[This Transcript is Unedited]
St. Regis Hotel
923 16th Street, N.W.
Washington, D.C. 20006
Agenda Item: Call to Order, Welcome, Review of Agenda
DR. CARR: I will call this meeting of the National Committee on Vital and Health Statistics to order. Welcome, everyone, and I would like to start by introductions going around the room.
I am Justine Carr, Steward Health Care System, chair of the committee, and no conflicts.
MR. SCANLON: Good morning, everyone. Jim Scanlon, executive director of the committee and deputy assistant secretary for planning and evaluation at HHS.
DR. STEINWACHS: Don Steinwachs, Johns Hopkins University, member of the committee, no conflicts.
MS. MILAM: Sallie Milam, West Virginia Health Care Authority, member of the committee, no conflicts.
MR. LAND: Garland Land, member of the committee, no conflicts.
DR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the committee, no conflicts.
DR. MIDDLETON: Blackford Middleton, Partners Healthcare, member of the committee, no conflicts.
DR. HORNBROOK: Mark Hornbrook, Kaiser Permanente, member of the committee, no conflicts.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and Quality, liaison to the full committee.
MS. PRITTS: Joy Pritts, chief pharmacy officer, ONC, presenting today.
DR. FRIEDMAN: Charles Friedman, chief scientific officer, ONC, liaison to the committee.
DR. EDWARDS: Brenda Edwards, NIH liaison.
DR. WARREN: Judy Warren, University of Kansas School of Nursing, member of the committee, no conflicts.
DR. CHANDERRAJ: Raj Chanderraj, newly appointed member, no conflicts.
DR. CARR: And welcome, Raj. Raj is a visitor today, and when we'll be finished with the paperwork, we'll count you as an official voting member.
DR. OVERHAGE: Good morning. Marc Overhage, Regenstrief Institute, no conflicts.
DR. FRANCIS: Leslie Francis, member of the committee, University of Utah, no conflicts.
MS. GREENBERG: Marjorie Greenberg, National Center for Health Statistics, CDC, and executive secretary of the committee.
(Introduction of staff and guests)
DR. CARR: Do we have anyone on the phone?
MS. HORLICK (via telcon): This is Gail Horlick, CDC Atlanta, staff to the Subcommittee on Privacy, Confidentiality and Security.
DR. CARR: Do we have Lorraine on the phone?
PARTICIPANT: She sent her apologies.
DR. CARR: All right. Well, then, we'll turn this over to Jim for an update from the Department.
Agenda Item: Update from the Department
MR. SCANLON: Thank you, Justine.
I will update the committee on a couple of things. I will start with the policy and strategy levels, some strategic plans and other documents that set the framework for HHS goals and objectives. I will bring everyone up to date on our budget situation, which still is kind of murky, kind of working on 3 years at once. Then I will address some other initiatives we are planning.
I left at your place the newest HHS Strategic Plan. This covers the period from now through 2015, so this is really the latest version of our plan. I hope everyone has this. You can see the plan in all its splendor on the hhs.gov website, which links to a lot of other things.
I wanted to talk a little bit about what the goals are. You will see objectives under each of the goals. Basically, these major goals are the major states that HHS is trying to accomplish, and the objectives you will see are how we do it programmatically and administratively. But again, you will see that virtually every one of these involves the work of the committee and the interests of the committee, both the data and statistical side for policy research and decision-making and evaluation, as well as the health IT side for promoting transformations in health care. You will see that much of the activities and programs of HHS can be grouped under one or another of these various goals.
I will not go through the objectives because you can see those later. But in terms of the overall goals, the first is transforming health care. This is really focused on health systems change, the Affordable Care Act, and a number of other demonstrations, health systems delivery initiatives, payment coverage issues that we are trying to expand and improve through HHS programs. You will see one of the objectives there is to promote the adoption and use, and the meaningful use, of health information technology.
The second goal -- HHS is one of the largest scientific agencies in the federal government and probably the largest funder of biomedical research in the world -- so here the goal is to advance scientific knowledge and information, and again, not just the basic discovery side of this but to actually try to move the discovery and the fruits of scientific research through the regulatory pathway and into the care and to the bedside, into the doctors' offices as much as we can.
We have a big prevention focus, obviously, in HHS, so the third goal has to do with advancing the health, safety, and wellbeing of the American people. This focuses on all of our preventive efforts, the areas of CDC and others, as well as secondary prevention and risk behavior improvement, and so on. Again, there are a number of objectives under this area as well.
We have a big initiative focused on increasing the efficiency of our programs as well as their transparency and accountability. Under that goal you will see objective C. Specifically, it says “to use HHS data to improve the health and wellbeing of the American people.” We have a number of initiatives in that area. I will talk a little bit more about those shortly.
Then finally, the goal is to strengthen the nation's health and human services infrastructure and work force. Here we are looking at some workforce issues in health care, primary care particularly, looking at distribution as well as need and looking at the public health work force as well and at some basic infrastructure at the state and community level.
I will not go into much more detail, but you can see that is sort of the overall framework for HHS activities and operations.
Related, now, we have a number of other strategic plans and plans in specific areas, and they all align with the strategic plan. But let me mention a few of those. Some of them you are very familiar with.
Healthy People 2020 we have just published earlier this month. As you know, those are national health objectives for the nation. They include both objectives, base lines, and targets, which is unusual, to actually set a target for improvement by the time we hit 2020.
We have just issued last month a tobacco control strategy at a fairly high level. It looks at all of the efforts that HHS is engaged in, from regulation to prevention, and so on, to reduce cigarette smoking in the United States.
We published last month a strategy for HIV as well, both prevention and services.
We have in the works, as required by the Affordable Care Act, a national prevention and promotion strategy, which you can find on our website. There is an early draft of what that is. It was open for public comment. Again, that will be an attempt to pull together a national prevention and promotion plan and strategy.
On the open government side, let me say a few things. We published our open government plan last year. This is an administration initiative to basically make the operations of government agencies much more transparent and accountable. A big part of this is to make data about agency operations and data in general more transparent.
One of the goals here was to publish on a website called data.gov, virtually all of the data sets and the tools that HHS, well, that all federal agencies have. Again, the idea is to make them available, push them out, make them easily accessible where we could, with the hope and the expectation that folks will be able to pick up the data, use the data to improve health and to improve human services as well as normal research and public health surveillance, and so on.
In HHS we have kind of been a leader in all of this. We have published since last May probably over 200 data sets and tools on data.gov. We have a number of others in the works. A couple of examples. Hospital Compare I think you're all familiar with from the CNS world. We are pushing those on the data.gov set as well.
It turns out that folks who know the programs throughout the country, they know the website at CMS or NCHS to go to, but the data.gov website is a whole new set of customers, including application developers, Googles and Microsofts and others, who actually are looking for the data that they can -- their job, I think, and their focus and their business goal, obviously, is to take data and develop applications for computers, for iPads, for iPhones, and so on. They have already taken a number of our applications at the county level, for example, county data that we have and have published, and have already made various kinds of applications for it.
I think you met Todd Park at our previous meeting. Todd is our chief technology officer. Todd comes from the industry. He actually, you will remember, developed athenahealth. So he is quite comfortable with the whole venture capital, trying, failing, and hopefully succeeding. Todd has a good relationship with the apps developers.
The first phase of our data.gov data push, at any rate, is to put as much data as we can out there, obviously in a matter that protects privacy. We would not put identifiable information up. If anything, it would be deidentified. But the data sets so far are not like that even. They are for use by the research, the public health, the human services community and apps developers more generally. The whole idea again is to use the data, of which we have considerable stores, as you know, get it in a manner where it's available to consumers and others for actually improving health or engaging in community health discussions, things like that.
I told you about the CMS Dashboard, which is basically using the claims data and the payment data at CMS to provide local area patterns of utilization and spending. In addition, we will be having before long CMS claims data sets. Let me explain what these are. These are not linked data, these are called slim files, so much of the information is taken out of the claims, the data set that would identify an individual. They would be published separately for hospital discharges and for doctor visits and for different provider visits as well.
A third part of these larger initiatives for data.gov we've announced already, our Community Health Data Initiative, which was launched in January, and again, that is where we try to post virtually all of the community-level and county-level health indicators and data that we have. Again, the idea is that others would take that data, convert it -- I would say that it is less consumer oriented than it is developer oriented, at this point. The idea was to get the data out there, get it in the hands of apps developers, analysts, and researchers, who could then turn the data into information almost at a consumer and a planning level.
Let me turn now to our budget situation. We are well into fiscal year 2011, as you know. No federal agencies have an actual full-year budget. We have a continuing resolution until March, and I think it's anyone's guess what will happen next. I think continued full-year funding at some level is assured, but I think no one has an idea of what that might be. At any rate, all of the agencies continue to operate more or less at the level they operated at last year. It is hard to begin anything new, obviously, because anything could happen down the line, and I think we're trying to preserve options and flexibility for what might happen later in the year.
At the same time, the President will send up on Monday, Valentine's Day, the 2012 budget. Congress will consider that. 2012 would begin in October. Again, a lot of work on developing that budget. Some agencies will be going up, some programs will be going up, but many will be going down. You heard the President announce a freeze, basically, on overall spending. I wish I could tell you more about what is in that. We've made an effort, I will say, to protect some of our basic health statistics programs so that, much like the economic statistics, you sort of do know where you're headed -- are things getting better or worse? -- so I think in most cases we've made an attempt to protect at least current spending levels for our basic population of statistics programs. But we will see what happens when this actually goes up to the Hill.
At the same time, as I have indicated to the committee before, we are always working on three budget years at a federal agency. We are already beginning to look at the 2013 budget. Probably a fairly austere budget, but again, we are looking at planning for that as well.
Maybe I will stop there, Justine, and see if there are any questions.
DR. CARR: Thanks, Jim. That's great.
Yesterday -- we will hear more about it later -- we had a terrific array of presentations from community data. Actually, Todd was here early on and has invited everyone, I think, to the June 9 event at the IOM, I guess everyone in the room.
But I think one of the things that we heard, that came through loud and clear from the community groups, is the variability of their infrastructure in getting and aggregating and manipulating data. At the same time, we saw very excellent examples of the work that Todd has been doing in the Sonoma County dashboard that has just simple temperature indicators, red to green, and where things were.
Some of the discussion at the end of the day was about creating data sets, like in Hospital Compare to a certain extent, that are uniform across the board with appropriate benchmarks that have become a starting point for some of the communities.
I would like to open up for any questions for Jim.
The other thing that Todd mentioned yesterday was that the data is also in a site that is manipulatable by users, and that was a new addition, just launched in January.
MR. SCANLON: Yes.
DR. CARR: Leslie?
DR. FRANCIS: Users mentioned that they would love to get some kind of newsletter about what all the new stuff is, because they find it hard to keep up, they are so oppressed by everything that's here.
MR. SCANLON: We're going to reach a plateau, believe me. We're way ahead at HHS on these.
Actually, that has come up previously, and we are trying to think of how -- did Todd talk about healthdata.gov, that sort of plan?
DR. CARR: Yes.
MR. SCANLON: Within data.gov, which is all the federal agencies, you can get aviation, you can get waiting times for flights, and you get weather information. It's all the federal agency information.
What we planned to do was to have a sub-web page within overall data.gov where we have just the health-related data we call healthdata.gov. So it would be HHS data as well as EPA data, some other agency health data as well. Our focus now is to be sure that we get our best data sets and tools and some, Todd calls them APIs -- Paul, you know what that is -- but it helps run your application. It is sort of a bridge. So we are looking at what we would put there first.
But I think you're right. It is a little easier for aficionados to use, and developers, than it is for communities to use, unless you have analytic skill and some statistical background. We will have to work on that.
We are also taking feedback and we're looking at it, so if folks have ideas about -- they think a data set may be portrayed differently, or another data set or some improvements or an application or a tool -- we have a lot of mapping tools, as you could imagine, where you can put in your ZIP code and it will take you to information about your area, whatever we have. So we will be looking, at least, Justine, at what folks give us in terms of feedback.
But you're right, there is not that intermediate step of a help desk where we could actually help, because you're right, at a community, even a county level or a municipal health department level, there is not a lot of public health infrastructure necessarily there, particularly at this time, to help with this.
DR. CARR: I think we could take all of the twenty-somethings that are unemployed at the moment and live with their parents and hook them up, and it would be a jobs program. They could solve anything.
MR. SCANLON: That's right. All right, this summer.
PARTICIPANT: Give them free internships.
MR. SCANLON: That would be nice
(Laughter)
DR. CARR: I'm serious. Think of it. No training required.
With that, two things. Walter just joined us. Do you want to introduce yourself? And then Lorraine is on the phone with the CMS update.
DR. SUAREZ: Thank you, Justine.
Good morning, everyone. I am Walter Suarez with Kaiser Permanente. I am a member of the committee, cochair of the Standards Subcommittee, and I don't have any conflicts.
DR. CARR: Lorraine?
MS. DOO (via telcon): Good morning, everyone. This is Lorraine Doo with OESS. I am lead staff to the committee and representing CMS and OESS.
DR. CARR: Go ahead with your presentation.
MS. DOO: Oh, terrific. There are not slides, so you'll actually just have to listen to my voice. Hopefully, it is coming through clearly. I am holding the handset.
DR. CARR: We're good.
MS. DOO: Something that probably you all are waiting with bated breath for is that we are working on the interim final rule regulations for the operating rules for eligibility and claims data as well as the health plan identifier. Those actually are scheduled to go into the clearance process tomorrow. That means that they start wending their way through CMS and HHS review before they go to the Office for Management and Budget for their final approval. The dates that we had targeted of June 24 for the operating rule regulation to be published and late July for the health plan identifier rule to be published are both on target. So that is beginning its work.
We also received application from the three entities applying to be authoring entities for operating rules for electronic funds transfer and electronic remittance advice. Those were X12, CAQH/CORE in concert with NACHA, and also NCPDP. So we are going through that review, and we will be obviously coordinating with the Standards Subcommittee, because they have to do the ultimate analysis and recommendations. But that work is under way. The submissions were due on January 31, so we did receive all of them on time. So that analysis is deeply under way.
From the standpoint of 5010 -- and I am going to give you a couple of updates on this, and when I use the words “Medicare” or “CMS,” there is a differentiation, and it is very clear. When I talk about what Medicare is doing with respect to 5010 or ICD-10, it is specifically on Medicare as a health plan, as any other entity in the industry that has to comply with the regulation. When I mention CMS, I am talking about CMS as an industry ally, if you will, with overarching responsibility for communicating across industry, whether it is related to Medicare, Medicaid, and every private health plan and provider or clearinghouse. So there really is a differentiation.
For Medicare, they have started doing their 5010 testing but not of the errata, which were just announced last year. The testing of the transactions with the errata program will actually start in April. So Medicare is doing its version of 5010 straight testing and is talking about doing an industry-wide testing day where everyone would just use version 5010 without any supplement of 4010 information or 4010 version transactions.
We did this a couple of years ago for the national provider identifier. We just had this day where everyone got to submit as if it were the implementation date, so the errors really could be brought out and understood and worked as a community, if you will. So there is conversation that has just begun related to that kind of industry-wide, coordinated testing. But we don't have a date for that yet. The discussion literally started, I think, in the last 5 days.
From a CMS perspective on launching awareness campaigns, 5010 obviously is quite well under way. There is a new campaign that will be starting on ICD-10 awareness. As you can imagine, and you have probably heard, the industry is reeling with all of the requirements that have come up, whether it has been through the Recovery Act, the EHR incentive program, 5010, ICD-10, wondering what is going to be happening under health reform, what is happening with the Office for Consumer Information and Insurance Oversight.
To get them on track with ICD-10, which is so critical to many of these other initiatives, we are launching an ICD-10 campaign. That will be going out in professional journals. There is a lot of listserv activity, all of the CMS provider outreach listservs are being active, and the ICD-10 Coordination and Maintenance Committee is continuing to do outreach on what the crosswalk is, what the outcome of the meeting in September was in terms of that. They either call it general equivalence mapping or the crosswalk. So there will be much more information over the next couple of months related to that.
There will be, as we've talked about with our HIPAA report, survey work that we will do, again on a much more ad hoc basis -- it is very difficult to get industry to tell you what the issues are, but we are going to make that effort from a CMS perspective to see what the problems are and what kinds of delays are happening and where they are happening so we can target additional outreach efforts.
On the EHR incentive program, some of you actually may belong to associations that will be receiving today an announcement about a new listserv specific to the program that will have more timely information about the incentive program, how to apply, technical issues, where to go for help, and just much more available information. It is going out to the partner associations, who will then roll it out to all of their constituents and encourage people to sign up. But people are also able to go -- probably it will start -- the message will go out today. People would be able to go onto the CMS website on the little EHR icon on the right-hand side of our front page and also be able to sign up for that, because some of the feedback we've been getting is while there is good information, they want more timely information when something happens or if there is new information about what might be going on with the application process.
I did get information this morning about the number of registrations that have come in thus for, and it looks like for Medicare-eligible providers, there are about 20,000 that are either active or in process, and it looks like 18,000 actually in fact have been successful registrations to participate.
In Medicaid, there are currently 777 active that are registered and ready to start. For hospitals on the Medicaid side, there is actually only one. Medicare hospitals, there are 23. These reports are going to be generated every week, and I don't know when this kind of information will be posted, but I am assuming that they will begin to share this kind of thing on our website or to do some of these communications to let people know that people have been able to successfully register and that in fact some organizations may actually be receiving payment. We will obviously be happy to share those once I get these fully vetted with NCVHS if it is something that you're interested in tracking.
Those are the items I had on my update. I am not certain if I have missed anything or if there was anything else you wanted to know about what's happening here.
DR. CARR: Thanks, Lorraine.
Let me ask Mike Fitzmaurice.
DR. FITZMAURICE: Hi, Lorraine. This is Mike.
I have a question, and that is if we're going to be moving from ICD-9 to ICD-10, what is CMS doing about the DRGs that are grounded in ICD-9, the quality measures that are grounded in ICD-9? There is diagnosis and then there's the hospital procedures, which is ICD-9 going to ICD-10. All of those will have to be reconfigured, won't they?
MS. DOO: To my understanding, the DRGs have been completed and are probably on that ICD website, that that crosswalk has been done. When I last spoke with Pat Brooks, actually -- I think it is probably a month or more ago -- we had this question before from another meeting, and I had checked with her, and that has been completed.
In terms of the quality measures, I can check with OCSQ, the Office for Clinical Standards and Quality, to see if that also has been done or what the schedule is for that, so I can do a follow-up.
DR. FITZMAURICE: Thank you, Lorraine.
MS. DOO: Sure.
DR. CARR: Any other questions? Raj?
DR. CHANDERRAJ: Thank you for the information.
The registration process for the incentive payment for the physicians is a very commercial process, and they are insisting that the physicians themselves do that rather than the staff do it. Has there been any change in that process?
MS. DOO: I have not heard that. It is helpful. I will, after today's meeting, go and speak with them. So the issue is that there is some requirement that it be a physician versus a staff member, and is there some verification that it is the physician in fact doing the work?
MS. GREENBERG: Yes.
DR. CARR: Marjorie?
MS. GREENBERG: I just thought, in light of some of the activities that Lorraine mentioned for basically payers, providers, et cetera, related to ICD-10, I just wanted to share with you that the Public Health Data Standards Consortium, which we talked about a little bit last week, executive committee yesterday agreed on a similar type of plan to work with public health agencies and others who are using the classification for encounter reporting and statistical reporting and possibly discharge data, et cetera, on the transition from ICD-9-CM to ICD-10-CM and 10-PCS, so it is something we might -- I think we have on our agenda to hear from them perhaps at the June meeting in any event, so that is something they could report on.
DR. CARR: Yes, good idea.
MS. DOO: And I will follow up on this issue of the EHR registration and send a note back that can be sent out to the committee.
MS. GREENBERG: Thank you.
DR. CARR: Actually, following on Mike's question, is there a kind of landscape of all of the things that are tethered to ICD-9, kind of an inventory of where we want to be looking? Has anybody done that?
MS. DOO: There is one through what CMS has done in terms of all of the changes that we have to do. There is actually a graphic that shows all of these touch points and obviously the risks. It probably is very similar to what will be done in other agencies.
I will get a copy of that and share it with you. It probably doesn't itemize the kinds of things that Mike mentioned that you might be thinking about. But when you see it, you can also perhaps say, well, what about this and what about that? We can see if it fits what you're thinking of.
DR. CARR: I think that would be very helpful, and I think it would be helpful to the public as well, because I think it is hard to grasp all of the different things that in fact are tied to our ICD-9 system. So I think it's a good way to be thinking about it.
MS. DOO: Sure, and it's a graphic, which you love.
DR. CARR: I love graphics.
MS. GREENBERG: We know that.
(Laughter)
DR. CARR: All right. I think, then, seeing no more questions, thank you very much for filling in.
Oh, I'm sorry. Walter? Pardon me.
DR. SUAREZ: Hi, Lorraine. Good morning. This is Walter.
I have a quick question. What has been the experience thus far -- and I know it's only about a month and a half since the testing for 5010 started -- but what has been the experience thus far, from Medicare's perspective, on the implementation of 5010, of course at this point without the errata?
MS. DOO: I don't have the detailed sheets of the issues that are popping up. Certainly there are some. I don't have that, but I know that there are weekly meetings on Monday, for example, when they list what those are, and I can probably get a copy of that and just give like an outline of them, of where the particular problems are happening, because as you said, it's only a month and a half, so some of them are probably pretty high-level issues. But I would happy to pull that, because I do get a copy of it.
DR. SUAREZ: Yes, I think that would be great. Thanks, Lorraine.
DR. CARR: Okay, thanks. Let's now turn to ONC, and Chuck and Joy, you're up next.
DR. FRIEDMAN: Thank you. Good morning, everyone. It is terrific to be here, and I'm sorry I wasn't able to join you yesterday.
I will be speaking about some aspects of what ONC has been doing that fall primarily in my domain and areas related to my interests, and then Joy will give a separate update on matters related to her domain of interest and responsibility.
I am going to cover three specific topics. My first specific topic is a general one. I am going to give you a few bullet points relating to progress in different aspects of ONC's broad agenda. I will then briefly report on two workshops we held recently on topics of interest, and then to the matter much on everybody's mind and in the forefront of our attention, the recent PCAST health IT report, and I will say a few words about a workgroup that we have formed specifically to consider the findings and recommendations of the PCAST report.
Here is my general program update. There are some late-breaking statistics here that I will share with you. We do have the 2010 data from the NAMCS supplement on office-based physician adoption of health IT. We have broken it out for primary care physicians. If you break it out for primary care physicians and look at those who have adopted a basic EHR, these are a very small number of basic but important functionalities, by no means what is required for meaningful use but indicative of having a kind of foundational system in place. You will see that among primary care physicians from the NAMCS data, the proportion with a basic EHR by a consistent definition thereof has increased from 19.6 to 29.6 percent from 2008 to 2010.
From the same survey, we have data on intent to be part of the meaningful use program by seeking to achieve meaningful use and apply for the incentive payments that are forthcoming to those who achieve it. From these data, 81 percent of reporting hospitals indicated that they would be striving to achieve meaningful use, and 41 percent of office-based physicians. Of those hospitals, two-thirds said that they would seek to achieve meaningful use either in 2011 or 2012. Four-fifths of the practices saying that they would seek to achieve meaningful use said that they were going to try to attain that this year; that is, 2011.
Moving to the next bullet, the number of certified EHR products continues to grow. I actually check the website with the list of products just about every day to watch the growth, and I have the URL here for you. It is readily accessible from the main Health IT HHS website, the URL, which I will show you at the end of my remarks. As of last night, the total was 350 certified products, 250 on the ambulatory side and 100 on the acute care inpatient side.
The next bullet goes to the number of professionals who have enrolled formally with our Regional Extension Center program to work with them to move toward meaningful use. As I think you know, we have funded 62 extension centers, which pretty much geographically cover the entire country. The latest data we have show that about 38,000 providers have entered into formal arrangements with the extension centers.
Finally, with regard to our workforce program, this too is growing very rapidly. In our community college consortium program with 84 colleges participating, we now have about 3,400 students currently enrolled in these 6month programs. A few have already graduated from some of these 6-month programs, but the majority of the first cohort are going to graduate in February or March, and then new cohorts will begin. We expect this program to have enrolled about 7,500 students before the end of the year. We have 645 trainees enrolled in 1-or-2-year university programs under our university-based training program.
Let me just stop here and see if there are any questions about this. Yes, Leslie?
DR. FRANCIS: Are there any breakdowns by types of primary care providers? For example, are pediatricians getting left behind and internists taking much more advantage of this?
DR. FRIEDMAN: The 2010 data, to the best of my knowledge, Leslie, is just in, and the survey itself is publicly available on our website. But we would have to look at the level of granularity. I don't recall it regarding specialty. I suspect within primary care the different primary care specialties are broken down. Those analyses obviously can be easily done, but I don't have those statistics right now. I'll past that request along. I'm sure that is something we are going to do.
DR. CARR: Walter, then Marjorie.
DR. SUAREZ: Hi, Chuck.
I am somewhat surprised with the second bullet. If I am reading correctly, 60 percent of office-based physicians are not going to intend to reach clinical use through the program, according to the survey, of course -- this is survey data -- so is that the right number there? When you say 41 percent of office-based physicians express their intent to reach clinical use, that means that the other 60 percent are not expressing their intent.
DR. FRIEDMAN: I would say at this moment they have not expressed such an intent. I don't think that necessarily means they are saying they are never going to do it. It means they have not expressed a positive affirmative intent at this time. I think there is a subtle but important difference in that interpretation.
Joy?
MS. PRITTS: I am not familiar with this survey, but do you know if the question was asked just of people who were eligible, or is it of all, all primary care because not all physicians are eligible.
DR. FRIEDMAN: This is everybody in the survey, not just primary care.
MS. PRITTS: Right. But of the office-based physicians, is the question asked just to office-based physicians who are eligible for the incentive payments or for all office-based physicians?
DR. FRIEDMAN: I obviously don't know the answer to that question.
DR. SUAREZ: That could be just an artifact of it.
DR. FRIEDMAN: Yes.
MS. GREENBERG: And we can find that out.
Can you define a little more what would make someone not eligible?
DR. FRIEDMAN: What would make someone not eligible for the incentives? My understanding is that all physicians are eligible professionals.
DR. SUAREZ: If they didn't see Medicare or Medicaid populations --
DR. FRIEDMAN: They could choose not to apply because the incentive that they would receive because of the proportion of Medicare and Medicaid patients they have is low, but that doesn't mean they are not eligible.
MS. GREENBERG: All right.
I want to get down to the last dot point there, because as Justine mentioned, during yesterday's workshop, which -- actually, almost the entire committee was there, so I thank you all for your participation and to those who set it up. It was really an exciting day, and you will be hearing more about that. But the need for technical assistance at the health department level, at the community level -- we primarily were hearing from communities and local people yesterday -- was tremendous for using information, for disseminating information, for analyzing information.
I wondered to what extent these programs -- this came up -- through the extension center and the training programs that you're funding are directed towards use of people in local health departments, people using population health data, as opposed to HIT in clinical environments.
DR. FRIEDMAN: A great question, Marjorie.
I can tell you that specifically with regard to the university-based training program, we encouraged through the funding opportunity announcement applicants to specify training tracks for public health, and actually we set as a target that 25 percent of the training slots at a minimum would be targeted for folks to either come from or return to physicians supporting public health work in public health agencies or other public health organizations. We've met that goal in terms of the number of training slots available.
Whether we will, over the lifetime of the program, which expects to train about 1,800 students, actually recruit at least 25 percent into these slots, I don't know, but there are categorical training opportunities for public health roles and public health professionals in this program.
MS. GREENBERG: One of the issues that came up was sort of on-the-job training or short-term training, the people who cannot actually be full-time students and who are not necessarily going for the doctorate level but who are working in the vineyards here. I don't know the extent to which the extension programs also provide some of that or if it is primarily just university based.
DR. FRIEDMAN: It's a many-part question.
First of all, most of these programs, not all of them, are offered through distance-learning modes. So they are very amendable to people who are working and cannot leave wherever they are to go wherever the training is physically based.
Second, with regard to the community college program, we have, through a separately funded program, developed a very extensive set of educational materials, 20 curriculum components, each one roughly corresponding to a 3-credit-hour course. Each component is also divided into units, and each unit is a standalone piece of educational content.
When these materials go public, and we expect that they're going to go public in June, they will be available in this atomizable form for people to take just the bits and pieces of content they need, and they are all amenable with computer-based delivery and distance learning. So I think we are poised to do the kind of thing you're talking about.
MS. GREENBERG: Okay, great. Thank you.
DR. CARR: Just to follow on to that, are there measures of success that you've identified when folks have gone through this program? How will we know that we're better because of it, or they're better, or what happened because of it?
DR. FRIEDMAN: The measures of success are recruitment into, successful completion of, placement in appropriate positions, and success in those positions. All of those are going to be measured, and we have a separate, through NORC, evaluation contract of the workforce program that will be looking at these things, particularly the outcomes of the training after people graduate and seek and hopefully obtain positions.
DR. CARR: Blackford?
DR. MIDDLETON: I had a similar thought. Thank you. Good morning, Chuck.
I guess the key question fundamentally is, are we succeeding? I worry on a couple of dimensions. Let me ask some very specific questions and maybe have a follow-up, if that's okay.
What is the best leading indicator of adoption, in your mind? I think the NAMCS data, of course, are really trailing indicators. I wonder if registration or other indicators might be a better leading indicator of adoption that might actually be beneficial to the office. Do you have any thoughts?
DR. FRIEDMAN: We are putting in place some more, we call them “finger-in-the-wind” indicators, where we really can get a sense that is less detailed than what we get from the NAMCS but more immediate than we can get from that annual survey.
I am really not comfortable talking in great detail about what these are, in part because I don't have the latest knowledge of where they stand. But suffice it to say, we are looking to address just the matter you're bringing up. This is obviously a very quickly changing situation, and the periodicity of one year to take measurements is not frequent enough.
DR. MIDDLETON: Speaking to the choir, I'm sure.
I guess the other just quick follow-up would be, do you have a sense of the number of physicians registered for the incentive?
DR. FRIEDMAN: Registered for?
DR. MIDDLETON: For the incentive. You actually have to go through the registration process.
DR. FRIEDMAN: Right. I thought Lorraine reported.
DR. MIDDLETON: Did I miss it? And CMS is the definitive --
MS. DOO: Do you want that number again?
DR. SUAREZ: Did you say 20,000, Lorraine, at the beginning?
MS. DOO: Yes. For Medicare-eligible professionals it is 18,000; hospitals, 23. That's on the Medicare side. For Medicaid-eligible professionals, it is 777, and the hospitals is one.
DR. CARR: I know you have three parts to your presentation. We have Joy and we have a break at 10:15. I will have Raj and then Larry, and then I would like to give you the opportunity to move to the next topic.
DR. CHANDERRAJ: My question is the training programs. Where can we find a list of where the qualified training programs are, or if a university can apply for this?
DR. FRIEDMAN: This was a one-time funding opportunity. In terms of obtaining funding, that opportunity has come and, unfortunately, gone. But the list of the programs is available on our website. I will show you the URL. You can pretty easily navigate to it from the landing page.
That said, for institutions wishing to stand up programs like this, we have resources for them. The curriculum materials, for example, are going to be available in June to them. Speaking as a lapsed university professor, I know how much of a head start it can give in starting up a new program if you have these kinds of materials available to get you started.
DR. CHANDERRAJ: My second question was the free clinics where by governmental regulations we cannot charge any patients, and are therefore Medicare patients not eligible to be seen in these free clinics? These are volunteer clinics, and they are not getting any incentives.
DR. CARR: In the interest of time, that is a great question but very granular. To keep it at this level and to get through, I will ask you to talk to Chuck at the break on that, if you would.
DR. CHANDERRAJ: All right.
DR. CARR: Larry?
DR. GREEN: Chuck, in the spirit of your slide, General Program Update, I want to do one very specific and two general things here really quickly. The very specific thing is the best data set I am aware of in the United States that is assessing family physicians' uptake of electronic health records is the American Board of Family Medicine's registration data set that our board-certified family physicians must complete. It has a 100 percent response rate and a 100 percent data rate or they don't take their part 3.
One of the questions on there is just a straightforward, “Do you use an EHR in your practice?” We've been monitoring that for years, and there is a steady upward trend of these guys year after year. Last year it ran it over 60 percent who answered, “Yes, I use an EHR.”
I am quite confident that Blackford's comment about these data trailing, the state of things, particularly in primary care and particularly for family physicians, that indeed they are trailing. I think we should celebrate what successes we can find.
DR. CARR: One other question. The 350 certified EHR products, are they fully certified to meet all of meaningful use, or are some of them are modular?
DR. FRIEDMAN: Some of them are modular.
DR. CARR: Do we know how many are fully certified to meet all of meaningful use?
DR. FRIEDMAN: I don't have that number off the top of my head. Joy, do you have that?
MS. PRITTS: I don't have the -- well, let's see. Of the 350 -- no, I would be guessing, but I will say that the number of modular products is higher for inpatient care than it is for ambulatory, which I think everybody would expect. It's about two-thirds to one-third in that context.
DR. FRIEDMAN: I showed this statistic in part, Justine, to make the point about the rapid growth, that the certification program is identifying a market, a flourishing market, of EHR products, and I think that is the macro conclusion I would like to draw from this.
Could I just respond briefly to Larry?
DR. CARR: Sure.
DR. FRIEDMAN: One point, Larry, and thanks for making that point. This 29.6 percent represents a proportion of primary care practitioners who, on the NAMCS, checked a specific subset of boxes. That is always going to bring down, since you have to touch all the bases, the number who meet that criterion.
There is an overall question on the NAMCS, “Do you have an EHR?” and it generates numbers very comparable. I don't have the exact number for 2010, but historically that number has been very comparable to the number the American Board of Family Medicine has gotten on its survey.
DR. GREEN: I wanted to make two comments about performance related to ONC that I have heard since our last meeting and your last report. They both relate to what you have on your slide there about assistance.
The first one was yesterday at our population privacy workshop. There was high praise for the ONC and the way they're working with the beacon communities and complimenting the cooperative agreement arrangement. To be very specific, Patrick Gordon in Grand Junction basically said, “This is a good federal program.”
We are talking about the west slope of Colorado here, and they really appreciate what the OMB is doing and like it. This was unequivocal communication. This wasn't hemming and hawing. They said, “This is a great relationship we've got; we're glad to be a beacon community.”
Secondly, at Fort Morgan Community College in Fort Morgan, Colorado, out on the eastern plains, the community college president there, speaking in behalf of community colleges all across Colorado, said how enthusiastic they are and how pleased they are to have these programs related to HIT and how quickly they have brought them up.
Once a community college gets a course number for this thing, at least in Colorado -- and it was his belief that this is nationwide -- that course number works in every community college. That curriculum can be transported, et cetera.
I think this is another huge success story you guys are having in terms of building assistance, and I wanted to report that.
DR. FRIEDMAN: That was our goal, Larry. Thank you.
Justine, I need advice from the chair. I want to be sure Joy gets some time.
DR. CARR: Yes. What I would ask is if you could just give us a quick update on the workshops. Let's hold the PCAST because we have some time after the break. We have 45 minutes to talk about PCAST, so you could give some introductory comments and then -- will you be here after the break?
DR. FRIEDMAN: Yes, I will be here all morning.
DR. CARR: Okay. So let's just hear about the workshops and then on to Joy.
DR. FRIEDMAN: I just want to mention two workshops which are, I think, forward-looking and touching on important topics, both of which took place in January.
Working with the National Institute of Biomedical Imaging and Bioengineering, the NIBIB, we held a workshop on January 10 and 11 entitled “Images, EHRs, and Meaningful Use.” The motivation for this workshop was an observation that images, not the reports of imaging studies but the images themselves, are important biomedical data that had not yet been contemplated in any systematic way by the meaningful use machinery writ large. So we got about 130 people together, and a public report about this will be forthcoming soon to explore the roles of image and imaging data, not just in image-intensive subspecialty practice but in primary care and all components of health care.
Also, because the imaging community got out in front of this problem very, very early, what we can learn from them about how they have made images exchangeable, mobile, and liquid through their dot-com standards and other mechanisms the imaging community has done.
So just be on the lookout for this report. I think it is very interesting.
Another workshop we had on January 20 and 21 actually touches on the PCAST a bit. It was called “Next Generation Interoperability for Health.” This was a fairly technical workshop focusing on the 5-to-10-year long-range view of information mobility. We actually integrated specifically in this report, into these deliberations, the findings of the PCAST report. Three of the leads of the PCAST work were there. A very useful perspective that if you want some nighttime reading, I would highly recommend to you called, “Ultra Large-Scale Systems Engineering,” and as soon as you read this, you recognize that this is the kind of thinking that has to be behind the creation of a national-scale environment for secure and trusted health information exchange.
Then a topic that is a little bit arcane but, I think, very, very important, called the semantic web, which is mechanisms for actually, through metadata tagging and other mechanisms, actually being able to connect pieces of information that are related by their meaning but stored in distributed locations across the Web. We are working still to put the findings of this workshop together, but I also think this will be of interest as a long-term vision when it is forthcoming.
Let me just say in conclusion, I just want to be sure everybody knows that the ONC PCAST workgroup is holding public hearings on February 16 and 17. I did not want to miss the chance to just make everybody aware of that. Is that the wrong date, Paul?
DR. TANG: I will check – 15th and 16th.
DR. FRIEDMAN: Oh, 15th and 16th, okay. Sorry, I don't know what I was thinking.
Then, please, if you want to continue any of this dialogue, feel free to contact me directly. Much more detail on everything I've discussed can be found at healthit.hhs.gov.
Let me repeat, the date on this slide is wrong. The PCAST workgroup hearing is February 15 and 16.
DR. CARR: Perfect. We will go back to PCAST.
Joy, turning it over to you now.
MS. PRITTS: Good morning. I am going to give you a little update on the privacy and security activities of our office, ONC's office in particular. At the end I am also going to give you a little bit of information on privacy and security activities at the HHS level that I think you would want to know about.
We continue to work with the HIT policy. There is a privacy and security tiger team with that. They have produced a number of recommendations. We are processing those recommendations internally with hopes that we will have formal action on those sometime this year.
While we are doing that internal track, we are also continuing this, what I would call the external track, of continuing to have public hearings on key privacy and security issues. Many of the issues that we are addressing in the tiger team have come through our programs or through other means of stakeholders identifying these are key issues that we believe need to be addressed first.
There are countless security and privacy issues to be addressed. So what we are trying to do is prioritize them and get to address the ones in particular that really need to be addressed in order for people to be able to achieve meaningful use.
The most recent privacy and security recommendations coming out of the HIT policy committee address provider authentication, I would say at the organization level, and they deal with digital certificates. They recommend that everybody who engages in health information exchange be required to have a digital certificate and that -- I am going to skip some of the detail in these, given our time here -- but that we should not reinvent the wheel here, that there are organizations that issue these certificates, that there are organizations that should rely on existing criteria because there are a number of things that you can use as the basis for authentication, and in particular that we should leverage existing processes such as the federal bridge.
They have recommended that ONC establish a new accreditation program for reviewing and authorizing certificate issuers, and that this should be part of the Governance Work Group. As you know, a lot of the work that we do in privacy and security overlaps extensively with what is going on on the governance side here.
They also recommend in specific that ONC, through the Standards Committee, select and specify standards for digital certificates in order to promote interoperability, and that EHR certification should eventually include criteria that make sure that everybody is able to actually use these certificates for the purpose in which they were intended.
In addition to this kind of high-level authentication issue with providers, the tiger team also held a hearing in December addressing a very crucial issue on patient information matching. The entire video of this hearing is available on our website. It was a very informative hearing. The ultimate conclusion there was that there is a lot of research and work that needs to be done in this area. Particularly, I would like to highlight to this group that they recommended that research be conducted to establish metrics for establishing an acceptable level of matching data to the correct patients. Some of the discussion here was quite interesting, as there are fairly strong opinions in this area as to what should be done, but the testimony from a number of experts was almost uniform in saying they just don't think we know enough to be able to be measuring things yet.
The next step of where they are now is they are looking at provider authentication. I call it the human user or the carbon-level life-form level, which is what level of assurance is appropriate; under what circumstances is it going to deal with the two-factor authentication in some circumstances, just as the DEA regulations require. That is the one of the things that has been brought to their consideration.
Also, patient ID management, which is very crucial for individuals to be able to access their own health information as we go forward.
As a follow-up, I wanted to give you a little update on a follow-up to a prior recommended we have received from the group, which has not been formally acted on in the department, but we are pursuing the recommendation nonetheless, which is they had made recommendations on what is called data segmentation, which is the ability to send certain health information but not all in a record, which is a key issue in dealing with sensitive health information, in particular substance abuse-related information, which by federal law requires patient permission to send.
We are actually in the process of funding some projects with respect to finding out how this is implementable in the real world, looking at potentially some standards that may come out of this and seeing how it actually works.
The focus that we have in our projects is on behavioral health, because there is a federal law and because there is a uniform need for this across the country. We are working very closely with SAMHSA and ONDCP, which is the Office of National Drug Control Policy, on this issue.
We are also at ONC doing a lot of work concerning the Affordable Care Act. There is an enrollment workgroup which has a privacy and security task force. They are addressing a lot of issues of privacy and security, including patient identity management here, also. The enrollment workgroup is trying to set up what I call one-stop shopping for individuals to enroll in health insurance, food stamps, and other social services, which is part of the act.
It is a very complicated area, as you can only imagine, because all the different agencies are subject to different laws and restrictions as to how they can share their information. But they all have this need for making sure that the patient identity is matched here, because this is your entryway into obtaining potentially a lot of different social services.
We have also been working on some of the accountable care organization privacy issues. I believe Don Berwick, in his speech recently, said that they recognize that there are issues that surround how that information will be shared even within the accountable care organizations and between CMS and those organizations.
An update on personal health records: Our workshop on this issue was completed in December. We have a study under way which is in its second drat, and we are hoping to get a report to Congress with recommendations later this year on which federal agency, if any, should be regulating personal health records.
In addition to our work, we are also working with other government agencies and departments on privacy and security issues. You should be aware that there is, I would say, an administrative-wide privacy initiative going on, stemming from primarily the Department of Commerce and the FTC. Some of this is in response to the EU directive updates. There is a big move in Europe to update their privacy directive to make it more Internet focused and how information is being shared now, and the United States has been criticized as being a little bit behind the game in that respect. So some of our activity here is in response to this kind of outside pressure.
The Department of Commerce has issued a green paper. For those of you who don't know what a green paper is, it's what you get before you have a white paper. So it's not a formal policy but it's in its green stages first. So it sets out some considerations that they are making, including voluntary industry standards for adherence to fair information practices for all commercial exchange of identifiable information on the Internet.
The FTC is also very active in this area. They have released their FTC privacy framework recently, which was written by staff. Just the other day they released some more guidance on medical identity theft.
Turning to a broader concept, at least within the department, the Federal Register contains a notice of projected agency activity in rulemaking for the next quarter. It is of note that the last update in 2010 listed a number of different activities that are happening at HHS that really do impact privacy and security very directly. One of them that was listed is an NPRM respecting individual access to protected health information held by CLIA laboratories. So that is an NPRM that is projected to come out, I believe the first quarter this year, because that's how the information is sent out.
Then there are also final rules that are predicted to come out early this year, including those on breach notification, the HITECH modifications to HIPAA privacy/security enforcement, and the GINA, the Genetic Information Nondiscrimination Act, the GINA regulations.
I haven't caught us up, but I hope to have closed the gap a little bit.
DR. CARR: No, that's great.
We have time for two questions. Walter?
DR. SUAREZ: A very quick one, Joy. Any updates on the accounting or disclosure regulations? I know OCR was expecting to publish that within the next few months, perhaps.
MS. PRITTS: I think the information that you have is probably the most current and that it would be an NPRM.
DR. SUAREZ: An NPRM, yes.
MS. PRITTS: Yes.
DR. CARR: Leslie?
DR. FRANCIS: Any projected dates for the final rules on breach notification, HITECH, or GINA?
MS. PRITTS: It is my understanding that the way the Federal Register notice -- I am only going to give you dates that are set out in the Federal Register notice -- and it is my understanding that that predicts your agency's activity. They issue that twice a year. In fact one came out in October, so they were expecting to accomplish that within the next 6 months, which would be before April.
DR. CARR: Okay, one more. Go ahead, Mark.
DR. HORNBROOK: This may be an unfair question given how much workload you already have. But is ONC thinking at all about, say, a consumers' handbook for the people who own electronic medical records? That is, what should I as a patient know about my electronic record and how do I manage it?
MS. PRITTS: First of all, most people don't own an electronic medical record. We use that term for the provider's record. Are you referring to a PHR or the provider's record?
DR. HORNBROOK: The provider's record and how the patient is going to interact with that.
MS. PRITTS: There is a large -- actually, there has been in the works, the planning stages, for a number of months a consumer outreach campaign. There is a provision in HITECH that directs the Office for Civil Rights to conduct such a campaign to advise individuals about their rights and how their health information is used.
We are going to be conducting a number of what you might call town hall meetings in six different areas starting, I think, fairly -- hopefully, those will all be done before August.
One of the purposes of those meetings -- I mean it's just going to contact a small fraction of the individuals in the United States, of course -- is to gather information about what information would individuals like to know about this, what is important to them, because there is a lot to know, but not all of it is really relevant from the consumer perspective. It is serving the public purposes for us for kind of fact-finding to figure out where we should head with this campaign and to develop additional materials going forward for individuals, more consumer-oriented materials, but also to engage the consumer groups at both the national and the local level in this process going forward, because we cannot possibly do this on our own. We really do need the consumer groups to be able to work with consumers locally to help answer some of the questions that they may have.
DR. CARR: We are going to stop for a break now. Joy, that was great. Thank you. You really covered a lot in a short amount of time. The same, Chuck, thanks very much. We will get back here at 10:30. We have a lot to accomplish today, so quick break.
(Brief recess.)
DR. CARR: The meeting will resume.
Let me ask, is there anyone on the phone who has joined the meeting or continuing on the call?
MS. DOO: This is Lorraine Doo still on the phone.
DR. CARR: Lorraine. Okay, great. Anybody else?
(No response)
Agenda Item: PCAST Report Review
DR. CARR: Our next topic is PCAST report review. We had talked about this on the executive subcommittee. Just by way of a brief introduction, then perhaps I will turn to Chuck to ask for his comments, but basically the PCAST report -- yes?
PARTICIPANT: Chuck just went to the lobby.
DR. CARR: All right, then you have me.
The goal, by my read, the PCAST report focuses on developing a universal exchange language for health care and also to have atomic data elements with metadata tags. These metadata tags improve search technology to locate data and to protect data.
I think what we wanted to talk about with the intent of the PCAST report is the resonance with the goals of NCVHS. I think certainly some of the things stated by this report, the purpose is to realize the full potential of HIT to improve health care; second, to increase interoperability; third, improve health care delivery, support comparative effectiveness research, decrease cost.
I think that there have now been a number of commentaries coming from various groups. I think Chuck can probably take us through this, but I think the areas of focus have been on the dramatic goals of reorganizing data in this way, the time line, the effects on ONC progress to date, the process of implementation, considerations about privacy and security and then also about standards.
So what I would like to do is, Leslie or Marc, in Leslie's absence, would you like to go through the PowerPoint that we have at everybody's place?
DR. OVERHAGE: The first note was, just as Justine alluded to, that there are a number of aspects of the PCAST report that are well aligned with the things that NCVHS has been thinking about, a number of things that are well aligned with the trajectories and directions that NCVHS has been thinking, the next hills they've been looking over, including thinking about ways to strengthen privacy and security of data, in particular in these different use cases, enhancing the possibilities for using information in ways that are less likely to be able to be linked to individuals.
On the next slide, improving clinical care through efficient health IT infrastructure; structuring information in EHRs for real-time secondary uses, which correspond with strengthening the privacy and security for use; and fostering the network effects, the network externalities that can increase the utility of information.
On the next slide, what we tried to do was create a group process to come up with some of the areas or questions where reading through the report raised for folks that might be jumping-off points for discussion.
Looking at it primarily from a privacy standpoint, first, that linking the data points in a record for secondary use and really thinking about how does that translate when you still have to bring the data together in a single place, that, presumably, you are going to have to do that for genetic data, and there may be some real challenges, and some of the geneticists that folks talked with about how you might be able to implement that kind of linkage for genetic data in particular. But I think it is probably a pretty generic issue.
Would you like to just go through all of these, or would you like to have some dialogue about the points as we go?
DR. CARR: What I am thinking is if we could even just go through, have each of the subcommittee co-chairs give a couple of high points and then let's come back to say where do we go.
Larry, you sent me an email.
DR. FRANCIS: In particular, the point there was about if you need to link data points, then the deidentification vision is potentially gone.
DR. CARR: Right. I think we would benefit by hearing from everyone, and perhaps Chuck will be back by then as well, and then we can get into the detail, because I think the question for us is do we want to put together a letter with some of these points, and would it be addressed to the secretary and/or to other agencies? So why don't you keep going, Marc.
DR. OVERHAGE: The second, and I will just stick with the major bullets and folks can read and look at the sub-bullets. We just recently prepared a letter about the tagging of categories of information. I think many of the issues we raised in that letter apply in this model as well. So that still needs to be addressed.
That really is the next point as well: the meta tags applied in a consistent and efficient manner across providers, across populations.
It was interesting that they observed the limitation on page 31 that was created by the need for agreements between organizations that were going to exchange data, but then they never came back to that, and I guess some of us did not quite follow how their approach solved the need to have agreements for data sharing between organizations.
On the next slide, they talk about, on page 46, informed consent could be more fine-grained privacy protections, and that seemed a little broad, without a lot of development, as there were a number of things.
We thought it would be useful to talk about the role of patient autonomy, as they allude to on page 45.
Then the question of how far does this go. The focus seemed to be on electronic health records, but obviously, as we've talked about, the same issues with personal health records, health information exchange, and so on, could be raised.
So those were the key points.
On the next slide there is just a listing of a summary of those at a very high level.
DR. CARR: Blackford, do you want to add?
DR. MIDDLETON: It is hard to follow Marc, as always, and the great thinking of the security, privacy, confidentiality, and standards committees, et cetera.
But the quality perspectives, we felt the PCAST report was useful to contribute to the notion of improved tagging of data and metadata surrounding our use of data in clinical systems, as well as quality reporting and clinical decision support. Certainly the history in syntactic data standardization and semantic modeling is to proceed from messaging architectures into increased modeling and tagging to better identify what the data is, where it came from, who supplied it, how it should be used, and how it should be maintained, and how trust and privacy can be propagated associated with the data.
I think the PCAST is useful in describing ways in which we may improve the liquidity of data and facilitate data aggregation once we have a better understanding of data in flight or in transit. However, it is critical to really make sure that, as we think about tagging strategies and standards around metadata assignments, to start with a clear understanding of what source data is from the source systems. Our feeling was there was a little naïveté or perhaps inadequate attention given to how these data are generated in source systems, where they come from, and the state of the art, the real world of where clinical data is.
You cannot start with a de novo DEAS or universal data set. We have to start with the data which we have. The industry is flush with data. We can improve upon it, but we cannot just ignore it and chuck it out the window. So we think it is important to have this clear understanding of source data, the data systems, and current data integrity, and it is naïve to think we can create de novo a wholly new data set. It really must be an evolutionary process.
Thus, it is important, we think, to align PCAST-type thinking with other incipient and emerging efforts around data standardization, normalization, and currently just pointing to the NQF/QDF efforts, which started as the quality data set, now called the quality data model -- my apologies to QDM -- as well as other efforts in HL7 and elsewhere. I think that's the most important thing.
I did forget one other bullet, I am sorry. We should also think about how the tagging and metadata work can improve the knowledge-management processes for data and knowledge associated with data. This is an exceedingly difficult challenge, even with the best constructs from SNOMED and other standard terminologies and whatnot. Once you begin to apply these constructs in use for CDS, for data representation, or for quality management, if they make a change in those resources and you have a whole bunch of systems using that representation formalism or the semantic associations, it can be really hazardous when they make changes that are not well forewarned or whatnot. So we think there is a knowledge-management and sort of process-support part of the tagging that deserves more attention.
But I think the most important point -- I meant to conclude with this -- was to align with existing emerging incipient efforts around NQF, HL7, and others to bring the tagging idea into the real world with existing data sets and efforts.
DR. CARR: Excellent, thank you.
DR. MIDDLETON: I will ask Paul if he has any other comments.
(No response)
DR. CARR: Judy or Walter?
DR. WARREN: I will start, then Walter will chime in. Actually, Blackford stole already a lot of my comments. But I think we are going to find that in this report.
When I approached this, the first thing I had to do was to back myself out of it, because I kept responding to it from my own experience and how I've spent my career. I wanted to be open to try to really figure out what they were saying in there, because I also agree that to me the report was kind of naïve because a lot of work did not reflect some of work that has happened through the standards organizations, the SDOs, especially work from HL7, SNOMED, ICD-10, RxNorm, so some of the terminologic standards.
I was also struck by, we were going to put all these meta tags on the data. So my first thing was, who is going to generate the meta tags, or does everybody generate their own and we're still in the same shop? The messages can get passed around, so if it's like the Internet, yes, we can pass a lot of information around the Internet, we can get it there accurately, we can read it when we get it, but we still cannot aggregate it, we cannot combine data, we cannot look at it, unless it's some of the stuff that you've seen in mashups that have been generated that way. Usually that data is fairly simple, where health care data is very complex.
I agree with Blackford, part of that is we've got legacy data, and we've got data that humans, in their wisdom, put down the right data, but they put it there within their own frames of thought, not with any idea of using that data later on for something else. So it's a one-input, most of it is not well formatted for machine readability, et cetera. So I was worried about the meta tags, because it seemed like we were just going to perpetuate whatever we were doing.
Then they talked about choosing the right granularity for data tagging, and I thought, well, who is going to choose that granularity level? There was never any debate about that. I think that has been one of the discussions we've had in the informatics community; that is, when we build EHRs, how far down do we code the data elements? Do we code everything and make everything selectable? Do we also do notes? When do we switch to images? When do we switch to other kinds of data? None of that was being talked about either.
They talked about atomic level of data tags. Again, who defines what's atomic? What is atomic to one person may be more molecular to somebody else.
It didn't really go back and use a lot of the work that both ONC and NCVHS have started, basically through looking at HIPAA, of trying to come up with standards, trying to get where we can harvest data out of our EHRs. So I was concerned about that.
Those were my kind of high-level hits.
DR. CARR: Walter, did you want to add anything?
DR. SUAREZ: Yes, a few other points, I think.
To me, the biggest, or one of the big issues, I guess, I found was the lack of a definition of what are some of prerequisites to be able to achieve the ultimate goals of the report. I think the report paints a particular vision of the future that involves tagging and metadata and much bigger integration of health information across the board, but it doesn't seem to recognize the technical and political and policy prerequisites that would need to be put in place before that can be achieved.
I think we are just transitioning our whole industry into electronic health records, moving at a relatively faster pace over the last few years, with all the investment that we are making, and this puts a picture of a vision of integration of health information that, if borrowed really from other industries, other sectors, including social networking and all these other activities that are happening, without recognizing in full detail, first of all, the complexities of the health care industry itself, as well as the current status of evolution in terms of infrastructure, I think that is a big, big element that is missing from the report.
I think the other aspect is really the aggressive time frame for trying to achieve these and the risk that this time frame imposes on things like patient safety and privacy. Certainly those are, to me, the two most critical issues about the quick adoption and implementation of these types of recommendations, the impact that they might have on patient safety, number one, and on privacy.
The third one is really this concern about the need to have policy first before technology. I think many of the questions and many of the recommendations and the directions provided by the report assume some quick technical solutions without considering the need for developing a policy context for those solutions. I think that is the other major element.
Lastly, I think just to emphasize another point that ought to be made is really, over the last 5 years -- 5 years ago we were just starting this journey -- in the last 5 years we have seen a lot of development of standards, interoperable standards. We put a lot of work on all the initiatives back 4 or 5 years ago, including HITSP, with the development of a number of interoperable standards. There are efforts like IHE internationally to develop interoperable standards. Many of them haven't been started to be implemented yet because they are just in the process of being tested.
All of that did not seem to have been taken into account necessarily. They could have jumped from maybe where we were 5 years ago into this vision without really looking at all the work that has been done and the availability of a lot of these interoperable standards that are just evolving and beginning to become available in all sorts of aspects of information exchange, not just purely the transport mechanism or the formatting standard or the vocabulary standard, but things like privacy and security and privacy preferences management and things like that.
So I think that lack of recognition or acknowledgment of the fact that there is a wealth of work that has been done that is being tested and that there are some success stories out of those and some lessons to learn out of those, they didn't take into account.
DR. CARR: Thanks, Walter.
Larry or Sallie, do you want to add on?
DR. GREEN: Sallie and I want to point out that we haven't had this nice, thorough discussion of this with the populations committee, and we're looking to more discussion about this. But at this point we have reached agreement about two or three things, just between the two of us.
One is we looked at the PCAST report parallel with the IOM digital infrastructure report and sort of took them as a package deal that were in play concurrently. We thought there was a lot of consistency between them pointing in similar directions.
We don't have comments to offer separately for the two reports at this point, but between the two of them, we would say that we don't think anyone is going to accuse them of lacking ambition. As sort of normal folks, as opposed to people who live and breathe IT, we found the reports simultaneously inspirational and totally intimidating.
We are not at this point certain that this is NCVHS territory that requires NCVHS to do anything, nor are we certain that it does not.
(Laughter)
So we are looking for some clarity about what the NCVHS's position might be here.
We would share two draft conclusions. One is we would like to surface that perhaps while we are designing the new world to exchange everything, that we do something that would make it possible to exchange something.
(Laughter)
We think that that ought to happen pretty darn soon.
Secondly, which is a bit of a political contextualization of it, as these reports were put into play, our President is emphasizing the need for the United States to step up and lead in innovation in challenging ways.
It seems to us that these two reports spot a very big challenging innovation problem on the order of landing someone on the moon. We suspect that it is maybe a little more complicated than that was, and we suspect it will be at least as expensive.
DR. CARR: Good.
Did you want to say something?
MS. MILAM: I will just mention briefly I thought it was interesting to look at our committee's reactions to it. Privacy seemed to find more advantages in it than maybe some of the other committees, and that is sort of reflective of what people I guess across the country as a whole are reflecting.
One of the staff to this committee circulated a website that categorized all of the different commentary from the different national associations. The privacy watchdogs and associations seemed to find more value than did the American Hospital Association or HINs or some of the others.
DR. FRANCIS: Could I interject in that for a second? I actually think that the privacy, although there is a great deal of wouldn't this be wonderful, highly granular, there are lots of concerns from the privacy folks that start with the question of whether policy is driving this or technology is driving this.
Just to give you an example, take what Joy talked about, about SAMHSA. There is a legal requirement that that be handled separately. Now, whether the way you do that is via a meta-tagging mechanism or via some other type of mechanism, that's a technical question. Meta tagging might be a very useful technical way to do that. I don't know, I'm not a techie type. Whether you do it and what you classify as sensitive behavioral health information are policy questions, and that has been our territory as NCVHS.
DR. CARR: Chuck, I want to turn it over to you, but just a point of clarification. I thought part of it was by having these atomic elements and metadata that there would be an option for patient control, that that would be part of the goal.
DR. FRANCIS: The privacy worry about that is that patients want default settings. So if I say, for example, I want my substance abuse information kept with certain sorts of special handling, it is impossible for me as a patient to go say this is substance abuse and this is substance abuse and this is substance abuse.
DR. CARR: I do want to give Chuck time. Is this critically important?
DR. SUAREZ: This is specific to this point of meta tagging and its use for privacy preferences and privacy preference management. When history was around, we worked significantly on this concept of how to allow for privacy preferences to be linked to information and then be manageable from the perspective of the entity that has the data as well as the entity that receives the data.
Clearly, while technically there are some ways to achieve that, and we actually created a standard for that, or a profile for that, the biggest concern was granularity. The more granular you go down into allowing tagging at the field level, at the data element level, and then controlling for several variables about that, including who can disclose, to whom it can be disclosed, when it can be disclosed, for what purpose can it be disclosed, how long can it be disclosed, all those factors about that particular one element inside a whole medical record is totally, at this point, totally impossible, not just from a technical perspective but from a cost perspective and a management perspective.
DR. CARR: Right. Okay, great.
Chuck, I would like to turn it over to you.
DR. FRIEDMAN: I was going to speak actually to Leslie's point as well. I think the people in this room, and I would include myself in that number, who have had the sublime experience of actually designing and deploying systems that have to work in the world, all understand that there are a very, very large number of details in this relative to the implementation of the PCAST recommendations that have to be worked out. So let me just put that forward as a premise or a preface.
That said, I am going back to our discussions about data segmentation and our having a sense of déjà vu, because I was saying -- and the PCAST report wasn't out yet, but I knew what it was going to say -- keep your minds open about this, because I think this PCAST report, when it comes, is going to give us a kind of liberating perspective in the sense that, with full recognition that we have to define what an atom is, and whether things are protons, atoms, or macromolecules is going to need to be worked out, the vision I think that is in the PCAST report is one that says that an atom will inherit its sensitivity from the metadata that enwrap it -- and I realize I am oversimplifying -- but we don't have to create a vision where one category or class of data elements is sensitive for all time and another set is not. That can be conveyed, the sensitivity of any element of data can be conveyed, through a context that is encoded in the metadata that wraps it.
I find, just speaking for myself, that to be a kind of liberating vision. It gives us a flexible way to think about things that we didn't have before and maybe gives us options that we didn't have before. With options come all kinds of complexities, but I would rather have those options than be forced into categorizations which, once made, are very hard to change.
DR. FRANCIS: That it is technically -- it allows for all kinds of interesting flexibility. I mean that's why it's cool. But it doesn't get rid of the questions that are the prior policy questions.
DR. FRIEDMAN: It doesn't write the policy. No question about it.
DR. CARR: So, Chuck, did you want to fill in any more? We didn't give you the time earlier to speak about ONC and PCAST.
DR. FRIEDMAN: Oh, with regard to the report? I was just going to show a few slides describing the charge to the PCAST working group that ONC has put together. I was going to make the point that it is a working group of both the standards committee and the policy committee. It has 17 members, some of whom are members of those committees and many of whom are not. The chairs are Paul Egerman, who was an IT consultant and a member of the policy committee, and Bill Stead, who was a member of neither committee but, of course, is a well-known informatician and the lead author of the report from the National Research Council that came out about a year ago that has been so informative about some of the challenges of electronic health records.
I just wanted to make those general points. Their report to the Health IT Policy Committee is going to be due and forthcoming in mid-April. I think the target date is April 13, with the public hearings next week.
DR. CARR: And who is speaking at the hearings next week?
DR. FRIEDMAN: The agenda is on the website. It is a very long list of folks in the usual format, with thematic panels and several informed individuals on each panel.
DR. CARR: What I would like to do, we have about 10 minutes to talk a little bit more about NCVHS and what we want to do or say and to whom we want to say it.
DR. SUAREZ: I guess I would say that we do have a number of things to say, that we should say them, that we should actually formally draft a letter and submit it to the secretary, who is the person that we report to, really, or provide advice to. The time frame, we can work it out, because I think there are some steps that we need to take in order to achieve that.
The second point that I wanted to make is I think it is going to be beneficial to, in that letter, certainly -- and I think this was mentioned, perhaps -- go back to some of the recommendations we have made in the past and emphasize some of the points that we have made, as a point of reference more than anything. I know this experience might be liberating in many respects, but it creates a lot of challenges in many other respects. So I think it is going to be important to have that.
Then the third thing I wanted to mention is perhaps we can benefit also from the information that will be presented next week during the two-day hearing. Some of us will be actually at the hearing, participating and attending.
DR. CARR: Bill?
DR. W. SCANLON: I guess the question I would have, I've heard sort of multiple perspectives here, and I think I am going to pick up on Larry's use of the word “inspirational.” That I think serves as the general tone of how difficult some of the things that the inspiration might imply will be.
The question in this letter in terms of where the emphasis will be, you could ask how fast can you run, and the answer might be, well, it depends on who is chasing me. I think that this situation is that if you think that the health care system is going to operate as it has in the past with business as usual, then the challenges are overwhelming. We will sort of work through an evolutionary process -- you know an evolution can be quite protracted --or if you think the environment is going to change, and Jim was very polite this morning in talking about the budget and the budget deliberations, because we have a focus here in Washington right now on deficits and substantial reductions in deficits, of which health care is going to be a part of that. The question is going to be, do we have the instruments to make those reductions in a very well-informed and less harmful way or not? Because they may ultimately happen regardless. That is the kind of concern I have.
I want to say we need to put enough emphasis on the inspirational part, enough emphasis on the fact that we do really need to think about how do we accelerate our activities, overcome the challenges, because if we don't, there is the possibility that there is going to be real harm that happen when necessary reductions do occur within how much we spend.
DR. CARR: Well said.
I think when we talked at the Executive Subcommittee, Paul, what we said is the format that Leslie and Marc have put together, what is the alignment of PCAST within NCVHS priorities, what are the hot points needing work, and the challenges? And we should say the strengths are important, not just the alignment with us but actually the additional strengths, and what are the hot points.
I think, clearly, there is a lot of work being done to think through all of the challenges that come about with a disruptive transformation.
To your point, I think we would perhaps have a letter that would outline alignment, benefits, and challenges to have our voice heard but defer to the very detailed work that is ongoing already with that.
Blackford?
DR. MIDDLETON: I just had a related thought. Paul and I talked briefly and he brought this up, so whether it's good or bad, you can blame Paul, and he is not here.
How common is it for a FACA to comment on another FACA's report? I wonder if there is precedence, or is that the normal operating procedure? It could be that we note this report and wait for the implementation phase and somehow engender ourselves to be involved in whatever the appropriate activities are. Or is it more appropriate to say something now?
MS. GREENBERG: This is a report to the President. This wasn't specifically a report to the FACA, I don't think. Even if it were --
DR. FRIEDMAN: PCAST, as I understand it, is a FACA.
DR. W. SCANLON: Yes, it's a way --
MS. GREENBERG: Oh, all right. I thought you guys were just --
DR. FRIEDMAN: PCAST itself is a FACA, and this report is a report out of a FACA.
MS. GREENBERG: Not a problem. All the more so.
I am thinking back several years ago when there was a president's commission -- and whether these things are federal advisory committees or not is sometimes a little murky -- but on quality measurement, and the committee commented on that.
I have a few concerns. One is, can we in a timely way put together comments that will achieve consensus from the whole committee -- it sounds like we are not at all different places on it, although you might emphasize one part or another -- and have it have some value? Timing and all of that is -- it would need to be timely, and I think you would want it to come out before this April 15 study. I think it would have to be pretty high level.
My other concern is that I think the stakeholders of this committee, who are growing daily, probably are looking to the committee to at least make some observations related to this rather visible report in an area that, although more technically in depth than typically we deal with, certainly an area that the committee is very involved with.
So I think if we could put something together, again, I would support it, and I don't see any problem with it.
DR. CARR: I am going to get Jim's input, but I think the issue is which question we address. I think what we've heard around the table are the comments if we do this. I think the controversial would be should we do this, and I think we can limit ourselves to if we do this, these are the benefits we see, these are the challenges we see.
Jim?
MR. SCANLON: Same thing. I think there is no issue with commenting on another FACA report, but remember, our comments are to the secretary, they are not to the PCAST.
Again, it sounds like clearly there is an interesting vision here, and I think the goals are quite similar. I think they're trying to get to the same place as more traditional EHR approaches. But the approach is quite different.
You may want to focus on goals and questions, actually. I don't think you want to pan the vision or the goals. You probably agree with them. But it's a matter of how would this work and how would it build upon current capacity. Where is it? Is anybody doing it now? And is there some other industry that we can learn from? But those are the kinds of -- I think higher level thoughts and questions and analyses will be more helpful than mechanical tweaks at this point, just because it is so broad a framework.
DR. CARR: Walter and then Leslie.
DR. SUAREZ: I think procedurally my suggestion would be -- I can see the letter having some high-level comments that cut across all topics, and then you can have a selected set of comments related to, for example, standards -- we can help draft those -- privacy, population, and quality if that's the case. So I think we can create a letter that has some overarching comments in the front part and then the various comments from each of our respective groups.
DR. CARR: Leslie?
DR. FRANCIS: I really like the way Walter framed it in his comments a minute ago about policy coming first and reminding the secretary of some of the core policy questions that NCVHS has been interested in, as a frame of a way to look at it.
DR. CARR: Mike?
DR. FITZMAURICE: If we do a letter, I would suggest that one of the recommendations to the secretary is that we need a thoughtful proof-of-concept study because we don't know everything that we need to know about this, one that generates a list of things that we need to have to obtain this improvement in our health system, like what data standards, what privacy profiles, what is the governance desired in privacy, in standards? What needs to be governed, who should do it, what is the government's role?
Coupled with this we need a pilot study that follows on the proof-of-concept study that implements this concept in two or three places that exchange data, with a section of this pilot study that speculates on what happens to costs and benefits of such tagging technology as we multiply it by 10, multiply by 100, so that we can get some lessons for the whole economy.
DR. CARR: Okay. So to wrap up -- I'm sorry, did you have one other comment, Marc?
DR. OVERHAGE: I'm sorry, thank you, just one thought, and that is it seems to me that there are a couple of areas that we might want to make observations about related to population health and the implications for a model like this for population health, since that's one of our major remits, and I think there are many potential implications there.
The other thought is that I see that one of our roles is to be looking out, down the distance. ONC and many other organizations have near-term deliverables and deadlines, and tomorrow this rule has to be out, next week this has to be done. We sometimes have the luxury of taking a little bit longer view and putting it in that context. I think it speaks a little bit to Mike's point about -- I might even ask the question, when is a good time to be doing those things? Is it today, given everything else that's on everybody's plate, or is it tomorrow? Building on Larry's comment, perhaps, let's get some of the things done that we've started on and hope these things are -- but that would be a decision that --
DR. CARR: Chuck?
DR. FRIEDMAN: Thank you. Just to second Marc's point, I recall some statements in the early parts of the PCAST report that go to the fact that they saw as key to their mission from the outset creating a vision of interoperability and data liquidity that would specifically support population health and research and the other quote/unquote secondary uses. So that would be very appropriate and very much in line with their original intent in doing the report.
The second point I would make very quickly. If you were going to produce this letter, I would think it would be very helpful to have it arrive coordinated with the time line of the ONC PCAST work group report, so all of this input flows forward in a synchronized way.
DR. CARR: Yes. That's great.
DR. SUAREZ: What's that time line?
DR. FRIEDMAN: Mid-April.
DR. CARR: We are going to draw this conversation to a close. I want to summarize what I think I've heard, that we will have a letter to the secretary, that we will be focusing more on, if we do this, these are things that are benefits, these are challenges, this is aligning, focusing on areas of alignment with the committee, particularly our interest in population health.
The way we will do this, I would suggest that the subcommittee chairs build on what you've already got, and I think it is really quite good already, and maybe some discussion today, and we could put together -- perhaps then work on a draft and then use one of our designated Friday conference times to review and discuss and refine.
I want to clarify, Marjorie, if that executive subcommittee group works on it, then the next step would be to circulate it to the full committee? So we would be working electronically, obviously, because our next meeting isn't until June. Then with the agreement of the majority of the full committee, we would move the letter forward?
MS. GREENBERG: Well, we would need to hold a teleconference that would be open to the public and announce it on our website et cetera for the committee to discuss the letter and vote on it.
DR. CARR: Okay, great.
MS. GREENBERG: Now, I think we are going to need -- you know what it's like writing a letter by committee. Somebody is going to have to take the lead on writing this, I think.
DR. CARR: Yes.
MS. GREENBERG: I think there is input from everybody. At this point I don't know if we have a staff person who is knowledgeable enough about this particular area who is coming forward to do this. Are there any volunteers?
(Laughter)
DR. FRANCIS: I will certainly help. I cannot do the --
DR. CARR: And Matt has volunteered.
MS. GREENBERG: Okay, our standards guy back there.
DR. CARR: That's standards, quality, population, multidisciplinary expertise. So Matt will be the point person then, and then I think we'll go from there. Thank you, Matt.
MS. GREENBERG: Thank you, Matt.
DR. CARR: Final comment, Walter.
DR. SUAREZ: Yes, just one kind of quick logistic suggestion. I think we should set out some date by when co-chairs of the subcommittees should send their draft, decide the comments we want to insert. Then there will be some overarching comments outside of those that have to be crafted.
DR. CARR: I would ask that today you put to paper what you have said, and hopefully we can soon get a transcript, pretty soon. But let's just try to put the bullet points together today:
• What is the alignment with NCVHS?
• What do we find as the strengths?
• What do we find as the challenges?
If we just start with that, I think that would be good framing, and then we can give whatever form you have to Matt, who will work on it.
DR. SUAREZ: But we do have until April, roughly mid-April.
DR. CARR: We will come out with a time line as well.
DR. SUAREZ: We can stretch a little bit the time line, too.
DR. CARR: Yes.
Okay, moving right along, next on our agenda is you again, Walter. Standards letter.
Agenda Item: Standards Letter - EFT Operating Rules and Remittance
DR. WARREN: If you will bring up the letters, the way Walter and I decided to do this is I will give you overview comments and then I am going to run to the laptop and take notes, and Walter is going to take us through recommendations.
Our letter is on tab 5. This letter has had quite a bit of work done already by Walter, Lorraine, and me, with the help of Margaret A. We then had committee responses to the letter and a phone call with the committee, and then also the Executive Subcommittee has looked at it.
What you will see under tab 5 is the letter itself, and then you will see the agenda that we had for the hearings, and then after are briefing booklets, so all the exquisite details that you would like to know about the standards and their impact and stuff is in the briefing booklet. That briefing will be an appendix attached to the letter.
In the letter, we have our basic introduction to the secretary laying out what our task and charge was by the PPACA law. Then we came to an agreement that we needed to make some overarching observations, because this is the second time that we've made recommendations about operating rule entities. So there were some patterns that were beginning to evolve that we did not want to miss, so that we could see whether or not they held true for the rest of the standards that we are going to have to designate operating rule entities on.
You will see that we have three observations that are there. We then made some comments about the electronic funds transfer. This is the first time where we are going outside health care to look for a standard. The standard comes from the banking industry, so a really new area for NCVHS to follow, and in fact we do have some representatives here from NACHA; that is, the organization that develops the standards. So if there are clarifying comments, we have some experts in the room.
We made some comments about that, and then you have our actual recommendations about what should happen and then a call out for -- part of the law, if you remember, is that the operating rule entity has to submit us the operating rules for us to evaluate. So the last couple of paragraphs there of the letter address that.
With that, I will let Walter make some comments about our recommendations, and I will run to the laptop.
DR. CARR: Great, thanks. And, Walter, maybe you can start by reading what was the assignment from the Affordable Care Act, just for the record.
DR. SUAREZ: Do we have that in the letter?
DR. CARR: Yes, it is in the letter.
DR. SUAREZ: It is in the first part of the letter. So the introduction, and then I don't know that we need to read word by word this first page, but the assignment -- and this is again, Judy was mentioning, this is the second in a series of letters out of the Affordable Care Act. Specifically, the assignment was to -- I am looking for that --
DR. CARR: A, just start with A, B, C, D, E.
DR. SUAREZ: Oh, thank you. I'm sorry.
So advise the secretary whether or not a nonprofit entity meets the requirement for the operating rules development, review the operating rules development recommended by such entity so that the actual operating rules, we need to review them and make an assessment and make a recommendation about it.
Determine whether such operating rules represent a consensus view of the health care stakeholders and are consistent with and do not conflict with other existing standards.
Evaluate whether such operating rules are consistent with electronic standards adopted for health care information technology.
Then submit to the secretary recommendations as to whether the secretary should adopt such operating rules.
These are the Affordable Care Act tasks related to operating rules.
Now, as Judy mentioned, we divided the letter into those three sections she highlighted. The first section, which starts on line 81 -- and the previous sections are really noting some background information about EFT and ERA, and a lot more background about it is provided in the environmental assessment that would be part and attached to the letter.
If we want to go into the overarching observations, I think we can highlight those. Again, it starts on line 81. That's the first section of the letter. We highlight on line 85 basically that there is value in establishing an active, open process that ensures communication among authoring entities and between authoring entities and standard-development organizations.
This is one of the first and probably most important observations after two rounds, if you will, of this new experience of evaluating and recommending operating rules, the fact that there are going to be authoring entities, some of which might be a standard-development organization, some of which might not be a standard-development organization. So that is one group, authoring entities of operating rules.
Then there are the standard-development organizations. If you recall, in an earlier letter, in the previous letter, we recommended that authoring entities be made part of the DSMO, the designated standard maintenance organization group, to facilitate that communication. It seems that that might not be necessarily the best vehicle, incorporating the authoring entities into the DSMO, so we are now looking at an alternative way to convene and to facilitate and to foster this communication between the authoring entities of operating rules and the standard-development organizations to ensure that there are no conflicts before the operating rules are written and completed, and that the standard ultimately incorporates any issue that might have been identified in the operating rule development process, because that is truly the cycle that we want to see, less need for operating rules, if you will, and much better defined standards and less need for having to create these operating rules that clarify the standard or that create ways in which the standard is to be adopted. The standard should be the one that has that information in it.
So that is one aspect of the next step that we see, that we need to really look at establishing this active process. We are thinking, and we will be talking about this probably tomorrow as part of some of the recommendations of what we will be doing this year with the work of the subcommittee and how we can bring these two groups together in a more harmonious way. That is the first observation.
The second observation starts in line 94. “There is a transition path that needs to be recognized for health plans and providers to prioritize and plan for applicable investments in technologies and processes that will support new standards and their operating rules.” Again, clearly, here what we are finding is that there is still a degree of optionality in the standard that is making it more difficult to adopt and implement in a very standardized way these administrative transactions. So we are looking at improvements in the standard by reducing the variability. It is going to enable better use of that standard transaction.
Then the third high-level observation starts in line 102, page 3 at the top: “There is value in ensuring consistency in certain aspects of operating rules across all transactions.” Here the concept is the following: There are nine transactions at this point, and there will probably be more transactions -- 10, 11, 12 transactions over the next 3 or 4 years. If we create operating rules for each of those transactions, and there are some components of those operating rules that really apply to all the transactions, and those components are different from one transaction to another, it will create a much more complicated implementation process.
So we are highlighting the need, the fact that there is a set of standard operating rules that apply really to all transactions or that would likely apply to all transactions, and that consistency in those operating rules will be very important. That's what we are highlighting as an observation after this second round of experience with the operating rules.
Let me stop there and see if there are any questions or comments or reactions from the observations.
(No response)
All right, let's continue.
Line 111, starting the second part of the letter. I want to make a point that the charge for the second round was to identify a standard for EFT, the electronic fund transfer, number one; and number two, the operating rules for EFT and ERA -- those were two different tasks, the standard for EFT and the operating rules for EFT and ERA. The second part of the letter focuses on the standard for EFT. The third part of the letter focuses on the operating rules for EFT and ERA.
With respect to the standard for EFT, we have in line 114 through the remaining of this page a description, a discussion about the standard itself, the way that EFT occurs in health care. We provide that background, the fact that there are basically two formats in the current transactions, something called CCD+ and another called CTX, the main difference being that the CCD+ provides for a transmission of basically the monetary information plus a re-association key, a multi-digit re-association key, that gets passed from the health plan to the health plan's financial institution, from the health plan's financial institution to the provider's financial institution, when the transfer of funds happens, and then from the provider's financial institution to the provider. So that reassociation key in the EFT allows the provider to link back the money that came in with the --
DR. CARR: Would it be helpful to refer people to the diagram picture?
DR. SUAREZ: You have a diagram?
DR. WARREN: Yes, it's on the last page of the briefing booklet.
DR. SUAREZ: Oh, thank you.
DR. WARREN: Justine wanted a picture, so we brought a picture.
DR. SUAREZ: It's in the last page of the briefing book, page 19? No? I am not sure --
DR. CARR: I think actually there's another one on page 7 for beginners.
DR. SUAREZ: Yes. The one on page 7 is the one that kind of mentions that process.
So there is the CCD+ and then there is the CTX. The CTX is, just in rough terms, basically the health plan sends a copy of the remittance advice itself, with all the details, including personal health information, of course, to the banking institution of the health plan. The banking institution of the health plan is expected to pass that to the provider's banking institution, and then that comes down to the provider. That is the CTX format.
Lots of discussion during the hearing about the differences, the current use in health care of the two formats, basically highlighting that pretty much CCD+ is the most --
DR. CARR: Again, Walter, because I know you dwell in this area and it's intuitive to you, but I really think for the full committee to understand this, I just want to be really kind of a little bit slower on 7.
DR. SUAREZ: Okay. Well, let's go through the recommendation.
DR. CARR: No, just to get -- so the key thing that you're saying is where does the -- does the sensitive health information travel separately or together?
DR. SUAREZ: Yes. The difference between CCD+ and CTX is that CCD+ doesn't really transmit any protected health information from the plan to the banking institution of the plan, to the banking institution of the provider, down to the provider, because the re-association key allows the provider that receives the deposits and the fund transfer information to go back and link that information with the remittance advice that the health plan sends directly to the provider. The remittance advice is a separate transaction from the EFT.
That is the main difference, I guess, between CCD+ and CTX. Again, for the most part, what we heard during the hearing was that CCD+ was the main approach currently being used.
The recommendations on line 154 start -- we make five specific recommendations. The first recommendation is, as always, with all the other HIPAA transactions, we have to recommend a definition of the actual transaction. If you recall, in all the other HIPAA regulations for all the other transactions, we defined what a health care claim, an encounter, is, or what a health care claim payment is as a transaction. So we are recommending that the secretary define the health care EFT transaction as it says in line 156, “an electronic message used by health plans to order, instruct, or authorize a depositor financial institution to electronically transfer funds through the ACTH network from one account to another.” That is the recommended definition of an EFT transaction. Not yet the standard. The standard comes next.
Now, the source of this definition is primarily the definition being used in the current 835, the current electronic remittance advice standard, which defines an EFT transaction as basically this. There might be some wording we might need to consider, depending on what we hear, but that is basically the recommendation.
The second recommendation is about defining the EFT standard. We are recommending that the EFT standard as the format and content required for health plans to perform an EFT transaction -- I am sorry, we are recommending that the secretary define the health care EFT standard as the format and content required for health plans to perform an EFT transaction. That is a statement about the need to define what is the EFT standard itself.
Then 1.3 and 1.4 and 1.5 define the standard format, the standard development organization that develops that standard format, and then the implementation specification. 1.3 recommends the secretary to adopt as the standard format for the health care EFT standard the NACHA CCD+ format in conformance with the NACHA operating rules. 1.4 recommends the secretary to identify NACHA as the standard development organization for maintenance of the health care EFT standard. 1.5 recommends the secretary adopt as an implementation specification for the content of the standard being recommended, CCD+, the implementation specification described in the 835 transaction, basically, the electronic remittance advice.
We added a statement at the end of this 1.5 that it is acknowledged that there are other forms of EFT, including CTX, which are not widely used in the health care industry, and this may be something to be considered in the future, these and others that might come out as standards for formatting content into the future.
So that is the core of our recommendation with respect to the standard itself. Let me stop there and see if there is any question. Yes?
DR. STEINWACHS: Just so I am clear, on that last statement about these may be considered in the future, is what is being said is that in the future there might be one standard used or that there might be a switch?
DR. SUAREZ: No. That is one of our roles, defining the Accountable Care Act, and one of the roles of this process is really to evaluate now every 2 years, at least, how the standard is doing and whether the current standard is the right one or there should be a different one to be adopted. This does not mean that we are in the future going to add another standard, but we are going to evaluate the current standard.
DR. STEINWACHS: My suggestion, for what it is worth, I would probably take that out of the recommendation. You may want to remind the secretary that every 2 years you are looking again at these and coming back.
DR. CARR: And I think, given that we've set out A, B, C, D, E, I think if we had some symmetry in responding to A, advise the secretary, this is what we are advising; B, review the operating rules developed. Well, today, we don't have the operating rules, right?
DR. SUAREZ: Yes. Those A, B, C, D, E up above are all related to operating rules, really. Those are the responsibility that we cover in the third section of the letter.
DR. WARREN: I would like to respond to Don's comment. When you look at the NACHA standard for EFT, there are different formats in the standard. So we are recommending the standard, and we are only recommending one of two formats. So what we're saying is in the future when they're being reevaluated, there may be other formats that we look at again and recommend. So it's not a standard that could be changed. The standard is the same. It is the format within it.
One of the solutions that may make you feel better is we could put that in a footnote, that one sentence, and that may make it clearer. But one of the problems that we had, and you will see it in our recommendation of 1.1 and 1.3, is NACHA defines standard differently than the other health care SDOs. So what we are trying to do is do that bridge.
So, for them, it is the format that conforms with the standard. The standard is something else. So we are trying to be a bridge so that we use the words in a way that we're familiar with.
DR. STEINWACHS: That does help, and I appreciate it. You might take the two sentences and put them in a footnote. It sort of sounds like you're justifying this mainly because the other things are not widely used.
DR. WARREN: So if we drop that down to a footnote and say, “per the law, we will reevaluate this”?
DR. STEINWACHS: Yes.
DR. WARREN: All right.
DR. STEINWACHS: I think that would be a strong message.
DR. WARREN: All right.
MS. DOO: Judy and Walter?
DR. WARREN: Take this part, Don --
DR. SUAREZ: It sounds like Lorraine --
DR. CARR: Are you finished, Judy?
DR. WARREN: I just want to be sure. It is these sentences, Don, that you're --
DR. STEINWACHS: Yes. I would just make the recommendation the recommendation. Take the comment out of it and put that elsewhere.
DR. CARR: We have Lorraine and then we have Mark. Lorraine?
MS. DOO: Thank you. I know I'm out of order, but I can't see the hands.
The one thing that I wanted to mention, at the beginning of our letter -- and it might be something you want to consider adding -- because the operating rules are not available yet and we are just evaluating the potential candidates, I thought you might want to think about putting something in, that the reason we're focusing on the standard here is because we're in the process of evaluating the operating-rule authoring candidates and that that would be a separate letter that would come in the next 6 weeks or something.
DR. CARR: I agree. Because this is so complex and not familiar to a lot of people, I think, to the extent that we can tick and tie what we were asked to do, what we're doing and in some cases what we're not doing and why, it will be very helpful.
DR. SUAREZ: Yes, that's a very good point, Lorraine. I think what is missing from the intro -- again, we are focusing the intro only on operating rules primarily because we borrowed, I think, from the previous letter which was only focusing on operating rules. But the Affordable Care Act provides for NCVHS to evaluate and make recommendations on an EFT standard, not operating rules, the EFT standard. That should be added in the first portion of the letter, that the Patient Protection and Affordable Health Care Act calls for NCVHS to make recommendations on the EFT standard, and then make recommendations on the operating rules.
Then on the third section of this letter, we clarify why we are not in this letter making recommendations on --
MS. DOO: Exactly.
DR. WARREN: So if you look at the highlighted standard, this is right under our charge in the law, and I think this does what you're asking for, Justine. “Based on the above, this letter is another in a series we are writing concerning the new changes to the committee for recommendations on operating rules, in concert with our existing responsibility to advise the secretary on the adoption of standards. Our first letters were on the health plan identifier and operating rules, and all three entities for eligibility and claim status were sent to you on September 30. This letter addresses transactions for electronic funds transfers specific to health care use and health care payment and remittance advice, commonly referred to as electronic remittance advice.”
So does that handle --
DR. CARR: I see it.
DR. WARREN: I think we have to go back and make sure that --
MS. DOO: A future letter will address operating rules for EFT and ERA once the evaluation of the candidates is completed.
DR. SUAREZ: I think what we need is, in line number 25, where it says, “Specifically with respect to operating rules,” we need to insert a new sentence that says, “Specifically with respect to standards, NCVHS was tasked to recommend an EFT standard, and with respect to operating rules, NCVHS was tasked to” -- A, B, C, D, E.
MS. DOO: And it does look like it's around line 187, is where we talk about doing it going forward.
DR. WARREN: Right. So all I am going to do right now is capture in red that we need to insert a sentence there about the standards. I do think that that's the right place. Then the paragraph below our direction in PPACA will cover the rest.
What I am wondering is, based on your comment about the complexity, if we also need to put in here right before our observations that this letter has three parts --
DR. CARR: I was just going to say that.
DR. WARREN: -- general observations, the standard, and then the operating rule.
DR. CARR: I think that would be very helpful.
DR. SUAREZ: I think that would be good.
DR. CARR: I think just carrying through what we were asked to do, this is where we are in our assignment and this is what we're doing and what we're not doing would be very helpful.
DR. WARREN: We've already got it, believe it or not, right here.
DR. CARR: And it may be, yes, just formatting it and kind of getting it -- go ahead.
DR. WARREN: Maybe a header here?
DR. CARR: Why don't we work on -- I want to make sure that we get all the content. Mark?
DR. HORNBROOK: Two questions. One is do we need to worry at all that the account label could have PHI in it, that it's Mark Hornbrook's account or it's security number XYZ account? First question.
The second question is are we dealing with also transfer from my bank account to my provider, my individual electronic funds transfers, or is this only --
DR. SUAREZ: No, it doesn't. To the second question, it doesn't deal with that, no.
DR. HORNBROOK: That's a whole separate world?
DR. SUAREZ: As a patient, you mean? Your bank account?
DR. HORNBROOK: Yes.
DR. SUAREZ: No, this is -- any exchanges between a patient, a consumer, and anybody else, whether it's a direct payment to a provider or a health plan paying the patient, that's not subject to any of this.
DR. WARREN: However, though, Mark, it is covered by the same standard for the banking industry. So it is the banking industry's job to make sure that your data is not compromised, but it is not health care's job, because your personal account is not part of this.
DR. CARR: Wait. But with what we send them, we've made the decision that we are decoupling --
DR. WARREN: No. What Mark is worried about is if he is making a payment to his provider, does his provider get the information about his banking account? We have specifically said that was not part of this task. It is only when a health plan pays it, and it is the health plan's bank that gives it to the provider's bank. That's where that information is passed.
In the two formats, we have one format that has the data about the money piece and a re-association key to the PHI. That is the format we are recommending. There is a second format that includes PHI that had all kinds of implications on whether or not banks became covered entities. So we chose at this time, especially since no one was using that format, not to recommend that format. But we held it open that in the future we may look at it again.
DR. CARR: You mentioned that we have experts in the room. Is there any input we've gotten from the industry that we want to hear about?
DR. WARREN: Go ahead.
MS. ESTEP: This is Jan Estep from NACHA, and I appreciate the opportunity to speak for just one minute, because I had a couple of quick observation that I think link into the comments just made, as well as, then, a couple of ideas relative to the recommendations themselves.
Certainly the legislation calls out the need for the secretary to define an EFT standard, and that's what we're focused on right now. I think it is less clear that the legislation asks to define the EFT itself and/or it is not clear exactly where it says that EFT will be a HIPAA transaction.
So I think there is clarity that perhaps we can offer again as we're trying to bridge the health care industry to the financial services industry relative to recommendation 1.1, because we not only tried to clarify it in our testimony in December, but the Kaiser testimony also called out that the 835 implementation guide definition of EFT was not accurate. So I would hate to promulgate a letter using a definition that is potentially inaccurate, and I would like the opportunity, if you can define our organization as an expert, to raise up a definition for consideration of the subcommittee that is different than 1.1.
In a related area -- and again to comment on Judith's comment -- I think the definition will help further discussion, because the definition has to include the full transaction, not just one part of it. So it is not only the payment order from a planner or a provider to their financial institution but it's the whole transaction.
Again, EFT is the funds transfer; it is not just the order or the advice. So if we consider a more robust definition that can be inclusive of all the parties that are involved, I think it will be helpful.
With that regard, ACH, as Judith called out, is one of the EFT options laid out in the 835 implementation guide and the 835 definition, along with other electronic payments that are called out in (interference) 114(?) in the letter. But if ACH is the standard and CCD+ or CTX are the format choices underneath that, I think that then has implications for recommendations 1.3 and 1.5, whereby I would ask that, as opposed to limit payment or format options, which were asked for in the testimony, that the committee consider actually recommending a pilot along with a refined definition of EFT that would allow for CTX or CCD+ when a provider chooses to use that, because that was a clear call-out in the testimony. I think, along with an enrollment utility, it would provide for the standardization that we are looking for and efficiency.
So there are three sub-recommendations.
DR. CARR: So guide me. I have to look to the co-chairs.
DR. SUAREZ: Can I ask one question? What is the recommended definition of EFT transaction? We have to provide a definition of what the EFT transaction is, to be incorporated into the regulation, just like there is definition for every other transaction under HIPAA.
By the way, this is going to be under a HIPAA transaction because it is incorporated into the HIPAA section of the public health law.
MS. ESTEP: I think we can discuss where is that requested, and again, it is one of my question marks, just having viewed the letter today. But the definition is one that I could assist with during the subcommittee tomorrow, because right now the definition only talks about one piece of the transaction, not the whole transaction, and that could cause, I think, problems into the future.
DR. WARREN: We made plans that they're going to attend our breakout tomorrow morning, and we'll work on the definition then and bring it back to the full committee.
DR. CARR: All right. Are there any other comments, suggestions?
I think with that we will break --
DR. WARREN: No, we've got a third section.
(Laughter)
DR. CARR: Keep going, then. We will continue.
DR. SUAREZ: We can do that in 3 minutes.
DR. CARR: Go ahead.
DR. SUAREZ: Line 187, page 4, is the section 3, which is the observations related to operating rules of EFT and ERA. I have to mention, as part as our process, we have to first identify who are the authoring organizations of any operating rules and then what are the actual operating rules that are being proposed in order for us to make recommendations to the secretary to adopt operating rules and name a specific entity to be the authoring entity.
At this point we did not clearly have recommendations for operating rules, and so instead of making any recommendations in the letter, we are making some observations, primarily that the observations are basically that we will be requesting potential operating rule authoring entities to present their applications to be authoring entities for operating rules for these two transactions. Then they will be reviewed by NCVHS and make recommendations about them.
That is what you heard earlier this morning from Lorraine, that we have already received three applications from entities that want to become authoring organizations for the operating rules for EFT and ERA. That step has already kind of moved forward and started happening. But that is why in this letter we are not making a recommendation to adopt a particular operating rule; we are making a recommendation to -- we are basically informing the secretary that we are pursuing the process as it was delineated in the regulation of identifying authoring entities and then requesting those authoring entities to develop the operating rules and provide those to us.
DR. WARREN: And to designate the EFT as a HIPAA transaction standard, because there were no transaction standards identified or recommended before.
DR. CARR: Questions, comments?
(No response)
Any closing comments, Walter?
DR. SUAREZ: No. I think that tomorrow, as we mentioned, we will be meeting as a subcommittee. We will be aligning some of these elements. We will hear some more about this potential -- we will bring back --
DR. CARR: We will have a very tight time line, because the subcommittee is 8 to 9, and the meeting starts -- is the subcommittee --
DR. SUAREZ: We will have a final letter for adoption by the committee at 11 I think is when we have.
DR. CARR: All right. I'm happy to help.
DR. SUAREZ: We're meeting tomorrow morning from 8:30 until --
DR. CARR: So we break for lunch, get back on time, 1 o'clock, and we have the quality letter and then a report out from yesterday's hearings. Thank you very much.
(Whereupon, at 12:00 noon, the meeting recessed for lunch.)
DR. CARR: Welcome to the afternoon session of the NCVHS. We will start off the agenda with a review of the quality letter.
Blackford, take it away.
Agenda Item: Quality Letter - Quality Measures Roadmap
DR. MIDDLETON: Actually, Paul was going to do the intros, but hopefully he is having a nice extended lunch. Allow me to remind you of what we were doing with the quality letter, which began in the fall of last year with our testimony from a variety of stakeholders in quality measurement and quality management across the country and across the continuum of care, if you will.
The key questions we were trying to address were these:
• What is the issue we are trying to address?
• Why did we choose this issue?
• What did we hear from various testifiers?
• What are we recommending, and why?
• What are the areas of controversy.
The key issue we are aiming to address is that, really, the essence of quality measurement is going through dramatic change, I think, as we think about the adoption of HIT and the acquisition of data from a much more wide variety of data sources and the like.
We wanted to look at the future of quality measurement and examine the activities necessary to support both medium-term and longer term stakeholders in their assessment of quality: consumers, specifically; providers, of course; professional organizations and accreditation organizations, and regulators; and payers and group purchasers.
So we had those four stakeholders in mind, and we wanted to, based upon their testimony, try to outline a quality measures development roadmap to take advantage of the changing IT infrastructure and world.
We will tag-team this a little bit.
DR. TANG: Why did we choose this issue? It is because it is so important to actually getting, of course, the care out in the first place. So it should be, above all, meaningful to the folks that are working with patients as partners for high-quality care in order to better help; and that there are more sources of data available electronically, not just on these pieces of paper, through PHRs, for example, so you can get information directly from patients themselves; and that, clearly, not only is reform more focused on quality but also payment is going to be more focused on the output of the quality measures themselves.
Right now, the committee did not feel that the current measures do much to take advantage of this new source of data and the richness of the data that is available. So that is the motivation.
So what did we hear? It started out, actually our first panel was consumer representatives. The overriding messages were, You know what? The current measures actually don't give me, the patient, what I need to make decisions either about my care or about the people I work with, my health care providers. So that seemed like a pretty decent challenge.
So we figured that we needed to shift the paradigm to something that is measured just because it's there, the old administrative and claims data. It is something that we would want to know about. That is a whole big shift. Health reform really gives us both the motivation as well as reinforcement of being able to use better quality measures. So that is the basis for our recommendations.
So what are we recommending? The first is what I alluded to, which is to say, Let's make these measures something that consumers and patients would be interested in, and providers would also be interested in what they do and how well they do at this.
The reason for recommending that is that the current measures lack the relevance to consumers. For example, we have these risk-adjusted quality measures, and they apply to the, quote, average patient. So we normalize it to try to make the average patient. Well, none of the patients actually feel that it applies to them, and that is legitimate. As an example, you would rather have something that was stratified so I can see where I fit in and whether that care would be appropriate to me.
Consumers also want to know about -- well, that's the third point. It also doesn't take advantage of the emerging models for care delivery, like the team-based care and the emerging sources of data, as we mentioned.
So the request is let's move towards quality measures that have much more relevance to the individuals they pertain to, consumers or patients, and that use the broader sources of information that can apply to that. Make it and display it, render that information gained through quality measures in ways that I can understand how I as a patient am affected.
DR. MIDDLETON: The second area -- maybe what I will do is just highlight all four areas and we can go into each one individually. The four areas are the consumer's perspective, the value perspective, accountability and care coordination, and then a systems perspective on efficient acquisition and use of health care data for quality.
Moving to the second area, focus on health care value, as Paul has alluded to, and as we know from the health care reform efforts, there is extraordinary pressure on demonstration of value in health care. Building upon prior experience in pay for performance and managed care and capitation, et cetera, we believe there has to be more attention to defining measures of health care value itself, starting with better assessment of cost, relationship of cost and charge, and understanding value in the broadest way, defined as quality over cost.
The recommendation is to fund research and development of improved assessments of the value of health care based on measures and information about cost and quality that are relevant to all health care stakeholders. We had everybody -- consumer, provider, accreditors, regulators, et cetera -- giving testimony during the hearings.
The reasons are it is clear, as Paul has alluded to already, from the consumer-centric point of view, consumers and purchasers want information and transparency about cost and quality to inform their health care decision making. What does it really cost me to have this knee procedure or this other whatever? Providers need information and measures to assess evidence-based decision making and continuously improve the quality of care and optimize health care costs.
As we think about care redesign, optimization of care and prevention of unwarranted costs, we basically need, of course, to know how to measure costs and value correctly.
Further, payers need methods to assess the value of health care services and health care system efficiency so they can optimize plans and payment mechanisms for care rendered and being delivered. Inconsistent definitions and methods are used to assess value currently. There is a lack of consensus on how to measure cost of care. Cost information needs to be transparent. It also needs to be shared within the context of quality across the continuum of care.
The next area, we heard a lot about emerging models, new models of care, new sources of data as well, but of course health care reform is pinning a lot of expectation and hope on improved understanding of accountability and new models of care that more tightly ally patients to providers and, hopefully, optimize care in the medical home-type models and accountable care organizations and the like.
We believe, though, there are not yet adequate measures or sufficient measures to make assessments of accountability in care coordination. So the recommendation is to fund research and development to provide information and measures which enhance the ability to assess accountability and care coordination in health care.
Reasons: New measures and information is needed to capture information valuable to consumers to hold the health care system accountable for things important to consumers. We need a core set of measures that can be used to compare performance between health care systems and ACOs. And if systems, providers, or ACOs are to be held responsible for the health and wellness of a cohort they become accountable for, a reliable and transparent method is needed to track patients across delivery settings and episodes of care.
DR. TANG: The final recommendation out of the four recommendations really builds upon our meaningful measures kind of hearing and sets of recommendations. That says that in order to produce better measures that are coordinated, that more efficiently take advantage of resources, of people developing measures -- that is, less rework and also less burden on the care provider -- we all ought to work together. There should be a coordinated effort to have everyone in the measures-development and use supply chain work together. I think they individually would like to do that as well.
But there is no convener of that. AHRQ convenes the clearinghouses, for example, and NQF convenes some of the measure developers, et cetera. But there is no convening function to make sure that we all align our efforts but also the underpinning infrastructure, leverage the same infrastructure, whether it is the data, the standards, the definitions. That would be enormously beneficial to everyone.
So our recommendation is that someone -- and possibly the government or public or private sector -- convene the quality measurement stakeholders to formulate the strategy and in this way coordinate our efforts.
So that is the final recommendation.
DR. MIDDLETON: Some of the most powerful testimony actually we heard was maybe the consumer side of things and then very powerful testimony from Artie Milstein on this idea of coordination of measure development and exploiting the data that is in the pipeline already in various places so it is gathered once, reused many times, a common NCVHS theme, and it would become more efficient at data acquisition and data reuse.
What are the areas of controversy? For those of you who were in the room and had the benefit of listening to the testimony, it felt at the end of the two days kind of like a fundamental paradigm shift, not that we haven't talked about patient-centered care or patient-centered measures before. But to really think about what that actually means from the patient's point of view, we felt like we were really trying to acknowledge and spur on a paradigm shift from the current system, in which regulators and payers drive measure development, to a much more patient-centric -- whatever the right words are for that patient point of view.
So that is fundamental, and that is going to be central, I think, going forward. I am not sure it is necessarily controversial per se, but it is a complete shift in orientation.
What is controversial, though, is providers use different measures for internal quality improvement than for public reporting. Can we deal with a common set of measures that actually make sense for both? Providers in their own operations, quality improvement, et cetera, within hospitals and clinics and systems may be doing one set of things that make sense to them, but it may be completely separate and oftentimes is completely separate from external reporting requirements. It would be nice if those could be harmonized and make it easier for the provider to gather the data which would be used for both internal and external quality assessment.
How can measures be created to address individual conditions and preferences without increasing collection burden? This goes back to partly a measure-development issue but also a system-optimization issue. Make sure that the data that is relevant to quality assessment, internal and external, is readily available and itself is harmonized, as well as creating more measures that reflect more of the different dimensions of morbidity and mortality, and again from the patient's point of view.
I hope I am capturing those issues correctly.
We recognize that measurement of cost is controversial no matter who is measuring it. It is always whose perspective on cost are you interested in trying to measure, and the value proposition suffers from the same stakeholder perspective. Stakeholder perspectives can actually dramatically shift the assessments in many interesting ways.
Are providers wholly accountable for patient care, or must measures actually be able to differentiate provider accountability, patient responsibility and accountability in a broader definition of accountability at large?
So we have drafted and redrafted a letter which is in your packet under tab 4. This has been generated by the subcommittee and reviewed by the executive committee. I will pause now for questions on any of the backdrop, or I will ask if people have questions about the letter that is in their packages.
DR. CARR: Yes, Leslie?
DR. FRANCIS: This is not a question that is about disagreement so far with the letter, but it is a question about how radical the letter really is. In part it is motivated by yesterday's discussion where the folks from Denver made quite clear that actually the stuff in clinical records wasn't top of their list. What was top of their list was how did I get here and why did I get here, rather than how am I being managed now.
The reason I ask that is it could be -- this is a letter about more fine-grained to patients in a sense that might be more meaningful to them. But consider some other measures. How well was the set of possible alternatives, including no treatment, explained to me? General questions about communication. That might be something that is extremely meaningful to patients, but that is not at all on the table as a quality measure in a more fine-grained look at what are essentially clinical records.
Another question like that might be, to what extent were there efforts made to elicit my own preferences and to ensure that whatever my values were, they got embodied in my care? This reads to me like better clinical care, which is great. I am not criticizing that. But I think it is less radical in terms of consumers facing quality measures than perhaps some consumers might have thought about.
DR. TANG: Can I respond? I am not sure where you're reading that it says that, because the questions that you pose are included in recommendation one, actually.
DR. FRANCIS: Well, it didn't feel like that to me.
DR. TANG: So maybe it depends on how radical the reader is, because that's what the intent was.
(Laughter)
DR. FRANCIS: The question is what types -- are we arguing for entirely different types of measures, or are we just arguing for measures that are more tailored to a subgroup of patients that this individual falls into clinically? That distinction I did not see in recommendation one.
DR. CARR: So I have Leslie and Bill and Judy and Don.
DR. MIDDLETON: Let me just follow on Paul's comments, too, for Leslie's great question. I think it is captured. It might be tuned to be more reflective of actually what we heard. What we heard in the room was that patients don't really want to know what the population outcome is for my knee replacement. What is my outcome? What will actually -- can you predict for me when I'll be back to work, or can you tell me how much this is going to cost, even?
DR. FRANCIS: Yes, but see, I was actually asking a different question, which is, did you try to find out from me how much pain matters in comparison to, let's say, mobility? Or did you try to find out from me how much I understood about when to take a medication? Did you try to find out from me whether there are other stresses in my life so that I need help with something else as a way to deal with the pain meds that I get?
DR. CARR: Let me jump in, because I think that there is a paradigm shift here, that we are focusing on the patient's perspective, and there is a huge array of things that could be covered in that. Some of them already are, the HCAHPS or whether you were asked about did you understand your medications, and so on.
I think, as we heard this morning, there is very dramatic disruption, like with PCAST -- throw out everything and start anew -- and this is more in the incremental -- a paradigm shift but work with what we have today. Am I saying that correctly?
DR. MIDDLETON: Yes.
DR. TANG: You are agreeing?
DR. MIDDLETON: Pardon me?
DR. TANG: I think our focus on paradigm shift, all the words we try to say, is it's not business as usual.
DR. CARR: Right.
DR. TANG: It's far more am I going to walk again, am I more likely to walk again, and how soon with this provider, with this procedure, than the other, than it is what -- I don't even know what in the orthopod world, what kinds of measure you have -- well, postop complications, things like that. You still are interested in that as well.
DR. FRANCIS: Oh, of course.
DR. TANG: But the paradigm shift is, it is going to focus on what could be useful to individual consumers and individual providers than the population.
DR. MIDDLETON: And, Leslie, maybe the last point on this one is the whole second bullet is all about value, and of course explicit actually in the discussion there is consumer preferences and their own value tradeoffs, as you are describing, which are very, very important and not done at all.
DR. CARR: So you're thematic and you're more granular I think is what we are seeing.
Bill?
DR. W. SCANLON: I have concerns on a number of levels. I think in terms of the paradigm shift, maybe I am taking some umbrage from your last slide in terms of payers and regulators. Having spent a lot of time with the Medicare Payment Advisory Commission, and we spent a lot of time on value-based purchasing and pay for performance, certainly it seemed that the focus was on the patient and what are the outcomes that the patient experiences, or what are the experiences of the patient; and that the handicap primarily was the limitations in terms of the kinds of data that were available. Some of the things that Leslie mentioned would be potentially ideal to include in a performance measure, but there is this question of where are the data.
I think that is one of the things that concerns me now in that in some respects what we are talking about in terms of this paradigm shift is a question of degree as opposed to a total paradigm shift, and it's a question of the patient being able to be part of the decision process with a whole lot more, close to perfect information, which is so difficult to obtain.
I am one who in many contexts argues against averages in favor of distributions, because I think averages are so misleading, so stratification as intuitive appeals to me. At the same time, when we've been dealing with pay for performance for physicians, we discover the small-numbers problem very, very quickly. So we create the situation where we worry about -- and I've heard in the last week that in some measures changing four patients changes your score dramatically as a physician.
So do we want to create an incentive for behavior that we would not value, which is to exclude certain patients because they are going to affect my ultimate score? So there is this question of are we going to get the sufficient data to be able to do what we're saying here?
Another context in which I worry about this letter is that the department, in terms of recommendations two and three, is very aware of recommendations two and three and in some respects are overwhelmed by them and, hopefully, scared by them, because we are embarking upon changes that are very, very real because of the Affordable Care Act. We are going to have accountable care organizations, we are going to bundle post-acute care in a pilot with hospitalizations. We are going analyze hospitals for rehospitalizations.
There is a question of can we do it well enough in terms of measuring quality, measuring appropriate risk, and my sense is we have to worry that we cannot, that we do not necessarily have the measures. If I am dealing with a vulnerable population, if I am a hospital and my patients when I discharge them don't have a usual source of care too often, what is my rehospitalization rate like? That is something to worry about. Do we have data on those kinds of things? The answer is very often not.
So it is this issue of thinking about the context in which we're operating. I think this is not news to the secretary, but it's how are we going to fix these things? The pipeline of data, to me, is the key part here. We have to increase what is flowing through the pipeline because we can then improve things that a payer and a regulator who is thinking about patients can do. Ultimately, maybe we will reach a point in time where we have enough data that individual patients can use it for their decision making, but I am not sure we will get there.
I also think about the patient making the decisions in the context of the health care team. We go around the room at the beginning of our meetings saying there are no conflicts of interest. Well, guess what? When that health care team sits down and interprets their data for you, there is an issue of conflict of interest. So it is not a model that I necessarily think, even when we get the data, is going to work on a wide scale.
DR. CARR: Are you making a recommendation?
DR. W. SCANLON: I don't know. I mean no. I have expressed these thoughts before in other contexts. It's the issue of where the committee is in terms of the letter, not where I am in terms of the letter.
DR. CARR: But are you saying that the letter should not go forward or that there are parts of the letter or it could be reconfigured?
DR. W. SCANLON: Again, I would acknowledge that it is much less of a paradigm shift and much more a question of trying to enhance what measures can be used for the benefit of consumers, not necessarily by consumers. I think that is one aspect of it. That is recommendation one.
Two and three, I think there would need to be more acknowledgment of what is currently under way in terms of the development of policies that are going to implement the Affordable Care Act.
The issue of cost, Blackford, you raised this question about whose costs. That is where I guess I feel like it's so complicated, it's kind of dangerous to get too close to it, because this is one where you could improve your situation with respect to cost if you went to an insurance company that bargained harder. That is something from the perspective of what is the cost coming out of my pocket or on my behalf, between what comes out of my pocket and through my premium. So there is that.
Then the fourth recommendation, I think the issue is the pipeline, because convening the stakeholders to work with the same limited resources that we've had in the past I think doesn't really enhance the evolution of better measures here. The stakeholders need better data.
There are MEDPAC recommendations saying we want lab values for physician visits. They've been standing there for years. We do assessments now of skilled nursing facility beneficiaries at points in time, but we don't do it when they're discharged, so we don't even know what the outcome is. We just get them at points of time, so there is a recommendation about that.
It is recommendations like that, about where you can intervene in terms of getting specific kinds of information, that will enhance the potential for measurement, that I think would be an important addition in the fourth area.
DR. CARR: I have Bill, Judy, Don, and Larry. Did you want to respond to Bill or shall we just run -- let's hear from the others. We could do that, too.
DR. WARREN: I guess my responses were just to clarify what I heard. So in number one you're saying let's look at what needs to be measured, not what is easily measured, and interact together and figure out how to measure those and how to make the data available that Bill is talking about, that currently is not, right?
DR. TANG: And with the most meaningful perspective being from the consumer/patient and the provider influencing the payer.
DR. WARREN: Then I wanted to clarify number three. Number three, to me, is where you're radical. This is where we are actually talking about coordination of care, not just the new buzzword coordination of care but all the handoffs from one provider to another and following that quality through. For me, that has been the huge gap that we've always had, is that nobody pays attention to what the patient is like on discharge, and then all of a sudden they show up again somewhere, maybe a doctor's office or an ER or someplace else, and we don't know what they were before. We start all over again with a blank page.
So we are now talking about doing some research to get some indicators for what those handoffs and the coordination of those handoffs would require. Is that what I'm hearing? Great. Then I have no problems with this. That's great. Then I won't be radical.
DR. TANG: It's only a roadmap.
DR. CARR: Don?
DR. STEINWACHS: I started off with a simple comment, and as I hear others, I have a lot of empathy with what Bill is saying. Let me start with my simple comment, and then in time I'll backtrack.
Recommendation four, is that something you would see this committee as taking some significant role in? You sort of had something at the bottom of that, but maybe it's sort of a blanket statement, “NCVHS stands ready to support the department in accomplishing this goal.”
DR. TANG: I guess it could be a recommendation to the secretary to play a convening role, to fund somebody to convene this, to somehow cause this convening to happen with the goal of this coordination and the efficient use of resources.
DR. STEINWACHS: You made the point, Paul, I thought, that there are subgroups here that get convened.
DR. TANG: Yes.
DR. STEINWACHS: There is not a mechanism about how you convene a larger group. The only reason I am raising it, I thought if there was interest here, you might want to think about communicating a desire to take some next steps, because it doesn't strike me that this is going to come across as a high-priority action for the secretary, but I may be totally wrong.
DR. TANG: We thought that was correct, convene quality measures stakeholders, so you could literally convene this meeting with a certain charge, to produce a strategy for the nation to come up with.
DR. STEINWACHS: Yes.
DR. TANG: One of the anecdotes is on the AHRQ-convened clearinghouses groups, the idea that they ought to all get together and meet like this, and the measurement developers meet came out of that meeting. So in a sense, I think there is a desire on the part of them to have this kind of coordination so they don't all reinvent the wheel.
That is also part of the genesis for something Blackford mentioned earlier, which was the NQF's quality data model. Gosh, if everybody could reach in and get the same data elements with the same definition, that would just move things -- you heard that from the public health folks -- that would just move things tremendously along. But that was sort of NQF coming up with its own, by hearing from the various stakeholders.
So this whole convening function is, I think, desired and asked for and I think would be a reasonable thing for the federal government to do. That was the point you had there, right?
DR. TANG: Yes.
DR. CARR: To clarify then, by saying, “The NCVHS stands ready to support the department in accomplishing this goal,” what did you mean by that in the letter?
DR. TANG: That might have been written in -- I wanted to sort of throw it at them. I thought that was at the end of every letter.
(Laughter)
So I think came with the temper. What I can I say?
DR. CARR: Don, I'm sorry. Did I interrupt you?
DR. STEINWACHS: I was just going to make one point, sort of building a little bit on Bill. It seems to me my interactions with consumer groups -- and most of those have been in the area of mental illness -- many times consumers say, “Well, why don't you learn from our experience?” So it comes at, really, patient-reported outcomes, which Bill was getting at, this question of how would we tap into those, much like when you get discharged from the nursing home, as well as, I think, the points that Judy and Bill were making about other kinds -- and Leslie.
It would be great, it seems to me, if at some point this group tried to look at how could we, peaceably, begin to capture some of that. There is research going on to actually getting portals built into electronic health records where physicians request outcomes measurements be reported by the patient, come back. I think it is a doable part of this, but I think there is a lot more faith among most consumers and patients about the things that they care about being the outcomes that others lack from experience.
PARTICIPANT: That is not the case.
DR. TANG: In some sense, this is already happening, and we are actually catching up in this sense. Tomorrow, a group from the HIT policy committee are going to decide what to recommend for stage 2 and stage 3, and they include these patient-captured data, from presumably PHRs, to go into experience of care -- I mean this is already happening. This letter is almost backing up that we should be working much more in this direction. We should be pointing our -- what is it called, our lens in the submarine?
DR. STEINWACHS: Periscope.
DR. TANG: Our periscope in that direction. That is where the puck is going, and we're just putting that down in words in this sentence.
I think it also addresses part of what Bill said, that we can't use the same substrate, the same data substrate. We're saying no, we need to create new ones, and they ought to be much more relevant to patients and providers.
DR. STEINWACHS: Does that come through clearly?
DR. TANG: Maybe not.
DR. CARR: Could you just clarify? The meaningful-use recommendation is going to be that EHR be populated with information from PHR?
DR. TANG: I don't want to say that.
(Laughter)
In public forums conducted by HIT policy committee, there has already been a groundswell of desire for measuring the outcomes as it pertains to the patient.
PARTICIPANT: The patient-reported outcomes.
DR. TANG: The patient-reported outcomes. There is already an assumption that there are other data sources than the, quote, EHR. So I just don't want to connect the dots and say that's going to happen, because these are things that are actively being discussed and actively being discussed in the context of this meaningful-use program, which has its finite time line. So I am just saying that's where the puck is going already.
DR. CARR: To Bill's point about if we don't have this but we're saying that we need to make those connections where we can to get that data, that there is a potential roadmap to get there.
Just one other point that Bill raised, and I had the same question. Is it worth referencing what we've already begun to learn through HCAHPs, that that was one step in saying how are we doing, what's your experience of care? Is there an answer? Is there any thought to referencing the work already done in HCAHPs as a first step, the patient's voice?
DR. MIDDLETON: We can reference it, but I am not sure it actually is all that relevant. HCAHP information is not available to the treating physician in the encounter. It means nothing to the treating physician.
DR. CARR: Oh, I see what you're saying.
DR. MIDDLETON: What we would like to have is patient-reported outcome measures actually in the record. The HCAHPs is all after the fact downstream. This is part of the orientation I think we're trying to flip.
DR. CARR: My only point being for the first time we said how are we doing, and we learned about 50 percent.
Next is Larry.
DR. GREEN: I've been listening and thinking about the evolution of this letter from the hearing to the draft to where it was to where it is. I have two points I want to make.
One is I actually think the letter has arrived at a good point. I think the points it makes are defensible, proper, relevant, and sufficiently radical, to go back to that point. I believe we err if we underestimate the importance of recasting our gaze toward quality measures that actually are meaningful to people who dare become patients and get into the health care system. That is a stunning recommendation, from my point of view, to say instead of trying to develop quality measures that everybody says I can meet them at the 98th or 99th percentile and get my bonus payment, to direct them toward what people seek and need and want. Maybe I am just losing my energy level or something, but that strikes me as being relatively radical and very much worth the letter.
The second point I wanted to make is I remain satisfied with the letter. In reviewing it before the meeting, I actually thought it came out at a pretty good spot. I thought it was understandable. I thought it was quite faithful to the hearing and what we heard, and I think it is reasonably well constructed. I really would like to see it go forward.
DR. CARR: Leslie?
DR. FRANCIS: Part of why I was asking about new sources of data and how radical this is, and your raising this point, I think there is a really important privacy question that needs to be on the table with respect to data that come directly from patients, rather than data that are recorded by a provider about a patient.
I will use an analogy. I never get to know which student filled out course evaluations, precisely because there is a concern that I might be vindictive in my grading. Imagine how a patient might feel about the accessibility by a provider if you're locked into that provider, which of course some patients are, to fill out honestly information about what the quality of the interaction was with the patient, or potentially information about levels of compliance.
Once you start shifting the ground in some ways you were suggesting the health IT policy committee might be, the questions about privacy and patient honesty are huge. I am not saying how they should be dealt with, but I just want them out there on the table, particularly to have the provider whose care is in question see it.
I might love to have my provider see everything, but I might not. And it might give me better care if my provider sees everything, but on the other hand, it might not. If providers know that certain patients don't like them, that may not be good for the patients.
DR. TANG: Where is it that we say that the providers know?
DR. FRANCIS: Well, you didn't, but that's why I wanted to -- you didn't say that they wouldn't, and for patient-entered information and who sees the patient-entered information, I just wanted the privacy question out on the table.
DR. MIDDLETON: I think clearly there are distinctions between satisfaction or the personal interaction kinds of assessments, which might be more appropriate for a hospital administrator, case manager, or not the provider him- or herself, who are challenged to try to equalize this asymmetric relationship in many ways. And yes, there are problems with being locked into certain care providers or certain systems or what not, but I think in the end, hopefully, we will get to the point where the feedback data is well taken.
Obviously, the clinical outcomes data, the patient-reported outcomes on how many steps am I walking after my postop knee, that is incredibly important and not threatening to the provider at all. They are extremely interested in that, and that is what they want more of.
DR. CARR: We've heard from some people. I wonder if we might just go around the room and get further thoughts about the letter, and then I think -- do we need to read the letter here? You've outlined what the concepts are.
DR. MIDDLETON: We weren't planning to read the letter.
DR. CARR: No. All right. Mike Fitzmaurice, did you want to make any comments about the letter?
DR. FITZMAURICE: No. I like the letter.
DR. CARR: Okay. Mark?
DR. HORNBROOK: One of the things that we're trying to do in Kaiser Permanente is establish evidence-based guidelines. So in oncology there are over 420 treatment protocols that are programmed into the oncology management module, medical management module, that have all gone through official review for evidence standards, and there is a whole list of footnotes and things.
The most important thing is the fact that it is changing physician behavior. The oncologists are working as a national team rather than local independent practices.
So it raises the whole issue of whether we can use this letter and the general structure of electronic medical records to raise the evidence standards for practice and raise the ability to ask whether practices are being held to evidence-based standards.
DR. CARR: So that's a good thing, right? You are saying that by --
DR. FITZMAURICE: It is a good thing. It turns out the physicians are leery of it, and many older physicians are saying that's not what they signed up for.
DR. CARR: But you are saying getting a new feed of information is valuable to expanding the perception?
DR. HORNBROOK: Yes.
DR. CARR: I understand.
DR. MIDDLETON: Mark, that is an interesting thought. Most guidelines, as you know well, of course, say nothing about patient preferences. There is no assessment of subjective patient preferences or whatever in the typical guideline for almost anything. So in a way, this will augment perhaps the evidence base in a subjective way beyond just the physical. To that point I agree wholeheartedly.
DR. HORNBROOK: The next thing is not just documenting the evidence base for what you can prescribe but then the evidence base for how you interact with patients who have preferences over the different domains, which is, of course, at a much higher level where we should be going.
DR. CARR: Bill, do you want to make an additional comment?
DR. W. SCANLON: No.
DR. CARR: Garland?
MR. LAND: I don't have any comments. I don't have any problem with the letter per se. I have a lot of questions if this concept is doable. But the concept of just doing research on it, I would support that.
DR. CARR: Sallie?
MS. MILAM: I like the letter.
DR. CARR: Larry? Don?
DR. STEINWACHS: I always support research funding on general principles.
DR. CARR: Marjorie?
MS. GREENBERG: I would just say that I've followed the process. I wasn't able to be at the hearing, so I am not as immediately informed by that. But I think the process has been due process. There was a hearing. We've had very knowledgeable consultants involved, went through a process of discussion last meeting, and I think you took on board a lot of that.
I particularly like recommendation one, and I think just having that coming from the National Committee has value. I am fine with the others as well. I think the time has come for this letter, yes. I thank you for the work you've done it and the others who have also worked on it, Matt and our contractors, et cetera.
DR. CARR: Leslie?
DR. FRANCIS: It's the phrase at the bottom of the paragraph following recommendation one. “Issue preference-sensitive measures,” which are different from measures of patient preferences, and “measures incorporating patient-generated data.” If you could drop a footnote there to the effect that part of what this ought to involve is some consideration of whether different privacy issues are raised by new forms of measures as part of what is on the table, then I would be delighted with the letter.
DR. MIDDLETON: Would you care to draft a sentence or two and send it?
DR. FRANCIS: Yes, sure.
DR. CARR: Marc?
DR. OVERHAGE: Nothing to add.
DR. CHANDERRAJ: I am quite a newbie to this, but the only thing I would comment on is the subjective interpretation of the patient satisfaction data. We are trying to quantify everything to the informatics, and I don't know how we can quantify patients' subjective feelings of benefit from visiting a provider.
Philosophically, I feel a patient's symptom to his illness is only 25 percent of his illness. Seventy-five percent of the symptom is a manifestation of the emotional reaction to his illness. I don't know how we can address that in trying to quantify that.
DR. CARR: So hence the research, I think.
Judy?
DR. WARREN: I think it's a great letter. Kudos.
DR. CARR: Walter?
DR. SUAREZ: I am for the letter. The only comment I would make is in observation number one. Two points. The first one is relative to the title, “Focus on consumer's perspective.” My sense is that we are really talking is a focus on the consumer's need, right? Because consumer's perspective gives the impression that we're going to be looking at measures that include the consumer perspective of health care quality and self-surveys and that kind of thing. So maybe the wording might be better to say something like “consumer's needs.”
The second one is something about the fact that somewhat, it gives me a little bit of an impression that we are not necessarily acknowledging all the work that has been done in this field. In many respects it is a lot of work that has been done, but it has not been yet very successful because, clearly, we haven't fulfilled the needs of consumers.
So my suggestion was, in the actual recommendation, to prioritize creation and funding for advancing the development of new measures, sort of more into the advancing the progress that had been done rather than giving the impression that we need to invest for the first time in this.
Those are the two comments.
DR. CARR: Any other comments, suggestions? Yes?
DR. EDWARDS: I usually don't say very much, and I'm a little bit out of my field by coming, and I don't speak for NIH, but clearly this whole domain is one we in the cancer field have brought into our population data systems in cancer surveillance, and we routinely try to incorporate these measures on outcomes. Also, I know there is a fair amount of interest in the patient and certainly survivorship.
So, in general, it seems to me this pulls together a lot of things that are, I think, pretty standard and the sorts of objectives with which I have been involved in that connection between surveillance at the population level and the clinical care arena.
DR. CARR: Great. Thank you.
With that, we have comments and this will come forward tomorrow.
Well, look at that. We're ahead. Now on to --
DR. MIDDLETON: Thanks for everybody's input.
DR. TANG: And is there an action on that?
DR. MIDDLETON: The action is tomorrow.
DR. CARR: The action is tomorrow, right?
MS. GREENBERG: Yes. I think there are just a few things you said you were going to modify or add, like that sentence and a few other things.
DR. CARR: Yes. We have a couple of modifications this afternoon, and then we will get the final copy in the morning and have the vote tomorrow.
MS. GREENBERG: I would expect it to be quite quick tomorrow. Are you both here tomorrow?
DR. CARR: And thank you again for all the work, because you really have been very responsive to the input.
Agenda Item: Community Health Data Initiative
DR. CARR: Larry, Sallie, Marc, and Leslie. Who is going to speak? Sallie.
MS. MILAM: On behalf of Larry and myself, we felt the workshop yesterday was just incredible, and I think probably everybody else did as well who attended.
For those of you who were not there, I will just draw your attention to the agenda. It is the last item in tab 1. You can see just at the highest level that we had three panels. We had a public health panel, we had a community health panel, and a health information exchange panel.
We heard about how each of these different organizations are using data to inform their community, how they've been developing indicators. We heard some common themes around needs for standardization, needs for infrastructure. At the end of the meeting, with folks from all of the panels, including membership from the committee and staff, we went around the room and identified common themes, emerging themes, and areas for opportunity. We had a lot of convergence.
Susan Kanaan took notes for us on those themes, and I think we will be getting into those themes in some depth in our subcommittee meetings after this. But I asked Susan if she could just touch on some of the highlights, because I thought that they did a pretty good job of condensing some of the important points from the day.
Susan?
MS. KANAAN: Somebody made the point yesterday when we were going around the room to mention the themes we heard that the tendency is to hear the themes that you sort of came in with, the interest that you already had. So I cheated a little bit, because I have 25 pages of notes.
I just went through them very quickly. I have been doing that while listening to you all. Some of these themes are things that I identified from the background conversations that I had with everybody. If you have any time to take a look at the background write-ups, they really are quite fascinating, I think, and worth spending a little bit of time with just to get a flavor of these programs, these wonderful communities.
I will just give you a few of the highlights that I have from my notes. As I say, some of these come from the background conversations and some from yesterday's meeting.
I was struck by the fact that, really, we need to start thinking of the community as a data user. When we talk in this environment and others about data users, the community is a data user. It is a very purpose-based and solution-oriented user. We saw lots of different kinds of evidence of that fact.
I would say the workshop had very much an assets focus. We certainly talked and identified a lot of needs, a lot of gaps, but both the tremendous energy in the room and just what people are doing, they are very focused on their assets as communities and what they can do. So, really, we did identify a lot of opportunities.
Some of the specific themes. Certainly it will not surprise you to know that there was a great deal of attention and a lot of programs and policy work around social determinants of health, and in particular the environment, so really kind of joining personal behavior, health, and environmental factors. It is not theoretical at the community level, and it is very easy, I think, for communities, once they have that perspective, once they have that insight, to make that real and to go out and find those factors and to try to figure out how to change them.
In that context, certainly health disparities is a very common focus and concern. The disparities vary from community to community, but they are all there.
There are extraordinary coalitions in these communities, and there are many, many types of coalitions. I think there is a lot to be learned from the work on the ground in building coalitions. Again, that is an embodiment of this very broad approach to health and the determinants of health. You have health agencies working with education and transportation and housing agencies. You have community-based organizations from these different sectors, et cetera, et cetera. I could go on.
They really affirmed over and over again the importance of data in building coalitions, influencing their local politicians and decision makers, building credibility. So they want data, they need data, they collect it from many different sources, including things that they design themselves, often in collaboration with their local academics and people who know how to do that right. But they see it as an important source of credibility and of local action.
Some of their fact finding and research is community based, it is participatory research. We heard some fascinating stories of community-based participatory research. But again, in many cases, especially Denver, it was really kind of the leading example of rigorous community-based research, very exciting models.
Community-based research is really a bridge to action. It engages the community right from the point of identifying what the issues are, gathering the information, et cetera. So that was a very interesting theme as we went along.
Certainly the importance of trust was a theme. Interestingly, some people made the point that involving people in the beginning in data collection helps to build trust among the people who are most suspicious about government use of data, et cetera. So there are confidentiality and privacy issues, but there are also some strategies that were demonstrated that really show how to build trust.
Some of the issues that were identified, the most common theme we heard probably, or one of them, was the challenges of the limits of small-area data and also data on small populations, racial and ethnic populations, and repeated cries and appeals for better small-area data and better strategies for getting the data.
We saw some remarkable tools, especially in Sonoma County. I think that's the star of data presentation to stakeholders. That includes many different sources, very many audiences for data, and that was something that a number of them stressed. But some of the communities have really developed some remarkable tools for presenting their data in ways that are very useful to the community.
Walter verbalized for us the issue of the digital divide -- sorry, I am just reading this list here, so it's not organized in the best possible way, probably -- concerns about a digital divide between the clinical information world and the public health information world. There was, I think, common agreement among the panelists that that is indeed a concern and a lot of questions about what to do about that digital divide.
There was talk, especially toward the end of the day, about the potential economies of scale in helping local health departments, because there is a lot of variation in the levels of sophistication of staff members and a need for better analytics. That was another recurring theme. They need help with data analysis, both their own data and whatever data they can get their hands on. This is certainly one of several opportunities for NCVHS to provide advice. I am not ready to give you the list of requests or opportunities for NCVHS, but there certainly were a number of them.
So needs for training and technical assistance and ways to do that with economies of scale. You cannot do it for all of the, what was it, 3,000 local health departments in the country, I think they said? Maybe it's more than that.
Finally, a great deal of excitement actually. Todd Park talked about the Community Health Data Initiative. People were really excited -- a woman who is a community organizer in South Los Angeles. Even though the data initiative cannot yet probably provide the kind of small-area data that people want, they could see the potential for this, both for training, for networking, for having everything in one place, and as Leslie mentioned earlier, they would like to have alerts for what is the newest thing, because just getting the information and staying on top of things is really a challenge.
But it was nice to see that connection, because one of the things that struck me in my interviews was how few people seemed to even know about the Community Health Data Initiative. So it was an opportunity for some learning, both from them and to pass on some information to them about new resources.
MS. MILAM: Thank you, Susan. That was terrific.
It was truly incredible to hear from the different communities about how they used data, how they worked together, and then how they were able to effectually change within their own community.
Larry, do you want to add anything?
DR. GREEN: I would like to hear from Marc and Leslie.
DR. FRANCIS: Privacy was a little bit along for the ride in the first one, in the sense that we were partners in planning, but this first one was a lot about what are the ways that communities are getting, using, becoming involved in, and generating change through data, with an eye to looking at how can that be enabled through the kinds of privacy protections that promote trust. We were not focusing on the privacy side.
So what I am going to do is just give you three themes that I picked up as ones that I think will be privacy agendas over the next little while.
The first is the general one of how do we think about what are the best practices for protecting privacy in some of the kinds of community uses of data, both data involving clinical information but also data involving non-clinical information and new forms of information. The role for NCVHS there would be best practices.
The second theme in question is, many communities want very directly local small-area information, qualitative studies, the ability to tell a story that a qualitative study enables, and are there different kinds of privacy issues that emerge when we're using information like that?
One of the examples was publishing the names of landlords where children have been diagnosed with high lead levels in their buildings. They solved the patient privacy problem by publishing the landlords' names. Well, maybe, I found myself thinking. Those are fascinating and serious, tremendously information, but how do we think about privacy and confidentiality there?
The third one -- maybe this is just reflecting my lawyer wonk -- but some of the kinds of information that matter come from non-clinical records, and schools are a big source. One of the groups has begun to pilot a way to deal with the HIPAA/FERPA divide problem and considering whether -- I will generalize this -- considering whether a sectoral approach to privacy of the kind we have in the U.S. today with one law about school records and another law about clinical records, just to give you one example, whether there are some ways to try to get beyond that.
PARTICIPANT: We wrote a letter about that, right, already?
DR. FRANCIS: We did, but the whole point is there may be new stuff out there to work on it.
MS. GREENBERG(?): Yes, we have written a letter on it. But we haven't solved it.
DR. OVERHAGE: This didn't come up in the testimony so much as in thinking about it later. I was struck by the -- and this is like so many of the things we deal with -- the inherent tension between -- you heard some comments here about, and some of themes that were summarized, about wanting smaller, more localized data. We saw some examples presented yesterday down to the census block level. Your comment about the landlord is another example, I think, of this. We've got this ongoing tension of wanting to be able to do things at an actionable scale, but when you do that, you start to bump into identifiability very rapidly because of the small numbers. Even if you just say there is one person with this diagnosis in the census block, and it's a male between 40 and 60, we know who it is. That tension, I think, in being able to create actionable information, whether it's tying it to the patient, to the geography, or whatever, and still manage through the privacy issues I don't think came up in the testimony so much as I was thinking later about how do you reconcile that.
It reminded me a little bit about Brad Maelin's(?) more recent work looking at identifiability thresholds and metrics that you start to apply and say, okay, here's a level that's --
DR. CARR: Could I ask, what did they say about, in the Bronx REO, about the information that they send to DPH? We heard different perspectives on how much or how little information they send.
DR. OVERHAGE: They said everything was available to the public health, they just didn't use it much.
DR. FRANCIS: Yes, and then -- that was just the starter on the privacy question.
One of the possible ways to think about the kind of tension that Marc was just underlining is if you have the community involved from the beginning in the design of the questions and the thinking about what you're going to do with the material, you may get very different answers to what it's okay -- you may. It's not to say that you would, but it's a different -- the issue is going to be to try to think about what the various appropriate models are in that context.
DR. CARR: Marjorie, and then Matt had something he wanted to share as well. Go ahead.
MS. GREENBERG: A lot has been said, and it was really an excellent day, and I thought it was excellent that the committee really have the community voices as part of our agenda, because we hadn't really had anything quite like it before.
I think Garland asked a question about types of data that were most useful, or what do you find most use for, or what data are you actually able to use for action, et cetera? You could repeat it better than I can here paraphrasing it. But I think that that is an area that needs more -- and they answered, and they sort of said all of the above, which was the national data, whatever, more like the survey data, the DRFSS, et cetera, and then actually locally created data. They didn't say they just wanted local data. They clearly didn't feel they could just use national data. They really found uses and value to all of them, and then they added the qualitative data, as Leslie mentioned.
But I think what needs more investigation is understanding the extent to which -- where local data really are needed. There was a lot of talk, as you heard, about environmental assessments. Clearly, that has got to be done at the local level. You've got national data or international data about the negative effects of lead in lead poisoning, whatever. But as to whether there is lead in buildings, you need to do an environmental assessment locally, not in some other community.
Because we, particularly in this environment -- well, in any environment, frankly, even when we're in less of a deficit-ridden environment -- there is limited money for doing local or even state-level data. It is certainly a problem in my agency. The National Center for Health Statistics would like to have more at least state-level data. So we need to understand better just where having data about a community specifically is going to add that value. I think we have a basis for looking at that more. We covered a lot of things yesterday, and I think the challenge will be to see where do we want to dig down.
I was thinking last night -- we were all thinking about this last night, I guess -- but whether we might be leaning towards some type of primer like the primer we did on stewardship, of course involving these communities and others, because I think my main concern was that not everybody be reinventing the wheel. There are a lot of good models out there. So I think there is a lot to harvest here.
DR. CARR: Matt?
MR. QUINN: I was going to say, exactly in that vein of not reinventing the wheel, I just wanted to make sure that one of the projects that I was working on at AHRQ and the final report for it is actually, once I finish editing it, it will be ready. But it's called “Community Collaboration: Lessons Learned for Health Information Exchange.”
The point of this project -- and I wish I could have been here yesterday; I just wasn't able to make it -- was that community collaborations occur every day in many different domains, whether they be community planning, whether they be education or land use or transportation issues -- and there is rich literature around both, what has been successful and what hasn't been successful, as well as different models. And so for this project we did that literature review, then we brought in folks from successful and less-than-successful health information exchange efforts, as well as folks from different domains of community collaboration and some of the people, the academics in those areas.
What we did was we looked at some of the success factors for health information exchange and said, What can we learn from these others, in both the planning, formation, and sustainability of these? It's a little bit different here, but there are some really concrete things. It also speaks to the roles of different levels of government in this. What we found was that there is a real paucity of involvement at the mayoral kind of level or the county level on this, and there is a real opportunity.
We asked Cory Booker, who is the mayor of Newark, to come, but he didn't make it.
PARTICIPANT: He was busy.
MR. QUINN: He was busy with the new $100 million.
I think it's a report that would provide some additional context on this, and I am more than happy to make it available in its present form for this. I really wish I could have made it yesterday.
MS. GREENBERG: That was actually one of the questions I asked on this whole area of collaboration which was so critical: Are there templates or are there best practices, or is everyone just kind of -- because even though each community had its own unique characteristics, there was so much commonality across them.
MR. QUINN: There is so much to learn from other domains of this. One of the things that we really struggled with in this report is that health information exchange, both as a noun and as a verb, can mean very many different things to many people.
In one way it is sort of an infrastructure to serve the whole community. In another essence, it is for specific purchasers and customers that are somewhat of a subset of that broad set. There was a tension around that in terms of what the goals -- and this was specifically in the context of the money that ONC has set forth for this.
So I am more than happy to make it available and I will send it.
DR. STEINWACHS: It was striking to me, because at the Population Subcommittee we still frequently talk about diseases and disorders instead of health and the population. But these were really health oriented, so it made you really feel good at the community level. It wasn't about disease by disease unless that was a dominant issue. It was about health.
The second thing that came through -- they are in a declining resource environment, as the states are -- and Todd Parks, as he talked about what HHS is doing government-wide, it made you really think that the federal government could play a huge role in making data available that could be used by these communities. There is a slimmed-down Medicare record that Jim Scanlon was talking about that has become available. They have Medicaid data. They could get that down. Things like food stamps and other things could be collected by the federal government from the states and then made available again, because otherwise, if 3,003 counties have to redevelop all of the basic infrastructure, recognizing they still want to do their own service, they still need to do community organizing, I think we get a long ways, and I would think the states would find it a relief not to feel that they're being burdened each individually trying to get data to each area for some of these things that are really national resources.
DR. CARR: Larry?
DR. GREEN: This is a great summary from my perspective. There are two things I want to cull out at this point, having listened to those and also earlier discussions today and having had a chance to sleep a bit after the workshop.
One of them is, it appears to me that someone forgot to send a memo to America's communities that we are in a resource-constrained freeze. There is a ton of stuff going on at the community level that is desperate to improve the health of their communities. Communities everywhere see health as a fundamental capacity. You heard it again yesterday. It's the foundation for achievement.
The American people and the towns they live in really care about health. We had exemplars, heard scouting reports from Washington State to -- well, all across the country, the Bronx to South Carolina, to Los Angeles, to Minnesota, Missouri, and Colorado. I mean it was a very nice dispersion of size, range, red and blue, the whole thing. It was very nicely done.
We should relieve ourselves and disabuse ourselves of the notion that at the community level people just don't know what to do, or they don't know how, or they don't care.
My abiding take-home bottom line for that workshop is that it exposed the missing translational infrastructure necessary to connect communities and knowledge that they need in a way that is usable for them. The services needed from that infrastructure were announced in capital letters throughout the workshop. Several people said analytics, analytics, analytics -- knowing what is in the national centers' national data sets and the items that are there and the ones can be used so effectively at a local level, how to do a qualitative analysis properly, to do a mixed-methods thing to get a valid and useful result; the education of the public about the uses of their health information and how it can benefit their whole community if they share it, as opposed to if they don't share it. So there is just a long list of those things that came out.
But a unifying idea that I want to just stake out some territory on here is the nation needs a different type of data-use infrastructure than the one we've got. Just like we doctors need to get over the way we used to practice medicine that doesn't work very well and replace it with another one, I think health statistics needs to recognize that there is a new world coming. It was just trying to burst out in this room yesterday to heal that schism between public health and personal health systems, social determinants of health and other determinants of health. It was so clear that that is the wrong dichotomy, those are the wrong ways to think about it. It is the integration of that and pulling it together.
The more I thought about it -- it sounds like Marjorie and I were both thinking last night about this again -- that may be territory for us to focus on and walk into and to see if we can begin to sort out the nature of the sort of infrastructure that would take advantage of what we already have.
Almost all of them left data on the table. Many of them did not know that they had left data on the table, and if they were only helped a little bit, they might not have, and we might get value for the investments we make in this.
As the morning went along, and I listened to Jim Scanlon's report and everything, I wish to express opposition to the notion that this committee should hesitate in any way to not (sic) continue to work the territory that we are assigned to work to figure out what we need to do to have a proper data structure and information system in the country to improve health and health care. Even if we are in a 3- or 4-year period of uncertain budgets and flat budgets and everything, I am just going to keep saying, Well, the problem is the people in Missouri are still making progress; the people in Minnesota are still under way. South Los Angeles is making a difference. Sonoma County, look what they're doing.
PARTICIPANT: And South Carolina.
DR. GREEN: That still remains one of my favorite quotes: “South Carolina has concerns about government intrusion.”
DR. CARR: I was also thinking, but I was rereading this 60th anniversary, and the closing comments here are the recommendations from former chairs as to “…set a number of challenges before NCVHS that it is sure to keep in mind as it plans future work.” So here they are:
• Think big;
• Think ahead;
• Set your sights 3 to 5 years out;
• Add research, education, and communication to the NHII vision and work on a research agenda;
• Create communication standards to complement information standards to greatly improve impact;
• Help establish accountability for health outcomes;
• Make the vision understandable to those working in the trenches;
• Take full advantage of the 21st century tools and capabilities.
It sounds a lot like what we've just been talking about, I think on target.
I want to just get very concrete as is my penchant for a few minutes now about what we do for the rest of today and tomorrow. One thing is we have a plan to get together with Todd Park on what we've learned from yesterday's hearing and to participate in the June 9 event at the IOM.
Every time I hear it, I am excited about it, but I cannot always remember what it is that we're doing. But I am hoping that one of you took more detailed notes. I think when he first spoke you were talking about how these data are coming together and juxtaposing them and learning things, and I think we saw great examples of that yesterday again, going back to Sonoma County. But we did talk about what are the kinds of privacy things that we should think about, and as Leslie said, we didn't get very deep on that.
So I think one of the things we need to do when you're meeting this afternoon is to think about how are we going to participate in that, and are we going to have a work product out of yesterday's hearing that will transmit to that group to enhance? But I think we are going to need a little dialogue with them to make sure we are doing what they want.
PARTICIPANT: Can you just describe the June 9 meeting?
DR. CARR: Last year, remember, our last year's homework was to watch the video. So that event, which was showing the liberating of government data and the partnership with Google and all the mashups, they're going to come back again this year in June and do an update of what they've learned, and so on. The committee I think is invited to participate.
He was very enthusiastic about the value we could add, but I just want to make sure that we are clear on what the expectation is and that we are aligned with what the expectations are. So that is one thing.
The second thing is we've talked about -- I think it goes back to, and I am reading our minutes from the last time, that we do want to be thinking 18 months to 3 years out anyway about what the work ahead is, the direction that we're going to go in, and we said that we would do that, and I think that we need to go back and do that.
We also talked at the last meeting -- Chuck Friedman was enthusiastic about our interface with the learning health system, the IOM report. Again, it is something that we felt enthusiastic about, but as I try to do the crosswalk, I think I am not exactly sure of what specifically coming out of that report becomes our charge. We talked somewhat about it. So if you could just read over that summary again tonight and let's think tomorrow about how does that integrate and is there a next step there.
Just a couple of other things. We have letters, so a couple of edits on the quality letter, a couple of headings on the standards letter, and we will vote on those tomorrow. And PCAST, if you could have the time today or tonight to put a couple of thoughts down so Matt can take a first pass at that.
The only other thing, we had some good discussion, and sometimes I worry that we lose the thread, but Blackford has said, at the last meeting, how do we assess how we're doing in our eyes but in the outside world? I still think that is an important question. We are not going to answer it right now but it's something to think about: Are we adding value? Are we participating in a space that is not redundant and that seems to add some value going forward?
MS. GREENBERG: Could I just -- two quick things. One is related to what you were just saying. We've streamlined the work plan for the committee and also incorporated into it information we've gotten from the Standards Subcommittee, which has a more detailed work plan at this point because they've got all these mandated requirements. So that is in tab 8.
We have always carried a lot of historical stuff in it, which is helpful to us for certain reasons, but we didn't feel we needed that in the version that you all use. So it would be helpful to us if each of the subcommittees, when you meet, just look and see, A, whether this is capturing the main projects that you're working on and planning to work on, building towards this roadmap that you're talking about. Then if there are particular columns or information you think we should be capturing which maybe relate somewhat to Blackford's issue about how are we tracking how we're doing or what we're doing -- do you want to say anything more about that, Debbie?
MS. JACKSON: That's the main thing.
MS. GREENBERG: Okay, we would appreciate it so that we can work with you on that.
The other thing, and it relates to what we were talking about with the Community Health Data Initiative and Larry suggesting that maybe we need a 21st century vision for health statistics -- I think we have that -- but anyway, I believe that the Board of Scientific Counselors, the National Center's Board of Scientific Counselors, has been reconstituted. A number of members went off and they've now got new members named, and they did have a one-day meeting the end of last month. I believe we need a new liaison to that board. Certainly as we work in this area of health statistics, along with everything else, I think having a liaison and then having them have a liaison to us -- Mike O'Grady, who is -- well, Jim Lukowsky(?) or whatever, he has gone off the committee. He was the principal liaison from the BSC to this group. Then Mike O'Grady, who was local and so participated and was the alternate, I believe his term is also ending. So that is just something -- I guess, I think, would you delegate that to the Populations Subcommittee to make a recommendation? The person wouldn't have to be from Populations, but that is where the most overlap is.
Anyway, I don't want us to let that drop, because I think Bill was the liaison, and he has ended that term.
DR. CARR: Yes, because that went with Populations.
MS. GREENBERG: It went with Populations, and he is local, so it made it a little bit easier for him, and we want to thank you and appreciate your contribution there. Also, he worked with them on, I think it was an actual long-term care project in another capacity. So it was an appropriate assignment, but he has discharged it, and so now we do need a new liaison, and they will have to deal with giving us a liaison, but it works both ways where we're going to have that transition.
DR. CARR: Anything else? Okay, we will adjourn this session, and now let the subcommittees begin.
(Whereupon, at 2:30 p.m., the full committee adjourned, to reconvene in subcommittees following a brief recess.)