.

DR. SUAREZ: No, we should leave it there. There is one point we didn’t include here which is the prioritize. So specific to ICD-10, CMS should promote the establishment of testing scenarios, and then after financial enter a comma, and we insert a sentence there that says what Judy was mentioning which was prioritizing the outreach effort –

MR. SOONTHORNSIMA: That is the next section, that’s recommendation 4.

DR. WARREN: This should also probably be like a 4a or a 4b.

MS. DOO: The comment was, that I made a note, was that we wanted to gear it to the little guys which is what we’ve been talking about.

DR. WARREN: What are the clinics we call where everybody goes who doesn’t have money?

MR. SOONTHORNSIMA: Community Health Center?

DR. WARREN: No, there’s a special phrase that lets you know that these are the indigents.

DR. CHANDERRAJ: We have clinical volunteers in medicine.


SPEAKER: Federally Health Qualified Center?

DR. WARREN: No, we’re close with free clinic. There’s another one that kind of captures all of those. We’re looking at the small physician practice.


DR. WARREN: Safety net, thank you. Because they’re the other ones that are having trouble in implementing all of this because they don’t have the talent.

DR. CHANDERRAJ: The free clinics are not reimbursed, so they are exempt from all these things. They don’t get any incentive.

DR. WARREN: I know the safety net clinics in our area are trying to be this.

DR. SCANLON: And they do seek payment. Not the free clinic, but the community health center or some other kinds of clinics are safety net providers. I mean it’s more defined by the population they’re serving than it is about how they do things.

DR. SUAREZ: I think that captures it very well. And I think that’s it.

DR. WARREN: Recommendation 7, somebody wanted the word “sample” included in there.

MS. KLOSS: Where was that?

DR. WARREN: Recommendation 7, to insert the word sample. But I didn’t capture where he –

MS. KLOSS: Yes, enforcement.

DR. SUAREZ: I think right after adequate, probably. Right after the word adequate, “conduct adequate sample compliance audits”.

DR. WARREN: We weren’t doing a complete audit of everybody, it was –

DR. SUAREZ: A sample.

MS. DOO: I put it by conducting sample proactive compliance assessments. Or should it be –

DR. SUAREZ: That is right too.

MS. DOO: Was that not the right place?

DR. WARREN: I think the concern was is the way that it’s currently worded could indicate that every single entity should be audited, and that was not the intent. The intent was you should only audit a sample.

DR. SUAREZ: Your concern again in both conduct adequate sample provides audits in accordance with authority and use the findings. So we can use the word sample both in the first paragraph and then in the actual recommendation, right after the word adequate. Right there after the word adequate, sample.

MR. SOONTHORNSIMA: One minor question that Jim had, “absorption of change”, or changes.

DR. WARREN: It should be “sample of compliance audits”. Adequate sample of compliance audits, is that right? Right after the word sample – oh, I’m still down at 7, sorry.

MR. SOONTHORNSIMA: Just a comment, Jim was wondering if we’d used the right word, “absorption of changes”, or did we mean adoption?

DR. WARREN: So we want to —

MR. SOONTHORNSIMA: This will continue to improve industry absorption of changes and optimization. Don’t change anything, but we intentionally used the word absorption. But do you guys care? Adoption? Absorption?

DR. SUAREZ: Adoption would be fine. Absorption sounds a little – All right, I think we have the letter.

DR. CHANDERRAJ: Besides the AMA has any other medical organizations been invited, like American College of Physicians, Radiologists, or Cardiologists entity?

MS. DOO: Have they been what?

DR. CHANDERAAJ: Have they been invited to testify?

MS. DOO: Oh, absolutely. Of course. They’re often here, GMA, AMP.

DR. CHENDERAAJ: I know the AMA does but I don’t see any other organization.

MS. DOO: MGMA, AAFP, they’ve come.

DR. SUAREZ: We sometimes don’t get the specialty associations.

DR. CHANDERRAJ: What’s happening with the physician community? Because there was a comment made that there was only one single entity that was presenting the loss of business because of nonpayment. The reason I’m saying that is because other physicians tend to, to minimize their cost, they’re only joining one organization and usually they’re joining their specialty organization and AMA therefore has very minimal representation whereas the subspecialist organizations have more representation. I don’t see any of the subspecialists except the family practice.

DR. SUAREZ: We do have them come to our testimony and we have received written testimony in some cases from them. Lorie?

MS. DOO: Just to affirm what Tammy and Lorie were talking about, certainly in the transition to 5010 there’s no doubt there were issues with cashflow. I only know about it from the perspective of Medicare, but I can’t imagine that other health plans weren’t addressing it as well, but every health plan dealt with the transition differently. So we don’t have a real way of knowing the impact, but I don’t know that NCVHS wants to get into the business of talking about cash flow because the industry deals in it in such a different way. I don’t know if that’s the purview. But certainly it’s not an unknown issue.

DR. WARREN: So another way to think about it is the purview of NCVHS is to look at our data and information and how it could be impacted, and one of the impacts is cash flow. But for us to actually go look at cash flow is beyond our scope. We see it as a factor that the disruption of data or whatever can impact. Does that make sense?

DR. CHANDERRAJ: It makes sense as a company but in the actual treating physicians practice it doesn’t make it, because there are a lot of physicians. You’re making a big impact in the way they conduct their business because they’re unable to conduct a business because they’re not able to survive.

DR. SCANLON: I think the concern was that the evidence that was presented was that one practice, sort of out of we’ve got 700,000 plus physicians this country, one practice sort of went out of business sort of because this cashflow issue. So that’s the issue of sufficiency.

There’s another reality that I think we’ll have to face, the healthcare system is changing and business practices are going to be affected and they are going to be affected potentially negatively. This happens all the time. If you’re in an industry and your customer base shifts in terms of what it demands, you’ve got to adapt. And you’re maybe not as well off as you were before, and if you disappear then your customers have to go to some other alternative. That’s probably not even remotely possible here, that we’re going to have a disappearance of the supply of the care, but we are going to have changes in the way care is provided and in the business of care. It’s got to happen, there’s just not a way to sustain sort of what’s going on in the past.

DR. CARR: So Raj, at the hearing, I think that it was not about what was the impact, per se; it was like lessons learned, and I think this concept of end-to-end testing for 5010, timeliness and all that, I think it was important to hear that there was downstream financial impact. That was sufficient to get that to the table and that’s where we wanted the letter. It was not intended to now quantify that, I mean AMA or MGMA or someone could do that, but I think that we do want to get that into the understanding of the issue because all of this testing becomes even more important so that this disruption doesn’t happen.

DR. WARREN: Certainly picked up beforehand, things can be done so that we don’t get to practices closing and stuff.

DR. SUAREZ: All right, so I think we are done with the letter and we’ll present this tomorrow. The other item that we have for tomorrow is a brief mentioning of the HIPAA report, but the outline will be we’re not going to have a HIPAA report this year. So we’ll recommend that and we’ll talk about it tomorrow and we have talked with-

MR. SOONTHORNSIMA: I think we followed our principal, right, being we need an audience, we have no audience.

DR. SUAREZ: So let’s just switch gear for the next 20 minutes before the end of the meeting here to talk about the next stage, and kind of the overall work plan of the committee.

So I think out of the executive retreat, one of the things that came out clearly was that we’ve been in sort of a reactive mode to try to fulfill certain requirements, and that certainly is a responsibility that we have, but we also have the opportunity. And this is a perfect timing, and given the concept around convergence and around standardization and with health reform upon us and all that, to take a step back and look at the business of health care, how it’s been done, and also how the exchange of information to support that business of healthcare is going to change into the future with health reform, with payment reform, with meaningful use, with all these concepts that we are doing.

So I think the goal that we wanted to try to discuss here very briefly was to take a few meetings over the next couple of months of the subcommittee to frame this area of work that we’re going to get into, and really kind of put it into a much larger context.

Now, in this letter that we just finished we recommended the development of a strategic plan and a roadmap for all these elements, and we’re going to be working and currently we’re looking forward to this work that we’ll be doing with CMS in defining that. So that’s going to be clearly a major component of our next wave of activities.

A second major one which is coming up and something that will both allow us to fulfill some of the requirement but also look at the larger context again of convergence and how the business policy is going to be different is this area of attachments. Now we know that, and this is a very large aspect of what we do. We know that there’s regulations that need to be written about the standards for attachments. We know that there is work being done in the data and in the standards world to fulfill the requirements. There is going to be work done on the operating rules side, and so a lot of it is moving along.

And what we wanted to do is to take a step back and look at the concept of information exchange. We call it attachments; it’s been referred to as attachments in the regulations, in the law, but in the reality as we’re moving into the future this is no different than an information exchange between a provider and a payer in support for a business need, which in this case is reimbursement. And what is going to be different is that the whole concept of attachment is going to be really not attached to anything necessarily, it’s going to be supplemental information that is going to be exchanged between payer and provider to support a particular business need, in this case reimbursement.

And it could come in different forms. It could come in the form of a copy of documentation of clinical care. It could come in the form of other types of documentation that we again today call attachments.

So that’s kind of the opportunity that we have, and I think Bill, through some thinking out of the box as he always does very good, I think, he suggested actually bringing together and convening a hearing of a group of people that can shed some light on these new perspectives about how exchanges of health information can happen and where are the business needs, really, that’s kind of the bottom line.

So I think that’s, just to go back to the larger question, that is the second big bucket of work that I think we see coming up. And then a third – and we’ll get to that in a minute – and a third big bucket of work is certainly going to be this area of all the administrative transactions that are happening and particularly the transition to ICD-10 and the concepts around testing that we recommend here, the concepts around compliance certification of health plans that are going to have to demonstrate end-to-end testing, the role of end to end testing for more than just compliance but a larger benefit for the industry. So that entire area is sort of a third bucket of activities that we have.

So I think I want to stop there and open it up really for additional questions, and then towards the end of the next 15 minutes or so we can talk about some of the process and what we can do over the next three months and then over the next year as well to do that. But let me stop there and see if those three buckets really represent what the subcommittee at this point would be focusing on in terms of work.

And again, bucket number one is sort of this strategic roadmap. Bucket two is this whole concept of attachments right now, locked into a much larger view. And bucket number three is sort of administrative transactions and the testing of those, ICD-10 coming up, all those things.

DR. SCANLON: Let me add a couple of things about my, quote, out of the box thinking, although I don’t think it was necessarily out of the box. I mean it goes in part sort of to what we were talking about earlier with respect to efficiency. I mean the IOM has said that administrative simplification or administrative extra costs are the second largest component of unnecessary cost, and so what we can do to reduce those is I think probably one of the number one priorities of the committee, and certainly of HHS.

And attachments, as having said on standards for a while, attachments sort of seem to jump out at you. I mean we had the hearing about the volume of them. Any kind of information exchange has cost to it, but what makes it worse is when it’s not anticipated, when it’s special purpose, when you have to think about it more, and that’s sort of the nature of attachments.

And so the issue was how do we kind of change this. Combine that sort of idea, which is how do we create sort of a way to make attachments easier, combine that with sort of – and this goes with the strategic vision, which is what’s the strategic vision of healthcare payments sort of in the future, and it’s different than the present. It’s trying to move away from fee for service into bundles and various types. It’s trying to reward sort of value and reward quality. And those things require a sort of information.

So if we’re going to make them work we’re going to have to ask for more information. If you try to do it sort of on the basis of current information ever provider can legitimately say, wait a minute, that’s not an accurate reflection of what I did. And you want to put yourself in a position of saying we had adequate information and we can characterize sort of what you did. And it’s going to be something that is essential to try and sort of change some of the unnecessary care. The number one item in the IOM study was unnecessary services, services that just shouldn’t have been delivered. To be able to identify them, to be able to create incentives to sort of eliminate them, we’ve got to sort of have more information and we’ve got to change sort of the payment structure.

So what I was thinking about in terms of potentially at some hearing that we have, that we learn more about what the peoples’ intentions or goals are for payment reform. What is entailed sort of in bundling? What is entailed sort of in sort of the risk adjustment? There’s supposed to be a value modifier for physician payment that’s coming up in a couple of years. There I think people are very sensitive. Did you take into account the severity of my patients? And therefore the question is sort of how did you risk adjust. Sort of, did you do a good job on that or not? So it’s thinking ahead, the kind of people that can sort of come and talk to us about that. There’s other issues, in addition to what I sent to you all in sort of an email, it occurred to me program integrity is also potentially sort of here, which is that program integrity people in CMS could be talking to us about what they think of our data needs for the future. As opposed to having to go and sort of seek information, what can we get on sort of a regular basis?

Now, what makes all this potentially possible is the electronic health record and the fact that we’ve made some kind of linkage between this information request and the electronic health record, so that it’s as minimally burdensome as we can make it. When we had this discussion a couple of years ago Mark Overhage was on the committee and the whole issue came up of “I don’t want to test somebody, ask somebody a question, just to report data to you.”

I think that’s a perfectly legitimate, totally legitimate sort of position to take. So the people who are developing new payment methods and other sort of methods that are associated with this need to start thinking about how do you maximize what you can learn from partial data. They didn’t do this test that you may have for somebody else. You’re not saying let’s go and test everybody in the world for everything so we have a complete data set. That’s not going to work. There needs to be sort of an economy of data and a recognition of partial data is going to have to be used, but it’s going to be better to use that partial data than no data at all.

DR. CHANDERRAJ: I have a little perspective that, as a position. I don’t think a human body is a body that you can bundle it into a pigeonhole. There are variations in an individual and no test can define an individual and no DNA can identify a complete individual. I mean it’s not possible. There are variations in disease processes that affect humans in general. There are so many variations so I don’t think any data, even if it is complete, can fulfill our obligations to provide this. Partial data I think has no meaning at all. Even full data leaves some question.

I think we are all humans and we all vary in our different approaches and we all have diseases affecting us differently. The same hypertension is not the same as occurs in any other individual. So I think we should take into account this variability of humanity rather than pigeonholing all of us into a data structure and trying to put them into our business model of health care.

DR. SUAREZ: Thanks. Dan, are you going to introduce yourself?

DR. RODE: Dan Rode with HEMA, and past co-chair of the X12 committee that originally put these transactions together. This is a great conversation. I would suggest a couple thoughts.

One: The whole idea of attachments, and the whole idea of the X12 transactions, especially around claims. We’re all built on the basis of a paper claim, that we’re built on the basis of looking at how we went from paper to an electronic form that by its nature identified the paper. So I suggest, I understand that we have legislation related to attachments, but I suggest maybe it’s time to question the way we transmit information for the claim in the first place which may eliminate the need for attachments.

The second area that I think you need to be concerned about, because we certainly are, is we still have the mandate for minimum necessary. And so from a provider perspective, how do we deal with minimum necessary when we begin to have the capability of supplying practically the whole record, even as an electronic stapled attachment to the claim. So I wish I had all the answers and I certainly look forward to the conversation.

DR. SUAREZ: Thanks Dan, those are two great points. And yes, I think in reality, and this is spurred also out of the work that meaningful use is doing by establishing standards and how providers send clinical information to other providers for transitions of care, and establishing standards on quality reporting, electronic quality reporting, electronic capturing and reporting out. All those elements are the ones that are giving us a new way of thinking, I think, and the opportunity is there to do that. And in terms of if I’m a provider and I’m going to have to send a summary of care record to this other provider for purposes of transitions of care and their meaningful use, and I use their standards and I use this code sets and I use all these elements, if I have to submit something like that to a payer to support some bundled reimbursement, I would like to do the exact same standards, I will actually use the same type of information and not create a sort of conversion into some other version of something. And that’s where I’ve seen this coming together of these two worlds that we had, the electronic administrative transactions and the clinical exchanges, because in reality all those are going into and they are already blurring around.

So I think the opportunity that we have is to look at all those, and the good news as I was mentioning in another email, in response to Bill’s email, is that in the standards development world, particularly the work that is being done to support meaningful use, these same standards are the ones that are being used to build up onto the concept of what we call the attachments, which again even the term attachment is something that we might want to get away from, but today we have it. So it is the same concept and conceptually we’re building these standards in a way that allow us to send data for clinical purposes and reimbursement purposes, and it’s the same data, same standard.

So what I wanted to propose, because I know we’re running out of time and the next committee is going to start in the next few minutes, is we wanted to convene in the next three months, basically, or in October and November at least, one 90-minute conference call that we can bring the group together, continue this discussion, continue to flesh out the details.

And then I wanted to suggest – and we can explore that with Marjorie and with others – to actually organize a hearing on this topic for the November meeting. We can actually do it the day before. We meet November 15th and 16th, Tuesday and Wednesday. We can try to do it Monday, half day if we need to, just the second part of the day, and focus on this topic that Bill just mentioned. I think we have the opportunity to start that discussion then.

We also want to advise and talk to Marjorie and the staff about early next year when we would need to plan a second hearing at which point we would be expected to receive the input and the recommendation from the industry on the standards for these attachments, which again as you will hear and you will be listening to these discussions, they are standards that will supply and will support not just what we traditionally consider now attachments but all types of supplemental information.

So the suggestion was specifically to have a hearing on February 27, which is the day before February 28 and March 1st, the full committee meetings. And that hearing will be the one that brings us together some of these recommendations, we can decide whether it’s a full day hearing or a half day hearing. So those are the next steps, it’s really monthly conference calls, we’ll schedule it an hour and a half in October and November, we’ll have a hearing in November, we’ll have another call in December, and then in January, and then in February we’ll have a hearing again on this topic.

DR. SCANLON: I think we need to meet more, but aren’t we meeting on the 13th and 14th of November? And the day before is Veterans Day.

DR. SUAREZ: Well, then we can do it the next after, the day after.

MS. DOO: The November meeting got very convoluted because of the schedule.

DR. SUAREZ: I think it is Tuesday and Wednesday, so we can still look at the possibility of doing the next day after the full committee.

DR. CHANDERRAJ: Can we have conference calls from Pacific Coast time so that it starts from 11 o’clock or something?

DR. SUAREZ: Oh, absolutely. Yes, we will. We will plan the calls I think like 3:00 p.m., usually. We will do 3:00 to 4:30 or something like that so West Coast people don’t have to wake up too early.

(Whereupon the meeting was adjourned.)