[This Transcript is Unedited]

National Committee on Vital and Health Statistics

September 23, 2014

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

Proceedings by:
CASET Associates, Ltd.


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

Agenda Item: Call to Order, Review Agenda

DR. GREEN: Welcome. I think we will commence. We will very quickly run the table. Have people introduce themselves again. This is day two of this session. We are starting out with the Populations group leading the meeting but before they start, we will start over here with Raj and reintroduce ourselves for the record.

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

MR. BURKE: Jack Burke, Harvard Pilgrim Health Care in Boston. Member of the Populations committee, Privacy, Security and Confidentiality committee. No conflicts.

MR. SOONTHORNSIMA: Ob Soonthornsima, Blue Cross and Blue Shield of Louisiana. Member of the Full Committee and Subcommittee on Standards. No conflicts.

MS. JACKSON: Debbie Jackson. National Center for Health Statistics, CDC. Acting executive secretary.

DR. GREEN: Larry Green. University of Colorado Denver. Chair of the Full Committee and on no subcommittees.

MR. SCANLON: Good morning. Jim Scanlon, HHS, executive staff director for the Full Committee.

DR. MAYS: Vickie Mays, University of California, Los Angeles. Full Committee and members of Pops and Privacy.

DR. FRANCIS: Leslie Francis, University of Utah. Member of the Full Committee, co-chair of Privacy, member of Pops and no conflicts.

MS. KLOSS: Linda Kloss, health information management consultant. Member of the Full Committee, Privacy, Security and Confidentiality, and Standards subcommittees.

DR. STEAD: Bill Stead, Vanderbilt University. Member of the Full Committee and the Pop Health Subcommittee. No conflicts.

DR. COHEN: Bruce Cohen, Brookline, Massachusetts. Member of the Full Committee, co-chair of the Populations Subcommittee. No conflicts.

DR. CORNELIUS: Llewellyn Cornelius, University of Maryland. Member of the Full Committee and the Population Subcommittee. No conflicts.

MS. GOSS: Alix Goss, Pennsylvania eHealth Partnership Authority. Member of the Standards Subcommittee and the Full Committee with no conflicts.

MS. WILLIAMSON: Michelle Williamson, CDC, NCHS, staff to the Standards Subcommittee.

DR. PAUL: Tammara Jean Paul, CDC, NCHS, staff to Population Health.

MS. JONES: Kathryn Jones. Staff to the committee.

(Introductions around the room)

DR. GREEN: Okay, I think we are good to go.

Agenda Item: Population Health

DR. COHEN: Thanks. I will start out. I will spend the first half of the Population block talking about the roundtable that we are going to be having on October 27 and 28. Then I will turn it over to Bill and he will talk about where we are with the framework activity.

We have been spending an enormous amount of time planning what will be an exciting day and half roundtable. The focus – and you have in front of you the latest version of the agenda.

The goal of the Framework is to bring together community. The name of the roundtable is Supporting Community Health Data Engagement. The idea is to bring together three groups; community data users, folks that we are calling data connectors or intermediaries, and data providers.

Our notion is that these three groups have not had a chance to be in the same space to discuss how best to share information. Our goal is to have conversations that will promote the use of data. Basically having the community and this whole group of data intermediaries or connectors, describe their issues, their gaps, and some of their successes using data. And having the data providers primarily feds, but other data providers as well, listen and react to how they can disseminate their information more effectively and efficiently to be used at the community level.

We are very excited by this. I don’t know if these three groups have been in the same physical space together to hear each other’s perspectives.

The roundtable is going to focus on interactive conversations rather than presentations. We hope enough background material will be provided beforehand, so everyone will come in educated to some extent, about what the community activities are and what the data connectors do as well.

We so far, where we are at in the planning is, we wanted to cast a wider net than folks who could actually be present. So we have developed a feedback tool – an online feedback tool that we distributed to our colleagues at universities and community coalitions, to send out to their networks to get feedback that will help guide some of the conversations and help us actually form recommendations.

What do we want to see as an outcome for these two days? Our focus is on developing recommendations for the Secretary and for HHS about what the feds can do in terms of not doing additional work, but reorienting some of their existing work to be more useful and valuable at the community level. We recognize that we cannot ask for more resources, but there might be better ways to serve communities with existing resources. So that is our ultimate goal.

Copies of the feedback tool were just provided. If anyone wants to distribute the feedback tool to networks or colleagues or community organizations or data providers, please talk to Tammara and she can give you the appropriate URL. This is an online feedback tool that will take 10 to 20 minutes for data organizations to complete that will help provide context for our conversations.

Our goal is to try to get as much feedback in the next several weeks, so that we can analyze it for use at the Roundtable. This is a really superb tool that I would like to see continually in the field so that we can perhaps accumulate more feedback from a variety of groups even after the Roundtable. We have got I think, between 20 and 25 online responses so far. So that is the feedback tool.

I will stop briefly. That is not going be my focus of my discussions but if anybody has any questions about that?

MS. JACKSON: If it is acceptable, you can just forward that onto the Full Committee just so that they will have it for information.

DR. COHEN: Okay, that is perfect. If you could send it on to the Full Committee and the Data Work Group as well, that would be great.

DR. SUAREZ: This is Walter Suarez with Kaiser Permanente. I don’t have a conflict. I am a member of the committee.

I have a question. Do you have or does the tool include a set of definitions – term definitions – that might help people understand some of the terms or concepts used? Or do you see no need for that?

DR. COHEN: We did not include definitions and terms Walter. I think people will self-select and they will understand the content. We tried to make it as self-explanatory as possible. Feedback on the feedback tool is always welcome if you think we are missing some definitions. We can add that to the current content. It is pretty easy. I will defer to Tammara, but I think we can add information if we think it will be explanatory and more helpful.

DR. SUAREZ: Have people used already, the tool?

COHEN: Yes. I don’t think Tammara has had a chance to analyze any of the data but we did try it out on some folks and it has gone through a variety of iterations. We will see what we get. Feel to send – I know you are involved in lots of different networks, if you think it is valuable.

DR. PAUL: I was just going to comment, it is very easy to update. So if you have any suggestion to add definitions or anything, just let me know. We received 24 responses thus far. At the December meeting we will have some results that we will be able to send out.

DR. COHEN: So the Roundtable. So far, I will get to the conference and the design and the agenda in a second, but we have done some really superb outreach. Let me give you a quick list of who is committed to being present. We are going to have representatives from San Francisco, Douglas County, Nebraska, New Orleans, Seattle King County, Sonoma County, County Health Rankings, NQF, NCI, Community Commons, RWJ, and we are reaching out to Kellogg. We don’t have anyone from Kellogg Foundation yet and we are reaching out to Smart Chicago, as well.

In addition we have just begun our invitations to our federal data providers and partners. Hopefully we will have representation from the providers who are represented by the Data Council. Vickie Mays has had some superb ideas about some other folks we need to reach out to. If you have any suggestions about people who should be in the conversation, please let us know.

Of course everyone from the Full Committee and from the Data Work Group are also invited to attend. Just let Debbie know if you are interested in coming.

The data providers who were interested in having attend are folks in the organization who have some technical understanding of the data that are generated but who have a broad policy view about how data can be disseminated more effectively at the community level. So we want sort of a blend of people with some level of technical expertise, but people in positions so that they can influence the way the data are collected and disseminated.

Any questions or comments about that? Yes.

DR. FRANCIS: I don’t know how to find these people but do you have any examples of failures or refusers? Folks who tried and could not get the kind of data they needed or folks who tried and met with resistance?

DR. COHEN: I think most communities it is a journey. Some of them are ultimately successful but there will be impediments along the way and gaps. Do you have the list of questions? Maybe this would be a good time to put them up. We are going to be asking the community respondents to address specific questions around data gaps.

DR. FRANCIS: I wasn’t thinking just about gaps, I was thinking about people who either would not give them the data or people who encountered resistance in getting the data, not the absence of data or knowing what to do about it, but they just plain could not get it. Or community situations in which the community was concerned about anybody getting the data?

DR. MAYS: I can offer a suggestion which probably I am almost going to beat Larry to this one. That is if you talk to some of the CTSI’s, they have had to work in their various communities through data refusals, negotiating data agreement, coming up with their data concerns.


DR. MAYS: I am sorry. Clinical Trials Scientific – what is the I? The Clinical Trials Group.

DR: GREEN: It is NIH. It is called NCATS Office is where it is organized. It is not in any one institute, it is across institutes. They are called CTSA Award, Community and Translational Science Awards. They are now seven years in the business. There are 60 of them across the country. They are all required to have community engagement components. They vary widely. Some have done very, very, very well. Some have done very little.

DR. MAYS: And the other thing is that what they could bring to the table – I think your question is an excellent one – is that they have been working on some of the models. I notice in your report you had – I think you were calling it the deliberative democracy model. The NIH applications went out for what they call “deliberative community engagement model”. They actually can bring some models to the table.

DR. COHEN: If you have suggestions about specific communities – if you have any suggestions about specific folks that you know that we should invite, please let us know as soon as possible and we will reach out to them.

What I am sort of scrolling through here is we recognize that it is very important to focus our conversations. Rather this is not going to be – the idea of this roundtable is not for communities to present their stories. Hopefully there will be enough background information provided beforehand so that folks will know their stories. But the focus will be on responding to specific questions and issues around use of data and data communication. What has worked and what the impediments were.

Any suggestions about additional foci that we can ask communities and data connectors that would be incredibly helpful. Any ideas about folks that we should invite, whether they are in the connector community or actual communities of data providers, federal or state or local agencies that are operating in this space, please let us know.

DR. SUAREZ: One question, I don’t know if you have included in the agenda, I was trying to look for any involvement from providers and health care provider organizations and perhaps even health plans sources of data and sources of tools and resources for community. Have you thought about including some of that?

DR. COHEN: That is a great idea. I guess I would, if I had to put them in one of the three baskets, they would be data providers. We are in the process of asking for participation of the data providers. If you have any suggestions – I hope you are available to come and perhaps address how Kaiser provides data. If anyone else has any suggestions, Bill?

DR. STEAD: I think our discussions were that they would be engaged in two very different ways. One, the providers or health plans that were part of the community stories would be part of those stories as part of the consortium that had successes, failures, needs. The others would be as a data supplier.

So our thought was that is how they would parse it, I believe, Bruce.

DR. COHEN: Again we were actually focusing on government data providers, but you are right we should try to incorporate health care providers who provide information to communities as well. Any suggestions would be welcome.

DR. SUAREZ: My thought is that in most local communities, now a days, health care providers and health plans – but in great respect, health care providers are more actively engaged in working with communities. Particularly under the Affordable Care Act with the call for engagement on community health assessments and other activities. I think there is going to be a lot more opportunity to show that engagement and ultimately role and responsibility of health care organizations to work with their own community.

DR. COHEN: That is actually a good segue to start reviewing at some level, the agenda. You can see in the first block of discussion we are going to focus CHNAs and CHIPs, community health needs assessments and related activities. We will make sure to have as part of the discussion, how communities have worked with the health care providers around the community health needs assessment. Thank you for that suggestion.


DR. GREEN: That morning session that starts at 8:30. It seems to me that in each of those sessions up to noon, there is an opportunity to solicit from the community leaders as they report their experience, what experiences they have had with getting data out of local health care providers, out of schools systems, from employers, and don’t forget PIs. Principle Investigators, researchers in their communities, that possess data sets. The sorts of folks that I think are going to show up at the table, they are going to have experience with those different groups.

Piggybacking on Walter, rather than thinking that we need to invite health plans to the table, I think this is a position to ask the community leaders what they have done before and thereby spot a gap where we have not ever talked to Blue Cross/Blue Shield. We never talk to those guys. Who are they? Who are you talking about? That in itself is an important finding.

DR. SUAREZ: I would not say “rather than”, I would say “in addition to”. In other words, I don’t think it is a matter of only asking community people to discuss their highlights of how have their experiences been with providers and health plans. I think it is worth engaging, bringing in perhaps a few providers and health plans to participate.

DR. GREEN: I don’t disagree with that but that could be in the 3:30 session.

DR. COHEN: I expect both of you gentlemen to be there to ask these questions. Part of the beauty of the design of this day and a half, there is going to be a chance for small group work as well as general discussion. I could see that being a part of the small group work. The day and a half is designed to maximize interaction. So these are the kinds of questions that would be wonderful to hear from everyone who is in the room.


MR. SOONTHORNSIMA: I am just curious, when you talked about the data providers, are any of the entities that you listed earlier, are they involved in multi-payer database initiatives? Some of the states seemed like they have. The community organizations – I should not say community – they are mostly non-profit entities that have been contracted by the state to create this multi-payer – all payer claims database.

They might be a good entity to include.

DR. COHEN: That is interesting. The state level all payer claims databases that I am familiar with are all funded by the state and are usually state government. We are trying to reach out to several states to get them involved. But use of APC data, APCD data, it hasn’t happened I communities yet but I think it is the next wave. We will try and cover that topic. Thanks for the suggestion.

DR. MAYS: I think the suggestions that are coming up are really good. What I am trying to understand is the concreteness of the schedule that is going to allow that to happen. Because it appears that your schedule is more experiential and I am trying to get a sense of if there are very specific things that the committee is saying it would like to see, is there the structure to make sure it is going to happen? Like do you have in mind, we have been inviting community groups, but this is a different ear than I am hearing now, than maybe the groups that we have invited.

So what is the procedure, in case some of us can think about specific groups that would help, to say – like getting data from the health plan, there are fewer groups that do that. So we should think a little bit more about who would be a good example. I don’t know if we have those hopper.

We may be on the side of more feds and they don’t come into later. I am trying to get a sense to meet the needs of what we are asking about, the best way to do that.

DR. COHEN: This is great input. We are having another conversation on Wednesday, the planning group, to work more on the agenda. So all of these suggestions are great and we will discuss them as refine the agenda. So this is really helpful. We will try and integrate some of these ideas throughout the day.

Also I think this roundtable is sort of a space that allows us to continue the journey around communities as a learning system. I don’t see this as – I hope that this is not a one-off, there might be a variety of issues and a variety of people that we find are not at the table during this discussion. Frankly, I won’t be dissatisfied because that will lead to more opportunities to engage them at a later point in time.

I guess I feel that we needed a place to begin and pulling these groups together to start, will help us on this journey towards understanding the dynamics. If we need to continue this conversation and have additional roundtables because we missed folks and have not covered all the issues, I think that would be great.

If we can begin building the momentum for this interaction between data providers, communities, and this emerging group of data connectors, I think we will have achieved an enormous amount. You are absolutely right, we are not going to be able to do it all in a day and a half. We are not going to have everybody at the table who we would want at the table but I think this is a great place to begin.

So these suggestions will either be helpful for this particular roundtable or for future roundtables that might be needed to follow on.


DR. STEAD: From my perch If we could come out with a clear list of findings which are from each of these three perspectives – a table with three columns. What don’t you have that you need? What do you have that somebody else could be taking advantage of? If those were not findings then based on that we can make initial recommendations of what could be done to address those findings.

Some of those are things that can be done by the three stakeholder groups themselves, other would be things that might take federal action. If we could capture that in the feedback tool in the day leading up and then we could really refine those lists on the morning of the second day, we would have moved the ball. As Bruce says, we would be able to plan for the things I addition to releasing the initial recommendations.

DR. SUAREZ: Do you have that table? It would be good to have a table that shows those three perspectives and the type of questions and outcomes that you hope to achieve at the end of the day. I think that would be very valuable.

DR. STEAD: Amen.

DR. FRANCIS: I wanted to try to think procedurally for a bit because it could be all too easy to have this conversation look a lot like some of the earlier conversations that have been had with community groups. Linda don’t take that away because I am sure you are going to have more to say that is sensible than I.

I think you need to think about who is going to moderate each session. What are going to be the primary questions addressed in each sessions? And who are going to be identified as the primary panelist for that session? It could be 30 people around this table but there ought to be somebody taking charge with defined objects of inquiry for each session and with some priming of the pump so we know you have an answer to this that you thought about, rather than having everybody just sort of come and talk.

DR. COHEN: Yes, you are exactly right. We have engaged a Monte Roullet, who has worked in this area before who is going to be the facilitator for the day. He is helping organize the specific folks who are going to be at the head table to begin these discussions. This is an example of trying to refine some of the specific questions. But we will need to do more of that.

So the idea is I guess, – we are loosely calling them panels – is we are going to have specific questions that we want the panelists to discuss and the we will open it up for a more interactive piece. Then throughout the two days we will have smaller group exercises where people will be charged to address specific questions.

What we see is the difference between what we are doing here and in the past, is we are not going to be asking communities to tell their stories. We are going to be asking them to address specific issues around data and we are going to be having the conversation with the data connectors who have acted as intermediaries to provide these data. We are going to have reactors from the data providers to get them to think strategically about how they can refine what they do to help support the communities.

I think you are spot on, Leslie, the success of this day will depend on our ability to provide – it is a fine line between providing structure for the discussions and enough opportunity for people to be creative and express ideas that we have not heard yet.

A couple more comments and then I really need to turn it over to Bill to talk about the framework.


MS. KLOSS: I guess I was following onto Leslie. I was just wondering if you might want to just walk us through because how you see the day coming together.

My second question is, and maybe this will come, where does the framework play in this?

DR. COHEN: I will let Bill answer that during his half-hour. We are talking about how to integrate the framework and the stewardship toolkit. Certainly we are going to develop packets of pre-reads that will be posted for people to look at. We have not really thought exactly how to integrate them into the day yet. That is the simple answer. Bill might want to expand on it.

Vickie, I will let you ask the last question and then I will go briefly through the agenda.

DR. MAYS: I was going to say I hope that Tammara wrote down exactly what Bill said and that that is a big part of structuring this.

DR. COHEN: So the structure is essentially a table that has the three groups and what outcomes – the questions and the outcomes for them. Is that what the comment was?

DR. STEAD: Not quite. I have got it down. We have been through it on one of our earlier calls. This was not a new thought – I was just trying to bring it to the Full Committee.

DR. GREEN: There is actually no such thing as a new thought anyway.


DR. COHEN: So I will spend a few minutes going through the day. I am sure you have all had a chance to peruse it. Our first conversation is going to be more formally about community health needs assessment from the IRS and community health improvement projects and projects that are ongoing, done in a variety of kinds of ways.

The focus will be on having some communities describe what their data related issues are during that conversation.

The second set of conversation is a group dialogue – I am not sure have figured out who the panelist will be for this but participatory approaches to research that might not fall into some of the more structured frameworks that we discussed in the first panel.

During the afternoon, then we are going to talk about collective impact and perhaps have some reflectors try to pull together our learnings from the morning.

In the afternoon our focus is going to be on hearing how the emergence of this group that we roughly call “data connectors”. Some of the work that Robert Wood Johnson is doing on the culture of health, I think will be very important to this conversation. Sort of a description of how they see their role and what data providers could be doing to help support their role.

The fourth discussion is around the culture of health specifically. We had not really refined what that fourth discussion is going to be. Hopefully that will include reactors reactions from data providers.

Although data providers will be involved in the conversations all the way through. It is going to be structured in terms of the interactions. We have not refined specifically what the breakouts will be but we feel that we would like to have smaller group discussions around targeted questions as well.

Then the day wraps up in preparation essentially for the second day, which is really going to be focused around developing specific recommendations. Targeting – I think one thing that is going to be different is – we have not finalized it yet – yesterday we talked about audience. Our primary audience, I think, is going to be recommendations to data providers. This is the opportunity for the community and data connectors to say, here is how you can help us more effectively and more efficiently.

A lot of our work has not really targeted data providers per se, but the basis of our primary recommendation I think are going to be to the data providers.

That is the thought currently, but again this is a dynamic process. We are going to continue to refine this.

Leslie, last comment. You look incredibly puzzled there.

DR. FRANCIS: I don’t even understand what is going to happen in the afternoon. Are you going to have big data for the common good? Do you envision having some of the huge data mining groups coming?

DR. COHEN: No, it is just a placeholder for some kind of interaction for folks, primarily data providers and reactors.

DR. STEAD: The thought when that item was put in was we would have a very short vision block. That having addressed specific questions that were based on real world experience in the first three panels. That before we moved to suppliers, we would have one vision block to sort of get us up a tier.

Ideally that would be RWJ around the culture of health. That is really trying to say, where are we trying to go? It is not going to be a detailed block. Then we will come into the data suppliers. That is the thought as of yesterday afternoon.

DR. SUAREZ: Very quickly, logistically you are talking about a group of how many? Fifty people total or 30?

DR. COHEN: I think we will have between 30 and 50 people at Hubert Humphrey. We hope to have some connectivity online and interactively for people who can’t be present. As we discussed yesterday, that changes the interaction and dynamics. We are thinking about strategies like for people who are listening in to submit questions and then have a block where we address some of those issues that the listeners. There are some folks that who we really wanted present in the conversation but can’t be there physically, so we might give them specific opportunities to contribute. Like some folks from Chicago who are in the middle of budget business and stuff like that. That is what we think it will look like.

It will be in Hubert Humphrey. I talked briefly to Jim about maybe securing additional space if we want to have smaller breakouts in some rooms for some groups as well.

Any suggestions, we are still open. I think we have come a long way. We have got some great folks who are going to be attending. But ideas to help us refine where we are going would be most appreciated.

DR. STEAD: Could we bring up the short agenda for this block on the screen?

DR. COHEN: Who is on the phone?

DR. WHITE: This is Jon White from AHRQ. I have been listening for a while but suddenly it went really quiet.

DR. STEAD: What we are hoping to do in this next little block is to not go through the overview and status report in micro detail, but to look at it as a snapshot of generative process and answer questions and suggestions about it as an iterative work in progress.

We then want to spend a little bit of time around the key learnings. Both in terms of what we are really discovering about the complexity of looking at things from different points of view and different levels, if you will. Then this idea of the Framework and the toolkit and other like resources, as key ingredients to a much more broadly defined path to interoperability.

Hopefully have time for real discussion around where do we go from here? Who should see this report? Right now we have been treating it as an internal working document. We are going to propose that it be given to the Roundtable as a pre-read. What would be our threshold for dissemination more broadly in some form and how do we work with others to further elaborate the framework. Those are sort of the questions that we wanted to put on the table this morning.

With that let us hop into the overview and status report. As I said, this is a generative process. This is not a historical report of what happened at the workshop. It is actually taking what we learned at the workshop, those rich discussions and input, and updating and reflecting those in an updated overview and capturing that experience of the workshop in a way that we hope it connects with people who were not there. That is what this in fact is.

With that introduction, you have had it, I am sorry, given our process, we sent you an original version as part of the agenda set. Then we had another rich call and we made changes and we sent you the red line from that. There have been no changes since that red line.

Let us stop and take questions and suggestions at this point.

DR. SOONTHORNSIMA: I think there are sections, maybe I did not completely understand it, when you talk about the framework, it really has two key components; data continuum and the categorization. Then we started getting into implications for the Framework. Those to me seem to be sort of key characteristics or additional dimensions. They all make sense. To frame it up how do we think about those?

DR. STEAD: Let me try and put some color commentary, Ob, it is a very good questions. So the framework is, if you will, the outline that starts on page 18, it is appendix one in this overview and report. We are now thinking of the framework as a set of classification resources. One of those is the data continuum and the other is what we are now describing as the method categorization.

In particular the later we think will be – could turn into metadata that we could use to tag various data sources. So if you think about the rich discussion we had yesterday around the stewardship toolkit, then we would like to actually end up in this with a categorization of data collection purposes.

Right now we have got that heading in there and then we have got a dot, dot, dot. Which means that we would need to build that out to what is the taxonomy of purposes that would be useful to tag the purpose that a dataset was collected for or the purpose of a secondary use. Or if we want a different word than secondary use, actually replace that word in the categorization.

That is the Framework. When we talk in the body of the status report when we are really describing what we did at the workshop. What we did was work a use case and then we worked the specific examples of timeliness and granularity. At the end of each of those we stopped and said, okay, having talked about this example for a good bit, how do we now go back and the change the framework. How do we edit, how do we iterate the framework? Because the framework is designed to be extensible and iterative. It is not designed to be prescriptive. It is designed to be a way that we can actually create a view of the categorization space and a view of the data continuum.

Is that helpful?

MR. SCANLON: At the beginning Bill, it looks like we are saying that the project is designed to generate recommendations for the federal government. I would just broaden that – it is not just the federal government, it is the whole ecosystem of data producers – it just leverages a lot if you add the others.

DR. STEAD: Good point. One of the key things we want to make clear is we are trying to get the concept of the Framework down. It will take a community effort to build and extend it. You would really view it as a resource that anybody could extend because it is not meant to be prescriptive. That is a good point, Jim.

DR. MAYS: I just want to talk a little bit about models and kind of where we are in the field and just some of those issues.

So in your data continuum where you talk about the epidemiologic dimension, there will be a real push and pull around that because first I think it privileges that perspective. Whereas in, particularly when we talk about health care, it might be a health services approach. There are a number of different ways to kind of think about it.

If you look at the materials that have been produced in recent times by the federal government, we actually talk a lot about the social determinants of health. It is not quite George Kaplan – may be more like John Lynch or some of the other groups.

There is a lot of – what is the word that I want – development that is a little different around four. The model four, epidemiologic dimensions. Both in your model, the little box model that you have in this, you will have people not listen just because it says epidemiologic dimension. I might even just talk about it as a social determinants. I might talk about it differently because the methods of the inquiry are different.

The models that people use, for example, if you think about the Institute of Medicine model that talks about health disparities and kind of where the differences are and the emphasis. Epidemiology has an emphasis that is very different than health services that is very different than some other fields. You kind of will lose impact by making it I think, as narrow as this is.

The other thing about geographic dimension, I think a big component has become neighborhood and neighborhood affects. While you talk about census track or subset, neighborhood affect is actually very different than that because the way in which the boundaries of neighborhoods get defined. They are defined actually more by culture and characteristics. Sometimes we have a very hard time because we have to figure it out relative to the coding around the census track and stuff.

That is a big area now is to talk neighborhood affects. Some of the query systems now are trying to move towards neighborhood affects. TIS(?) is going to display at the upcoming APHA a whole neighborhood query. So that is kind of like the direction that people are moving in that I would say you want to capture under your geographic dimension.

I think the big thing of the models and what the prevailing models are right now.

DR. STEAD: Good point on both and I am the generalists that is trying to create something that the people that know different dimensions can then put in the right ones. In my IOM social and behavioral determinants work, the Kaplan Model was one, the Ansari Model was another, the MacArthur Network was another, and I believe there was a fourth that I am not remembering.

So I need to know if there is agreement that that should be a social determinant dimension. If that fits with people that would be fine. If so it would be helpful to know what you would see as the dimension from proximal distal that would go in there because what I did was drop in the Kaplan thing simply as an example of the nature of that.

The other thing that would help me is there are not just three dimensions. There will be many dimensions. So I need to know – and this again can evolve – but is there one social determinants dimension now that actually could be a common meeting ground across the various models in the field? If so, if you would outline that for me. It doesn’t need to be long. We will just drop it right in.

Or as we have those conversations, are we discovering that they are actually two different dimensions or maybe three different dimensions, that need to be separated or disambiguated. I don’t know – I can just pose the question.

If we are going to build this thing out, which I hope we will, then what we have got to do is to where experts can help us develop pieces that we can plug in. Does that make sense?

DR. MAYS: Yes, it makes sense. I can send you some things in which these very debates are going on. I was trying to align us with what the federal government is doing which is they really are threading throughout a lot of their materials social determinants models. Which means then you don’t have a particular analytic approach but you can then do it across several different types of analytic approaches.

DR. STEAD: I like that. So I assume we will move in that direction and you will give us some more detail? Larry.

DR. GREEN: I take Vickie’s point but I want to offer a counter-argument. The data I know, a fourth, the epidemiological dimension is about the determinants of health. Social determinants of health probably explain about half. I think we want to be careful in developing a data continuum and not exclude from consideration the other half.

The other half includes a lot of pathophysiology. Which is currently here. I hear Vickie eloquently making the case that we have got to attend to the social determinants. All I am saying is that in the data continuum, just because that is where there is enthusiasm and that is an important critical shift, the data continuum cannot forget that there is another whole set of data that comes from this other —

DR. STEAD: So let me ask then, is a middle ground killing epidemiologic in having it be just determinants of health dimension? So in determinants of health, then maybe the current outline within that is okay or maybe it is not. You can then say are those sub-headings right or not. Does that help?


DR. COHEN: Maybe this first column called “social determinants” rather than “determinants”.

DR. STEAD: I am not sure that doesn’t conflict back into – if we are making, help me know how to handle the suggestion around neighborhood effect. Does that go between – where does that go?

DR. COHEN: We talked about whether the focus there should be county or neighborhood. We generically just put sub-state to include all the thing larger than the basic building block but smaller than the state.

So actually even though that is listed as one row, it really is a variety of potential geographic levels.

DR. STEAD: I can imagine how neighborhood affect is not exactly geographically bounded. I don’t quite know whether we are moving into a different dimension. It is a little bit like we got into the discussion we had around organizational and we in the end decided organizational dimension we needed to set it side-by-side with the geographic dimension. Not aggregate them. Not mush them together. Is neighborhood affect a different thing?

DR. COHEN: I think there are two things going on. Neighborhood is increasingly seen as the actionable unit of analysis where you can target programs to make change. The census track is too small, the full city or town is too big. People live and work in their neighborhoods. They shop in their neighborhoods.

So if we are talking about actionable interventions, neighborhood is an important geographic dimension. That is one cut.

The other neighborhood affect, I guess Nancy Krieger’s work is some of the best in this that I have seen, it is not the absolute income but it is the difference in income within an area that leads to the stress that leads to adverse outcomes.

Whether it is clearly delineated in terms of Main Street and Jackson Blvd. there is an effect by locale that is a different dimension than the geography of the specific neighborhood. I think there are both of these going on.

DR. MAYS: I think that is why they often talk about place. Place matters because you get the intersection of those two things. One is that there is a very specific geography around it. But then when you start talking at the effects level you are often talking the locale.

Often what you will have to do sometimes is to ask neighborhood groups – the neighborhood – like where does it really begin and end. It does have geographic boundaries but not the way that we typically do them in terms of the specific address.

DR. STEAD: So help me. I am hearing that neighborhood fits between above census track – it is bigger than a census track. I am also hearing that sub-state may have a legal definition or a jurisdictional definition.

What I am asking is should we decompose those two or not?

COHEN: I guess we should ultimately decompose sub-state into county, community and neighborhood. Those are the three technical geographic levels to me that compose sub-state.

DR. STEAD: What is a community?

DR. COHEN: A town, a small town. Bethesda can be minor civil division. For some town it works but in larger urban communities the concept of city or town is really replaced by neighborhood.

DR. STEAD: Could we get away with census track, neighborhood, sub-state, city, civil division?

DR. COHEN: Yes, we can work on that.

DR. STEAD: The nice thing about this is it will continue to live in a word processor. This discussion is showing is the complexity of trying to get to an interoperable term.

We are about midway through our block. Other questions or suggestions or can we move to the key learning and where do we go to hear – you just relieved the complexity that we discovered in the workshop.

I think one of our real learnings is we have got to face up to this messiness and try and actually end up with an extensible taxonomy that lets us make it something we can point to and understand.

DR. SOONTHORNSIMA: Are there other dimensions that have not been considered or are we just going to limit to six at this point or five?

DR. STEAD: There is no attempt to limit this. I have not thought of more than what is on here and it has not been suggested. But everywhere in this thing that you see a dot, dot, dot, that means extend it. So six is dot, dot, dot.

The point here is it is actually since no conversation will need to involve all the dimension. If whenever we are having one of these discussions, we can say the distinction we are making between neighborhoods and sub-state, is the latter, is a civil jurisdiction, and the former is defined by the neighborhood. The minute we can decompose it with that clarity, we can have an easy discussion and know how the two sit on top of one another.

Does that help?


DR. MAYS: I am just trying to understand two, which is organization dimension. Can you explain it more?

DR. STEAD: And Walter can pop into here. If you take an organization like Kaiser that covers large geography. In fact, views itself as having geographic subdivisions and they roll up. It says one example. Another example is the school and the school district.

So there are organizational structures that sit on top of geography that are not the same as geography. Can you help me Walter?

DR. SUAREZ: That is right. I think there is different ways – to use not a very good – segmenting the different levels of populations. Different organizations, whether it is private sector organizations, like Kaiser or school districts or others, cover populations that are aggregated up in different ways. That is what creates the difficulty of cutting across continuum within a large quote/unquote, community.

Because in a community, even in Kaiser’s situation where in some places we represent 75 percent of a community or offer services, there is still a population that is not fully covered or completely served by one single organization. So there are different levels of aggregation, I think, trying to be depict here.

DR. MAYS: I just don’t get it relative to the other categories. I understand it, but I don’t get it in terms of how it flows as well in terms of an organization dimension and it is just single in aggregate. I don’t get how it fits well enough in terms of what you are trying to talk about.

DR. STEAD: The key way that it fits is that it is important actually to disaggregate things that overlap so that they become explicit. Therefore once we got in the discussion saying it is a different dimension. We need to be able to look at something, both by the different aggregate layers within an organization and geography, and in sometimes they will be the same and in others they just relate.

The fit is that it is important to disaggregate it is the best I can say.

DR. MAYS: That I get it but why organizations? Why is that the unit?

DR. SOONTHORNSIMA: There might be a third, since we brought it up, single aggregate and virtual. First example, if you think about population health as being managed by multiple provider organizations in an ACO. That is the first thing that came to mind.

So you may have like a Kaiser that feels like it is a single entity that is rolled up from multiple Kaiser organizations. But you also have these accountable care organizations that are loosely bounded or – do you see where I am going – and they manage –

DR. STEAD: That is a neat thought. If we make single, aggregate and virtual as three different.

DR. MAYS: That really fleshed it out.

DR. STEAD: Since this is a status report and update we can have an additional discussion box that drops in that just reflects this. It will be awesome.

We are now down to 12 minutes. I think I will err on the side of saying we hop to where we go from here because we are going to run out of time. We can continue the rich discussion we had around this very broad definition of interoperability. We can continue that electronically.

So let us talk a second. I think that when we go into the roundtable, we do need to give this post edit, plus I would recommend, if it is okay, the then current edit of the stewardship toolkit to the participants as pre-reads.

I think they communicate how the National Committee is thinking about the complexity of what we need to do in a way that nothing else can. So the real reason I wanted to get them as pre-reads is to help shape people loose from thinking we are asking questions the way we have always been asking questions, to we are actually now thinking about what are the resources? I think the toolkit and the framework are, if you will, bookends of kind of resources.

What are the resources that would help us collectively do what we are trying to do? That is the reason I have been trying to drive to get this to where maybe somebody who had not lived it could understand it, or at least begin to appreciate it. That is my thought as to how it would actually feed into the roundtable. We need to think about how do we put that into the agenda because I don’t want to spend a lot of our time describing the framework. It is too hard. It will take hours.

My second thought is that – I will volunteer to do this or I would love to have a little group help me do it – as the communities get at specific data sources that they have that people are not using or that they need and don’t know how to get. I think that it would be useful to take those specific examples and try and tag them to the data source to the characteristics in the framework, and in that process discover does it help, are there gaps, just in the framework. Then do the same thing with their proposed use. I think that would be another way to iterate them.

So those are my two thoughts about how to incorporate it. Let us get reactions to that or other suggestions of given the preliminary nature of this, where do we go with it?

DR. FRANCIS: I have a very simple question of when do you want to circulate the drafts?

MS. KANAAN: October 15th.

DR. FRANCIS: October 15th. Okay, that is when we will have the next draft of the toolkit.

MS. KLOSS: I think it would be perfectly acceptable to put these out with the watermark draft on it. That helps people understand that they are making a contribution to what the final product is.

I see an opportunity to drop in at the end of day one, without spending time briefing people on either of these documents, but drop in some discussion on now that we have been through this experience, what recommendations might it suggest for the framework and for the toolkit and get some feedback at the end of that day. I think we could structure that for an hour and we could perhaps cover both. But go through the experience of the workshop and then pull it in.

DR. STEAD: So it would be just like we had here. It would be a harvesting. They would have had it, we would have had the experience. I love it.

MS. GOSS: I think you want to create an on-going dialogue since it is a living, breathing document. I think it is one thing when you are in the moment, you have read something in advance, you are sitting in a dialogued workshop, and then maybe you can walk away, let it kind of seep in, and then come back and maybe if you run out of time with your agenda, don’t make it part of that day but maybe make it as a follow-up call so that you can continue the dialogue to have them involved in getting it to be something useful since they are walking through the mud.

DR. MAYS: I was going to suggest something very similar, which is, you build an evaluation tool into both of these so that you send it to them. I do think you do have to have a few words in the beginning that introduces the why and the what, and all that. So from that 8:00 to 8:30 thing, I think you really should say something about it.

I think what you really want to say is that these are documents. We won’t say they live in the computer but these are documents that are alive and we want some input.

I think what you do is you consider either to send the evaluation with the documents so that they can be thinking about what they want to tell you. But ask them to do it after it is over or to follow-up after. The reason I am saying there is this strategy of sometimes if you send an evaluation with something, people are more likely to fill it out and you get it back because they get invested and they start doing it. Versus afterwards, the meeting and they are on to the next thing. It is just how to get data.

DR. STEAD: So I am hearing that we will send a separate e mail to the people who are going to participate in the roundtable, in advance of the roundtable, October 15th, that will say why we are sending these two documents. We will include the two documents, and include a cut at an evaluation instrument that would be completed afterwards. So it would actually be a separate send. It would not be combined in everything else about the roundtable. So it really did focus just on this and not get lost. Is that a good idea? Is that what I am hearing or not?

MS. GOSS: I heard it more as let’s make sure we are clearly managing expectations in what we are sending out in the documentation in advance. Making it clear what we are asking those people. Setting them up to get the best feedback and then making sure we clarify all of that again in the first thing on Monday morning because what I am worried about is people are going to want to go to the rabbit hole of the framework and not to get to your end result of getting more global feedback.

MS. KLOSS: That was my comment, you want them to know that we are going to solicit their feedback in the workshop. I don’t know about the formal evaluation. I would raise that as a question. If somebody has comments later that is terrific – but I don’t know.

MS. GOSS: I think it is better as a follow-up workshop. Those who really want to get engaged put them on a conference call with us.

MS. KLOSS: I don’t think I would send an evaluation of these two documents ahead of time, to a group that has not convened and is not sure of their purpose. I think that would be a little intimidating to get both of these.

MS. KANAAN: And it creates expectation that we are going to take their recommendations.

DR. STEAD: Are you okay with that, Vickie?

DR. MAYS: I am fine with it, I am just more nervous about trying to have a discussion about it in the workshop. I think then you have two different things. You have a free-fall for people to really start to talk about stuff. Then if there is something that is off-target I don’t know where you are going to go to kind of bring them together. It is the end of the day and I am going to assume that most of them are going to leave – that they are not staying necessarily for day two.

I don’t know, it just worries me that that is how we are coming to the end of the day. If you want to call later or do something.

MS. KLOSS: But it is how you frame the question. I guess I would not frame it, we would like your suggestions on these two documents. The framing is what has today’s discussion told us about what we might do to further enhance these? I think it is a different question. And then we could manage that discussion at the end of the day well.

DR. GREEN: For both the October 15th email and the product of the workshop, I want to call attention to footnote two on page two of the current project. I think that footnote is wonderful and it is absolutely critical for the framing and people understanding how this is going.

That positions it in the work of NCVHS really beautifully and succinctly. I think that will help manage expectations.

DR. STEAD: So if we in essence put that footnote in the email that we are using to send it.

DR. GREEN: My observation is that footnote is more important than being the second footnote in the document and that it could be very useful in managing expectations about what we are about and what we are trying to do.

DR. COHEN: It is a nice way to begin the engagement at the end of the day around the discussion of how the discussion of the first day converges with the other activities of the Committee.

DR. STEAD: I am just trying to make sure I know what you are saying. One, are you proposing that this footnote be promoted to the introduction of the document?

DR. GREEN: I am proposing that that footnote is very important to defining what we are going to do, how it fits with our work, and to manage expectations, and that it could be put to good use. The initial communications with who is attending and the final report, it will actually help frame it. It is too important to leave as a footnote inside the middle of the document.

DR. STEAD: Ob and then Linda.

DR. SOONTHORNSIMA: This is for you to help frame up the objective again or the expectation. My understanding is this meeting is really geared to help improve or recommend to data connectors and suppliers. Correct? In other words, as we go through the framework in answering all these questions, what recommendations would we have, or this group would have, at the end of the day, to the data connectors, people have their roles in the communities, and the data suppliers, which in this context by and large, are either federal government or state, local entities.

Did I miss it? Because we are not really talking about private sector yet.

DR. STEAD: You are talking about the roundtable?


DR. STEAD: I think the roundtable is meant to develop an understanding amongst communities, connectors and suppliers, about what they need to be more helpful to each other. And I think it is intended to help the National Committee make recommendations for federal action.

Am I saying that right?

DR. COHEN: That is a much better characterization than my initial – I focused on trying to define the primary audience, but really we have three audiences, but in terms of recommendations I wanted to be true to what we could leverage around the feds.

DR. SOONTHORNSIMA: I think it is well said. The question I have is a little bit more specific perhaps. When you are talking about data suppliers, can you frame it down a little bit more, frame it up a little bit more, where we are talking specifically about entities like public health institutes or even HHS data sources. Am I making sense? Otherwise it is too broad.

DR. COHEN: Yes. I guess, I had made the assumption that for this roundtable our first focus on data providers would be government data providers. That was primarily what we are focusing on. Although I did not mean to exclude other data providers, I just don’t know whether we can do it all.

DR. SOONTHORNSIMA: That is the point about setting expectations. If you frame it, what you just said, it limits the conversation a little bit, but that does not constrain us. But that would help set the expectations.

DR. CORNELIUS: I just have a quick comment that there are really four constituencies by default. The three that we have in the document, plus the federal government, in our capacity as a committee. The community, connectors, suppliers, the roundtable, plus the actionable items that relate to the life of our committee and its connection to the Secretary of HHS.

MS. KLOSS: In the interest of time I can hold this to later but I was thinking more about where this goes next. Right now it reads as partly a summary of our workshop and partly a standalone concept paper. I think it needs to move to the second and leave the experience of that June meeting behind as just one of the steps we took in developing it.

I think I can see it standing alone and being used to engage groups in some interesting dialogue or conversation about this because I think it is going to live in the word processor for some time.

I thought for example, AMIA meeting coming in November, is it possible to do a little focus group of some folks that have been on this committee and helped shape documents like the 21st Century Health Vision of the 21st Century. I really see this as taking that vision and beginning to flesh it out in terms of the data continuum.

It might be good as we go along, to have some brainstorming about how to really make this a working document and getting additional input into it. Maybe that is a topic for a little longer conversation. I think after we get through this roundtable we should grow into that.

DR. COHEN: I just want to build on that for 30 seconds. Susan Kanaan and I were talking on the bus on the way over here, perhaps in December as part of our strategic planning, we need to step back and look at all the communities as a learning system documents as building upon each other or creating our own rainbow series of documents in different aspects of publications, reports, dissemination of learning system, volume one, basics, stewardship, privacy, data sharing. Really building a body of work that we can refer to not only as reports but for outreach as a stream of output for the National Committee.

MS. GOSS: I really like that idea because I also think what it does is it starts to force us to get back to the convergence conversation and what are our products and what value are we bringing not only for HHS, but the larger community as a whole. I think it is a great idea.

MS. JACKSON: I would say, ditto on the last three comments that were made is exactly where I was headed as to where this fits in the promulgation of what is going on within the National Committee. So December is going to be a wonderful pivotal meeting for these things to percolate and go.

DR. STEAD: Awesome discussion, very helpful, thank you.

DR. CHANDERRAJ: I heard a lot about organization of this and the composition of this study. But I also think some time should be spent on timeline of where you are trying to start to disseminate this information and start this project. Also a timeline for finishing the project and getting the word out to the providers of the data and also implementing that. Also have a follow-up of what the results were.

DR. GREEN: Okay, did you guys just adjourn this part of the meeting? For those of you who have joined by phone, our apologies, we are about 10 minutes behind. We are going to start in about two or three minutes and reconvene to take up the 9:30 item, Action on Standards Letters.


Agenda Item: ACTION — Standards Letters

DR. GREEN: Walter, why don’t you present the four Action letters we discussed in detail yesterday, in any order that you wish.

DR. SUAREZ: Thank you. We finished up yesterday the final edits based on the input that we received from the committee members so we wanted to present the five letters. I will go in the order that we presented yesterday.

DR. GREEN: Did someone just join on the phone?

(No response)

DR. SUAREZ: The first one is X12, XML schema. Basically the main change – we did not do a lot of changes from yesterday. We added some spelling out of some of the acronyms that we used. Then we looked at the –

MS. GOSS: Could we change that word “correspondence” to “correlation”. I think it reads a lot better. There is a one-to-one correlation between EDI and XML. I just think it is an awkward word.

DR. SUAREZ: So this is all new text that we have inserted to help explain a little better the concept of XML schemas. This new text is replacing the old text, as I mentioned yesterday. All this again is introductory text that we reviewed yesterday and it is all clarification text and corrections.


In the main recommendations – this is where the main changes of recommendation two was adding this language. Yesterday I think we did not make any changes to this particular addition. I think people felt okay with that addition on the recommendation two. It is important to point out that this is considering an XML instance document valid according to NACE. XML schema – that means the general parameters and corrections is from a content perspective. So this is really about the content of the standard. The schema are about the content of the standard – these are not about the transport or the transmission per se.

Then recommendation three, I think we left it the way we presented it yesterday. There is no changes in there. It is basically asking X12 to make the schemas available alongside with the standards.

That is our first letter – X12.

DR. GREEN: So Walter, would you make a formal motion to approve?

DR. SUAREZ: I will move approval of this letter as edited from our conversation.

DR. GREEN: Do you think you have any chance of getting a second out of someone on the committee?

DR. COHEN: Second.

DR. GREEN: Any further discussion? All in favor. “ayes”. All opposed. (No response). Any abstentions? (No response).

What is your next letter?

DR. SUAREZ: So the next letter is our letter on virtual credit cards. So this letter – again, actually on this one we did not change too much of the introductory part, except for this language that we changed, and yesterday we modified it again. In this paragraph at the beginning of the page, we talk about NCVHS recognizes that there are health plans and providers who see the virtual credit card as a better value. Consequently NCVHS will stand ready to participate in future discussions regarding the use of virtual credit cards.

So we did not formally state anything about future hearings or anything like that.

Then in the recommendations themselves, we added the concept of and other appropriate agencies. That HHS would work with the health care industry and other appropriate agencies to do all this point that we are recommending.

That is basically it for this letter. We did not do any other changes.

DR. GREEN: Would you make a motion?

DR. SUAREZ: I will move to approve this letter as edited from yesterday’s input.


DR. GREEN: After a good night sleep for at least some of you, any further discussion, insights or concerns about the virtual credit cards?

I see none. All in favor. “ayes”. All opposed. (No response). Any abstentions. (No response).

What is your next letter?

DR. SUAREZ: Okay, the next one is the letter on UDI in claims. Here also we did not make any changes or make changes on the introductory sections. I am just going down to the recommendations. Basically we agreed that on recommendation one to modify the references to cost/benefit to say, cost and benefit. To avoid any higher expectations or increased intention of any conduction of a full flesh-out cost/benefit analysis.

We also added this, which transmission, if any, or other mechanism, would be best to report UDI. We deleted the last bullet that we had added as a suggestion.

Then on recommendation two, again modified cost/benefit and separated them, and added a privacy implications of incorporating UDI.

And at the end, to address Jim Walker’s suggestion, we added this statement: Pilots should initially focus on reporting high risk implantable medical devices and evaluating the future inclusion of additional devices so that we find an appropriate ordering prioritization process.

No changes on the third recommendation. Then the fourth recommendation we only kept the first statement: NCVHS suggests that FDA and stakeholders work together to improve existing mechanisms for post-market surveillance of devices. And eliminating the rest of this recommendation.

That is basically it. So I will make a motion to approve this letter as submitted.

DR. GREEN: And Lew seconds it. Any further discussion? I particularly want to make sure that Leslie and Linda are comfortable with the insertion. Did that cover the issue we discussed yesterday?

DR. FRANCIS: Privacy implications – yes.

DR. GREEN: Anything else? Are you all ready to vote? All in favor. “ayes”. All opposed. (No response). Abstentions. (No response).

Your next letter.

DR. SUAREZ: Next letter is the letter on Health Plan and ID and ICD10 and coordination of benefits. No changes on the introduction. In the coordination of benefits side, again, we did not make a recommendation. On the Health Plan ID side, we did make a couple of modifications to the recommendations.

Recommendation one, I think we covered yesterday the deletion of “be required to”, and just say “will not use HPID in administrative transactions”.

Then recommendation two, HHS should further clarify in this upcoming certification of compliance final rule, when and how HPID would be used in that health plan compliance certification program. And if there will be a connection with the federally facilitated marketplace program with respect to the use of HPID.

So far there are a few users really of HPID on the marketplace but there are some so we just thought it would be helpful to clarify that.

Then on recommendation three, with respect to ICD10. We made the changes in blue. HHS and industry leaders should proactively emphasize to congress the merits of ICD10 programs made to health industry. To implement ICD10 and cost to the health care industry associated with any part of it.

So with that I make a motion to approve this letter as well.


DR. GREEN: Any discussion? Leslie.

DR. FRANCIS: My only question is who counts as industry leaders. I just think we ought to mull on that a minute because there were some – as I understand it it was the AMA, MGMA, – they might think of themselves as industry leaders.

MS. GOSS: They can but we are asking them to be proactive – positive here, about the goodness of ICD10.

DR. FRANCIS: Yeah, okay.

MR. SCANLON: We are recommending that they emphasize the positive aspects.

DR. SUAREZ: I think that was one of the main themes that came out of the ICD10 hearing was really we as an industry, need to work together in a long – with the various perspectives of this point. So AMA, specifically, MGMA, and other provider groups and the concerns that they have expressed. We need to ensure that before they again look into possible further delays, we work with them as industry leaders to try to address this issue.

MR. BURKE: One of the responsibilities of an industry leaders is to collaborate and not be silently –

DR. CHNADERRAJ: I think historically, AMA and MGMA, were opposed to the ICD10 introduction. I think physician leaders approached the congress to delay this because the other people were for it.

The reason they opposed it was because of the cost involved in converting to ICD10. This cost was never addressed by any federal body.

They incentivized the physicians to go with the EHRs for Meaning Use but they never incentivized – they only disincentivized for the implementation of ICD10 by imposing penalties and not paying.

I think maybe if you add the cost to the health care industry for and against implementation, that will be a better wording than just delaying – cost involved in delaying.

MS. GOSS: Raj, I am struggling with what actual changes you are requesting to recommendation three.

DR. CHANDERRAJ: Cost to the health care industry.

DR. SUAREZ: We already have the cost.

DR. CHANDERRAJ: The cost for the health care industry in implementing and also the cost in delaying these.

DR. SUAZREZ: You are saying add the cost associated with implementing ICD10.


PARTICIPANT: Cost to the health care industry including implementation and any further delay.

DR. SUAREZ: Something like that is what you are suggesting?



DR. CORNELIUS: I want to come quickly back to the whole thing about the inclusion of industry leaders. If you recall yesterday, the whole spirit of adding that was so that it wouldn’t only be HHS going to congress, but HHS and some leaders.

It is not an issue about a taxonomy or seeing wherever we can get a sample or a thousand leaders there, it is really that we do not want just the HHS at the table. We want others to speak affirmatively about this issue knowing that there is all this other action going on at the same time.

DR. SUAREZ: Exactly.

DR. GREEN: That is exactly it.

MS. KLOSS: I think this is in the spirit of the testimony that heard because we heard from industry groups about forging new alliances to speak clearly, and primarily to speak clearly to congress about the implications of these delays. I think this is consistent with the testimony.

DR. GREEN: Let’s separate this out as a separate action. Let me just ask, Raj, can move this amendment and we will treat it like an amendment to the letter we discussed yesterday. Just to be clear about this.

Did someone second?

DR. COHEN: Second.

DR. GREEN: Further discussion about adding implementing ICD 10 and – Linda.

MS. KLOSS: I do think that we have gone on record as supporting the implementation of ICD10 and certainly the final rule addresses issues relating to costs associated with implementation. Whether everybody agrees with those conclusions or not.

I worry about reopening the issue of implementation costs. I think what we were talking about specifically here were cost incurred and delay one and delay two, and trying to avoid subsequent costs. I don’t think we want to open up the debate about the cost/benefit of ICD10. That is not the intent of this recommendation.

DR. SUAREZ: The main issue has been that the costs – the investments already made in preparing to ICD10 and the cost already for the delay. That is one of the main issues to have happen. During the hearing that is what we heard is people have already invested in the transition of ICD10 and any further delay is going to mean additional unforeseen costs.

It is that point that I think we wanted to highlight.

DR. CHANDERRAJ: The main reason that congress opposed it is because of the physician’s lobby saying how much it costs them.

I think what we want to emphasize to the congress is the cost/benefit has been discussed and we want to make a recommendation to lobby the congress. In other words, this is what lobbying is. Emphasize to them the cost of implementing and the benefits so they will realize the cost and benefits.

DR. SUAREZ: I would say that – well, there are a lot of debate about the reasons, but I think one of the main reasons why there was a delay was not so much the cost but the not readiness, the lack of readiness among providers and that they needed additional time to implement.

DR. GREEN: Let me interject here. The purpose of this letter is not to adjudicate why the AMA and the MGMA oppose ICD10. That is not the intent of this letter. That is not where it is headed. Jim just said that is their privilege and we respect that and honor that.

This recommendation does not have to deal with that. In my view should not deal with that. This is really minor wording and I yield to you, Walter, about this.

Maybe what we want to say there is, cost to health care industry associated with implementing ICD10 and also any further delay.

There are costs associated with it and there are costs associated with not doing it. That is our key finding. We have heard that loud and clear in the interval testimony. I feel like we are in-scope, over the target in saying what we have evidence to support.

It creates a balance and fairness in this point which is actually to emphasize to congress. Our recommendation is make sure congress knows – just Larry Green talking now. What we are trying to say is, don’t mess with this anymore. That is really what we are saying and I think that is respectful of the information that we have.

MR. SCANLON: If I could just note for the record that there was a full benefit/cost analysis to the company, the rule, everybody commented on it. I don’t think that was ever a secret. That is quite transparent. It is not like it was never done, it is there were other factors that it introduced. Plus having change.

MS. DEUTSCH: I think we have to look at the fact that that recommendation is specifically in emphasizing or educating, whatever term you want to use. So the decision is what do you feel is necessary for congress to be educated on.

As you indicated on the final rule, there was the impact analysis, and that covered all the information. Everybody was cleared and it was enacted. So if you want to have a separate recommendation about educating them on the cost, I don’t believe that from just writing it in thought, that that one sentence takes both together.

DR. GREEN: Do you have an alternative suggestion?

MS. DEUTSCH: I’m giving the recommendation that if you want to talk about the cost of implementing, which has already been addressed, then perhaps you do that as a separate recommendation and leave the education and emphasis on the fact that there is a cost attributed to any further delays. That is the point of what this letter is about. That was brought up at the hearing and that was brought up by most of the people that presented.

As Linda indicated, there was a discussion among the different entities about getting together and educating congress. They used the term “educated”, which is why we used it.

If you want to talk about costs attributed to implementing that is a separate recommendation and you would want to look at it – you should look at to see if it belongs in this letter.

DR. SUAREZ: I would actually suggest the following because I think we can put it in the same sentence but actually emphasizing the cost/benefit information that we already have that Jim already mentioned.

We can say, the cost/benefit to the health community associated with implementing ICD10 and also the additional costs associated with any further delay.

So we are emphasizing the importance of informing congress about the cost/benefit that already has been documented.

DR. GREEN: So are you proposing further words added to this recommendation in contra-distinction to what Teri was just talking about? What are you suggesting?

DR. SUAREZ: I am suggesting that we can include in this sentence the cost and benefits associated –

PARTICIPANT: Walter, can you pause for a minute because not everyone is on your page.

DR. CORNELIUS: I was trying to call the question.

MS. KLOSS: But the question is to vote on the amendment.

DR. GREEN: All in favor of the amendment. (Ayes). Let us do a hand count here. All in favor. All opposed. Okay, the amendment fails. Let us take it out. Let us go back to the letter.

MS. GOSS: I would like to make a motion to approve the letter.

MS. KLOSS: Second.

DR. GREEN: Further discussion. Seeing none, all in favor. (Ayes). Opposed. (One). Any abstaining. (No response.)

Next letter.

DR. SUAREZ: The final letter is about attachments. This letter – the only change we did really under recommendations. Here are the changes. We did not change anything about recommendation one. On recommendation two, we simplified the language because it was becoming too long to say that in the first letter and the letter from June, we recommended a broad application of attachments. In these recommendations we are limiting the initial implementation to health care claim attachments, for which HL7 has defined templates. That is all we are really doing is simplifying the language.

In the first recommendation we said be broad in applying attachments. We are now recommending to limit the scope to claim attachments.

Then the recommendation three, we changed the timing of the implementation of and inserted implementation of this standard should be aligned with the implementation of stage three. So it is not about the timing, it is about the implementation itself.

Those were the changes made to this letter. So I move approval of this letter.

MS. GOSS: Second.

DR. GREEN: Further discussion. All in favor. (Ayes). All opposed. (No response) Any abstentions. (No response).

Okay, I think we are out of letters.

DR. GREEN: For the record and to be precise, I would ask for a motion to authorize the Executive Subcommittee to deal with any minor editing issues that surface between now and the finalization of these letters.

MS. KLOSS: Second.

DR. GREEN: Okay we have a motion and second. Anyone want to speak in opposition to that? All in favor. (Ayes). All opposed. (No response). Any abstentions. (No response).

Okay, Walter, let us talk about that charter again.

DR. SUAREZ: So the charter, we reviewed it yesterday. We actually did not make any changes to the charter. I think a lot of people expressed very strong support for it. We made some comments and cite notes about the charter. We made a couple of editorial changes. In- stead of saying, at the next meeting we said, at the subsequent NCVHS meeting we will be presenting all these recommendations from the Review Committee. So we did not change anything.

A couple of points about the comments. We did say two things – or we discussed two things. One is this side comment, and this is with respect to the process that we will be following. The first one is we should come up with a protocol about how to handle gray areas when it comes to things that we are dealing with as a national committee, and other FACAs, ONC and others are dealing with. There are some areas where we are seeing some overlap and need for further coordination.

The other comment was with respect to the process. Suggesting adding a hook for a few things like a summary sheet of transaction standards, et cetera, that will be covered by the Review Committee. So we would all have a sense of this is the list of all the things, in a simple one page piece of paper.

Collecting data and analytics about why transactions standards are working or are not working. This was a comment from Bill that we should look into what are the kind data that is helpful and need to be collected. And working certainly with the industry, to help collect that data.

Then the Review Committee would make recommendations about the type of information that would need to be collected, and this is part of the process of looking not just at what the status of the standard, but also looking some process measures, collecting measures about the implementation of standards.

Then I think the last comment was from Linda about really having a larger discussion at the December meeting of the work that we will be doing as a review committee, consistent with all this process steps that we have laid out in this charter.

With that I would certainly love to have us formally accept this as a charter to move it forward.


MS. GOSS: Is that a motion or do you need me to second it?

DR. SUAREZ: I am making a motion to approve the charter.

MS. GOSS: I will second it. I have a question. I think this is great work. I think we need to make sure that everyone else knows what is going on. I am curious as to what kind of educational effort we might do to make people aware that maybe it just naturally happens as a part of the December meeting. I did not know if there were any thoughts or conversation about that to date? About anyone else knowing that the Review Committee now is here.

MR. SOONTHORNSIMA: Clearly, what Walter and Terri outlined in terms of what additional item from the process, from the measures and the metrics, so we will have to take this off-line and as a subcommittee we will come together through our conference calls and sort of frame up what then are the processes to vet through the gray areas.

And what potential measures and metrics might we frame-up so that in December we can talk about how to evaluate those transactions have already been adopted or rather those standards have been adopted and operating rules have been adopted, and how well they are actually performing – whether they are meeting their goals. So that is basically what our next step is.

MS. GOSS: Maybe I was not clear. I apologize, if I missed your opening because the gentlemen was correcting the microphone dynamic.

My question is, how does the industry as a whole, know that this is now our body of work and responsibility? Are we putting out press releases or something on the website?

DR. SUAREZ: I think there would need to be some formal display of this. Usually what we do is we use our website to include any formal notification like this and let the industry know. I think by virtue of having a charter place or define and upon approval by the Secretary, of course, I think this can be displayed and then shared throughout the list of all our contacts that we usually share information like this.

MR. SOONTHORNSIMA: A question for formality. So now the charter has to be approved by the Secretary?

MR. SCANLON: No. She has designated the committee. It is in the committee’s hands now.

MR. SOONTHORNSIMA: So the committee post this on our website.


DR. SUAREZ: Normally you can see on our website we have the charter for each of subcommittees.

DR. GREEN: I think Alix is pointing out that this is going to be a well-kept secret unless something more than posting passively on a website. I think she is suggesting that once this is clear, can this be made a public document and can there be an initiative of some sort that informs whatever we mean by “the industry”, that the Review committee has been appointed, is in place, and is now operating.

MR. SCANLON: I will see if we can issue a press release – HHS.

MS. GOSS: I think that is good and I like Walter’s suggestion about the usual suspects that we have in our contact list. The DSMOs, the SDOs, the DCCs, they all need to know about this. Look how much confusion we had about existing versus emerging and standards and all that stuff. So I think if we can get ahead of the curve on educating people that would be good.

MS. KLOSS: I would just suggest that we cull down this charter to a couple of paragraphs that describe where and what and there will be more process information forthcoming.

DR. SUAREZ: I think that is a good point. We do have only this section, which is the charge of the Review Committee and defines what is it and what it is not. All the rest of the document is really the designation of the National Committee and then some clarification about the roles, the membership and the actual Review Committee process.

So yes, we have a defined section that is simple and short.

DR. GREEN: So let us back up to your motion. The motion is to indicate the committee’s agreement with this charter and that we understand it and that we are planning on doing this. Are you ready to vote on that?

All in favor. (Ayes). Opposed. (No response). Any abstentions. (No response).

Most of our discussion — and now how do we proceed on how do we get this implemented and get the information disseminated. I think we should recognize that this is Jim’s territory and that we made suggestions about steps that we think would help us do this, and now it is in his hands and he does whatever you want to do.


DR. SUAREZ: One specific step we can take is actually post this on the website and then disseminate the information about the posting on the website to the groups that we usually disseminate information to. I think that is going to be valuable. In fact it will be helpful for when we meet in December, people would have already this.

MS. JACKSON: We have our gov delivery process that hopefully all of you are signed up on. We give you notice – not just thrown something on the web, but let the public know. Those folks who are part of the standard bodies, should be on that list. If not then they can always subscribe.

My question was what is the next step? Posting it is one thing and letting people know it is there, but would people be as interested in the next steps as to when groups are meeting and things like that. Kind of implementation of it. We will get into more of the details in December, but as much information that we have then we can alert them. When we send out the notice about the December meeting that would be a great time or maybe even before.

DR. GREEN: Debbie’s comments helped me realize I should make explicit something I have been assuming all along, from this point forward, forever more until rescinded by somebody, when we publish our agendas there will be a new category of agenda work, which is called the Review Committee. That Review Committee will be understood to be to have a scope and a reach and an agenda that will be different from time to time, from the Standards Committee.

So we now have a new category, we have an extensible taxonomy, it is part of the dot, dot, dot, that will show up and make obvious to people when things are going to happen.

It is important to the industry to know when the Review Committee is behaving as a review committee and when it is behaving as a standards committee. We must pay attention to this.

Also we have to recognize, as with the Working Group, that whatever happens here becomes work of the Full Committee – the National Committee on Vital and Health Statistics. When we get to this point where we are right now in this meeting, there is likely to be from time to time, an agenda item or something that comes from the Review Committee that requires explicit action and explicit attention of the Full Committee.

Unless you guys run me off of this for the next few months, we will not take the Review Committee and put it out by itself acting as something else. We will continue to function largely as a committee of the whole, and this is just another of our functions.

As we go along you can object and make alternative suggestions, but for now we are not going to categorize this and start operating in a way of oh, now we have a brand new thing and we are going to do it totally differently from everything else and set it off by itself.

MS. GOSS: Can you remember to say that for next meeting for those who are not here right now.

DR. GREEN: I don’t think I will ever be able to repeat that.

MR. SCANLON: Remember the Full Committee has been designated. For purposes of that, some committees don’t exist. They are considered, legally, they are considered to be –

PARTICIPANT: That means you all have to join —


DR. GREEN: One of my missions is to repopulate the Standards Committee. I thought we had just done it without –


Walter, anything else?

DR. SUAREZ: No, that is all. Thank you very much.

DR. GREEN: Thank you, Walter.


DR. GREEN: And Jim, I speak for the committee, I think the committee is pleased to be asked to fill this role. We appreciate your leadership.

MR. SCANLON: Certainly would not want any other group doing it.

DR. GREEN: As you will notice, appear to be ahead of schedule. We might just want to pause for a minute and think about that.


DR. GREEN: Mya is planning on being here shortly.

DR. FRANCIS: I have just been in touch with her and she was planning on being here a few minutes before 11.

DR. GREEN: Rather than leaping over the break to the action on the Stewardship Toolkit, I would like to ask your indulgence for us to take 5 or 10 minutes before we take a break, then we will reconvene as proposed.

If we can take 5 or 10 minutes for your responses and your thinking about how we are doing in the process. It was an unusual meeting in the amount of formal communication with the Secretary that we authorized and approved. It was made possible by extraordinary commitment on the part of the Standards group to work between our June meeting and this meeting and our conducting virtual meetings.

Some of you may recall when the Standards committee meeting did the survey monkey and established four meeting times in the summer, in the middle of the vacation period, and then those worked. People showed up for those. That is how it happened and that has become a modus operandi for us that we have sessions in between our face to face meetings.

I am really quite interested in your reactions to how is that sitting with you?

MS. GOSS: I think it is essential that we do it, to be able to distill down the feedback that we get from the industry and enable us to reflect on our thoughts with a little bit more deliberation and vetting out what they really can represent.

My recommendation is that we continue to do it but that we establish a routine cycle of meetings to enable us to more effective. I think I missed one of the meetings and I missed a lot by just missing one. So if we can schedule ahead of time it makes it easy for me to work my schedule around it so I can continue to be supportive.

I also think that we need to complete the appointments to the Full Committee, with a focus on Standards, and background, or at least somebody who is willing to focus in that arena. I again, forever, want to not have Ob and Walter ever be term limited.

DR. COHEN: This is a more general comment about how we are doing business as a committee of the whole, virtual subcommittee of the whole. I mean we are trying to integrate all of our activities, and in the population work having feedback from people technically not on the Population Committee, has been wonderful but I think we are still struggling for how to be most efficient.

One change I have seen in the three years I have been here, is more demand for work in between meetings. I expect that will continue so we need to figure out how to do that in a way that does not overburden members and staff but keeps the ball rolling. There is a lot of work that needs to be done in between meetings. I think most of it is getting done. I don’t want us to come into the meeting to have to read things for the first time or give our feedback for the first time.

I think we are still struggling around that balance so that the meetings can be a discussion of the feedback that has been generated electronically, rather than going through initial rounds of feedback. I think that will even make us more productive than we have been.

I think we are making progress but we still have a way to go in workflow.

DR. GREEN: Good points.

DR. STEAD: I second that. I think this meeting – each meeting we are now jelling as a full committee. The way that we have really gotten inside each other’s subjects – Ob was giving me a tutorial on the way up around operating rules, that I needed – so we have actually got to have the time to get in each other’s heads or each other’s spaces and understand it. I think we are achieving that.

I think it would help me to the degree when the Standards hearings are going to be, it would help me if we got those calendars out with the Full Committee calendar now at least we can block those dates so we can participate. I think that would be extremely helpful.

And to re-second this question of the business of reading. With the framework piece, we did send out an original draft and then when we got the red line, we went on and sent it out and we understood that we might be causing some rework. But with the red line we were trying to sort of say, if you haven’t yet read it, use the red line. If you have read it, just read the red line.

I think we all feel accountable for having those letters and we did and we had notes. So for us to have had red lines on those coming in, even if they just get to us before the flight time, will be adequate. I think if we just recognize we are working as a committee, with the subcommittees getting things ready. It is a different dynamic.

DR. GREEN: Lew, we skipped over you.

DR. CORNELIUS: Ditto. I think there is a theme that is occurring and that is in order for us to be efficient in our meetings, there is quite a bit of work we need to do outside.

I like the comment about knowing the schedules for the subcommittees. That just allows us to pipe-in. And also the kind of sequence of events. So if you miss a meeting of an active workgroup, you can kind of catch-up, so to speak.

I definitely like what Bill was saying that even if just before the meeting if we have the most – I liked when we received the red line letters coming into the meetings, so we have the most current thing to look at. Even though it is on the screen, I am still tactile.

MS. KLOSS: I think that Bill’s characterization that we are working as a committee of a whole with the subcommittees preparing the work, doing the leg work, is a good way to look at it. That just really changes the responsibility.

I have been trying to keep up with all of the groups and it is tough. Maybe we should consider having a committee block time. We had that for the Executive Committee but maybe it is possible to do a committee block time and then organize how it gets used a couple of times a month.

Also, I think this issue of red line and all of the emails, if would be possible for us to use the Sharepoint, that is what those tools have been created to do. I know we prefer to work through email but we could be assured that we were always looking at the latest and greatest if we could bring that discipline to ourselves.

DR. FRANCIS: So I guess I have comments that go in a bunch of different directions. One is I think we really need to do a lot of work in between and the more notice and scheduling we have of that the more effective that will be. I felt really terrible because I wanted to be on a bunch of framework calls, but I wasn’t on the first one, and then they got scheduled like boom, with a couple of days’ notice, and it was always when I was teaching. It just wasn’t until the last one – I was out of the loop for a while, when I genuinely did not intend to be. If can figure out how to set aside some time blocks I would really like that.

A second thing is that – I think we kind of – some of it is on us, but some of it is more complicated. We really tried to get feedback and get it incorporated and get it sent back to people on the Toolkit. Because it was a lot of work and people had limited time it did not always work the way we wanted to. We got some feedback really late and we also got some feedback that was kind of hard to decipher.

We thought we had answered it but it turned out we had not. I think we were maybe more delayed than might have been optimal. Obviously we have got another big round on this one and we were sort of hoping not to. This is kind of a plea for it would be really nice to – we will try and do it in two weeks, but we are thinking of October 15th – wow. There is not going to be a lot turnaround time so if there are suggestions that people have – you could even do it by a phone call to one of us. Which might be more explanatory, right. Anyway, please help us out. This is a plea for help.

Then I just have a third little observation, which is I miss dinner because I like everybody. I understand why. Just an observation about the culture of the committee. The significance of dinner has changed. It may be that dinners are a thing of the past for this committee.

DR. GREEN: No, I don’t think so.

DR. FRANCIS: Attendance has gone way down at the dinners. They have been very different than they were a year before Marjorie retired. Actually they were starting to go way down – they were seriously starting to go way down in the last couple of years Marjorie was here. It may simply be that they don’t make sense. But I thought I would put that out there.

DR. MAYS: In terms of feedback, first thing is this has been an exhilarating and overwhelming meeting in the sense of the convergence. You just keep expanding and learning how to put these things together. So I think that has been good.

I think the concept of the scheduling is probably the biggest. I just had a bear of a summer and it would be you would get something and you would go, I can’t even think about it at this moment. Then you would put it aside and you would go, oh, the moment really extended to three or four days. Then I would feel bad about well, I saw stuff crossing so I would go, I am too late. Then I would find out later people would say, no you are not too late. But I just did not realize it at the time.

One of the things that I think might be helpful is we are not working any longer as individual committees where you are just kind of, okay, that group is doing its thing and you focus on your group, but you are really being asked to focus on all. I think we need a different kind of – it is not just the scheduling, but it is giving people priority times.

It is kind of like okay, you have this deadline coming up. In some ways we have got to help because you have a deadline coming up, and then you have a deadline coming up. But we need some kind of way to do like this big schedule and to have a sense of we have to prioritize because this affects that and that and that now.

It is almost like we need one of those kind of expensive calendar systems where you can see that you have this and it relates to that. It would help to some extent. So then if somebody is trying to schedule something then they could see if you have to do it this week you are going to cut down on the committee’s ability – it is no longer just the group but at the subcommittee, but the committee’s ability to do something. We may have to look into getting a consultant or getting one of those complex calendars where we can actually do that kind of thing.

Then the other thing is, and I just want to say this from the point of view of the work group, and Bill will like this, I talked about this framework of a guiding principle. Do I really want a framework? I have been watching Bill? Is that a good idea? Then I thought, Bill has a framework – let’s just wait. We will leave the word there.

I guess what I am trying to say is that the work group has inter-digitation to do among all this other stuff. When I put this schedule out – Leslie your email was such warmth. I was like, I was so hoping you were going to do this. But I kept feeling like everybody had so much work. So when you sent the email I was like – she sent an email saying about the privacy stuff. I was just so happy. But I realized that part of what I was also being so tentative about is the workloads are so heavy on everything else that I have been kind of tentative about well, what about this and what about that. Don’t build this agenda too huge because we have a ton of work. The work group is only going to work if there is a way in which it can happen. I am going to put that out there that that is the hope and the vision. We just have to figure out the time.

MR. SCANLON: Just a couple of things. Number one, I want to thank all the members for serving and for taking on the tasks we send your way. I have said before, say it again, we probably have 300 FACAs in HHS. This is probably among the most productive and highly regarded and hard working. Again, I want to thank you for that.

Secondly, I think Larry and I and Debbie, if there are any ways we can make our work easier. We have to follow the law in terms of when you are in a formal deliberative process for the Full Committee, but if there are ways to make things easier through virtual meetings or email or other ways, let us know. We don’t have to drag you here necessarily for full meetings.

Third, members to fill vacancies, we have a slate that is in the process now that will fill the vacancies we now have, which is two or three, I think. Then we are coming up upon a year, the 2015 class, where we just have a number of people whose terms will be expiring. Some we will be able to renew, but where we have already had two terms, we can’t, except for Franklin Roosevelt.

So, again, I think it would be fruitful if you have, from the point of view of each committee, but also for the overall best-athlete as well, best athlete available kind of a concept where you wear several hats and you fill more than one slot of expertise. If you would start sending to me confidentially obviously, any ideas you have for who would make new members, we will put them in. We have a process – it is an open process – we will put all the candidates into the pool and then we have to vet and we ask within HHS as well, do people have ideas and so on. Then we will go ahead.

I think 2015 class is probably – I don’t know why that happened with scheduling. We try to do this like the U.S. Senate, where we don’t lose that many in each year, but through various retirements and other things, we ended up with a lot. So give us your ideas and we will start planning now.

DR. GREEN: Okay, we are two minutes away from break time. It is Debbie’s time. Why don’t you guys report by exception and say, agree plus.

MS. JACKSON: Just quickly, I already have in my mind what we can develop as far as the group calendar, so you can get it, click onto items, kind of know where things are going. So we will develop that.

Dinner social on December 2nd is ago. Please that on your calendar. And number three, I am really still enjoying this mic.

DR. SUAREZ: Just a couple of comments. I totally agree with what has been said about a lot of more coordination. I think one topic that has been mentioned is, not only we are working more collaboratively across teams, but we are actually now, in my view, getting deeper into details. I think the challenge is going to be balancing on how not to dive too deep into things and try and stay high as an advisory committee to the Secretary. That is one of the challenges we always feel in the Standards Subcommittee.

That is one thing that I think is going to be important is we are going to be faced with more and more details and specifics because things are getting more complex, just in general. Learning more and understanding better the standards concepts, for example, in the Standard Subcommittee is going to be more significant.

I do want to note and I neglected to say it, and I want to say it here, I think nothing of the size and amount of work that we have been able to achieve as a subcommittee, could have been done without the work of our staff, I think has just done incredible. A group of support, led by Teri herself. It has been amazing having a person that is so much at task and keeps us with our marching orders very clear. It is very, very helpful. I have seen the same, at least from my participation on the other subcommittees, with the rest of the staff. So really a big thank you to the staff.

The other important element that we found was very critical was in our interfacing with industry, publishing our draft letters early in the process, was very, very helpful. The industry appreciated that. We got a lot of very positive points and comments. Very important and good clarification and feedback. I think that is very critical in that process. So we need to build that into the steps.

Lastly, I wanted to just mention, I forgot to mention that too, but I will take the time to say it here. I was invited to present to another FACA, this one on heritable conditions on children and new born. It is a special advisory committee to the Secretary on that topic and that area. The first time we met at the National Library of Medicine, which is where they meet, it was an incredible group of people. All the different representatives on this very, very, significant topic.

They asked us to present about the recommendations that we made on the public health information systems and infrastructure points and standards. At the end of the presentation they made a motion to recommend a letter of support of our letter to the Secretary.

So there is an advisory committee supporting the advancement, the move forward, with the recommendations that we made. And that was very significant. I think it was very valuable. Very exciting to see what is coming down. It is an incredible group of people that I have the pleasure to work with. That is my feedback, thank you.

MR. SOONTHORNSIMA: Ditto to everybody’s comments around time because it is becoming increasingly difficult with our day job – increasingly difficult.

With that point, I will echo also the appreciation and phenomenal support that we have from staff, Teri, and Susie is here, and Jim and Susie have been extremely helpful in collaborating around RC, Review Committee, so thank you. Hats off to all of you.
Last point, because my time is so limited, when we get on the phone, and we get on the conversation of the meetings, facilitating becomes an art. It is essential to any of these conversations, staying to topics and to your point, not getting so much in the weeds, it is so critically important. Some of these skills are so necessary in managing the meetings and conversations, especially on the calls. Again, focus on content, context, themes, and what we really need to deliberate and not getting 2,000 feet below where we are needed to.

Last point, you talk about recruiting. Bill, you learned how to spell X12 and you know how to spell OR, operating rules, you are ready. You have got your certificate.

MR. BURKE: A couple of other groups I am affiliated with have similar governance level structures and it is not uncommon for all of the work to be done in committees. Probably 75 percent of the work done outside of a larger meeting in a subcommittee. Here we are still in this migration. I think of us all being part of every committee and that requires certain discipline. I think we will get better at it, although we are getting better.

I would second Vickie’s notion about this vision of a master calendar, but not only with the dates of meetings but with key deliverables, deadlines, cut through all of our work so we are not just seeing when the group is next going to meet, but what the Executive Committee has declared as a deadline or what one committee has determined to be a deliverable date. So we can keep that in sight. And perhaps not make that until we are used to its existence, something that we go looking for but something that is pushed out to us once a week so we have a fresh to-do list.


DR. GREEN: Thank you very much. I want to add my thanks to all of you. I don’t know how you do what you do. The amount of volunteerism that actually makes the engine run, matched up to the staffing that we now have. The writers that have participated with us. It is an inter-digitating complex adaptive system that depends on all of its parts. Whoever succeeds me as chair is going to have a challenge to be responsive to three or four of your points. Keeping the conversation at the right level. That is hard to do with you guys. Timely feedback that matches up with the deliverable pace. That is hard on all of us to meet because of real life happening to us and getting in the way of this. We have good intentions but we don’t get it done.

Then part of the chair’s and co-chair’s challenge at that point is do we back up? Do we wait? How much repair work do we do or do we keep going? That is more of an art form than anything else, but it is hard. It is a challenging part of this.

I just want to express personal appreciation to what I see as stepping up into the space on everybody’s part. The committee is performing in a different way, at a different level, and the staff are performing at different way and a different level. Until you guys tell me otherwise, I am not going to feel like we have a crisis on our hands anywhere, other than the following. I ask you to remember this – your appetites are bigger than your plates. All of us are sort of character-logically flawed in the same way here.

We want to be as mediocre as we can be so we can get out of here on time. That is just not the way we are. It is the old pogo thing – if you want to know who is really to blame for the pace and the work, just look in the mirror. Whoever is looking back at you bears some of the responsibility for where we are. Don’t hear me complaining. It is a real privilege to get to attempt to facilitate the work going on.

I want to say again, I would welcome hearing from you individually about things you would like to see done differently in the meetings and behaviors you would like to see me change or talk to someone about or encourage something. That will always be welcome.

Let us reconvene in about seven minutes.


DR. GREEN: Let’s reconvene. We are set to do the action item, stewardship toolkit, and I will turn it over to Leslie and Linda.

Agenda Item: ACTION — Stewardship Toolkit

MS. KLOSS: We want to thank you for all the valuable input yesterday. It was terrific. We talked about what our next steps are in getting to the next draft as expeditiously as we can using the remaining time that Maureen has on her contract with us, backed up by writing work on some sections by Leslie, me and Maya. So we will piece this together and move it quickly.

Assuming that we figure out how to move it through the approval process and we have a toolkit, I think we wanted to take a few moments to pick your brains about how we might disseminate this. I would like to open that up. I think it was great to have the comment of the Confidentiality Coalition yesterday with all of the member organizations that that represents. So that clearly is an opportunity for dissemination. And the upcoming roundtable.

Other suggestions. We had contemplated the people who have come to the joint meeting and earlier subcommittee hearings on this topic as a distribution list and our regular NCVHS distribution list, but we just open this up to other groups.

DR. FRANCIS: The more thoughts the merrier.

DR. MAYS: One of the things to think about is that there is a big group called Campus Community Partnerships, and they do a lot about trying to help community groups use data. So I would actually try to work with them. They have a conference. I don’t know if you want to even try and see if you can do a presentation at their meeting, because you get a great response

The other is the community health group that is in APHA. If you can have like fliers or something – the APHA meeting is in New Orleans this year, November 15th to the 19th. So if you had fliers that could be distributed at the various things I am happy to put them around and then people can at least see them – I don’t think you will have the polished thing ready, but the announcement I think could be good. Some of us can go into the exhibit hall and we can leave it there – there are lots of tables of people that we know that will allow us to leave the fliers.

MS. KLOSS: So the flyers would just explain what it was and give the link.

DR. MAYS: Yes, exactly, and say it is coming, you can tell them to go to a web site. You could tweet about it. You could do all these things to get them excited.

Then I would suggest that one of the things you do is, you can do a little countdown and give pieces of it, and then say what your release date is.

MS. KLOSS: Any other ideas?

MR. SCANLON: The American Public Data Users Association is not just health, it is all sectors of the economy, health, housing, population and so son. They meet once a year. Their meeting is coming up. I think we would want to at least tell them and there is a big focus – there is national data – but there is a big focus on community data as well. So we could probably get it to them.

DR. FRANCIS: Maureen is on the phone, we gather, so welcome Maureen, thank you.

MS. BERNSTEIN: This is Maya, I think the APHA idea is great. I am wondering if we could use that as a deadline for action, so we could be working toward that November 15th date. I don’t know how long it takes for NCHS to get a nice piece printed. We would have the whole month of October. I am wondering if we think it is possible to turn the thing around in that time-frame?

MS. KLOSS: Well, we do and we had an earlier discussion this morning, Maya, that we want a good draft, the next draft. It doesn’t have to be final approval, but the next draft for dissemination before the roundtable at the end of the month. So we are under the gun.

MR. SOONTHORNSIMA: Linda, I think you might have done this. You have already reached out to public health institutes, right? All the PHIs? You have already?

MS. KLOSS: No, we haven’t.

MR. SOONTHORNSIMA: The people in Louisiana, I know them. Those are the PHIs – is that what they call them? Those are the organizations that possibly could help disseminate this.

MR. BURKE: I have the same idea that Ob had and I was curious, Bruce, if Massachusetts is an example, how likely is it that the Secretary of Health would be aware of community level interest throughout his or her state? Or is that going to be turf to someone in the agency?

DR. COHEN: Each jurisdiction is different. I don’t think they are the best contact. Maybe ASHTO or something like that would be a better agency – state and territorial health officers – or CSTE or NACHO, organizations like that better than those. But those are great ideas.

DR. FRANCIS: The Campus University Partnership for Health, which is what Vicki was talking about – their meeting is in Ontario, Canada, this coming year, the 25th through the 29th of May. So there is an opportunity there.

DR. GREEN: I think this discussion should be seen as a subset of the larger issue that we have got, which is that Linda announced I think the first year she was on the committee, is that you do all this work and then where does it go? I am hearing an echo here. What I want to call out that is particular to this instance is that the audience for this report is stunningly unusual. This is not a report for the public health community. This is not a report for the IT community. You get my drift here? This is a report for trying to bring people together who need each other and need to find each other in order to make progress on local health issues. That means that the intended audience turns out to be broad.

The last point I want to make, Linda, is that this report, in one person’s view on the committee, I think it its quality as such, and its focus is so relevant targeting and timely that we simply must adopt a very active approach to disseminating this report, more so that – my own sense of priorities – this year we are to really emphasize dissemination of something it should be this. This merits special attention and an active push, not passive, but push this thing out in diverse areas.

Then after we do that it really is up to the communities and these different sectors that we are trying to stimulate to work here. Then they have to decide what they are going to do about it. I hear very little about pushing this report into the hands of the clinical delivery systems.

MS. KLOSS: Actually I was thinking that one of the routes should be, with a clear explanation about its purpose, is through the delivery system privacy officers. I think they get tapped all the time by groups that have questions about what the obligations are outside of this. So I actually think – one of the thoughts I had was going through AHIMA and HIMS and the others who have special interest groups for privacy officers.

MR. BURKE: That is a point of convergence within those organizations on those requests. Privacy officers.

MS. KLOSS: Maureen, any other suggestions from you?

MS. HENRY: The one thing that is hardest to design, and why things got scrambled at various times, is because I very much had this in mind as a web site. So I would hope that we could take the formatting, which was focused in part on making it amenable to being on a web site and get it out there some place. I am not sure what the mechanisms are that are available to us, but I think that may be the most helpful approach to dissemination.

MS. KLOSS: Particularly because we don’t really have a budget for print. So it will be much cheaper to do a micro site on the web.

DR. COHEN: I think, building on that, places like RWJ and their emphasis on the culture of health. This is an opportunity to really connect to Community Commons and the foundations, to help us get the word out. And we can also use the roundtable. This would be a good question to communities. We want to build our capacity to connect with communities to disseminate the message. So may one of the other questions we ask as part of the roundtable – if the federal government, or if government wants to get messages to you and folks like you, what’s the best way to do it?

MR. SOONTHORNSIMA: To echo – I forget who said it – about the health care delivery systems or entities, perhaps focusing on these areas that are underserved, like community health centers, federally qualified health centers, because those are typically safety net providers, that would align very well with some other federally funded initiatives.

DR. MAYS: A couple of things. I can’t remember if it was last year or the year before when we actually did our presentation on a panel at APHA, and we had Claudia, who was from the Institute of Medicine, where the learning system framework really comes out of that office. I think it would be useful maybe to invite her or – I can’t remember who the other person was in her office – is to invite them when we are at that point where we were talking about this series, but to have a discussion with the IOM about kind of what we are doing and kind of pushing out our side of that framework.

The other thing is that again, many of us are going to these meetings. I think we are nto asking necessarily for travel because we are already going. It might be to put together a bit of a dog and pony show, so that if we are going somewhere where we are going to reach, and particularly the community groups, that we then could do the presentation. Like to APHA I was trying to think what could we do as a group? We didn’t have anything ready because I knew Ob lived there, and it would have been nice. So if we can kind of think ahead for some of the places we want to go and then to kind of have a slide deck that has kind of the different committee perspectives, then some of us could actually try and do presentation.

DR. FRANCIS: So this is very close at hand, but if we had a little flier, the American Society for Bioethics and Humanities is meeting the third weekend in October, along with the Hastings Center. I am going to be there, and in addition to that that same weekend, Linda, are you going to be at the Public Health Law Network? I think Sally is going to be at the Public Health Law Network, which is another nifty place. So if we had a flier about this that could at least indicate the web site for those two meetings – like coming soon, right?

MS. KLOSS: And talk about the other products, and feature what is coming soon.

DR. FRANCIS: And if somebody just e-mailed me that with some pretty colors, I can print up a hundred of them and I can take them to ASBH and maybe Sally could take them to the Public Health Law Network.

MS. KLOSS: Any other suggestions?

MS. BERNSTEIN: I was thinking that our colleagues who participated in the webinar and so forth, aside from sending it to them, many of them may be going to these same meetings and might be willing to do what Vicki suggests or promote the thing since they had a hand in it.

The other thing I was thinking is something much more basic, which is just send it to the public health schools in the country, the top public health schools. Somebody will no doubt direct it to the right place.

DR. CORNELIUS: I would also send it to an organization called ACOSA — the Association of Community Organizers and Social Administrators. I can get you the contact for that.

DR. GREEN: Are you part of that group?

DR. CORNELIUS: Well they are also part of the social work education and research, and I am trying to remember if they will be at the October conference I am going to. So I need to check in with myself. But I know a couple of contacts as ACOSA.

MS. BERNSTEIN: Even this is focused on health, there are many other organizations that would benefit from this, even if they are not doing health-related research in particular, education, other kind of social concerns, and we might direct it to some of those as well.

DR. FRANCIS: I look at my own schedule. I am going to figure out if I can get to Campus-Community Partnerships, because that is a place where those would turn up. But if others are interested, too.

MS. KLOSS: I guess, Debbie, we’ll need to work with you on the staff resources and the web resources and all of that production resources that somehow we need to find the resources for.

DR. GREEN: Maya’s comment reminds me – I assume we have a written record of the people over the last three or four years who have come to our meetings and testified or participated? Shouldn’t we just put this right in their in box? All of them and not just the ones that were on the recent call but going back three or four years ago or so. That is a ready-made network for this?

MS. KLOSS: Do all those people get automatically added to the distribution list?

MS. JACKSON: Not automatically. They have to ask for it. But we do have the major players that started when we had the standards letters and the call this summer. We pulled together those who were signed up to be on the delivery, so we have the major folks.

MS. KLOSS: What is the size of that group, do you know?

MS. JACKSON: I have to check with Marietta but I thought it was maybe three or four hundred.

MS. KLOSS: So that may be another task, to look at building that group.

MR. SCANLON: Do you think the school of public health is appropriate? You never know, but that is where they are training people.

MS. BERNSTEIN: Great idea, boss.


DR. FRANCIS: I think we are in great shape on that. We did want to float, in the last three minutes, May is going to follow up on this, but we were talking yesterday with Rachel Seeger from OCR, about ways this committee might be helpful to them. The minimum necessary and the civil monetary penalty issues are ones where she is going to follow up and communicate with Maya about where they are. Rachel’s initial take was that they would love help, and that this committee might be the right one to do it on one or the other.

But we also wanted to ask you, Ji8m, if you have anything where you think next steps for privacy, confidentiality and security might be.

MR. SCANLON: They have a new director obviously. I am thinking of the regulations in the guidance area – let us circle back. Remember that we talked yesterday about areas where we could help. It actually helps a lot if an authoritative group like this makes a recommendation in a certain area, because it sort of gives added weight in terms of an option.

We will check in with her and see what they are thinking in terms of guidance and regulations.

MS. BERNSTEIN: Jim I missed her briefing the other morning, but could I clarify – the new director is the head of all of OCR, both civil rights and privacy, right/ So we do not yet have a successor for Sue McAndrew?

MR. SCANLON: I think Christine –

MS. BERNSTEIN: Christine Hyatt has been acting very ably. The other thing – outside of HIPAA, sort of non-HIPAA privacy stuff that is health IT. Are there other things coming up? I am thinking of things like PCOR or other things, where this committee might be helpful?

MR. SCANLON: The segmentation issue is coming up for some other regulations. It is a general issue of sharing information that may have sensitive information in it. I think we heard yesterday from ONC about some of the pilots they were doing with SAMSHA and the VA and others. But I don’t know what the state of the art is there. From what I understand the standard at the moment is a document-wide standard. It doesn’t focus only on those items. Maybe we just need to see where the pilots are.

MS. GOSS: It is a good point to do some data sharing with the HIT policy committee, whatever they have been relabeled to.

MS. BERNSTEIN: We have been having a series of meetings with Karen DeSalvo that Debbie has been arranging, which has been terrific. So that will come together some more than it has been, say, in the past few years. They are evolving, too. Their budget is very different and their staffing is going to be different going forward. So I think that will be very helpful to both committees.

MR. SCANLON: I think they will be focusing – I think Karen DeSalvo’s first three priorities are inoperability, interoperability and interoperability. And really the grant programs I think they are in a new phase now, where interoperability will be the highest priority moving forward. But let us check with them. Their previous privacy officer has left and we could see on their agenda what they need.

But OCR, I think they would be very grateful if we could help them with some of the work. They are a regulatory office and they really have to rely on groups like this.

DR. FRANCIS: That is in the next steps.

Maureen, are you still on the phone?

MS. HENRY: I am.

DR. FRANCIS: Excellent. I just wanted to take the last second to say how wonderful it has been for us to be able to work with Maureen and what a fantastic job you have done and will be doing as we clean up the last steps of the toolkit. I want to congratulate you on your wonderful new job with – and I hope I get this right – NCQA.

MS. HENRY: Thank you very much. It has been wonderful to work with you. Thank you for that opportunity.

DR. FRANCIS: And you are also Dr. Henry now, right?

MS. HENRY: Not quite – by December.

DR. FRANCIS: Maureen, thank you and congratulations. Hopefully the toolkit will be in final form before too very long. Thank you, Debbie and others for getting us Maureen.

MS. KLOSS: We will turn it back to you.

DR. GREEN: One more wrap-up issue for this. I think we are agreed that Debbie will post a formal meeting of NCVHS, we’ll do whatever process we need to do. We are assuming that this will occur probably in November, but we will be having a virtual meeting of NCVHS if for no other reason to review and finally approve this took kit. And we anticipate having that done prior to our December meeting. It will not be on the December agenda because we will have done it in the interval.

Thank you all very much.

Vicki, we have this thing called a working group. What’s up?

Agenda item: Working Group on Data Access and Use

DR. MAYS: We do. It is a hard-working group. As we know, there has been a transition. Justine did her last meeting in June. One of the things I did before we came to this particular meeting was I scheduled a time to talk with all of the members of the group. I think I only missed two people. It was very enlightening and I am very happy that I did it because, as I say now, I call them the “awesome group.” They are absolutely, incredibly awesome in terms of the things they do. But they are very different in a lot of the skills and talents they have. That makes for a very interesting meeting.

So part of what I have been trying to do is to really learn a lot of the areas that they cover so that we can make sure that we can bring them all to the table. So what we have done, in talking with them what became clear is that they wanted some structure. So we have no kind of split the meetings so the meetings will be in two phases. On phase we will hear form Damon, and Damon will give us a sense of what it is that HHS is doing. We will act as solution people, as recommenders. That is that kind of off-the-cuff we can give you suggestions, how can we be helpful to you. Having Damon has been great because he is also helping us in terms of planning and thinking of other ways to help HHS. And we have also brought on other staff, so we have Wendy Nillson, who is from NIH. She has been very helpful keeping us abreast of the kind of developments that are going on in technology, and ways we can think about implementation and rolling things out. So we will be glad to have her there as well,

We have Lilly, who has been doing a great job in supporting us. Susan Queen. So the planning has been going along I think quite well.

The second half of what we are going to do – and this is the experiment – so in the second half they actually wanted very specific projects. They wanted something to do. They wanted toe how to be helpful and to come up with a solution, and kind of watch it play out.

So part of what we thought we would do is to work with HHS agencies and say how can we be helpful you in terms of increasing use and access of your data? Part of what that led to, when we were having our call, is thinking about we should probably come up with some guiding principles for data access and use. We will have some general principles, and that is what we are going to start to work on today. But as we meet with each group we also want to have things that are specific for that particular group.

So our first group, and again it is not by accident, our first group is going to be NHIS, coming in today, and they are going t talk us, and they pick the person whose job it is to actually get the data out the door, used and accessible. Again, it is not somebody who is going to come in and tell us all the dimensions of the survey. Instead they are going to tell us how it is that they actually try to get that data out the door.

It will be a little clunky because we haven’t done it before. We haven’t developed a set of questions. But because NHIS is king of inside, and Charlie was great about saying not quite sure it is going to work but, yes, we’ll volunteer.

We want to see how we can be helpful. We want to try and figure out how to develop these guiding principles. So its like, you know, I an following in the footsteps of my colleagues here in the sense that we want to roll something out that will be general principles about if you have a data set, here are some basic things to think about no matter who you are, and then to try to customize those same things for the various agencies.

Damon is good in the sense that he is working with us to help us know which agencies are probably the most amenable. Some agencies have already spent their budget in the sense of doing their changes. So we may want to get them on another cycle. So we don’t want to do a lot of work and say, that’s really great, but I can’t come back until about two or three years from now. We are actually going to work with those who are in a place where they are wanting to make the changes.

The other thing I am trying to do in the meeting is try to get us to know who each other is as well as to have a sense of what is going on. I am trying to reserve some time, and I have a feeling doing it at the end is going to be hard and I may eventually change it to the beginning. But it is a time when everybody can make announcements, can invite people to things, can relay let you know of cutting edge activities, things that are coming up so that we can keep on exchanging that. Because there are a lot of things that they want some cross-disciplinary fertilization on. So I though we need to be able to do that in our meeting.

It will be kind of Larry’s version of running the table, but it will be I have something to share in terms of you may want to come to it kind of thing. We’ll see.

So those are the plans. So we will see how it is all going to work out.

MR. SCANLON: On a sort of pilot or experiment, we picked the health interview survey because it is sort of the flagship health survey. So we are going to ask the group to brief them on it, but we are really asking for their advice on disseminating and getting the information out from their point of view.

We release the data the normal ways. We do an issue brief or a statistical brief, press releases – well, we don’t do press releases there. And we often have a public use file that is made available on the web site. Then it is sort of over and we see who takes it up, But I think we will be asking the group to look at it from their perspective, from the people who might pick it up and apply it to other settings or make it available to new audiences – what would they advise. So it is kind of a different perspective on it all, and if it works well we will pi another survey. Then we will get the vital statistics group. 60 ;

DR. GREEN: Let’s take a quick survey. How many are able to stay for at least part of the working group meeting? It is going to be in this room. Vicki is going to convene it at one o’clock. Sorry for the rest of you that you are going to miss out on all the fun. I hope you have safe travel.

I asked Jim to do one other thing here. Given the turnover in the terms of the committee members, I asked him to run the books on this a little bit and to clarify, looking past the December meeting and the February, to the June meeting about who is supposed to be here. What is your verdict?

MR. SCANLON: Well this is in the form of a projection. I think we have several folks who go off in June 2015. We hope to reappoint some who have had one term. Others have had two terms and we can’t reappoint them. But I think our expectation is, and we will confirm this, that we would expect the members to be here for the June meeting. We may have to draft you longer, I think sometimes when positions haven’t been filled we ask you to stay on until they are filled. I think I can go up to six months, but you should plan on the June meeting, long term calendars.

DR. GREEN: When you look at the roster and you see your name and it says your term ends 6-1-15, you should not take that as permission to clear your calendar for the June meeting. You need to keep it on there.

MS. GOSS: I heard that everyone has to keep it on there through the calendar year 2015.

MS. JACKSON: I am following up with committee management at CDC, so we will give you final, final clearance on that as soon as we get confirmation.

DR. GREEN: So we will consider this a two-step proposition. For now don’t let go of June. And maybe by December we will know if there is any – I take this in the spirit in which I say it, but being on NCVHS is not a life sentence.

MR. SCANLON: Yet it feels that way.

DR. GREEN: All right. I think we are done. Debbie, what else?

MS. JACKSON: I had to stand up and take a look at Katherine Jones, who is team leader and keeps the trains moving. Special thanks also to Mary Etta Squire. There is so much underpinning that makes things work. Nicole Cooper and Tammara, as well as Jeannine Christiani. So this team just keeps rocking. So thanks very much.


DR. GREEN: I think we should adjourn. All of you should grant yourself credit for getting out of here fifteen minutes early.

As you noticed, three times in our session we have asked for public comments. The last comment we got at the last meeting is it would be good as you went through you did this instead of just having five minutes at the end. Not having done that I forgot that we can do it now.

Anyone on the phone or anyone in the room who wants to offer any further public comment?

Then we are adjourned.

(Whereupon, the committee adjourned at 11:45 a.m.)