[This Transcript is Unedited]




September 23, 2009

Washington Marriott Hotel
1221 22nd Street, NW
Washington, D.C.

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

Table of Contents

P R O C E E D I N G S (8:05 a.m.)

DR. WARREN: We don’t seem to have a whole lot of people here. We now have a
quorum with you Jeff.

MR. BLAIR: Okay, sometimes quality time is –

DR. WARREN: With that we would like to go around the room and identify who
is here.

I am Judy Warren, University of Kansas School of Nursing. I am co-chair of
the Standard Subcommittee, member of the Full Committee and I have no

MR. BLAIR: This is Jeff Blair, co-chair of the committee. I am with Lovelace
Clinic Foundation. To my knowledge, I have no conflicts of interest.

MR. REYNOLDS: Harry Reynolds, Blue Cross and Blue Shield North Carolina. No
conflicts. Member of the subcommittee and Jeff’s brother.

DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Restriction
Quality. Liaison to the Full Committee. The only conflict I have is that I am a
FOJ, which is a friend of Jeff.

DR. SUAZREZ: Good morning, I am Walt Suarez. I am a member of the
subcommittee and I don’t have any conflicts.

DR. HORNBROOK: Mark Hornbrook, member of the Full Committee, Kaiser
Permanente, no conflict.

(Introductions around the room)

MS. DOO: Lorraine Doo, CMS, Office of E-Health Standards and Health
Services. Lead staff to the Standards Subcommittee.

DR. WARREN: Just for the record, Jeff and I want to acknowledge that this is
Loraine’s first meeting with us and welcome.

MR. BLAIR: Welcome, Lorraine.

DR. WARREN: Before we start on the agenda, is there anything anybody else
wants to add to our agenda?

(No response)

DR. WARREN: I have one thing to add and we will add it to the end, in that
we need to be talking about our 2009 HIPAA Report that will be due by the end
of the year.

I would also like to give a brief report, I attended the Population
Subcommittee yesterday and we had some interesting kind of proposals that will
be coming out to the Full Committee later this morning.

Agenda Item: Plan hearings on the readiness to
implement 5010 and ICD-10

With that, what I would like to do is kind of open this up for discussion
about hearings in December. Let me give you some preface with that, and then if
Jeff or Harry have anything to add, they will do that.

We have been asked by Tony Trenkle, who is one of our customers, who is very
concerned about the implementation of 5010 and ICD-10 and it’s nearing
deadlines. What he would like to see is for us to hold hearings to see what
people are planning to do. So not really looking at implementations yet, as it
is a little premature, but there is concern that with all of the effort around
Meaningful Use and some of the other things that are happening right now in
health care, that 5010 and ICD-10 are not really being worked on.

I personally have concerns because we heard very clearly in our hearings
that people needed enough lead time to get ready for these two requirements. We
have given them pretty much the lead time that the industry said that they
needed, so now we want to look and make sure that the evidence is there that
they are beginning to plan for that.

Jeff, you want to add anything to that?

MR. BLAIR: No, that is just fine.

DR. WARREN: Harry, you want to add anything right now?

MR. REYNOLDS: (Nods no)

DR. WARREN: So, with that Karen Trudel, Lorraine Doo, Harry Reynolds, Tony
Trenkle and I, had a phone call about two or three weeks ago to see what kinds
of things we wanted to have on this hearing. What I thought I would do is talk
to you about how we see this playing out and then get some ideas from the
committee about how we might put these panels together and begin to craft the
set of hearings.

We began to derive a list of testifier groups. At this point, it is far many
more people than I think we have time for. Right now we were looking at
providers coming in, quality improvement people, various vendors – and
these are EHR vendors, as well as both in-patient and ambulatory,
clearinghouses, hospitals and clinic groups, billing services, health plans,
CMS, WEDI. That is my list. I don’t know if you have any more on your list or
not, Loraine?

MS. DOO: The additional vendors would be the practice management and
software vendors, so not just the electronic records but those that are
actually conducting the transactions on behalf of the providers and plans.

MR. REYNOLDS: Did you mention the training companies that do training?


MR. REYNOLDS: That is training based on the code sets and the possible
process implications that ICD-10 creates. I know I said for example, in my own
company, we are going to have to train more than 2000 people on some facet or
some degree of ICD-10, especially. Your normal process of training is not going
to play out nicely when you take numbers where you are used to doing 20 at a
time, and you start talking about those kinds of numbers.

DR. WARREN: You were also talking about business processes and helping
people understand what those might mean.

MR. REYNOLDS: I think some of those will come up in the questions and
Loraine’s got the copy of it. Remember you had assigned Karen and I and
Lorraine to work on the questions – so we can go over those whenever you
want to.

DR. WARREN: I thought we would try to get down people first and then

Mark, and then Mike.

DR. HORNBROOK: Just a question, I did not hear the words fiscal
intermediaries or carriers, which are Medicare concepts, and I did not know
whether you did that on purpose because you had a broader – but it seems
to me that Medicare is going to be the bell weather here if we don’t have
Medicare –


MS. DOO: CMS would incorporate the intermediaries and carriers because that
is how the work gets done.

DR. HORNBROOK: Similarly, for the states that have Medicaid claims
processing contracts – at least the largest states; New York,
Pennsylvania, Texas, California.


DR. FITZMAURICE: Judy, you might have included this, those who provide
billing services. That is physicians say, here is the paperwork on the people
that came in. Turn it into something I can get paid for.

DR. WARREN: Right. Dan, you had a question?

MR. RODE: Dan Rode, AHIMA. You may also want to also consider the vendors
that are coming up with new products in the area of coding and potentially the
groups that will be working on N-coders because there is a new set of vendors
that will come into the equation.

I would also suggest that you consider looking at some of the smaller
Medicaid’s organizations because I would be concerned that they may have more
problems than the larger ones.

DR. WARREN: I am surprised that you are not suggesting AHIMA.

MR. RODE: I figured we were all ready on your list.

MS. DOO: You are on mine.

MR. REYNOLDS: As we have worked this out, the purpose of the hearing is not
to require people to come in and put them in a position that they may not be
moving fast enough or may not be considering things. The purpose that we worked
on was to get a sense of how people are approaching it, put down some lessons
learned, put down some other things, so that our communication and/or what CMS
could use from our situation, could be sent out to the industry to move people.

This was not a readiness – I mean this is not a readiness hearing. This
is more how are people approaching this? What are the things they are running
into? And we will go through that list in a little bit. So, Dan, in that fact
the reason I am answering it that way is the thing you don’t want to do,
especially with ICD-10, you don’t want to necessarily make people feel that
they are being judged this early in. We are trying to build a body of work so
that people will be able to pick it up and use it whenever they do have the
right time.

We are trying not to be over draconian at this point, in scoring people when
– some of them could say, well, I am not starting ICD-10 till now. That is
a request we had.

DR. WARREN: You said it much better than I did.

MR. REYNOLDS: We are really trying to make sure that we are not going
somewhere that we should not go.

MR. RODE: Thank you, Harry. My concern is we have some of the same concerns
that you do and what I am actually more concerned with right now than ICD-10 is
the 5010 transition because I have encountered in trying to find out where we
stand, a lot of folks who have never been through a HIPAA transaction upgrade.
We were not there for the first one and I think your idea is great and I
definitely like that, but I also think it is also important that I think there
are some folks out there that may be blowing in the wind right now because they
don’t know what to do.

DR. WARREN: I think that is why we had the trainers and companies like. The
other note that I had here is what we were trying to produce is a set of
ah-ha’s for how to think about planning implementation training and transition
into using these.

I have Walter, Mark and Mike.

DR. SUAREZ: Thank you. I don’t know if I heard or not, including Medicaid


DR. SUAREZ: I think that would be an important group. Also, on the provider
category there are a large group of a variety of providers – so in-patient
and out-patient. In-patient there is a whole group of entities from the
traditional hospitals to long-term care and others. Then on the ambulatory
side, beside the medical clinic, there are other important groups that are
going to be affected like dental clinics and ancillary services, which will be
important to consider their way of transitioning.

The other one to consider perhaps, more as a reference point, is the DSMO’s
and the standard development of organizations.

DR. WARREN: Thank you. You had a rebuttal?

MS. VIOLA: Allison Viola, AHIMA. Just something you might want to consider
as you are trying to build a body of work to serve as best practices or
something similar to that is those countries that have gone through this
implementation, Australia, Canada, that could perhaps share their lessons
learned and some of the challenges that they encountered and how they overcame

DR. SUAREZ: You talking about ICD-10, specifically?


DR. HORNBROOK: Help me understand here, we are not trying to do an expose of
how unprepared the country is. We are trying to do an educational lesson about
where the people are who are doing it right and can serve as leadership
examples and teaching examples for the rest of the world who is following
along? If that is the case, I think the burden on us is to find those diamonds
somewhere out there and get them identified and verified.

DR. WARREN: So, if you know of any?

MR. REYNOLDS: Yes, when we took on this assignment we realized that real

DR. WARREN: I think what we are going to find is some are better at some
phase of the process than others, so it behooves us to try and put together a
network there.


DR. FITZMAURICE: I took some lessons from what Harry was saying. We may want
to learn from them what is your baseline? What are you planning to do? What
kind of timeline do you think should be done? Then maybe synthesis that into,
here is what we have heard about how to plan for it. There are different ideas
out there. Not so much a cookbook, since we don’t do this, but learn from the
people who have to develop their own cookbooks and ask them what the barriers
are, the clichés. Maybe it is having sufficiently trained personnel to
actually do this. And where are you going to find them – nowhere, you may
have to train your own people Just lessons like that that help people get

We might have to hear from Blue Cross, from Kaiser Permanente, from WEB-MD,
the people who have large operations that have to do this.

MR. REYNOLDS: As we go through this, in 5010, for everybody who has done the
HIPAA before, 5010 is kind of the ramp-up to ICD-10, it is not a dramatic
change, however the fact that we are changing the code sets forces other people
who have not been at the table. Anyway we can help.

Judy, the other thing I was going to say is I would not be restricted by the
fact that we could not talk to everybody. I would even consider whether or not
we do 2.5 days. The point is we are in the front-end of a huge launch, in the
midst of everything else we talked about yesterday with the Meaningful Uses and
everything else. If we needed to do two full days, two and a half, I am willing
to talk about that because once we do this and then we put this body of work
together – and let us say we do it in December, and we have it out
sometime in January, you are into ‘10. 5010 is due at end of ’11, and you
better be running full speed not too long after that on ICD-10.

That would be kind of the industries main shot in an open public forum. CMS
and others are doing a lot of outreach, but our ability to make sure that we
touch all the right things and all the right people, I don’t want to be
restricted. I would rather look at what you and Jeff, and others, think who we
should talk to. Not necessarily the fact that we just have got a day and a half
and we want to leave these people out because this thing sweeps up a whole lot
of other people we never had before. It sweeps up a whole lot of thinking we
never had before. If we are going to be the launch-point of really pulling this
together in this kind of an environment, a little bit like we did Meaningful
Use, then let’s make sure we have the appropriate list and then we will talk
about whether that is a day, day and a half, two days. Does that make sense?

DR. WARREN: Jeff and I have talked before in planning meetings, and came up
with a couple of alternatives that I think are worthy to consider as we engage
the dialogue. One of them is to have two full days and not a day and a half,
and see where people are in trying to get back out of town with that.

The other one is, what we have done a lot of times in the past, is ask for
written testimony. So that is kind of the second half of the dialogue that I
want to have is what kinds of questions – because we need to start
inviting people like within the next week or two. So we really need to kind of
hone down our questions that we want these people to answer in testimony.

So with that, Walter and then Mark.

DR. SUAREZ: I just wanted to ask this. I think we are sort of jumping from
identifying organizations to kind what kind of questions to what is the purpose
to how long it should be. So we are kind of jumping into different topics and
maybe it would be helpful to sort of go in order to understand what is the
purpose first and then what sort of questions are going to ask.

In the purpose, like I agree, it should not be an expose, but it should
allow us to understand what is the level of readiness in the industry. Not to
expose issues with readiness, but more to understand where are the pressing
points and what are people doing to alleviate those pressing points.

Whenever we are ready to go into the discussion about the purpose and the
question is –

DR. WARREN: Pretty much, I think, Harry captured the purpose. Remember we
are being asked to do this by Tony Trenkle. Harry, do you want to clarify this?

MR. REYNOLDS: I don’t even want to just say Tony. It is important to the
industry and CMS that there be a view as to how things are going. Tony talked
to us but this is really kind of – because one thing I can say about CMS
in general in this one, they are out front quite significantly on ICD-10 and I
commend them for that. So making sure that we get the right people in here.

Again, Walter, where I might push back a little bit is having people declare
this early on rather than declare how they are approaching it and which will
help us understand where they are and where we need to shore them up. There is
a lot of concern that a lot of people won’t come in here and/or you can create
a fire storm that people are not going to get there.

DR. SUAREZ: This time it is different – the implementation process.
This is not a deadline by which we have to comply.

MR. REYNOLDS: There is clearly – 5010 is ’11 and ICD-10 is ’13, so
there are clear dates. But people are – again, this is the first thing out
of the shoot. If you are talking to me in the middle of ’10, then a readiness
discussion may be much more serious from an NCVHS standpoint. We have not been
asked nor do I think this far ahead – and again, most of the discussion in
my opinion, is going to end up on 10. There are people who are coming in who
will be talking about what they are doing on nine – the big groups are
able to do that.

Now, who do we need to pick up and what does or doesn’t it do and what does
it create on some things. Again, working with a partner and a customer, I don’t
want us – it is going to be easy for people to come in here and start
talking about the dates. It is going to be easy for people to come in here and
start talking about I’ve got too much to do. We are looking at the landscape,
the dates are set, nobody is talking about anything other – those dates
are going to happen. That is all – we are trying not to send a signal that
if you come in and you are not far enough along, then you will be identified as
not far enough along, and that is all.

So we are trying to gather from everybody how are you approaching this? What
are doing? You will hear the list of questions. We made a huge list of
questions all ready and subjects. So that is all I am saying. I am trying to
not create some kind of an issue here – we are launching this. This hasn’t
been launched in any open public environment to this point, as to how it is
going, how are people approaching it, or anything else. So, best practices are
not on the table, except CMS has done a great job with their own work and are
passing this out, but not necessarily hearing from the entire industry.

DR. WARREN: Just to follow up on that, we are still crafting the words for
the purpose. I don’t think we are quite ready to do that. When those words get
crafted they will come out to the Committee for viewing.

MR. BLAIR: Harry just mentioned that you have crafted questions. As I was
listening to Harry, and Harry tell me if this is echoing back the overall
guidance you are giving us. It sounded to me like we wanted to know what each
of the testifiers felt were the major challenges, and what are they doing to
address and overcome those challenges?

MR. REYNOLDS: Yes, that is fair. Again, when we go through this category of
questions, not the specific questions, this category of questions that we all
met on yesterday getting prepared for today, and then anybody else will add
areas, I think you will see that it will bring the things to the table –
those that are doing it will be able to explain how they are doing it and why
they are doing it and what it means. Those that are not doing it, would be able
to hear from these questions, even from the people that are doing it, what are
some of the things that they have run into that are different than the other
implementations and so on, so that that could be a body of work used.

I would say this to you, it might not be kind of bad to have not done some
of these other things. If you have this hearing and we get the things done that
are listed here, you might be able to jumpstart yourself without sitting in
your own environment worrying about what I should do. If we get some of these
things accomplished, it would be almost like a consultant coming in and saying,
here are the things you ought to worry about. Here are the things you ought to
do, and oh, by the way, get going on it. Versus right now, that is kind of hard
to get going.

As you know, my day job is implementing these so I feel the pain clearly,
but I also feel the positives. That is why we are doing this and that is why I
think we can be of great service to a lot of people to do it as initially a
helper, and almost the primer, visionary, that kind of thing. Then, I am sure
that starting in ’10, we do have a responsibility to help understand the status
of the implementation and what does that mean.

DR. WARREN: Is that all, Jeff, or can we go on?

MR. BLAIR: It just reminded me, did we have WEDI on the list because I know
that they have come up with a roadmap?


MR. BLAIR: For one of the folks that would testify – I think that the
WEDI roadmap might be helpful.

DR. WARREN: We have that on the list.

MR. BLAIR: Okay.

DR. HORNBROOK: In thinking about the big building blocks, this conversion is
for ICD-9/ICD-10, is a scientific technical and cultural turnover. It seems to
me that if I were going to craft these day and half/two days, I would want to
start off with a very brief concise statement of any differences in principles
and differences in the major conversions issues. What blocks of the code are
essentially mapped over one to one? What blocks of the code are totally turned
on their head? What are the new codes and what are the condensed codes? Sort of
a meta-classification of the mapping, the cross-mapping, to give you a sense of
the theory and the principles that the 10 developers are trying to get to.

I would not spend hours on this. I would just try and do it – hit the
tops of the mountains but to set the foundation for what the technical problem
is and a little bit of what the principles were that the developers of 10 were
thinking about.

Then there is the question of whether it is – I think it is going to
actually happen – but what are the implications of taking existing 9 data and
running it through a 10 grouper. Somebody out there is going to have a 10
grouper that will take 9 data and run it. Of course those of us in research
really need that because we are going to need to have our data in consistent
fashion from 9 into 10, when we have our data systems going across these years.
Some of the systems will do that.

Again, can anybody speak to the implications of that as being a sub-optimal
but feasible way of getting through because they have to send in 10 data that
will get through the utilization review mechanisms?

Then the final third leg would be talking to the folks who actually have to
do the coding. So they are looking at the text language of the diagnosis and
the reason for visit or reason for services, whatever, and they are putting the
number in. That is going to be the medical records people in the hospitals, it
is going to be the physicians in the electronic medical records, and it is
going to be perhaps, billing clerks inside physician offices.

Of course some of those are going to have access to major consulting –
able to come in and help them do it. And they are going to have a huge roll-out
and a training program. They are going to have self-training within the
organizations. A lot of physician practices are going to be left on their own.

Somewhere in that spectrum you want to come down and give an optimistic
perspective on how to get through this, rather than simply saying we are out to
get you if you don’t do it right.

DR. WARREN: I agree. I have Mike and then Dan.

DR. FITZMAURICE: In the questioning, one of the things that come to mind is
are you doing 5010 and ICD-10 in tandem or sequentially? It is laid out time
sequentially, but what tasks are common to both and more efficiently when done
together rather than separately. This would get into areas of training,
software modification, personnel hiring, linking with providers with others who
feed information into your system, and what software do you find helpful in
making this transition? To what extent are they combining 5010 and ICD-10?

MR. RODE: Thank you. Dan Rode, AHIMA. I just mention that some of this
discussion has just occurred at the coordination in the Maintenance Committee
Meeting mid-September. Those decisions are still within the CMS. While I think
the questions are excellent, I think it may be a little premature to try and
get that detailed at this point. I think in looking at what people are laying
out as their roadmap to I-10, they may be able to make some comment on it. But
because the roadmap is two years longer, you may not be able to get all those
answers quite at this point. There will be some other decisions coming out of
Coordination and Maintenance that will impact some of those questions.

DR. WARREN: Are you talking about both 5010 and ICD-10?

MR. RODE: No, just the ICD-10. Among those are the freezing of the code
sets, which was a major part of the discussion in September, and when that
might take place, which will impact what some of the approaches will be.

DR. SUAREZ: I just wanted to comment on the structure itself and the type of
questions. I think we do need to separate – and as much as I like Mike’s
idea of bringing together also ICD-10, I think basically trying to meld
together the two, I think we need to ask a series of questions – and I
have them grouped in my own way – but I am sure we will hear from –

DR. WARREN: Yes, I want to start with –

DR. SUAREZ: So I will wait for that but my suggestion was we need to
separate and talk about 5010 first and have a series of questions on issues
about 5010. Then have specific questions on issues about ICD-10. Most of the
people that are going to testify will be able to talk about both. I suppose
pretty much everyone that is listed will have in one way or another, going to
deal with both, but I think it would be important to address the specific
transitional issues of 5010 and understand how things are going to be
transitioning because as I said, even though there is a deadline, there is a
different transition process this time. The transition itself, from 4010 to
5010 is not going to a major change from what we had, which was from zero to
4010. I think it would be helpful to separate the two and try and address
topics on each of the two.

DR. FITZMAURICE: I agree with Walter and everything is laid out the same
sequentially, so one does come before the other. My contribution was let us
find out from them are they planning to do some things together and save time
and money by saying here is 5010, and you have got ICD-9 in here now, be aware
that ICD-10 will come in and replace this segment of the training we are giving
you today. Or may they would say, we are not even thinking about ICD-10, we are
swamped with 5010. Just information we don’t have.

DR. WARREN: Okay. Jeff, do you have anymore comments about the kinds of
people that we should bring in and gather testimony from?

MR. BLAIR: I have no additional thoughts at this time.

DR. WARREN: With that, I would like to turn it over to Harry and have him
talk about the categories of questions that we have all ready started putting

MR. REYNOLDS: Again, this was an assignment that I had as a member of the
Committee not as the Chair. Playing off of Walter’s comment, I think I would
maybe amend it just a little in the fact that I think one of the messages we
need to hear from people that come in is can you do 5010 and ICD-10 separately?
Shouldn’t you be thinking about ICD-10 in everything that you do in 5010? So
that is one question. I did not say I have the answer – I know how we are
doing it at our place, but that is a question because many people that are
doing it right now feel that it is one effort. The reason is you better build
the platform the right way to – but we will leave that to the testifiers.
That allows them. It is two separate efforts in some cases, but in other cases
it strategically –

DR. FITZMAURICE: Find out what they are doing?

MR. REYNOLDS: Yes, that is a good question. So one of our other things is
bringing in some of the people in early that have done these things before;
what are the surprises? I know for example, I can list numerous surprises.
Having done all this before we can list numerous surprises as to what we needed
to think about, not the issues – so are there any surprises.

Are there industries and adequacies versus previous implementations? So for
example, are their truly a whole lot of people that can help you out there that
have done it? If not, what does that mean? If not, where would you seek help?
If not, then what does it mean?

Again, we are trying to build something so that somebody would know where to
go and somebody would know how to think about getting help. We are not
chastising or applauding, we are making sure that that is on the table. Those
things are issues. They are issues for discussion.

Areas of focus. What are the things you need to do? Mark you mentioned a
couple of them and I put that under ICD-10 codes. The codes themselves –
now that you understand the basis of the code, does that make a difference or
not? So there are things like that. Those are areas of focus.

Best practices. I know CMS has got some best practices. I know other people
in the industry that all ready have some best practices as to how to start. I
did not say how to finish – nobody has finished this yet, ever. I know the
other countries have done it, but the other countries have not really done it
to pay and the other countries have not really used this in an extensive code
set. So I think there are variations there that we need to – so best
practices. Again, if we can get best practices on the table by February of ’10,
that starts giving the world a whole lot better – again, ours is to gather
up the whole flock and bring it forward, not to necessarily prove who the
leaders are.

What is going on in the states? I know for example in North Carolina, we all
ready have committee that is going full speed on how should everybody in the
state think about doing it and outreach and everything else. Are there other
states that are doing similar things? If so, have them come in, testify, talk
about what is going on, so you also know how to group up within your
environment because we all have to get where we are going.

The next thing is ICD-10, the codes, their translations and things to
consider, because this idea of how are you going to use them. And then one
thing that I know is on everybody’s mind is how are people going to pay on
those and what does that mean and some of those things, and whether or not
those get added.

DR. HORNBROOK: Harry, you just mentioned, is there a link here for birth and
death certificates for ICD-10? Is it on the same timeframe or is it a whole
different timeframe?

MR. REYNOLDS: I don’t know.

DR. SUAREZ: Electronic birth certificates?


DR. SUAREZ: The use of ICD-10 codes in the birth certificate system –
is that what you are asking?


DR. SUAREZ: I think that is expected to be done before that but I am not
exactly clear. I think it is October of 2013.

DR. HORNBROOK: You get less lead lag lessons from vital statistics or not?
If not, then just forget the question.

MR. REYNOLDS: It is a good question. I will let someone else figure that one

The next one is strategic opportunities. As the industry goes through this,
what are the strategic opportunities that any groups, segments, individual
companies have come up with that are strategic opportunities that this affords.
Just the more detail on the code itself starts to give you ways to do things
differently. Again, listing those up front by anybody that has come up with

The next one is lessons learned. I would say to you, CMS being probably
number one, has spent an awful lot of time and effort looking this. So what are
some of the lessons learned?

The next thing is outreach. This Committee has heard numerous testimony, and
we will go back to NPI and you can pull up the testimony where there was a
significant problem finding everyone that would be affected by NPI, well, a
number of you have stated there may be some new players in 5010 and ICD-10 that
have not been at the table before in the same way that they are. Much of the
industry is depicting this to be 5010 is 80 percent system and 20 percent
business. These are just philosophies. ICD-10 is 20 percent systems and 80
percent business. We have not had any of the HIPAA stuff or anything that we
have done up until now, that had anywhere near those kinds of percentages as it
related to business versus systems. So that is another key discussion.

Let me finish the list and then Judy has got the ball. We made a list of all
the things that we have. We did not say it was complete. We were asked to bring
something in to start the discussion today – period. Then I am going to
stop talking about it.

The outreach – the testing. The testing on some of this will possibly create
that entities – and I know if we were testifying, there are dramatic
differences on how you are going to test this and what you might or might not
have in place with your current testing environment to be able to do these
things as you go forward. That is another one.

Training – we all ready talked about that some as a group. What not to
do? I was in a meeting the other day – great example, I was in a meeting
the other day where somebody said, I am starting to get contracts from people
that are committing that they will be ICD-10 compliant. So we may talk about
some of the things that are out there now and what might that mean because
there are going to be a lot of people running around looking for help and maybe
there is some discussion about what they might not think to do.

With that, to the Chair, I have submitted our list for consideration.

DR. HORNBROOK: This is a check on the level of detail you want to go. If you
are a hospital, ICD-10 are going to have to go into the DRGs. Do you want to
talk about how in the world CMS – or do you want them to talk about how
they are going to convert to an ICD-10 based DRG system? Then for HMOs, they
are getting paid by APCC and the risk adjustment mechanism underlies APCC, when
is the ICD-10 diagnosis going to be put into that and will it change the
payment co-efficiency? Medicare fee schedule – if you have to submit a
bill with the diagnosis on it, what kind of affect is it going to have on your
payment if your diagnosis is illegal? Is it any different than the current

That gets you into utilization review and compliance issue. Is CMS going to
have a period of grace here? Are they going to be draconian and throw
everything back that doesn’t need the screening criteria for strong teaching
position? I don’t know how far you want to go down this in the space of two

MR. REYNOLDS: The initial discussion that we have had, and again just to put
it on the table, this is not to come out with everything they might or might
not have to happen in not putting CMS ahead of where they are or anybody else.
This is talking about the people that are having to start thinking about —
your list of questions is a great set of questions for us to come out of this
with to say if you are doing this, these are things that you are going to have
to make sure that are straight. And when they are available, you know that you
had the question.

The most important thing I think we are trying to come up with, how do you
give all the people that are doing this – how do you learn from the ones
that are all ready moving and how do you give the ones that are moving and are
not moving, the other set of questions? That as they go back home and try to
make something happen and we put this out as a print – however we put it
out – it allows the water level in the industry to rise because if you
give somebody the questions that they did not even know, you dramatically
affect their ability to make a difference with it.

I think that is how NCVHS, working with CMS in this case, can get in front
of this because we are doing it in an open forum, we are doing it in a way we
are asking people to come in and talk about it and we are doing it in a way
that then it can be filtered into everything that CMS is doing, everything that
the rest of the industry is doing, everything the states are doing. So that is
our purpose in doing this.

So rather than getting those answers because those answers will come out
whenever the individual entity that is being discussed with, would be ready to
answer that. Having that list of questions is – we have been working on
this a long time and I did not have this list of questions. I love those
questions – I would take them out of here and use them.

That is where we are going. It is not to say, tell us right now how you are
going to do something. It is to say, what are the questions you better have so
that when they come out you have at least thought about and you better be

DR. WARREN: Right.

MS. DOO: I actually have a couple. All of your questions are very
operational like what is CMS going to do? Which is a little bit different than
what we were originally planning for this forum, which is what is the industry
preparing? What are they thinking about?

These are great questions for me to take back. I know they are working on
them but it is a whole other area of CMS, and very valid, and maybe it makes
sense to have something for us to think about, because we have not talked about
it, is a grounding of here is where CMS is. Here is where Medicare is. Then we
want to hear more from the industry and then we will come out probably, with a
whole compendium of questions.

That is part of a preliminary response because I need to think about it a
little more because they are great issues.

The other thing I wanted to mention to complicate things a little bit is we
talk about 5010, there is also D.0, which is the pharmacy transaction. And
there is 3.0, which is the Medicaid subrogation, which has never been done in a
standard that everybody has to comply with before. So that is a new standard
between Medicaid’s and health plans and we need to address that as well, and it
is something we should think about including in this as well.

DR. WARREN: Is that the NCPDDP 3.0?

MS. DOO: yes.

DR. FITZMAURICE: What is subrogation? Is that where Medicaid pays and then
comes and gets the money back from Medicare?

MS. DOO: Yes, it is not Medicare, it is from private health plans. It is the
pay and chase’s philosophy of oops, we paid this. We should not have. You
actually owe it. Now there is actually a standard for it that we have adopted
and everyone calls it 5010, but it really three new changes that have to

DR. FITZMAURICE: I suppose it would not be – why not let the private
companies do the pay and chase? Chase Medicaid – that is a policy issue
that we don’t need to get into.

DR. WARREN: No. Thank you. Walter.

DR. SUAREZ: I have three comments. The first one, the pharmacy should be a
specific segment of the industry that we should look into to understand better
their work. That is another sort of category of people to come. The other one I
thought of which is something that came up from Harry’s comment is where are
states. There are state groups in the nation that are helping in the state the
industry to proceed. I always try to give the state where I feel I belong to,
which is Minnesota – in Minnesota there is a specific group that is an
industry group called the “Administration for Vacation Uniform”
– and administration uniform committee, which is the group that is leading
in industry the transition development. They discuss all the issues about 5010.
It is sort of the group that meets every month to address and review and they
have workgroups to look at specifics. I think it would be great to have –
there are probably a group like that in several states.

The second comment is I tend to think in a more structured way so I try to
organize the groups of questions that we would try to ask. I found that there
might be too many categories. We want to ask a few overall questions. We want
to ask a question about preparedness. We want to ask a question about
coordination, transitioning – which an important part of this is the
transitioning. This is the first time that we are going to have two standards
acceptable during a period of time; 4010 and 5010.

So even though we have a deadline of January of 2012, there is a period of
time where 5010 and 4010 are going to be available and permissible. So
transitioning will be another category.

Testing, remediation, implementation and allocation. Those are the
categories of questions I was thinking we could ask. They are just my
categories. I can send them to you via e mail.

Then the last comment I want to make – this is a very critical
opportunity. I have been involved in some of the discussions that have been
happening at state level preparing for 5010. There are a number of issues that
are specific to the transition. For example, NPI. How NPI is going to be done
5010 is going to be a little different. There is some transitioning of the NPI
approach. NPI is one type of issue.

I have companion guide, which is another interesting aspect of the
transition. Paper transactions, of course, we always have to think about. The
qualification of things like the insured versus the subscriber versus the
member – major issues on 5010. They totally revamped 270-271.

I have a whole host of more detail issues. Even when you think about it,
there are specific issues about each of the nine transactions that we are going
to be transitioning. Even though are thinking more overarching, it will be
helpful to ask people what are your three or four issues – five issues
– for the various transactions. A-37’s, the A-35, the coordination of
benefits. The 270-271, it is a mess – not a mess but it is a very
challenging one because it is a major transition. So there are specifics.

Those are some details that we can throw into the mix.

DR. WARREN: Let me ask for clarification so that I understand what you are
saying. We sort of talked about or a comment had been made during our meeting
that one of the ways we might want to start out the hearings is to have an
overview of what the changes were in 5010.

So all of the stuff that you just talked about, if that were included in
this overview, do you think that would be helpful? Also, to illicit some of the
questions that we need people to start asking.

DR. SUAREZ: I do think that would be helpful. I do think it would be helpful
to ask people to specifically identify in their testimony issues related to
some specific priority topics, if you will, that the industry has all ready

To dive a little more into the specifics about what other things that need
to be done between now and 2012, it would be helpful.

The last comment, I think, and Lorraine you clearly hit it too, I think
there is a major distinction – I have always highlighted that, a major
distinction between CMS, the regulator CMS in Medicare implementation. So when
we say go to CMS, we do need to think that CMS could do also some of the
overview – kind of the 5 minute overview, 10 minute overview, on what the
regulations are, the timelines, and the specifics. And then Medicare, itself,
can be a testifier for different groups.

DR. WARREN: Mark, Mike, and then Harry.

DR. HORNBROOK: Just a random thought here. We need to ask ourselves at some
point, whether it is really bad or good to ask the trade associations, the AHA,
AHIP, AMA, MGMA, State Medical Society, Society of Actuaries, whether they have
something to add or they just get up and preach at us. Some of them have huge
memberships and huge resources.

DR. WARREN: We would sort of lump those under provider and would tease those
out because those were all examples of what we meant by providers when we were
coming up with the initial list. So provider is this really huge bucket right
now with lots of stuff in it.

MS. DOO: I think you are right. What we don’t want from the associations is
just a list of what the issues are but some real representation from real
providers talking about what they are doing, what their practice vendors are
doing, because we have heard all of that. So we are really trying to get some

DR. WARREN: Okay, Mike.

DR. FITZMAURICE: One area we should probably look at is the quality
improvement activities. That gets into what changes we have to make in your
screening software, in your quality measures, in your performance measures,
because if anything, because of the move from 4010 to 5010, and certainly
because of the move from ICD-9 to ICD-10.

They might also comment on their meaningful use performance measures. So
maybe Harry might want to touch base back with ONC to see are there any
questions you would like to have us ask about these quality improvement
measures that get into performance measures. That maybe they would reveal to us
before some other testimony before the other FACA committees, what issues they
have with a meaningful use performance measures? Is there clear enough guidance
as they move from 2011, 2013, 2015, enough guidance from ONC that they know
exactly what they have to report and what the codes are that they have to
report? Or will this throw them for a loop?

DR. WARREN: Again, let me ask a clarification question, and this is for
Lorraine and Marjorie, as well. Currently CMS requires the reporting of certain
events, which are also some of the quality metrics that are in meaningful use.
When we do that, is it ONC we should talk to or can CMS, the regulator, speak
to that?

MS. DOO: CMS should be able to speak to that.

DR. FITZMAURICE: Both. Or maybe it is CMS. CMS, also, for the meaningful use

MS. DOO: Right.

DR. FITZMAURICE: Since CMS has to receive them. You are right. Good
clarification, Judy.

MS. GREENBERG: I just wanted to echo what Mike said because as I think back
on the cost-benefit analysis that this committee commissioned for the
transition to 10-CM and 10-PCS – of course they go together with the 5010.
All the benefits had to be kind of estimated because it was to some degree,
hypothetical. It is a hard thing to do but they were very much focused on being
able to do better disease management, better quality monitoring, and all of

Again, I think it is an opportunity that we really want to encourage. Kind
of like what somebody was saying yesterday about the whole HIT and EHR
revolution, that there is a lot of potential but it is very possible we won’t
realize it. I think that is a role that we should really play.

DR. CARR: Mike, that really peaked my interest what you said because a
couple of years probably after the ROI was done, the patient safety indicators
were developed through AHRQ and they are very ICD-9 dependent and they are
embedded into a current screening and P for P and all of that.

Would AHRQ reconvene a group to do the cross-walk from ICD-9 to ICD-10?

DR. FITZMAURICE: We should ask AHRQ that. I don’t know but a good question.

DR. CARR: That is big.

DR. FITZMAURICE: I know the place where that work would be done. I don’t
know that it is going on.

DR. CARR: I think that is a very important one. That is a great example
because there is strictly built off the ICD-9’s.

Right now, a couple of years ago, we made these patient safety indicators.
So who is doing the cross-walk of those?

MS. GREENBERG: That is being done by CMS and NCHS. There is a contract with

DR. CARR: I understand that but there are really two parts to it. Because
these are coded interpretations we find year over year, even with the existing
ones, that there were nuances that were not anticipated. I would say it was a
two-step thing; one is that you do the actual cross walk, but the other is to
go back and say, when I look at the universe of these things have I included
people in the population that I did not mean to or have I excluded ones that
should be in?

So there is really a quality analysis that goes with the patient safety

MS. DOO: Right. CMS is doing the cross-walk from ICD-9 to ICD-10. But there
is work, whether it is AHRQ or any organization has done based on ICD-9, you
are absolutely right, everybody has got to redo their work and now using

DR. FITZMAURICE: I think what Judy and Lorraine are talking about, and
please correct me if I am wrong, is that it is an issue of the validity of
these patient safety indictors; are they still valid and do we still know to
what they apply?

MS. GREENBERG: You might want to get some testimony on that.

DR. CARR: I think that is really important.

DR. WARREN: Let me clarify that. So get some testimony on once we take these
indicators and switch them from ICD-9 to ICD-10, are they still valid for the
purpose for which they were –

DR. CARR: Right, because most likely it is going to be a one to many
relationship. So then as you look at the many, do you want to include them or

MS. GREENBERG: 3M is not only doing the cross-walks, but they are also doing
the mapping to the MS DRGs. So there is that work too, that will inform the
process. They should be posted on the CMS website from ICD-9 CM Coordination
and Maintenance Committee meeting, a very comprehensive report or set of
Powerpoint slides, by Rhonda Butler from 3M, about not only the actual mapping
of the two classifications, but then the mapping to the MS DRGs. I think that
would refer you to that.

DR. WARREN: Let me ask a question and then Justine you can reply and then it
is Harry. When I am thinking about the purpose of these hearings and what we
are doing, this seems to be something that we would want to investigate after
we have the first set of hearings. This would be a follow-on, because this is
more implications. Where what we are trying to do at the hearings is to
identify best practices for people getting to do the implementation of 5010 and

So does that kind of fit with what you are thinking, Justine?

DR. CARR: That logic makes perfect sense but in the meantime, I mean, maybe
you will be bringing that back to AHRQ.

DR. WARREN: It may be something that Standards and Quality want to take a
look at doing there as we go down this path to adopting ICD-10 and so what are
the issues in quality metrics, et cetera, that your subcommittee – your
other subcommittee – chair is looking at.

DR. CARR: In a way it is a follow-on to the hearing that we had probably
three years ago, about administrative data as part of quality, and being in
this hybrid world. Because the other thing that could change, if we are looking
ahead to 2012, is that as EHR data becomes more available – even
independent of 5010, would we be looking at a greater reliance on EHR data and
a lesser reliance on administrative data? So it is a very interesting –

MR. REYNOLDS: I think if we could take all of these things that we have
heard about, make sure that they come up with subjects, there is an entire
ecosystem out there. It is a little bit like how do we train the village to go
help everybody rather than it takes a village to do something.

We just talked about other NCVHS hearings, we just talked about something
that AHRQ could pick up, we just talked about referencing a document that is
all ready out there from what somebody is doing. There is conference, after
conference, after conference, going to happen on this. If we can build a body
of work out of this hearing – not every answer – the body of work as
to what the questions are, what the issues are and the other things, then as
you look at all these conferences that are going to go on, hopefully that will
be what they will use to pick up and go that next level. We are talking about
two, two and half days.

I know, as I said, in my day job, I can bring enough questions in here to
keep you busy for two and a half days – as far as that is concerned. I
think if we can build that body of work, build things to look at and things to
do. If we decide as NCVHS out of this, Quality could pick this up. If Mike came
in and said, that is something I know that AHRQ is going to be working on. If
we heard from other people in the audience – that is one of the things we
will make sure is covered in our next conference.

Our point is to energize the entire industry – and industry being
everybody, in that this is going on, that it is happening, what are people
learning? We have not done some of this before, and oh, by the way, here is
your check list. Here are your things to think about and here are the things to
do. Oh, by the way, we are going to take these three and NCVHS will go deeper
here, and then we hope the industry and others pick these others up. If not,
then maybe we need to have another hearing to go deeper into that. We are going
to be sitting here going, whoa, never thought of that one. Whoops, did not know
somebody was running into that. That is the body of work that we are going to
try and do in this first initial kick-off.

But for some of us that are ahead of the curve on that, that is not where we
want to end up. That is for sure. We want to get a little further faster. But
we got to bring this whole group together – and there are a lot of people
out there that can’t even have the discussion we have had today, let alone be
talking about what they are going to do with it.

DR. CARR: Perhaps you covered this before I got here, but I think a key
piece of this is how institution’s budget for this. Is that something that we
had talked about earlier in terms of what are the elements to think about and
how do you anticipate and properly budget?

MR. REYNOLDS: For example, I just got our budget approved last week for all
of 2010 on ICD-10 and 5010. Again, those are the lessons learned. Those are the
things to tell people.

DR. CARR: I think the breakdown of here are the categories of workforce that
you need, IT time, whatever it is, so that at least there is a roadmap for how
to anticipate.

MS. DOO: I think – Harry, correct me because you would know it –
the WEDI roadmap for project plan, I think has some of that in it. So when they
actually do their presentation, assuming we are going to invite them, and
Walter you would know as well, they try to anticipate some of that. But the
industry is so huge and diverse – it can only be buckets.

MR. REYNOLDS: But I think if you took a panel and you had WEDI talking about
the general roadmap and then you took some of the entities – say you took
a state and a couple of entities that are all ready well into it so that they
could play off of that, now you start saying, this is a great overall picture
but oh, by the way, here is some of the things that are specific in there that
maybe don’t come out quite so easy.

So if you built that panel and they could look at the WEDI roadmap that was
presented and then they could take it down and say, in these areas if you are
this kind of group you have this issue. If you are this kind of group you have
got this issue. That is the kind of thing that I think then starts.

Hopefully, whenever we finish, I wish I had had this before we started,
somebody doing it could pick it up and start making a difference in their own
shop and be much more educated than they could ever get meeting with a vendor,
a person, a group. We can give them the subject and then we can help shepherd
the subject between now and when they are all implemented. But boy, I think we
could be a big service to the industry – the entire industry – and I
mean people in industry that have not been in before.

DR. WARREN: I wanted to leave time for all us to take a quick break before
the full meeting starts. We have got about five to ten minutes left of the
meeting. For this topic on the agenda, are there any last comments or thoughts
that people want to add to it?


MS. BICKFORD: As you were talking about engaging the industry and helping
flesh out the ICD-10 issues, you might think about e-Health Initiative in
helping them organize strategic initiatives to focus on the actual
practicalities of ICD-10.

DR. SUAREZ: Quick addition to the testifiers and a concept that I think is
also – it used to be one of the big issues when 4010 was around, or its
implementation was, the quote/unquote certification of a compliant transaction.
There used to be this vendor priority and others, that would validate and help
the industry – well, trading partners, confirm that this is truly

It might be helpful to understand what role that group or that type of
services would play and to what extent it would be needed this time around, as

DR. WARREN: This is certification of the transaction before it goes to CMS?

DR. SUAREZ: If it is compliance confirmation, more than certification – the
confirmation that the transaction is compliant with the standard.

MS. DOO: With the format and the content. This says you have got it right
and not just to CMS.

MR. REYNOLDS: Many people have set up websites that were standard that can
take the transaction, process it, and go back to – Why don’t we have that
category be testing/certification, because both of those really go hand in
hand. You can test all you want to – if you are not certified then your
testing is just your own joyous event rather than something that plays in the
real world.

DR. HORNBROOK: This is getting into the level of micro-detail as we close
down. But from the perspective of a Medicare Advantage contractor, these data
conversions have very important compliance implications however CMS chooses to
do this. All HMOs with Medicare Advantage contracts send pseudo claims data to
CMS – even though none of us ever see it sitting there, it never gets
used. I guess it gets used for setting the AAPCC for risk adjustment.

One of the questions of course is, how is CMS going to manage the transition
process in the AAPCC from one system to the next and how many years is it going
to use a mixed or weighted approach or is it?

Then there are a series of data reviews that the intermediaries and the
carriers impose in the data pipeline – because we send data through the
pipeline that the fee for service hospitals and providers use – and they
use the same data screens as fee for service gets. So, HMOs are on the cusp or
on deck for under and over reporting, both diagnoses, upcoding and undercoding
and procedures, upcoding and undercoding.

So there are some issues here about whether business risks are going to
change for the HMOs the Medicare Advantage contractors in this particular data
transition because there seems to be some black holes in here that could end up
with somebody getting a huge fine because they did not understand how CMS is
going to interpret the compliance issue.

DR. WARREN: So, you are concerned about data integrity basically; are codes
being put in appropriately? Will they be used appropriately? What changes in
business does this change have? Whether anybody is going to get thumped with a
big stick if they don’t get it right?

DR. SUAREZ: Right.

DR. WARREN: Any last comments?

MS. DOO: I will just say this. All of the questions are really similar to
what we went through in our CMS Gap Analysis, which is what every organization
has to do. It is iterative. We just keep finding things under every office and
every department and then there is the hand that gets raised three weeks later
saying, wait, we just thought of something else. All the things you are
bringing up we have been through and every organization is going to have to do.

DR. WARREN: Okay. So I am going to bring closure to this part of the agenda.
We will be putting out a list of questions. Jeff, do you have anymore about
this set of hearings?

MR. BLAIR: I do not at this time. I am very sorry I was not able to be with
everyone. Thanks for allowing me to kind of tie in by phone. I look forward to
seeing you in November.

DR. WARREN: Okay, but we are not quite done with the meeting yet. I just
wanted to let people know too, that we are getting ready to write the HIPAA
report that we are required by law to write. We will be putting together the
2008-2009 report. That will begin sometime soon, after Marjorie and I finish
negotiating how that is going to happen.

Do you want to make any comments about that or is that enough?

MS. GREENBERG: I did talk to Dale Hitchcock yesterday and asked him to
follow-up with Jim Scanlon. We have gotten some help from Jim’s office, the
Data Policy Office, in the past. I assuming this will be a joint venture –
the writing of it – with CMS.

What I would encourage everyone to do is go back and look at the 2007
report. I don’t think we have to repeat everything that was in that report but
I think we can refer to it. It is on the website so people have easy access to
it. Actually I think it could really enrich the 2008-2009 report, to include
some information or findings whatever, from this hearing that you are going to
have because this is exactly what I think, Congress would want the committee to
be doing. Since the last report, two major regulations have come out. Of
course, I guess NPI has been implemented since the last report.

I can think we can be pretty brief on the history and then focus on the
major activities that have taken place. Hopefully we can – I think our
goal would be to have a draft by the December meeting.

DR. WARREN: Do you mean November?

MS. GREENBERG: Your December meeting. Which would not include of course,
anything from the hearing. I would think we would want to have it approved at
the February 2010 meeting by the Full Committee.

DR. WARREN: I think that is realistic for us to take a look at even with the
hearings coming in December. Justine is worried.

DR. CARR: Do we have an outline of what are the elements that we include
year over year? It has been a while since I looked it up and I know it is the
letter. Even abstracting from that, that every year the following ten elements
are reported on, and do we go back and seek quantitative things? How many
– the OCR things. They have looked at the CMS complaints?

DR. WARREN: I don’t know. Do you know of anything like that other than to
pull the old reports and look at them?

MS. GREENBERG: I know the first several years we just kept going over the
same territory. Then I think it may be the 2007 report where we really tried to
streamline it. I think if we look in the legislation – if you look at the
hearings in the last report, again, I think that can be really brief, what are
the standards? What are the ones that have all ready been implemented? Which
ones are still in development? What progress has been made since the last
report to congress? What activities has the National Committee been pursuing?

First it is kind of a review of what the Department has done because the
committee is suppose to be monitoring that. Then specifically, what the
National Committee has done and then what are the outstanding issues? By the
time this actually comes for approval, it may be new responsibilities for the
National Committee in health reform legislation. There would probably be some
reflection on that, too.

Generally, I guess, we included a little bit about e-prescribing but that is
more under the MMA. As I said, then actually the 2007 report included this
lessons learned sort of reflecting on the 10th anniversary of HIPAA. As I said,
I think the first place to start is to review this report – you can look
at the legislation too, but I think it is very general. It is like a few
sentences at most as to what the report should do, but it is always good to go
back and look at that.

Then I think read this with fresh eyes. Most of us haven’t probably looked
at this in quite a while, and just see if you want to follow this within in the
legislative constraint – follow this general structure or you want to do
something different. I think this probably provides a good structure.

DR. CARR: My recollection is that it is qualitative. I am just making a plea
for consideration of putting some quantitative things in.

MS. GREENBERG: Like what type of quantitative? Because certainly it does
always talk about the specific standards with how many have been implemented,
how many have not been implemented. Which ones are still outstanding? Where
there needs to be more work.

What kind of quantitative –

DR. CARR: Let me take a look at it.

DR. WARREN: I can see – I really agree with Justine on some of the ways
that you can use tables to clarify things. While you may want to describe those
in paragraphs, it would really be nice to have it summarized at the end with
here are the things that have been finished. Here are the open questions.

MS. GREENBERG: If you look at the Bacchus Bill, they sort of go through a
review of what was passed, what was not. I think a table would be very nice.

DR. CARR: I remember Larry Green’s first meeting, he was a little bit
outspoken about certain questions people might want to know. So it might be of

MS. GREENBERG: The other thing is I would definitely engage the Privacy
Committee and ask them to actually take the lead on that section because it is
part of HIPAA and they have done a huge amount – and again, we can just
refer to things that will all ready be on the web. I think if Lorraine and ASPE
could work on the whole standards part of it and they could do the privacy part
and security.

DR. CARR: I think we have a good story to tell really. Looking at it, here
is where we were, here are the hearings that we had, the recommendations that
we made, here are the new changes is ARRA legislation. To kind of demonstrate a
kind of journey.

MS. GREENBERG: A think a nice executive summary – we can use sort of
nice meaty – because there is a lot to tell – one of the advantages
of not doing it for a while – there is more to tell, but a nice executive
summary. We could also use as part of the 60th Anniversary and outreach and all
of that. That doesn’t get written until after you have done the first of the
report but I think we should think in terms of –

DR. WARREN: We should just blow our own horn is what you are saying, an
executive summary and say –

MS. GREENBERG: It could even be like a little monogram.

MR. REYNOLDS: Also, I think if you add in there how we have been able to
help streamline – something like the NCPDP. In the past everybody thought
about standards being overly cumbersome, taking forever, we have been able with
NCPDP, to move that along with the reverse –

MS. GREENBERG: I think something about the committee’s effort to look at
streamlining and the problems that are caused by this long regulatory process.
I certainly think that is still relevant. We will see if maybe there is some
remedies that come out.

DR. CARR: Even a timeline would be nice. We did that in the uses of data
where we sort of said, historically these are the things that have happened.
This is what we have done. This is where we are going. I think a timeline would
be very interesting.

MS. GREENBERG: yes, and also visual aids would be good. It can be kind of a
dry report but it is really important.

DR. WARREN: Okay. We have five minutes until the main meeting. Unless there
is something pressing, I’d like to adjourn this meeting.

(Whereupon, the subcommittee meeting adjourned at 9:25 a.m.)