[This Transcript is Unedited]
National Center for Health Statistics
3311 Toledo Road
Hyattsville, Maryland
P R O C E E D I N G S (9:40 A.M.)
Agenda Item: Call to Order, Review Agenda, Mr. Reynolds
MR. REYNOLDS: We've got all the players around the table. Let's go ahead and get started. Good morning. I'd like to call this meeting to order. This is the second of two days of meetings of the National Committee on Vital and Health Statistics. The National Committee is the main public advisory committee to HHS on health information policy. I'm Harry Reynolds, work with Blue Cross Blue Shield of North Carolina and Chair of the Committee.
I want to welcome Committee members, HHS staff, and others here in person. Also welcome those listening on the internet. I'd like to remind everyone to speak clearly and into the microphone.
Let's now have introductions around the table and then around the room. For those on the National Committee, I would ask if you have any conflicts of interest related to any issues coming before us today, would you please so publicly indicate during your introduction. And I have no conflicts. Marjorie.
MS. GREENBERG: Good morning. I'm Marjorie Greenberg from the National Center for Health Statistics, CDC, and Executive Secretary to the Committee.
MR. HOUSTON: I'm John Houston. I am with the University at Pittsburgh Medical Center. I am a member of the Committee and I have no conflicts.
MR. BLAIR: Jeff Blair with Lovelace Clinic Foundation, member of the Committee, no conflicts that I'm aware of.
DR. WARREN: Judy Warren, University of Kansas School of Nursing, member of the Committee, no conflicts that I'm aware of.
DR. GREEN: Larry Green, University of Colorado, Denver, member of the Committee, no conflicts.
DR. W. SCANLON: Bill Scanlon, National Policy Forum, also member of the Committee, no conflicts.
Marc Overhage, Regenstrief Institute and Indiana Health Information Exchange, member of the Committee, and no conflicts.
MR. RODGERS: Tony Rodgers, Health Management Associates, member of the Committee, and no conflicts.
DR. HORNBROOK; Mark Hornbrook, Kaiser Permanente, member of the Committee, no conflicts.
DR. FRIEDMAN: Charles Friedman, Office of the National Coordinator for Health Information Technology and ONC's liaison to this Committee.
MR. LAND: Garland Land, National Association for Public Health Statistics and Information Systems, member of the Committee, no conflicts.
DR. MIDDLETON: Blackford Middleton, Brigham Women's Hospital, Partners Healthcare, member of the Committee, no conflicts that I'm aware of.
MS. MILAM: Sallie Milam, West Virginia Healthcare Authority in West Virginia Health Information Network, member of the Committee, and no conflicts.
DR. SUAREZ: Walter Suarez with Kaiser Permanente, member of the Committee, no conflict.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and Quality, AHRQ's liaison to the National Committee.
DR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the Committee, no conflicts that I'm aware of.
DR. CARR: Justine Carr, Caritas Christi Healthcare, member of the Committee and no conflicts that I'm aware of.
(Introductions around the room)
MR. REYNOLDS: Okay, good rousing day yesterday and as we start day two, it was good to know that the Quality Letter was reviewed on C-Span this morning. Good to have you guys available so we could watch what was going on over there. We're excited to hear about the Letter and then we're going to hear the update from Chuck Friedman, then OCR updates and then the HIPAA draft review.
And then I'd like to, Marjorie, if it's okay with you, I'd like to move the sub-committee reports up to the 11:15 slot because I know some people might be having to leave a little bit early due to flights, and so I'd want to make sure we get to read outs before we talk about the 60th anniversary and so on.
MS. GREENBERG: Okay.
MR. REYNOLDS: So, with that, I'd like to turn it over to whoever is going to lead the discussion on the Quality Letter.
DR. CARR: Right.
MR. REYNOLDS: So they have a letter. They just don't have any idea how they're going to present it to us.
DR. CARR: We just are waiting for our hard copy and my thumb drive is with that. So if you want to make some introductory comments?
DR. TANG: Well, I think we
MR. REYNOLDS: That's why you have coach here so you can hand it off to somebody. Would you like that I have Chuck go in and
DR. CARR: I think that would be best.
MR. REYNOLDS: Chuck, welcome. Put your electronics away and now you have to present.
MR. HOUSTON: You're assuming Chuck doesn't have to wait for slides himself.
MR. REYNOLDS: Yes, that's right.
DR. FRIEDMAN: I have paper handouts, as well.
MR. REYNOLDS: Alright, good. Thank you for being prepared. Available at an earlier time slot.
Agenda Item: ONC Update, Dr. Charles Friedman
DR. FRIEDMAN: I'll just wait a second for the materials to come around and I apologize to folks back there. I hope we may have enough copies that we can share. I think I made 25. There should be some available. I'm sorry I didn't bring more.
Okay, so this handout is offered with the intent of providing a kind of framework for an update. It represents a somewhat different view of analyzing and reporting ONC activities. And in part, I'm presenting it here to you to get your reactions to this way of looking at it. So in addition to giving you a very brief high level update on what's going on, I want to see how you all react to this framework.
And this framework is what may be called an element-based view of what could be called the National Health IT Agenda or whatever rubric one might use to describe the activities that ONC is coordinating. And in this element view, you can think at a very high level of these activities as consisting of two elements. I realize this is a simplification, but perhaps it's a simplification that aids understanding.
Element One can be seen as the progression toward adoption of health IT systems. Obviously, the goal here is to bring individuals in a variety of roles, including care providers and patients and others, routinely for productive purposes into contact with health IT systems, thus the diagram that is used underneath Element One.
Element Two, obviously related but conceptually distinct, is the establishment of a trusted national pathway to exchange health information. If you go, and that's illustrated by the inter-connected devices superimposed on a map of the nation.
Moving to the next slide, if you then superimpose Elements One on Elements Two, on Element Two, one might argue that one has the basis through this superposition of meaningful use. And you can see this by looking at the statutory components of meaningful use that include adoption of certified EHR's, thus Element One; health information exchange, thus Element Two; and quality reporting, which obviously requires the combinations of Elements One and Elements Two.
Moving on to the next slide, called Building Element One, it may be that a useful way of understanding our activities is to think about the initiatives that with many, many partners and with a great deal of support that can be seen as being primarily, although not exclusively, targeted toward that element.
So the payment incentives, which of course is primarily driven through CMS and authorized by Title IV in the HITECH Act, is one of those initiatives primarily driving Element One. The Regional Extension Centers Program, another. The Health IT Workforce Grants, another. And the Certification Interim Final Rule forthcoming before the end of the year and the certification criteria that it will establish, yet another.
In the right side of that slide, you see our United Way style target for adoption, and based on the latest data you have, I think the qualitative portrayal is enough, although I could put the numbers on it for you, this would suggest that we obviously have a ways to go toward the President's vision of every American having an electronic health record by 2014.
Let me move on and then I'll cycle back and give you an update on each one of these. If you move to the next slide that says Building Element Two, which is the establishment of a trusted pathway to exchange information, again, we can identify a set of primary, although obviously not complete, set of initiatives which are directed toward this goal.
Standards, which again will be a major component of the Interim Final Rule, this first set of adopted standards that will be part of that rule forthcoming before the end of the year. The program of grants to states under IRS section 30-13, is another primary initiative toward a trusted pathway for the exchange of information. The progress toward the establishment of a nationwide health information network, another component. And then, obviously, privacy and security, yet another, as the crucial element of under-girding of the trust aspect of information exchange, which is obviously essential.
One, if you have to make a choice about where to put privacy and security, if you go to put it in one place, it probably belongs more in Element Two than in Element One, but it obviously belongs in both places. I see John Houston nodding his head.
So let me now cycle back and give you a very brief overview of where we are with each of these primary initiatives. Then I will describe yet another element which I'm going to call Element Three, which I think completes the portrayal that I'm going to present to you today. But before I do that, let me just review where we are with regard to each element.
Harry, I assume CMS gave the Committee an update yesterday about the status of the payment incentives and the NPRM, so I probably don't need to delve into that, so that was just a placeholder. So the Regional Extension Centers grants, I think at the time of the last meeting, remind when the last meeting was.
MS. GREENBERG: September.
DR. FRIEDMAN: So I did report at the last meeting that the funding opportunity announcement for the Regional Extension Centers Program had hit the street on August 20th. So that is not new news to you, but reminding you all that there are envisioned three cycles of application review and award of Regional Extension Centers.
We are well into the process of cycle one, and will make a determination, although it is not entirely clear when the awards can actually be announced, but we'll be making a determination fairly soon of who will be the recipients of these Regional Extension Centers awards on this first cycle. So this program is preceding a pace, and the first wave of Extension Centers will be rolling out as soon as this is humanly possible to do.
The Health IT Workforce grants, you may recall from my last presentation that there are two sections of the HITECH Act that relate to Workforce. There is section 30-15, which contemplates an optional program of support for the education of health professionals while they are still in various stages of the educational process. That is an optional program and we have not yet made any decisions regarding that program.
The other aspect of the HITECH Act which relates to Workforce is in section 30-16 and this is building the health IT workforce, per se, those who will support the implementation and ongoing use of health IT. And that program is a statutory requirement and it will happen. And what I can tell you at this moment is that we hope to be able to announce this program very soon.
Regarding certification, I probably can't, in this setting, say anything more than I said previously, that work is proceeding on an Interim Final Rule as required under HITECH and our target, of course, is to comply with the statutory deadline of December 31st for the issuance of this Interim Final Rule.
Let me stop here and see if any members of the Committee have any questions. Yes, Larry?
DR. GREEN: Thank you, Chuck, very much. I have two questions that actually, that are interrelated about the Extension Centers and the IT Workforce grants. Could you just say more about the scope of work that you're now seeing and anticipating that the Extension Centers will actually do, the nature of that work, I mean, what are, now that you're into this round one and you're getting close, can you say more about what they're actually going to do?
DR. FRIEDMAN: Larry, I hate to say this, but I probably can't because of the, I really can't say anything more than what's in the funding opportunity announcement because we're in the middle of a review and selection process. I'm really sorry.
DR. GREEN: On the IT Workforce stuff, this may be equally brief, but I'm wondering, has anyone spotted any opportunities in the development in the Workforce for there to be a well-defined and direct connection to the National Center in Health Statistics with this Workforce so that the data and the information available from the National Health Information Network is actually aligned to produce the nation's health statistics?
DR. FRIEDMAN: Okay, just relate this back to the Workforce and where you see the connection.
DR. GREEN: The Health IT Workforce grants and those titles that you were talking about, so, and you mentioned that one had not gone very far but another one was moving along. As we produce a workforce to actually help with the adoption and use of information technologies in the healthcare world, there are obviously going to be huge implications for the use of those data for the generation of health statistics and healthcare statistics, population statistics, and et cetera.
What I, just on this as a member of the Committee, I continue to notice how a lack of a clear connectivity between developing that workforce and the workforce that has to be developed in order to use these data in imaginative, new, unprecedented ways to actually get the value for the country.
We've heard testimony in hearings over the last couple of years or so about the relative lack of a human capital program at the National Center for Health Statistics and what I'm looking for is the slightest or the biggest of any opportunities that could evolve here so that as that workforce is built it is connected properly to the National Center for Health Statistics.
DR. FRIEDMAN: So here's Ed Sondik sitting right here, the virtual Ed Sondik, so I'm looking to him. Seriously, I'd like to take that comment as useful input to me rather than, more than a question I have to respond to because there's very little I can say. But I'm appreciative of that comment and I think it's safe to say that we are aware of that need and are factoring it into the planning of the program.
MR. REYNOLDS: Okay, Justine.
DR. CARR: So I too have a comment with regard to the Workforce grants and that would be, well, question in terms of whether we've identified who are the people with the skill sets who can teach this and also is there a curriculum, a standard curriculum, that will be taught?
My experience is it is exceedingly difficult to find people, particularly at the, that have sufficient clinical and IT understanding or knowledge base and then the understanding of the interface. And I would just suggest that we think in terms of some level of curriculum that needs to be covered, or even job descriptions of what is the workforce, who are these people, what are the skill sets, and at the end of their development, what are they able to do?
DR. FRIEDMAN: Yes, thank you Justine. Those are excellent comments. Let me mention, relative to that, that in August of this year, ONC did sponsor a multi-stakeholder workshop on workforce. And that workshop focused, because it's a HITECH priority, on those roles for which six months or fewer of intensive preparation might be adequate to produce a person capable of being helpful in the field.
And on our website, if you, healthit.hhs.gov, if you search on workforce, you will see six roles identified there for which six months or less of training might be adequate and you will see a very preliminary set of competencies that that group identified for each role listed there.
I also take your concern about the availability of faculty to be instructors for these programs and can assure you that that thinking is being factored into the design of the program as well.
DR. CARR: Thanks.
MR. REYNOLDS: Chuck, I'd like to move through the rest of your stuff a little quickly if we could.
DR. FRIEDMAN: Okay.
MR. REYNOLDS: Did you have questions there? I thought you guys were waving as a team over there. Excuse me, Paul has a question, Paul.
DR. TANG: Hey, Chuck, so one is a piggyback on Justine's and the other one is just a question or a comment. So you developed, divided up into two Elements and the first one you labeled Adopted in red. I just wanted to make sure there's no nuance about that being a meaningful user all you have to do is adopt an EHR. So that's the only nuance question.
DR. FRIEDMAN: No, no, thanks for that clarification. No, these are two Elements that create the potential for being a meaningful user.
DR. TANG: Okay.
DR. FRIEDMAN: You do not automatically create a meaningful user.
DR. TANG: And the other one piggybacks a bit on, and I think you answered it partly, so is there a thought in the Workforce grants, just like the Recs have a sort of a Mother Rec, a Hit Rec, is there a thought that there could be even curricula, and I don't know whether that's exactly what you said, for some of the higher level people that are going to help implement these things? So curricula and potentially even a certification.
Some way, just like we tried to reduce the risk in purchasing an EHR system. In fact, the greater cost and probably the greater contributor to success, is the workforce that helps you implement and get the value out. So is there any thought about a comparable kind of risk reduction strategy, like a core curriculum and certification of people that do this?
DR. FRIEDMAN: Right. So two comments, Paul. Obviously, from what we've published out of this workshop, we're obviously thinking in terms of competencies. And number two, let me take your thoughts as useful input to the planning thing.
MR. REYNOLDS: Okay, Walter.
DR. SUAREZ: Yes, on the Workforce training topic, we've had quite a bit of experience in the past with developing core competencies and curricula for training one of the sectors of our workforce, the public health workforce in public health informatics arena. And there's been a divergence, if you will, in terms of the approaches.
One has been, you know, develop a very elaborate, academic level core competencies type for the higher occasion trained professionals, Ph.D. levels, to become public health informaticians and then help a state or local public health agency do work around public health informatics.
And then the other is really the training for the masses, if you will, for the vast majority of public health professionals that need to learn some of the basic skills around public health informatic. Looking at this, it seems to me that there is a similar opportunity and concern as well, you know, the opportunity is to make sure that we try to approach it in a way that leverages as many resources but also is directed to as many people that need to learn the skills and to be able to be helpful in implementing this product.
So the opportunity is there to really direct this into a much larger group. The risk, of course, or the concern is that if we try to focus this too much into a program that is directed to higher education level training for individuals that take two or three years, or whatever time it takes, it is not going to be put in place in time.
So I don't know if there has been some thought put into that area of making sure that we don't just direct this to the higher level occasion type training but to ensure that there is a much larger approach that involves a larger segment of the healthcare workforce.
DR. FRIEDMAN: Very useful input, Walter, thank you.
MR. REYNOLDS: Okay, I got one comment. We'll let Tony make a comment then we'll move, what I'd like everybody to do is to take these other sections and get back to you with any comments.
DR. FRIEDMAN: Okay, we're out of time is what you're saying?
MR. REYNOLDS: Yes. My comment is I don't see sustainability anywhere in any of these. And I think as some of us work on the ground at home, this is great work and it's moving along well, but how, having sustainability discussed and helping people think about sustainability as all this is moving along I think would be very helpful.
Just giving you that as a comment not as a challenge, just a comment because it's the part that everybody's, you know, you've heard the word the gold rush, it's the gold rush to what's going on now, but in the end, this is great stuff and we've got to keep it going and make sure that they know how to keep it going.
So part of this education and other things, any examples where people have done that well, showing up continually in these discussions, I think would be very helpful.
Tony, and then we'll move on to the Quality Letter.
MR. RODGERS: My comment and kind of a question, as you've reviewed the proposals for strategic HIT development at the state levels, and looked at your different Elements, do you see that there is commonality and understanding about the state level planning, strategic planning and development of health information exchange to, in effect, create this new future, if you will?
Or is there going to be a lot of work bringing those plans into some kind of common vision, common direction, et cetera, and specifically, the timing that you think the state level planning will be mature enough that we'll have data from that or we'll have information from that that we can use for implementing some of the other parts of quality reporting, et cetera?
DR. FRIEDMAN: Well, the bad news is that a lot of work has to be done in two years. The good news is that a lot of work has to be done in two years. My crystal ball is not giving me real precise views of the future here, but just in response to one piece of your, well, I'll respond with two comments that I think are appropriate to make at this point.
One is, and the structure of our program reflects this, is a strong belief, not only on our part but on the part of they who drafted the legislation, that the states have an extremely important role from about 16 perspectives to play in establishing this trusted pathway to exchange information.
And I think our funding opportunity announcement did a very good job of outlining in those five functionalities areas, or I think they were called in the FOA, domains, what those roles could be. So there is no question that we have made progress toward putting a structure on what the role of the states is, but filling in that structure is what's going to take time.
Part two, with regard to time, because of the way this work is paced, both through the grants and the timelines in the grants and other collateral activities that are happening, I think there's going to be tremendous progress in a year. And even more after that, but the pace at which things are going to progress I believe is going to be unprecedented.
MR. REYNOLDS: Chuck, thanks and we look forward to your continued participation with us. And if anybody has any other comments or questions, I'd like to make sure we get them to Chuck and we appreciate that.
DR. FRIENDMAN: Right and Harry, thank you and I hope, maybe at the next meeting, and I think it can wait till then, I might dilate a bit on this Element Three.
MR. REYNOLDS: I also want to give you a little more time next time too.
DR. HORNBROOK: Because there is, I think there would be useful discussion between the Committee on the Element Three.
MR. REYNOLDS: Yes, right, and what I want to do next time I want to make sure we've got more time.
Agenda Item: Quality Letter – ACTION, Mr. Reynolds
MR. REYNOLDS: Alright, the Quality Letter. First, what I'd like to do since, obviously, we're entering into this new phase of moving things along quickly. So what I want to make sure is that I'd like to see a show of hands of everybody that was on the Quality Committee involved in the Letter and I know that Larry Green stepped out of the room and told me he's in, and Marc was there, okay.
So basically, we build subcommittees so that we have people who hear what we say, hear what we did, and we had a lot of great discussion yesterday. So we're moving this forward. We've got X amount of time. I'd just like to make sure that if you have questions, that it's a substantive change or a substantive disagreement, because if we're going to be practical, we've got to protect our process, which is making sure everybody's involved.
But on the other hand, I want to make sure that we respect the groups of people that we ask to do things and approach it accordingly. So I would ask us to look at it that way. You may have a little better way of saying it, but it needs to be a much better way of saying it, if we could, as we move forward at this pace.
So with that, I'd like to turn it over to another.
DR. CARR: So thank you, Harry, and really, thank you to everybody who gave input on this. This was a remarkably efficient process. What, we had great input yesterday, helped us to kind of reframe this a little bit. So we actually didn't give you the version with all the changes because essentially the content is the same but the configuration is entirely different.
So what I'd like to do is just walk through and read this and so bear with me on it. There's a couple of little things that might have gone wrong as we were editing. So and just to say that we took, in particular, we took your recommendations that we have an observation to precede each recommendation.
Alright, so, the Re: is Meaningful Measurement of Quality Healthcare Using Electronic Health Records. Dear Madam Secretary, the NCVHS is the Department of Health and Human Services Statutory Public Advisory Body on Health Data Statistics and National Health Information Policy. A key focus is to monitor the nation's health data needs and current approaches to meeting those needs.
A second focus is to identify strategies and opportunities for evolution from single purpose, narrowly focused health data collection strategies to more multi-purpose, integrated shared data collection strategies. Next paragraph.
The National Committee recognizes that the Health Information Technology for Economic and Clinical Health Act, the Hi-Tech Act, is a major initiative intended to accelerate the adoption and meaningful use of electronic health records systems, EHR's, to measure and improve healthcare processes and health outcomes.
In order to effectively produce comparable data quality, EHR's must be designed with quality reporting requirements in mind. For example, EHR's must be designed to capture relevant clinical data using standardized data definitions and quality-measured definitions. In order to earn HITECH incentives, providers should produce data to build quality reports. I realize there's a few typo's in here. Any comments on that paragraph?
MR. REYNOLDS: John.
MR. HOUSTON: Maybe this is too picky. You use the word comparable in the middle. Is that comparable or comparative?
DR. CARR: Okay, thanks, you know what, in the interest of time, if you have these little wordsmithing things and you can write them down, that would be great. Any, Mike, did you have something that's
DR. FITZMAURICE: On the last sentence, instead of in order to earn HITECH incentives, you might consider in order to receive HITECH incentive payments. It avoids trying to explain what earn means.
DR. CARR: Yes, great, got that met. Very good, thanks. Next paragraph. In order to understand better the increasing complex landscape of quality measurement, development, and use, NCVHS held a hearing on October 13th and 14th, entitled Meaningful Measurement. We heard from a number of experts in quality measurement, both public and private sectors, and will attach all of the testifiers to this Letter. See attached.
Testimony focused on four questions. How do we approach building meaningful measures? What is the current process for developing measures and does it adequately address measure development for key national priorities in sub-populations? How do we introduce new data sources, clinical data from EHR's, user generated data, et cetera, into the measure development process and how do we exchange them for old measures based on administrative data? And finally, how do we maintain and update measures and what are the health IT system implications? We're going to call this four areas because there's like six questions.
Okay, next paragraph. We heard testimony on a wide array of efforts to develop and use health quality measures, largely occurring independently of each other. As a consequence, providers are burdened by the multiple, non-aligned reporting requests. NCVHS believes that the burdens can be reduced through standardization.
Incentives in HITECH represent an excellent opportunity to accelerate the development, standardization, and utilization of quality measures derived from clinical data in EHR's and other clinical sources.
We believe the aggressive timeline of meaningful use requires that this strategy be developed quickly. In order to accomplish these goals in a timely way, we recommend that HHS take the following actions. Questions, comments?
Hearing none, observation number one: Testimony demonstrated that while there has been significant progress in the development and application of quality measures, the absence of a national framework has undermined effectiveness. Testifiers highlighted an array of challenges and barriers to achieving robust and comprehensive quality measurement.
In particular, the initiatives presented were independently designed and described without a consisting connection to national goals for healthcare quality improvement. This situation not only impedes creation and adoption of valid and comparable measures, it increases the burden on providers who must report different quality measures to different agencies and health plans. Comments?
Recommendation number one: National Quality Measurement Coordination. HHS should develop a national quality measurement strategy and designate or establish an oversight structure to coordinate and align existing initiatives in the national strategy. This recommendation is consistent with the Institute of Medicine's Performance Measurement Report which recommends a national strategy for quality measurement, development, maintenance and effective use in performance reporting. Might need a little wordsmithing in that one.
Observation two: Testimony revealed a lack of standard definitions for measures and their underlying data elements among reporting initiatives. Because standardized data elements are the critical building blocks of current and future measures, a common data framework would help align the efforts and output of the quality and performance measurement field. An example of such a framework is the Quality Data Set, QDS, developed with the AHRQ funding by the National Quality Forum, NQF, HITECH health information technology expert panel. We've got every acronym in there.
Through this initiative, NQF decomposed its current portfolio of more than 500 quality measures into data elements that have been standardized and are accessible to all stakeholders in the quality measure supply chain. And we're going to just add this schematic of the supply chain. Comments? Yes, Walter.
DR. SUAREZ: You seem to, and maybe this was deliberately or not deliberately done, but you seem to combine quality measurement with performance measurement. And the two have a little bit of a different connotation. So now, I think it would be nice to have a national quality and performance measurement coordination. So I don't know if the recommendation from the hearing was that a coordination of both, a national quality measurement and the national performance measurement aspects.
And so if that's the case, I would suggest framing recommendation number one aside, national quality and performance measurement coordination and then across several places in the Letter, adding the word performance where quality is because I think that will expand the scope of this program.
DR. CARR: That sounds great. So the recommendation is we add to the title of recommendation one, National Quality and Performance Measurement Coordination. And then where we talk about quality measurement, we change that or supplement with performance.
DR. SUAREZ: Supplement it with quality and performance measurement where appropriate. I think in most cases, it's probably appropriate to have both.
DR. TANG: Do you think it's acceptable for us to explain, as we described in recommendation one, both concepts to say that performance measures are often built on quality measures and then from then on call it quality measures?
DR. SUAREZ: I think that would be very good too.
DR. TANG: But you bring up a good point about there's two kinds of use there.
DR. FITZMAURICE: The sentence of, through this initiative the NQFD composed its current portfolio of more than 500 quality measures into data elements that have been standardized and are accessible to all the stakeholders in the quality supply chains. I would refer to Paul on this. I wasn't aware that they had done it for 500. I thought it was more like 18 or some smaller number than 500 and that the bulk of them remain to be done and might be a useful project.
DR. TANG: So actually they did have a QDS-a-thon and went ahead and did the whole 500.
DR. FITZMAURICE: So we have the data elements for, very good, very good.
DR. CARR: Okay, recommendation number two: Establish a Quality Reporting Specifications Library. HHS should fund creation of a library of essential EHR data elements and their specifications. These elements would be the building blocks for quality measures and risk adjusters. These data elements need to use precise, standardized definitions and terminology and must be assigned codes, e.g. LOINC, or RXNorms, SNOMED, NCPDP, ICD, et cetera, to ensure they can be unambiguously identified.
The set of data elements also needs to be sufficiently robust to support the computation of current quality measures and to support research on future measures. The NQF's Quality Data Set may serve as the initial basis for this library of data elements. A strategy should also be developed, maintain, expand, support and make this framework publicly available.
MR. REYNOLDS: Is there any reason to mention in here that those then be used, looks like you go to CCHIT next, so.
DR. CARR: Right. Yes, should we
MR. REYNOLDS: Okay, no, that's fine. In other words, then pulling them into the certification processes. Is that what you're saying?
DR. CARR: Let's read observation three and recommendation three. So anything else on two?
Observation three: Multiple testifiers commented that existing EHR systems, including those certified by CCHIT, are not designed to produce easily the quality reports required by the various public and private reporting initiatives. As one testifier remarked, there exists no proverbial F7 key for producing quality reports from EHR systems.
This disparate data definitions and capture methods complicate data aggregation and reporting and clarifies requirements for EHR vendors. I know, we had debate about whether to have a quote. There was one sense of tying it back to the testimony, but if people, show of hands, who thinks we should take it out?
DR. TANG: Well, let me explain the background. So we wanted to make sure that we're not saying that all, this was the point we discussed yesterday of not all data is going to lie in the EHR's and that we want to be inclusive of all these sources of standardized clinical data. And that reports themselves may not come out of the EHR software itself, but that it is derived from data that predominantly is housed in the EHR.
So that kind of distinction, some felt that that, to use the F7 key quote might mislead people to think that you just literally, it comes out of and only out of an EHR. So that was the point that was discussed.
DR. SUAREZ: I think that's a great point and I think the first sentence made the statement, I think, the quote actually make it sound like, you know, it's as simple as pressing an F7. And it takes away some of the complexity and the realities that this, even though that the goal is to go there, to be able to achieve a product that can generate easily quality reports, making it sound so simple as an F7 takes away some of the power.
DR. CARR: Right, so, I think we can take it out. We don't have other quotes.
MR. REYNOLDS: I think it should go. It forces the person to stop a second and translate, what are you trying to tell me.
DR. CARR: Yes, right. And I think we will have available the summary on the website and so on where we'll capture this. But I think realistically, we heard a lot of things and what we're reporting on is our synthesis of the gaps that we heard.
MS. GREENBERG: The last sentence, something, seems to be something missing here, the script data definitions and capture methods complicate data aggregation and reporting, and then what should it say?
DR. CARR: Yes, right.
MR. QUINN: I made a change up here.
DR. TANG: So the idea is that when you have different ways of capturing data, they all don't necessarily mean the same thing and hence, the definitions are not the same. That makes aggregating data very complicated. So to the extent that we can use standardized data definitions, then that would improve
MS. GREENBERG: I know that, but just say data definitions and capture methods clarify requirements for EHR vendors
MR. REYNOLDS: Matt, did you make a change?
MR. QUINN: I did up here.
MR. REYNOLDS: Let's, read your change
MR. QUINN: Disparate data definitions and capture methods complicate data aggregation and reporting for providers and lead to a lack of clarity in requirements for EHR vendors.
DR. CARR: I got it. As you can see, we were getting close to the end.
Okay, recommendation three: Align EHR certification with quality reporting requirements. CMS should require, as part of the EHR system certification for meaningful use, that EHR vendors use standard data elements from the library and data exchange methods to support the computation of quality measures, whether computation is internal or external.
Further, as part of continued certification, that EHR's have the capability of timely update or addition of data elements once they are identified. Initially, this could be the NQF QDS. I can see this was our last paragraph.
PARTICIPANT: Nothing like ending on an acronym.
DR. CARR: What's that?
PARTICIPANT: Nothing like ending on an acronym.
DR. CARR: Two acronyms.
MS. GREENBERG: The second to last sentence.
DR. SUAREZ: Yes, there's something wrong with that.
DR. CARR: Yes, right.
MS. GREENBERG: It needs a verb or something.
DR. CARR: Yes, EHR's should have the capability of timely update or addition of data elements.
DR. TANG: So, the point is that it's not, we're trying to avoid any kind of hard wiring of any existing measures and so we want EHR's to design and develop and program their systems so that as the measurements evolve. Well, Bill is going to say about the data elements, we need to have the flexibility to get the data elements that make up the measures and evolve with them as they, as the measures evolve.
MR. REYNOLDS: Chuck and then Judy.
DR. FRIEDMAN: So this is more of a technical point, going to the first sentence of recommendation three. As I understand HITECH, CMS is responsible for the meaningful use recommendation but ONC is responsible for certification criteria. So if the point of sentence one goes primarily to certification, then it should say ONC. If it goes primarily to meaningful use, it should say CMS. If it goes to both, it should say both.
DR. TANG: It should go for the EHR certification, so it should go to ONC.
MR. REYNOLDS: Judy.
MR. QUINN: Is the part about use standard data elements from the library and data exchange methods clear or is that from the library a confusing prepositional phrase?
MR. REYNOLDS: We'll leave that to the subcommittee.
DR. CARR: Yes, right.
MR. REYNOLDS: Judy.
DR. WARREN: Well, I just had two comments and one, that next to the last sentence that starts with further, I think it will be better if you got "that EHR's should", if you get rid of the that, so it's not as passive. And on the very last sentence, I know we've already done the acronym, but I think it would be better if we put NQF Quality Data Set so that there's not, I mean, it just reads better and leaves the person with I get the idea instead of an acronym.
MR. REYNOLDS: Bill.
DR. W. SCANLON: Well, we actually, we were also going to add data elements and then we wouldn't have to end that in an acronym because the NQF QDS has two components to it and we're talking about here is to the elements, not the other component to measures.
MR. REYNOLDS: Walt.
DR. SUAREZ: I just want to say this is a terrific Letter in the sense that it is so critical, so seminal, creating this or calling for the creation of this coordination. And so I thought, and this might have been heard during the testimony and so if that's the case then we can drop it. But I thought another important aspect of this national coordination is calling for the establishment of a national coordinated occasion strategy on quality and performance measurement, adoption, and use.
I don't know if that was again heard or highlighted or mentioned, but it seems to me that having a national coordinated quality, or national quality and performance measurement coordination and then establishing a quality reporting library, you know, an important element additionally to that is sort of a occasion strategy and the need to go out and create the mechanisms to ensure that people out there understand it and use it.
So, I don't know if that was again heard, but I think it would be worth noting it as a specific recommendation. Again, the creation of a national coordinated occasion strategy on quality and performance measurement, adoption and use.
DR. CARR: Our recommendations are based in many ways on what we did not hear, on the gaps. And I think it was the gaps and the asynchrony and discoordination that drove this Letter. So, we heard wonderful work and I want to underscore that each of the folks who provided testimony showed us wonderful programs, very thoughtful, very attentive, and what struck us was the lack of coordination.
And so I think that your point is well taken that the teaching and actually, they made me take my little bullet points off this, but one of the things I think that we did note on our supply chain, we had little challenges that we actually did hear and that is in many ways where testimony came from, but who does teach and ensure the data entry and so on.
MR. REYNOLDS: And your answer to Walter's question is?
DR. TANG: First, I want to spread the credit around. The seminal thought you were describing was described in the IOM Committee before. We might have come up with it independently and once again, but because our short term memory, but they really can. And in their envisionment of a separate body, and that may have been of the barriers to acting upon their recommendations, was an education function. So indeed, that's very important. They called off for it.
MR. REYNOLDS: Are we going to call that out in this report?
DR. TANG: I'm trying to give Justine enough time to figure that out.
DR. CARR: But, so the question is, I mean, I'm open to it. Do we want to impress the need for education?
MR. REYNOLDS: I notice your other friends on the Committee have frozen, so.
DR. CARR: No, it's a simple question. I don't have a problem with it. It's obviously important and necessary and I think it's appropriate.
MR. REYNOLDS: But is it a recommendation or are we making a comment early in the Letter or what are we doing?
DR. TANG: So one of the reasons for the hesitation is we're trying to be lightweight about the recommendation. It gets its power I think from the new context that we're in compared to 2006 when the IOM Report came out. And if we load it with a lot of things, and I don't know what the answer is, we'll start to build another organization and that's a little of what we wanted to try to avoid. I think you're right, the point is extraordinarily important.
MR. REYNOLDS: The other thing is remember, we're going to, we talked about the journey yesterday. And this is installment one. And then in February, we hope to have another, or sometime soon, another drill down and we could pick those things up. But the point we want to say here is, attention please, these are the gaps, here's what's going on, and here's what needs immediate attention.
And then we're going to have to build this eco. So, the magic chart, we're going to have to build the eco system out for this whole chart to make all this work. And that may be the appropriate time to add that number.
DR. TANG: So I think you provided the good out because the strategy obviously will include education. Then they can add it to the strategy.
DR. CARR: So, I have a suggestion, though, just to get that, before we get to that, at the last sentence, in recommendation two, the strategy should also be developed to maintain, expand, support, educate and make this framework publicly available. You just add the word educate?
PARTICIPANT: Good. That will be great.
MR. REYNOLDS: Chuck, you had a comment?
DR. FRIEDMAN: Yes, and I'm doing a little bit of catch up here with the thinking of the group and I'm sorry and just stop me if this is redundant with the discussion if it has already happened. But as I look at recommendation three, to my way of thinking about it, there seems to be a concept or a construct here that is missing.
The recommendation talks about the need for data elements to be standardized and for them to be incorporated as part of certification criteria. I understand that. And that they must come from the library, which is called out in recommendation two.
But what I don't see here is any way that that set of measures, which must be present, is articulated. In other words, there's a library to choose from. The ones in the library are standardized. Use of them must be part of certification, but how do we put brackets around the set that has to be used?
DR. TANG: It's a good question and maybe this is a strategic question in terms of how to approach these letters. So between the lines, we know about the NQF HITECH activity that was described to us. And their, so NQF has a process to endorse measures, which includes comparing them to existing measures to try to get to more of the few good measures.
And also their new process emphasizes those that draw on the clinical data in the EHR's and other sources. So all that sort of already exists. So in some sense, we're relying on that exist-extent process to come up with the set of data elements.
Then what we're asking in, and so challenge me where that's not clear, and that in a sense is built in and perhaps we didn't make that explicit enough or describe that in enough detail and then three then says, oh, in addition to all the measure developers using this common set of data elements that can be used for standard quality measures, the EHR developers should also use the standard data definitions in that library. So was that not clear?
DR. FRIEDMAN: Well, no, it's implied.
DR. TANG: Right, that's what I'm, that's the problem.
DR. FRIEDMAN: Right. But a library is a collection. And clearly, at any given time, the intent of this Letter is to suggest that some subset of that collection, in standardized form, use thereof, should be a certification criteria.
DR. TANG: Right.
DR. FRIEDMAN: But you're leaving it to the reader to sort of figure that out. And then the last sentence says, initially this could be the NQF Quality Data Set. So that sort of says, okay, well the initial version of this bracket it set that you have to use might be that. It's a lot of work for the reader to do. And I think there's a statement that needs to be made establishing this set in standardized form from the library.
DR. TANG: Okay, so there's two things we did not make explicit. One is how the QDS data set gets created and maintained and the other is how do you get this subset. Is that what you're saying?
DR. FRIEDMAN: Right, well, I would establish the subset that you are recommending be, if I understand it correctly, be part of the certification criteria.
DR. TANG: Would that then, would that derive from the measures that are spelled out in the meaningful use criteria? So you would say that the CMS decides what the measures are that are going to be used for the High Ttech incentives and then those measures should use standard data elements in this library? Is that your point?
MR. REYNOLDS: Created by your measurement coordination.
DR. FRIEDMAN: Right, right.
MR. REYNOLDS: Walter and then Mike.
DR. SUAREZ: Yes, I thought Chuck's good point was to suggest that we have the measurement development coordination, we have the library, and then someone says, okay, if we're going to measure diabetes, this is the subset of the library that is used to measure diabetes and then that gets actually codified into the EHR system for capability.
And then your, I thought you were saying that the part that's missing is who developed the subset that said this is how we measure diabetes. Because, if we're going there, you know, yes, I think that's a good question, who does the designation of, in order to measure diabetes, these are, the way of the library, this is a subset that measures diabetes. That was your?
DR. FRIEDMAN: Yes, there's a piece of a complete process that is left implicit here.
MR. REYNOLDS: Mike.
DR. FITZMAURICE: In looking at how we could work that in, I've got a couple of thoughts. One is establish a quality and performance measure specifications library. Consider that. It's a, I don't feel strongly about that, but it does bring more than just quality measures. And then on the top of page of one, two, three, HHS should fund creation of a library of essential, et cetera, how about HHS should fund creation of a library of quality measures or performance measures and their specifications, including the essential EHR data elements, so that you have the data elements, which you should, they have them under a hierarchy here of quality measures that use them?
That would bring in Chuck's point of how do we know what they're associated with and where do we find the listing of the quality measures?
MR. REYNOLDS: We're not, are we saying that HHS should create them? I thought we picked a national group should do it?
DR. W. SCANLON: We've wrestled with this topic, okay, and I think what we're trying to do is move away from the concept that you develop the measures first and then that you use them to imply what the data elements are that you want to have. Because we have in the recommendation, that we want data elements that will support future measures.
We think of this measurement development as a dynamic process and in order to minimize the burden on both EHR vendors and providers, you've got to be able to anticipate and, in fact, if Carol McCall was here, she would talk about this hearing as adopting the Gretske's, sort of maximum, go where the puck is going to be, okay? You want the elements that are going to support the future and you want to get them with the minimum of amount of cost that you can.
And so the idea is to specify a robust set of data elements that will support all current measures and there's the potential built in there to develop future measures and so that we don't go back in 2012 and say, wait a minute, let's retool everything and add this set of elements.
And so that, we were trying, and I see your point, we were trying to kind of walk that line and in some respects, it's a shift. I mean, it's saying CMS should start with thinking about do I have all the data elements I need? That should be question number one. And then question number two is I can calculate today these measures and I'm also over here working on the measures that I want to calculate tomorrow.
MR. REYNOLDS: We've got Mark and then Tony.
DR. HORNBROOK: I assume that we are relying, and I just want to check the accuracy, are we relying on an organization like the National Quality Forum for dealing with all the issues of structure process and outcome of quality so we don't need to say anything about that in this Letter?
DR. FITZMAURICE: I would say that NQF is a primary source but not the only source. You may get quality measures from other areas. You may want to pass them to NQF to get them endorsed, but inclusive but not restrictive.
DR. HORNBROOK: Because, you know, the key issue is there's, in the context of an EMR, and even of its feeder data systems, there's some intrinsic limitations in today's technology about what you can really measure in the way of outcomes, domain of outcomes, and I don't know whether we wanted to say anything about as you look to the future, you expect to have these systems include patient-reported outcomes because that's what we're working on research right now and doing and making sure that it gets in across the board.
MR. REYNOLDS: That sounds like a journey item. Now remember, we're going to do multiple sets of letters. I think we're trying to keep, I think it's a great question and I hope the Committee is capturing it, please.
DR. HORNBROOK: Okay.
MR. REYNOLDS: Tony.
MR. RODGERS: I think one of the assumptions was that the basic data element is the foundation for constructing any future quality reporting systems, whether at the state level, local level, in the private sector, et cetera. And if we could get those standardized, it allows CMS to have their own reporting specifications, true, but I know states also want reporting specifications.
However, what drives complexity is when the data is different, when those data specs, so if we can get standard data specs, it doesn't matter how I report, pull out those data and then construct my report, and that was kind of what I think we were trying to say.
Get that right first, and then you have a flexibility and you don't drive complexity back in to the architecture of the data because the data is standardized. You're just reframing what kind of specs you want on your report for your quality performance.
MR. REYNOLDS: Paul and Justine, how do you want to proceed? I don't hear a fundamental change. I hear a clarification of how the pieces work together.
DR. TANG: You know, can I ask about question, back to Chuck then? Because we did, we motivated the timeliness and we tried to capture the moment in terms of the HITECH incentives, but I don't know that we want to limit the scope of what this new coordination scheme, the national strategy. So in your asking about what's the subset, do we need to know that? That would tie it to the incentives, but do we need to limit the work of the group that produces the strategy and executes it to a subset?
DR. FRIEDMAN: Yes, I see what you're asking Paul. I mean, obviously this is up to the Committee to decide where it wants to stop with regard to specificity here. To say that in the first sentence of recommendation three that EHR vendors use standard data elements from the library, may be where you want to stop. But maybe then you should say wherever quality measures are used, they should be standard ones taken from the library. And that, framing the sentence that way begs the question that I think you may want to beg at this point of which ones.
DR. TANG: So we can say EHR systems should be designed to code standard data elements, but in the context of meaningful use, then they should ensure that the data elements that support the measures required for the meaningful use requirements are codified.
DR. FRIEDMAN: And the which ones comes from the meaningful use reg. You're just making compliance with that possible.
DR. TANG: Right. So that's why it's important to set this strategy now. But our goal is to have the EHR developers to look inside this repository of data elements, to keep drawing from that. And that's the way it keeps feeding forward in
MR. REYNOLDS: Bill, can you close us out?
DR. W. SCANLON: Yes, I was thinking to Chuck's point though. I guess there's a question of whether this library, so let's say it's going to have 2,000 elements, okay? So are we saying that each EHR has to have all 2,000 elements or what we should be saying is that ONC, in consultation with CMS, should specify a set of data elements from the library that a certified EHR include?
So, I mean, I think that was kind of your point, which is, are we talking about the whole library, like the old English dictionary, or are we talking about a vocabulary that's going to be specific?
MR. REYNOLDS: Is everybody in agreement that's what we're saying?
DR. TANG: Yes. So I think we can work with that.
MR. REYNOLDS: Alright, so with that said, obviously what I'd like to ask Justine and Paul, are you willing to make that change, no substantive changes other than the clarification of that? And then Marjorie, I would guess we should, if we're going to do that, we should either route it around to the Executive Subcommittee or since it's not a substantive change, can it come directly to me for signature? What would be your recommendation?
DR. SUAREZ: Do you need a motion?
MR. REYNOLDS: I want to understand protocol first. Let me understand the protocol as to what my leverage might be so that then I understand it. Then the appropriate motion can be made based on the protocol.
MS. GREENBERG: Okay, so you're going to add the -
DR. TANG: We're going to clarify recommendation three to use as an example. So the concept is that the EHR vendors would use data definitions that are in this standardized data set. For the meaningful use criteria, we would recommend that the EHR certification part of meaningful use would ensure that the EHR vendors use data definitions in support of the meaningful use measures.
MR. REYNOLDS: Said differently, we're just cleaning up precisely what everybody just agreed to.
MS. GREENBERG: I also heard you say something about specifying the subset.
DR. TANG: Right, so as an example.
DR. W. SCANLON: And Tony raises the point offline here, that we want this set of elements to be big enough that it is not just current measures but is also future. So it's that issue of if it's too narrow, and particularly if CMS and ONC is doing it, not that they would ignore the state, there is this issue of well, are they getting everything that's basic. So it's kind of the question of we want this to be a robust data set, then we may need to think about how we make sure that's --
MS. GREENBERG: Okay, I think I would be most comfortable if you revise that paragraph, we send it around, gave people 24 hours.
MR. REYNOLDS: Okay, who's people?
MS. GREENBERG: The whole Committee.
MR. REYNOLDS: Fine. I'm just making sure I understand people.
MS. GREENBERG: 24 hours, up or down, I mean, they don't have to respond, you know. No response is you're fine. And then we finalize.
MR. REYNOLDS: Mike.
DR. FITZMAURICE: You might want to put in there, and this may sound a little self-serving, but CMS and ONC working with AHRQ because AHRQ has research in the quality domain and could be more encompassing in its mission than maybe CMS or ONC could be.
MS. GREENBERG: Could just say the Department.
DR. FITZMAURICE: Department is fine.
MS. GREENBERG: That the right parties be, but I think it can be voted on now with this --
MR. REYNOLDS: So Walter, I'm excited about your motion.
DR. SUAREZ: So I move to approve the Letter submitted by the subcommittee with the understanding that it will, recommendation number three we revise according to the comments and that we will receive again the Letter for just vote in favor, proposing, voting I guess.
MS. GREENBERG: There will be no voting by, just that it will be circulated before finalization.
DR. SUAREZ: Confirm that everything is fine.
MR. REYNOLDS: So as everybody will have another shot if you see something in there that you are against. And then if necessary, we can pull it up then to the Executive Subcommittee for making, I'm just, the reason I'm being a little particular on this one, as we start thinking about trying to stay viable in this fast moving situation, I want to start building a body of agreement amongst the Committee as to how we can move faster and different than we've had to in the past.
So if you want to play fast, then let's make sure we set some rules right up front on playing fast. Then nobody around the table thinks they're left out. Nobody around the table didn't have a chance to say what they thought. That's all I'm trying to do here.
Because we've done it all kinds of different ways since I've been on the Committee, but I just want to make sure we build a good solid, fast, that everybody's head is nogged about and nobody feels left, because we are a consensus body, 100 percent and that's the way we're going to continue to play. But when you move fast, I want to make sure that we all agree in that consensus. So we have a motion.
PARTICIPANT: Second it.
MR. REYNOLDS: All that's in favor?
(Chorus of "ayes".)
MR. REYNOLDS: Opposed? Okay, nice work, and on the 20th day it did happen. So you've now set a standard.
MS. GREENBERG: So we can expect this from you by Monday, let's say.
DR. CARR: I'm trying to do it right now.
MR. REYNOLDS: Okay, good.
DR. HORNBROOK: Harry, just a personal observation. In the world of ongoing EMR's, there is two very strong imperatives that we're trying to push. One is the ability to recruit for research for clinical trials in particular, which means that you can automate pre-selection of patients for presumptive eligibility based on automated data in order to bring the proportion of people in clinical trials much higher. It's pretty low.
And the other one is figuring out ways to put in measures of outcomes as part of the routine part of your healthcare, that as you as a patient expect to tell our doctor how you feel and to answer standardized questions both generic health status and disease specific about your knee or about your bowel function or your bladder function, and I'm sorry that I don't hear that and I'm wondering when and how we get to that.
MR. REYNOLDS: No, and again, I think any of these, we've started a journey on how we're going to try to influence this. And I think as we continue through the Quality Committee and other committees, those are exactly the things we're going to build on. I'm going to cut off the conversation now.
Sue, I'm sorry. I know we've had you sitting on the phone for 28 minutes and I'm sorry about that. But hopefully, we're moving everything forward. So we're sorry to hold you back, but I couldn't figure a way, we're on a fast track and we're sorry we slowed your track down.
So please go ahead and give us your update and we understand you're on a tight schedule and if you have to shorten it, we know where you live and we'll have you back next time and the next time and the next time, so.
Agenda Item: OCR Update for Security issues, TBD
MS. MCANDREW: Okay, can you hear me?
MR. REYNOLDS: Yes, sure can.
MS. MCANDREW: Okay. Well, I appreciate and I've been enjoying the conversation. I was asked to give you an update about the many changes that have been going on in the office for the past period of time, almost the past year. And I will try to be brief and welcome questions if there are any.
Starting from the top, we do have a new Director, Georgina Verdugo was announced, I'm going to say in September, as the new OCR Director. She comes with a civil rights background. She served at the Department of, the Justice Departmen,t as well as did counseling, civil rights advice for the LA school system and has also been in private practice. So she has a great diverse background and we have been enjoying her leadership here in OCR. And I, if you need her biography, I would be happy to supply that.
In June of this year, we were officially re-delegated or delegated the authority now to enforce the HIPAA Security Rule, which I think will be very helpful moving forward, particularly as the drum beat picks up on HIT Adoptive. So we have been cooperating with CMS in the transition of the cases and the systems that support, that has supported their enforcement efforts in the Security Rule.
And we are up and running as of June of this year. So we actually just this week had our lead investigators in from each of our 10 regional offices for intensive day and half training on the Security Rule and we are very excited to have this added to our authority. But I think it makes a lot of sense going forward for complaints to be looked at from, jointly from both the privacy and the security aspects of whatever occurred.
Just also having the OCR apparatus of regional office investigators will facilitate more onsite activity for the Security Rule cases. As far as I know, we have tried to make the transition as seamless as possible. For the public, we maintained the CMS portal for the intake of Security Rule complaints.
But in point of fact, most of the Security Rule cases have really come in not through that portal but through the OCR privacy complaint process. So that hasn't changed, but this just puts us in a better position to move forward more effectively on these cases and have a more uniform approach.
We continue to work with AHRQ on the patient safety issues. Our authority to do complaints in the patient safety arena began in January and AHRQ has set up the apparatus to list and certify patient safety organizations. They also, this Fall, had their first annual meeting with patient safety organizations. We, luckily, have not had any complaints under that system, but we are proceeding with that authority.
And just one other point before we get to HITECH is we have issued, in conjunction with DOL, CMS, and Treasury, our component of the GINA regulations. This, for privacy, requires that genetic information be treated as PHI, which it always has been, and to prohibit health plans from using genetic information in their underwriting activity.
This complements the nondiscrimination provisions under GINA which are going to be enforced by DOL and CMS with respect to their various components of the industry and EEOC with respect to employment activities.
The HIPAA piece came out as an NPRM and comments are due by early December. I think it's December 7th. The other components came out as an interim final regulation and, but they will be taking comment on those as well.
Then we move to that other little matter that they dumped on us earlier this year, the HITECH provisions that effect what we're doing in HIPAA. We have, as you are probably aware, issued our first set of regulations, actually two sets of regulations, under our HITECH authority. We did an interim final rule to implement the brief notification obligation.
We had issued guidance in conjunction with CMS and ONC back in April to define encryption or total destruction as means of protecting this information sufficiently. That if it is lost or stolen, you wouldn't need to do a brief notification because the information had been, through encryption or total destruction, rendered unreadable and unusable to the unauthorized person.
But the brief notification obligation for other unsecured protected information went into effect in September. This requires entities to provide individual written notice to individuals whose information has been breached and also requires reporting to the Secretary when there has been a breach. It's a contemporaneous report if it is 500 or more individuals involved and it's an annual report for other kinds of breaches.
We have been getting reports through our web portals which we put up to collect this information when there has been a breach. And we are working now to develop the web page that we are required by statute to use to make public the brief notifications that we receive.
In addition to the HIPAA breach notifications, at the same time, SPC also issued regulations. They have a parallel brief notification obligation under HITECH which is limited to vendors of personal health records that do not qualify as either business associates or a covered entity under HIPAA. So with regard to those entities, the FTC has oversight over a parallel set of brief notification obligations on those PHR vendors.
As far as I know, they also have been receiving reports but none of them are from an actual PHR vendor. So I think they've gotten some reports. I think the dentist community is a little confused because they have been getting reports from dentists' offices.
The other regulation under HITECH that we have gotten out in interim final form goes to our enforcement authority. The HITECH Act increased the penalties for a violation of HIPAA and also tied those higher penalties to tiers of, we've been calling them tiers of culpability by the covered entity, that underly the violation.
The statutory increase in the penalty scheme was actually went into effect upon enactment. So these higher penalty amounts are in effect for violations that occurred after the enactment in February 17th, 2009. These, we wanted to do an interim final rule to make sure that the enforcement regulations were accurately, were accurate and reflective of this new penalty scheme so that there would be no confusion by someone by looking at an outdated set of regulations.
The enforcement scheme essentially requires a CNP of at least $100 and it can go all the way up to $50,000 per violation and that tier is limited to incidence where the covered entity did not know and with reasonable diligence would not have known that there was a violation.
If there is a knowing violation but there was no finding of willful neglect, the minimum penalty for that tier is $1,000 and again, that can go up to $50,000. And then finally, if there is willful neglect, the minimum penalty for uncorrected willful neglect is $50,000.
In all cases, we now have the authority to accumulate similar types of multiple violations of the same type up to a maximum of $1.5 million dollars in a calendar year. So we wanted to make sure that those higher penalty amounts were reflected in our regulations. While it was an interim final rule, we are taking comments on that and comments goes through the end of December.
With regard to the other HITECH provisions, we are working now, even as I speak, on a notice of proposed rule making where we will address the other HITECH changes, including the new liability under the components of the Security Rule and for uses and disclosures under the Privacy Rule for business associates, other aspects of the enforcement scheme that were changed by HITECH, and then the other kinds of changes that were made to the rule, including changes in marketing, fund raising, sales, PHI, minimum necessary, right to request restriction, and electronic access to records.
We will not at this time be addressing the changes in the HITECH Rule for accounting for disclosures. ONC, the way the statute came out for the new accounting for disclosures, which required accounting for treatment, payment, and healthcare operations, if you have an electronic health record system in place, our regulations follow the announcement by the Office of the National Coordinator on an initial set of standards that will define the functionality for an electronic health records to produce this kind of accounting. So the accounting for disclosures really has a longer string on it than the other provisions under HITECH.
There are a whole range of non-regulatory requirements under HITECH and I'll just touch on a couple. The states' Attorney's General now have authority to enforce HIPAA violations that affect residents of their state. We are working with their, with the National Association of States' Attorney's General to provide training to the states' Attorney's General in 2010 on the HIPAA requirements so that if they choose to exercise this authority, they have a good understanding of what's required.
We are also moving forward with looking into ways in which we can conduct audits. This is a new authority that the HITECH Act gave us and we are consulting with experts to figure out how to design the most cost effective audit program that complements our current enforcement authority.
And finally, we are hoping to hold some public forums, or at least one public forum on the topic of de-identified information and best practices in de-identifying
information and we will be looking to do that again in early 2010. Lots of other things on our plate, which I won't, we can talk about later, but I will stop there and sigh heavily.
MR. REYNOLDS: Sue, you listed a lot of things. One of the things I'm going to ask Leslie and John to do, as Chairs of Privacy and Security, is maybe touch base with you. You listed an awful lot of new and different things that are going on and you know, how do we help, how do we interact? Are there any comments that would be helpful that if we did some work on them, that we could bring them forth to continue that, your move forward.
It's funny. You said sigh. I sit here and reflect that for awhile, we had you on how you were enforcing privacy and you know, your presentation was five minutes. Now, your presentation could have been two hours with everything you've got going on. So that just is another re-statement of how the landscape is changing so much.
So John, if you and Leslie would be willing to work with Sue and kind of touch base on all these issues. Because there were so many things listed, it had been good to have those listed in front of you, but if you guys wouldn't mind doing that, then maybe coming back to the Committee as to what, how you think.
MR. HOUSTON: I think we should because I know a lot of things that Sue even brought up on the phone are things that as I try to operationalize them are becoming incredibly difficult, at least in the large scale environment.
MR. REYNOLDS: Good. Well, Sue, we really appreciate you updating us and rather than let everybody ask you a lot of questions, we're going to get our two co-chairs to get with you and we're going to engage in the right ways that you think are appropriate and with things that we have. So we'll do that. But I'm really sorry you had to wait and thanks so much for updating us.
MS. MCANDREW: That's okay. Okay.
Agenda Item: Subcommittee Report Outs, Mr. Reynolds
MR. REYNOLDS: Okay, what I'm going to do next is I'm going to move into the subcommittee report outs. I know that specifically John has to leave. But what I'm going to also do is a couple of things. So, go Privacy, Standards, Populations and Quality if Quality has anything else to add. But when we do Privacy, John, you do yours. Standards, Judy, go ahead and cover the report at the same time you're on the agenda for. And Bill, when you do Populations, if you'll go ahead and mention the NCHS and do that, any comments there, so that once we give somebody the stage, take it and complete your business. So, John.
MR. HOUSTON: We had a really good break out session yesterday. We're, I guess, searching for how the subcommittee and what it works on next and one of the, I think, the theme that really permeated the discussion yesterday was this, with everything that's going on, with respect to ONC and the policy work group and standards, how do we best coordinate activities.
We don't want to do things that are either not timely or are not complementary to what's going on. And at the same time, we also don't want to step on toes. We don't want to come out with some recommendation on something that's in a vacuum that ultimately impacts plans and activities that are ongoing. So we had a very good discussion, as I said, and we've came up I think with two possible avenues we wanted to explore.
The first does require that Paul talks with Dr. Blumenthal, just to get his sense on whether this is a topic that we should explore and it relates to trying to better categorize sensitive information. This would be an area where we did earlier recommendations, but the recommendations that relate to sensitive information really intended for there to be follow-up work.
And so one of the things we're going to do, as I said, as Paul is talking to Dr. Blumenthal about that, we would, Leslie and I would be doing some research as to prior testimony, get thoughts from just understanding through that as to where we would have to focus our work and with the understanding that this would have fast-tracked because clearly this is an area of great interest. And so we can't do a letter that's going to come out in a year.
The second area that we were interested in possibly pursuing relates to the issues associated with the interstate, interchange of information between different states, thought being that we need to understand what the different vehicles are that we can use to make recommendations in the framework of, to facilitate interchange of information between states.
As I think Jeff has brought up a number of times, it's an area of great concern. We recognize, with all the activities that are going on, that this will become a much more common occurrence and yet we need to make sure that if there are specific things that need to be done to facilitate that transfer, then we should go through and try to make recommendations as appropriate.
So those are really the two areas that we're considering and it really does, it does, I think if Paul comes back and says, yes, we're very interested in you talking, you doing work in the sensitive information area, we'll work on that first I think and fast-track that.
MR. REYNOLDS: And one thing I'd add is we're not asking permission to do things. We're making sure that we really buy into this let's make as much happen as we all can. And there's three of us as committees and let's go. So rather than, you know, so really just trying to move this ball forward as we've talked on everything that we're doing.
The other thing is I think if you add your third thing, which is everything that Sue just threw out in the middle of the floor here, I think we've got, I think that would be
MR. HOUSTON: We could stay busy with what Sue has and just helping her out and bring in guidance and help.
MR. REYNOLDS: That's what I'm talking, yes, so I think that's, Larry, you had a question.
DR. GREEN: I have one comment and then one question. The comment is I want to applaud those two directions. Those make complete sense. And there's an intersection between interstate exchange and the exchange of sensitive information that I wish to flag, well, but it's specifically a category of sensitive information that has historically been called mental health.
But another part of the changing landscape or our journey is the inseparability of caring for people and getting to population health if we isolate sensitive information in certain categories from the mainstream of looking after people. And in the spirit of Harry's metaphor as a journey, I think our privacy may be, folks, as you do that, I just want to flag that as, boy that is something that is begging for attention.
MR. HOUSTON: Well, I think one of the, I forget who I was talking to, it might have been Sallie or Bob, but I made the comment that a lot of mental health information actually, well, a lot of information that's gathered as part of a mental health encounter actually is not mental health information. It's information that has broad implacability outside of mental health. And if you took it outside the context of the mental health encounter and just said here's the data point, you wouldn't even know it was a mental health-related information.
You know, it might be a blood test or a lab test, a radiology test, something of that sort, and so we also have to look at ensuring that we aren't overly, that we don't over restrict, even in that mental health side and other types of sensitive information side, information that really frankly needs to be part of the general record anyways. So, I mean, this is a non-trivial issue to try to address, but I hear it all the time at my institution that doctors need information and if they don't have that information, they don't make good decisions.
MR. REYNOLDS: You've accepted Larry's amendment about your concern. Thank you.
MR. GREEN: Harry, my question really comes from my Population Subcommittee hat is, if anyone on the Committee can fix this or anyway they want to, but repeatedly in our discussions, we go back by our concern that the National Health Information Network's capacity to move into new epidemiology, new estimates of what besets people, what's going on in the country, that we may elaborate a system that's capable of doing that and then trip over the use of those data without consent or with overly complex regulatory issues there for that. And I think the whole Committee is up to speed on this, but when you start talking about for the next year or two, again, I want to ask, is that on the agenda, distinctly, or?
MR. REYNOLDS: Well, I think a point you make is one thing we have to be credibly careful of is that if we take a multi-dimensional subject, which is what you brought up, and we put it in a committee that has a label, it will be looked at under that filter maybe too strongly. And so I think what you're saying is some of these subjects that we're talking about beg a different thinking because as soon as you put it under privacy and security, then it's going to be led philosophically by the thinking of privacy and security.
So, no, I'm right there with you. So I think that's a great discussion for the Executive Subcommittee is how do we take these things that one wins and the other loses and we're trying to make everybody win and what does win look like and what does it feel like is one of the struggles that I think the whole industry is doing.
And now that it's moving faster, they're all coming together at the same point and people are going I'm moving this way, but that stopped me. We had a lot of those discussions yesterday in that session. So I think that's a great point. I think it's something we need.
So I think those are the subjects that would be our sweet spot because most other people are moving pieces forward against the goal and we ought to be able to step back from some of this and look at it maybe a little more holistically and a little more focused in that way.
Paul and then Walter.
DR. TANG: I agree with you that that would be a major contribution to this whole area. We would have to essentially do that, I mean, that's not the same thing as re-looking at our old testimony and coming up with an answer.
MR. HOUSTON: No, I don't think that was intended either. We just wanted to get some sense of things by looking at old testimony as background for
DR. TANG: But I'm saying this would be a major contribution, actually, but it would probably require us to do something akin to what was done over at Privacy, I mean the Policy Committee, which is to have a hearing like within a month, making it almost, well, that's the pace that the Policy Committee goes. Our month would be a little bit compromised by the holidays, but it would be approximately that timeline.
I mean, it is interesting that one that we didn't hear from a psychiatrist, purposely, to deal with the issues of exchange and it turns out Harold Pinkus from Columbia, when asked about this question, did respond actually, you know, I think we need to educate our patients more about the implications of segregating that data.
So I think there could be a spectrum of use we could hear about and try to get informed and make a recommendation. And I think the contribution would be for us to make a recommendation instead of just list the pro's and con's again. So there's good work if --
MR. HOUSTON: Well, that's another thing too. I mean, it doesn't foreclose us from looking at testimonies such as through the Policy Committee to glean information from it.
DR. TANG: There's only person, then we ought to get that whole spectrum that Larry just talked about.
MS. GREENBERG: Yes. Actually, I guess that would be my last question. You don't currently have any, you're not planning any hearings or meetings between now and the February meeting?
MR. HOUSTON: Not yet, but again I think the issue is if this has to be fast-tracked, we may come back to you and say we need a hearing or we need to do something to gather data. I understand what you're asking. We just don't, until we get some clarity from --
MR. REYNOLDS: But also let's think about it based on Larry's comments not just the other, so, as to what that would look like. Okay. Alright, that's right, Walter, I forgot you, excuse me, I forgot Walter.
DR. SUAREZ: Well, and before you go John, I think it's important that I told you as to not being just to actually here, it was my first meeting of the Health IT Standards Committee and I'm also a member of the Privacy and Security work group of the Standards Committee.
And I think yesterday we had actually a full hearing on security in which we heard quite a bit about data segmentation and health, the sensitivity of health information and how in the real world this is being handled by Chief Information Security Officers and our testifiers were primarily the information security people.
So I think in addition to, because I think there needs to be coordination, now we have three parties here playing, if security and privacy new work group under the Policy Committee, our security/privacy work group under the Standards Committee, and now our security and privacy subcommittee of NCHS, I think it's
MR. HOUSTON: Maybe what we need to do here is, I'll talk to Leslie, what we probably need to do, it sounds like, is we need to get everybody together from the different constituent groups so that we're not either stepping on toes or doing things that are uncoordinated. So,
DR. SUAREZ: Yes, that actually was as suggestion I had, it was really convene a, and this applies not just to Privacy and Security, I think it applies to Standards as well, and a couple of other places where it will be good to have a group of people in the same room that participating in this very group and help understand and guide David's decisions about what expectations he would have on the various committees as well as understand us here at NCHS, what are opportunities.
MR. REYNOLDS: Marjorie, did you, were you, did you, couple of seconds.
MS. GREENBERG: I just wanted to point out, as you all are reporting back, that we are meeting February 10th and 11th, so that's early. Sometimes we meet late in February, but or even early March, and of course, the holidays are coming up. So right now, I don't believe we have any subcommittee that's asked to meet in conjunction with that meeting, either for or after.
But, or I don't believe we've, and we'll hear now, whether anyone is planning to hold a hearing or wants to hold a hearing in January. But obviously, as we're going into the holiday season, we really have to focus on with that.
MR. REYNOLDS: One thing I want to temper the Committee with is the structure of ONC, the support structure and what they're doing is dramatically different than us. So I think we will be fast when fast is the right thing. We may need to be contemplative on items that would appear to happen fast, but I don't believe that the subject that we just brought up and Larry just brought up, things will occur.
But I'm not sure the end game will be fast. And I'm not sure that the complete detail, and so I believe that in some of these we will support where we can to help other fasts go on, but we may have to step back and look at some of these subjects in a little different way at times and we do have that purview and we need to take that purview.
So we've all committed and Walter, you weren't here yesterday. We're as interchanged between us and ONC and everybody as we can be in a lot of things. And so your specific point was a good one, but we had that significant discussion yesterday that we're doing that and that's, we're doing that with Chuck.
So we need to do that, but I want to make sure, we're going to step back at times and not just go fast until their implementation. We've got to uptake some of these subjects and build them a little differently, so.
DR. FRIEDMAN: Just a quick comment, Harry. Thank you. Of course, I want to endorse the express needs for coordination and also point to the fact that I have in my Blackberry here several communications to the process of setting up interactions to align agendas as appropriate. So those mechanisms are being established even as I speak.
MR. REYNOLDS: Yes, and the other thing I would challenge each of us, anybody on the Committee that is involved in these multiple things, you bring them forward. I mean, so, in other words, just like you did, bring them forward so that we don't have to go find what's going on. We've got players in there and Paul did a good job of that yesterday with the Privacy. Bring them forward. Let's make sure they're on the table and we know about them. So, good. Alright, Judy.
Agenda Item: HIPAA Report, Draft Review, Mr. Jeffery Blair and Dr. Judith Warren
DR. WARREN: Okay. So just as report of the Committee, let me talk about what we were planning and then I'll talk about the HIPAA Report. We have a set of hearings that will be happening in December that will be talking about the implementation issues that are coming up for the regulation of 50-10 and ICD-10. It became pretty obvious to us this morning as we were working on this that we may, after we have those hearings, also need to further those hearings.
And then we too became involved with HIT Standards, as Walter informed us, that they were starting a terminology workgroup. And certainly that's some of the work that we see in the coming year, especially as we start looking at some of the mapping issues and things between ICD-9 and ICD-10, SNOMED CT, RX NORM, and LOINC, and all those intersections, so we will be developing a strategy for that as we go.
The other thing that we did is we talked a little bit about the Population Committee's request for support in the work that they're doing on their report. I attended their meeting yesterday and what they're going to be doing is re-framing that report and then asking Standards Committee and some of the others, I guess Standards and Privacy, Bill, to respond to that and to contribute to that report making. So we tried to get ourselves organized for that.
Now our big item that we have is, and Marietta has just reported out and I'm asking Lorraine to bring it up on the screen, is our annual report to Congress on the implementation of HIPAA. Due to a variety of situations and occurrences, we actually, this will be a two year report for both 2008 and 2009.
And so what Harry asked me to bring to you today, and we sent it out to you literally right before the meeting and then you've got copies now on your desktop, is an expanded outline of what that report will be.
So Lorraine and I realized this morning, we should have put the word right up in front, outline, and we didn't have that on here. So this looks like a report. It's not. Okay, so I'll just make that up front. And what I'd like to do is to walk through the structure of the report and then open that up for questions. We went over this in subcommittee meeting this morning. We have lots of ideas where to go for, but I'm going to highlight points that I really need help from the full Committee to fill in some of those gaps.
So the way this starts is we have a content section. We've left it very brief because this is the executive summary on top. The executive summary then has pretty much some boiler plate language of letting Congress know what this report is about and why NCVHS is submitting it to them. And basically it's a requirement that we have in the HIPAA legislation.
So that as you'll go to page two, just a little bit of background about what administrative simplification requires and then there will be a brief report to be written that will summarize everything that comes after this. And in the conclusions, we will have our recommendations. So those have not been written yet.
In the body of the report, which begins on page three, one of the things, oh, and by the way, Lorraine Doo has been working very closely with me on this, as well as Susie Burk-Bebee from ASPE, and then Mya Peterson joined us from OCR because we realized we needed a lot of information about privacy and security in here as well. And these ladies have been absolutely superb in stepping up to the plate and getting things done.
So, again, the introduction is pretty much boiler plate. Most of the previous eight reports have had similar language. We felt that that language had been successful. We updated the parts that we needed to update and left it there to kind of give you a handle on what we were looking at.
Part two of the report then is background about the HIPAA administrative simplification. And in that we will be developing a listing of all the regulations that we were asked to monitor and report on. Those are not here yet. And then also a statement about the organizations covered by HIPAA simplification and I think that's probably even more important today since ARRA is extending some of the coverage as Sue McAndrews just mentioned.
Part three then talks about specific progress on each of the standard's implementation and the, I've given you a list, they're the underlined pieces. Walter had suggested that we cluster the list better by types of things and we will do that. We also have a couple of things that are in italics. Those are mainly placeholders to let us know that there are some new things to be added in there, such as the re-assignment of certain responsibilities from CMS to OCR to manage under HIPAA simplification.
We then will be talking about claims attachments on page five. Some of the biggest work that we've done there will be looking at the 50-10 and ICD-10 that are now out in regulation and then talking about clients' reviews, excuse me, compliance reviews for security complaints.
We felt that this was also a section that we wanted to have the latest report by the DSMO, which was specified in the regulation, of a way of coordinating all of the standards that are coming out of, that were specified by HIPAA. The other thing that Lorraine and I felt strongly about is one of the things that CMS and OCR both have done is they've really stepped out up to the plate with looking at outreach activities, trying to educate people.
And they've done that as a result of recommendations of this Committee. And so we want to acknowledge all of those outreach efforts that have occurred in the last two years.
And then we're going to end with in addition, and that last paragraph that's highlighted, that will take some wordsmithing as we've completed the rest of the report that goes in front of it. And where I need, really need help from the full Committee is if there is anything about describing what we've accomplished or stories that you think would be important to either inform the report or be in the report in part three. Please let Lorraine or I know about those.
And then the last section, section four, is our conclusion. We will hit the high points that were in the report and then make our standard observations and recommendation comments that will go to Congress. What our plans are at this point are for the four of us to continue trying to gather this report together, to finish up the pieces that are in there, and then put that back out to the full Committee so that you'll see the draft of that.
But then we're going to need help in deciding what our major observations and recommendations need to be at the end of this report. So that's our strategy. And Harry, do you want me to talk anymore or do we open it up for questions?
MR. REYNOLDS: No, I think, let's see if anybody's got any questions or comments. Larry.
DR. GREEN: Is this an annual report covering two years or four years? It says differently in the draft here. One says 2006 to 2009 but I think it's 2008.
DR. WARREN: No, that was, I thought I got all the typo's out. I did that. It's 2008 to 2009. So it's supposed to be an annual report. We missed doing the one in 2008, so this report is for 2008 and 2009 to catch us back up into cycle.
MR. REYNOLDS: So Larry, you hit on a good point. We're either doing a yearly report every two years or every four years. That was a good question.
DR. GREEN: I just wanted to make sure it wasn't an annual report covering four years.
MR. REYNOLDS: There you go. That was a good question.
DR. WARREN: One of the things the subcommittee did talk about today is actually, starting in January, starting to get ourselves ready to put together the 2010 report so that by the time we get to the end of the year, we've got a much better handle on it than we have this year. A lot of things kind of conspired to bring this gap.
MR. REYNOLDS: Again, this goes to Congress. We do ask you to play when you see copies of it. Don't, this is different. So, you know, this takes us outside of our comfort zone, which is usually directly to the Secretary. So let's make sure that we put together a document that you want to have your name on. So I look forward to you helping out there. Judy, anything else?
DR. WARREN: No, unless there were any other questions of things that people thought that should be in the report that you didn't hear me talk about.
MR. REYNOLDS: Yes, and again, don't hesitate to send them to us. Okay. Bill.
Agenda Item: NCHS/BSC Update – Vital Stats, Dr. W. Scanlon
DR. W. SCANLON: Okay, we had a rather lively session following up sort of into full Committee discussion of what we're trying to do, as you might have anticipated. One of the things about, sort of talking about a vision, is that if you really start to get into all the details, it becomes sort of overwhelming. So that was certainly part of the experience yesterday.
And we concluded that with Tony's suggestion that we actually need to kind of think about how to structure sort of all these thoughts and his suggestion was I guess maybe a journalist perspective of sort of what are we trying to accomplish, why are we trying to accomplish it, you know, how are we going to do it, and over what time frame? And then sort of structure things in that way as a sort of prelude to the next steps.
And Don, after he left, volunteered to do that. So, but in terms of sort of next steps, I mean, one of the things we want, we're going to do this, we're going to do it quickly, and we made a decision that by December the 10th we're going to decide whether or not there should be a half day session that is associated with the February meeting in order to continue the discussion.
We believe that we can do, what we're going to do for June is all going to be based upon either prior work that's been done in terms of hearings, reports, et cetera, and sort of future discussions among the subcommittee as well as other subcommittees and the full Committee, not a new hearing with some additional external input.
And we might want to think about whether a kind of new way of getting some external input is a possibility. If we can get something together, say by March, posted on the website and ask for comments, that comes sort of through via the web, that's one way of getting more input because I think that we are an advisory committee and having the public input is an important part of what we do.
I mean, that's all that out sort of as a possibility.
We talked about yesterday, I mean, we really do want this to be full Committee, not just buy in at the end, sort of voting yes or no, but getting input about different aspects of it and so we felt very good that Judy was there yesterday.
We will be sharing in December as we move along with the other co-chairs of the subcommittees, sort of where we are at that point. I don't know what your plans are for an Executive Subcommittee discussion, but I think that we want to be part of that too so that we can think about what kind of coordination that needs to be on.
It's kind of frightening to hear sort of John's agenda for privacy, knowing that he's got a crowded calendar already. Judy's also got a crowded calendar. How are we going to get to these so that we're a part of that. So that's the plan for Population's for the next between now and the next meeting and still leading toward a report in June of 2010.
In terms of the BSC, and that may be points to add to this as well, I mean, I was there for one of the two days of their last meeting and then there was another important discussion I think on the second day about the whole issue of data on the uninsured and the conflicts that we have in terms of depending upon where the, what the source is.
We get different numbers and in some context, that's not critical because the numbers are all big enough that we really need to worry about them. It becomes critical when we start to think about well what's going to be the cost of trying to deal with them if you're a CBO and you're trying to say I'm going to, we have this proposal to close the gap in terms of the uninsured, then those kind of numbers become critical.
The day I was there, I was there in part, not just as a liaison, but in part of being a member of the panel that reviewed the long-term care data systems or data surveys of NCHS. And some Johnny-one-note, I mean, the same there is we've talked about yesterday to a degree is that in thinking about how we get adequate data, that one of the things that we have to consider in terms of being efficient and dealing with the resource limitations we have, is that it's going to involve through some combination of surveys and administrative data.
And one of the things, one of the handicaps that NCHS has had in the past is that there is not enough resources to really survey long-term care. I mean, because long-term care is done by what you might think of as visible providers that, you know, nursing homes, home health agencies. Home care agencies are marginally visible, but they still are somewhat visible.
Then you get into a market where there are all kinds of paid providers that are being hired one at a time and this is a part of long-term care. And if we really want to understand long-term care, we need to know that. And then there's the huge informal care market where no one's being paid at sort of et al. I mean, it's not a market. It's kind of a family relationships, et cetera.
And so to get a good sense of how care is being provided, and more importantly potentially what are the gaps and what are the consequences of that care being provided in terms of burden on families, one needs to think about a relative place of intensive data and information gathering sort of strategy. And so in dealing with limited resources, some combination of administrative and survey is we think the way to go for the future. That would be the BSC Report unless Ed wants to add something to it.
DR. SONDIK: I think that covers it good.
MR. REYNOLDS: Okay, any questions? Bill.
DR. SONDIK: I actually have a question. Since I, I have a question since I missed the discussion yesterday. Could you summarize where you see the enhancing health information going?
DR. W. SCANLON: Again, I think that if you start and try and answer the question what are we trying to do, okay, I mean the end, you survey a whole set of people that are in this room as well as sort of outside, well, you end up with I want to know information about this and I want to know information about that.
And there is, I think that there's no question that there's strong reasons why that whole array of information is important. And so our issue is how do we best gather that? And that partly involves an assessment of what are we getting now? What are the gaps instead of how can we work to eliminate some of those gaps?
A part of what we're doing, in mind for June, is that we said that this is an opportune moment. We've got the investment being made, sort of been electronic health records through HITECH and the question is how is that going to change what our opportunities are in this? And it's, again, I'm kind of going back to the long-term care review.
There are opportunities created by electronic health records, if people follow our recommendations from this morning in terms of information flowing from those records. Then how is that best used in terms of the different objectives we have with respect to population, health monitoring, sort of healthcare, et cetera?
And that I think also complements, we discussed yesterday, a part of this would be, a part of what we looked at is the gaps. And part of the gaps are not going to be satisfied by electronic health records. And we have to recognize that they're not being satisfied by existing surveys. And so there's an issue of how we also span the potential there to fill in more of those gaps.
One of the difficulties I think we have is we're aiming for June of 2010. So the level of specificity that we're going to have in this report is going to be limited. As Harry said, we're not writing our final report on this topic. In some ways, we might be outlining a work plan for the following year and the year after that, in a way. So, I hope that captures what we were talking about.
DR. SONDIK: I was concerned that in the part, when I was here, it seemed to be focusing on electronic health records as the core of new information. And I would hope that it's broader than that. The vision document was across the board in terms of information. I go back to that diagram, again. And I think asking are we getting the information that we need for health policy, for health research and how can we, if we're not, getting some external input on that I think would help.
And then how do we enhance what we're getting and how do we incorporate what could be new sources of information in part of electronic health records. But it could be any number of other things, including better use of the web, maybe changes in the way we do surveys, reconfiguration of the surveys, better coordination across the department, et cetera.
DR. W. SCANLON: We've actually identified that in prior discussions in the Committee. I mean, there's been this whole question of that NCHS does not have in some ways a research division to do methodological studies on a continuing basis in order to think about how do you maximize your gain from the resources that you have available. And so that would be, we're thinking about, we bring those kinds of things into this report.
At the same time, again I think it's this question of what's the window we have here? There may be more emphasis on the electronic health record sort of component in terms of additional contributions, but not ignoring what you're, what I just said, and not ignoring the kinds of things that you're raising.
MR. REYNOLDS: Okay, Mark.
DR. HORNBROOK: We did have a flight of fancy thinking about NCHS moving away from institutional respondents and personal respondents to geospatial units, sort of ecological picture of the nation's health that would include environmental and built environment as well as air pollution, water pollution, a whole set of things that can be measured and tracked to a latitude/longitude, not to just a person. And we thought maybe that was another way of conceptualizing terminance of health of this country that we should be looking at.
MR. REYNOLDS: Okay, Larry.
DR. GREEN: I appreciate your bringing this up, Ed. I want to make a cut at making two points. The first is that I think the Populations Committee is dangerously close to showing signs of vigorous life.
(Laughter)
DR. SONDIK: I knew we could put life into it.
DR. GREEN: That was point one. The second point is as we do this, I think a co-committee and this staff, everyone should just assume that over the next few meetings there will be waxing and waning of things that we're emphasizing to some extent because of the timeliness of the issues.
But my own observations over the last two or three years here are that we have members on the Committee that I believe share a large common space that really comes back to, this Committee is assuming there's going to be robust vital statistics, that we're going to have robust, properly constructed population surveys and that we're going to continue to have claims data of some sort.
But we're also assuming that that world of the National Health Information Network certainly provides unprecedented opportunities to do better and also to do different. And so to build off of your point, the linkages between ecological data and the work that the consultants, they produce these tables of where else in government we have data that is crucial to how health is won or lost.
In this new world, there's going to be new ways of using these data better. And then so we have our usual audiences. I think Bill is, at least for the moment, and I would label him, he can disown this if he wants to, but he's been our champion about wanting to help decision-makers who are facing very challenging questions and needing to know whether what they're doing seems to be going at least sort of the right direction, that they need much more rapid responses in some way and information systems that are capable of helping them in different ways.
And so to the usual decision-makers plus someone that says, you know, if I do this now, can we get an estimate of what its effects were out of the delivery system in six months, we're not just smoking stuff in there, at least not all the time, but we actually are beginning to see that it may be possible for certain types of questions to do much better, to do much better.
So stay tuned. I think this Population Subcommittee may be, may need you to tap us back in bounds from time to time and that sort of stuff, but I, this is going to get interesting.
MR. REYNOLDS: So for purposes of the minutes, we will take the dangerous as exciting, and then we'll go from there. Good. Thanks. Bill, anything else you got?
DR. W. SCANLON: No.
MR. REYNOLDS: Okay. Anything from Quality?
DR. CARR: Well, I just want to say again what a great effort this has been a last few weeks in the input. And you know, really appreciate the input of Tony joining us this morning and Harry Heffernan, joining us because these points of view were just so thoughtful and it just made for a wonderful process. So we didn't actually get to our next steps beyond the Letter.
MR. REYNOLDS: You were whining about them only having 20 days.
DR. CARR: And we'll probably have a call and decide where we go with the next steps.
MR. REYNOLDS: No, I kid a lot, but incredible effort. And the thing that's been fun to me is to, I went to the hearing but to watch when it went out, as far as drafts and everything, people at times agreeing to disagree with the common good in mind, and it really turned into one heck of a product.
And that's the one thing that I cherish in this Committee is that we truly come from different venues and agreeing to disagree towards the common good, this is the perfect product of that. This is, I mean, so I commend all of you very much. Don't hold back, but don't oversell yourself. I watched this one go back and forth, up and down, but it did it for the right reasons because we were really trying to get to making a difference.
And so thank you all for that very much, having watched it and I'm sure that has appeared to spark some interest in Paul. So he's picking up the mic.
DR. TANG: Well, our only mistake was giving Bill three chits but he only needed one.
MR. REYNOLDS: No, no, your mistake was you gave him three and he used the same one three times. Now you guys have got to give better definitions now. You've got to work with that.
DR. CARR: One thing I would ask is, Susan Kanaan also did a terrific summary of the presentations and we haven't even really. The Letter was focused on what we didn't hear, but we now need to go back and focus on what we did hear as we elaborate our next steps.
MR. REYNOLDS: Okay, so Marjorie do you want to touch base on the couple of things you had on here?
MS. GREENBERG: Okay, Debbie why don't you come forward too. And just while we're doing that, Katherine, could you just update the Committee on what's happening with the Share Point. I know you sent an email out to, just so that people know we are working on it. Just come on up. I thought of it when, the Share Point is more of an internal thing, but when you talked about posting things and everything and knowing that we are going to really be having to work in real time here over the next 6 months, I thought it would just be good to know we have made some progress here.
MS. JONES: We have not a whole lot, but we are making progress. Mark Hornbrook, Blackford Middleton, and John Houston agreed to partner with me in trying to get something deployed. We do have something that should come out in demo phase perhaps in the next couple of weeks. And we'll start getting emails to you all in terms of access and user guides and so on and so forth. But, it's coming.
MS. GREENBERG: And we're working with NIH.
MS. JONES: NIH, yes, we had to go through NIH in order to get it because the Share Point that's offered by NCHS is internal.
MS. GREENBERG: Okay. Oh, that's good. Okay. I mentioned yesterday, you know, that since you had last seen us, several of us had been in Charlottesville and I just thought I'd ask Debbie if she could just tell us a little bit about, I mentioned what happened, how we had the world histories, we had the informal discussion, we had the afternoon roundtable discussion.
I didn't mention that we also had a celebratory dinner, so, but it was a great, it was really a, I thought it was very special. And those who were there want to comment, that would be great. But now Debbie, I would just appreciate it if you would tell us what our next steps are here.
MS. JACKSON: Next steps are very dependent, reliant on some incredible background material. Susan Kanaan might be on the line now.
MS. KANAAN: Yes, I'm here.
MS. JACKSON: Hi, we wanted to make sure you got a chance to put your two cents in because she was the GwenIfel of the facilitating and interviewing and pulling so much and extracting out. Harry got this across. Larry and Bob were instrumental in bringing out so much of the quality of the family history, family practice, and that connection there with Charlottesville. So everything really aligned beautifully.
What I'll be doing in December is looking at hours and hours of footage from the individual interviews on the video tape. Susan has already listened to the audio tape for the individual as well as the roundtable and we have a transcript. So with that, we'll be pulling together the visual tape material put on tape by this fantastic editor.
I must say the camera person and the crew were like nothing I've seen and I've had my share of being in front of a camera for awhile. But he had a sensitivity for the anthropological significance of this Committee. He taped and got into the moments of it.
And from the discussion afterward, he was so taken and smitten by what this Committee has done, what was really brought out in the interviews. To hear his take and to hear where his excitement was as he was doing some preliminary edits was very exciting and I wanted to transmit that.
So for December, I'll be working with him and Susan, in looking at the individual interviews as well as the roundtable, pulling out snipits. Our intention, or Marjorie's dream, is to pull out moments that, you know, exciting moments from the round as well as a snipit from the individuals, put them into a collage and have them available for the anniversary as well as have them even before that time uploaded and linked onto the web.
So we're trying to get some footage, amazing video, historical record and legacy that is a good testament for this Committee and I think we're on a good track.
MS. GREENBERG: Thank you and actually you reminded me that I really do want to thank Larry and Bob Phillips from the American Academy of Family Physicians, who connected us with these folks at this University of Virginia School of Medicine in the Family Practice Group and the head of that group, if you can remind me of his name, he was terrific. He was terrific. They were so committed to this and they really were wonderful.
In fact, the videographer, or whatever, he was supposed to go to his daughter's birthday party that last afternoon, and we kept saying you have to leave and he said we just have to get it right, you know. He became more invested almost than we did. He was just amazing and Susan and I had just a very exciting time working with them. Susan, did you want to say anything else about Charlottesville?
MS. KANAAN: The only thing I would add is that there is now a transcript of the wonderful two and a half hour roundtable discussion. And if anyone really wants to get down into the details and the richness of the discussion, I would imagine that that could be made available. I found it very good reading, I must say.
MS. GREENBERG: I think we should actually email that to the, or put it on some internal website that, I mean, we don't want to put it out yet, but I think it would be very good reading before where we're going between now and the February meeting. I encourage as many of you as possible to read it.
DR. GREEN: Could I just underscore what Marjorie just said? This, Harry, fits so well to the way you're wrapping the meeting up here is on the one hand, we have some urgent things and we have to move quickly. But I heard you say awhile ago at other times, we need to be contemplative. And I think one of the great benefits that the Committee could derive from the Charlottesville exercise was when we listened to the Chairs of this Committee cover about 40 years of the developments of the healthcare delivery system and the public health system and its waxing and waning, it is critical context to realize that in some instances, when we think we're taking on a new issue, we're just going back 30 years ago and going back to an issue that got left on the table that's still unresolved.
And those are different types of problems from one that's produced, say, by new legislation or the National Health Information Network. So it's, I guess I'm also just verifying quite publicly here, I must be just getting old because I'm discovering I can learn a lot from people that did things 30 and 40 and 50 and 100 and 300 years ago and we had no Chairs there that were that old.
MS. GREENBERG: But we did, although he wasn't able to participate, Dr. Carr White just infused the whole experience and actually I think you did meet with him and let him know how so many of the Chairs had been influenced by him in their development.
DR. GREEN: To the current Committee members, if is there a way to scan through that and get that, when these guys started talking, I mean, how many times have you assembled a group of people to talk about health statistics and it's been gripping?
MS. GREENBERG: Yes, well, Susan can, they breathe life into it. Right. Susan was supposed to be Chairing that or facilitating that roundtable, but it was pretty hard to get a word in edgewise except for the fact that you didn't need to. I mean, she said just let her relax a little bit. But anyway, we will make that available.
MR. REYNOLDS: Justine, you have a question? Justine had a comment.
DR. CARR: I just wanted to underscore, I think it should be required reading for the Committee.
MS. GREENBERG: I wanted to say that but I didn't know if I could.
DR. CARR: For the 50th anniversary addition, for me, just gave an understanding of where on the playing field we belong and what we do best. And I think when you see this collective wisdom, I'm imagining it's similar to what we had at the 50the. I think it's so important to understand where our role fits and I think that we'll all learn from it. So I would
MS. KANAAN: I'd like to add one anecdote, if I may. I hope I'm not interrupting. The audio is a little dim. But since I had the privilege of interviewing the Chairs individually, that was a very interesting experience and I had this very clear image of a relay race, with much more continuity that I had ever perceived before, talking with one person after another, and a sense of the baton being passed from one Chair to the next and just all the value in that baton as it's passed. So that was a strong image for me.
MR. REYNOLDS: If you look at the information, you will feel different about being on this Committee. It was overwhelming. It's amazing, the juice in this place that's been here for a long time and then you, I mean, it does, it sets you free when you really start realizing the difference that a lot of those people have made and now it's our turn. And I think you will, I think it will give you a whole different feel about a lot of things.
MS. GREENBERG: What was heartening to me, too, was that their service on the Committee really it was meaningful to them and it continues to be meaningful.
MR. REYNOLDS: And they think, and a lot of them think they're still Chair. They made that perfectly clear to me as we were going through that. There's, I wrote Marjorie a note yesterday, remember, they told us to do this, so we've got to do this. I mean, I'm telling you, they're on us. So you've got to go guys.
MS. GREENBERG: I mean, you know, that was my dream to bring everyone together and then it was like well, if we build it, will they even come. And when the last one arrived, and every single person we invited did come, I said now I can die and go to Heaven, but she wouldn't let me yet, so.
MR. REYNOLDS: The other thing is, everyone of them came shovel-ready. You got a whole sense of what shovel-ready meant. You need to understand, this was a vibrant group.
MS. GREENBERG: Yes, it was just exciting. Okay, so we're going to end tab, what tab is it, tab 5, you just have a one-pager overview of the 60-year history document. By the way, speaking of required reading, Tony, I'm sorry to tell you, but you will have to read the 50th first, of course. And, well, let's make sure he has it.
MR. RODGERS: Is there a movie vision to that one too?
MS. GREENBERG: I always really appreciated that Justine did do that and would refer to it.
MR. REYNOLDS: And she knows that, and that's why she
DR. CARR: Changed my life.
MS. GREENBERG: We'll make sure that you get the 50th. And in any event, we're not going to change the 50th, but you want to just walk us through this Susan, or, given that you're on the phone, it might be a little difficult for you, so
MS. KANAAN: Yes, go ahead Marjorie. It's fairly simple.
MS. GREENBERG: Okay. We're going to have this document that will not be, it will be about 20 pages or whatever. It is going to be, it's going to be and woven through it will be all these insights and commentary from the Chairs and executive staff and exec staff director who also participated. There will be a brief re-cap of the 50 years but then an overview of the last decade.
And I think what will be really helpful to you is you will have this report, well you'll receive it before the February meeting, but we will be bringing it for your approval essentially or finalization at the February meeting, which means, I don't know, I think the holidays are, like just, we're going to forget about them this year. But you'll also have the HIPAA Report for approval.
And of course, these are two very different reports, but there might be things as we discussed this morning that you would have thought, oh, maybe we should include those in the HIPAA Report but they don't really have to do with HIPAA. But we look and then make sure that they at least get into this other report because we used to do annual reports of the National Committee long before HIPAA ever came along.
Then we just, things were moving at such fast time, we started doing these bi-annual reports of the National Committee and the annual HIPAA reports. Now we've got a bi-annual HIPAA report but we have not done a report of the National Committee, total, since 2006. So this document that Susan is preparing will include the last 10 years but more detail on 2007 to 2009 in lieu of doing, I mean, you can only do so many reports. So that will be part of this.
Then with some looking ahead, so obviously Susan will get us started on that, but that's going to rely a lot on the executive subcommittee and really all the members that we, because we're leading towards the June symposium and it may be that the 2010 report will talk even more about looking ahead than, or whatever comes out of that symposium, because we only have so much time. But in any event, that's going to require all of you.
She, and she has down here what Susan has proposed to make the sort of organizing principle, the history document, which were the major themes that came out of the meeting with the Chairs. And those are listed here but what are the most significant developmental trends and changes, what are the Committee's most significant contributions, how have our customers and constituencies changed, what makes us succeed, what do we do well, what are our major challenges, strengths and limits of a federal advisory committee, and then looking ahead.
So, Susan is absolutely the right person to do this and she wrote the 50th and I think wrote the 45th and has beeN with us. We're really, we're very fortunate to have that kind of continuity. So are there any comments on this or questions? If you have any thoughts in the next, soon, week or two, whatever, please send them to me and I'll share them with Susan because she and I will be working on, I mean, we're working on a draft as we speak, but we're obviously under some real time pressure to move this forward.
DR. SONDIK: You know, Marjorie, I saw the word opportunities. I guess I see it more as, I don't know, forces, you know, as opposed to opportunities.
MS. GREENBERG: Forces?
DR. SONDIK: Yes, forces on the Committee. What direction will the Committee be moved in by its mission, if you will, as opposed to opportunities?
MS. GREENBERG: Okay, we can discuss that further, but I'm not sure I completely understand the distinction, but
DR. SONDIK: Well, in one case, it's sort of opportunities that's sort of up to the Committee. In the other case, there's direction and I think over the last several years, the Committee's direction has been dictated by major changes that have gone on in a number of things related to its mission as opposed to its okay, now where are we going next.
MS. GREENBERG: Oh, yes, no, there's no doubt about it. The context is in which the Committee operates, did operate, does operate, will operate is a critical feature of this.
MR. REYNOLDS: And that was one interesting thing that came out from all the Chairs, wasn't it seven Chairs instead of six, but the thing that was, everybody talked about the forces as they were Chair, what were the forces, what were the idiosyncrasies that made the Committee do and think and be what it was during that time frame as you talk about it.
MS. GREENBERG: There were six, I think, including you and then Carr White as a former Chair there in spirit and having inspired a lot of it. But what you were saying is I think, Ed, is that really in the past, like pre-HIPAA, the Committee certainly was asked to do things by the Department and, but it had, it was sort of in a more independent, I mean, there weren't as many demands on it, certainly from outside of NCHS.
I think one of, which always has interacted with the Committee from its inception, from NCHH's inception, since the Committee, you might not know this, but NCHS will be in 2010 celebrating its 50th anniversary and the Committee its 60th.
So, but there's certainly been a linkage from day one, and, but I think a very important development over the last 10 years has been the BSC, the Board of Scientific Counselors, which has been able to deal more in depth with NCHS.
I mean, Davis, it used to be years ago the NCVHS did an in-depth look at say the NHIS. It can't do that now, but we've got partners. In a sense, you know, it's a crowded space. We've got HIT committees, and we've got BSC, et cetera, but the opportunity for all of that to synergize is something. So anyway, we do welcome your input.
Now so we've got this document. We've heard that Population's working with the whole Committee, working with Executive Subcommittee. It's going to try to help us and probably with some consultants, but that has to be finalized, help us pull together this enhancing health information for the 21st century, building to some degree on the vision for health statistics.
We're moving past that, we're incorporating that as we move forward. As Debbie said after we talked about it yesterday afternoon at Population, she said this is exciting and terrifying because Debbie knows that the buck stops with her. She's the one that I say, okay, is everything ready to go for June 17th and she blanches.
So, but the way she pulled off Charlottesville, I've a lot of confidence. But it's going to require a lot of your support and involvement and maybe quicker turn-around and more engagement than you might, some of you might be used to, although some of you I know live, breathe, and drink this Committee everyday as it is. And I wasn't, I'm looking at you Justine, and Paul, and well, a number of you.
But anyway, so we're going to bring in the Privacy. It's going to be part of this. We haven't quite decided whether it's going to be one big sort of presentation for the symposium on Enhanced Health Information for the 21st Century with a component from Standards, a component from Privacy, and sort of Populations framing it, or whether we're going, you know, we really haven't decided. We have to decide by the February meeting. I mean, we can't, we will lock the doors. We can't leave without having decided that.
Now you know that Leslie is still moving ahead with her March, first week in March, a symposium and she still has a little wiggle room with that. This is out at the University of Utah on privacy and security issues as we go forward in the 21st century. If there's something from what your, Bill, the Population Subcommittee is working on that you think it would be really good if they had a session on that or something that could be keyed in since it is the beginning of March? It's not too late is my understanding. So I think that should be on our agenda.
We know that Standards stands ready to contribute, but they've given, the lead is in Population Subcommittee. So just a lot of thinking and work that has to go on. Then Judy, you told me you also are having a session in recognition of the Committee in part. Can you just mention that?
DR. WARREN: Yes, remember Marjorie had encouraged all of us if the opportunity arose to submit abstracts and stuff. So, I'm part of a group that submitted a panel at the American Nurses Informatics Association Conference, which I believe is in Boston in April. And so, we just found out about two weeks ago that our panel was accepted and so I will be covering NCVHS and its contributions and what we have been doing the last couple of years.
Of interest to know, the other two panelists are Judy Murphy from the HIT Standards Committee and Connie Delaney from the HIT Policy Committee. So, we just kind of decided we'd put it all together and wow folks. We had put in an abstract. They've given us a whole panel so.
MS. GREENBERG: That's great and also I'm assuming there's nothing else of that ilk at this point, so those are the complementary activities. There is one more complementary activity and that is that NCHS is holding its Data Users Conference in August of 2010, of course, you will all be invited to.
There will be a celebration of the Center's 50th anniversary and we're going to have a session, we want to do something also from the 60th. It could be a reprise of what we do in June. And that's still kind of being worked out. It could be really in conjunction with the part, the plenary that celebrates the 50th birthday of NCHS or it could be a separate concurrent session.
That's still kind of being worked out, but we have at that conference, you can have as many as 1,000 people who are users of NCHS data and public health data and population health, et cetera. So it's a great audience. We did present to them the 21st Century Vision from Health Statistics back in whatever conference that was, Data Users Conference years ago.
So that's the last thing that I have planned, but there, you know, that's only August. If you want to do something in the Fall, that's good too. So anyway, we have a lot of stuff going. It's going to require a lot of work, but I think it's going to be exciting and I appreciate all of your participation and any ideas or suggestions, send them on.
MR. REYNOLDS: Eat right, get plenty of physical activity. We've got a lot to do. With that, this meeting is adjourned. Thanks everybody, Marjorie, and everybody, thanks.
(Whereupon the meeting adjourned at 12:43 P.M.)