[This Transcript is Unedited]

National Committee on Vital and Health Statistics

Workgroup on Quality

September 9, 2005

National Committee on Health Statistics
Room 1404
3311 Toledo Road
Hyattsville, MD 20782

Proceedings by:
CASET Associates, Ltd.
10201 Lee Highway, Suite 180
Fairfax, Virginia 22030
(703) 352-0091


  • Call to Order, Welcome and Introductions
  • Robert Hungate, Chair

P R O C E E D I N G S [9:00 a.m.]

MR. HUNGATE: We’re close enough to all here that we’re going to start —

We’ve got to go around and get people recorded so the transcription can record who is here. I’m Bob Hungate, chair of the workgroup of the NCVHS Quality Workgroup and we’re here to discuss our work plan, and I’ll go around and each will identify themselves in turn.

MS. POKER: Anna Poker from AHRQ.

MR. LOCALIO: I’m Russ Localio from the University of Pennsylvania School of Medicine, I’m on the Subcommittee of Populations visiting today.

DR. HOLMES: I’m Julia Holmes, I’m a staff member of the Workgroup on Quality and I work at NCHS.

DR. CARR: I’m Justine Carr, member of the committee, member of the workgroup.

MS. MCCALL: Carol McCall, vice chair of the committee —

MR. HUNGATE: Co-chair is the more appropriate term.

MS. MCCALL: Oh, all right, co-chair.

MS. KANAAN: I’m Susan Kanaan, writer for the committee.

MS. MCCALL: There’s some material, does everybody have this?

In terms of what you want to do today, this was talking, I’ll put it up on a flow chart —

MR. HUNGATE: Carol offered to help out with an agenda.

MS. MCCALL: Right, based on what I have, so what I’m going to offer to do is put it up there and then what we’re going to do is you’ll have unfortunately kind of in real time let’s all agree what we want to accomplish and we have only like 90 minutes, not much time, and there is another kind of new document coming in that we’ll have to decide how we want to leverage, whether we want to leverage it today or some other day.

Now we have a flip chart, what we don’t have is a marker, so one item —

MR. HUNGATE: Just read them off.

MS. MCCALL: I’ll just read them off. The first is one item that we said that we wanted to do and we won’t necessarily take it in this order but one is to develop an agenda for our meeting on I believe it’s the 18th of November, is that right?

MR. HUNGATE: November 18th agenda.

MS. MCCALL: Right, and we may not get it fully fleshed, there will be kind of take home assignments and all of that but so that we’re all clear about what we want to accomplish and who has what assignments, so that’s number one.

Another one is that I’m going to hold up a piece of paper here, is to actually, agenda for 11/18 meeting, the second one and I’d like Bob in particular your reaction to spending some time on this today —

MR. HUNGATE: It’d be useful.

MS. MCCALL: Okay, I do too, we’ll call this the focus portfolio process framework, so we’ll discuss that, and at least orient everybody to it, there may be some homework assignments coming out of this but this could be just a really great mechanism for organizing our activities and so yes, we’re kind of stealing from another group but that’s a good thing.

MR. HUNGATE: That’s what we want to have happen, we want stealing back and forth as much as we can get.

MS. MCCALL: Exactly, so we’ve talked about that, so that will be good.

We’ve also talked about creating at least an outline of additional Quality Workgroup products, not to actually do those products here today but creating at least a straw dog list so that we can begin saying how we coming on those. We’ve said Wednesday one of those would be a set of guiding principles, so that would be a piece that we would need to create. We also talked about another one on Wednesday which was this picture and Bill had talked about that, Bob, so that would be, it’s not so much a product in the formal sense, it’s kind of an internal deliverable to ourselves —

MS. POKER: So you’re talking about the picture about what the work flow is, is that sort of what you’re thinking about?

MR. HUNGATE: Information flow.

MS. MCCALL: We said that that would be useful to us in getting —

MR. HUNGATE: That would be very useful.

MS. MCCALL: So that would become an interim deliverable.

We’ve also had down in some of our other documents an interim concept paper so what I’d love for us to do is just start a punch list of things that we need to do and make sure that we hold ourselves accountable to those deliverables which would be great.

So that’s what I have in a fairly short period of time.

MR. HUNGATE: What’s everybody’s estimate of the timeframe for each of those?

MS. MCCALL: Oh, I’m sorry, and we need to calendar future meetings for ourselves.

In terms of amount of time on the agenda I would say 20 minutes, let’s give ourselves 20 minutes for that. This one is going to take —

MR. HUNGATE: That could take too much time, I think just, it’s an overview that we accomplish today, what does this do, what does it cover, how does it function in the structure —

MS. MCCALL: And how do we order some next steps with that, let’s give it 20 at most. Outline of future Quality Workgroup products, again it’s a list with some time for each one. I think that that’s probably, where are we at, 40? Give it half hour at most. And we have the calendars and future meetings. Does everybody have their calendar? We talked about that Wednesday, bring your calendar, we’re going to try to do —

MR. HUNGATE: I’ve got it, it’s the paper variety. You don’t have any idea how much anguish there is when it gets misplaces.

MS. MCCALL: So we at least need to get the next one, I’ll bet, don’t lose it. And then we need to talk about just general next steps.

MR. HUNGATE: The thing that I might think about adding to that one is the linkages outside —

MS. MCCALL: That’s precisely what’s going to be in here.

MR. HUNGATE: Because that gets partway, it doesn’t get all the way I think for our —

MS. MCCALL: And this is just a starting point so let’s actually focus on the agenda, let’s go back up, and somebody —

[Multiple speakers.]

MS. MCCALL: Is it the process that they should tell you that they want to dial in or should we dial in as a matter of course?

MR. HUNGATE: Let’s go ahead and do it and make sure.

MS. MCCALL: Yeah, I just don’t want someone hanging out there.

MS. POKER: I think I have it here, do you need the phone number? Is that what you need, Cynthia?

MS. MCCALL: Okay, so we’ll dial in when she brings that forward.

Okay, the agenda, I’m sorry for the point of order, so who’s taking minutes? Who takes minutes?

MR. HUNGATE: We have a transcription. To the extent that things get recorded Susan is usually the —

MS. MCCALL: It’s more about kind of action items so that —

PARTICIPANT: I usually do that.

MS. MCCALL: Do you? Okay, very good.

MR. HUNGATE: It’s very useful, very helpful and very accurate.

MS. MCCALL: So 11/18 agenda, now you actually have some reference to that in this work here, right?

PARTICIPANT: That’s what a lot of this is about.

MS. MCCALL: So we’re not recreating, we don’t want to reinvent the wheel we started to try to chisel out on Wednesday —

MR. HUNGATE: Question of sequencing, can we do the agenda before we can do the outline of products? Or do we have to have some kind of an outline of products before we do the agenda?

MS. MCCALL: We can swap those. Do you want to do that? Okay, let’s do it —

MR. HUNGATE: I’m just wondering if we don’t need to take them in that order.

MS. MCCALL: That’s absolutely fine with me. Okay, are people comfortable with that? We swap that order around? Okay, very good.

So let’s talk about the things that we said that we wanted to deliver, at least to ourselves, to keep ourselves moving forward. One was this set of guiding principles —

MR. HUNGATE: And thinking about the guiding principles last night I think there are two categories of guiding principles, ones that are overall like privacy and security of information is an overall requirement but it’s not one that we’re going to delve into because that’s being dealt with other places. It’s an assumption that this is taken care of in other places so we don’t have to deal with that content. Follow me?

MS. MCCALL: Yeah, I do, what would be interesting —

MR. HUNGATE: Because I think we need to separate those things which are variable with our content versus those which are given and we’re not going to spend time on.

MS. MCCALL: Do all the other areas and kind of deep concepts, do they have a set of guiding principles?

MR. HUNGATE: I’ve never seen any.

MS. MCCALL: Well, we were working with like a list from the other day, now they weren’t from the other subcommittees but they were in the prior documents.

MR. HUNGATE: Well this one was from the Populations Subcommittee in a sense. Did you participate in that in any way, Julia?


MR. HUNGATE: I didn’t think so. So we have the only one that participated in this, you did, and Marjorie did, so that’s our institutional memory. Now I have lunch with Dan Friedman who was the primary author of this about once a month when I’m in town and so we’ve got access to how that was done if we need it. But I think a lot of these that are in here are these givens that are not fundamentally variable with our content.

MS. MCCALL: I guess what I hear saying is that there are other sets of principles and values and beliefs out there from a variety of documents that are related to health information and we should bring them forward, not to use them but to reference them. So I think that that’s a really good point.

MR. HUNGATE: Assumptions about things that are taken care of —

MS. KANAAN: If you look at page three, section 6B, I put the foundation for this work was sort of the way I talked about it, 6B1 —

MS. MCCALL: So this captures that —

DR. CARR: It’s principles and I’m struggling with this but principles underlying what —

I’m trying to connect, the principles, is it principles of Quality Workgroup, principles of the upcoming hearing, principles of a deliverable, I’m not sure what —

MR. HUNGATE: Principles underlying the deliverable.

DR. CARR: And the deliverable is?

MR. HUNGATE: The first hazy vision leading toward a later stronger vision, in other words in terms of what we identified up front as the most important, a vision was the most important of those things, in other words the first three items of the table that you put together, that’s what we said was the most important thing for us to do.

DR. HOLMES: I thought the principles were supposed to be the guiding principles for the product which was how can IT, health IT support quality, health care quality —

MR. HUNGATE: That is the vision.

DR. HOLMES: So I thought that’s what the principles were supposed to become this.

MR. HUNGATE: That’s the label we’re attaching to the vision is health IT with some other words that we haven’t worked out yet. Does that fit conceptually?

MS. MCCALL: Yeah, so is that clear to people?

DR. CARR: It’s still not clear to me but I think, I guess it’s we have some macro vision and we have some micro vision and we have some macro tasks and micro and I’m just not feeling like they tie together. I mean I wonder if we stepped back and —

MS. MCCALL: It’s almost like we haven’t clearly for ourselves enough articulated the boundaries of the end product, because whatever that end product is it’s going to be the guiding principles underlying the scope of that and so without, it’s like we’re trying to map into a cloud because it’s not concrete in itself.

DR. CARR: It may be that the agenda that, the sequence that you initially said is we’re going to have a hearing on November 18th, what are we asking and what will we do with that information. If we clarify that then we might have some guiding principles as to who we choose to speak, I don’t know, I’m just not that familiar with the guiding principles concept, I think I probably address it in different ways but I’m just not —

MR. HUNGATE: If our vision, if the vision we have been asked to provide is the vision of a performance measurement system which fuels improvement in quality and improvement in health then that’s what our hearing should be directed toward. See there’s, they work back and forth.

MS. MCCALL: Okay, although I think we need more time on this, that our end product is a vision for what because, and so I think we need to actually have at another meeting just devoted, this is going to be a work in progress but this takes more time I think then we’re going to be able to give it today. I think what we can do is we can continue to make progress and the reason that I want to make sure that we devote enough time, what you articulated is a vision for a performance measurement system, okay, that has very specific implications and it may not be, it’s not completely the same as what we talked about before.

MR. HUNGATE: I think it’s very close.

MS. MCCALL: And it could be. My point is that we all need to agree to that and understand the implications of what’s in that and what’s outside of that and I don’t think that that’s something that we’re going to be able to do in the next five, ten minutes. So it is of the most profound importance that we clearly articulate it is a vision specifically of what and for what purpose.

DR. CARR: My take on it would be —

MR. HUNGATE: I don’t understand the reluctance, I don’t understand the problem.

DR. CARR: I know, it’s just probably my own inability to visualize but I mean our, of the things we spoke about the other day performance measurement is one component of quality health care —

MS. MCCALL: Let me talk about what —

MR. HUNGATE: See I’m not trying to talk about quality health care, health IT is the definition that I’m trying to —

DR. CARR: Right, but as we said other day —

MR. HUNGATE: Because that’s the way we bridge into population health and we recognize the integration in information between individual health and population health and the adjustments and view that one has to make to make them both work. That’s the, if in fact we’re trying to do a document that takes the next level of specificity in system design between these two then I think that’s what it is.

MS. MCCALL: Performance measurement?

MR. HUNGATE: It is performance measurement where health is the objective.

MS. MCCALL: I’m going to disagree only because I think that if we’re going to say that today what we talked about Wednesday was something else, it was medical knowledge, and that was a fuzzy term but I would submit that medical knowledge is related to but distinct from performance measurement in terms of the boundaries that we create for ourselves.

MR. HUNGATE: I would argue that medical knowledge is the color(?) of the health IT, the reason for doing health IT intersection is the generation of medical knowledge, which informs the validity of a measurement system to be used by professionals to self assess, to be used by purchasers to externally assess, that I focus on the performance measurement because of the input from Peggy O’Kane in our hearing which says you’ll have more luck if you move from the term quality to performance measurement. I’m trying to build on the information we listened to and articulate it in the terms that will fit what I thought I heard Steve Jencks, Brent James, Don Detmer frame in their comments. And that’s what I’m trying to do.

DR. HOLMES: Is performance measurement then health system, quality of care of the health system? Does that equate?

MR. HUNGATE: No, because quality of care gets to a provider base, not a patient centered definition, so that’s where we have some, this is a very important discussion, we probably cannot finish it today but I agree, but I think we just need to, it needs to be worked out and I’m just saying these are posts that we have to remember that we have to deal with. Now I’ll back off on that and say okay now we have different bases of knowledge and we got to get our knowledge to common ground and we also have to get it linked to the rest of the world so we’re in sync, and those are the two tasks that are —

MS. MCCALL: Let me ask a different question staying on this deliverable, which is to say okay, do we agree that we need a set, that we want to put just on a list, that we want one of those so that we have some institution memory, so a set of guiding principles. Is that, I know that it begs a lot of questions, I’m just saying that let’s assume for a moment that we had the answer, do we believe that we need a set —

MR. HUNGATE: I think it’d help us.

MS. MCCALL: Even absent all what we’d like to know about vision and being able to articulate the boundaries of our final product do we think that we can make progress on such a set of guiding principles, that there are some things that no matter what vocabulary we use, we’ve made some progress already so can we get started on it —

MR. HUNGATE: I think we can. I’m optimistic about our, this is a very dedicated group, this group is not hesitant to speak its mind and it also listens, so those things can make progress.

MS. MCCALL: If we think we can at least get a starter set that will, it’s going to morph as we get more clarity around our end product, we’ll have to come back and check, then I think that we can put it out as a deliverable for ourselves, that we can start. So what we need is if that’s going to be a piece, do we think that we need that before this meeting on the 11th, in November, or can it be a parallel process?

MR. HUNGATE: I think it can be parallel because I think we’ve got some things that we’ve got to get started on.

MS. MCCALL: So who’s going to take, kind of have their name next to that one? Just in terms of around this table when we look at trying to divide and conquer the work just to create a straw dog.

MR. HUNGATE: I’m willing to take that one on if people are willing to —

DR. HOLMES: Don’t you think that has to be related or subsumed under that principles —

MS. MCCALL: Eventually it will.

DR. HOLMES: — laid out in the health vision, I mean IT is an information process —

MS. MCCALL: Yeah, we talked about it on Wednesday so we already kind of covered that and how to at least take a stab at integrating those which is I think what you’re saying.

DR. HOLMES: So whatever principles we come up with I would think should be related to those.

MS. MCCALL: I’m just looking for a name and a date.

MR. HUNGATE: That’s fine and I appreciate that, the only way to make progress I think if is I set something down and send it to a vote, then I got to have answers back why isn’t this a principle if you think it isn’t, and if you think there’s one that I’ve left out then add it and tell me why —

MS. MCCALL: And we’ll talk about it, but it’s to give people something to react to.

MR. HUNGATE: But we need to do that probably offline from the meetings because it’s content, it’s very specific and it takes work —

MS. MCCALL: And I think part of this is going to be related to our own tempo of getting together so that what I would love to do is whenever that next meeting is, unless it’s like next week which it won’t be, that there actually be a straw dog for reaction that we can, there will have been time for people to react and give feedback so we can so okay so how we coming on it so there would at least be some sort of progress and what do we think about our progress update at the next meeting, which is probably going to be a month from now or somewhere —

MR. HUNGATE: October timeframe?

MS. MCCALL: Yeah, I think so.

DR. CARR: Do we want to stop right now and try to see if we can even calendar that next one?


MR. HUNGATE: That may be a conference call as opposed to a face to face.

MS. MCCALL: Oh, absolutely, there’s going to be a lot of conference calls.

MR. HUNGATE: It’s likely to be mid-November.

MS. MCCALL: The next outline, we said we wanted a flow chart and a picture —

MS. POKER: Didn’t Bill say he was going to do that?

MS. MCCALL: So Bill is going to do that one and so actually we’re just going to put Bill’s name and the same timeframe for that one —

DR. STEINWACHS: Oh, give him an earlier time.

MS. MCCALL: Now we also said that, we didn’t talk so much on Wednesday about a concept paper but the actual, the document, Susan, that came out of, or actually came as input into that talked a lot about having kind of iterative kind of fuller and fuller and fuller concept papers so the question is, because that one I think is the most vital one to say somebody’s got to take a stab and just step off that cliff knowing that there’s going to be tons of feedback —

MS. POKER: Can we use some of what Susan already did as sort of, because I mean it seems like —

MR. HUNGATE: I think Susan’s our workhorse on that piece of it.

DR. STEINWACHS: She wanted to be a gazelle, she didn’t want to be a horse.

MS. KANAAN: So are you talking about, yesterday Bob was talking about a storyline kind of, just a descriptive piece of the thought process, is that the way people visualize the initial document? I know Marjorie has also talked about, and maybe this is what it will eventually evolve into, she envisions, and I put it in the item two in this highlights document, having a document that people could respond to in the second hearing so maybe that’s another iteration that we’re aiming for down the road.

MS. MCCALL: I’ll go ahead and put my neck out there for the very first step —

MS. POKER: Which is —

MS. MCCALL: The first step for the first draft interim concept paper for us.

MS. POKER: So you’re going to do that, Susan?

MS. MCCALL: Susan is going to write, I’m just saying the issue is who’s name goes next to it, she has to work but I end up having to, unless we can assign you work that is just, okay, Susan has to write it, no, I don’t mean the actual act of working with somebody, who is the accountable party —

MR. HUNGATE: I think you’re fine.

MS. MCCALL: You have to have somebody on the committee where the committee has the ultimate responsibility.

MR. HUNGATE: The letter on the PHR which we worked on yesterday and which we’ll probably approve today greatly benefited from having the picture from the NHII in the front of it. I think repetition of that is not inappropriate and I would suggest that we consider adding the similar graphic from the other document that we’re talking about trying to link in between —

MS. MCCALL: This is such an important concept I’d even take it further then that, I think your point about linkages to these other products is vital, that we need to pull as much conceptually vocabulary as we can so that we demonstrate a continuity with all that we’ve done, so I think that, I think it’s a really great point.

Now whether or not, I think that a deliverable should be at least an outline so I don’t know if all the words are going to be there but at least kind of chapter headings, a stab at a title, kind of a skeleton so that people can go you know what, I don’t even see this concept represented and then some pieces will actually have some flesh and I think that that should be for our next meeting. Just to kind of push to product.

MS. KANAAN: And you’re talking about this probably conference call in mid-October.

MS. MCCALL: Mid to late.

MS. POKER: You said mid-November.

MS. KANAAN: That’s the face to face.

MS. MCCALL: It’s somewhere between splitting between today and our November meeting.

MR. HUNGATE: Put a nominal time on it of say October 12th, which is a Wednesday —

MS. MCCALL: Just because it’s halfway between —

MR. HUNGATE: We’ve got to start someplace and you’ll adjust that based on what the calendar says —

MS. MCCALL: We’ll have to pull up calendars here.

MS. KANAAN: So I’m going to put in a month.

MS. MCCALL: Are there other work products that we, those were kind of the big three that we had talked about —

MS. KANAAN: Can I get a little more clarification on people’s thoughts about how they envision this document right now or would that be inappropriate?

MS. MCCALL: You want to spend a few minutes on that?

MS. KANAAN: Just a couple. The combination, the storyline is a kind, I visualize as a kind of narrative of how your thinking has evolved, both areas of agreement, areas of disagreement, inputs from the outside and so on. And it certainly is possible to link that to these other important sort of pillars of the committee’s work conceptually but that is bringing in a different dimension —

MS. MCCALL: You mean to bring these in?

MS. KANAAN: Yeah, that’s kind of looking ahead rather then just describing what’s happened so far. And is that what they’d like me to try to accomplish is both of those things?

MR. HUNGATE: I think so. Now my sense of what we heard from Detmer, James, Jencks, was their vision of the problem information wise that is present, it’s not an answer, it’s a conception of what it is that has to be grappled with. And so that’s a piece of the storyline. Another piece of the storyline is the preceding work of the Quality Workgroup which resulted in a report, a set of hearings, a certain level of action and a lot of conclusions about the process around this information and there’s some emergent things from that part of which I think relate to what Justine probably got tuned into in the Standards Committee yesterday —

MS. KANAAN: So it really is a storyline very much with reference to these sort of constructs that you’re trying to relate to —

MS. MCCALL: We’re just trying to borrow from the constructs from the past, not repeat the storyline.

MR. HUNGATE: That’s right, it’s the constructs that came out of the events.

MS. MCCALL: So for example, I think the great example is the picture that was put into the PHR letter, they had a lot of specific things to talk about and because they were able literally to reference a prior work whose sum total was maybe that picture they can kind of by taking the picture grab all the concepts that came before if somebody really wants to go there and then proceed forward. So if there are opportunities for us to do that that’s what I hear that we’re going to want to do rather then have to unpack them all again.

MS. KANAAN: I think it almost inevitably and I’m really happy to take this on, but it almost inevitably takes, means that I’m going to be moving out ahead of you conceptually to even begin to think about how these links might happen, so in a way I’m partly describing your thought process to date and partly moving ahead —

MR. HUNGATE: It would be helpful for you to articulate for others the other involvements you have had with NCVHS because you’ve been involved in a lot more material then most of us have.

MS. KANAAN: I helped to write both of these, I mostly edited but —

MR. HUNGATE: And she has written the annual reports and other reports.

MS. KANAAN: Okay, well that, I appreciate that extra few minutes on it because it helps me understand what you’re looking for.

MS. MCCALL: And we can spend obviously much more time because I think some of it is not necessarily you personally staying ahead as it is we’re going to create a likely chapter outline and then we’re going to fill it in, and it’s not going to be a single person effort, some will come from hearings by definition, some will come from testimony, some will come from key connections to other activities going on, whether it’s to AHRQ, whether it’s to CMS, whether it’s to any other entity because it really needs to be a synthesis of thought across a variety of domains. I don’t want you to feel like we’re going to send you up to the top of the mountain, that is not at all what’s going to happen.

MS. KANAAN: And indeed that wouldn’t be appropriate because it needs to be your intellectual work ultimately, but yeah, I think I understand the assignment.

MS. MCCALL: Okay. Are there other work products, kind of interim deliverables to ourselves that we’ve listed that we want to make sure that we capture?

DR. CARR: Well in terms, I don’t know if we’d call it a work product but when we get to this model that Harry put together, I think it’s the idea of our scope and our balance of near term, future term, current, and our process. I think that that is a very, very important work product for us so that we can leverage our time and energy in the most effective manner.

MS. MCCALL: So I think those will be some deliverables to ourselves which is really about how we go about doing our work and it’s really kind of a roadmap.

There’s one more that I’d like for us, before we actually talk about that, for us to put up on the list and we’ve talked about it before and it’s almost like the business case or the theory of the case for quality. And I know it sounds stupid but somebody at the dinner that I was at last night, because I used that term, they’re like how could anybody not believe the case and they go that’s not the point, the point is about not that there’s a case but shining a bright light on specifically in the short, medium, and long term, where is that business case or theory of the case going to be the strongest —

DR. CARR: It reminds me of the first meeting I ever came to, the first Quality meeting when we were looking at things and saying what’s, it was two axis, what’s the cost and what’s the benefit and making it to four grids, and we did it in two ways, we had our recommendations and we said cost and benefit, where do things sit in a paper world and cost and benefit, where do things sit in an electronic world. And I’d like to actually go back to that —

MR. HUNGATE: John Lumpkin pushed us very much in that direction —

DR. CARR: And I think that is an interface because as these P for P initiatives multiply, I’ve not seen that anyone has done this case of what is it costing and what’s the actual benefit and I think that that is a very important question because the weight of multiplication —

MR. HUNGATE: And the more important provision asks for us to solve the problem of why it does that, that’s what we have to grapple with and so how do we change that.

MS. MCCALL: I also think back to the document that we had put together and used on Wednesday, or actually had on Wednesday, they’re on page two, it says what is the best frame for the workgroup’s contribution. And we talked about a lot of different ways to frame it and one of them is, we don’t have to pick here but one of them is advising on HHS investment including where they should make additional investments to create this interface. And so it’s almost like saying it’s not what are all the things I should do but what should I do first, where’s my “cost/benefit”, the best ratio today, given the links to other areas, etc., so not only build me the case for all of it but build me the steps to get to it or the right order. And those could literally become if you think about it specific recommendations, not only broadly but to say here’s the broad context and here’s our recommendation on that which needs to be done early because there’s opportunity or there’s synergy or there’s gap they can close or speed to execution is the fastest, whatever it is, and we’ll find those things out. But I would like to put that down as a, I don’t know if it’s a specific deliverable but it’s a way for us to begin to organize ourselves and organize our work. So that’s food for thought, I don’t know what to do with that but I think it’s a powerful frame for us.

MS. KANAAN: I’m sorry, Carol, can you back up and which one of these are you referring to?

MS. MCCALL: G, 2G, I mean advising HHS on investment is basically about telling them where their bang for their investment buck, and dollars is not always financial and benefit is not always financial.

DR. STEINWACHS: So the business case is really the social business case, not the business business case.

MS. MCCALL: Absolutely, not the business business, so it’s really the theory of the case —

DR. STEINWACHS: Societal cost effectiveness or cost benefit —

MS. MCCALL: And some of it will be financial and some of it will be personal and some of it will be about the value which is tough that you can’t monetize patient centricity but that becomes a value —

MR. HUNGATE: I’m uncertain here because I think the decision is already made to put the money in the AHIC activity.

MS. MCCALL: Oh, it’s not about whether or not to spend, it’s where to spend first as respects quality, not on infrastructure —

MR. HUNGATE: I’m trying to think how much effect we can have in what way —

DR. CARR: Well, I think we can shine the line on did you know that you’re spending all this money and most of the money is going into projects that will have a low benefit for a small number of people in a very long timeframe and the diversion of that money preempted the money that can get you a quick hit for low investment if that’s a fair thing.

MS. MCCALL: Well think about AHIC, AHIC is silent on —

MS. POKER: I’m sorry, do you have different versions here?

MS. MCCALL: We referring to two documents, we’re referring to the one from Wednesday.

[Multiple speakers.]

MS. MCCALL: It’s a void, they need something, they need somebody to tell them what to do in the early term, and so what I would love to do is not only make the case but make it specifically enough about where’s the sweet spot early that says here’s what you need to start doing now to get to a longer picture and I think we only have a short window of time to influence this process before it will speed past us. So I think it’s not so much a deliverable —

MR. HUNGATE: I firmly believe in quality improvement and quality improvement is where the provider is able to manage their own quality in a way that others can see it, I think you’d agree —

DR. CARR: I think that’s one part of it, I mean some of it is —

MR. HUNGATE: It’s a strong piece of it —

MS. MCCALL: It’s a piece, I don’t think it’s everything but I think it’s a piece.

MR. HUNGATE: Quality improvement modalities tend to be most efficient in the long run because you build quality in the places the work is done and if that’s the primary tenet under which we work then trying to get the conditions for quality improvement to work is our contribution, trying to help that. Now that’s a conclusion, that’s my operating premise which is based on a lot of years of working with the problem and so I believe in that premise and so I want to see how does that relate to the short term, how does it fit.

MS. MCCALL: Well, maybe the deliverable here is that, is to have somebody put together how that type of frame of cost and benefit over short term, medium term, long term, how can we articulate it better so everybody understands it, put it on a page or two at most, then we can say okay yeah, I like that frame, then we can decide how to bring it into, it should influence the hearings, how we structure the hearings, the types of questions we seek, and so I think that that is a very important thing, it could even inform the specific way we handle the 18th of November.

MR. HUNGATE: And it ties very closely what Bill’s talking about in the information flows.

MS. MCCALL: It absolutely does.

MR. HUNGATE: It will have I think specific phases in it, we went through a hearing where we said we’re going to change the claim form and we found that that was not a productive avenue to follow fundamentally. The next best course in that line is the claims attachment, which is coming out of the HL7 language which is intended to deal with that same information flow in a different way, and then there’s probably a third stage beyond that which might be what are electronic, that’s the IT intersection, so there’s phases there, all of which influence this process.

DR. CARR: The only thing I would say is that the electronic health record IT thing is not about reporting, in fact it’s probably weakest on the reporting, the claims is an opportunity for getting reporting of compliance and so on whereas the electronic health record affords the opportunity for in the moment interventions, whether it be legibility, timeliness, decision support. So I’m seeing them as different, all helpful, but claims and so on are ways of reporting back, they don’t change practice, electronic health records —

MS. MCCALL: I heard you using that as an analogy, the claims bit as an analogy, not something we’re going to go back and —

DR. CARR: Scope is changing —

MR. HUNGATE: But I’m talking about the phasing of information, the health IT intersection model says we’re going to try to take advantage of what is in the electronic record in some collected way to better inform the knowledge, the feedback —

DR. CARR: But I think that’s exactly, that’s the question on the table, what is the capacity of the electronic health record to feed back —

[Multiple speakers.]

DR. CARR: So I think shining the light on here is the typewriter that actually is a computer and a work processor, you can use it as a typewriter, you can use it as a word processor, you can use it as a data integration system, and we are kind of thinking about the typewriter but we need to think more about it’s a computer.

DR. STEINWACHS: It seems to me if you look at where the whole committee is it’s really sort of a three legged stool now, we started out with claims and we still have administrative records as part of this, we had the EHR as part of this, and now we have the patient health record. And those don’t necessarily have to relate to each other at all, they can be three totally parallel independent things. It seems to me part of the shining the light is how do you build the important interconnections —

MS. POKER: And Don they should relate to each other.

DR. STEINWACHS: Well, I agree with you but they don’t have to.

DR. CARR: And we heard yesterday, secondary use of PHR is probably off the table so as we’re trying to think about information coming back that is not a given that you can ever get information from the PHR for aggregated data so I think that was a real helpful understanding of —

MR. HUNGATE: In terms of vision I don’t think you have to take it off the table —

DR. CARR: Well, that you can access, I mean I think I heard pretty profoundly that there’s not a given —

MS. MCCALL: Here’s what I would say that I heard that from a long term vision no you don’t take it off, from a sweet spot in terms of it’s probably, given what we heard yesterday you wouldn’t start there. So that’s where I think if we have a framework for saying what is the value and then what is essentially the effort to get there, that we would not shine a light on PHR, that would be an example, the migration, the first thing you do is you don’t try to integrate claims to say EHR —

DR. STEINWACHS: But the only caveat is we’re now, a link that says where to anchor(?) your draft PHR.

MS. MCCALL: Understood, understood, the question is it an oil slick, or is that the place where things are going to come up first and the reason I ask is we said on Wednesday that the likely agenda question for the 18th of November was the following, what is, think about the EHR okay and let’s talk about, if you assume that it is in place how it can be used to enhance quality, let’s talk specifically how, let’s talk about maybe some different settings, inpatient, ambulatory, and so we wouldn’t even want to talk about EHR if we really said our best guess is that the big bolus of information coming through is going to be the PHR intersection with claims. If we really had a strong belief we’d change our agenda.

DR. STEINWACHS: The reason I’m putting some folks on PHR is that most of what we have to do is try to influence individual behavior, the patient and the consumer in the community, and so we get it through, the EHR is a lens of what happens between the health system and the individual but in many ways the issues of education, I mean part of the frameworks you’re talking about, how do we get people to seek care at the right time, to manage down the road. And so the only reason for not wanting to take the PHR off the table it seems to me is not that it’s a focus on it but it is, in a sense it’s our representation of the IT tool for the patient or for the consumer —

MR. HUNGATE: Maybe the best help to population health information.

DR. STEINWACHS: And I think it’s in many ways you talk about where is the sweet spot to the extent you can help support people to better in taking care of themselves, whether it’s a chronic disease, now that probably is. Now whether the PHR ultimately does it or not I don’t know but it seems to me it’s our tool, it’s our playground —

MS. MCCALL: And I don’t think we artificially avoid it, I think what we have to ask ourselves is do we tackle on the 18th both of these —

DR. STEINWACHS: But I think you’re right, I would start with EHR, I just didn’t want to take the other two legs of the stool —

MS. MCCALL: Oh, we never take them off —

MS. POKER: Well, that’s a patient centered, I wanted to just point out, Carol, is who are you going to ask the questions from because if you start asking —

MS. MCCALL: Let’s come back to that, we actually are, we’re talking about the agenda but we’re not officially into that point. What I want to do is close out the outline of workgroup products. So we actually added one more to the list which is —

MR. HUNGATE: Which is mine.

MS. MCCALL: You want to take the framework?

MR. HUNGATE: I think I have to, I’m the most dedicated to it —

MS. MCCALL: In terms of the cost and benefit?

MR. HUNGATE: Well, it deals with the pay for performance which is cost and benefit, value, it deals with the health information, it deals with the measurement system. Because it’s not just improving quality, it’s improving the understanding of quality across the system. If the inefficiency is now caused by the inability to judge quality and the demand to do so, which is I think the case, then what you have to do is fix it so people can judge it in a more efficient way.

MS. MCCALL: Now I want to make sure we all understand what this particular is. It’s not writing out what —

MR. HUNGATE: It’s a picture.

MS. MCCALL: No, it’s not actually articulating what we think the cost/benefit is yet, what this deliverable is is a framework for us to begin to guide our work, so when we talk about cost benefit what are the elements we’re going to consider, who are the people we need to talk to, what are the different venues of EHR/PHR, so it’s a skeleton, it’s a frame. That should make it —

MR. HUNGATE: Let me put another comment on that in terms of the expectations of our work. We are not going to design the information system, we can’t do it, but we can articulate a process by which society can design a measurement system and that’s what I think I’m going to try to put down.

MS. MCCALL: We need to keep going guys, we get to actually cross this one off now, we need to talk about this agenda and then we’re going to talk about this portfolio process, and we’re going to have to find some time together and we have 40 minutes. So let’s, which is not a lot so we’re kind of compressing it down, we’re going to telescope down. Let’s move on to the agenda. We actually have something from Wednesday, where is that —

MS. KANAAN: Section five, if you look at page two of section five, I’m sorry, sections four and sections five, which are on pages four and two, the first are sort of some of your concepts for how you described it and then the questions and I would actually, what’s listed second should be listed first under Roman numeral five, how can an EHR improve quality, because then it goes on, but these are, mind you these are things I took out of my notes of what you said on Wednesday and I tried to eliminate redundancy but I didn’t totally succeed. And down at the bottom you’ll see, remember Barbara read you her formulation of it down there between the dotted lines.

MS. MCCALL: These are great questions but it seems like there’s like what’s the highest question that’s there and all of them become kind of refinements on the theme.

MS. KANAAN: Well, the highest question is what I put here in bold face under four, the EHR and how to leverage it to enhance quality, is that the overarching question?

DR. HOLMES: I thought that —

MS. MCCALL: I think it is, I think it is, so that’s really the theme. Are people still comfortable with that?

MS. POKER: It depends who you ask it from, some people aren’t going to know the answer to that —

MS. MCCALL: Well then we won’t invite them.

MS. POKER: You ask it differently from, that was my point that if you ask a physician how can the HIT improve the care you provide they may not know the answer because they haven’t used HIT, they don’t know. That doesn’t mean if you ask them how would you like to improve the quality of care you’re giving today, how would you like to do it, they can articulate it very well.

MS. MCCALL: It’s not about the technology —

MS. POKER: It’s not about the technology, it’s about how can we improve the care.

DR. CARR: But I think Bob’s point is correct that we’re not building the system, I think what we’re trying to do is reflect back and say okay, we’re in phase one of electronic health records, what have been the early wins, what have been the obstacles and where do we want to leverage, again it’s the low cost/high cost, low effort, low yield/high yield, and what are the things that we’ve gotten better simply by having, whether it’s typewritten on a prescription, I mean that’s huge, I mean it’s not razzle dazzle kind of claims, it’s not data, but it’s huge. I would not ask people who don’t have one, that’s sort of an NHII kind of thing what do you want, I would hear from, well the usual suspects, AHRQ, CMS and so on to get their ideas about what are they envisioning and asking and what will bet the intersection with the electronic health record and/or can we talk to best practice models to say we did this and we got this much better.

MS. POKER: Can I ask why we’re doing that when we have an IOM report that’s already did all that asking? I mean I’m just asking —

DR. CARR: No, where are we today, I mean we have a roadmap for this is what we ought to do, what have we now done, that’s right, we could follow-up on that and say here’s all the things that it said, AHRQ should make a decision support building guidelines, let’s get an update on that —

MS. POKER: I don’t know if in two years we’ve done a lot —

DR. CARR: And it fits in again with the way Harry and them run security, we need to be keeping tabs on it, IOM had that report in ’03, great ideas, let’s bring them back and say where are you on these, what worked and what didn’t work, what is going ahead and what’s not and if not why not —

MS. POKER: And what if almost zero is getting ahead of it —

DR. CARR: Well, that’s important, that was a pretty important report.

MR. HUNGATE: I’m inclined to ask a gut question of Paul Tang and Stan Huff —

MS. POKER: Brent James would know too.

MS. MCCALL: To bring it in as another product so that, you don’t want to get hearings on it, or take hearings on it, you want to get the information in another way, is that what you’re saying?

MR. HUNGATE: Well, I think that we’ve got within our committee that knowledge in those two people specifically.

DR. CARR: Well, they know what they’ve planned but I don’t know if they know what AHRQ did or where it sits in AHRQ’s —

MR. HUNGATE: I’m not talking about AHRQ —

DR. CARR: I mean it specifically says AHRQ will do this, AHRQ will do that, that was the part I was —

MR. HUNGATE: I understand that, I heard that —

MS. POKER: I was the person at AHRQ who had to respond to that report and as of date we’ve done very little yet to actually respond to that. Now you could have Scott Young come in and he would talk to you about the HIT initiatives which are ongoing, I don’t know if we’ve got findings from it but I think he’d be a great person to come in.

MS. MCCALL: That’s a great thing, we should actually as one of the things on the agenda we want to try to find people who can bring in findings on successes and not to date.

MR. LOCALIO: I think it might help to think in terms of sources of funds and uses of funds for the questions you’re asking, just listening that’s what it appears to be, in other words it may be that AHRQ was supposed to do X, Y, Z but AHRQ has only done part of X because there hasn’t been enough resources to do that, that’s what I suspect. Also to the extent that others are, AHIC is supposed to be doing work, others are supposed to be doing work, what are they doing with what, focused on only your question here, on only your question, so who are the players and what are the resources they have and what are they doing because it may be that AHRQ hasn’t done —

MS. MCCALL: Kind of view of the landscape of what the activity is and successes to date.

MR. LOCALIO: How can you asses today, 2005, as to who’s doing what? Now AHIC it seems wants to do a lot but I’m not sure that what they’re doing is focusing on your question and it may be that, what is it, it’s ONC or ONCHIT is doing something in their —

DR. STEINWACHS: You reluctant to pronounce that?

MR. LOCALIO: Well, there are two different versions, the Federal Register says ONC, but ONC’s Office of Policy and Research is supposed to be doing something but what are they doing, how much are they doing on this question —

MR. HUNGATE: The thing I’m worried about is that there’s an offset from the real world at AHRQ, the real world is at VI, is it Intermountain Health, is at Palo Alto —

MR. LOCALIO: I don’t know where VI is getting its money, but I’d love to find out where they’re getting their funds to do all of this work —

MS. MCCALL: And it would be great to know but I think what they have the money, they’re doing the work, we want to hear how it’s going.

MS. POKER: They went for Regenstrief, go for these ones who really do —

MR. LOCALIO: I would ask them, I would try to figure out who’s doing, who has funding to do what and that would give you an idea of what is ongoing in terms of the questions that you’re saying, you want to do the things that have the lowest cost and the highest —

MS. MCCALL: I understand what you’re saying which is to say look, somebody out there has been funded to do something and if we know what that research agenda is or that initiative agenda is then that’s a future sweet spot. If there’s a big pile of money there to do X then guess what, that needs to get taken into the equation because the barriers are going to be fewer. Is that your point, Russell?

MR. LOCALIO: Yeah, it’s just an accounting —

MS. MCCALL: Yeah, we need to find that out.

MR. LOCALIO: Who’s doing the accounting, figuring out what’s going on with regard to the specific question you’re asking here. Before we started we had a little sidebar here about does the right hand know what the left hand is doing in certain areas of research and I think this is an area where somebody has to figure this out —

MS. MCCALL: How much time did it take you to get to the answer no? That’s what I want to know. I’m teasing —

[Multiple speakers.]

MR. LOCALIO: But it seems to me there may be an opportunity here to figure this out and we certainly have talked to the people who might know because when I read these things, whether it’s in the Federal Register or when I read things that is in our summary of our meeting in June and what I know out and about just listening to people I don’t think there’s a good —

MS. MCCALL: We got to keep going through, I think it’s a great point —

MR. HUNGATE: Thinking back to our hearing that we held here where we decided which ones would go forward and which ones would not we had use cases where there were demands for information, costs in general with those, and the system was not working well. Could we use one of those use cases as a focus for this kind of discussion, the kind of thing that you’re anticipating?

DR. CARR: Are you thinking about Hackensack hospital presentation?

MR. HUNGATE: Well, I don’t remember Hackensack —

DR. CARR: They were the ones who talked about how many people they had to hire to meet the data demands and what it meant every time a new —

MR. HUNGATE: Well, but I’m trying to narrow it down to a narrower piece, like diabetes, trying to get it down to a specific enough place that —

DR. CARR: I think what we’re saying, when it gets back to, if we wanted to focus only on disease management we could say how has electronic lab data supported good diabetes management, I think that’s too narrow. I mean this is, we did a rough draft yesterday but just this is about how are we better by the IOM dimensions of care with electronic health records, what is actually happening, what is potential to happen, what is going to be difficult to happen. And so as we spend our dollars maybe the simplest things are the most effective if you have a typewritten prescription, 90,000 lives are saved if you write —

MR. HUNGATE: I see your specific focus on the immediate quality change, well my focus is on the measurement system change and the efficiency of that measurement system, that’s a difference in our —

DR. CARR: And they’re both important but it’s the, and again it’s sort of like claims data helps you measure, electronic health record, what we’re realizing is it’s not going to help us measure much at all not the way it is today, and so I think we want to understand that and is there any way we could do that —

MS. MCCALL: I think there’s two sub-questions guys —

MR. HUNGATE: I got to make an observation on that, I don’t see how a professional can manage care well and build quality in if information for somebody else to see that that was done is not there.

DR. CARR: Well, it is there but it’s here in a narrative, if you’re reading your patient’s chart you sit there and you read it. If you’re in Washington and want to know everybody in the Northeast who asks the question about tobacco cessation you’re going to have to do some word scanning to get it out of the narrative.

DR. STEINWACHS: And what of ambulatory outpatient records —

MR. HUNGATE: Does HL7 intend to deal with that by building supporting terminologies and structures, SNOMED, the adoption of SNOMED, it seems to me decisions have been made that are not yet implemented, that are related to that issue.

DR. CARR: Doctors are not, I don’t think doctors are going to dictate in SNOMED codes or do their own coding.

MR. HUNGATE: I understand, but now it seems to me that this is a question that Stan Huff and Paul Tang can give us authoritative answers on so that we remove it from our discussion, that’s what, get it to common knowledge —

MS. MCCALL: I don’t think our discussions should be about SNOMED or interfaces or anything the like so I’m not quite sure honestly kind of what the issue is just now —

DR. CARR: I think we should hear from Stan and Paul about where things are with that, I don’t think they are where we want them to be at the end user point but the concept —

MS. MCCALL: I think we need an inventory, I think an inventory of what is research, I think to Russell’s point where is the money, funded, what’s research that’s been done on progress, research that’s funded to find progress, and also kind of a state of the state as respects what Stan and Paul can do. So that’s a to do and we’ll have to come back and make some assignments but I think for our —

MR. HUNGATE: That will be a content of the November 18th session.

MS. MCCALL: An update on that? Do we want that in the agenda? Let’s leave it in there for now because otherwise it doesn’t have a home, that will force us to answer the question and get people assigned to it.

But back to this page two, I hear a different question there —

MR. HUNGATE: Page two of which document.

MS. MCCALL: Page two of our notes from Wednesday. So page two, this section five, possible questions for our November meeting. And it’s also kind of the same on page one, how to leverage it to enhance quality. I see the question as really, how can the EHR be used to leverage and enhance quality, how is it actually happening today and how can it happen in the future, how can it be leveraged. So it’s not all just about what are our wins today, but what we need to know is from people who use this, who are familiar with it, they know how to drive the car, to say where you going to go tomorrow —

MS. POKER: So you want someone like Brent James who’s using it. But one of the things that he points out —

MR. HUNGATE: Stan Huff is from the same place.

MS. POKER: Right, but they’re different users, Brent James is more of a quality person whereas Huff is more of a standards kind of person. But one of the things is quality, you want to look at it as a place that can identify vulnerabilities, I don’t know if I need to know measures in quantitative as much as I need to know whether administrative, where the vulnerabilities are to address them. And that’s what HIT can do and that’s one of its principle reasons for using —

MS. MCCALL: We keep wanting to talk about the topic, I want us to get back to the agenda which is is that a decent, is that kind of the one line question that can help us get the right people and scope the content.

DR. STEINWACHS: I think it’s good to the extent you want to add sort of a bullet under that, to what extent does it or does have a potential to improve health because quality and health link is a part of sort of how do we put this back into the broader perspective and so many times improving quality has a rather minimal effect on health, they have an effect on many other things —

MR. HUNGATE: Barbara Starfield is one of the best people for our articulating the health focus.

MS. MCCALL: Now do we want our focus right now because we’ve talked about different types of quality, individual health, system health, kind of population health, can we scope this for the first one down to individual and then maybe in later hearings kind of take it broader?

DR. STEINWACHS: I’d probably go individual and I’d probably go with two settings, we talked about doing hospital and primary care —

MS. MCCALL: I think that will be great, that’s a huge scope for now.

DR. STEINWACHS: The EHRs are very different in those settings —

MS. MCCALL: All right, we’ll come back I think but what I don’t want us to do is given population and then have somebody go well what do you mean by secondary use and then the whole thing just kind of goes —

DR. STEINWACHS: If it’s any use I don’t care about it, not secondary —


DR. STEINWACHS: That was a definition in that room but no one would say it.

MR. HUNGATE: If we build a base for population health by looking at individual health with people who understand population health we have more likely ability to move —

MS. MCCALL: Let’s just two or three bites on this one I think we’ll be better off, so it will be a focus on individual, we’ll get people who have been in the trenches with success and failures and have beliefs, have actually seen what is delivered today for quality and health and have a point of view about what it could be tomorrow. And it will be inpatient and ambulatory, primary care —

DR. STEINWACHS: On the primary care it would be great to have at least one place that has a highly structured EHR. In the old days, Russ you’re probably more on top of it then I am, it was Harbor Pilgrim, the old Harbor Community Health Plan had the most structured EHR versus I think Kaiser is more open and the VA is probably even more open but is to have some contrast because I think part of this issue of potential could very quickly goes into sort of this discussion of what can you get back out of it other then clinician reading it.

MS. MCCALL: Right, okay. So in terms of —

MR. HUNGATE: Question, if we could I’d like to add to that a question of how do you demonstrate that quality gain to others —

MS. MCCALL: Yeah, how do you know —

MR. HUNGATE: How do you convey that to somebody else because that’s the gap we’ve got —

DR. CARR: You’re saying what are the metrics that show that quality has improved.

MS. MCCALL: I think there’s a to do in here that actually says for the actual agenda, kind of what are all the sub questions that we need to try to pull through to give these people guidance, like how do you know and what are your barriers and what do you think it would take to make that real, so that will help us get to our benefit cost stuff.

MR. HUNGATE: I think this is the place where we want to link into that, what is it AQA organization that you talked about the ambulatory quality? Debbie, when does the full meeting start, 10:30 isn’t it? Because that’s one of the linkages, it’s actually not on the list that Marjorie has and it should be, the acronyms, it’s AQA right, there are two acronyms there that need to be added to the Marjorie list of organizations.

MS. MCCALL: We need to get to this item, we’ll end up creating our own list here, this will be our little strategy on a page type of document.

MR. LOCALIO: Could I respond to the question of how do you figure out whether something works?

MS. MCCALL: If it’s brief, otherwise we’ll you have there for —


MR. LOCALIO: I would suggest that you take a look at the systematic review that came out in JAMA on March 9th, effects of computerized clinical decision support systems on practitioner performance and patient outcome. I printed this out two days ago —

MR. HUNGATE: Do you want to email it to us?

MR. LOCALIO: I can, the reason is that it’s, it really shows the variety of studies that have been done and the frailties of those studies and what they are trying to measure and it’s a good summary, it’s done by some people who had done a summary earlier, it comes out of McNaster, Western Ontario, and it’s a Canadian product, Brian Hanes. It’s just a good summary so I’d say this is only for computerized clinical decision support systems —

MS. MCCALL: That’s okay but it’s a great starting point. Can we get copies today or is it, is that reasonable? Okay, excellent.

[Multiple speakers.]

MR. HUNGATE: Press on.

MS. MCCALL: All right, pressing on, I think that the what I want to know is what are the next actions with respect to finishing up the agenda, I think we have a nice frame, we said with that, and I think it’s an offline for what are the other kind of sub questions underneath there and let people respond. We’ve got to get a list of invitees, that’s really what I get the most concerned about is getting on people’s calendars. We’re only two and a half months away, not even, so do we have a short list of people that we know we’d like to have?

MR. HUNGATE: I sort have Paul Tang and Stan Huff because of their past experience —

MS. MCCALL: Have them put on a different hat, kind of put on their past hats?

MS. POKER: Well Simon Cohn is also a writer for the IOM, he also wrote that —

DR. CARR: He can’t remember it, every time I bring it up he’s like what report is that, like you’re the author —

[Multiple speakers.]

DR. STEINWACHS: Just if you’re on the committee it doesn’t always guarantee.

DR. CARR: Don’t we want Jon, our friend from AHRQ who is the HIT —

MS. POKER: Jon White or Scott Young, either one of those, Jon is one of the program managers, Scott heads all of them —

DR. STEINWACHS: Scott used to be part of our subcommittee too.

MS. POKER: Either one would be wonderful.

DR. CARR: So do you want to start with Scott and he can delegate to Jon should he so choose.

MS. MCCALL: Okay, who else?

MS. POKER: Did you guys want Brent James?

DR. CARR: Why? I mean we did hear from him once —

MS. POKER: [Comment off microphone.]

DR. CARR: Right, but I mean we’ve read the IOM report, I don’t think we need to hear from the writers so much as look at what the recommendations are and hear from AHRQ, where are they, what are the obstacles, I think reading this article actually —

MS. POKER: He’s also an Intermountain user and he knows about quality and what the systems can do so he has that perspective also.

MS. MCCALL: Well, we maybe can get somebody else from Intermountain that lives it, breaths, it, so Stan is there, he may have somebody.

Who else from systems, now remember we said we wanted acute and we wanted ambulatory —

MS. POKER: I can ask Jon because he’s on a committee that just started for ambulatory, I forgot what it is, who would be a person he’d recommend —

DR. CARR: You had some friend, who was your person that you know —

MS. MCCALL: Oh, he actually works for a vendor but Peter Geerloffs —

MS. POKER: Now the vendor community you can ask certain questions especially if the vendors, they’re health care practitioners, they are good people to ask some of these questions —

DR. CARR: Because they’ve done the walk through of don’t go there, you’ll never get it.

MS. MCCALL: So let me ask Peter to come, Peter Geerloffs, and we talked about him, I brought him up with respect to decision support which would be a great little add in, what makes that easy and hard.

MR. HUNGATE: I mentioned Barbara Starfield from the standpoint of patient centricity and the health measurement part of it, because I think we need to get that teed up in our thinking —

DR. HOLMES: Or you could have someone from FAC, Foundation for Accountability —

MR. HUNGATE: They’re out of business, they’re gone.

[Multiple speakers.]

DR. CARR: Are we going to personal health record because —

DR. HOLMES: Well they’re the ones that had the dimensions on the patient perspective on care for the quality report, whatever remnants exist of that organization —

DR. CARR: Do we want to change, we’re talking about individual health in the setting of the ambulatory care and in the setting of the hospital, and we’re talking about electronic health records, so are we adding a new column? Because if we do it obligates a lot of resources, I thought we were going to do electronic health record —

MS. MCCALL: We are, I think it’s EHRs from a provider point of view which is really all we talked about or do we want a patient centric point of view, somebody who’s job it is, not getting consumers in here because they don’t know enough but is there somebody whose spent a lot of time looking at it through a consumer lens —

MS. KANAAN: Well David Lansky —

DR. STEINWACHS: Well, either David or talk to David about who he’d suggest —

DR. CARR: And the question we’re asking them is —

MR. HUNGATE: What do we have to do to change to a patient centric view in electronic health records?

DR. CARR: I think that’s the PMR —

MS. MCCALL: See, no, I think it’s the same question but I want somebody who doesn’t think always about the provider to answer it —

DR. CARR: About the EHR —

MS. MCCALL: Same question about the EHR —

DR. STEINWACHS: Same question about realizing the potential, right.

DR. CARR: So then it’s sort of like what Paul was referring to yesterday, EHRs that have a patient window —

DR. STEINWACHS: Not necessarily —

[Multiple speakers.]

DR. STEINWACHS: — EHRs to trigger clinicians to do things that help patients, or inform patients. It could be a window, I mean that’s —

DR. CARR: I’m just picturing in my mind, I’m running filters of who we would ask and I’m not sure who I, I mean we can —

DR. STEINWACHS: I think if you ask someone from the consumer side then you’re asking sort of what they want or feel is needed, and then you have to interpret that back.

DR. CARR: But we also said we’re not inviting physicians who don’t have electronic health record to talk about what they think ought to be in it —

DR. STEINWACHS: We heard Davis talk yesterday and so you’re looking at if you took someone like him then you’re looking at someone who has thought a lot about the consumer side or been involved in trying to say what consumers are wanting and so it’s a way to bring it in or you can wait on it but I think it is important.

DR. HOLMES: Perhaps there already are some initiatives out there that are using information technology to support the consumer perspective.

DR. CARR: There are, there definitely are.

MS. MCCALL: I understand what you’re saying though, Justine, which is —

DR. CARR: I’m just keeping on making the framework and saying we have this amount of time so by bringing in a new population we’ll shrink the time on the other folks and is that okay, what we come back with —

MS. POKER: How many days of hearing are we planning for?

MS. MCCALL: Right now we’re calendared for one and so we need to be really crisp and so we may want to have actually a whole day on PHR —

DR. CARR: We want to have a couple things at the end that we know.

MS. MCCALL: Because we need a lot of time to go patient or person centric —

MR. HUNGATE: We’re going to have a hard time getting around to understanding patient centricity because we don’t, the systems are not set up that way —

DR. CARR: Right, for exactly that reasons —

MR. HUNGATE: I would argue that we’re going to have to give it shots, that we won’t answer it all in one big hearing, so I would argue that we need to give a little piece of it each time we do it in order to make us keep that perspective in mind.

MS. MCCALL: Is there somebody who say from Markle wears a patient or a consumer hat and can look at the same question just so that we get that flavor? And David, put David’s name down and we’ll see if we can come play —

MS. POKER: David Lansky?

MS. MCCALL: Yes, or he may be able to recommend somebody. We’ve got about ten minutes left folks. So you were going to say something about the doctor —

MS. KANAAN: He might be able to recommend something else —

MS. MCCALL: And I think what we’re going to find folks, we’re going to look at that date November 18th and it’s kind of getting into that really horrible window of holidays, we may find that we have a tough time getting this puppy calendared so we need to start with a nice big list so that we can actually —

MS. POKER: I’m going to ask Paul and Stan today if they can make it for the 18th, is that okay?

MS. MCCALL: That’s fine, ask them if they also have any other names that they would recommend. And so in terms of just so, who’s going to contact folks, what are the next actions with those —

MS. POKER: I usually do the, well, I have Paul Tang, Stan Huff, Scott or Jon at AHRQ, I’ll probably reach Scott Young and let him —

MS. MCCALL: Can you reach out to all of these people?

MS. POKER: Now Peter Geerloffs —

MS. MCCALL: With the exception, I will do Peter —

MS. POKER: And Barbara Starfield and David Lansky —

MR. HUNGATE: You know Barbara better then I, what’s your sense of my suggestion? Does it make sense or is it not yet time?

DR. STEINWACHS: I think Barbara is very good about talking about the framework, I’m not sure how she would relate to EHR, I don’t think Barbara’s connections are not, she knows a lot about medical records but not per se, she’s not focused on the EHR. I would probably wait on Barbara.

MR. HUNGATE: Would there be a way to put someone else in a panel with her who does know more about this where we could promote discussion around this? How do we get to an patient center model? Maybe we’re not ready for it now but I think it’s just going to be something that we have to grapple with because nobody else is going to do it.

MS. MCCALL: Yeah, we’re going to have to —

[Multiple speakers.]

MS. KANAAN: — he’s more inclined I would think to —

MS. MCCALL: Do you know Dan? Dan Friedman who spoke at the last meeting?

MR. HUNGATE: I have lunch with him once a month.

[Multiple speakers.]

MR. HUNGATE: I think he will be here for the full meeting, we could ask him to stay over for the next day.

[Multiple speakers.]

MS. MCCALL: So instead of Barbara we’ll put Dan and you’ll talk, you’ll ask him.

DR. STEINWACHS: Bob gets Dan.

[Multiple speakers.]

DR. CARR: Do we want anybody from CMS? I mean if you want somebody, but it may be redundant with the person that you have, I mean we have a physician whose built our ambulatory online medical record, decision support —

MS. POKER: And he works with John Halumka which gives him a huge —

DR. STEINWACHS: Is the VA sort of the other extreme?

DR. CARR: Well, on lessons learned about what’s not working, what’s hard to do, what’s easy to do, so I think —

MR. HUNGATE: We ought to make sure Eduardo joins us.

[Multiple speakers.]

DR. CARR: We have CMS, do we want any representation of how do they see with their growing list of demands —

MS. MCCALL: I’d actually tackle that in a separate meeting, I really want this to be about people that touch it, feel it, loved it, hated it —

MS. KANAAN: Do you think that among the VA people might there be somebody better then Eduardo? I’ve interviewed two people at VA who, there’s probably still theoretical rather then touchy and feely, they might be closer then Eduardo.

MR. HUNGATE: Eduardo is very practical and he is down in the nuts and bolts —

MS. MCCALL: Well, is he so far down though that he’s going to end up talking with me about interfaces —

DR. CARR: Prohibited language list.

MR. HUNGATE: Let’s test it out, let’s test it out.

MS. POKER: Paul Tang, Stan Huff, Scott Young, Peter Geerloff, David Lansky, Dan Friedman, Eduardo Ortiz, is that yes or not?

MS. MCCALL: Ask him to recommend somebody, so don’t ask him to attend, ask him who would you recommend —

MR. HUNGATE: It would be nice for him to attend as a staff member to this group for that discussion.

MS. POKER: If he recommends himself what do I do?

MR. HUNGATE: Say okay.

DR. CARR: I think we say what we want to hear and he’s the right person, fine, we don’t care who it is, we care that we get the question answered. What about HEDIS, NCQA —

MR. HUNGATE: I don’t think that will fit the spectrum of the questions.

DR. CARR: Russ is a famous co-author of a famous paper —

DR. STEINWACHS: Do we have anyone representing the more structured —

MR. HUNGATE: Okay, are we moving along?

[Multiple speakers.]

MS. MCCALL: Open your calendars, ladies and gentlemen, start your calendars.

MS. POKER: So wait a second, is that enough? Because I don’t have a long list here —

DR. CARR: We only have one day. Anna, could you make a grid of here are the types of things that we had, structured, unstructured, doctor’s office, hospital, contemporary, legacy, and just see if we have every block filled in. So you show us the gaps and we’ll find —

MS. MCCALL: Are you comfortable, Anna, that you know precisely the question, when you invite these people —

MS. POKER: Well, I write a generic kind of invitation, if you want I’ll send it to you and you can tweak it if you wanted to —

MS. MCCALL: That would be great and that way it will be, because I think there was a to do and we don’t have a name next to it against identifying the sub questions and framing the agenda, so if you take that —

MS. POKER: We’re not even there, at this point I’m just asking them to come in and then I’ll tell them —

MR. HUNGATE: How are people’s calendars for the 17th to the 20th of October?

MS. POKER: I’m out, I’m not there.

MR. HUNGATE: Okay, how about everybody else?

MS. KANAAN: I might be available, I am available on the 18th and 20th but probably not the —

DR. STEINWACHS: This is telephone we’re talking about?

MR. HUNGATE: This is talking about a telephone conference call.

MS. MCCALL: I am great all days except the 20th and there’s just like tons of white space.

MS. KANAAN: How’s Tuesday the 18th?

MR. HUNGATE: 18th?

MS. KANAAN: I have a provisional contract that I don’t have the contract yet but if I get it it will be Monday, Wednesday, Friday —

MR. HUNGATE: My day is clear so someone that has —

DR. STEINWACHS: Afternoon would be better for me.

MR. HUNGATE: If this is something that somebody has got conflicts state a window and we’ll work.

DR. CARR: I do, I do, what time are you thinking of?

MR. HUNGATE: Whatever you’re going to tell me right now.

DR. CARR: I’m absolutely unavailable at 4:00, I’m available, is this a one hour?

MS. MCCALL: No, I think it’s longer.

MR. HUNGATE: Hour and a half is the limit to my ability to focus —

MS. MCCALL: But that’s important —

MR. HUNGATE: I just get too damned tired.

MS. MCCALL: If we can give 90 minutes because we didn’t get a chance to do this, that will I think be plenty of time to keep us —

MR. HUNGATE: So you pick the time, Justine, you have 90 minutes on —

DR. CARR: If that’s the only day I’m going to have to cancel a bunch of things.

MS. MCCALL: What about Monday or Wednesday? The 17th or 19th would be the Monday or Wednesday.

DR. CARR: Monday I’m free from 1:00 on.

MS. KANAAN: If I’m expendable go ahead with that, I may not be able to do that.

MS. POKER: Cynthia, would you be taking notes? Would somebody be taking notes of the meeting?

MR. HUNGATE: Somebody name a time that they know is clear for them, I’m clear again.

DR. CARR: Was Wednesday a better day?

[Multiple speakers.]

MS. MCCALL: I’m thinking it’s looking like Monday, why don’t we say 3:00 p.m. eastern time, 3:00 to 4:30.

MR. HUNGATE: Does that work for everyone?

MS. MCCALL: Now one of the items we will try to talk about, let’s look at the calendars again, is to set kind of a regular rhythm and pace for, that we can try to honor with hearings and then our own kind of strategy sessions that are deep with kind of punctuated short or how we doing meetings to see if we can just kind of get something that we can begin to block out on a regular basis.

MR. HUNGATE: Let me get Justine to comment just for a minute on your going to the Standards meeting yesterday because I know they were talking about claims attachment and secondary uses.

DR. CARR: Only that they’re having the hearing on the 21st and I’ll conference in on that, no detail. Their meetings are very different from ours, they have their thing and they ran through, the meeting went 25 minutes, they went through each of the things, are we doing this, this, this, what do we need this, I mean it was the most efficient meeting I’ve ever gone to in my life —

DR. STEINWACHS: What’s wrong with them? Do they need therapy?

DR. CARR: Well, no, I think we’re going to try to model this because I think having mapped out here’s what we’re doing, here’s who’s responsible, here’s the update, it was unbelievably efficient.

MS. MCCALL: And this is again, they’ve earned the right to that efficiency by taking the time to say okay, who’s on point to what, we’ve talked about key relationships to external, and so we will, we’ll do the very same thing and it will be nice.

MS. POKER: I have to ask a logistics, some of these people who you’re inviting, they may not, they’re going to ask me when do you want me, like not just the day but the time —

MS. MCCALL: Just ask for preferences and so that we can begin to try to calendar it, so we’ll have to get back to you, if it doesn’t fit we certainly understand and we’ll try to hurry up.

MS. POKER: All right, if anybody has any additional names they want to run by please email it to me because we have a very short list right now.

DR. HOLMES: Could I ask one, bring up one issue, I wonder if you might want to consider whether you have the right staff support for the —

MS. MCCALL: That will be another topic.

DR. HOLMES: In terms of where the committee is going with respect to information technology and so on —

MR. HUNGATE: We do not —

MS. MCCALL: That’s a great point, and I think right now —

DR. HOLMES: I mean Anna, that’s her area, so but for people from NCHS or people from CMS —

MS. MCCALL: I agree —

DR. HOLMES: You might want to have other staff that have more of a substantive expertise in that area.

MR. HUNGATE: We do need that and part of getting that I think is getting some initial framework of what we’re working on so that somebody knows what they’re tying into —

[Whereupon at 10:33 a.m. the meeting was adjourned.]