[This transcript is unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

September 22, 2011

Embassy Row Hotel
2015 Massachusetts Avenue, Northwest
Washington, DC

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030
(703) 266-8402


P R O C E E D I N G S (10:00 a.m.)

Agenda Item: Call to Order

DR. CARR: Good morning. Welcome to Day 2 of the September meeting of the
National Committee of Vital and Health Statistics. I am Justine Carr, Stewart
Health Care System Chief Medical Officer, Chair of the Committee and no

MS. GREENBERG: Good morning. Marjorie Greenberg, from the National Center
for Health Statistics, CDC, and Executive Secretary to the Committee.

MS. MILAM: Sally Milam, West Virginia Health Care Authority, member of the
full Committee, Populations and Privacy, no conflicts.

MS. KLOSS: Linda Kloss, member of the full Committee and the Quality
Subcommittee, no conflicts.

DR. NICHOLS: Len Nichols, George Mason University, full Committee, Quality
Subcommittee, Population Subcommittee, no conflicts.

DR. COHEN: Bruce Cohen, Massachusetts Department of Public Health, Full
Committee, Population Health Subcommittee, no conflicts.

DR. SUAREZ: Walter Suarez, Kaiser Permanente, member of the Committee, on
several subcommittees. And no conflicts.

DR. WARREN: Judy Warren, University of Kansas School of Nursing, Member of
the Full Committee and the Standards Committee and Quality Committee, no

DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Research and
Quality, Liaison to the full Committee, Staff to the Subcommittee on Standards
and on Quality.

MS. SOONTHORNSIMA: Ob Soonthornsima, member of the Standards Committee and
full Committee, no conflicts.

DR. HORNBROOK: Mark Hornbrook, Kaiser Permanente, member of the full
Committee and the Population Subcommittee, no conflicts.

DR. BURKE: Jack Burke, Harvard Pilgrim Healthcare, member of the Privacy
Committee and the full Committee, no conflicts.

DR. MAYS: Vickie Mays, University of California Los Angeles, Member of the
full Committee and member of the Subcommittee on Populations and Privacy.

DR. MIDDLETON: Blackford Middleton, Partners Health Care, Harvard Medical
School, member of the full Committee, co-Chair of the Quality Subcommittee and
member of the Population Subcommittee, no conflicts.

DR. CHANDERRAJ: Raj Chanderraj, practicing physician, member of the full
Committee and member of the Standards Committee.

DR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the full
Committee, co-Chair of the Quality and member of the Privacy Committee.

DR. FRANCIS: Leslie Francis, University of Utah Law and Philosophy, Member
of the full Committee and co, I hope, Chair of the Privacy Subcommittee, member
of the Populations Committee, and I have no conflicts.

(Introductions around the room)

DR. CARR: A couple of announcements; first, I’m happy to announce that Linda
Kloss has graciously agreed to assume the role of Co-Chair to the Privacy
Subcommittee. I think that Linda has done significant work both through AHIMA
and very knowledgeable in the area, and will be a nice partner for Leslie, so
thank you, Linda.

Second, I want to remind folks that we hold, is it one Friday a month, from
3:30 to 5:00, the third Friday of the month, please put on your calendar a hold
for 3:30 to 5 p.m. We don’t often need it, but we keep it in place so we don’t
have to do so much searching for times for calls, Eastern time. Just put that
as a standing hold and if we’re not using it, fine, but at least we’ll have it

Also, I want to acknowledge a number of folks. Karen Trudel has been our
liaison for CMS, and she’s now moving into a different role at CMS and will not
be our liaison, but we want to thank her for her diligent efforts and insights
and support of the Committee. We welcome, as her successor, Robert Tagalicod,
who is now Director of eHealth Standards and Services, together with Lorraine,
who’s Deputy Director of OESS. So we’re really fortunate to be working with all
of you, yes.

MS. GREENBERG: And we’ll prepare a letter for Karen.

DR. CARR: Great. I want to also acknowledge a number of awards that just
keep rolling in to the Committee; Marjorie is going to be the recipient of the
NAHDO Elliot Stone Award for Excellence in Health Data Leadership. And as we
all know, that’s very well deserved, so Marjorie, congratulations. Some of us,
as we discussed yesterday, will be at that meeting.

I also want to acknowledge not only is the Committee being recognized for
leadership in technology by WEDI, but so is Lorraine, and extremely
well-deserved, so congratulations on that.

A couple of other little housekeeping things: I’d like to just get a clear
accounting of who is on which subcommittee, so we’ll have Linda joining the
Executive Subcommittee as a Co-Chair, and then as the Subcommittee on
Standards, I have Walter, Judy, myself, Raj, Bill Scanlon, Ob, Jim Walker. Did
I miss anybody? Is there anybody else who’s on Standards? Okay.

Next, on to Privacy. So Leslie and Linda, Jack Burke, Sally, Walter and Paul
Tang. Did I miss anybody else on Privacy? Vickie – okay.

Then moving onto Population Health. I have Larry Green, Sally, Jack, Bruce
Cone, Mark Hornbrook, Vickie, Blackford, Len Nichols and Walter, on Population,
and Leslie. Anybody else? No.

On Quality I have Blackford and Paul as Co-Chairs, then Larry Green, Linda,
Len, Bill Scanlon and Judy. Anybody else? Bruce, excellent. Mark Hornbrook.

Terrific. And then finally, when we spoke yesterday about the report to
Congress, I asked a couple of members to help put fresh eyes, read the report
and pull out the key points that we would want to put in an Executive Summary
introduction to Congress. So as we saw, the report is incredibly detailed and
rich, but we want to get a very compelling headline in the first three
paragraphs. So Ob has agreed to coordinate input, and Raj and Mark, Leslie and
Linda, have agreed to give input to that, so what I would like you to do is go
through that and find the salient points and let’s put them together. Ob,
you’ll then draft a kind of Executive Summary and then work with Judy and
Walter in terms of how that fits.

MS. SOONTHORNSIMA: Can you repeat the members again?

DR. CARR: It’s Linda and Leslie and Mark and Raj. The timing would be over
the course of the next week.

So on the plane, on the way home, take out those yellow markers and we’ll
get them, so that will be terrific, thanks very much.

At this point, turn it over to Walter and Judy and Lorraine.

Agenda Item: Standards Letters – ACTION

DR. SUAREZ: We’re going to bring back to you the three letters of
recommendations related to the administrative simplification provisions. The
first one is acknowledgments; this was the letter that we presented to you
yesterday, recommending the adoption of a standard for acknowledgments instead
of operating rules and requesting that this get moved fast in the regulatory
process. So the only change that we heard – two changes that we heard that
were recommended – the first one is, and I’m highlighting here the actual
recommendations of the letter, so the set of recommendations we didn’t change;
adopting the ASC X12, TA-1, 999 and 277 CA acknowledgment of transaction, the
standard transaction, and defining it as is noted in this section.

The second one is adopting the ASC X12 standard and corresponding
implementation guide, and then the third one is where the first change occurs
– define the conditions under which each of the acknowledgment
transactions will be expected to be used, and we said, on the second one, the
ASC X12, the ASC X12 999 implementation acknowledgment should be required as a
response to all HIPAA transactions, is what we had, and it was recommended to
change to all ASC X12 transactions, regardless of the submitter of the
transaction. That will be more consistent with the current practice and the
fact that if we say all HIPAA transactions, they will apply to pharmacy and
other sectors that do not do this, other transactions like the pharmacy
transactions that do not use 999. That was the first change.

And then the second change was on recommendation 1.8, where we had
originally considered excluding real-time transactions from the requirement of
using the acknowledgment standard, but as we heard, there are some instances
where industry trading partners doing real-time transactions do use the
acknowledgment, so the recommendation was to have a statement that says that if
those entities choose to do the acknowledgment transaction on real-time
transactions, then they should be required to use the standard adopted. So
that’s what we’re trying to say here, “Require the use of the recommended
acknowledgment standard for entities that choose to use electronic
acknowledgments in connection with real-time transactions.”

So this is not forcing everybody that is doing real-time transactions to do
acknowledgments; that’s very important to state. This is not forcing everyone
that is doing real-time transactions to use acknowledgments, this is requiring
that those that choose to do electronic acknowledgments when conducting
real-time transactions, to use the adopted standard.

Any comments or questions? I don’t know if Justine, you want to take each of
the letters and move for approval?

DR. CARR: Yes, why don’t we do it one at a time, so we can entertain a

DR. SUAREZ: I’ll move to get approval.

DR. CARR: To accept the letter as amended, and I think I saw Mark second.
Any further discussion? All in favor? Any opposed? Abstain? Passed. Thank you
very much. Next.

DR. SUAREZ: The next one is the letter on ICD-10 and 5010 before the hearing
about the current status of ICD-10 and 5010. There were two changes that were
considered; one was changing in the recommendations; so in the recommendations
related to Medicaid, we noted that HHS, to establish, communicate and enforce a
deadline, but there were concerns about the word “enforce”, so we
agreed to modify it to adhere. That was the main change. And it didn’t change
any of the other elements.

DR. FITZMAURICE: Could I suggest maybe adding a “to” to that
adhere to, a deadline?

DR. CARR: Walter, any other discussion, any other information?

DR. SUAREZ: Yes, there’s another change that we talked about during our
subcommittee. We have become aware of a situation that occurred because of
having the standards be named in different regulations. So, the HIPAA
regulations name 4010 as a version when everybody’s using 4010, and now
everybody is going to move to 5010 because HIPAA regulations call for the move
to it.

Well it happened that the e-prescribing regulations that were adopted in
2005, and then in 2008, actually codified there as well that, when conducting
remittance advices electronically, that entities are required to use the ASC
X12 835, version 4010. And they codify that in the regulation of e-prescribing,
and that was never updated, and so we are faced with, on January 1, adopting
5010 and starting implementing 5010, and then, for transaction-related
e-prescribing, the rules still say 4010. So there is already work being done;
CMS is on top of it, and moving quickly to try to adjust that rule on
e-prescribing, to make sure that it says 5010 instead of 4010, but we thought
it would be helpful to emphasize that point in our letter, and so we added this
following statement:

“NCVHS has become aware that current e-prescribing regulations require
the use of an ASC X12 and 835 version 4010 standard, and that this has not been
updated to conform with the requirement to use the new version 5010. So the
recommendation is HHS should expedite the process for modifying the
e-prescribing regulations to conform with the national requirement to move to
the 5010 version for all administrative transactions naming the regulations, so
that by January 1, 2012, the industry does not have to use two different
versions of the standard for the same transaction.”

DR. CARR: Is there anywhere else that this could be? That’s a great point.

MS. DOO: Not that we know of. There’s just that one inconsistency because of
the timing of the regulation.

DR. WARREN: There is some concern from NCPDP that this is not true –

MS. GILBERTSON: It’s just a clarification. It’s not to move to the 5010
version; the e-prescribing regulations name the Telecommunications Standard 51
and the X12 standard 4010s. So it would be – the 5010 version is just only one
piece of the request; so it’s the national requirement to move to the new
version, or however you want to say it, it’s not just X12 5010. And CMS is well
aware of all this, it’s just I want it to be clear that it’s just not 5010.

DR. SUAREZ: Clear that it’s not eliminated, good point, thank you. The
national requirement to move the name for the X12 standard naming that
regulation to the 5010 version.

MS. GILBERTSON: Perhaps it’s just easier to say, to move to the named
standards in the regulation, and that’s both NCPDP and X12.

DR. CARR: Okay, Walter, anything else? Do I hear a motion to approve? Judy
moves, Sally seconds. Any discussion?

MS. MILAM: Isn’t that standard plural?

DR. CARR: Are we ready to – Walter?

DR. SUAREZ: I will edit it to make sure that it reads correctly, I just
don’t want to –

DR. CARR: Lynn can look at it, yes, we don’t have to watch you type. All in
favor? Any opposed? Any abstentions? Unanimous. Thank you very much. Do you
have something else for us?

DR. SUAREZ: One more. We have a letter with observations on the standards
and operating rules, maintenance process. We reviewed it with the Committee
yesterday. There were no changes recommended, so we’re requesting approval of
that letter as well. So I move to have the Committee approve the letter on
observations on the standards and operating rules maintenance process.

DR. CARR: What tab was that in? Four. Okay. And we did review this –

DR. SUAREZ: We reviewed it yesterday. It’s a letter with observations on the
– we note – there’s no recommendations, and we note in the letter at
the end that we are going to be holding hearings later this year to continue
the discussion and to develop recommendations.

DR. CARR: We were asked to render these observations?

DR. SUAREZ: In the Affordable Care Act, we are asked to review periodically,
actually, the process and the adoption of the standards, and so this is our
first step, really, in that process.

DR. CARR: So did I hear a motion to approve? Walter, and second, Judy. Any
discussion? All in favor? Aye. Any opposed? None. Any abstentions? None.
Unanimously passed, excellent, thank you.

MS. GREENBERG: The next item on the ANPRM, on the response to the ANPRM, are
you going to address that next?

DR. SUAREZ: Yes, thank you. Well this is not a Standards Subcommittee
activity, really, it’s more – this is not coming from the Standards
Subcommittee. This is a Committee activity.

DR. CARR: Let me just make a clarification; our agenda says that at 11:30
– we’re ahead of ourselves – So what we want to do now is talk about the
draft letter on metadata in response to the ANPRM from ONC.

DR. WARREN: We’ve deferred the discussion on the primer until the November
meeting. So we have time.

DR. CARR: Although we could preview – depending on how long this
discussion goes. So what would be helpful, I think, with regard to the letter,
is just a little overview of what the ANPRM is asking for, why we’re responding
and what is the basis for our response. Is it based on previous work of the
committee, previous letters, previous hearings or discussions? Just want to be
clear on how the voice of the Committee is being represented and that it is
uniformly the voice of the Committee.

Agenda Item: ANPRM Letter

DR. SUAREZ: I’ll take it. I offered to help this – one of the Committee
calls, I think it was the Executive Committee call, we thought it was going to
be very important to provide some comments on this ANPRM, and –

MS. GREENBERG: I think it was actually during the open call in which we
approved the letter on the PCAST report, and acknowledged that during that
process of our writing that letter, there’s now been an ANPRM –

DR. CARR: So everybody has a copy at their desk. Do we have a copy we could
put up on the screen?

DR. SUAREZ: So the background, to answer your point, Justine, the background
first and then we’ll talk about the source of the comments and how we organize
these comments. The ANPRM basically is about metadata standards, and it follows
pretty much as a next step of activities and actions from the PCAST report. The
PCAST report calls for the use of metadata, and the Policy Committee
identified, as well as the Standards Committee identified, a series of areas
where this metadata could begin to be tested. The Standards Committee, the HIT
Standards Committee, also made a few other comments regarding the steps, and
we’re citing a few of them here.

The rule itself, the Advance Notice of Proposed Rule, included a description
of the whole process that PCAST report, the recommendations on the PCAST report
regarding the metadata, the recommendations from the Policy Committee and the
response from the Policy Committee to the PCAST report, then the work that the
HIT standards committee metadata power team did during the summer; during the
summer, the Standards Committee created one of the power teams and was focusing
on metadata, and that was to look at what can be done with respect to adopting
standards for metadata used, along the lines of the recommendations of, again,
the PCAST report as well as the Policy Committee.

So the proposed rule, and it’s at the bottom of the first page, focuses on
three categories of metadata. Patient identity, and it describes the minimum
necessary data required to uniquely select the patient from a population with a
guaranteed degree of accuracy, that’s a first use case. The second one is
provenance; the minimum data element required to document the history, origin
and modifications of the data, which the metadata is about, and then the third
is privacy, the minimum data to document and transmit the data type,
sensitivity and patient privacy preferences about the sharing of his or her
information. So those were the three areas that are consistent with the
recommendation for the Policy Committee and the Standards Committee, of areas
that should be the focus of this initial proposed rule.

On the second page, we state at the top of the page that a few other summary
items, that the ANPRM is also considering the adoption of these standards in
support of Stage 2 of the meaningful use program, and establishing
certification criteria for EHRs to be capable of applying the metadata
standards for stage 2. So it’s not only defining what are the standards, the
proposed rule, for these three areas, but also recommending, or looking at
recommending, adoption of this to be used in connection with the Stage 2 of
meaningful use. And to use it in the certification of electronic health

So those are two aspects of this ANPRM that are important. Further define
the standard and then recommend to move it into Stage 2 and adopt it in
certification. The ANPRM argues that this metadata tagging capability may also
be applied to other directed transfers of health information, and looking
forward, the health care industry could gradually develop innovative ways to
repurpose this capability, to be applied to specialized sections to meet future
policy and organizational objectives.

So this is sort of a summary of some of the key points of the ANPRM. So we
start with some statements. Now to answer to your second question, Justine,
most of, if not all of, what we say in this letter tracks back to the main
document that we used, which is the PCAST report letter of recommendations,
observations and recommendations. So that is the main source of most of these
comments. The second point that is important to keep in mind is, we’re not
making recommendations in this letter. We’re staying away from the word, even,
recommendations. We’re making observations and providing our perspectives on
this. We can edit it – Page three has the word? I missed it. Okay. So it’s
important to avoid that and turn that into observations.

DR. TANG: It says do not –

DR. CARR: The way it’s written, it says do not incorporate, do not adopt
– the recommendations, there’s four, on top of page three, and they’re
written in language that looks like recommendations.

DR. TANG: And they’re not bad ones.

DR. SUAREZ: It’s important to note, when this was being drafted, the
recommendations, I wrote them, basically, and we discussed them, basically, as
conceptual recommendations. This wasn’t to be the actual wording of the
recommendations; we just never got to update the wording itself, but we can
talk about that.

DR. FRANCIS: Since these are comments, we don’t need to have the
recommendation form, we can make comments that reach conclusions, but this
isn’t a letter addressed to the Secretary, and that’s why we typically have the
bulleted –

MS. GREENBERG: So can we call them conclusions instead of recommendations?

DR. COHEN: Why can’t we call them recommendations?

DR. FRANCIS: We can. It’s just often not done that way in comments on –

DR. CARR: Let’s get the concept down; what are we saying, why are we saying
it, and then we’ll decide.

DR. SUAREZ: I’m still kind of on Page 2, but I realize that when I say we’re
not making recommendations, I see recommendations; I made a mistake there, so
I’m sorry for that. We’ll talk about that.

MS. GREENBERG: We should note that these comments are due tomorrow.

DR. SUAREZ: At the end of day tomorrow.

MS. GREENBERG: There’s no opportunity to leave this meeting and finalize the
letter, we’ve really got to redo it today.

DR. SUAREZ: That is if we want to submit these comments as comments to ONC
in response to the ANPRM. We, as a Committee that reports directly to the
Secretary, we can have recommendations next week if we wanted to –

MS. GREENBERG: You can make recommendations any time you want –

DR. CARR: But I think that we want to redeem ourselves in terms of our
capacity to adhere to timely timelines, and therefore I’d like to see us get a
letter out in response today.

DR. SUAREZ: So getting to the comments, we organized the comments into two
areas, basically; one is the overall regulatory approach, and then we had a
separate area for scope priority and recommended standards. Those are the two
areas in which we organized the comments and the recommendations. So the first
area, the overall regulatory approach.

We stated we believe the adoption of a series of standards for metadata
tagging via formal regulations is premature, and contrary to the process of
first testing and demonstrating how such standards, and the technical
assumptions that go along with them, will actually work.

DR. CARR: Because this is us all together for the first time, are we in
agreement with that statement? Okay. Next sentence.

DR. SUAREZ: We are concerned that the proposed standards, while they might
be appropriate in content, are not mature enough to: 1. Be formally adopted as
new national standards; and 2. Be required to be implemented as part of the
meaningful use program.

DR. CARR: Okay. Any objections to that? No. Three –

DR. SUAREZ: In this regard, we strongly agree with the conclusions reached
by the HIT Standards Committee, that the overall metadata tagging technology
approach, and, specifically, the standards to be used, be thoroughly tested and
evaluated prior to proposing these standards for adoption through regulation.
This is actually a quote from the regulations – the Standards Committee
made that statement.

DR. CARR: And we’re saying we agree with that. Any objections?

DR. SUAREZ: The ANPRM only mentions once, and in a very brief passing form,
ONC’s intent to “seek pilot testing of the metadata standard to gain
insights into any implementation level challenges that may exist”. This
goes against the concept of adopting, by regulation, new standards that have
not been fully vetted, thoroughly tested and widely accepted by the industry
with at least some implementation demonstration already underway.

DR. CARR: Any comments?

MS. GREENBERG: I think this is a double negative; it needs to be “this
goes against the concept of not adopting by regulation…” new
standards that have not been fully vetted.

DR. TANG: This goes against the concept – the concept is to –

MS. GREENBERG: Or you could say, if you don’t want to be too negative,
negative, negative, this goes against the concept of adopting, by regulation,
new standards that have been fully vetted, thoroughly tested –

DR. CARR: I think stating it in the positive, this goes against the concept
of adopting, by regulation, new standards – or maybe it’s by only adopting

MS. GREENBERG: Sometimes things are adopted that haven’t been fully vetted,
thoroughly tested and widely accepted by the industry. So I don’t think we
should – this can’t be an absolute.

DR. CARR: This goes against the concept –

MS. GREENBERG: Of adopting, by regulation, new standards that have been
fully vetted, thoroughly tested and widely accepted by the industry with at
least some implementation and demonstrations already underway.

DR. TANG: But that’s not exactly saying, they don’t seek to adopt everything
that is – but you would not want to adopt something before it is tested,
that’s the point –

MS. GREENBERG: I think this is a little bit too – I’d say this goes
against the concept of fully testing and vetting new standards before they are
adopted by regulations.

DR. TANG: Maybe what we’re shooting for is the spirit or intent. So in order
to avoid unintended consequences, you would not want to adopt things that are
completely new without first testing it. So that gives the – why would you
want to test something? When you’re promulgating widespread regulation, you
would not want to adopt new approaches, or new technologies, before testing it.

DR. CARR: Is it a concept or is it a practice? This goes against the
practice of first testing and vetting proposed standards before adopting by

DR. TANG: It’s going against their intent; I think that was – so they
would not intend to adopt new technology without testing. It’s not a concept.

MS. GREENBERG: This is contrary to the practice of –

DR. CARR: The practice. It goes against the practice of first testing and
vetting before proposing a regulation.

MS. GREENBERG: New standards; before adopting new standards.

DR. SUAREZ: How about this: This is contrary to the practice of adopting by
regulation new standards that have been fully vetted, thoroughly tested and
widely accepted.

DR. CARR: I think it gets confusing, because really, the practice is that
you test and then you adopt, so I would put it that way, this goes against the
practice, this is contrary to the practice of first testing and vetting new
standards before adopting by regulation. And that shortens it.

DR. SUAREZ: Then we say we also concur with the concerns expressed by many
commenters to the PCAST report regarding the timing of adoption of these
recommendations, in the midst of meaningful use stage 1, preparation for
meaningful use stage 2, implementation, regional health information exchanges,
the transition to ICD-10 process, the implementation of new HIPAA standards and
operating rules and the move toward new forms of health care delivery and
financing under the Affordable Care Act – the industry would not be in a
position to incorporate, test, implement and carry on with the many policy,
legal and liability implications that the use of metadata tagging will bring

DR. CARR: So are we really in a position to say “will not be in a
position” or “may not be in a position” or “would find it
challenging to”?

DR. TANG: One of the concerns of implementing – I’m trying to get the
word – one of the concerns in the industry of implementing a large number
of initiatives at the same time is their inability to do that successfully. And
your concept is, do you really want to add yet another unproven, or not yet
tested, technology to that mix? That kind of an approach.

DR. CHANDERRAJ: I think the word is challenging –.

DR. TANG: Or actually risk. So the point we’re having is, it’s risky to do
all this stuff and do we want to add on to that?

DR. CARR: So maybe we begin with “implementation of – would pose a
challenge and a risk”

DR. SUAREZ: In the midst of implementing –

MS. GREENBERG: Can you tell me where you are?

DR. CARR: Recommendations. There’s actually a very long sentence, first
sentence, we also concur, the next is in the midst.

DR. TANG: One of the main concerns expressed by many commenters to the PCAST
report is the timing of the document’s recommendations. Then you say – the
concern revolves around –

DR. CARR: How about incorporating, testing and implementing these –
what are we calling them, this –

DR. SUAREZ: I think what Paul was talking about was implemented and proven,
or untested –

DR. TANG: Not yet tested.

DR. CARR: Even if they were tested, it would be a challenge.

DR. TANG: That’s correct. We’re just trying to say, we have a number of
initiatives, a number of deadlines, coming up that are already CMS programs,
and that has been challenging to the industry and creates a certain amount of
risk to patient care. In that context, we would not want to add yet to be
tested new technology to that mix. Something like that.

DR. CARR: So introducing untested new standards – introducing yet to be
tested new standards in the midst of ongoing initiatives, including meaningful
use, et cetera, would pose –

DR. TANG: Additional risk.

DR. CARR: Why don’t we say, introducing yet to be tested standards poses a
significant risk due to the competing agenda of ongoing –

DR. TANG: That’s where I think you made the sentence – I mean, that’s
how the sentence got so long, too many things in the sentence. So set up,
people are busy doing some very important things with a deadline. We shouldn’t
add new –

DR. CHANDERRAJ: How about breaking that sentence into two parts, rather than
the second line that says “in the midst of meaningful use, the industry is
already involved in implementation of meaningful use, preparation for
meaningful use” and break that sentence at the Affordable Care Act, and
then start another sentence?

DR. CARR: Industry and providers are currently focused on a number of
time-sensitive initiatives, so industry and providers are currently focused on
a number of time-sensitive initiatives. And then we say introducing yet –

MS. GREENBERG: Do you want to mention which these are?

DR. CARR: Yes, as they are, including, there you go, and take out in the
midst. Including those, and then go down to code sets, operating rules, health
care delivery finance under Affordable Care Act. Period –

DR. TANG: I might take out implementation of regional health information
change, because that’s not falling on the providers.

DR. CARR: Industry and providers. Okay, take out implementation of regional
health information change –

DR. SUAREZ: No need to pile up everything –

DR. CARR: Transition to ICD-10, new HIPAA standards, operating rules and the
move toward new forms of health care delivery and financing under the
Affordable Care Act.

DR. SUAREZ: I would also – the transition to 5010, D.0 and ICD-10
causes –

MS. GREENBERG: We are taking out preparation for meaningful use Stage 2.
What are we taking out?

DR. SUAREZ: Implementation of –

DR. CARR: Regional health information exchanges.

DR. SUAREZ: Regional health information exchanges, that one.

DR. CARR: But I would put implementation of 5010, D.0 –

DR. SUAREZ: Implementation of 5010 and D.0 and the transition to ICD-10
– and 3.0 –

DR. CARR: And then period after Affordable Care Act. Marjorie, if you don’t
quite have it, I think we can come back and get to it. So the next sentence
then would say introducing a yet-untested new standard would pose significant
challenge and risk.

DR. HORNBROOK: Question for clarification; I thought metadata tags were
universal. Computers and programs attach metadata tags to any packet of data
that’s transmitted and operated on; it needs to know where it goes in the
memory, it needs to know where it came from, it needs to know what it’s
sending, Oracle puts on metadata tags, SAS puts on metadata tags, I thought
this regulation, then, was meant to regulate a practice that’s already ongoing,
not instigate a new practice. Am I wrong, am I misunderstanding things?

DR. WARREN: If you look at the tags that are in CDA documents, they tell you
specifically where to go look, so if you have two independent bodies adding
meta tags, they could add metatags that address the same thing differently, so
then you wouldn’t be able to match them up and aggregate them, and that’s what
we’re trying to get out. There’s nobody out there that is harmonizing metatags.

DR. HORNBROOK: Do we want to slow down on this regulation?

DR. NICHOLS: Can I jump in here, because I just feel like – I’m clearly
the least knowledgeable human being about what this is about, but I just want
to ask, what are we afraid of? And what happens to the meaningful use tool if
we pile on and say enough already, don’t do this? Are we – what are we
afraid of, what am I missing?

DR. WARREN: Starting over. We have standardized terminologies, we’re working
on standardized data elements, if we go to metatags we’ll throw all that out
and go to metatags, and start over with trying to agree which ones are the
metatags everybody will use. And that’s very simple.

DR. SUAREZ: And then the biggest concern is this, to be blunt. You don’t
regulate something that you don’t know what it is. You don’t create regulations
on something that is untested or yet to be tested or is something that
conceptually could work but we don’t know; nobody has done any of what is said
in the regulations at this point in health care.

DR. NICHOLS: So this is a gross overreach of what –

DR. SUAREZ: What we’re saying in the first paragraph – we believe that
this is premature, to start with regulations on something that is not yet even
implemented in health care at all. That’s the main point, really. Two years
from now, when the industry, when we have CDAs moving, actually flowing, and
when we see that this can be now tested to see if we tag a CDA with the
provenance and with the patient identity and with privacy, even, then we can
look for the establishment of some regulations to ensure that everybody uses
the same, and does it the same way. But in the midst of starting to do
messaging with CDA, trying to force untested or yet to be tested methods to
tag, it will unravel into something we don’t even know. So that’s the concern.

DR. BURKE: I think it’s better said later on in the letter, what our fear
would be is the technology is driving the policy rather than the normal course
of events, that’s the fear.

MS. KLOSS: To Mark’s point, on page 2, the second paragraph, I was a little
uneasy about, because metadata tagging is standard information practice, to
call it a promising new technology. I think this is really an application of a
technology rather than a new technology; it’s standardizing a certain set of
tag specifications for this use case – am I correct?

DR. TANG: So could we call it a new approach or even new architecture for
exchange of information? Architecture – because it has such far-reaching
implications on the current –

DR. CARR: What line are you talking about, what page two?

DR. SUAREZ: Page two, second paragraph.

DR. CARR: “We believe that the metadata approach to document and tag
certain characteristics of the data being exchanged is a promising aspect

DR. SUAREZ: New implication of a technology –

DR. FRANCIS: Just take out new.

DR. SUAREZ: The new implication of the technology in health care.

DR. CARR: You could just say, has the potential to – take out is a
promising new technology that – we don’t give it a name, we just say to
document and tag certain characteristics of the data being exchanged has the
potential to increase – so just take out is a promising new technology

MS. KLOSS: Because I think, as a Committee, we look at this as something
down the road that’s very aligned with our vision of information integrity and
standardization and interoperability, but this rush to apply it to a certain
document –

DR. CARR: To be clear then, there are metadata tags that could be
proprietary and are not aligned, and our concern is the lack of alignment will
lead to chaos down the road, so where do we need to be saying that?

MS. GREENBERG: Do you want to say we also believe in standardized metadata
tagging, to increase the interoperability –

DR. CARR: Yes, that’s a good one. We believe that standardized metadata –

DR. TANG: Correct. And then we could follow that down with we currently do
not have standard metatags; it’s a cart-horse kind of problem.

DR. CARR: So the second paragraph will say, we believe that a standardized,
a standardized metadata approach to document tag – that has the potential
to increase the reliability, dependability and trustworthiness of health
information exchange electronically. Then we go on to say we also believe that
metadata tagging can increase the interoperability of health information
exchanges by including metadata descriptions about the data being exchanged.
And the next paragraph, it says however, but really the however is currently,
there is no standardization. There are metadata tags, but they are not

DR. TANG: There are tags being used the way that they’re proposing, so I
almost would lump it in one sentence by saying, although metadata tags could
plot, there are currently no – this approach is not in current use and
there are no standard metadata tags.

DR. CARR: So where does that go, before this first or second sentence?

DR. TANG: You said, metadata tags could be useful.

DR. CARR: What he’s saying is, in the first sentence to say although, begin
with although – what?

DR. TANG: Use of standardized metadata tags could improve the
interoperability of data exchange, this approach is not in current use, and
there are no standard metadata tags. So there’s two points to that. Therefore,
the approach of pilot testing this approach is very reasonable. And then we
come up with the –

DR. CARR: She’s working on the introductory paragraph too – are you
talking about the specific – where are you in the document? Okay, so you
start it by saying although this approach is not in current use and there are
no standards for metadata tags?

DR. TANG: Start with the good thing. Although use of standardized metadata
tagging can improve interoperable data exchange –

MS. KLOSS: Marjorie, if you look at the last sentence, it has the language
that he wants after although. Look at the last sentence of that paragraph; that
has the language that he wants to move up.

DR. CARR: So that allows us to frame the challenge early on in the
discussion. So while Paul wordsmiths that, could we bring our attention back to
the top of page three, and with that framing – Linda?

MS. KLOSS: Can I raise one other framing question? I’m second to you in
terms of being the dumbest person at the table on this. But in the ideal,
wouldn’t we argue for metadata tagging at the data element level and not at the
document level? Isn’t this approach one that would need redo?

DR. SUAREZ: This approach doesn’t prevent the next step, which is going from
document to data. It does not, it just starts with document level. You can tag
and you can start tagging at the document level; later, when things are more
mature, you can begin tagging at the data element level, but there are
questions still about the appropriateness of tagging at the data element level
for certain things without appropriate context. That’s part of the argument we

DR. CARR: We’ll see what the wordsmithing is on the paragraph on the top of
page three. Next question, for us to keep moving this along, is – we have
four recommendations. So let’s look at those and say do we agree, and then
let’s entertain whether we call them considerations or recommendations.

DR. SUAREZ: If anything, the standards should be adopted only for testing
and demonstration projects, and in reality, you don’t need to adopt standards
in regulations to do testing and demonstration.

DR. CARR: So is adopt the right word?

DR. SUAREZ: No. I think it’s recommend the use of standards for testing and

DR. CARR: Test standards in demonstration projects.

DR. SUAREZ: Test standards.

DR. CARR: Test draft standards in demonstration projects.

DR. SUAREZ: Perfect, yes.

DR. CARR: Next one. Include in the NPRM the parameters, metrics and outcomes
for pilots and demonstration projects. Reasonable. Any objection there?

DR. FRANCIS: I’m not entirely clear what that means. Would that mean we
would be saying by rule that demonstration projects need to – it doesn’t
make sense.

DR. SUAREZ: One position, which is the first one, test the recommended
standard or the draft standards in demonstration projects, pushes the question
to are we saying withhold completely this NPRM, because there’s no reason to do
it, you need to test first, and then just not reference the second one; the
second bullet would be define parameters, metrics and outcomes for pilots and
demonstration projects.

DR. CARR: Articulate the performance expected from the pilots.

MS. KLOSS: Those two could be combined into one bullet.

DR. CARR: We are just doing a concept, we are on the recommendations at the
top of page three, but we’re kind of doing concept first and then we’ll get the
language. So do we want to combine them?

DR. SUAREZ: The question whether the first bullet should actually be more
explicit to say do not move forward with the publishing of an NPRM. That’s the
first question, because if we go that fast, then –

DR. CARR: Do not move forward – how do you want to say it, Walter? But
that is what we’ve been saying, right? Do not move forward with this?

PARTICIPANT: You’re advocating a delay?

DR. SUAREZ: We would be advocating for withholding – that might be the
– withhold the –

MS. GREENBERG: – NPRM until the standards have been tested –

DR. TANG: There are two approaches. One is to convert this NPRM into one
that is proposing standards, or proposing to develop standards. That might be
more of a positive way to say stop. So what we were building up is – our
rationale is, it is promising but new and untested, and we have lack of
standards, therefore it would be premature to create a final rule around this.
However, it would not be premature to propose to develop standards. So do you
think – hey, we’re working on standards with metatags, do you think that’s
a good idea; then you get feedback and then you go do something.

DR. COHEN: So we should say focus the NPRM on testing these standards –
developing and testing these standards, before –

DR. TANG: Then it’s no longer a rule.

DR. SUAREZ: But you don’t need an NPRM for that.

DR. CARR: Are we saying instead of putting standards in an NPRM?-

DR. TANG: We are probably saying what you said before, which is the activity
to be undertaken is to test out a new technology, which requires standards, and
we really aren’t saying to put in place an architecture that this ANPRM
proposed to do. So that is consistent with what you said, which is –

DR. CARR: Test draft standards and demonstration projects; before issuing?

DR. TANG: We just need to find a better way to say it.

DR. CHANDERRAJ: How about saying the proposed development of standards,
testing and then implementing it?

MS. KLOSS: That doesn’t speak to the NPRM.

DR. CARR: Let’s get our concepts down. I’m cognizant of the time; we are
going to get this done today. So the concept is, test draft standards in
demonstration projects before issuing an NPRM. We’ll come back to how we are
going to say that. Then we go onto the third bullet, do not incorporate into
meaningful use stage two.

DR. COHEN: I never saw that in the ANPRM, so I don’t think it’s an issue.

DR. SUAREZ: It is the objective of the ANPRM.

DR. COHEN: To incorporate into stage two?

DR. SUAREZ: And to create certification criteria. It is actually explicitly
stated in the NPRM to do that.

DR. CARR: So our points are: Do not incorporate into meaningful use stage
two and do not create certification –

MS. GREENBERG: Do not incorporate what? Metadata tagging?


DR. CHANDERRAJ: Three and four can be combined into one, right?

DR. CARR: So we want to say do not incorporate metadata tagging into
meaningful use stage two?

DR. FITZMAURICE: Justine, might I suggest to incorporate mandatory metadata
tagging? Because it might allow for the possibility.

DR. CARR: Do not incorporate mandatory metadata tagging into meaningful use
stage two.

MS. GREENBERG: Is this parenthetical here?

DR. CARR: No, we don’t need that, do we?

DR. TANG: I think we’re just trying to say what does this mean, it says
don’t create a measurement –

DR. SUAREZ: No, we don’t need the parens.

DR. CARR: And then do not create certification criteria for EHRs based on
the proposed standards until they have been thoroughly tested, demonstrated and
evaluated. So we still want to say that, we may want to say it a little bit –

DR. TANG: Otherwise it gets put in; that would cause the industry –

DR. SUAREZ: So the second part is the scope; priority areas and recommended
standards. This is a little longer because there are three priority areas. We
can review at the end, there’s only one recommendation, but there are some
things in that –

DR. CARR: Let’s start with the end recommendation, to see if we agree with
that, and then we can get back to the understanding. So the end recommendation
says, emphasize the need for ONC to first explore the feasibility of such a
system through pilot and demonstration projects and develop a policy framework,
including governance, privacy and security, before considering adopting and
requiring the use of privacy metadata tagging standards.

Now is there overlap with what we just were saying?

DR. TANG: We’re in a different – one they were talking about the whole
architecture and metadata tags, and now they also put a statement about use of
this in controlling the accessibility, the privacy of data. And we’re making a
separate comment.

DR. CARR: The first one was about the architecture?

DR. TANG: The second one was about the use of this architecture as a –

DR. CARR: I think that’s helpful in getting how we might say this a little
differently, to align with how the first recommendation reads.

DR. TANG: We’re trying to make a separate policy statement in the second
one, I think.

DR. COHEN: So Walter, was this last recommendation intended just for the

DR. SUAREZ: This recommendation is in the context of the privacy metadata
tagging only, because that’s where –

DR. COHEN: But there weren’t similar recommendations around identity and

DR. SUAREZ: No, we didn’t include any specific recommendations on the
patient identity and provenance; we made observations, for the most part.

DR. COHEN: So to me it seems like either there should be one for each, or
this should be a general recommendation that covers all three.

DR. SUAREZ: That’s why it might be helpful first to go through those and
then decide what recommendations. So we’re going back to page 3, scope. I’m
going to read very quickly here.

The ANPRM specifically states that the media scope is the association of
metadata with a summary of care record, or more precisely, the instance where
the patient obtains a summary of care record from health care providers,
electronic health record, or requests that the summary of care record be
transmitted to the personal health record. That’s specifically the use case
that they are trying to address with these proposed rules.

MS. KLOSS: Did anyone else question – we probably don’t want to go
there, but – it seemed like a limited, a not greatly used use case. Would
that even be a good test of this? We’d do a lot of work, and then have a use
case that is specifically limited to patient-requested summaries, when we know
that’s not a huge – there’s not a huge demand. So I don’t know if we care
to, but if we’re going to say test it, we may want to raise the use case

DR. CARR: We have recommendations admixed with background here, and I think
it’s important for us, in our fifteen minutes that remain, to say what is it
that we want to recommend with regard to these provenance areas.

DR. TANG: Maybe one of the reasons that privacy is being called up is that
it is – we have written specifically on this issue and had specific
recommendations about the scope, all in segmentation. And so this is
inconsistent with that, and we want to provide information for why we think it
is premature to go to this level of granularity.

DR. CARR: So should we really focus on privacy and our comment, and then we
can add there, if we have other recommendations on these other two. I just
think the way it’s set up, it sets an expectation of a recommendation, and then
there isn’t one.

DR. FRANCIS: Justine, I actually think it makes sense to read all the way
through, because there’s an unclarity in the ANPRM which this calls out, which
is whether it’s really meant to be at the document level, and I think you have
to have that to understand what comes later.

DR. CARR: But again, I think at this juncture, before we get into the
wordsmithing, I’m looking for the concept; what is it that we are trying, what,
for the most knowledgeable among us about this, what are the two or three
things that we feel we need to say? So something we need to say is that you
need to be clear about whether what you’re proposing is metatagging at the
document level for a certain use case, or metatagging at the data element
level, and the ANPRM doesn’t make that clear the way a lot of people read it.

DR. TANG: But we have already indication, since they have the data
segmentation, I don’t know whether it’s called –

DR. SUAREZ: Data segmentation.

DR. TANG: Is it in ANPRM as well?

DR. SUAREZ: No, standards and interpretability initiative.

DR. TANG: So we have that juxtaposition that says hey, there is intent
somewhere to go directly to the data, so we need to make clear what our
previous conclusion was, in recommendations.

DR. FRANCIS: But that suggests distinguishing at the beginning, as we’re
starting out on this, that a scope question is, is this about document or data
element? That’s all. I don’t want to derail us, but I think it makes sense to
read all the way through to decide whether we want to move this.

MS. GREENBERG: So what I was saying was, after stating what the scope seems
to be, that I moved up this paragraph, if I’m hearing Leslie correct, and I
agree with her, in any event, that there’s some confusion whether this is, the
focus is, at the document level, or the granular data level, and then we
actually say here, and I don’t know if you want that as a recommendation, but
we say here, we strongly recommend clarification of this point, in, I would
say, any proposed rule.

DR. CARR: And then do we draw upon our previous –

MS. GREENBERG: We further recommend that any proposed regulations must at
this time be clear and unambiguous about applying only to document level
tagging, as we do not believe data element tagging is appropriate and mature
enough. I don’t know if we need this statement here?

DR. CARR: I think we need to shorten this letter so that we only say what we
need them to hear. We don’t have time to do all the background.

DR. TANG: Then let’s just do the positive. We understand that there’s an
interest in using data tags in the privacy domain, and this is our

DR. WARREN: I think the last two sentences that Marjorie read were
recommendations, and were phrased that way. Let’s call them out right where
they are, put them on bullets.

DR. CARR: So there is interest in using metadata tagging in privacy –

DR. TANG: To control privacy. And we’ve written on this subject, we
recommend the following.

DR. CARR: We have written on this in our letter of last week –

DR. WARREN: There is a second one there, Marjorie, a second we recommend.
See at the end of the line? That we further recommend, the end of the line
you’re on?

DR. CARR: Okay, there’s an interest in using metadata tagging to control
privacy. We have written on this in our previous letter to the Secretary in
August. We recommend – and just go to that and take out all the background
so that we don’t –

DR. TANG: Instead of saying there is an interest, the ANPRM proposes to
– because there’s more than an interest.

DR. CARR: Yes, ANPRM proposes to use metadata tagging for privacy.

DR. FRANCIS: What’s happening to the comments about the overall syntax and
format standard that came before, and about patient identity and provenance?

DR. SUAREZ: We haven’t gotten to that. We’re still on page three.

DR. CARR: We are just going to take this letter as far as we can, so the
more efficient and focused we can be, the more we’ll include in the letter. The
letter has got to get done by 11:35 and a half.

The ANPRM proposes to use metadata tagging for privacy. We have written on
this in our letter to the Secretary in August of whatever. We recommend –

DR. WARREN: The recommendations are in that paragraph, so if Marjorie –

DR. CARR: So see privacy metadata standard. So what that says; do we want to
just put all of that in? First, we believe that lack of policy framework, okay
– second paragraph, we are concerned with the inclusion of patient
identifiers. We also believe that the use of privacy could create significant
liability. We are concerned that the ANPRM makes a number of technical and
operational assumptions. So all of those paragraphs stay in?

MS. MILAM: Justine, I’ve got a question. We refer to patient preferences
being represented in the metatags, but I’m not finding that in the ANPRM.

DR. CARR: What paragraph is that in?

MS. MILAM: It’s in the privacy metadata standard recommendation, it’s page
5, second paragraph.

MS. GREENBERG: I’m trying to move all the privacy stuff up, is that what you
want to do?

MS. MILAM: The sentence begins the fact that patients may be able to set
their privacy preferences, and entities will use metadata tags to attach such
preferences to specific documents, does not establish a legal requirement on
the receivers, but when I look at the privacy section in the ANPRM, it seems to
be speaking of a policy pointer and then content metadata, so there’s either a
disconnect or I’m not following how it fits together, because I haven’t worked
with metadata tags, so I just raised the issue.

DR. SUAREZ: That’s one of the areas that’s not clear. The expectation is
that the metadata will allow the consumer to declare privacy preferences, and
that that will be one of the elements of the metadata tag, to convey those
privacy preferences.

MS. KLOSS: To convey and communicate patient preferences, parens,
permissions or limits.

DR. SUAREZ: Privacy metadata.

DR. CARR: I’m concerned that we’re jumping around in the letter and that
Marjorie’s not with us.

DR. SUAREZ: Let me just suggest one thing; if we can go back to page 4 and
talk briefly about the overall syntax and format, and see if we want to keep it
or limit it. Then we can go to the next one, keep it or eliminate it. That will
be helpful.

MS. GREENBERG: Let me just tell you what I’ve done here. Starting here.
First under two. The first paragraph stays the same. Then I moved up the fact
that this confusion, created two recommendations here – this confusion
needs to be clarified, and furthermore, it should be clarified in the direction
of it being at the summary care record level, and then go into what our
concerns are about the adoption of metadata standards for tagging at the
element level.

DR. CARR: So just to be clear, Marjorie has totally reorganized the letter
based on comments that she heard.

DR. SUAREZ: So you moved all the privacy up front.

MS. GREENBERG: I moved all that up front. Because that seemed to be that
drew on the last letter, et cetera.

DR. CARR: Let’s not touch any more on the letter for the time being. Let’s
hold on the edits. Walter, why don’t you read the section you were proposing to
read, from page four?

DR. SUAREZ: Yes, the overall syntax. The ANPRM recommends a proposed of an
option of the XML syntax and format in the HL7 CDA header. This seems to be the
conclusion of the Standards Committee as well. The statement that we make,
while we generally agree with this approach, it is consistent with the
recommendations of the Standard Committee, we are concerned that the standard
will only be applicable to the specific use case, the summary of care record,
and that it might not be extendable to other adopted message standards, such as
those using administrative transactions and other health information exchanges
that do not use an HL7 structure. It will be important that the proposed rule,
or any future rule, clarify the scope and the limitations of the recommended
syntax and format standard. So this is a specific point about the syntax and
format, that it be recommended to all the tags, whether it’s for patient
identity, for provenance, for privacy.

MS. GREENBERG: I don’t think this has really been discussed by the Committee
before. This Committee.

DR. CARR: Is it something that is so obvious that everybody knows? Or is it
something –

DR. SUAREZ: We’re not recommending; we’re raising a concern. We’re not
making a recommendation, we’re raising a concern that the standard might not be
applicable to other areas.

DR. WARREN: So in the administrative standards, they don’t use HL7

DR. SUAREZ: We don’t do that, no. Exactly, that’s what we’re stating.

DR. WARREN: So no one’s talked about taking the meta, the tags, and moving
them into the administrative transactions, so if you’ve got tags in one and not
in the other – that’s your intent, Walter?

DR. SUAREZ: Yes, the concept is that if they are driving this down through
the adoption of an HL7, they use syntax for the metadata tag. What happens to
messages that are not formatted in HL7 format?

DR. CARR: Marjorie is raising the point that we don’t want to speak about
things that we haven’t spoken about before. Harmonization, or something along
those lines, that the scope ensures parity or something like that.

DR. FRANCIS: I think that it’s really important to bear in mind that these
are comments, these are not recommendations to the Secretary, and so if they’re
comments, we can agree on an observation; all we’re doing is flagging it for
somebody to think about.

DR. CARR: That’s what I’m saying. If it’s a fact, that is a fact, then we
just say we observe that there is a disconnect, because – whatever,
something like that. So how is it phrased?

DR. SUAREZ: It’s page four, the third paragraph – we are concerned that
these standards will not be applicable to other areas, basically, and only
applicable to the use case. So that’s a concern. We’re not making this as a
recommendation. I don’t know if anybody is not concerned about that.

MS. KLOSS: If I understood it, I’m sure I would be.

DR. CARR: However its stated, this is fine. Let’s go on to priority areas
and recommendations.

DR. SUAREZ: So basically, we divide this into three areas. The first one,
and this, by the way, is not in the order it was presented; the first one was
provenance, the second one was patient identity and the third one was privacy.

MS. GREENBERG: In the meantime I already moved privacy up.

DR. SUAREZ: So, patient identity metadata standards. Again, while we agree
with the overall value that patient identity metadata would provide to a data
payload such as a summary care record, we’re concerned about the accessibility
and use of this metadata beyond the main purpose of providing basic information
about the subject of the data being tagged. In the ANPRM, the description of
the expert analysis done on this topic shows that the patient identity metadata
includes the necessary data required to uniquely select a patient from a
population with a guaranteed degree of accuracy.

MS. KLOSS: That word guaranteed popped out in the ANPRM. What does that

DR. SUAREZ: With a high degree, high level.

MS. KLOSS: It’s probabilistic, though, is it not?

DR. CARR: Well it’s their words, not ours.

DR. SUAREZ: It’s their words, and they’re just stating that the expectation
is that that metadata will help with a certain guaranteed degree.

DR. CARR: I think they mean designated.

DR. SUAREZ: This does not seem to reflect the main purpose of this metadata
(document and confirm that the data tag is about a specific patient), but
rather the second theory, possible use, search and select data about
individuals from a population using the identity in the metadata.

We believe ONC needs to rectify the main purpose for which patient identity
metadata is being tagged to a summary of care record, and separate and
explicitly constrain the use of such metadata for secondary purposes, such as
search and selection of patients.

So in other words, what they said is, the patient identity metadata will
then be used to do search and selection, and the query health initiative is
about that, sending out queries and pulling out data, potentially using this
patient metadata. In reality, the primary purpose of patient identity metadata
is that when I send data as a provider to another provider, that other provider
receives that and confirms that the data that they’re about to see is about the
patient that the metadata says. That’s the main purpose of metadata at patient
identity level. A secondary use of it is in this population level gathering of
data. So it seems like they’re making the secondary use the primary purpose of
the metadata. And we’re kind of hoping that they will rectify that.

DR. CARR: So we’re saying that we think they need to restate the purpose,

DR. SUAREZ: We say rectify, but yes, restate.

DR. CARR: Restate the purpose for which patient identity metadata is being
tagged to a summary care record.

PARTICIPANT: How about refocus instead of restate?

DR. COHEN: I guess from my perspective, I can interpret the word
“select” to mean a variety of different things. You could interpret
it broadly to focus; they want to select somebody to make sure it’s the right
person when it’s transmitted, rather than interpreting select in the way you
are interpreting it, as culling out one individual from among records.

So I wasn’t as troubled – this is just my interpretation of the wording
in the advance notice. I didn’t distinguish between the intent of their select
and what we feel the primary purpose of the rule, which is to make sure you get
the right person.

DR. CARR: And also, it’s a function, and it will be applied in many ways,
and it could be applied to identify a population, but with the proper guidance
or governance or oversight, right?

MS. GREENBERG: I’m a little concerned that you might be explicitly
constrained. You might be saying things here about the uses of data for
secondary purposes that really goes beyond –

DR. CARR: I think that it gets back to our thing about having policies
guiding this powerful function, and I think, I wouldn’t try to – I mean,
the functionality, once it exists, will be used, and I think the focus needs to
be on having policies that guide, and governance, whatever.

DR. FRANCIS: Could I suggest wording? When you get down to “We believe
ONC needs to, instead of rectify, clarify, the main purpose for which patient
identity metadata is being tagged to a summary of care record, and separate and
explicitly govern by policy the use of such metadata for secondary purposes.

The only thing I would say is that it’s – once this functionality
exists, there may be very many other worthy goals that we use it for that are
not – so to clarify the primary purpose is, I think, the time limited. I
think the key thing is that when you use this functionality, you’re guided by

DR. FRANCIS: We’re just saying that it needs to be guided by, before you do.

DR. CARR: I’m just saying, it may not be that this is – it may be
today, this is a primary use, but tomorrow there may be other uses, so I don’t
think we should make them say this is the primary use. I think what we want to
make them say is that use of this function must be guided by policies governing
privacy and confidentiality. What do you think, Walter?

DR. SUAREZ: I think that’s fine. The point was really what is the main
purpose of patient identity metadata? And there’s different purposes. The
primary, like I said, is to identify the data that I’m sending to another
provider, the provider that is receiving it, to identify that it is the right
person. But the analysis and the approach seems to be more about using the
patient identity metadata tagging to do population-based analysis. Which is

MS. SOONTHORNSIMA: Have they stated some example of use cases? Any examples
of use cases or any specific use cases that –


MS. SOONTHORNSIMA: Perhaps that’s part of the recommendation, or an
observation; be very explicit that before you make any regulations, you would
want to be guided by, besides policy, but some specific use cases.

DR. SUAREZ: They need to define the policy for using patient identity, the
purpose, and –

MS. SOONTHORNSIMA: That way it’s very specific in terms of a framework,
anyway, so we’re not getting – in terms of the language of the –

DR. WARREN: Does that kind of stuff actually go into an advance notice of
rulemaking – the use cases and stuff, because that’s what you’re asking.

MS. SOONTHORNSIMA: That’s what I’m asking, yes.

DR. SUAREZ: Not use cases, but more the purpose, so that the policy and the
purpose is really what it’s about. Now that’s the first paragraph, patient
identity. The next paragraph is about the data elements, and we can comment on
this or not comment, I guess. We just state that we agree, at the bottom of
page four, we agree with the data elements identified for inclusion in the
recommended metadata standard, and then we just make a few comments about some
of the elements, so on the main element, we do not see the added value of
capturing a prefix, but this is perhaps too much –

DR. CARR: I think so, it’s too granular, let’s drop that and let’s try to
stay at the higher policy level.

MS. GREENBERG: So what are you keeping? Are you just keeping a statement
about – all I kept here was that this functionality of patient identity
metadata standards needs to be guided by privacy and confidentiality policies
for different use cases.

DR. SUAREZ: Different purposes, for specified purposes. I mean, it’s not so
much for different use cases, but for specified purposes.

MS. GREENBERG: For specified purposes.

DR. SUAREZ: Yes, I think that’s all we need to say.

DR. CARR: I think that’s right. All right, provenance.

DR. SUAREZ: Provenance metadata. This is basically, of the three metadata
areas, provenance, in our view, represents the area that offers the most
promising short-term applicability of the proposed new approach. We agree with
the data elements identified for inclusion in the recommended metadata standard
for provenance, being a tagged data element, identifier, time stamp, actor,
actress, affiliation and birth certificate. We are concerned, however, that het
purpose and applicability of the tagged data element identifier is not clearly
stated and explained in the ANPRM.

We believe that in defining the provenance metadata standard elements, it
would be best to decouple them from any particular security architecture so
that the metadata truly relates to and reflects the property of the data itself
rather than the security characteristics. And this was a specific question they
had about should the security, the digital certificate information, be encoded
and embedded in the provenance, or should they decouple provenance from
security. And so the recommendation is – but again, this might be getting
too much into detail that we really don’t need to. I think in the provenance,
my only recommendation would be that this is truly one area where people are
looking for this type of tagging, that it is one area that they should
immediately try to test and develop the standards.

MS. KLOSS: I would support that.

DR. SUAREZ: And then not get into the details of it.

DR. CARR: I would say less is more.

DR. SUAREZ: And then we get into the full privacy metadata standard. So here
we have several strong concerns regarding the adoption of metadata standards
for tagging a summary of care record document with privacy information, and
ultimately, establishment of the meaningful use requirements. Most of these
concerns have already been discussed in detail in our August 26 letter on
PCAST. We would like to emphasize a few points in this letter, and this is
where all these other statements come from.

DR. TANG: So to pare them, we might suggest getting rid of paragraph 3 and 4
– page six. Just paring this down. Number 3 is the liability, and I was
talking with Leslie, I’m not sure – it may be a distraction. Number 4 we
already talked about as far as the untested stuff. We could just try to get it

DR. SUAREZ: Absolutely. Simple.

DR. TANG: I don’t know about the next one. It’s a little bit wordy, it may
be a good point, we could either reduce the words or get rid of it, because
it’s not –

MS. KLOSS: Are you talking about the one that says – the current
metadata standard?

DR. TANG: It’s just long. And it seems like you’d have to do a lot of

DR. CARR: What about five; I mean lastly.

MS. KLOSS: Well for example, on referencing the policy pointer. Standard
assumes the existence of a privacy policy repository or registry. That did seem
like an important point to underscore, as being ahead of the –

DR. SUAREZ: Paragraph 4 contains some critical elements.

DR. CARR: Let’s read it – this one, the content metadata standard as
described in the ANPRM –

MS. GREENBERG: Is this still about privacy?

DR. CARR: Yes, privacy. We are concerned that the ANPRM makes –

MS. GREENBERG: Go up one paragraph.

MS. KLOSS: No; the second sentence in that paragraph; for example, the
policy pointer standard assumes the existence of a privacy policy repository or
registry to which the metadata would point, and that’s not in existence. I
think it’s an important point.

DR. SUAREZ: That’s an important point.

MS. KLOSS: It’s an example of why more development and testing is needed.

DR. COHEN: – the previous sentence.

DR. CARR: Leave that one back in.

DR. TANG: Actually we say first, we believe the lack of a framework for how
privacy metadata would be expected to use, just put that right after that
sentence. So that takes care of one paragraph.

DR. SUAREZ: The last one on that page six is kind of a general – it
seems clear that the proposed method relies heavily on theoretical concepts and
assumptions and little or no actual implementation or even testing of the
entire project is available.

DR. TANG: So maybe instead of velocity that’s just the concluding thing
right before we go to our recommendation. So we haven’t dealt with the content
metadata standard paragraph. It’s sort of interesting; it says if you’re
supposed to include all the organizational stuff in the metadata, that’s a lot
of stuff.

DR. SUAREZ: Conceptually, you have to imagine, there’s a document of a
patient in California, and now you have to tag the Federal law, and let’s just
say to simplify it, it’s not about behavioral health, but you have to tag
Federal, HIPAA privacy laws that affect that document’s privacy, and then –

DR. TANG: So it’s initially, this paragraph, just because it says –
this is a simple idea, but wow, I don’t know how you would include all that
stuff and how would you use it? How would the machine understand; oh,
California, let’s do – it’s not – the concept is simple but the
execution will be very challenging, and that’s, again, why you need to do the
testing. So maybe that paragraph is useful for that.

DR. CARR: So leave that in. So I think – my only other question is, the
way we have framed recommendations, this final recommendation doesn’t really
capture what we’re recommending in the other paragraphs. So do we not have
recommendations and just have it be a narrative of here are our thoughts, or do
we –

DR. SUAREZ: We can just say, in conclusion, it would be premature to move
forward with the adoption of standards for metadata tagging via regulations.

DR. COHEN: Take out the heading recommendation.

DR. CARR: I think that’s right. That we –

MS. GREENBERG: In conclusion, we believe we want to emphasize –

MS. KLOSS: I had a concept that I thought this conclusion might benefit
from; something to the effect that the feasibility in testing and a solution
upon which future development can build, because once we determine that this is
a viable and useful path, then we need to think more broadly about how it
extends beyond this one use case, and looks beyond – on which future
development can build.

DR. CARR: We have ten more minutes; it looks pretty good.

DR. COHEN: You need to take out the word privacy –

DR. CARR: 11:30 to 12:00 there was supposed to be discussion of the primer;
we took that off the thing. So I guess –

DR. COHEN: Do you want to address Linda’s comment? Do you want to add
anything to that paragraph?

MS. KLOSS: Maybe change the word system to approach? Pilot and demonstration
projects and develop a policy and technology, or policy and standards framework
on which future development can be built? Or, and if feasible, develop –

DR. SUAREZ: Yes, before develop; if feasible, before the word develop in
that first line on page six.

MS. GREENBERG: If feasible? Why are we putting if feasible there? Oh, first
explore the feasibility of such an approach through pilot and demonstration
projects, and if feasible –

DR. COHEN: Why don’t you put a period after projects and then start a new
sentence; if feasible –

MS. GREENBERG: If proven feasible, is that what you’re trying to say?
Otherwise it sounds – develop a policy framework if it’s feasible to
develop the policy framework. I think you have to say if proven feasible. If
the approach is proven feasible, then –

DR. CARR: Then develop a policy framework.

DR. FRANCIS: Actually, could I try a different way of doing that? To say,
the need for ONC to first explore the feasibility through pilot and
demonstration projects to inform development of a policy framework.

MS. GREENBERG: Except I thought we’d been saying develop the policy
framework first. But can you really not do that?

DR. FRANCIS: That’s actually why I said this is pilot testing to inform
development of a –

MS. GREENBERG: Because either way you need some policy here.

DR. SUAREZ: In the concluding paragraph, which is NCVHS acknowledges the
work and at the same time – believe that the nation cannot afford, we use
the word “untested” and I think Paul had pointed out, it would better
to say “yet to be tested”. New, yet to be tested, standard.

MS. SOONTHORNSIMA: Marjorie, going back to the previous paragraph, to inform
development of a policy framework, including governance, purpose/use cases. Is
purpose enough?

MS. GREENBERG: You want to put purpose there?

MR. SOONTHORNSIMA: You think purpose is broad enough – but in order to
come up with a policy framework, I assume that you have to have some specific
use cases are down in the weeds, so to speak, but high level enough; is purpose
broad enough to include all the possible use cases?

DR. WARREN: No, I would add use cases. Purpose, to me, is a pretty narrow,
succinct statement.

MR. SOONTHORNSIMA: So in that case we want to use “use cases”.

MS. GREENBERG: Instead of purpose, you want use cases?

DR. WARREN: Maybe purpose slash use cases. I think that would be better,
even though some of us don’t like slashes.

MR. SOONTHORNSIMA: That is what I had before.

DR. WARREN: Okay, I think that would be better.

MS. GREENBERG: Even though some of us don’t like slashes.

DR. CARR: I think that we have the concepts captured there. I would like to
just reserve the right to do a little formatting, or whatever, and so with
that, would someone like to make a motion about this letter?

Bruce moves us to adopt, Vickie seconds. Any discussion? All in favor? Any
opposed? Any abstentions?

(Whereupon a luncheon recess was taken at 12:00 p.m.)


DR. CARR: Could everybody please take their seats. I’m going to just move to
the next item on the agenda and then we’ll go back to it when he gets here.

The one question we had, the electronic funds transfer that’s in our books,
is there anything we were supposed to do with that, or is that just

DR. WARREN: No, that’s informational. First time the Committee sees it, we
went over it this morning with our committee, so that they are aware of all the
things, because we have to look at the operating rules. This is our first time
to do this, so we wanted to be sure everybody knew of where we were on the
process, in case we’re missing something they can holler at us before we’re

DR. CARR: We’ll start with Standards – this is just a report out of
where we are. We have Quality, we have Standards. I’m looking for Privacy and
Populations. Why don’t we start with Judy, if you could give us your report

Agenda Item: Committee Report outs

DR. WARREN: Walter’s not back yet, but I think it’s pretty straightforward.
Our Committee met this morning and we went over basically what we’re doing with
the EFT and ERA. We’re really coming in with now it’s time for us to actually
review the operating rules that have been submitted, and then to make a
recommendation to the Secretary for that. So in tab 7, we’ve given you our best
analysis of those rules. We met with the Subcommittee this morning. The
subcommittee will have a couple of calls in which we will do the final review
of those rules and draft a letter, and then our intent is to have a meeting
with the Executive Subcommittee some time, probably the end of October, to put
that letter forward to them, and then that letter will come to this Committee
in November for approval.

That’s one of these that again, I can’t say this too many times. As we go
through, this is our first operating rule that we’re reviewing, so as you see
the products that we start sending out to you, really think about that and help
us out, because we are starting a process that’s new to the Committee.

We also went over the agenda for our hearing in November, which will follow
this Committee in the afternoon, and then the second Friday. This is to begin
the next round of looking at operating rules. Also to begin the work that we
were tasked with in ACA of doing some collaboration with the two HIT
committees, odd work to come to some harmonization of looking at standards.

We didn’t talk about it this morning, we are going to be following up with
the HIPAA document and Ob is taking the lead on drafting of comments and stuff
like that. When he and his team are done, that will be shared with Walter and
I, and so we’re hoping to bring the final HIPAA letter for approval in
November, so those will be at least two things that we know will be coming

DR. CARR: You’ve done a great job. Any questions for Judy? Hearing none,
let’s move to Quality.

DR. MIDDLETON: Well, we had a great meeting with new members, welcomed Linda
and Len, Bruce. Jim Walker couldn’t make it this morning. Basically had two
activities. We reviewed the Quality Committee work with Matt’s help, from 2008.
We then took a look forward, thinking about, from where we are now, given
community health data, initiative activities, given the health benefits
exchange activities, given ongoing EHR/PHR adoption, how can we build upon the
rich legacy and really deliver some concrete recommendations –

DR. CARR: You’re speaking about the former co-Chairs and Chairs?

DR. MIDDLETON: Yes. And I guess the basic thought is, we’re going to flesh
out a couple of things. One is sort of a picture that integrates the various
policy initiatives relevant to the NCVHS, and use that road map of the policy
activities and HBE, Health Benefits Exchange, and HIT, and others, to try to
identify the opportunity points for really inserting guidance or suggesting
guidance. We think there’s an intersection between the HIE, HBE, PHR and EHR
activities that’s relevant to Community Health Data Initiative activities now
and what to offer some guidance, what can be done concretely, to help shape the
Community Health Data Initiative activities and meet the needs of national
priorities and GEMs 10 priorities as well.

So that’s a quick recap. We plan to have hearings possibly as early as
December, possibly in February, and we’re focusing that topic still a little
bit further, but anticipate a letter of recommendation from the Committee to
the full Committee for consideration, probably in the early Spring, late Winter
time frame. What did I miss, Matt and Paul?

DR. TANG: So we also looked at a new sort of a construct; we call it the
Lifecycle of Health Conditions or Health Management, thinking that in the
current medical model, it starts when you get sick, that’s the only thing you
need us for. In the future medical model, there’s all kinds of things that can
affect your health, and it can include non-medical things like the social
determinants of health. So could we track someone as they go? And you could
think of, let’s say obesity; it didn’t start that way, but there may be early
signals, like what happens in grade school, et cetera, and it doesn’t end with
what happens in the doctor’s office, it can go on with what’s the outcome.

So we think of the whole entire lifecycle of an individual’s health. We can
take signals from all over the place, pre, during and after. And so could we
have a measurement system that could track that? Both at the individual level,
for individual health partnerships, and at the community population level.

Another aspect is, we talked about this earlier, as a result of our
Meaningful Measures workshop, which is, meaningful to whom? And we wanted to
make it from the consumer’s perspective. And a consumer can’t relate to
risk-adjusted, all information taken out of measures, but really it should be
stratified instead, so they can identify where they are, who they are, what
group of health risk are they in, and who does the best job at managing that?
So a number of these ideas came from our new members, Len and Bruce, and so we
thank them for that.

And the final thing is, it’s in some way, it’s a recapitulation of our
Meaningful Measure letter. It’s just – that was written in early 2009,
before both HITECH and ACA. So after both of them, it’s far more relevant, and
perhaps that’s one of our entrees into saying hey, look, here’s the new world,
here are the new needs. Quality measures just didn’t have the relevance they do
today. And here’s what we think it would take, here’s the roadmap, or at least
a strategic direction they’re going. So we’re hoping to get that – so
Blackford mentioned late winter, early spring, and Justine’s new way of trying
to be timely as a way of being relevant. We’re going to try, even though it’s
due next month. We’re trying to at least come not too late to –- in a time
when it can have an influence on regs.

DR. CARR: Did you want to say anything about what Bruce had brought up about
informing, like health literacy in a way, for consumers who get this
information and what they do with it?

DR. TANG: So Bruce mentioned, I won’t say specific health issue, but people
have questions about their health. Right now, they go to Google. But wouldn’t
it be nice if you could identify yourself in these reports and these
organizations who concentrate on people like me, not me, people who have, it
could be a test they’re considering, it could be the result of their test
they’ve just gotten. How do you go the places which would be most pertinent to
you, whether it’s health education or treatment? So that’s part of the before,
during and after. It just expands the accessibility of the health information
and health advise tremendously.

DR. CARR: So you’re having a hearing in the winter, what is that on?

DR. TANG: In some sense, it’s going along this life cycle, and what are the
challenges, and probably some of these enlightened and inspirational committees
we heard from would be input. So whereas we previously focused on what’s your
story, we might take much more of a data-centric view in terms of what’s the
data and knowledge that could be made available, the relevant data and
knowledge that could be made available, to help you improve your health? It’s a
bit of a different spin than hey, what are you doing with community health
data? And it’s that kind of a thing.

DR. MIDDLETON: The only other thing I would add is perhaps at the same time,
we could consider how to fold in not only community perspective and details
upon their data, as they’re making community health assessments, but think
about what data are relevant to the individual consumer for a real consumer
point of view on his or her own sampling of health issues. Some of those data
obviously may intersect with community health data in behavioral, environmental
and social.

DR. TANG: This could be input to both Community Health Data Initiative,
because they’re sort of unleashing liberating the data, but not necessarily
spending a lot of time worrying about how it’s used, how it’s consumed, and
also to the whole meaningful use program, where we’re trying to get more data
captured, but what’s the data most relevant to the consumer? So those are a
couple of areas, but I’m sure it also influences, let’s say ACOs, and Len was
educating us on what’s required for the insurance exchange. The same quality
measure for them to be evaluated is required, and they’re having to do this on
their own, because there isn’t a national standard. It’s trying to get ahead of
things where if we don’t want 50 different system measures, we’d better provide
one for them, at least select for them.

DR. CARR: So at the November meeting, what would you see as the activity –

DR. TANG: Probably an update on our scheduled December hearing, where our
objectives will be panelists and what are the questions we’re going to ask

DR. CARR: With regards to Jim’s ten priority measures, is there anything
planned for that in the near term?

DR. TANG: I think it’s just keeping those in mind. We probably won’t get to
the health insurance coverage, as just an example of one domain. We may focus
more on the prevention side. There were some preventions domains he had. We’re
missing an important point. You know, the new Million Hearts campaign that CMS
just started; that could be something we could piggyback on and focus the
measurements and the premeasurements, in a sense. Measurements about
pre-condition and post-condition follow-up from an outcome point of view.

So we can take that, we can apply it to this high priority that HHS has
decided, and figure out how do you measure the pre- and try to intervene at the
pre-time, and how do you assess outcomes at the post-time? That’s pretty new
from a quality measurement point of view, and that would be useful from a PCO
kind of design.

DR. CARR: I think that is very very cool, and you put a lot of ideas out,
and I think that each of them could take about a year to do, but I think the
idea of looking at the — . So in November I know you’re not here in November,
but Blackford will give us an update and you’ll have sort of a more specific
plan around that. And then I think interfacing with the Community Data
Initiative is great, to sort of see the intersections and let people know in
the event that they might want to attend as well. So very exciting.

DR. WARREN: Do you have dates for the December meeting?

DR. CARR: It’s January, I think.

DR. TANG: It’s December, right Matt? It’s the first week of December.

DR. WARREN: Do you have dates?

DR. TANG: We’re looking at the first week, the 5th through
9th time frame. We’re trying, obviously, to go ahead of the
holidays, because then there’s another five-week down time, that’s if we can
start to set up the questions to answer and the people.

DR. CARR: Very very exciting. So I expect our speaker momentarily, but we
could move forward. I think it was Leslie reporting out on everybody else? Is
she here?

MS. JACKSON: We think for the population’s privacy, just administratively,
that the Full Committee was invited, and we built it and you all came. It was
one of the first times, not the only time, but we’ve had a precedent of that,
where the Committees realized that the confluence of everybody was important,
so rather than have concurrent break outs, we had the one full break out, and
just about everybody was there.

Susan provided information on the Community Health Information Project that
is going just full steam. We were wondering about the whole — so much in
there, and then wondered about the timing, but it really worked out, we didn’t
want to – we wanted to take advantage of what was in the report as is,
even though there were concerns about it being so broad. So Sally did set up a
time frame and schedule that Paul and Blackford will get me suggestions as soon
as possible.

DR. CARR: They already did, actually.

MS. JACKSON: Electronically, and I’ll pick those up first thing tomorrow,
and Susan will revise and report; based on the discussion and the
recommendations, we’re looking at mid-October to have a revised report, isn’t
that right, Susan? You can come to the mike as well. And the Joint Populations
Privacy Call in that mid-October range, so that the momentum that was
established today will continue, all in efforts to have a report in time for
review at the Executive Subcommittee in early November, so that everything will
be reviewed in time for the November meeting.

DR. TANG: You said something about Blackford and me; what are we supposed to

DR. CARR: I think both of you already did.

MS. JACKSON: Yes, that you did yesterday; I haven’t picked up –
everything that’s happening in real time.

DR. CARR: So we’ll see at the November meeting, we will have a report then,
this report as it is, and then we’ll make a decision about whether a letter
would follow at the next meeting.

MS. JACKSON: Yes, and that’s to capture the amazing amount of work that’s
already in there, realizing that there’s always a series of more to come.

DR. MAYS: In terms of the going forth, we talked about, I think, several
things. The one that I will raise is the social determinants; I’m trying to
remember without my notes; social determinants, LGBT and there’s one other
– SES. I’m willing to take a lead on that, because I have a lot of the
stuff, having done the same thing about the collection of data for that on the
IOM Committee that just finished, in terms of Healthy People, 20/20, leading
health indicators.

DR. CARR: Say a little bit more about that; I know it’s come up a couple of
times, that meeting. So what you’re saying is that a direction for the
Populations Committee is to address LGBT and SES, and so what would that be,
what’s the activity?

DR. MAYS: Here’s my understanding, is in 4302, there is a series of issues
that they’re looking for advice on standardization. This is going through the
Data Council, as well as, I think, some other aspects of HHS. And I know ASPE
is involved, because Susan Queen’s working on it. So there has been the request
for the race advisory, on race, disability and primary language. The next set
that are coming up, which are considered secondary, or it’s better to say
considered not required, but requested, will be social determinants, LGBT and
SES. And SES, the discussion has been to look at indicators. I think the two
big issues, and we had a long discussion at IOM about this, is the issue of
indicators and linkages; those are the two thing you want in terms of being
able to do that.

So my understanding of what we would do is just like they requested a
comment on race – they’re going to request comments on SES, LGBT and I was
less clear about what the request was going to be in terms of social
determinants, so I have to get that clear.

DR. CARR: And who’s requesting?

DR. MAYS: When the race came out before, it came out from – wasn’t that the
Data Council that was asking for it? Because I think that’s why Jim brought it

MS. GREENBERG: – Secretary for Planning and Evaluation. So I don’t remember
exactly who the request came from, but it’s part of the ACA, and they’re
starting with standards for surveys, and so they have an internal work group,
but by the time the request was published, it had like a month; really there
wasn’t time for the Committee to weigh in, and at that time, Jim suggested that
there were some new issues coming along, and they were actually mentioned, I
think, in what was published, but – I guess I wasn’t clear, I know it’s SES and
the LGBT –

DR. MAYS: That’s what I said – I was less clear, he said it, kind of
this last time. Before I thought it was just the two, so that’s something that
I was going to talk with the staff to get clarity on, because he went through
items so fast –

MS. GREENBERG: – social determinants; they’re starting to work on that, so
the Committee wants to get ahead of it so that they would have something to
contribute when the –

DR. CARR: So this would be to hold hearings to get input? What would the
input –

DR. MAYS: Again, I think we have to find a time line. And I think the second
thing that I would have to do is to find out if there’s any material that we’ve
already done that would give us a foundation to stand on as opposed to starting

DR. CARR: I don’t think that, at least with LGBT, in the last seven years
that I’ve been here, there hasn’t been anything, and SES. So again, is it going
to be a – I’m hearing a couple of different things. You’re saying there’s
new work, you’re saying the Data Council was looking for something. How does
this come together, because we have a couple of models; some are we get an
ANPRM, we come together, we draw on our all things and we sit together and talk
about it. Some are we’re having a hearing, we’re going to put something
together. I’m trying to understand where in the continuum, and where the
expertise comes from. You obviously are, and the IOM has already spoken on
this, so why NCVHS, that’s sort of rhetorical, and how, because I don’t know
that we have –

MS. GREENBERG: I thought the way we left it was you wanted me to talk with
Jim to find out what their time frame is and what opportunities there might be
for the Committee to contribute in a timely way on these things. So would a
hearing be useful? I do know that on the LGBT, the Department is holding these
listening sessions, and I’m not frankly sure that there’s that much more for
the Committee to do in that area right now; I think you should get a briefing
on it, and we can certainly have Virginia Cain, at a minimum, brief the
Population Health Subcommittee, because the next steps, having these listening
sessions, and then they’re going to pilot some questions in the health
interview survey. On that. On the SES, it might be more open-ended, because
there are several different – it could be occupation, it could be
education, what have you. So I think we have to find out what could be useful.

DR. COHEN: When you talk to Jim, it was incredibly provocative that they’re
developing these domains. To the extent that the Committee can contribute,
operationalizing these domains, particularly with respect to data available for
population health, and create standards for the collection of those data
related not only to population health but to quality data, I think would be a
nice perspective for us to move forward with, so I think when you do talk to
Jim, you could find out more about that, that might be useful for the
Population Health Committee.

DR. CARR: I think it would be excellent to have a briefing in November, is
that possible?

MS. GREENBERG: You could on both, but that might be a little late. I don’t
know what the timeline is for his work group. I think the same process in which
they came up with the other – and of course they drew on all sorts of
already-recommended things, but I think they are establishing that work group
now on SES, so November might be a little late, although it’s the first time
the Committee is meeting. I’ll check with Jim, and maybe we could have a little
conference call with him, a few members of Population Health.

DR. CARR: So at the end of this, however it works out, I want to understand.
We can be a part of the conversation if we have something to say, that is. This
has not been a topic that’s been –

MS. GREENBERG: I’ve made recommendations, not in LGBT, but on the
socioeconomic status, 20 years ago this Committee made recommendations.

DR. CARR: Exactly, I just want to line that up, or if it’s a new focus,
where we would have hearings, I like Bruce’s idea of tying it into work that
we’re already doing. I think that, again, there are so many aspects to it that
we want to make sure that we build on what we already have so that we can
continue to enhance the work products that we have.

MS. GREENBERG: And I suggested that if there were a hearing, the Standards
Subcommittee should also be involved, and then someone mentioned the Quality
Subcommittee; I don’t know. So again, it could be. And then there are privacy

DR. CARR: So there will be some conversation and we’ll hear what the plan is
with that. All right, anything else on populations? Hearing none, we’ll hold on
Privacy and we will welcome our speaker.

Agenda Item: DHHS Report on Eliminating Health

DR. GRAHAM: Thank you. I think Jim might have given you a preview of what
we’re doing, based on your discussions here. So I’m going to touch on that a
little bit, and hopefully can clarify terms of some of the questions you had in
terms of our timeline, or on our data collections standards, because that is
moving fast.

So my name is Garth Graham, and I’m the Director of the Office of Minority
Health, the Department of Health and Human Services. When I was asked to give
you a briefing on our Department’s action plan, strategic plan, if you will,
around health disparities, that we released in April of this year, this led to
a subsequent series of activities. One big focus of the plan is data, and like
I said, I gleaned from what you were talking about that Jim preceded me in
talking about some of our data plan, which is good, so I’ll kind of give you an
update on that as we move forward.

So the kind of onus that came about in terms of developing a disparities
plan was twofold; one, after some discussions with our Secretary, she wanted to
have a strategic plan that focused on activities and actions, and many of those
born out of the Affordable Care Act, but certainly some components of which
might not have been included in the Affordable Care Act, but included things
that we, as a Department, can and should be doing.

There are a lot of other plans that have been developed over the last year
and a half. We have been involved in all of these plans, so there’s been a lot
of synergy in terms of plan-making, one of the most significant of which has
been the national HIV/AIDS strategy, which has served to kind of focus a target
along the Department’s spending.

Our plan is twofold; I should say the disparities plan is twofold. It’s a
lot about focused spending and activities, but it also touches on just
increased coordination in terms of priority areas. So before I get into that,
just kind of background in terms of one of the other plans that we’re also
significantly involved in, and are also co-leading one, the disparities aspect
of it; the national prevention strategy. It was released on June 16 of this
year, as a by-product of the National Prevention Council, chaired by the
Surgeon General, but more importantly allowed the aspects of dealing with
social determinants of health by the representation of seventeen Federal
departments and Cabinet secretaries across the board. One of the components of
this plan, if you can jump to the bottom of this next slide, is elimination of
health disparities. The other areas also deal with health disparities in a
contextual manner, but really this is one of the focus areas, and what we try
to do, or what we’ll do with what I’m going to present to you later on, is show
some synergy between a lot of these public – these plans are made very
public, and what they do, like I said before, is kind of set a road map in
terms of priorities.

You’ll notice, as I go through, I’m going to skip through a lot of –
trying to get to some of the pertinent areas that I believe you are
particularly interested, and touch on much in terms of we’re going to be doing
our own data, and the data standards. Now we developed the standards, I think
Jim spoke to you about today, through the Data Council, our office, Agency for
Health Care Research and Quality and CMS, so you’ll see me kind of jettison
through some of the other slides to spend some time talking about that topic
area, because I think that’s the most interest to you.

Let me skip to the next slide. What we released on April 8 were two plans.
One was a national stakeholder strategy and the other one was the HHS Action
Plan. The national stakeholder strategy was the combination of a series of
meetings that our department had held with health disparities groups over a
two-year time period, and basically started with regional meetings, then
national meetings; we had people vote on national priorities, and they came up
with five specific overarching goals.

The whole idea was to have a series of activities that stakeholders
developed and brought in, along with priorities from the stakeholder world in
general, so this included folks in the private sector, housing, education and a
number of different areas to define some of those priorities, so to clarify for
you, on April 8 we released two plans. One was a stakeholder plan and the other
was an HHS plan that basically documented where HHS would be going, at least
over the next two years, and we define that in fiscal years.

So we released stakeholder strategy on December 4 at the same time. Then we
also released the HHS Action Plan, the Secretary’s action plan, that was really
developed as a departmental-wide response that the stakeholders wanted to see,
with some specific priorities that our Secretary wanted in terms of overarching
Secretarial priorities. The momentum for this certainly was building on the
Affordable Care Act, but a lot of it was activities outside of the Affordable
Care Act.

So the plan was organized in five general areas that are reflective of the
Secretary’s priority areas, so the Secretary, about a year ago, articulated her
priorities for the Department in five specific areas, and we aligned the
disparities plan with those generic priority areas, as well as she wanted some
overarching priorities for senior leadership at HHS in terms of Secretarial
priorities. So a lot of jargon, but suffice it to say, big picture, the
Secretary wanted to see some things that are important for her, but she also
wanted other activities to be aligned with things that are broader in the
department in terms of departmental priorities.

So here are the overarching Secretarial priorities. One was heightening the
impact of our HHS policies, programs and resources. Basically, what this meant
was looking at what we’re spending around disparities, looking at what we’re
not spending in disparities, having better alignment of resources in terms of
what we’re directly spending on disparities, and areas where we’re not spending
those monies that are targeting disparities, wonder if we should be doing that,
and how do we heighten the issue of disparities among HHS broadly? Also to look
at things such as health disparities impact statements across all our grants.
So an example of that would be, quite frankly, if you had a
non-disparities-related grant program, understanding what impact that grant
program has on disparities, and understanding how we can align some of our
grant infrastructure with that.

The second issue was increasing the availability and quality and use of
data. You all have been in tune to a lot of these things; certainly, Todd Park
has been leading with the Open Government Initiative from the HHS side, but
certainly building more on the Affordable Care Act and what we’re going to be
doing with some of the new standards there.

The third issue was measuring and incentivizing better health care quality,
so we’re looking at all the money we’re going to be spending with the
Affordable Care Act, with the Centers for Medicare and Medicaid Services, with
things like the Innovation Center, as well as other things that Rick and those
guys are leading over there, and understanding, how do we start to incentivize
quality in general?

And then last was to, on a biannual basis, review and report on whether we
are making any progress, whether all the stuff we’re doing is really working,
and be able to monitor and measure that and report it publicly. These were the
other goal areas that I’m going to touch on.

So one generic goal area was transforming health care and really, within
this generic goal area, the main action steps had to do with – these are
just a snapshot of some of what was here, but I’ll tell you about some that are
not here; had to do with mainly the implementation of the Affordable Care Act
and how would we implement the Affordable Care Act to emphasize issues around
improving access to care? So a lot of it has to do with certainly expanding
insurance coverage through Medicaid and things that you’ve heard about before,
but we also wanted to delve more into how do we utilize health information
technology, electronic health records, and mix that into everything that we’re
discussing around health insurance exchanges, new service delivery sites, et
cetera. I also wanted to certainly highlight some of the Affordable Care Act
provisions, and more importantly, target with specific outreach mechanisms how
some of the preventative services that were talked about in the Affordable Care
Act, and how do we target minority communities who are most in need of that?

So let me just take a step here and tell you where we’re going with health
IT in general. We’ve been working pretty closely with – we started working
with David when David Blumenthal was the National Coordinator, and continued to
work pretty well with Farzad, on how do we target specific health IT strategies
to reduce disparities. We’ve actually posted, for public comment, some things
that we’re planning on doing; it actually just went for public comment two
weeks ago. That’s our bottom post there, in terms of some of the things that
ONC will be doing with HRSA, OMH as well as other parts of HHS, to utilize
health IT to reduce disparities.

One of the things we noticed, to lead up to the next slide, is that quite
frankly, is if you look at the expenditures in the health IT world, government
spends a certain perspective, but a larger perspective is really the private
sector. So how do we engage private sector folks in a variety of different
ways? We started doing that, and over the last month, have announced some local
private sector initiatives; one with a Medplus Quest Diagnostics to donate the
license for electronic health workers, including equipment and training. We are
partnering up with AT&T and just announced last week some mobile health
technology that AT&T is going to be donating to work with diabetes
educators to allow patients to manage their own diabetes and information about
their own diabetes via mobile cell phones, via Smart Phones, actually. All of
these are just different examples of how we, in the past month, are working
with the private sector, quite frankly because that is where a lot of the onus
of expenditures are.

These are some other action steps that we are doing in terms of the plan. I
want to skip to the next slide because this contains some of the key things
that we are doing. One is, we are really emphasizing the issue of community
health workers and promotores. Promotores are community health workers who work
mainly in Latino communities who have specific skills and things that we
believe are a side of the realm of just how the Federal government normally
interacts. We, as a government, sometimes can’t reach people that well, but we
know that community health workers and promotores in communities are able to do
that, so we have been working with a number of folks, including agencies
outside of the Department of Health and Human Services, to highlight and
support those folks.

We are also redoing our class standards. Many of you are familiar with
those. Some of you might not be, but it’s a series of cultural and
linguistically appropriate services and standards that HHS just had moved
forward ten years ago, and we are redoing that as part of this activity.

There is also an emphasis on translation services, so we are working with
this issue of certifying interpreters, and what does a certification of
interpreters mean. Medicaid is also moving forward on, as many of you know
through CHPRA, there are some activities to increase the matching rate that
states have in getting aloft to provide translation services and use that as an

So I’m going to move quickly through some of these, and you can stop me with
clearing your throat or a hand signal or something if I’m moving too fast.

Here it just gives you some examples of some population-specific health
interventions that are ongoing, many of which are part of the plan, some of
which are outside of that. Many of you are familiar with the Community
Transformation grants. There’s some wording in there that specifically targets
minority communities, and the recently launched Million Hearts campaign, that
has disparities, and the wording of our plan, as we’re developing a plan, we’re
able to influence some of the way of the Million Hearts initiative. If you’re
not familiar with the Million Hearts initiative, it’s an initiative that was
launched by CMS and CDC to basically reduce the burden and incidence of
coronary artery disease, cardiovascular disease at large by modifying risk
factors in primary prevention, but certainly affecting secondary prevention as
well. It’s basically to save a million hearts over the next couple of years.

I’m going to briefly mention this here; we’re going to go into more detail,
this issue of collecting more data. It sounds like Jim has given you a preview
of what we’re doing here, so this was supported by the Affordable Care Act, but
as we’re developing this plan, we went outside of the onus of the Affordable
Care Act, in terms of some specific data activities, and I’m going to skip over
going through that detail now, because it’s the last set of slides, that really
open up for discussion. I’ll talk to you about where we’re at with that.

Now another thing that we’re doing that’s a part of the plan has to do with
what was previously known as Comparative Effectiveness Research, but has now
come to be known as Patient-Centered Outcomes Research. Whatever the issue,
whatever the terminology, we have been developing a series of activities in
terms of disparities and minority-related CER. We’ve started a grant program
over at the National Institutes of Health. We’ve also had some funds coming
from our office, and we’ll hopefully begin some work with the Patient-Centered
Outcome Research Institute, the quary that has been set up by the Affordable
Care Act, and had some funds to deal with issues around advancing CER.

So going back to data. The thing is, Jim talked a little bit about what
we’re going to be doing with data, so section 4302 required that HHS establish
data collection standards for five specific demographic categories: race,
ethnicity, sex, primary language and disability status. The law said that this
must be developed within two years, built from the OMB standards, and that the
data be used for analysis and results, and it was prodding the Department to
really move on this issue of data.

So in implementing this, we co-led an effort that was nicely supported by
Jim and the HHS Data Council, to develop a multi-pronged approach to move
forward on the implementation of this particular provision. As we were doing
this, we also realized that this provided an opportunity, though not explicitly
stated in the law; the law did give the Secretary the ability to develop
standards for other areas as well.

So we developed a progression plan for collecting LGBT data, primarily on
the National Health Interview Survey, but also allowing other agencies to start
doing that. I heard you mention a little bit about the IOM report and some of
the things that had been co-occurring there. Granted, when we started this
process, we did have the benefit of the IOM report, having already been out,
but we also faced some realities that IOM did which is called a budget, and so
honesty and the reality of developing a plan, saying that we will do this and
then being able to execute it in a time of fiscal challenges, so what we really
decided to focus on there was to start – this is now, I’m talking about
LGBT data, we have this focus on developing some standards for the National
Health Interview Survey, that will get some broad data.

We ended up having a series of listening sessions. We had three listening
sessions, and I heard somebody mention before, we’re actually not having a
whole bunch more listening sessions on certain of the topics that we’re talking
about. I’ll tell you what we have planned.

We had initially three listening sessions, the public health community,
minority communities and with LGBT communities, to get input from stakeholders
on how we go about doing that. And we also realized that though these
standards, as articulated by the law, should apply to all Federal health
programs, we knew that from a financial perspective, we could only start with
the population health survey data, and then work with ONC and other folks in
terms of looking at what they’re planning on doing around health information
technology, et cetera.

So we put this up for public comment on July first and had it opened up
until August 1, a month, and really, the public comment was supposed to be
targeted around race and ethnicity and primary disability status. We got a lot
of comments about the LGBT area, which we had announced at the same time, but
weren’t actually soliciting comments on that. We received a total of 466 public
comments, and for the most part the comments were generically positive.
Certainly we know that a lot of folks had challenges with the law and things
that the Affordable Care Act was promulgating, and received some comments
around those lines there.

So here’s how we broke things down. This might be a duplicate of what Jim
did, if he did this earlier – wish I knew he was coming, then I would have
coordinated better with his slides, but the proposed standards are in terms of
for race, white, black, as you can see here, African-American, Asian, American
Indian or Alaskan native – I’m breaking this down into a number of
different subsegments – Asian, Indian, Chinese, Filipino, Japanese,
Korean, Vietnamese and other Asian. Native Hawaiians, I’m breaking this down
into two major, native Hawaiian and other Pacific Islander groups, and then
having the option for other Pacific Islanders. Backing up to Hispanic or
Latino, Mexican, Mexican-American or Chicano, Puerto Rican, Cuban, and then
another blank area for other Hispanic or other Latino origin.

This was a description of the process that we did with the work group we
were chairing and kid of what we were planning on doing, and our plan is to,
having gotten the public comments, we’re in the process now of finalizing
these, and I think that’s the matter that Jim spoke to you about. And the final
standards will be, hopefully very soon, this fall.

The LGBT timeline is different, so the timeline for race, ethnicity, primary
language, as dictated by the law, necessitates that we be done with that by the
fall of this year, for surveys and other kinds of programmatic activities being
next year. The progression plan for LGB and then LGBT is going to take longer,
particularly because we did start a listening session activity with transgender
researchers to start getting more input on the T part of LGBT. So that might
have been what you heard about in terms of ongoing listening sessions. That
will be the T part of it. We’re not necessarily doing any more listening
sessions on the LGB portion, but we’re certainly going to be doing some more
meetings on the T part of it. We had our first meeting two weeks ago. It was
basically half the meeting that was led by Jim’s boss, Sherry Glied, with a
number of us that put input in that together.

So that gives you a snapshot of where we’re going data-wise, and hopefully,
I think, what we’re trying to figure out is 1. How do we make sure that we do
this correctly the first time, particularly on the language part of this –
I’m sorry, did I tell you about the language standard? There’s also standards
for disability, and that we’ll be completing as part of this overall process,
and language, which Jim might have spoke to you about, trying to distinguish
between spoken language and preferred language that is used in medical
settings. So all of that part of it will be completed this fall.

So the last line really is about how is HHS going to be able to do all these
things that we’re putting forward in this plan, and what’s our whole thing, so
the law has created additional minority health infrastructure, in particular
agencies, and we’ve created this strengthened infrastructure to deal with
minority health and health disparities issues. We’re going to be working to
streamline a lot of our grant processes, and as mentioned before, reporting
back on a biannual basis in terms of the progress that we’ve made overall.

So this October will be the six-month period since the release of the plan,
and our Secretary sent out a note to all her agency heads about three months
ago, having folks develop these six-month rolling plans that will be evaluated
to make sure that we’re making progress, and we’re going to use that to put
that all together in one plan.

So overall, the HHS Action Plan was developed as a response to this national
stakeholders series of meetings. It built on health equity provisions from the
Affordable Care Act. It was the first ever plan that HHS has ever had. It was
not meant to be just something set in stone; it’s meant to be fluid. We’ll
certainly revise this as we revise our progress on a biannual basis.

With a new office of minority health infrastructure in various agencies, as
well as the solidification of those minority health infrastructures, we think
we have more players on board to be able to execute this. Certainly, we are in
the throngs of moving forward and finalizing on our data activities, as you
probably heard from Jim earlier, so there’s a lot going on. A lot has been
supported by the Affordable Care Act, but we’ve gone outside of the Affordable
Care Act to deliver on a lot of things that we thought we should do right now.

If you have any questions about anything –

DR. CARR: I’d like to just put out the first question. Of the top three
disparities that are among the many that we are addressing, where are we today,
and where do we think these many plans will bring us, and by what date?

DR. GRAHAM: You know, certainly you can slice disparities a lot of different
ways; you can slice it by specific diseases in terms of you’re looking at
cancer, diabetes, heart disease, et cetera, but if there’s one thing, if I
could take a quote from Ted Kennedy – if there’s one disparity that
affects all of these that is the most overarching, certainly disparities in
access to care. So disparities in access to care impacts all these different
numbers. If I was going to articulate this, I would say that’s a number one
disparity priority. And where we are, if you use the various measurements of
access to care, is we are, prior to, I would say, the most recent AHRQ report,
maybe about a year ago, we saw that access to care, for the most part, was
staying the same for some communities, getting worse for some communities,
depending on what measure you were looking at.

Certainly the rate of uninsurance was not getting any better. In fact, if
you look at the minority communities that make up the bulk of the uninsured,
over half of the uninsured are made up of people in minority communities; you
see a worsening in that number and you saw a worsening, especially, for
Hispanic communities. So I would say that in terms of looking at the number one
priority, which I would say is access, because access affects all the other
disease entities, we have seen some a persistence of health disparities.

Now I’ll tell you that one of the things that we learned from a recent
exercise in terms of how to eliminate a disparity, has to do with disparity
around vaccination. So the CDC just published some data, final data last week,
showing where we are with flu and annual vaccinations, and for the first time,
we’ve actually eliminated the disparities in vaccination rates for minority
children, though the disparities for adults in vaccination rates still stay the

Two years ago we did a similar thing, like you saw we’re doing here. We did
that for flu. We did a big coordinating thing for FLU and vaccines and I think
it’s worked, quite frankly, and it does show that its issue of coordinating
resources, targeting resources and pulling in partners can work in general, and
I would say for its biggest disparity, which has to do with access to care.
That’s what we’re trying to get at now, and I think that’s a big part of not
just ACA but a part of what we’re trying to do here.

DR. CARR: Other questions? Leslie?

DR. FRANCIS: This is a question about data and data protection. We’re
currently involved, the Populations and the Privacy Subcommittee of this
committee, we’re currently involved in a project that’s looking at some of the
things that communities are doing to use all kinds of data to improve community
health, and one of the questions that’s coming up in that is how are
communities – what sorts of strategies are communities using to make sure
that people can trust that their data will not be misused. I also noted in the
Advance Notice of Proposed Rulemaking for Research, a question about whether
certain kinds of protections, say for the secondary use of health information
and research, whether there might be particular issues with respect to certain
communities and the use of their information. And so I’m asking this as an
interactionist question; are there things we could do to help you with respect
to the question of getting better and better data and putting that data to
better and better use? Are there things we could do with respect to data
protection initiatives, privacy, confidentiality, and the like, that would

DR. GRAHAM: And actually, I feel like as if – I had one big ASK for
this group, and I feel like you stole my ASK, because it was going to be along
those lines, but you articulated it better, which makes me refine by ASK
mid-stream, to re-ask what I was going to ask.

And so here’s what I would say. I would say that – I would ask your
question two-fold. I would say that one of the challenges that we face with
data collection in the generic community and you’ll see some of this in a
health affairs article that is going to hopefully be published in the next
couple of weeks, is certainly the perception and understanding of what we’re
trying to do with data, influences how people are approaching this. And whether
we are adequately protecting their information, as part of either the
collection process or the reporting process, is a major concern for folks
outside of – a major concern for the average person who is just hearing us
talk data, data, data.

And so I would say that we need a lot of help, particularly when it comes to
minority communities, in understanding how we articulate some of those
protections, as well as figuring out what are some of the best protections for
some of the newer kinds of research activities that we’re employing,
particularly as we move into this issue of CBPR, Community-Based Participatory
Research, more, and particularly as we move forward with Comparative
Effectiveness Research more and that community engagement model. Simplifying
this, to answer your question, I don’t have a good answer to your question,
because I was going to ask you to help us with those kinds of answers, in that
I think we need better explanation to communities of what we’re doing with
their data and how important their data is, and certainly I think a part of
that is certainly understanding how we protect their data better.

I think one of the things we learned from the public comment period around
Section 4302 is a lot of people think we are going to – not a lot of
people, let me back this up – one thing that we learned is that there are
some misperceptions about these data collection improvement efforts and what
they’re intended to do, and what they will do, and I think there’s a lot of
misperceptions around privacy, especially about race ethnicity data; not a lot
of that embedded in fact, per se, but I think a lot of that embedded in just
public perception of that.

DR. FRANCIS: That’s great, that’s just the answer I was hoping for.

DR. GRAHAM: And with my ASK, it builds on that, my more detailed ASK.

DR. CARR: I believe we have Walter, Bruce, Mike, Vickie and Marjorie.

DR. SUAREZ: Walter Suarez. I’m very pleased to hear about the plan; I’m a
member of the National Health IT Disparities effort, and this is very exciting.
On the lines of what Leslie was asking, actually, one of the interesting
elements on privacy is this famous, under HIPAA, Notice of Privacy Practice,
that entities have to provide their patients. I actually worked on translating
the Notice of Privacy Practice from English to Spanish in a number of places,
and found how amazing some of the translations of those turn things around in a
way that actually, the entities that are giving those to the patients don’t
even realize. Things like the way they explain data will be used turns out to
be totally the opposite of what it is supposed to say, and they don’t even
realize that they are telling that to the consumers, but the person that is
delivering it, of course, doesn’t necessarily speak Spanish. So I think
improvements in the education, as you point out, and in the communication to
non-English speaking minorities on how health information is to be used and the
privacy rights and expectations, it’s going to be very valuable.

The other aspect I guess I wanted to touch on was the extent to which some
of these standards are going to be sort of pushed, or moved, not pushed, moved
into the standards that we are using to capture data through electronic health
records; of course, under the current Meaningful Use program, they have
incorporated, and we were very pleased to see that, of course, incorporating
information around race and ethnicity and language preferences and things like
that, and they reference in those regulations the specific standards, but as
this new section 4302 defines the newer standard, or the newer categories of
breaking race and ethnicity, how will that be incorporated back into the

DR. GRAHAM: So part of the challenge with this, to answer your last question
first, but I do want to talk about your other question, because it also goes
back into the more detailed component of this ASK, so HITECH helped put in
place a lot of the meaningful use issues and a lot of the Standards Committee
and all those processes had already started before this work got underway. So
one of the challenges that we face, in terms of phasing this in, is recognizing
that this wasn’t a planned, staggered process per se, and I think the Standards
Committee, they were doing a good thing. Based on the information they had at
that time.

And so they moved forward and those things are moved forward, so we’ve been
talking with ONC about just that, how do we recognize the good work that has
been done but incorporate this eventually? Basically, what we’ve decided to do
is to genuinely do a staggered approach, so to the extent, because this even
hasn’t been finalized yet, so that’s a challenge; it’s like two trains that
need to meet and what we’re going to try to do is to force them to meet down
the line, but understand the practicality is, those two trains can’t meet right
away, because that other process was underway in a well meaningful process,
underway well before.

Let me go back to your last issue about the translation issue so that people
understand how important this is, not just in terms of Health Information
Technology, but if you look at some of the issues that have come up in
translation just for informed consent processes, right, so when people are
doing clinical trials, if you also look at the widest gap in last year’s
National Health Care Disparities Report for Hispanic populations, was the
ability, I’m going to paraphrase this, basically the gap in whether parents
thought that their provider was communicating well to them about their child.
That was the largest disparity gap in terms of all the various disparity
measures, or especially in terms of a proxy quality measure.

So how concerning is that – the thing that’s getting worse is you don’t
know if your doctor is understanding what you’re saying to them about your
child, and then vice versa. So these language issues, and then you overlay on
that just the dramatic growth rate in terms of the very plethora of languages
that are being spoken in any urban community, and certainly the growth rate in
the Hispanic community, you understand just how quickly we have to move on
these language access issues, and why we targeted Medicaid as a particular
incentivization structure to help promote language issues.

I guess another issue is that a lot of people think, well, I speak English
so that’s fine for me, but it really isn’t. Because these population dynamics
affect health care everywhere, and affect the way everything is happening, and
if you look at the data, that’s just where things are going. So quite frankly,
I think this is one of the key most important challenges. It’s going to be
hard, because obviously, we’re trying to deal with these challenges in a time
of other fiscal challenges, but I believe what we’re trying to do with
incentivization of language access, particularly in Medicaid, is particularly

DR. SUAREZ: Thank you so much for your amazing leadership on these issues.

DR. CARR: Bruce?

DR. COHEN: I’ve got an ask for you. I’ll do half an ask. I’m from the State
Health Department in Massachusetts, and we’ve gone beyond the OMB regs with
respect to collecting race and ethnicity data, and this has to do with our
experience, that I think is a key issue that hasn’t been addressed by OMH and
by other Federal agencies, and it’s essentially the encounter that collects
race and ethnicity information, we found that the real key to making this a
constructive, rather than an adversarial encounter, is training. And my ask is,
for regardless of the standards developed, is OMH dedicating resources, and is
all of HHS dedicating resources, for training of those who are responsible for
collecting the data? Initially, I know, the primary focus is on health surveys,
but the reality is, and as we discussed, this will all trickle down to all
health surveillance data sets, it will be incorporated into electronic health
records, and we went out into communities, the people least able to collect
this information are the registration clerks in hospitals, and a lot of the
front line people in community organizations, because they aren’t instructed
about why they’re collecting it, how they’re collecting it and how to respond
to reasonable concerns of clients and consumers.

DR. GRAHAM: I’ll say, on a practical level, certainly the OMH budget,
neither has the HHS budget, for those of you who will soon see the 2012 budget,
have not dramatically increased. So there is not necessarily a huge infusion of
new cash to do a lot of this training. So part of what we’re trying to do is to
move this out very slowly and then be able to utilize a lot of our local
networks for this training.

Now we have learned a lot from Massachusetts, especially with Howard Colby
being involved at the helm of this. We have learned so much. I’ve read so much
about Massachusetts; it’s just served to educate me even better. And I’ll tell
you that there is an additional component which goes back to the privacy issue
in Massachusetts that I think also came up, and I think that the best answer I
can say is we’re going to move slowly on this, certainly we’re going to
continue to move things on a staggered fashion. We’re going to try and
incorporate training as much as possible, realizing the realities of our budget
climate, and I think also, what we did learn from Massachusetts, and what we
are learning, especially from our public comment period, is how do you do this
bidirectional communication from folks in an efficient way so people don’t
think that you are trying to come in there and ask them about their race to use
that in a nefarious manner or something along those lines. So this is not a
simple, easy topic.

And it is not going to necessarily be a simple, easy thing. But to go, I
think I’m running out of time, so can I end with my last ask?

DR. CARR: From our side, you’re not running out of time. Because you started
at 1:20, we’ll give you your full time.

DR. GRAHAM: I think we need a lot of input and thought from you all on this
issue of both privacy, in terms of how we continue to protect, but privacy in
terms of generic communication, and that latter part, for me, is what struck me
the most in terms of what we were trying to do. I’m just going to plead
ignorance and assume that most people thought that we were using this for the
better good of the rest of the world, but I’ll tell you there are certainly a
lot of misconceptions about the privacy issues around data, and certainly, once
you get into some of the more sensitive issues, and even when you get into more
sensitive issues, like sexual orientation and things along those lines, you
trigger all kinds of different emotional privacy challenges. But the flip side
of it is, we do need to collect this data to better define the problem, so I
think – I’m not sure Jim talked to you on this earlier – I think one
of the things we would certainly want to come back and hear from you and engage
in dialogue with you, is communicating to communities about how important this
is, particular minority communities.

I’m not sure if my uncle understands how important this is. I’m not sure my
own family understands how important this is. Even in that realm, I’m not sure
I’ve communicated it that well. So then take, for instance, a lay person on the
street whose program wants to collect data on race and ethnicity and sexual
orientation – this triggers all kinds of dynamics. So I think the issue of
privacy is, I think, of paramount importance in terms of being able to use some
collective wisdom to help chart our path forward.

DR. CARR: We have a couple other folks; happy to put you on, Walter, after
the others. Mike?

DR. FITZMAURICE: Let me join the applause for all the action and activity
that you’re doing; I think that’s great. A couple of questions. Are your
categories mutually exclusive; that is, if you add them up will you get 100
percent of the population, or is there some double counting because some people
can be more than one?

DR. GRAHAM: I guess if we’re just thinking not on a disability or language,
if we’re just sticking with race and ethnicity, I guess theoretically it would
be mutually exclusive. There are some challenges with that, of course, in the
mixed race category, and that’s part of our ongoing discussions. We tried to
mirror as much as possible the American Community Survey and the sense of
dynamics there, as well as the calls for restrictions, because one of the
things, as Dr. Cohen pointed out, that we view, we know it’s going to trickle
down, so we know that whatever we do might impact a state that might not be
ready for this, so we are trying to do that, but one of the challenges will be
to that level of mutual exclusivity and how do we incorporate the mixed
dynamics of our culture?

DR. FITZMAURICE: You’re saying they’re in line with OMB, they roll up into
the OMB categories, correct?

DR. GRAHAM: Yes, exactly.

DR. FITZMAURICE: Did the Committee look at the levels of evidence needed;
for example, if somebody is taking in people for a program, they can use their
own eyeball, they can use the person’s last name, they can ask the person, what
do you consider yourself to be? Is there –

DR. GRAHAM: Yes, I think there was some discussions about that in terms of
the overall scientific validity of the self-report, or the co-self report, if
you’re there and somebody’s asking you, what are you reporting. And I think
there’s always some challenges in there. There’s always some challenges with
the issue of surname data, although there’s some good data that show that
actually it works in terms of identifying folks, we just decided that, so I
think there was a lot of discussion around that, but I think the decision was
to continue to go with the self-report aspect.

DR. FITZMAURICE: I think essentially it’s not so much a matter of the
scientific validity of which category a person falls into, but are they really
deprived of access? Are they really getting a different quality of care? And
being able to discern that in scientific studies.

DR. CARR: I have Vickie, then Len, Marjorie, Paul, Walter, and we’ll close.
So Vickie, you’re up next.

DR. MAYS: Thanks, Garth, for your presentation. A couple of questions,
because I’m trying to ensure I have some clarity about what’s done and what’s
the agenda that is left to do. In looking at your slide, I guess what I
understand is that you got LGBT comments within the race/ethnicity request?


DR. MAYS: So those came in through the listening sessions?

DR. GRAHAM: Maybe I should have explained that better. The law basically
dictated the five areas; race, ethnicity, primary language, disability status
and sex. It also gave the Secretary the ability to designate or develop
standards for additional areas. What the law did say was that we needed to
develop the five basically by this fall for it to kick in by next year. It did
not say and it didn’t really put any strict time lines on the other areas.

Now I think, as Jim pointed out to you, age and socioeconomic status, along
with LGB and then LGBT, are the other areas that we’re kind of proposing over
time. So to be very clear on the LGB portion, we did not believe that there was
enough data ready to propose a definitive LGB or LGBT standard by this fall, by
what we’re supposed to do. And that had to do with some challenges that the
– and I think Virginia can articulate it better when she comes to talk to
you. But certainly, as they were doing the National Health Interview Survey,
some pretesting they had done on LGB questions had shown some challenges there,
so what we wanted to do was to say to the community, we want to develop an LGB
standard. We want to develop activities to improve data collection for LGB and
LGBT populations. It’s not ready now, but we’re going to outline a plan to get
there that includes some funding for the NCHS to do some more testing, and
that‘s where they are in, and that’s what Jim talked to you a little bit
about today.

So that’s a separate but related train, but the train on the five standards,
race, ethnicity, sex, primary language and disability status, that train has
left the building and arriving where it’s supposed to arrive this fall, and the
LGB train has left the building and will take a longer time to arrive where
it’s supposed to be.

DR. MAYS: Let me make some comments, because like you reading Massachusetts,
I suggest reading California, because we have a lot of data on this, and I know
that there is some testing that’s going on. I wish Susan Queen was here,
because she could also talk a little bit more about that; this particular

DR. GRAHAM: Susan Queen from ASPE?

DR. MAYS: Yes.

DR. GRAHAM: Susan has been involved in –

DR. MAYS: Exactly, that’s what I’m saying. I think she could tell you how
much data there really is on that, and it’s a scientific issue, because it’s
actually been in the surveys off and on for –

DR. GRAHAM: We discussed that at length, and stuff with the CHIS and what’s
been going on there –

DR. MAYS: It’s not the CHIS, it’s actually we have the Williams Institute,
there are several other data sources. Some of us have been publishing several
years on the data that actually comes from some of the HHS surveys. But let me
ask my other questions then.

The TI, there’s listening sessions, I agree, I think that that’s going to
take much longer. One of these I’m looking at is the proposed standard in line
with OMB. When you have proposed data standards for race, you have then the
Asian category, and then you have native Hawaiians or other Pacific Islanders.
In the past we’d actually had Asians, native Hawaiians and other Pacific
Islanders, and I know that Inoue was very instrumental in making sure that
native Hawaiians actually were pulled out and had their separate count because
they have a set of very unique issues in terms of those who were in Hawaii,
those on the mainland, et cetera.

In this, it’s actually being – unless I don’t understand it correctly,
it seems that that’s being back-ended to what we used to –

DR. GRAHAM: No, it’s not. It’s pulled out. So it’s Asian standards, then we
have the native Hawaiian standards. It might be just how it’s presented there.

DR. MAYS: Yes, because it says native Hawaiian or – Okay.

DR. GRAHAM: Definitely did not want to do that.

DR. MAYS: It’s a little different on the slide.

DR. GRAHAM: It might have been just the way that my slides are –

DR. CARR: Okay, Len?

DR. NICHOLS: Well thanks for a great talk, and Lord knows, Godspeed. It
raises three questions from me, one of which picks up on Mike’s.

I was struck, in the public comments, what I would have guessed, and that is
a lot of guessing, a lot of recommendation, of a multiracial category, and yet
the decision was made not to have one.

DR. GRAHAM: I can’t say this –- the standards aren’t final. I mean,
that was the original proposed standards, these are the comments. So I’m just
saying that we haven’t – the final –

DR. NICHOLS: So this slide is not what you’re recommending?

DR. GRAHAM: Those slides are what was put out for public comment and in the
comments you see what was received in response to those public comments.

DR. NICHOLS: Okay. So the final decision has not been made yet –

DR. GRAHAM: No; I was saying, that’s a train that’s going to be arriving
this fall.

DR. NICHOLS: So where I’m headed is, have we changed enough, even with what
you put out for comment, that we’re going to have to go back and redo baselines
to really have a sense of how to measure changing disparities –

DR. GRAHAM: You’re saying has the makeup of the –

DR. NICHOLS: I guess the advantage of rolling up to OMB is you can always go
back to the old Latino, whatever.

DR. GRAHAM: This gets into an interesting issue. And it goes into basically
the bang for the buck. So how much have things really changed? So though we
know that, for example, there are more – I use myself, for example,
knowing that there are more Caribbean Americans here, is it worthwhile asking a
question about Caribbean Americans because I know that in New York City they
have got a ton of Jamaicans, and answer to that, basically, is from a fiscal
perspective, no. So though there might be areas where you would like to see
further development and further expansion, it’s not entirely clear whether
there is just enough population dynamics there, even though it’s changed over
years, to be able to adequately say we are going to say everybody should do
this, and you know that states are going to adopt doing that, and so I guess
what I’m saying is, I think we actually still have, just in terms of
percentages of people in the United States, it still does really roll back up,
because things, though they’ve changed, a lot of the drivers have been changes
in the Hispanic community in terms of major population demographics, changes in
Asian-American community in terms of the fastest-growing community, and though
the mixed community has grown relative to where they’ve been the question is
still whether that end number is still just as much as the others, if that
makes sense. So a lot of the questions we got, the mix of black may change, but
we still want to know if black is different from white.

DR. GRAHAM: Exactly. Because a lot of the mixes, and we got a lot of
questions, especially when we did the release, a lot of people were well, you
should do more Caribbean-Americans, you should do more X Americans, and though,
like I said, I would have liked to have said yes, we will, it just wasn’t that
practical benefit in terms of making that the baseline standard.

Now surveys can go deeper, and if you’re doing a survey in some place where
there is so much more diversity, then you can go deeper, but I’m not sure if
adding on Caribbean-American across the board will be helpful to the folks in
– I don’t want to be disparaging to any state, but just the place where
the density might not be higher. Does that make sense?

DR. NICHOLS: It does, although I would point out that to an interviewer’s
point of view, it would be very easy to recognize by the lilt in your voice, we
do love that. That is easy to pick.

But the last question is on this question of T. What is the a priori guess
about the percentage of the population that is T? And the reason I ask the
question is simply, I remember in the health insurance world, where I used to
spend a lot of my time, a lot of focus on this issue of have you been denied an
insurance offer? And we asked the question over and over again, and in the
population at large, it’s like less than 1 percent, couldn’t pick it up, HRQ
dropped the question after a while.

So I just – I don’t mean to imply in any way T’s aren’t worth study,
because there’s lots of clinical implications, et cetera, but maybe the survey
apparatus is not the one to get to them, and maybe –

DR. GRAHAM: Well that’s why we’re having these, a lot of these discussions.
Because if I was going to pay devil’s advocate, a lot of folks might say well,
you haven’t asked about how many T’s are out there, so you don’t really know.
So it is certainly at the national level, breaking new ground, so we are trying
to hear from as many experts as possible, because we don’t know what we don’t
know, and I think that the criticism of what we don’t know on the T end is
– it feels like we don’t know what we don’t know, so we need to do
something to understand what we don’t know. So basically what we’re doing now
with these listening sessions is just hearing from people who have been
knee-deep in this, to figure out what we do know and what we don’t know.

DR. CARR: Okay, so we have Marjorie, then Paul, then Walter. Marjorie?

MS. GREENBERG: One quick clarification; in the race/ethnicity, people –
at least in what you put out, you are recommending a person can report more
than one.

DR. GRAHAM: Certainly I think we might, going back to that earlier question,
certainly we’re trying to have things roll up to some degree into the prior OMB
categories, but we’re not banning anyone from being able to self-report –

MS. GREENBERG: But the OMB standard now requires – you have to be able
to give the person an opportunity –

DR. GRAHAM: That’s the tail part of my answer. You have the opportunity to
do –

MS. GREENBERG: That’s a different issue than having a category called
multiracial. So it’s consistent with the OMB guidance that you can report more
than one? That was not my question, that just came up in this last discussion.
My question was, and you may have heard us talking about this when you came in,
it’s my understanding the next issue, in addition to LGBT, we’ve talked about
that, is the socioeconomic status? Do you know what the timeline is for that?
Because that’s an area that –

DR. GRAHAM: We are hoping that the Data Council and those folks will be able
to complete that in about a six-month timeline period, starting soon. So
unless, and I’m hoping I didn’t put Jim on the spot, because he might have said
a year; if he said a year, go with what he said.

But if not, I think the plan is to actually tackle that next. So we’re
finishing up this, and kind of putting this out there, and the plan is to
tackle that, because it is part of what we are recommending eventually, we just
didn’t have a standard right now.

DR. CARR: Paul?

DR. TANG: Thanks Garth, for an incredible report and work. I just want to
make sure, for meaningful use, that we’re getting aligned with you. I think I
heard what you said is, when we first came out with stage one, that was before
the IOM, so we did what we did at the time; are you – we’re headed for the
IOM granularity in stage three. Is that aligned with you or not? Because you
made a comment about what’s nice, but what’s feasible.

DR. GRAHAM: That’s just in terms of all of these different categories.

DR. TANG: Yes. That’s this work and the meaningful – we want, actually,
all the work to be –- I want to make sure I understand what your –

DR. GRAHAM: I guess what I’m saying is I’m not sure we could ever deliver on
the level of granularity that the IOM recommended in a practical context. I am
not saying that it’s not needed, I’m saying that particularly, even in areas
like electronic health records, and trying to balance the workload, that when
IOM data people come to present to us, actually, and I think actually presented
to us twice, I think part of the challenge, I’m speaking for myself here as the
person involved in all of this, is it certainly is good thinking, certainly
very much scientifically based, but once you get into the practicalities of
going beyond a certain level of granularity, you get into some financial
challenges, both at the Federal and local level, that make that challenging to
do on a practical level.

So I think that it’s good for the IOM to recommend it. I think it’s harder
for us to say you know what, Minnesota; you should be doing all of this, or you
know what, – because it gets into just fiscal challenges.

DR. TANG: But if we require the ability to store this information, using
those granular codes, in the EHR, is that a good thing? It sound like, by what
you said, it might be a good thing for you; first of all, you’re not making the
ask, because you guys had this –

DR. GRAHAM: That’s a good question, actually.

DR. COHEN: We’re requiring hospitals now to report not only five broad race
groups, but thirty-two detailed ethnicity groups. So they’re collecting those
data; it’s only one more data field with thirty-two responses. So the answer
is, how you use it analytically, but the actual task of data collection, if
people are trained, is not that difficult –

DR. TANG: I think it goes back to training – can’t remember which of
you to ask, but it’s training, one, how to do it, how to do it appropriately,
but also how to do it accurately. Because otherwise we’re going to really mess
things up.

So you would not have an objection if this data were to magically populate

DR. GRAHAM: No, I would not have an objection. From my personal standpoint.
I wouldn’t have an objection; there’s just a lot of practical challenges.

DR. CARR: And Walter, last question.

DR. SUAREZ: This is more a comment than anything, but on the privacy side,
going back to that comment, on the part that you mentioned about educating the
community, the different audience, about this in a culturally appropriate way,
OCR, the Office for Civil Rights, is responsible, and is now developing and
maybe it’s already starting to implement, a national campaign to educate
people, just in general the community, about the benefits of electronic health
records and particularly the aspects related to privacy and security, so I
don’t know – there is a connection, of course, between that national
campaign and elements of that campaign to be directed to minority communities

DR. GRAHAM: It’s a good point, actually, and you know, the leadership at
OSA just recently changed and they have a new dynamic leader, so I think it’s
something we can explore. Those actually are good points, so thank you for
bringing that up.

DR. CARR: Well thank you for that very stimulating presentation and the
great work. I appreciate it very much.

Agenda Item: Committee Report Outs (Continued)

Okay, we have one and a half report outs to do. Leslie tells me that she
had some additional information on the population, so you take us through that.

DR. FRANCIS: First of all, I apologize that I stepped out just when I
wasn’t supposed to. This is what Sallie left me from Populations. I don’t know
if she left the same thing for Debbie or not – you have that? This piece,
from Sallie? Then the Populations is taken care of. Privacy is working with
Populations on the CHIP report. Privacy also, as a one-person band, I sent
around my effort to clip out various thoughts that people had had over the last
four years of next steps and what had been accomplished, and so on, and now
that in the Chair role, we are once again a happy duet, the Committee is, that
is, and also Linda and I are, we will be talking over the next week or so about
the ANPRM. I will be getting in touch with people about some areas; I know
several people have volunteered, and we’ll have a draft of that out.

We’ll be talking about further contributions to the CHIP report, and will
be speaking to next steps with respect, I think particularly, to what we just
heard. So that’s what I have to report out, and I’ll ask Linda if she wants to
add anything.

DR. CARR: Walter? Judy did the report out on Standards.

DR. SUAREZ: She did?

DR. CARR: I’m sorry, because we had the window of time, Judy reported on
Standards, and Debbie reported on Population. Paul and Blackford did Quality
and now we’ve heard from Privacy.

DR. SUAREZ: If I may just, one second comment – during the Standards
Subcommittee, we mentioned this, but it’s worth mentioning to the entire
committee – in November, and she mentioned it, I’m sure, Judy did, we’re
going to have three hearings, one on claim attachments, one on Section 10109 of
the Affordable Care Act that deals with some future areas for standardization,
and then one hearing on the standards and operating rules maintenance process
and trying to find ways to improve that process.

So those are three hearings that we’re going to have in November, but the
important point I want to make is –

PARTICIPANT: On the same day?

DR. SUAREZ: No, there’s going to be November 17 from 1:30 to 5:00; the
afternoon of our Full Committee second day meeting. So the second day of
November 17, the Full Committee will probably need to adjourn around 12:30, and
then at 1:30 we’re going to do the afternoon hearing on claim attachments, and
then on Friday morning we’re going to do the hearing on the Section 10109,
which deals with Workers’ Compensation, with claim edits, standardization,
things like that. And in the afternoon on Friday the 18th, we will
be doing the third hearing, which is on the improvement of the standards and
operating rules maintenance process.

But what I wanted to mention is, this is all part of the Affordable Care
Act request for NCVHS to provide input on these new areas, but the Affordable
Care Act also calls for the Health IT Policy Committee and so Paul, this is
mentioning for you the Health IT Policy Committee and the Health IT Standards
Committee, to provide feedback as well, so we’re going to be inviting members
of the HIT Policy Committee and members of the HIT Standards Committee to join
those hearings and so just wanted to bring it up as an information item.

DR. CARR: So just to recap, that means that some folks will be coming in
for the NAHDO lunch, right? For that panel, that’s Tuesday. The meeting is
Wednesday and Thursday. Thursday afternoon is Standards claims, and then Friday
is operating rules and the 10109.

Busy, busy week.

MS. JACKSON: Following up on that, thanks for putting that in the official
record. We will be planning the November agenda to adjourn accordingly, and
this is the shortest period between meetings that we have, between September
and November; this is essentially October, as it were, — need to get a lot of
the action items, the items that I have for action so far are the Community
Health Information Data Report, the HIPAA report will be in action, and then
the EFT Operating Rules. And then you would let me know if there are any
briefings that you would want, but the Executive Subcommittee will be very busy
with these materials coming in by November 1, essentially, for all these

DR. CARR: Is there anybody that we want to have a briefing from then at
that meeting?

MS. GREENBERG: You mentioned on the LGBT and the SES. It sounds like
somebody said the six months –

DR. MAYS: Let’s see, what’s frustrating is to have one and then you don’t
have time to talk. If we’re going to join at 12:30, that’s a really short time
to talk about all this stuff. I’d like to –, because I think there’s some
other – I want to make sure that if we do it, that one, we have time to
propose the questions that we want them to talk about, and then that we have
time to talk about what that means. So I think we need to look at the agenda,
and then let’s you and I and whoever else have a discussion with Jim so that
there’s greater clarity, because there are also other people involved who are
really leading this train.

DR. CARR: And I think also if you want to include the Co-Chairs –

DR. SUAREZ: Just for clarification, the full Committee needs a full day and
a half, so we have a full day on Wednesday and a half day Thursday, so it’s not
just a half day Thursday, the full Committee, we do have a full day of

DR. MAYS: I thought we usually end around three, so we’re ending around

DR. SUAREZ: On Thursday.

DR. CARR: On the other hand, that week, I don’t see how we can put any more
in that week.

All right, Leslie?

DR. FRANCIS: Two second question, I was just trying to check a calendar. Do
we know what day the last Friday in October is?

DR. SUAREZ: Last Friday?

DR. FRANCIS: The 28th. That’s after – our last Friday of
the month is our regularly scheduled –

MS. GREENBERG: No, the third Friday. – Set up October the
21st to approve –

DR. FRANCIS: So make sure – on the ANPRM.

MS. GREENBERG: You will need that set aside time on the 21st.

DR. FRANCIS: So I’m just reminding people.

DR. CARR: Debbie could you send out or make sure that everybody gets it on
their calendar officially?

DR. SUAREZ: And then we need to set up a meeting of the Executive Committee
in early November to review all the things that are going to come back to the
full Committee.

MS. GREENBERG: We had also talked about something more extensive with the
Executive Subcommittee, but we’ll have to talk about that off-line.

And last night people were even talking about the value of having like a
one-day, obviously not in November, but kind of retreat, in a sense, of the
full Committee, to really – because we’re always –

DR. CARR: All right, so let’s put that on the agenda for November. But I
don’t see that we can fit anything more.

MS. GREENBERG: Not in November, no.

DR. CARR: Okay, is there anything else? Now we really are adjourned, so
thank you everyone.

DR. SUAREZ: Thank you.

(Whereupon, the meeting adjourned at 3:00 p.m.)