[This Transcript is Unedited]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Committee on Vital and Health Statistics
The Theme Session (Joint Workgroup)
September 21, 2012
Hubert H. Humphrey Building
200 Independence Ave., SW
CASET Associates, Ltd.
Fairfax, Virginia 22030
P R O C E E D I N G S (8:20 a.m.)
Agenda Item: Welcome
DR. CARR: This is our new configuration — what traditionally had been the combined Quality and Population group. This is really our first foray into addressing one of our three themes yesterday, empowering communities, individuals, and families. We are looking, today, to begin developing the idea that we had yesterday that came out of the retreat. I am going to look to Larry, Leslie, and Paul —
MS. GREENBERG: And Sally.
DR. CARR: — and Sally to lead this. I’m sorry. I said Leslie when I looked at Sally. Leslie is off the hook. She worked hard yesterday. Sally and Larry and Paul. I guess we should start by going around the room. I am Justine Carr, in my final days as Chair of the Fully Committee, Steward Health Care. No conflicts.
DR. SCANLON: Good morning, everyone. Jim Scanlon, Executive Staff Director for the Committee.
DR. TANG: Paul Tang, Palo Alto Medical Foundation. No conflicts.
DR. FRANCIS: Leslie Francis, University of Utah. No conflicts.
MR. QUINN: Matt Quinn, staff to the Committee.
DR. KLOSS: Linda Kloss, member of the Committee and co-chair of the Privacy Subcommittee. No conflicts.
MR. BURKE: Jack Burke, Harvard Pilgrim Health Care in Boston, member of the Committee. No conflicts
DR. COHEN: Bruce Cohen, Massachusetts Department of Public Health, member of the full committee. No conflicts.
DR. CHANDERRAJ: Raj Chanderraj, private cardiologist, member of the committee. No conflicts.
DR. SUAREZ: Morning, everyone. I am Walter Suarez with Kaiser Permanente. The only conflict I have is with my wireless connection right now.
DR. WALKER: Jim Walker, Geisinger Health System. No conflicts.
DR. WARREN: Judy Warren, University of Kansas School of Nursing. No conflicts.
MR. SOONTHORNSIMA: Ob Soonthornsima, Blue Cross and Blue Shield of Louisiana. No conflict.
MS. MILAM: Sally Milam, West Virginia Health Care Authority, member of the committee. No conflicts.
DR. GREEN: Larry Green, University of Colorado, member of the committee. No conflicts.
MS. GREENBERG: Marjorie Greenberg, National Center for Health Statistics, CDC, Executive Secretary to the Committee.
MS. QUEEN: Susan Queen, staff to the committee
MS. KANAAN: Susan Kanaan, writer for the committee.
MR. DAVENHALL: Bill Davenhall, member of the working subgroup.
MS. JONES: Katherine Jones, CDC, National Center for Health Statistics and staff to the committee.
MS. TUREK: Kelley Tureck, AHIP.
MS. KHAN: Hetty Khan, National Center for Health Statistics, CDC, staff to Subcommittee on Privacy
MS. JACKSON: Debbie Jackson, NCHS, committee staff.
MR. RODE: Dan Rode, American Health Information Management Association.
DR. VAUGHAN: Leah Vaughan, member of the Working Group on Data Access and Use.
MS. GREENBERG: Anyone on the phone?
(Phone signal overloaded – inaudible)
DR. GREEN: So the agenda for the morning is actually summarized in the annotated agenda that we all got in advance. In case that is not immediately in hand, there is just a critical sentence that says that the second day morning session — that is us, now — will cover one of the three major themes identified in the Executive Subcommittee’s strategic working session, Empowering Communities, including Individuals and Families to improve their Health. This includes the topic of community health data, health data stewardship, and community health indicators.
We are doing this with Dr. Tang on point for the Quality Subcommittee and Sally and me for the Population Subcommittee. We are thrilled to have the opportunity to bring the committee and some of the members of the working group into what we hope will be an interesting and useful conversation that begins to scope out this theme and where we are going to head.
Sally and Paul and I, I think, are agreed that what we are talking about is not going to be something that is done between now and the November meeting, not between now and the April meeting. In fact, the size and scope of what we will be talking about, here, is quite likely to represent an enterprise that could go on indefinitely. We should be thinking in terms of a staffing point of view and from the committee’s work point of view that this is something that we think should be seen as a couple or three years of coordinated work.
Jim Scanlon, at our last meeting, as he often does, barely hearable over the microphone says a sentence that makes me have whiplash. Last meeting, he said, you know, there is really a need to identify all of the things that are converging. This situation is an operationalization of that. We feel it is really important to identify all of the things that are converging.
We sort of have a working hypothesis that there is work around measuring quality in a way that really matters to individuals and people at the community level. We think public health is in transition. We think primary care is in transition. We think the delivery system is in transition. We think the information highway is setting up. We think privacy, confidentiality, and security is in transition. There are a lot of moving parts right now.
If Sally doesn’t mind, I am going to go grab that computer for a minute and try to anchor our conversation this morning in the prior work of the committee. I have probably already annoyed you with this before, but I grew up in Oklahoma. Oklahoma and Texas have issues. There is a saying out there that if you are driving across that God forsaken panhandle of Texas and you see a turtle on top of a fencepost, the turtle did not get there by himself. That is what I am going to be talking about here.
There is a little glitch here for whatever reason. The important stuff is right here. This committee articulated a vision for the 21st century. We brought this forward in our Communities of Health Learning System, again republished it. Particularly for new members in the working group, this is a powerhouse conceptualization that we think fits with where we have arrived and what we are talking about and what we want to discuss this morning.
Zero in on the little white circle in the middle. Population health — that is really our goal. Some people think of this as a new discipline and that sort of stuff. The way we think about it is there are a lot of disciplines that are important to creating population health. This is what we want. This is our endgame. This figure offers us an opportunity to start with the end in mind. We want to do work together that actually increases the probability, the likelihood and enables improving population health.
Those who came before us drove this down to just the most amazing little table there, in the middle. You may not be able to read it, but it says measure disease, functional status, and wellbeing and get the level of disease, the level of wellbeing, but also look at its distribution. That just ties to all of the socioeconomic status work. It ties to just darn near about everything.
When you come out to that middle bubble, there, ten years ago, the committee placed this in the context of the community’s attributes. We really don’t need to spend the next two years deciding that we have to agree on what they are. If we are willing, we can just say there are social attributes. There are biological characteristics. There is the built-in environment. There are health services. There are economic resources. There are population-based health programs. And there is collective lifestyle and health practices. That is a pretty robust circle.
Communities don’t exist in isolation. They have their own context of their particular natural environment, their particular cultural context. As seems to be readily apparent this morning, they have a political context.
I want to jump to another piece of work that preceded us. We have been using this — as far as I know, the ONC gets a lot of credit for crafting this thing. Jim and Marjorie probably know its heritage.
MR. SCANLON: IOM. Actually, Jim Walker and others have been working on the IOM side of —
MS. GREENBERG: Although, ONC may have helped fund it. Or did ASPE? I don’t know.
DR. CARR: This came out of two summers ago.
DR. GREEN: So the committee has seen this. The committee has used this previously. Again, go to the bubble in the middle. A learning health system requires governance, engagement standards, trust, analysis, and dissemination. We can decide that we want to spend a couple years arguing about that. I recommend we just say go for it. That’s the deal. That is proper framing.
The next thing is arrows. A really important thing in this figure is just that all of the arrows are bidirectional. Information — data is going to be, it already is, and it forever more will be moving back and forth, back and forth, back and forth, back and forth.
Again, in this framing, they were talking about a learning health system. They put around the edges components of the system. It called out, again, the new world is coming. It is an integrated world where things come together. Things get matched up. There are new opportunities here.
Now, what the Population Subcommittee did was basically take this and, instead of looking at it from the point of view of the delivery system, we started thinking of the community as a learning health system. We can report. We reported it before. We published it. It is on the web. It worked. This idea has power. It has traction. It makes sense to normal people, not the nerdy heads that we are. You can talk about this with regular folks.
We learned — just to be quantitative for a minute — just the members of the subcommittee, in about 15 minutes, nominated about 45 potential locations across the country where just we had some concept that there was a community in action, in movement, doing something from the ground up, very organically, to improve their health. We were hopeful that maybe we could get three or four of them to come and talk to us about that.
We did. We held a workshop about that. To our delight and surprise, we decided to invite 14 I think it was, Marjorie, hoping we could get four or five because it was a short time line and all that sort of stuff and all 14 said yes, we will come. All of them came. It was really fun. It was just amazing to see.
I trust this won’t offend anyone, but communities across this land have given up on the cavalry coming. All of the states are bankrupt or close to it. They are broke. People aren’t saying the states are going to bail us out or they are going to help us. It is not like we are planning on the Feds showing up with a lot of money and help and that sort of stuff. What we can see is that people in localities are saying — it is the old Jerry Garcia quote, it sure looks like somebody has got to do something, it is just pathetic it has to be us. The communities are in gear.
We often sit around in meetings like this and in Washington and think that we need to provide leadership. To a large extent, the leadership is organic all across the country at the local level. There is a lot of stuff happening. There is the analog of this picture for communities. The stuff in the bubble — communities reveal to us, from their different locations all across the country, that there is a missing infrastructure. They don’t have the governance structure that sustains them past the two year project that the local foundation did.
Community engagement — that has NIH’s attention. How you do that is there is a lot known about that, but it is not for the faint hearted. There is a need for standards. Everything pivots on trust, hard won, easily lost. They told us straight up, the community engagement stuff that was anchored in public health departments, that the analytic capacity at the local levels across the country is stunning weak. That might exaggerate, in terms of how much there is because there are a lot of them that have none.
There is this problem about once you learn something, what do you do about it? We heard stories about threats of stigmatization of entire communities because of what they learned. Then they said why did we want to know this? That sort of stuff. I think this was another stop on the journey to where we are this morning.
Remember, the health data stewardship work. This really makes the case that Leslie’s work and that committee’s work, what they have been doing for years — this illustrates how the committee really needs to integrate and work as a committee of the whole because we also are at a point where we need a new health data stewardship framework. This committee has heard repeatedly about the limitations and insufficiencies of protecting human beings, particularly in the new world that is being born right now.
This came out very clearly, once again, a learning health system in the center, there — there are issues of data integrity. We need a data analysis workforce that is just not there. There are additional data standards. There is research to be done. This fits in the context of public education. I can remember Marjorie putting her hand up and saying, you know, there are a lot of serious issues that the public just doesn’t have any clue about and they don’t have a basis to understand. It is going to be hard to work together and get stuff done without some educational issues.
Ethical use and professional use of data — this is a big deal. Security. Oh, my goodness. I don’t want to go there this morning. I am not awake enough. Those are three stops on the road to this morning.
The way I would frame this and then I want to turn it back to Sally for any comments she wants to make is I think the Population Committee is really united and on board, recognizes great collaborative opportunities with the work on quality measures and developing proper security, privacy, and confidentiality frameworks. We just see this as ready to rock and roll. If I can talk with my hands, you know, slide one I showed you, slide two, slide three. It is time to prepare slide four. Sally?
DR. CARR: Let me jump in for a second. I know we talked a bit yesterday about the configuration of the committee. Although this is the customary time of Populations and Quality, I think we really want to think about this as a new thematic focus with representation from all sectors.
Len, did you want to introduce yourself? Welcome.
DR. NICHOLS: I am Len Nichols from George Mason University. I have no conflicts.
MS. MILAM: I love the vision. As we were saying yesterday, we are really in an exciting position to make a difference. I am excited to start thinking about, with all of us here, what is our next project? What do we take on? How do we make this real and engage the community health data initiative? How do we also leverage that project into this vision? I am anxious to hear from everybody.
DR. COHEN: I have a suggestion. Larry, could you put back the first vision? Or do we all have this embedded in our minds? The vision for the 21st Century —
MS. GREENBERG: We might actually recall that the drivers behind that were the late Barbara Starfield — she had done some similar things, but she did a lot of work on that — and one of your mentors, Dan Friedman.
DR. COHEN: Using the historical context and based on our discussion about aligning themes, I thought a way to put — slide four from Larry’s presentation should essentially be operationalizing this diagram. How this would connect to themes is, certainly, it would provide data to empower — it would provide information to empower communities to use the data.
MS. GREENBERG: Kerr White — he inspired, certainly, Barbara Starfield and was a chair of this committee.
DR. COHEN: It would lead, I think, to convergence of a lot of different data issues. It certainly expands the notion of population health to include what I consider crucial issues in terms of community attributes and context. I think there is also work to be done around standards when we operationalize some of these concepts.
Finally, I think this is a really wonderful opportunity to engage our new data workgroup to develop applications around, essentially, this framework. I would love to be able to go to my Blackberry and pull up these parameters, these operationalized definitions of contributions or influences or social determinants of population and individual health. In many ways, if we are looking for something that cuts across our committee structure and really aligns a lot of the themes that I think this committee could make unique contributions to, it would be essentially expanding this conceptual diagram into practical operationalized variables and values for individuals and communities.
DR. CARR: I think that is just exactly right. This is sort of the bedrock of this community for the last decade. I think we are at a time now where we suddenly have a lot of this kind of data — some at HHS, some at other agencies — and leveraging the expertise of the working group, both the population knowledge as well as the apps, we could pull this together and get our measures, but actually create new understanding about the intersection of these.
Matt helped me this weekend. I had to show our Board how different states have different quality measures. AHRQ has that half meter and some are in green and yellow and red. When you look at it you just get a snapshot of, oh, we are doing okay or someone is in trouble. I sort of see the same thing with this, with this construct to be able to say maybe this part is okay, but, guess what, we have other issues. As you integrate that, begin to see the contribution of these various factors. I think it creates a great venue to take the liberated data and now put it to work and see what it tells us.
MS. GREENBERG: I just want to mention two things. We would have to go back and look at what exactly we have. In fact, one of the things that Susan Kanaan had volunteered to do before this morning — and Larry did part of it pulling out what have we already done that relates. I always remember Adam Ulam, who was a Soviet history guy who I worked with in graduate school. When he sat down to write a book — and he wrote many — he surrounded himself with his previous books. There were a lot of them.
That is not the whole source of knowledge, but I do think, as you have pointed out, and there are many more things, too, but these are critical that the committee worked on. Unfortunately, we were in this in-between contract periods so Susan’s offer advantage of it before the meeting, but she is here so we can work with her on it afterwards if you want to.
Also, after Dan Friedman retired and was no longer on the committee, he started to do — we started to engage him to do exactly what you described, to look at this diagram — do you remember?
DR. CARR: Yes. It was probably a year or two early.
MS. GREENBERG: It was ahead of its time, I guess. I think the committee was somewhere else at that point and wasn’t really interested in supporting it. I think NCHS supported it a little bit. I don’t know. He actually did a first iteration of it. We will go back and look at that. We can even talk to him. He went off. He has funding from others so he may have work that would contribute. I would love to bring him in for maybe the next time we meet. He started to do that.
I also just wanted to briefly report to you because you mentioned the socioeconomic status work, which we see and the Executive Subcommittee saw as being very much part of this agenda. If you recall, at the June meeting, the Population Health Subcommittee decided to basically have these two streams, continue the community health data work and continue the work on socioeconomic status. I think, at least the Executive Subcommittee, but I would be interested in hearing what the rest of you think who were involved in that earlier work, felt that obviously the community, but also the SES work fit right into this agenda.
I did report on that work to the NCHS Board of Scientific Counselors last week. Actually, I reported to them. I gave them an update on the committee. They particularly — Virginia Kaine particularly wanted me to tell them about that. They had about a 20 minute discussion about it, which would have gone on longer, but we had run out of time.
They really grilled me, including the person who is an ex officio from OMB — wasn’t really satisfied with how far the committee got on this. She really felt that there needs to be a minimum set of variables that you get most surveys to collect. What we laid out as minimum was really — it was what was being done by the major surveys, but was more than you could ask for of everybody.
We explained the committee felt it had gone with that hearing, et cetera, as far as it could. It had done what the Data Council asked them to do. It has been turned over to the Data Council. Jennifer Madden actually said she didn’t think this was even necessarily something for the Data Council, not that the Data Council wouldn’t be involved, but she really felt this was an OMB responsibility. It was going back and forth. It was a very interesting discussion.
Of course, the surveys that we are talking about go well beyond those from HHS. She also felt that only — Jennifer — that only OMB really had the power, as it were, through the clearance process, really, and through the interagency federal statistical committee to get people to converge around a minimum.
MS. QUEEN: Marjorie, I just wanted to mention — was it Margo?
MS. GREENBERG: Margo.
MS. QUEEN: I am in this workgroup with Virginia Kaine and others across the — beyond HHS, but the federal government. There is a measurement group that is working on family structure, household size. It is organized out of the Statistical Policy Office. The work that they are doing — what we have done feeds right into what they are doing. They have so much more weight.
There will eventually be recommendations, but they are doing the same thing we were doing across the federal government looking at how all of the different surveys and systems collect family size, household structure. Some of them have to have it in a different way because for social security or legal purposes. If they are asking about marriage, it has to be are you legally married. All of the exact same issues are in play here.
MS. GREENBERG: Are you involved with that?
MS. QUEEN: Yes.
MS. GREENBERG: You will certainly bring forward the — I mean, another part of the debate was this is easy/ this is hard. It is both.
I wanted to bring that to you. Obviously, there is a lot of interest in different pieces of this, both, I think, out in the communities and in the federal government.
DR. MAYS: I just want to comment on Bruce’s comments. I agree. I think that is a great kind of next direction. It really would address a lot of the things that we have been talking about.
I want to add one other piece that I think is important that kind of pushes the envelope. Jim, I would be really interested in what you have to say about this. As we have begun to talk about the population health issues, we often come up against this issue of social determinants. Much of the data — not much, but some of the data that we need is not in HHS.
As you were describing this, one of the things I was thinking about was the issue of data linkage. If you look at the President’s HIV strategy, it has really started to push the envelope about wanting to get data from other areas. On the IOM committee that I was on that just finished, we began to make those same kind of recommendations. In the other IOM committee on the leading health indicators, we, again, said the same thing.
I am wondering to what extent that can be a little bit of the agenda of as we try to fill this out and identify data that is outside of HHS and begin to kind of task looking at the value of those linkages that we can kind of push that a little bit. It would help enormously for the population side of issues.
MR. SCANLON: Actually, I mentioned yesterday and at the previous meeting that within HHS, Dana Ketelson(?) was asked to look at our portfolio and look at both the technology we are using for surveys and research and data collection as well as the potential for integration or alignment. One of the recommendations — we should probably do a briefing of the data strategy for the full committee, but one of them was you foster integration and coordination several ways. One is data standards, obviously. The other one is linkage.
We actually discussed different types of linkage. One is the survey or the research study with administrative or medical data. The other was survey data linked with contextual data like census data, neighborhood data, economic data, which I think, actually, has a use(?). We have actually — we had a nice study that we did with NCHS where we linked EPA data with the Health survey data. Again, this is not individual. This is neighborhood or context with the location of the household.
All of what we are talking about is sort of a tool. It is a way of getting to some vision or goal. I don’t think it is the health statistics vision that we are thinking of. It may be a health data vision or strategy. I don’t want it to be statistic-centric because you sort of lose people. You lose all of the administrative and the clinical side when you do that.
Linkage, I think, standardization where we can — or at least a soft standards. Mandating a standard is a hard thing. Often, you don’t want to do that because you sacrifice a lot of variation that probably is justified when you do that. You have to know when to do that. Getting people to start using measures where we know why it is varied or similar, I think that is a very solid way to approach.
Linkage, I think, everyone — we were thinking, for example, that what we would do was list all of the linkage in HHS where we have done this already. We could certainly start there. There is a lot more. There are all sorts of approaches to linkage and what is linked exactly. We would be very supportive.
I think there are folks who say we have not really had the opportunity for health transformation until we had payment reform, delivery reform, EHRs, and data — better data. I would say without the data part of it you almost have no way of pulling it together. You don’t know what you are doing really until — what the output is until after that. Linkages are part of, I think, integration and an alignment dimension.
MS. GREENBERG: The population health subcommittee did do a whole set of hearings on linkages and did a letter on it. It was really more related to health reform, but I think that could be expanded.
MR. SCANLON: For community measures and for social determinants, I think this is a very positive way and it really provides insights that you couldn’t have any other way. Again, as I think Sue’s alluded to, HHS, alone, cannot be it. We collect a lot of information, but we can’t make estimates about income and unemployment, even though we collect that data. When we collect the data it is really meant to be a covariant or stratify or help understand. We really have to rely on the census bureau and others for the social. We can agree to do something a certain way, but if you want a mandate I think it has to be someone at OMB. I am not even sure mandating is always a good idea.
Again, that whole social side, environmental side, business climate side, health resources side, there are all sorts of links you can make. Some sorts have progressed on the mapping side where the basic platform is a map for the county level — again, this is not quantitative data. They are able to pull in, visually, at least, some of these contextual variables. For example, we use it in our emergency preparedness. We can literally call up a local area and see every hospital, every clinic, every nursing home, and a number of other factors there, as well. There are different ways to visualize.
DR. SUAREZ: Thank you. Great discussion. What I wanted to bring up — it is part of my thinking about the outcome, the product, what we want to look at — I think there are five — conceptually, five things that we are talking about. One is sources — sources of data. There is convergence in terms of sources of data.
The second one is metrics. In traditional conceptual approaches of quality, metrics are structured in this traditional structure process outcome measurement. One could try to extend that application into the community health metric development and looking at what are the structure, the process, and outcome measures to achieve community health improvements.
Source is the first one. Metrics is the second one. Granularity is the third one. Now, we are getting into the convergence of the two bookends, the individual and the population, and trying to bring the population as in the world and the country and the state and the county and the city and now the block down to the individual. That is the third, granularity.
The fourth is the linkages that has been mentioned and talked about. This is part of the linkages of the sources to generate metrics at a granular level to produce these measures.
The fifth one is tools. This is where, I think, we can really push the envelope is looking at tools that can help communities apply all of these concepts of sources and metrics and granularity. That includes identifying best practices/use cases. We heard, through the hearing, a number of excellent examples of how things are being done. Part of the work of the Health Data Initiative is really to expand that use of data in innovative ways through tools.
Those are my five: sources, metrics, granularity, linkages, and tools. Sort of across the spectrum of all of these five, I could not bring standards because they fit across the board along the way with privacy and security. Those are sort of, again, the two large dimensions that cut across these various areas. I think when we think in terms of the outcomes of this new theme for the committee, I think we should keep in mind those five concepts: sources, metrics, granularity, linkages, and tools.
MS. KLOSS: I was actually going to suggest work somewhat along the lines that you have so well laid out, Walter. I think when we look from these three framing diagrams, the piece that actually is weakest right now is our description and understanding of data and all of the collection, management, stewardship issues. I think, as I look from slide one to slide two to slide three, it does underscore the need to update that stewardship model. Perhaps, when we again read our letter we think about what a contribution that may make as a starting point.
I think in the current community dialogue, with all of the focus now on big data and these topics that are hyping things that really need some foundational guidance to understand what this means, improving that model — the third — into a more robust look at health data broadly would be a real important contribution right now.
DR. FRANCIS: I was trying to think of how some of this — you know, yesterday, we were thinking in terms of a matrix of themes going one way and expertise going the other way. In terms of the subcommittee that Linda and I co-chair, one of the really important things that we could be doing, if the committee wanted us to be doing, is looking at the stewardship questions that are raised by some of the kinds of linkages.
Do they differ with the kind of linkage? How should we be thinking about data where we are in the no-person’s land between population data and the individual as we get more granular? That is part of what is going to be happening. That is something we could be — that could be a task that is one of the aspects of the stewardship model that we have raised. We will stand to be instructed.
MR. SOONTHORNSIMA: So far I think we are talking conceptually of different dimensions perhaps, at the committee level we are talking about data linkages, standards, and so forth. And in this context I would like to kind of bring a different perspective, or a slightly different perspective.
At the end of the day, the center of that population health, at the center there, at the end of the day you have the individuals that I think we are trying to either enable, empower, for them to do something in their community, either improve their own health or the health of others, correct? So that is really who we are really targeting, I believe, not just the whole community. But it starts with the individual as well, I believe.
So here is a thought. Just going back to our themes and our key principles, who and what are the things that are actionable? So while we are looking at this in this larger context, if we can put that individual, whoever that person is, at the center, and what is going to be actionable for them.
Even some of the things that Linda just talked about, there is a vacuum in there where it is no person’s land, where you don’t really know where data can come from, or this vacuum of data, absence of data. How about some time in the future when people feel much more comfortable about volunteering information about themselves without us having to worry about governance. I think this is the work that Leslie —
PARTICIPANT: When we have trust.
MR. SOONTHORNSIMA: Yes, thank you. When we have trust. When they understand, when an individual is empowered, and really begin to understand why providing this data or information about myself can really help not only me, my family, but my community overall.
So that is just to call out to the point that there is that individual, the who we want to go after. And what are some of the actionable things including not only things that they can do but things that they can volunteer in terms of information and data?
MR. QUINN: Really, really good thoughts. To build off of Larry’s earlier comment about we are missing the local infrastructure for supporting this and that is what we heard, and then some of the other comments, I think that something that is really essential here is understanding and making recommendations about how to go about fostering, growing, sustaining an infrastructure that will support population health at the community level.
And then as Ob just described, tying that to specific, I don’t want to call them use cases, but contexts of use. And by population we are talking on one end it is an individual, but in the sub-community level there is an individual, family, their extended family, their primary care. One of my projects at AHRQ was called practice based population health. That is the idea of it is not just a claim by claim, patient by patient. You manage the 3,000 patients.
Then, extend it to the care team that is in the community. Then there are actual communities. So tying it to the individual, testing the infrastructure that we are trying to foster and the data that is available, and specific use cases like how do I find a good primary care doc, to how do I help the community lower its blood pressure? Or how do I manage the health and health care of an elderly parent? Those are the sort of community based things that we want to have an infrastructure to support.
And for each of the communities of the nation to do it in a way that is specific to their needs and populations, and priorities, but without having to reinvent the wheel. I don’t think anybody else is thinking about that. We are thinking about directing a message from one EMR to another. We are thinking about that sustainable infrastructure and how to build it at the community level, not the federal government do it, but their role in that.
DR. MAYS: Leslie has just reminded me of something that came up yesterday when she was talking about the issue with the matrix, where what we were talking about are themes and expertise. And Bruce kind of threw it out, but I would like to kind of bring it back. And that was the notion of a community member being at the table. If we are really going to take this seriously it may be that we want to think about, as we are thinking about changing our structure, also changing what we consider necessary expertise.
And that might mean thinking about having a community person. They may have to rotate a little faster than we do, because we have so many different communities that we are really interested in. But I think that as we start thinking about how to do these things, instead of us kind of imagining a person I think we need the expertise sometimes of that kind of person here to have a discussion with us.
So I am hoping that as we kind of go through re-thinking that we might think about — and I don’t know if it takes an act of Congress almost to get another person, but that may be something we want to also discuss about what is needed, for us to truly do this work with integrity.
MR. SCANLON: We do have community representatives who work at that level on the other workgroup.
DR. WALKER: It seems to me one of the obvious issues is how we do take this great framework and focus it down to a manageable project, big enough to be important, small enough to be completed in, what, six months outside? And a modest proposal.
So first I think we would have to identify one coherent type of community to focus on. And probably the one type whose effectiveness would most improve the health of the population. Second, we would need to do a needs assessment for that type of community. What kinds of information do they need to be effective?
And to Vicky’s point, that is one of the places where obviously they would have to be part of the conversation. And I would say large numbers of them, many more than — one sitting here, fine, but a real environmental scan and a serious needs assessment.
Then I think we would want to limit the information we talk about to information held by HHS and other governmental agencies. That isn’t the universe of information, but it is the information we control. And that combined with the needs assessment which would say this other information isn’t controlled by these entities and needs to be taken account of.
But we could start by having a framework for using the information that is under federal control. Then it would be obvious that we would want to say what are the information standards needed to enable this specific information set to be integrated, giving us a focused way to address standards that would obviously have to be extended in the future to other situations. Same thing with database linkages.
And then I think it would be a great way to use the principles that you guys have done. So we say look, these are high level principles that everyone who does this needs to take seriously. And then this gives us an opportunity to say, for this set of data stewards, for this type of community, this is how the principles would look in this concrete situation as a way of saying then for every other sort of relevance that we would do the same sort of analysis.
DR. CARR: I am going to jump in, because I did put my name on the list. The only thing I would say in response to that is that I would like, going back to what Bruce said, we have an opportunity to look at what data is outside HHS, to create the first landscape.
Because I think one of the things we may find is that one of these contexts or community attributes is an absolute driver of all the rest. And so if we have that opportunity to access and describe that information, I think we take this to another level.
DR. WALKER: That is the point of starting with a needs assessment. This is all the information that would be needed. And then saying, and this is available within HHS or some other federal agency, which makes it perhaps relatively more accessible.
DR. CARR: I was thinking the needs assessment would be this picture.
DR. WALKER: No, but I mean you have got to drive out of this to an actual needs assessment. They need ethnicity data that is granular enough, and they need –
DR. CARR: Right, but here is what we have and here is what it is telling us. We don’t have it all, but if we look at this, we have more than we have been looking at up till now.
DR. COHEN: And identifying the gaps, I think, and the different potential sources is just as important as identifying what is ubiquitously available. And that would ultimately be the key. I don’t expect that all of these data will be available for any particular community for ongoing data sets. Some of it will require communities to do the special surveys or special collections.
That is fine to say, because I think there are communities out there who have models of doing pretty much those kinds of things. That would be a way to stimulate the community involvement and development, in making this their own.
DR. CARR: I think it goes back to what Jim was saying yesterday. It is not so much even the analytics. It is the counts. Are there health services available? What is the unemployment rates? Just raw counts that when juxtaposed tell a story that informs the health.
DR. COHEN: Where do you go for domestic violence data in the communities? In a lot of the community needs assessments I am involved with, that is a huge issue. And there is no generalized federal or state or even local approach to that issue. But many communities have developed systems to be able to monitor that. To understand those kinds of data developments would add enormously to this conversation.
MR. SCANLON: I think the idea of — you are right, there is a whole field of community health and community health assessment. And typically what you want is a quorum that every community would want to think about, and then you would want to have the special areas that a community would look at.
But I think you are right, the limiting factor is that there is a lot of national data and then it sort of peters out, and very little at the community level. But there are categories of data. I think this is not a bad idea in terms of thinking through data. Even if it is a hypothetical community, you have to specify what is the unit and what do people generally recommend.
Usually it is from the public health side, which leaves out the clinical side and somewhat on the resource side. But maybe thinking of this, even conceptually, as a hypothetical community, looking at what has already been suggested as community needs assessment, and then looking at what is available where.
And we are not the first ones, obviously, to think about this. I think CDC puts together a states profile, maybe even a community profile. But that is not a bad way of looking at it, from the point of view of looking at what is available already.
And on the administrative data and the care side is where we have federal programs where we have claims data and so on, have some quality reports, hospital compare, things like that, that gets fairly granular. But we sort of run out of data there fairly quickly.
Economic data, there is plenty, actually, by the county and the metro area, demographic data, some other social, educational data generally. So that might not be — I am trying to think of how to make this into a doable analysis and I think without having to think of a large volume at the end, I think you sort of take it in steps. And the first one is this conceptualization of almost a hypothetical community, is the way to start.
MS. KLOSS: Following on to what Ob said, and suggesting one other piece that might be valuable as an adjunct to the process that Jim laid out, it may be useful to do some future scenario. What is this world that we want people to be living in with regard to accessing the data? And the community that is really functioning and accessing?
So a little more vision out there, even if it is a bit idealized, I think front ending this process then of digging down, it would kind of help us, and help us tell a story as to why this is important.
DR. TANG: That is a perfect segue to what I wanted to try to set up. Marjorie is always fond of saying how good NCHS is at laying out a vision. And I think one of the things we could do a little bit better is the implications of the vision, and I think that is a perfect set up for what this group could do.
I like how Larry started out with — and I am going to go cross-cutting, cross-cutting. So Larry started out with the learning health system, which is an activity at IOM. IOM just released a report earlier this month. It is the culmination of the health system, roundtable. And they had 10 recommendations that fall into three buckets.
One is near and dear to our heart. It is really setting up the data infrastructure. The second is to reorient the target. And I think a big part of reorienting the target is to focus in on both patients or individuals, and one manifestation of that is care decision making. So this goes a long way towards what Ob was saying.
But that is reorienting what we look for with the data. See, it is a different implication than we are used to. And I think we could benefit from some of that orientation. So when I look at this, it looked fine in 2009. I am not so sure. It looks pretty sterile in 2012, because the masses are far more, they have access to lots of stuff now and that doesn’t say that.
So I think what we could do is personalize that. And again, it is going back to what Ob started out. So for example, in shared decision making, we really don’t talk about your BTE prophylaxis. It is like saying, what is the temperature you cook the hamburger at. We don’t really care. We are really interested in how does it taste and how does it feel to be in your restaurant.
Similarly, and this goes back to what we created, measures that matter. And just yesterday I was at the NQF Board and that phrase came up. So that is cross-cutting, cross-cutting again. And I think that is the thing we want to do. We started this measure that matters. We ought to finish the job, but I think we are using it, because we are going back to population.
I know we use the term community, and I still love Susan’s definition for that. But it is really, the difference between population and community is, community has an implication of there are people living in it, and they are part of it. I am not part of a population, I don’t think, but I am part of a community. And I think that is how we reach individuals.
So can we turn population data that the government has and that many organizations have, and turn them into community data? That is part of the stuff we already had started working on, people data. And then can we impact the person? That is what is missing, even in the health insurance exchange.
We took that opportunity to say, hey, can we take this opportunity of posting data, comparative data about plans, and make it stuff that you could compare? And I think we want to do the same thing with this, to take population health and data and break it down to community. Only because it is the closest thing, it is the only way at getting at certain individuals, and individual decision-making about their health.
I think we have got the infrastructure. We could repackage it in 2012 different than what we conceived of, which was ahead of its time in 2009. But that is the implication, I think, we are looking for, and that is a statement of the vision. And then to bring it back to your first point, it really turns us into a learning system that involves people.
MS. GREENBERG: I guess it is because I am an E, but everybody stimulated a thought in my mind. At the end of the evening last night Susan Kanaan said to me, you must be exhausted. I said no, I am really energized. And she said, spoken like a true E. But I am kind of exhausted this morning, I have to say. Even Es get worn out.
I will try not to tell you everything that was stimulated in my mind by what was said, but particularly this issue of individuals, families, communities, populations. I think Harry Reynolds, who wasn’t able to join us last night, but he used to talk about the sweet spot. That is sort of the opportunity, and obviously I think this is a very good group to do it, if not the perfect group.
It is kind of organic, or to show how it is organic. I really like the fact that in the way we maybe tweaked it a little bit yesterday, but we talked about empowering communities, including individuals and families, to improve their health, and with data, et cetera. So there was a reason why the Executive Subcommittee felt that they needed that kind of paren.
So it is empowering communities, but the ways that the communities empower individuals. I guess because I come out of more of a population health and public health perspective, I think we have to keep that in play, and not zoom in too much on the individual. Partly because, I guess I worry that if it were easy to change individual behavior we would have done it a long time ago.
It is the hardest thing absolutely in the world. And yet communities, and however you want to define them in the broad definition Susan gave, are able to sometimes, I think, with the right types of resources and tools and the things that Walter mentioned, the metrics, the tools, the technology, whatever, make it so much easier for individuals to change their behavior. Or just almost make it impossible for them not to at the extreme.
You can’t smoke anywhere. And someone once said to me, do I want my apartment to be a den of smoke? That’s the only place I can smoke any more. Almost like, it’s no fun anymore. So this is maybe extreme, and I don’t want to get into big brother, but I think we need to keep that in play. And I think that organic relationships are ones that require — maybe that is slide four.
I like the scenario and the visioning. I loved what you said yesterday, Linda, about the core, the new, and the wow. And I also think I quoted this at the executive retreat, which was right after the National Conference on Health Statistics. I keep blanking on her name but she is the head of the Academy of Health — Lisa Simpson, it finally came to me.
She made a great comment where she said data make us credible, but stories make us memorable. And it was beautiful. So the idea, I like Jim Walker’s idea of kind of zeroing in on a prototype type of community, recognizing that each community is different, but they have a lot in common too, at least at a large level. And I think that we have to think about this. We have to think about resources, et cetera.
But we started an environmental scan with those communities. Susan actually interviewed each one of them. The information that we gathered on those 14 communities went beyond what we actually even got into the report, although here is an Appendix.
But there may be some way that we can, in a longitudinal way, engage those communities, and some other ones. Some of the ones maybe that you have worked with, Bruce, because I know you have done a lot of work in Massachusetts. But in this activity on an ongoing way.
We certainly don’t have the resources to bring representatives of each of them to all of our meetings. But I think we need to think about that because I think Vicky is absolutely right. It fits in with what Vicky said, what Jim said. We have communities we have already established relationships with. Some of them may be degraded, others have done more, but they are two years beyond where we first met them.
So I think we need to think about that, how to engage them through technology and other ways. Almost like an advisory group to this advisory group, but not officially. So that is something to think about.
I also started thinking about sort of the pop — we talked about summary health measures a lot at the retreat and we had some discussion about that yesterday. And Bob Kaplan from NIH is very interested in that. I really see this as an opportunity to engage. He is very interested in this project.
He was telling me yesterday he is really taken by this committee because it has such a different — it is not all like-minded. People from so many different viewpoints, and doing the translation centers and all of that. So I think it is a great opportunity to engage NIH.
I also think that in doing this we could really contribute to the third theme, which is a convergence theme. We have talked a lot about convergence this morning. I don’t want to see that going off in its own — I am wondering, because we do have band width problems, but it relates to much.
The one thing we found communities were not doing much with was health care system data. Like we asked them, were you using electronic health records? Well, it is early. But in some communities, that is clearly a growing piece of the resources of the data. So I think we could make that convergence piece much more real, too, if we tied it in with this idea of the community, the summary measures, whatever.
And finally, I do think that — I was just thinking of some of the pop culture, media or whatever, about communities that are good to live in. We may kind of throw that off. It is not something that the National Center for Health Statistics would publish. But, it resonates. And I think we need to look beyond even the basics, what statistical agencies do, what the federal government does.
For years people have been — my community that I grew up in, Fargo, North Dakota, despite the weather, is apparently one of the best places to work right now because there are jobs. That is one reason. So I think there is a lot of different streams that we can pull in. And the important thing would be to map that out.
What was your question yesterday, Justine, I think? It might have been about something else but it was how do we configure to do it. I am not talking about changing the subcommittee structure, but there are a lot of different pieces that I think we need to think through.
DR. CARR: I have Ob, Len, Judy, Walter, Paul. And then I think we need to decide on next steps.
MR. SOONTHORNSIMA: Just to combine some of the comments, like what Paul was talking about, cross-cutting things that go across all these different layers — and I like the word that you use, organic, in terms of how things are evolved. So going back to Bruce’s question that stuck in my mind, how do you determine for example domestic violence, it got me thinking about there is another source of data. We don’t call it data yet. This thing is social networking.
If you are talking about something that is cross-cutting, we talked about something that is truly individualized and at the same time community oriented. You want to call it community, because people do pick, an individual picks what he or she wants to be involved with. Now that is new. It is not data so to speak. And can you trust it? No.
But if we figure out how do you bring that piece of information, cull that down, it may help actually color some of the things that we are doing on big data, whether it is administrative, whether it is community, contextual, environmental, yada yada. Does that make sense? If it is something that we really want to focus on, our lens is now on the individual, how do we make a difference.
And then on the flip side, I talked earlier about people volunteering information. They are doing this today through these networking sites. And that is not only volunteering information. That is where they go to seek support. So there is some credence that we can look into, and that ought to be part of that vision that we call data, another source.
DR. CARR: So we don’t know how to use it but we know we can’t ignore it.
MR. SCANLON: Again it is qualitative, and we don’t know how representative it is, but there are techniques for analyzing that already. If not that, you get an estimate of it.
MR. SOONTHORNSIMA: But I think that needs to be part of our longer term.
DR. NICHOLS: I was really struck by Jim and Jim’s push to make it operational. And what I wondered is, if there is a way — we think about doing assessment of information needs. We might piggyback on what nonprofit hospitals have to produce now called community health needs assessments. Every nonprofit in the United States has to do its catchment area. And so therefore they have to produce precisely population health estimates of disparities and so forth, as best they can, with what they have got.
And I don’t know why we couldn’t just converge, and really pick some communities based upon those that are already out of the box. I am looking at Geisinger and guessing you all have already done yours. But there are some real hospitals that have done this for real for awhile. And it would be a natural thing to do, to say okay, here is the information you know exists.
MR. SCANLON: We could look at it firstly as maybe what the — this is an IRS Department, definitely.
DR. NICHOLS: And that would be filed by March of ’13. So half of them are done.
MR. SCANLON: This is part of the ACA. You will remember this. But it requires not for profit hospitals, largely, to prepare. I am not even sure if they have to submit it, but they have to prepare a community needs assessment. And there are some values there. And CDC has actually helped. I wonder if maybe we will get that guidance.
I don’t think it is as detailed as everyone would like. But I think some request for information, some guidance was prepared. That should be added to our resources. Now again, that may be a health care and health resources orientation, although it is not meant to be only. It could be population.
DR. WALKER: Just real quick, it does go beyond health care, but you are right, it would be limited. I think we absolutely ought to have that, but it won’t be everything we need.
DR. FRANCIS: It would be interesting to compare with what we think should be there.
MR. SCANLON: We will get the guidance that exists. It is the IRS, but I think that —
PARTICIPANT: It is referenced in our report.
DR. CARR: We have 10 minutes before our break. We haven’t heard from everyone so I will ask Judy and Walter, Paul and Jim to do it and then I am going to look to others around the room to make sure we have heard from all. So next up, Judy.
DR. WARREN: As I have been listening to the dialog a couple of things really hit me. When I think of population health, I think of an entity out there that has nothing to do with me. I am not involved in population health. It is a thing that the system is trying to get a handle on to decide what kind of services they think I need.
So I think we need to be careful with population health. As soon as you flip it to community, I am part of a community. I contribute to that, I live in that, that is who I am going to get support from in managing my own health. Whether it is from the formal health care association, whether it is from the Parks Department that gives me places to go, whether it makes my community safe so that I can actually go out and do things.
So I think that maybe we need to reconsider this whole wording and framing of population health. It may be time to move on. And that is what the learning community is telling us. This is an antiquated concept. It may have some of the same outcomes, but as we start getting into social networking I think people are changing the way that they can involve data.
The other thing that I wanted to bring up is years ago Linda and I had an opportunity — actually Linda provided me the opportunity — to participate in a scenario planning strategic meeting. And as I think about what we did for AHIMA at that point, it almost sounds like this activity could benefit from that.
And that is for us to come up with deciding what our preferred future would be. If we could have all the data we wanted, what would that be, where would it come from, how would we get there. And then I think we also created the worst possible situation and then kind of a middle ground. And it really helped us frame where we needed to go. Instead of really responding to things that we are hearing about coming down the pike, to identify some of those gaps.
And I found that to be a very powerful exercise. It is done relatively quickly. And I think at least for AHIMA I think it helped them save their organization. Because if they had continued on, I don’t think their organization would be in the position it is today.
DR. SUAREZ: I think one of the points I wanted to make as sort of the tension that we are seeing between individual and community. It is a health tension. Actually it is a good thing to have. But I am a matrix person. I keep thinking in terms of matrixes. If one can think of, there is individualized data for the individual, to help the individual support her or himself’s health, and to help empower them to improve their health. Individualized health for individuals.
There is individualized data for community. At the community level, getting individualized data to understand the community status of health. And then there is community level data that helps the individual make decisions about issues that affect their health. And then there is community level data that is directly related to the community. And when we say the community it means not just individuals but policymakers, decision makers, the community and all those things.
So I think it would be important to those perspectives in defining our area to focus on. Because there are a lot of organizations doing individualized level data to support individuals. That is a lot of what providers and the provider system and the health plans and others do. So that is, I think, the opportunity that I see, is consider in this two by two matrix, this concept of where is the area of focus for us.
DR. TANG: We all know that by 2030 one in five of us will be on or eligible for Medicare. There is an RWJ report that just came out that says about one in two of us will be obese, not just overweight. We also know that our medical technology, our medical interventions, maybe address 10 percent of the preventable mortality, and that behavioral is 40 percent. So I think communities are our ticket to individuals.
So what did the IOM say about obesity prevention in their recommendations? Make physical activity a routine part of life, create food and beverage environments to ensure that healthy food and beverage options are a routine and easy choice, transform messages about physical activity and nutrition, expand the role of health care providers in obesity prevention, makes schools a national focal point for obesity prevention.
I think that is the needs. We have the epidemic, we have the important priority. Everybody, the data says it, the Secretary says it, and we have some recommendations. Now that is the needs. Do we have the data to help us know where to go and how we are doing? That is in a sense the data requirements for addressing society’s epidemic.
I am not sure that we are to go and — it is sort of like, it is in front of us, let’s take advantage of it and do with it what we need to do, which is capture, manage and report on data that will make a difference.
PARTICIPANT: Several of the communities are working on obesity, that we talked to.
DR. CARR: Let’s give everyone an opportunity. I will start with Raj. We will go around the room with closing comments.
DR. CHANDERRAJ: I think that sitting through the hearings of the committee meeting, the most important factor to me at least was funding. Most of the community activities did not have enough funding to analyze the data they have. And unless we create that opportunity, either through private, corporate funding, just as Wal-Mart and other stores are now doing, providing health foods at a lower cost, at some of the downwind rates, these communities need money to analyze the data that would help them locally.
The second thing, what do we do? They have enough data already. I think the longer we discuss at these meetings, like Paul said, the data becomes staler. There is enough data already as to how to influence the health of a community, both by the Institute of Medicine and several epidemiological studies have shown what are the risk factors for disease processes. I think the data is already there. How we implement that data into providing better health to the community is what we need to focus on.
I don’t think we should have the government play a role in that, such as New York and New York City imposes regulations on the size of Pepsi or Diet Coke. And I think educationally, the communities, in trying to have a better community with the knowledge that we have gained from all the data that we already have — we don’t need to reinvent the wheel — I think the data is already there, we just have to implement it.
DR. COHEN: It was very interesting to listen to what Raj has to say. I have gone to lots of community meetings and I am the chief data geek and they say tell me what to do. Data don’t make decisions. Communities and individuals do. Having said that, in this particular information age we can add enormously to help individuals and communities understand what options are and get in touch with how to decide amongst priorities for how to make themselves individually and collectively healthier.
And I think this is an incredible opportunity for the national committee to move into this space, and to integrate a variety of things, both at the individual, clinical level, leveraging their expertise there, and at a broader public health level.
So I would like to see us, obviously, figure out how to do it and make it manageable. I think Jim’s comments were spot on. This could take us forever unless we organize it, and limit it. But I think it is the beginning of a process that could make a huge contribution.
DR. MAYS: One of the things that is emerging is this issue of the definition of community. Judy, as soon as you said that I was like oh, when you were like almost wanting to put population to the side and raise the notion of community health.
And then Walter also started doing definitions. And then yesterday, when we were in the privacy subcommittee working on the letter, the notion of what is the definition of community. It’s almost like that has to be I think now our first task.
Because as you refer back to the groups that came in, that is a whole different group. Those are really small entities quite often that represent a group that came together for a particular reason. I am not even sure the extent to which they are representative at the level of what we are trying to address. So our metrics are a little off.
I loved what you said. I am going to steal that from Lisa Simpson. I loved those stories. But then when we try and operate, we are operating at a very different level. So I think almost the first task has to be for us, maybe it is doing the kind of thing that you suggested in terms of strategic planning, but I think we have to decide what the community is for us in terms of the way we work, and where we want to have our impact. Which I think goes to then what is the portfolio for HHS.
Then I think the other thing is — and I want to put this back out there again — as we think about this part of what we keep doing is generating discussion. I think we have to also generate that guidance and help. And I really want to see us do these things like using technology to teach people about how to use their own data. We have to think about YouTube, and we have to think about the NCHS meeting sometimes, having a little training day for community people to use the data.
We keep training ourselves. But again, it is like, I am really going to say if we really want to take this community thing seriously, we have got to try and think, in terms of even our products, of translating them so that people are empowered. Yesterday, when we were doing our letter, there was this word help and it was bothering me.
I really wanted us to stay with empowering. It is not about us being in the middle of everything. It is about us giving things to people for them to then improve on them even. So I am hoping that this teaching component or training component can get raised in our thinking about a product piece for us as well.
DR. CARR: Referring back to our guiding principles yesterday and our stewardship, we have stewardship to each other — and to finish on time, and I see we have time later today to talk about next steps. It is such an important conversation we are not going to try and rush it. I will invite Bill or Jack. Did you want to make any comments?
MR. BURKE: I am intrigued somewhat by what Len described as using input from not for profits and the assessments that they do. My interest is in hearing from others already in the community being studied who are committed and accountable for improving the quality of care, whether it is decreasing the prevalence of disease or increasing functional status.
The primary care clinicians in that community, what do they see as obstacles, what do they see as opportunities? They have a lens into that community different from the other members of that community which is probably going to be very helpful. So I would like to figure out a way to bring that, even if it is only to ratify what other measures tell us, or what other observations suggest, to validate what they think needs to be done.
DR. CARR: I think this has been a phenomenal discussion. I actually think we should begin our day two meetings at 8:00 and do just like this with the full group. But of course I have no power. I am just saying that this is what we always say we need, the chance to exchange ideas and develop ideas.
So on that backdrop, I think when we get to the part of what next steps, that will be our chance to revisit this and think about how to organize this going forward. With that, let’s take a break and reconvene at 10:00.
(Whereupon, the session adjourned.)