Public Health Service
- Meeting Minutes -
The National Committee on Vital and Health Statistics was convened on Thursday and Friday, November 14 and 15, in the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Present:
Committee members
Don E. Detmer, M.D., Chair
Simon P. Cohn, M.D., M.P.H., F.A.C.P.
Kathryn L. Coltin
Robert M. Gellman, J.D.
Lisa Iezzoni, M.D., M.S.
Thomas A. LaVeist, Ph.D.
Sheilah T. Leatherman
John R. Lumpkin, M.D., M.P.H.
Clement Joseph McDonald, M.D.
Vincent Mor, Ph.D.
Barbara Starfield, M.D.
George H. Van Amburg
M. Elizabeth Ward
Staff and liaisons
Marjorie Greenberg, National Center for Health Statistics (NCHS),
Acting Executive Secretary
James Scanlon, HHS Executive Staff Director
Lynnette Araki, NCHS
Harvey Schwartz, Ph.D., Agency for Health Care Policy and Research (AHCPR) liaison
Bob Moore, Health Care Financing Administration (HCFA) liaison
Others
Jackie Adler, NCHS
Jack Ebeler, Acting Assistant Secretary for Planning and Evaluation (ASPE)
George Arges
Bill Braithwaite, ASPE
Gene Carruth, WEDI
Benjamin Curtis
Mark Epstein, NAHDO
John Fanning, HHS
Ed Hammond, CPRI
Laura Landrum, IL Dept. of Public Health
Korbin Liu, Urban Institute
Margaret O'Kane, NCQA
Mark Segal,
Margaret Van Amringe
Peter Waegemann, ANSI HISB
Henry Heffernan, EDPNS
Douglas Mann, Battelle
Lyndalee Korn, TRW
Barbara Hetzler, NCHS
Daniel Stanlec, NCPDP
James Schupina, WEDI
Robert Mayes, HCFA
Stan Edinger, AHCPR
Don Asmonga, AHIMA
Chris Bergsten, AAHP
Pat Namby, HBO&Co.
William Pessin, Battelle
Bent Latamonc, Atlantic Information Services
Thomas Spangler, American Dental Assn.
Barry Hurewitz, Hale and Dorr
Meryl Bloomrosen, Aspen Systems Corp.
Roy Bussewitz, NACDS
Lew Lorton, HOST
Balaji Gandhi, National Assn. for Homecare
Susan Krumhaus, Dept. of Veterans Affairs
Gregg Seppala, Office of the CIO
Jack Emery, AMA
Deborah Rudolph, IEEE
Ellen McCleskey, BNA's Healthcare Policy Report
David Brown, CMHS
Diedra Abbott, College of American Pathologists
Gooloo Wunderlich, IOM
Rosanna Coffey, AHCPR
Margaret Amatayakul, CPRI
Robert Owens, X12 and HISB
Brian Riewerts, HCFA
Jean Narcisi, American Dental Assn.
Cliff Binder
David Manning, ASTHO
Carolyn Rimes, HCFA
Susan Probyn, AAHP
Alan Richards, Medicare Administration Ctte.
Brian Thiel, Paul Magliocchetti Assoc.
Melvin Friedman, AAOS
Catherine Sullivan, NAHC
Gary Rutenberg, TX Dept. of Health
Joel Rosenblatt, MBS
Robert Kolodner, Dept. of Veterans Affairs
Cathy Brady, American Psychiatric Assn.
Donna Pickett, NCHS
Roger Buchanan, HCFA
Roy Bussewite
Cynthia Haney, AMA
Steven Melov, HHS
The Committee met in plenary session all day Thursday and part of Friday, and broke into three Subcommittees for part of the day Friday. Thursday was primarily devoted to an HHS briefing and discussions of the administrative simplification legislation with two panels and the Chair of ANSI HISB, in response to the Kassebaum/Kennedy mandate to hear standards groups and others with a stake in standards. All the presenters had been asked to address how their organizations would respond to the new legislation (the Health Insurance Portability and
Accountability Act of 1996 or HIPAA), their concerns and issues, and their advice to the Committee. Friday morning was devoted to deciding on the new NCVHS internal structure and allocating members to the three new Subcommittees (see list below).
The group heard reports from Mr. Ebeler, Mr. Scanlon, Mr. Fanning, Mr. Moore, and Mr. Braithwaite. In addition to reporting on the Department's activities in regard to Kassebaum/Kennedy, they offered thoughts on the National Committee's role in this area. The Committee has been given special advisory responsibility to the Department under the legislation. These and other speakers expressed hope that the Committee would develop a vision of standards evolution over time and a process for updating the standards. The HHS representatives also stressed the Committee's role as a bridge to the standards community. A detailed strategy and timeline for the HHS work on administrative standards is expected by the third week of November.
Peter Waegemann, Chair of ANSI HISB, was the first of several speakers representing standards development organizations (SDOs). Many of the themes of the day's discussion were introduced in the course of his talk and the Committee's response to it. He concluded by stressing that the challenge is to find a balance between existing standards and a vision of future needs, given that technology is always moving.
Mr. Waegemann and many panelists stressed the importance of the Committee's guidance to the Secretary through the standards process and offered their organizations' support and assistance. Many noted specific ways in which their organizations could serve as resources to the Committee. The inventory of standards under preparation by ANSI HISB is an especially important resource.
Dr. Detmer asked for an estimate of the total number of standards to be contended with, prompting a lively discussion that echoed through the two-day meeting. The prevailing view was that only 20 to 30 are of concern to the Committee. Mr. Waegemann said that about 30 percent of the existing standards are controversial. Mr. Carruth, representing WEDI, said standards are needed for each of the transactions listed in the legislation, plus the four identifiers. He suggested that it may be easier to have more than one standard for claims. The Committee also should be aware of activities related to technical matters and able to take positions on them.
Much of the discussion concerned the gap between the current capacities in the field and the desired endpoint in terms of automation and uniformity, with varied views about the best way to move the process forward. Generally, an incremental approach was favored, with varying preferences for the use of "muscle," incentives, requirements, and a totally voluntary approach.
Because opinions varied, it was suggested that information be gathered on the extent to which clinical offices' health information systems are automated, who is using them, and how, to have a better sense of the practical realities. Methodologies for assessing the cost effectiveness of implementing a new system were also recommended. Ms. Leatherman noted the disparity of opinion among the experts and the Committee's need for a common set of assumptions as it pursues its mandate. The two key questions in this regard concern 1) the current infrastructure in the country, including how many physicians' offices are computerized and to what extent, including the capacities of the office workers; and 2) feasibility parameters related to people's attitudes, understanding and acceptance regarding the need to computerize and have standards. Dr. Lumpkin suggested developing ways of testing the impact of the Committee's recommendations through "real-life scenarios" that test whether proposed recommendations would make things better or worse for people.
Many panelists noted the potential effect of changes on stakeholders and the need to weigh the relative costs and benefits of collecting additional elements and doing without them. Another emphasis of presenters was that the Committee must avoid making recommendations that would impede progress.
Dr. Mark Epstein, from NAHDO, suggested that the Committee consult with people at the operational level about their sense of the feasibility of implementing various options. These people are often overlooked when policy is made. He also encouraged close attention to state- level activities, where much can be learned about approaches to data privacy and standards. NAHDO suggests an incremental approach to standardization. He urged the Committee to work with NAHDO and thereby gain access to the perspectives of its constituents.
Dr. Korbin Liu, from the Urban Institute, offered these recommendations to NCVHS: 1) to assure that data linkages are made, and 2) to support new data systems in anticipation of the effects of new policies.
Margaret O'Kane said that NCQA recommends that the Committee address several issues: 1) the lack of consensus on structure, content and coding of the medical record; 2) significant cultural and operational changes needed to retool to computerized records; 3) insufficient guarantees of security and confidentiality of records; and 4) insufficient financial incentives to motivate providers to invest.
Laura Landrum of the Illinois Department of Public Health called attention to the need to protect the confidentiality of individual level data, and she urged the Committee not to allow the cost of security measures to be a barrier to these protections. She provided examples of how standardized individual-level data could be used effectively to improve public health practice - in population-based surveillance and in health care regulation. She also urged NCVHS to use its reporting mandates to discuss broader issues of the quality of information.
Margaret Van Amringe reported that JCAHO values the groundwork laid by NCVHS for a core data set, and hopes for continuing refinement and updating and an effort to encourage its use. The Commission urges that the Committee's recommendations on confidentiality protect not just the need of accreditors to look at medical records, but also the function of auditor, which has generally been omitted in privacy legislation. It also hopes the Committee will help reduce the time horizon for a computerized patient medical record; and finally, it stresses the importance of adopting unique identifiers for patients, providers, and payers.
In response to a question, these panelists expressed universal support for unique identifiers, with caveats about cost. Mr. Van Amburg pointed out that the patient identifier will not solve all problems because of variable data quality.
Ms. Leatherman observed that a common underlying theme in this discussion is the perception of data as a public good. She expressed concern that the policy issue of proprietary data and the trend toward privatization is not being adequately addressed in this forum or elsewhere. She wondered about the possibility of advancing a policy agenda considering options of legislation, regulation or voluntary incentives to move proprietary data into the public.
Dr. Mark Segal of NUCC noted the "substantial agreement" between the NCVHS core data elements and the NUCC's emerging data set. He expressed confidence that the NUCC process will permit future consideration and possible inclusion of the data elements the Committee has identified as not yet ready for implementation. He stressed his organization's desire to continue the dialogue.
Gene Carruth noted that WEDI members can assist in establishing implementation specifications, based on their extensive experience. The important thing, he said, is to keep the standards and implementation simple and clean. WEDI is undertaking several studies for an economic model on the differences of implementing existing electronic claims handling. Another WEDI concern relates to building a communication infrastructure, given the varied levels of automation among practitioners.
George Arges noted the variation among state administrative agencies' data requirements and capacities, which will affect their ability to adopt and follow coding changes. These plus variations on the clinical side raise issues about the cost of system changes. In addition, it will be important to communicate instructions clearly to consumers, vendors, providers, and payers. The time frame for compliance is key, as well. The NUBC recommends an incremental approach to these changes, following a strategic plan that defines the desired end and prioritizes the steps to get there.
Benjamin Curtis shared these concerns on behalf of AFEHCT: that the Department should consult broadly, and not just with the four organizations named in the legislation; that the legislation allows providers too much flexibility; that industry-wide security standards are needed; and that the NCVHS membership should include a representative of the clearinghouse/value added network community. He also expressed hope that standards would be sensitive to small businesses.
Ed Hammond of CPRI stressed that the lack of a common vocabulary is the barrier that takes more time than anything else, and the fundamental problem along with the lack of a common platform. He had this advice for NCVHS:
· to inform itself about all the topics in the standards area, to ensure "a higher playing field" in addressing the issues;
· to be visionary and view current challenges in terms of where the industry is going;
· to carefully judge the art of the possible, while keeping the connection to the community served by the Committee;
· to promote focused precision and completeness, including precision of definitions;
· to encompass and engage the entire community;
· to be bold, opting for "best" rather than "most popular";
· to follow up, stay engaged, and worry about the changing environment and how the standards are being implemented; and
· to drive the process and bring the Committee's constituencies' input "to the people who have the power to make this happen."
Dr. McDonald urged NUBC and NUCC to try and merge more of their activities and to strive for a new logic to underlie them.
Dr. Detmer invited comments on tax incentives and other ways of encouraging automation and standardization, and on the importance of education and how to accomplish it. Both of these areas, incentives and education, were flagged as ones that the Committee should explore. It was noted that a former HHS work group on computerization of patient information said in a 1993 report that most benefits of health care information EDI accrue to payers, and it recommended finding ways for providers to share the benefits.
Members agreed that opportunities are needed for further education of Committee members. Some ideas put forward were a glossary, summaries and standards on the Web for individual study, and an orientation session at a meeting. It was noted that the matrix developed for the core data elements project has useful comparisons among several claims formats and data sets.
Mr. Moore reported that HCFA is proposing to the Secretary that they put together teams to analyze each of the nine or ten transaction sets. They would report to NCVHS, the Data Council and others about what the transactions are, what data are there, and whether they meet the needs of the community. In effect, he said, these teams would be doing the staff work for NCVHS in this area.
Regarding the Committee's charge in this area, the general sense of the group was that the Committee is expected to look at the content and detail of standards and to recommend internal changes, or even something altogether different, if needed. Dr. Detmer said the Committee's mandate is very broad, although it will have to carefully explain its reasoning if it departs from that of the governmental team. (In the discussion with Ms. Stoiber about the Committee's impact, the reciprocal statement was made that the Department would have to defend its reasoning if it departs from NCVHS recommendations.)
Dr. Lumpkin observed that the work groups will inevitably become specialized and invested in their respective areas, and all members will need a commitment to cross-education so that recommendations truly come from and represent the entire Committee.
It was suggested that the entire Committee work on the patient ID, rather than delegating it to a work group or Subcommittee. Dr. Detmer asked all sub-groups of the Committee to identify such cross-cutting issues that need to be addressed by the entire group.
The consensus was that the Committee should begin working on the individual identifier before long, because of its complexity, but should reserve a final decision until it has thought through its recommendations on other issues.
The group adopted a shorthand for Kassebaum/Kennedy, "K2."
The initial discussion of reorganization was oriented to the Committee's response to the K2 mandate and the question of how to structure itself. The goal is a structure that permits attention to longstanding Committee priorities even as the Committee devotes major energy to the short-term needs related to the K2 mandate.
The differing interests and skills of members were acknowledged as a factor in restructuring the Committee. Another factor emphasized by some members is the fact that the current work on data standards is restricted to information exchange among doctors, hospitals and payers, and does not address the large segment of the health field in which many other kinds of providers conduct non-traditional medical, social, health and welfare functions. Some members were particularly concerned that this perspective not be lost.
The Committee was briefed on the thinking to date about subcommittees and workgroups. Several themes pervaded the discussion of these proposals:
· the most effective overall structure and division of labor for the Committee
· addressing the expectations of external constituencies
· what names best communicate the subcommittees' charges
· how the subgroups will interact and cross-fertilize
· how to accommodate and balance old business, current priorities stemming from K2, and new business as it arises
Ultimately, motions were passed establishing three Subcommittees: Populations at Risk; Health Data Needs, Standards and Security; and Privacy and Confidentiality. A Planning and Implementation group was ratified as a subcommittee of the Executive Subcommittee. The following points were made in regard to various Subcommittees:
· The Planning and Implementation functions will include identifying linkages with other groups working on overlapping issues, tracking progress on work plans and identifying barriers, and providing liaison between Subcommittees and the Executive Subcommittee.
· The core of the Privacy and Confidentiality proposal is for the Subcommittee to conduct a series of hearings by the end of February. The issues regarding information as a public trust will probably be taken up by the Subcommittee after the first round of legislation.
· The charge and function of the Work Group on Data Standards (established at the last meeting) were put into the broader context of a subcommittee that deals more generally with data needs and data quality. The Subcommittee will determine how to implement its charge and whether to have a separate work group on standards.
· Members acknowledged a shared responsibility for concern about populations at special risk. The Subcommittee on Populations at Risk will serve as a resource to the other Subcommittees and a reference point for outside constituencies. It will function somewhat like the Planning and Implementation group in "scanning" the work of the other groups.
· Community- and state-level data issues will be addressed under the Health Data Needs rubric.
· The structure and function of all subcommittees will be evaluated in a year.
Executive Subcommittee: Detmer, Coltin, Frawley, Leatherman, Lumpkin
Planning and Implementation: Coltin, Amaro, Cohn
Populations at Risk: LaVeist, Amaro, Arce, Iezzoni, Mor, Ward
Health Data Needs, Standards and Security: Starfield, Cohn, Coltin, Frawley, Iezzoni, LaVeist, Lumpkin, McDonald, Mor, Van Amburg
Privacy and Confidentiality: Gellman, Cohn, Frawley, Leatherman, Ward
The next meeting will be March 13-14. Members will be polled prior to a decision about June and September dates. The provisional dates for November are the 5th and 6th. The group referred to the February 1996 document written by Ms. Coltin and Dr. Iezzoni on NCVHS functions and form, and agreed to use it as a guideline for planning future meetings. The intention to use electronic communication between meetings and in lieu of meetings was reaffirmed.
The Committee can express its interest in working with this Commission on overlapping interests by sending a representative to one of its meetings or by sending a written statement to Ms. Norris, who is the Communication Officer.
Ms. Stoiber, Deputy Ethics Officer for HHS, reviewed the process for filing and reviewing Form 450 and disclosing other information relating to potential conflicts or apparent conflicts of interest. She offered the confidential counsel of her office or the Ethics Officer. The basic principle is not to improperly mix public and private interests, nor to give the appearance of doing so. She also stressed the need to clearly distinguish in public speaking between personal views and the Committee's positions. Members are asked to refer representatives of the press to the staff or the Chair. Although NCVHS meetings and discussions are open and in the public domain, it is also advised that in public speaking members only discuss Committee recommendations and decisions once they have been finalized, not while they are under deliberation. Dr. Detmer also asked that members not act on behalf of the Committee in their interactions with HHS unless authorized to do so.
Regarding concerns about contributing to the Department's work in the next few months, Dr. Detmer said a key point of contact is his participation on the Data Council. He also will talk to Mr. Ebeler and Dr. Vladeck about ways for Subcommittees to interact with the Department in the near term, and Subcommittees should consider these issues in their work plans.
Ms. Coltin suggested looking for opportunities for joint Subcommittee sponsorship of hearings, in various combinations.
Following the customary introductions, Dr. Detmer said that although the Committee is still in the process of reorganization, it is beginning to respond to its new congressional mandates. He welcomed Jack Ebeler, Co-Chair of the HHS Data Council and Acting Assistant Secretary for Planning and Evaluation, for the first presentation.
Mr. Ebeler highlighted the importance of the Committee's work with an example - drug use trends as revealed by survey data.
John Fanning then reported on the Department's work on confidentiality and privacy, as stimulated by the Health Insurance Portability and Accountability Act (AKA P.L.104-191, HIPAA,
and Kassebaum/Kennedy) which directs the Secretary to present to the Congress recommendations for medical record confidentiality legislation by August 1997. Those responsible are consulting every part of the Department and other departments with an interest in records, and they hope this Committee will contribute to the process. The Department plans to take part in Congress's review of pending confidentiality legislation, which is likely to take place in the near future. HHS has already analyzed the proposed legislation, and policy development will build on that analysis.
Some components of standards development relate to privacy, but this is not the major vehicle being used by Congress. HHS has an interagency working group identifying the privacy considerations that are applicable to standards development.
Bill Braithwaite explained that in enacting the bill, Congress was responding to a private sector request for national uniform standards for electronic data interchange (EDI), with potential savings estimated at $5.49 billion a year. The main purpose, therefore, was to decrease the cost of health care. A secondary concern was securing the computerized health information and making it private.
The Secretary is required to adopt standards for electronic exchange of administrative data within 18 months of enactment, and those who choose to exchange information electronically then have 24 months to comply with the standards. The recommended standard must have been developed by an ANSI-accredited standards development organization (SDO), unless the Secretary can demonstrate that it will substantially reduce administrative costs and that it was promulgated under negotiated rule-making. If there is no ANSI standard, NCVHS can recommend a standard to the Secretary.
The timeline for the work is very short: Because the approval process can take up to a year, the Department really has only six months from enactment to do the work, three of which are past. Congress has until August 1999 to enact general privacy legislation, and if they have done nothing by February 2000, the Secretary can issue privacy regulations for EDI.
The many issues in adopting the standards include conflicting standards, conflicting implementations, incomplete standards (e.g., with no implementation guides), proprietary code sets, the considerable cost of change, privacy fears (particularly concerning the Social Security Number), and security issues (involving protection from failures of availability, integrity and confidentiality). In addition to the security issues, which are technical, there are the privacy issues, which are a matter of policy -- e.g., the tradeoffs between recommended privacy mechanisms and the cost of implementing and maintaining them.
Mr. Braithwaite offered his thoughts on NCVHS's role in this area. Congress has asked it to synthesize and present the private sector input to HHS, to recommend new standards where appropriate, and to help the Department with recommendations about the choices between the existing standards. He said he expected the "broad thinkers" on the Committee to develop a vision of standard evolution over time and a process for updating the standards.
In Mr. Moore's absence, Mr. Scanlon commented on the current HHS implementation process, which involves not only a Department-wide but a government-wide effort. HHS is working to have a very fair and open process in which all perspectives in the standards and users communities are heard, including that of NCVHS. The approach is intended to involve all HHS agencies with an interest in standards, including payment, grant, and research programs. Other federal agencies will be invited to participate. The Department will publish any formal NCVHS recommendations in the Federal Register. The Committee is the major vehicle for providing input from the standards community. The Department plans to have several working groups do the substantive work on this, under the policy guidance of the Data Council. A detailed strategy and timeline for the HHS work on administrative standards is expected by the third week of November.
Turning to the next segment of the meeting, Dr. Detmer explained that the Committee is beginning the process of responding to the Kassebaum/Kennedy mandate to hear from standards groups and others with a stake in standards. Representatives' presentations will be interspersed throughout the day. They have all been asked to address how their organization would respond to the new legislation, their concerns and issues, and their advice to the Committee. The first speaker was Peter Waegemann, Chair of the American National Standards Institute Healthcare Informatics Standards Board (ANSI HISB), which recently submitted a report to the Department summarizing existing standards.
Mr. Waegemann proposed that five levels of standards are currently of interest: networking, financial, clinical, security, and interoperability. These categories share three "common grounds": a bitways level, a middleware level, and an application level. Only the last is specific to health care. By way of introduction, he stressed the differences between the consensus of an ANSI-accredited SDO, which has to be balloted, and the expert opinion of a consortium. He also noted that ANSI does not create standards in health care; rather, its healthcare Informatics standards board (HISB) coordinates, mainly among the seven accredited standards organizations (American Dental Association, ASTM E31, HIBCC, HL7, IEEE, X12, and NCPDP). HL7 is the main standard in hospitals; X12 is the EDI communication standard and the organization most involved in the issues of the bill.
In the U.S., some 4,000 to 5,000 volunteers are working on health care standards, and 8,000 to 9,000 worldwide. In addition to the seven SDOs that ANSI HISB coordinates, others participating in the standards development process include imaging and middleware standards organizations, health Informatics consortia and professional organizations, government agencies, and industry. ANSI HISB focuses in four areas: technical coordination, a slow process with the goal of creating a harmonized U.S. set of health care standards; international coordination; publicity and education; and legislative and regulatory standards.
The aforementioned ANSI HISB report is entitled "Preliminary Inventory of Administrative Standards Which Must Be Adopted by DHHS Within 18 Months of the Enactment of the HIPAA Act." Its underlying question is how a universal transaction standard can be created, or how to balance user acceptance and system needs.
Mr. Waegemann then reviewed the details of various transaction standards and supporting standards and some of the specific issues involved. Problem areas in transaction standards concern eligibility and payment and admittance advices. In part B of supporting standards, there are 15 codes and code sets, and the question is whether a single set should be chosen. This involves not just quality but implementation issues and political issues, worldwide. These, and the possibility of linkage, are major issues to be addressed in the coming months and years. Another issue concerns unique identifiers. He noted that the issues surrounding patient identifiers are primarily political rather than standards-related.
He observed that most discussions of security confuse confidentiality and security. At the center of both are eight patient rights, including the rights to privacy, access to information, anonymous care, and the opportunity to correct erroneous information. There is an emerging awareness of the right to be treated using all the information in the provider's possession. All of these rights correspond to confidentiality measures.
Systems security has four major areas: accountability, data integrity, availability, and auditability; standards are needed in the last three. ASTM has initiated a major program to develop 13 standards to be ready by early 1997. They include standards for security training, audit trails, and telemedicine.
Mr. Waegemann reiterated that HISB is working on harmonizing activities in all of these areas, and he invited questions and comments.
Dr. McDonald called attention to Internet standards for sending EDI over Internet, which should remain high in the Committee's sights.
Dr. Detmer asked for an estimate of the total number of standards to be contended with, prompting a lively discussion that echoed through the two-day meeting. Dr. McDonald asserted that the total number is not important, as only 20 to 30 are of concern to the Committee. Mr. Waegemann suggested 5,000 as the rough total number, including about 30 key applications standards and several hundred networking standards. He agreed that some are far more significant than others, but pointed out that it is necessary to be aware of all of them because changes in any of them can affect "the upper layers." The focus should be on the application standards, which number about 1,200 worldwide. To help maintain a focus amid the vastness, Dr. Lumpkin suggested as a lens the changes that would simplify the operations of a clinician in his/her office.
Dr. Starfield was the first of many to praise Mr. Waegemann's lucid presentation. She observed that the standards seem to neglect patient attributes; Dr. McDonald responded that many standards do allow for considerable information on patients.
In response to further questioning, Mr. Waegemann estimated that 30 percent of the existing standards are controversial. He pointed out that the focus of the discussion thus far is on what exists, not what is needed in the future, and the latter is of equal or greater importance. Dr. Detmer agreed that the Committee must avoid making recommendations that would impede progress. Because of the complexity of this area, Dr. McDonald suggested that time be set aside for some basic orientation of the Committee before it proceeds.
Dr. Cohn noted the value of the ANSI HISB inventory, which identifies the standards of concern. He called special attention to the code sets within the standards, which he thinks should be a major concern of NCVHS, to ensure that they are comparable and contain the requisite information.
Mr. Heffernan (EDPNS) called attention to the need to develop implementation guides for some individual standards and/or for their collective implementation. Dr. McDonald suggested that a good and complete standard may not need an implementation guide. Mr. Moore said that HCFA has submitted a proposal to the Secretary that would involve the development of implementation guides for standards adopted by the government. In some cases, the guides may be those already developed by an SDO; others may need further work. An inter-agency effort is underway to evaluate what is needed, with a focus on the provider level. He pointed out that a transition to one or just a few standards will take time and require compromises by every SDO. The idea is to identify a goal and work toward it, but not to expect it to be achieved overnight. In response to a question, he said HCFA did not plan to have its concepts and programs tested by users in a prototype or reference development tool, believing that much of the testing has already taken place and the concepts have been accepted.
Dr. Cohn noted that the Committee is responsible for reporting to Congress on implementation, and it therefore needs a briefing on the status on current standards implementation and an evolving sense of what needs work and where the problems are. Mr. Moore said that HCFA, too, wants to know the frequency of use of the standards by the industry. Dr. Lumpkin pointed out that it is also important to have a sense of the untapped market -- clinicians' offices that have not been automated. This prompted varied speculation and information about the extent of computerization in the nation's clinical offices.
Mr. Moore said that about 95 percent of HCFA's claims are on the NSF, the flat file. The agency does not intend to force providers to buy more equipment or software to comply with new standards, but rather visualizes a slow transition process as clinicians' information capacities grow more sophisticated. He added that HCFA saves five to six billion dollars a year in claims processing by using computers. Doctors' offices have indicated in surveys that they are willing to spend money on information systems once all payers agree on a common format. Thus, the first step is to "get that environment straight and ready."
In conclusion, Mr. Waegemann observed that the challenge is to find a balance between existing standards and a vision of future needs, given that technology is always moving. The tension between these two provided another focus of Committee discussion over the course of its meeting. Mr. Moore stated that his agency cannot sacrifice short-term practical imperatives for an ideal that may never materialize; others acknowledged the deadlines in Kassebaum/Kennedy, but noted the pitfalls of getting locked into old technology.
Returning to an earlier point, Dr. Schwartz suggested learning more about the extent to which health information systems are currently automated, who is using them, and how, to have a better sense of the practical realities. He also wondered about methodologies for assessing the cost effectiveness of implementing a new system.
Ms. Leatherman seconded this suggestion, noting the disparity of opinion among the experts and the Committee's need for a common set of assumptions as it pursues its mandate. The two key questions in this regard concern 1) the current infrastructure in the country, including how many physicians' offices are computerized and to what extent, including the capacities of the office workers; and 2) feasibility parameters related to people's attitudes, understanding and acceptance regarding the need to computerize and have standards. In this vein, Dr. Lumpkin suggested developing ways of testing the impact of the Committee's recommendations through "real-life scenarios" that test whether proposed recommendations would make things better or worse for people.
Dr. Detmer thanked Mr. Waegemann for meeting with the Committee, and praised his international work as well as that in the U.S.
Mark Epstein, Executive Director, National Association of Health Data Organizations (NAHDO)
Dr. Epstein, like his fellow panelists, stressed the importance of the Committee's guidance to the Secretary through the standards process and offered his organization's support and assistance. He and others noted specific ways in which their organizations could serve as resources to the Committee.
NAHDO is dedicated to improving health care through the collection, public availability, dissemination and use of health data. Its members are from the public, non-profit and private sectors. Among other things, it works to promote uniformity and standardization of health care collection and dissemination, and to encourage uniform privacy standards and strict penalties for misuse of patient data. It has just released a new guide to state-level ambulatory care data collection activities, and participated in the AHCPR-sponsored Healthcare Cost and Utilization Project (HCUP-3), which has developed a de facto standard for hospital discharge databases.
Dr. Epstein noted that many of NAHDO's 1994 recommendations on information for health reform are consistent with the Health Insurance Portability and Accountability Act. He then offered several suggestions to the Committee in regard to that Act, starting with agreeing with others about the need to develop a vision and look at the big picture. He noted the effect of changes on stakeholders and the need to weigh the relative costs and benefits of collecting additional elements against doing without those elements. He pointed out that states have considerable experience in regard to the balance between promoting access to data and protecting privacy.
Regarding implementing HIPAA, Dr. Epstein suggested that the Committee consult with people at the operational level about their sense of the feasibility of implementing various options. These people are often overlooked when policy is made. He also encouraged close attention to state- level activities, where much can be learned about approaches to data privacy and standards. NAHDO also suggests an incremental approach, as articulated by Mr. Moore. The organization's National Health Information Resource Center, an on-line interactive clearinghouse (www/NHIRC.org), may be a useful resource to the Committee. Finally, he urged the Committee to work with NAHDO and thereby gain access to the perspectives of its constituents.
Korbin Liu, Ph.D., Urban Institute
Dr. Liu was asked to present the perspective of an analyst of the Department's work. He is with the Urban Institute's Health Policy Center, which has been conducting research using HCFA data and survey data for 20 years. He noted the pros and cons of surveys and administrative data, both of which are needed for analytical and research purposes. He also noted the importance of continuing collection, consistency, better linkage (notably at the provider level), and person-level data, and pointed out the increasing importance of state data systems with the shift of program authority away from the federal government. His recommendations to NCVHS are 1) to assure that data linkages are made and 2) to support new data systems in anticipation of the effects of new policies.
Laura Landrum, Illinois Department of Public Health and Association of State and Territorial Health Officials (ASTHO)
Ms. Landrum's focus is the present and future role of health information in the conduct of state level public health functions. She noted that states are under pressure to improve outcome measurement, to assure accountability, and to reshape population-based services, and many are developing creative individual-level MIS systems and public health surveillance systems. A fundamental principle in public health is that individual level data systems must be conceptualized in terms of their utility for the many uses of aggregated data. These include policy development, health status assessment, research, surveillance and regulation, the latter two of which in particular use individual level data. In surveillance, a priority need is for more promptly reported individual health data. In regulation, where the paradigm in public health is shifting toward an outcomes orientation, states need access to health plan outcome data as well as data from elsewhere, such as patient satisfaction and risk factors.
Ms. Landrum called attention to the need to protect the confidentiality of individual level data, and she urged the Committee not to allow the cost of security measures to be a barrier to these protections. She also urged NCVHS to use its reporting mandates to discuss broader issues of the quality of information. In conclusion, she emphasized that public health practice can be advanced with increased access to meaningful, timely and standardized individual level data.
Margaret O'Kane, President, National Committee for Quality Assurance (NCQA)
NCQA's mission is to assess and report on the quality of managed care plans. Ms. O'Kane said the organization is considering upgrading its medical records standards to encompass both paper and computerized records. NCQA will be releasing HEDIS 3.0 in early 1997. In the development of HEDIS 3.0, it became clear that limitations in health plans' information systems make it difficult to collect the information needed to assess plan performance. The information requirements of HEDIS 3.0 will encourage improvements in information systems. As part of HEDIS 3.0, NCQA is issuing a report that assesses current information systems, projects the information needs of performance measurement and defines a plan for migration to an integrated patient record that can support both patient care and performance measurement. Ms. O'Kane will supply a copy of this report to the Committee.
The ultimate goal in regard to information is for plans to be able to exchange and use all types of data in order to manage care. NCQA has identified three phases in the widespread adoption of an integrated patient record. The current phase is the first one, infrastructure development, and NCVHS can advance those efforts significantly. It has been estimated that phase 3, institutionalization of the integrated patient record, will be accomplished in 10 or 15 years.
NCQA recommends that the Committee address several issues: 1) the lack of consensus on structure, content and coding of the medical record; 2) significant cultural and operational changes needed to retool to computerized records; 3) insufficient guarantees of security and confidentiality of records; and 4) insufficient financial incentives to motivate providers to invest. One idea advanced in regard to the last is broader financial incentives such as tax benefits.
Margaret Van Amringe, Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Ms. Van Amringe said standardization and data confidentiality are essential to Joint Commission activities, along with data quality. JCAHO requires quality of care information from diverse providers, and now accredits more non-hospitals than hospitals. All are required to meet comprehensive information management standards. Standardization of information is key because they are required to compare their performance against like organizations, referenced data bases, and the national standards of practice. Ms. Van Amringe offered to share the Commission's standards and guidelines, as well as its experience in other areas, with the Committee.
JCAHO is implementing a continuous accreditation program that routinely collects and analyzes outcome and other performance data. Ms. Van Amringe described the components of this effort. In general, she said, the Commission hopes that by acting as a resource to the field and disseminating the most scientific measures available, it will encourage the use of credible measures and move the field toward increasing levels of standardization. She noted that the Commission's definitions of such terms as health status and health services also may be useful to NCVHS.
JCAHO sees the groundwork laid by NCVHS for a core data set as valuable, and hopes for continuing refinement and updating and an effort to encourage its use. Four or five elements, in particular, need clarification and definitional work. The Commission urges that the Committee's recommendations on confidentiality will protect not just the need of accreditors to look at medical records, but also the function of auditor, which has generally been omitted in privacy legislation. It also hopes the Committee will help reduce the time horizon for a computerized patient medical record; and finally, it stresses the importance of adopting unique identifiers for patients, providers, and payers.
Mr. Gellman queried whether the activities represented in this panel -- research, public health, and quality assurance -- are entirely complementary, or in any way different or even at odds. He explained that the development of statutory standards must determine to whom they apply, and here the question is whether any differences in these functions need to be reflected. The query stimulated a variety of responses noting both the similarities and the differences among them. Dr. Lumpkin observed that protecting the health of the public involves issues related to confidentiality and public trust that go beyond service delivery, and Ms. Landrum reiterated her point about being attentive to the potential uses of individual level data in the aggregate. Ms. Coltin pointed out that research has no direct, immediate benefit to the person whose data are used, but it is essential to the development of quality measures, which do have direct benefit to patients.
Dr. McDonald noted that much can be learned from the public health sector, which has found ways to collect communicable disease data from laboratory systems. Similarly, NCQA is a model in its development of aggregate data sources without being too burdensome for the organization that has to provide the data. Ms. O'Kane encouraged public health to use its limited resources by partnering with the private sector health plans to achieve public health goals.
Dr. Cohn asked for comments on unique personal identifiers. Ms. Coltin described her organization's experience trying to link data to understand the low birth weight problem. It found that by going through some hoops, it is possible to get birth certificate data, which provides more accurate and reliable rates than other sources. Taking up the theme of hoops, Dr. Epstein noted that one problem is that every state and jurisdiction has different ones. He added that having unique personal identifiers would make it much easier to link data across sectors of government within states. Dr. Liu noted the centrality of linking data to research activity, and added that the current confidentiality protections imposed on researchers seem to work quite well. An explicit policy of enforcement must be included in the measures. Ms. Landrum said that in public health, not having unique personal identifiers makes it impossible to do such things as eliminate duplicate accounts of clients in different agencies, look at trends over time in a valid way, develop personal histories of clients, or track users across multiple programs.
On that subject, Ms. Van Amringe noted that to meet standards regarding the continuum of care, it is necessary to track patients across settings. In addition, some quality improvement measures could be enhanced if providers had access to tumor registries and if immunization records could be compiled from all community sources.
Ms. Leatherman observed that a common underlying theme here is the perception of data as a public good. She expressed concern that the policy issue of proprietary data and the trend toward privatization is not being adequately addressed in this forum or elsewhere. She wondered about the possibility of advancing a policy agenda considering options of legislation, regulation or voluntary incentives to move proprietary data into the public.
Mr. Van Amburg cautioned that the common identifier is "not the end-all that will solve all the problems." Even with a common identifier, his agency has found that linkage is not easy because of quality issues, among other things.
Ms. Ward pointed out that some of the "hoops" referred to earlier are necessary, because they are imposed by institutional review boards and human subjects review. She noted that NCVHS has a good track record of caring for data that must continue to protect against abuses.
Mr. Gellman called attention to the tension between two values advanced by the panelists -- more and better data, and confidentiality rules. Ms. O'Kane agreed that there are trade-offs, and what is needed is an honest dialogue about them. Dr. Detmer said the Committee hopes to facilitate just such a dialogue. Dr. Epstein observed that there is a lot of misinformation afloat about supposed violations of confidentiality and privacy; in fact, his organization has not found instances of any violations by state agencies.
In conclusion, Dr. Detmer thanked all the presenters and said the Committee is open to continued dialogue on these matters.
Introducing the next panel, Dr. Detmer said the Committee intends to hear from additional groups in the future. He welcomed the panelists.
Dr. Mark Segal, National Uniform Claim Committee (NUCC)
Dr. Segal noted that P.L. 104-191 calls for consultation with the NUCC, the NUBC, WEDI and the American Dental Association, a mandate that recognizes these organizations' track record in delineating data content and its application in the health community. The four organizations have written to the Secretary expressing their shared commitment to standardization.
The NUCC is comprised mainly of payers and providers and chaired by the AMA. It has two major goals: developing and promoting the uniform minimum/maximum data set for use by the non- institutional health care community, and reducing the number of attachments required to process a claim. It has been focused on developing its initial data sets, and in this connection has followed with interest NCVHS's work on core data elements. Its own process has as a key element getting proper input from the healthcare field, and Dr. Segal described that process for the Committee. The initial data set will be voted on at the NUCC's next meeting, and it will hold open meetings in 1997.
In other areas, the NUCC intends to do further work on coordination of benefits, and jointly with SDOs on a data dictionary. In addition, its Subcommittee on Attachments is working on reducing the number of attachments and clarifying the data required.
Dr. Segal noted the "substantial agreement" between the NCVHS core data elements and the NUCC's emerging data set. He expressed confidence that the NUCC process will permit future consideration and possible inclusion of the data elements the Committee has identified as not yet ready for implementation. He stressed his organization's desire to continue the dialogue.
Gene Carruth, Workgroup for Electronic Data Interchange (WEDI)
WEDI is a non-profit association consisting of public and private organizations including payers, providers, vendors, SDOs, government organizations and others. All will be affected by the outcome of the legislation and the standards developed, and they can provide "a real world business perspective" on the feasibility of standards.
Mr. Carruth outlined WEDI's major concerns in this area, starting with the unique identifier, which it supports but with caveats about the pitfalls of unreasonably expensive implementation. He noted the risk that the proposed national payer and provider identifier system could become overly complex and too expensive to maintain, as well as the need for "a good business perspective on how they will be used." WEDI's second concern is the need to ensure an orderly transition to the new processing methods and standards, with a specified time frame. It favors requiring providers to fully support the electronic standard, because otherwise plans and payers must support both electronic and manual processes. It also recommends considering the development of incentives to small providers and plans to participate in administrative simplification, possibly through tax breaks. Mr. Carruth noted that WEDI members can assist in establishing implementation specifications, based on their extensive experience. The important thing, he said, is to keep the standards and implementation simple and clean. WEDI is undertaking several studies for an economic model on the differences of implementing existing electronic claims handling. Another WEDI concern relates to building a communication infrastructure, given the varied levels of automation among practitioners. Thus, incremental and simple steps are needed to implement the infrastructure.
George Arges, National Uniform Billing Committee (NUBC)
Mr. Arges stressed the need for the health care community to understand the process of collecting, disseminating and applying health data. Data quality is important to the NUBC, which for many years, and "without the benefit of the law," has been working on developing uniform standards for reporting. He noted that the new legislation has established a framework for a process to make things more uniform.
The NUBC's goal is to develop and maintain a process whereby the collection effort is understood by the wider community. It spent seven years developing the UB82, and then controlled the rate of structural change to that document because of associated costs. In the meantime, it recognized that although the UB82 was designed as a billing instrument, there are many other uses for the information. Mr. Arges noted that Kassebaum/Kennedy calls for demonstration of the value of given information before it is collected. He added that the NUBC is working with the NUCC and others to reduce the redundancy in the information currently collected. Also, although Medicare receives some 96 percent of its claims electronically, a uniform bill is not yet accepted and there are variations in reporting requirements. Changing that situation is an NUBC goal.
The organization involves many state hospital associations that are also active in state uniform billing committees. This cross-fertilization is a source of ideas about state data needs. The NUBC also works closely with EDI organizations including WEDI.
As for his organization's concerns, Mr. Arges noted the variation among state administrative agencies' data requirements and capacities, which will affect their ability to adopt and follow coding changes. These plus variations on the clinical side raise issues about the cost of system changes. In addition, it will be important to communicate instructions clearly to consumers, vendors, providers, and payers. The time frame for compliance is key, as well. The NUBC recommends an incremental approach to these changes, following a strategic plan that defines the desired end and prioritizes the steps to get there.
Benjamin Curtis, Association for Electronic Health Care Transactions (AFEHCT)
AFEHCT is a trade association of vendors and suppliers to health care EDI industries, with a membership similar to that of WEDI. Mr. Curtis explained the key role of value-added networks and clearinghouses in transmitting claims. He noted that for each claim submitted, there are as many as 11 other transactions.
AFEHCT supports the Kassebaum/Kennedy administrative simplification provisions, but also has concerns about their implementation that are similar to those of other organizations. One relates to the consultation requirement. Mr. Curtis expressed concern that the HHS staff involved in standards policy might only consult with the four organizations named in the statute, and he urged consultation with a wide variety of groups, including AFEHCT. He noted that the vendor community will bear the burden and responsibility for the standardized transactions.
AFEHCT is also concerned that the Bill allows for too much flexibility by the user; it favors a standard implementation of the transaction. Regarding security standards, the organization notes that there are no industry standards for security, and it is hopeful that the policy process will remain sensitive to the smallest healthcare provider and EDI processor. In regard to NCVHS membership and duties, Mr. Curtis said AFEHCT is "awed by" the qualifications of current members but "deeply troubled" by the absence of representatives of the clearinghouse or value added network community, who figure prominently in data transmission and who must make the capital investment to fulfill the promise of EDI.
Ed Hammond, Computer-Based Patient Records Institute (CPRI)
On November 19 in Washington, D.C., CPRI is hosting a summit conference to address the chief barriers to realizing a computer-based patient record system, as identified by the major health Informatics organizations. The calls to action that will be proposed at that meeting have three common features: education, self-legislation, and the need to be specific about the details. There are three recommendations:
· that legislation be enacted to task and fund the Social Security Administration to add a check digit to the Social Security Number and to issue the SSNs in a way that supports their use as a universal or unique health identifier
· that policy and provisions be adopted on confidentiality and security of individual health information, and that compliance be ensured
· that action be taken on a common vocabulary and terminology
On the second recommendation, Dr. Hammond asserted that most of the technology and understanding are available to achieve it. What is needed is a clear definition of what is required, so that vendors know to build it into their product, plus a standard set of security features and an effort to educate the public and help them distinguish reality from perceptions. On the third recommendation, he noted that the lack of a common vocabulary is the barrier that takes more time than anything else.
The first step in addressing these issues is to gather everyone with a stake in the issue, taking extreme care not to miss anyone. That group then needs to commit to a framework to meet everyone's needs, and assign responsibility for coordination.
Dr. Hammond then turned to his advice to NCVHS.
· He stressed the Committee's need to inform itself about all the topics in the standards area, to ensure "a higher playing field" in addressing the issues. He noted that creating standards is a real world exercise, not an academic exercise.
· He urged the Committee to be visionary and view current challenges in terms of where the industry is going (e.g, the disappearing distinction among administrative, financial and clinical data).
· The Committee should carefully judge the art of the possible-- including, e.g., not underestimating the field's potential for automation. He recommended "stretching the rubber band" to think in terms of what is possible, while keeping the connection to the community served by the Committee.
· Another value is focused precision and completeness, which permits understanding as to which standards and groups of standards deserve attention.
· Another value is precision in definitions.
· The Committee should "encompass and engage" the entire community. Dr. Hammond lamented the forces that cause divisions between the government and the private sector, and he called for openness and cooperation.
· The Committee should be bold, opting for "best" rather than "most popular."
· The Committee should follow up, stay engaged, and worry about the changing environment and how the standards are being implemented.
· The Committee must drive the process: "You are it, and we are depending on you as bringing our input to the people who have the power to make this happen."
Dr. McDonald commented on the problems caused by the excessive level of detail in some existing transaction standards, and the need for creative thinking about a better organizing principle. Both Mr. Arges and Dr. Segal described their organizations' efforts toward greater consistency and uniformity, and Dr. McDonald urged them to try and merge more activities and strive for a new logic to underlie the activities.
Dr. Hammond agreed that the fundamental problem is the lack of a common platform. He noted that now, at least, various systems are close enough to each other to see where they overlap; now the task is to develop the common platform and a shared vocabulary, in which "the one exception" is not an exception but "accommodated within the fabric." Mr. Carruth called attention to the time constraints and argued for beginning with "something that is simple and clean," from which the field can evolve in incremental steps.
Dr. Mor noted the dominance of information systems and standards by pricing considerations, and he cautioned against setting up a system on that basis, only to have the pricing factors change. This point generated several comments. Dr. Detmer agreed that few information systems are organized around patient care, adding that while the goal of the legislation may be to move toward the electronic medical record, it calls for the establishment of privacy protections first. Mr. Carruth suggested that payment issues are a reasonable place to start with standards.
Dr. Lumpkin observed that even with the major transition to capitated systems, a good deal of information will still be needed about the components of that care, as well as about services bought outside the managed care system. He added that the hardest thing for clinicians about reporting requirements is that everyone does it differently; that is where the simplification is needed. Dr. Segal said that is the reason for NUCC's efforts, and it and NUBC are focusing on a core set of data elements that are needed, regardless of the format and reimbursement method. Mr. Arges added that the law will advance efforts to achieve uniformity, and he stressed the need for "flexing a little muscle" in promoting consistency. Mr. Curtis noted that many of AFEHCT's members do business outside U.S. borders and deal with health care systems where clinical information is often more important than payment information.
Dr. Hammond reiterated his observation that the dominant problem is vocabulary, or code sets. He called for efforts to understand the common denominator among all the stakeholders, regardless of their emphasis, and suggested that it may be the computer-based patient record.
Mr. Gellman asked his view of Kassebaum/Kennedy's failure to support uniformity and nationwide standards in the confidentiality area, choosing instead to recognize varied state laws if they are stronger. Dr. Hammond speculated that much of the variation is due to a lack of education and understanding, and he expressed hope that in time all states will accept the strongest laws.
Ms. Greenberg noted the Committee's recommendations about collecting certain data at the time of enrollment, and asked Dr. Segal for his views on moving ahead to define an enrollment data set, given the fact that it is not in the purview of either NUBC or NUCC. Dr. Segal commented on some of the specifics, stressing the payer's need to look periodically at enrollment information to be sure it is accurate, and suggesting that the provider should not be responsible for gathering information on things related to socio-economic status. Mr. Arges said that the NUBC has talked about being more proactive in respect to enrollment.
Dr. McDonald praised the opportunity to "stir the different perspectives" represented at this meeting, because people need to get to know each other better. He noted that many clinical and financial standards have been evolving since the early 1980s; the problem is that they are "growing up like topsy and they have to connect." This is what the Committee and others need to look at. Dr. Cohn added that the mixed environment of paper and EDI, managed care and fee for service, will continue for a long time, and the Committee must figure out how to manage this mixed environment.
Mr. Moore explained the abundant clinical detail that HCFA requires as a function of its obligation to combat fraud and abuse and be stewards of tax dollars. Mr. Arges echoed this emphasis on accountability, noting that the data sets of NUBC and NUCC were designed for that purpose. Dr. McDonald said his point was simply that clinical data should not be picked up one field at a time.
Dr. Detmer invited comments on tax incentives and other ways of encouraging automation and standardization. Mr. Carruth gave some examples of financial incentives and disincentives, including charges for paper claims and tax credits for capital investments. He reiterated his point about needing a core infrastructure, centered on the eight transactions identified in the law. On that basis, the effectiveness of uniformity can be demonstrated, and "it will be a very easy step" from there to demonstrate the effectiveness of computerization.
Dr. Segal spoke for the lawmakers' wisdom of not requiring physicians to submit electronically, arguing that a mandate would have produced a backlash when in fact progress is happening and many incentives and trends already favor computerization.
The earlier question of the size of the universe of standards needing standardization was put to this panel. Mr. Carruth responded that standards are needed for each of the transactions listed in the legislation, plus the four identifiers. He suggested that it may be easier to have more than one standard for claims. Dr. McDonald later added that although it need not actually develop them, the Committee also should be aware of activities related to technical matters and able to take positions on them. Dr. Segal added security issues such as the digital signature to the list.
Dr. Hammond called for more attention to employers, who are key to the reimbursement process and should be motivated to send information electronically. He noted that organizations have difficulty deciding when to "cut away from paper and go electronic," and to illustrate his point he asked if NCVHS uses e-mail and electronic media to transmit all of its information or still uses paper and fax. He called for the leaders of this effort to be clear in stating that "this is the expectation," because people are often driven by expectations. It is also important to believe that automation truly will save money.
Mr. Arges pointed out that the cost savings stem first from uniformity, and secondarily from electronic transmission. He stressed the importance of understanding what data elements to collect, when, and how. He later commented on the need for greater clarity about the purpose of the data requirements for each transaction set, to combat the proliferation of unusable data.
Dr. Cohn returned the group to the question of incentives, something that the Committee should address. He noted that a former HHS work group on computerization of patient information said in a 1993 report that most benefits of health care information EDI accrue to payers, and it recommended finding ways for providers to share the benefits. The Committee should follow up on this. Mr. Curtis pointed out that not all benefits and incentives are financial, and there may be other ways to motivate providers.
Dr. Detmer then invited comments on education, which the Committee sees as one of its obligations. Agreeing that it is key, Mr. Carruth said that all associations should develop ways of participating in the effort. Dr. Hammond noted that education happens at many levels, and this meeting is an example of "a tremendous amount of education." He also urged getting outside "the choir" to gain insight into other perspectives, something that is necessary for knowing how to educate others. Reaching the general public is critical, and must be done via the media.
Dr. Detmer thanked the panelists for their stimulating and helpful contributions.
Dr. Detmer introduced Ms. Patricia Norris, Communications Director for the National Bioethics Advisory Commission. Ms. Norris said the Commission was created in October 1995 by Executive Order, to advise the Office of Science, Technology and Policy (OSTP) and other appropriate government entities on human research subjects protections and genetic information issues. It plans five meetings this fiscal year, including one in July outside Washington, D.C. In addition, a special panel will soon convene at an international bioethics conference in San Francisco to talk with bioethicists from around the world about how their commissions have been managed and the issues they have dealt with.
The Commission held its first meeting in October 1996, focusing on exchanging information about each Commissioner's particular interests and reports from the Office for Protection from Research Risk and the NIH Human Genome Project. The 18 members include lawyers, physicians, bioethicists, and representatives from the public. At its recent meeting the group formed subcommittees on human research subjects and genetics. Meetings are open, and all will have a public forum when people can present their concerns and issues. Ms. Norris said that if the Committee is interested in working with the Commission, it can express it by sending a representative to one of its meetings or by sending a written statement. Dr. Detmer noted the connection between the two bodies' concerns, particularly because Kassebaum/Kennedy has mandated that NCVHS make recommendations on privacy.
The Commission's web site is at:
http://www.whitehouse.gov/WH/EOP/OSTP/hmtl/OSTP_Home.html
Ms. Norris also maintains a mailing list for the Commission, and people can ask to be put on it.
The Commission was established to last until October 1997, but OSTP wants to extend that lifetime. Asked about the stimulus for its creation, Ms. Norris said it was not, as has been rumored, spawned by the Radiation Commission, but rather came about because of the longstanding interest of Senators Hatfield and Kennedy, partly in regard to genetic information issues.
Dr. Schwartz asked if it would get involved with survey-related research, for example in regard to respondents' rights, especially those of children, and informed consent. Ms. Norris said she would take the idea back to the Commission. She added that upon creating the Commission, the President directed all government agencies to submit reports regarding the status of their research with regard to human subjects. The Subcommittee on Human Research Subjects will analyze those reports and produce a report on that by the end of this fiscal year. The Commission will also consider what to do about projects that are not federally funded.
Dr. Detmer thanked Ms. Norris, and expressed the Committee's interest in having a dialogue with the Commission.
He then invited the group to reflect on the day's discussions and insights.
Much of this discussion centered on the charge and role of the Committee in respect to the Kassebaum/Kennedy legislation, and perceptions of the nature of the task. It was agreed that the order of magnitude of the number of standards the Committee needs to be concerned with is closer to 20 than 5,000. There was some discussion of the meaning of key terms, such as "transaction," and agreement that opportunities are needed for further education of Committee members. Some ideas put forward were a glossary, summaries and standards on the Web for individual study, and an orientation session at a meeting. It was noted that the matrix developed for the core data project has useful comparisons among several claims formats and data sets.
Dr. McDonald said a pivotal problem is the variability among standards and their unsystematic content, and he suggested that the Committee help the Department think about how to regularize things without changing the standard. Everyone will benefit from more universal code sets. Dr. Lumpkin pointed out that the Committee will be looking at the schema of the various standards and analyzing where they contradict each other and how they can be simplified.
Mr. Moore noted that the HISB inventory shows that for some transactions, only one standard has been identified. HCFA is proposing to the Secretary that they put together teams to analyze each of the nine or ten transaction sets. They would report to NCVHS, the Data Council and others about what the transactions are, what data are there, and whether they meet the needs of the community. In effect, he said, these teams would be doing the staff work for NCVHS in this area. They will also go to the SDOs and other organizations to find out about their priorities and concerns, and on the basis of these discussions they will simplify and standardize to the fullest extent possible. The final product will be put into a proposed regulation that will go through the Department, OMB, and out to the public, which will have 60 days to comment. Then the process will be repeated, with another NCVHS opportunity to respond, followed by the posting of a final regulation by February 1998.
In response to a comment, Mr. Moore said that this analysis would include identifying data gaps, and Dr. Lumpkin noted that the Committee will want to see, for example, if the standards permit an adequate description of the patient. Mr. Moore noted that given that the charge is administrative simplification, it will be important not to do much data expansion for fear of making things more complex.
Regarding the Committee's charge in this area, the general sense of the group was that the Committee is expected to look at the content and detail of standards and to recommend internal changes, or even something altogether different, if needed. Dr. Detmer said the Committee's mandate is very broad, although it will have to carefully explain its reasoning if it departs from that of the governmental team.
Dr. Lumpkin observed that the work groups will inevitably become specialized and invested in their respective areas, and all members will need a commitment to cross-education so that recommendations truly come from and represent the entire Committee.
Ms. Ward raised the issue of the patient identifier and how best to approach it, a subject that generated considerable discussion. Mr. Moore said he doubts that recommendations on the individual identifier can be ready by February 1998. It was suggested that the entire Committee work on the patient ID, rather than delegating it to a work group or Subcommittee. Dr. Detmer asked all sub- groups of the Committee to identify such cross-cutting issues that need to be addressed by the entire group. As for process, the consensus was that the Committee should begin working on the individual identifier before long, because of its complexity, but should reserve a final decision until it has thought through its recommendations on other issues. Dr. McDonald pointed out that good analytical work and research would help the Committee support and defend its recommendations -- e.g., on the relative cost of various alternatives, the security tradeoffs, and mechanical and technical issues.
Ms. Greenberg observed that the Department needs to think through how the Committee can be most effective in the standards area and inform the Department's technical work. She noted that several of the earlier panelists had mentioned the Committee's potential contributions in articulating a vision. Another area is holding public meetings and serving as a forum, something that Mr. Scanlon said would be critical, with the Committee providing outreach to the standards community.
On the unique identifier, Ms. Greenberg pointed out that the Committee has a longstanding record of advocating a unique identifier and calling for work on this issue.
In anticipation of the next day's discussion of the Committee's structure and work plans, Dr. Detmer asked members to review the draft charges. In response to a question about the difference between work groups and subcommittees, he said the former has a more limited life and stature. The Executive Committee thinks that the likelihood that privacy and confidentiality issues will remain important for a long time means that there should be a standing NCVHS Subcommittee to address them. In contrast, for data standards, the thinking is that standards issues and tasks related to the legislative mandate should be addressed by a work group that is part of a Subcommittee with a broader charge encompassing other NCVHS data priorities such as survey data.
At this point, Dr. Lumpkin suggested a shorthand for Kassebaum/Kennedy -- "K2" -- in reference to the rigorous challenge facing the Committee and the nearly Everest-sized mountain with the name K2. It was adopted with enthusiasm.
In response to a question, Ms. Coltin reviewed the Executive Subcommittee's thinking about the relationship between the old subcommittee structure and the new one under consideration. The goal is a structure that permits attention to longstanding Committee priorities even as the Committee devotes major energy to the short-term needs related to the K2 mandate. In regard to data standards and other data issues, she noted the differing interests and types of expertise represented on the Committee. Those interested in surveys and general data content may not wish to work on technical Messaging issues; thus another goal is a structure whereby shared interests can be discussed and a smaller group can take on technical details. Dr. Mor commented that a more fundamental distinction is that the current work on data standards is restricted to information exchange among doctors, hospitals and payers and does not address the large segment of the health field, especially from the perspective of geriatrics and long-term care, in which many other kinds of providers conduct non- traditional medical, social, health and welfare functions.
Dr. Detmer responded that ultimately, the goal is to have intersecting computer-based consumer health records, computer-based population records, and computer-based patient records using a broader definition of "patient." Dr. Cohn pointed out that the Committee has an opportunity now to put in place data sets that meet real data needs, and to do so in a way that meets other needs. He asserted that this important process needs everyone's participation, including "the people who actually have an idea of what the data need to be used for." He added that in the future, surveys, too, will likely be conducted with the aid of transaction standards.
Noting that this discussion of structure and priorities would continue the following day, Dr. Detmer recessed the meeting.
Dr. Detmer reviewed the major themes of the previous day, noting in particular that the issue of proprietary interests needs Committee attention; that some tension exists between the goal of administrative simplification and the need to facilitate public health work and patient care through more complete information; and that the forthcoming departmental work plan will be a useful reference point for the Committee.
The Committee was briefed on the thinking to date about subcommittees and workgroups, and reviewed draft charges and work plans for each group. Several themes pervaded the discussion of all of these proposals:
· the most effective overall structure and division of labor for the Committee
· addressing the expectations of external constituencies, the Department and Congress
· what names best communicate the subcommittees' charges
· how the subgroups will interact and cross-fertilize
· how to accommodate and balance old business, current priorities stemming from K2, and new business as it arises
Ms. Coltin explained the Executive Subcommittee's thinking about the Planning and Implementation (P&I) Subcommittee, envisioned as a subcommittee of the Executive Subcommittee. The P&I functions will include identifying linkages with other groups working on overlapping issues, tracking progress on work plans and identifying barriers, and providing liaison between Subcommittees and the Executive Subcommittee. Dr. Detmer said tracking the implementation of standards would fall to the standards Subcommittee; Planning and Implementation will simply help see that all the pieces fit together. It will not duplicate staff work.
Mr. Gellman said that the core of the proposal is for the Subcommittee to conduct a series of hearings by the end of February. Given that Congress has already decided there should be health privacy legislation or regulations, the question is what their content should be. The hearings would be unlike typical Congressional hearings in that they would not be for the purpose of building public support or educating, but rather would get the major interest groups and players to go over proposed legislation in detail to look at specific trade-offs. Bringing about this process is something the Committee is uniquely positioned to do, and it would be a significant contribution to policy development in this area. It will be critical that all points of view are represented and forced to confront alternatives, on the record. The process will create a background that will help focus and inform the Committee's recommendations to the Secretary, and also will focus attention on the sharp conflicts raised by legislation. Mr. Gellman referred fellow members to an article he authored on the basis of confidentiality issues.
Dr. Starfield said that the current thinking is that the charge and function of the Work Group on Data Standards (established at the last meeting) should be put into the broader context of a subcommittee that deals more generally with data needs and data quality -- e.g., clinical data, including the Committee's past work on core data elements, and population data.
Mr. Van Amburg noted that two objectives of the reorganization are to reduce the number of subcommittees and to have a home for outstanding activities and agendas of previous subcommittees. Dr. Lumpkin noted that some mechanism is needed to ensure attention to changes underway in NHANES and other surveys. In general, Committee members favored finding a way to have a short-term focus on responding to K2 without losing sight of broader concerns such as surveys. It was noted that standardization itself may prove to be a long-term activity of the Committee, and it should not be assumed that it will recede. There was general agreement that whatever structure is chosen for this and other Subcommittees will be reevaluated in a year or so, to see if it is working or needs to be changed.
(Discussion on this Subcommittee resumes below.)
Dr. Iezzoni began with some history, noting that among the discontinued NCVHS subcommittees are ones on minority and other special populations, long-term care and disabilities, mental health, ambulatory care, and state and community health data. Some NCVHS members have been concerned that this structure supported a sense of looking at data within settings of care, and that this set of lenses leads to problems and should be transcended. Dr. Iezzoni noted the value of relating to various constituencies, especially those left out of the health care system, and of assuring advocacy for their interests in the policy debate.
Regardless of the name, the underlying concept for the Subcommittee in question is people who are at risk. The three categories that put people at risk are:
· difficulties with financial access
· the burden of chronic illness
· difficulty negotiating through the health care system caused by various attributes (e.g., race and ethnicity, being very young or old, immigrant status, language barriers, geographic barriers)
Each of these causes of vulnerability has implications for both privacy/confidentiality and standard setting, so there are overlaps with the other NCVHS Subcommittees.
Reflecting on these comments, Committee members started from the assumption that these are critical issues that warrant the Committee's continuing attention. The arguments for and against having a separate Subcommittee and embedding these priorities in the charges of the two other Subcommittees were put forward. Dr. LaVeist expressed the prevailing view, that the importance of having a permanent, visible presence and reference point for this set of concerns justifies creating a separate group to assure that the concerns get the attention they deserve. It was noted that such a group could also help bring people and points of view into the Committee's processes that otherwise might not be represented.
Dr. Mor described the difficulty in the Association of Health Services Research of getting on the agenda anything related to sites of care other than ambulatory settings and hospitals, even though "lots of things happen" in those other settings. Advancing this broader perspective also requires advocates within NCVHS, to ensure that other sites, classes of visits, activities and therapies are incorporated into its process.
Dr. Starfield stressed the need for the entire Committee to feel a responsibility for concern about populations at special risk, and she added women to that list. She also observed that even if it establishes a subcommittee on populations at risk, NCVHS will probably disappoint groups like the mental health and long-term care communities that have been able to relate to subcommittees dedicated to their interests.
After a straw vote indicated a preponderance of support for having three subcommittees, the group discussed the implementation of a new structure. Dr. Detmer said it is assumed that Committee members will serve on at least one subcommittee. Dr. Iezzoni suggested that the Subcommittee on Populations at Risk generally meet in conjunction with full Committee sessions, so that members can participate in another Subcommittee and only have to travel specially for those meetings. Mr. Van Amburg observed that community- and state-level data issues could be addressed under the Health Data Needs rubric, even though the uninsured are also a highly vulnerable population.
Ms. Ward observed that it will be useful to the other Subcommittees to have a group designated as experts and resources on the issues of populations at special risk, to advise on their implications for Subcommittee agendas. Dr. Detmer suggested that this Subcommittee function somewhat like the Planning and Implementation group in "scanning" the work of the other groups. The structure and function of all of the subcommittees will be evaluated in a year.
A motion was then passed to establish a subcommittee on populations at risk (with the final name to be recommended by Subcommittee members), with the responsibilities outlined above.
The discussion of how to reconfigure the work group on data standards focused in part on whether there should be just one body or a broader subcommittee with a work group within it dedicated to the K2 mandate. Ms. Coltin pointed out that one reason for the latter structure is to accommodate any new issues that do not fit the more narrow charge. In this model, a broader
Subcommittee would develop an annual workplan reflecting current priorities, which for the present are to address the K2 issues.
A motion was made that the Committee establish a Subcommittee on Health Data Needs, Standards and Security. It was suggested that the Subcommittee contain a Work Group on Standards and Security, but Dr. Cohn advised that once its charge is worked out, the Subcommittee be allowed to determine how to implement it. There was considerable discussion of the name and purview of this group, reflecting concerns about external perceptions, the Congressional mandate, and the balance between K2 and other data priorities. Dr. Starfield explained that the word "Needs" is important in the title because many elements in the Committee's core data project that are necessary for clinical decisions are "nowhere yet." The Committee then passed the motion establishing the Subcommittee, as named. Dr. Cohn commented that the charge needs another bullet, but this was not addressed. The draft charge was approved, with minor wording changes to be submitted to the Executive Committee.
All Subcommittees were asked to submit their work plans to the Executive Subcommittee.
On the timing and organization of meetings, the group referred to the February 1996 document written by Ms. Coltin and Dr. Iezzoni on NCVHS functions and form, and agreed to use it as a guideline for planning future meetings. Mr. Scanlon mentioned the intention to use electronic communication between meetings.
The following assignments were made, with members volunteering for the three Subcommittees just established. Ms. Coltin asked each Subcommittee to designate representatives to the Planning and Implementation Subcommittee, whose current membership list is provisional. Chairs' (or Acting Chairs') names are underlined. Dr. Detmer will check with absent members to confirm their Subcommittee membership preferences.
Executive Subcommittee: Detmer, Coltin, Frawley, Leatherman, Lumpkin
Planning and Implementation: Coltin, Amaro, Cohn
Populations at Risk: LaVeist, Amaro, Arce, Iezzoni, Mor, Ward
Health Data Needs, Standards and Security: Starfield, Cohn, Coltin, Frawley, Iezzoni, LaVeist, Lumpkin, McDonald, Mor, Van Amburg,
Privacy and Confidentiality: Gellman, Cohn, Frawley, Leatherman, Ward
Dr. Detmer noted that K2 speaks in terms of the electronic medical record, thus making it at least a future issue for the NCVHS agenda. He asked what members wanted to do about it in the near term. Dr. McDonald advised caution to avoid "prejudicing the future by the present," and care in defining administrative centers. Both the Planning and Implementation and Health Data Subcommittees were asked to keep in mind maximizing feasibility for the next stage as they consider their work plans.
It was confirmed that the next meeting will be March 13-14. Members will be polled prior to a decision about June and September dates. The provisional dates for November are the 5th and 6th.
Dr. Detmer said he tries to get to all Data Council meetings, but he may occasionally ask others to represent the Committee. Concerning staffing, Mr. Scanlon said that the Council will always have a representative at NCVHS meetings. It is arranging staff for Subcommittees from the pool of experts on its own working groups, which correspond to those of the Committee. HCFA will help staff the Subcommittee on Health Data Needs, Standards and Security.
In response to a question about public hearings, Mr. Scanlon said the Subcommittee on Privacy and Confidentiality plans four to six, and these can be a model for other hearings. The hearings will be open, and some people will be invited to testify. Ms. Greenberg advised building in time immediately following the hearing to process and discuss what has been learned and consider next steps. The hearings will be announced in the Federal Register. A transcript and minutes and/or a summary will be produced.
Dr. Detmer described plans to use the Committee's Web site for public comment on minutes and other documents, as well as for a bulletin board. The Internet can be used to exchange useful materials among Committee members, for continuing education.
He reported that Congress has not yet named the two new members mandated in K2. The process has been very consultative so far, eliciting the recommendations of both Dr. Detmer and the Department. He hopes the appointees will be in place before the March meeting. He and Mr. Gellman predicted that new versions of old privacy bills will be reintroduced in this session, but probably not for a few months.
Dr. Detmer introduced Susanne Stoiber, Deputy Assistant Secretary for Planning and Evaluation and Deputy Ethics Counselor. Ms. Stoiber expressed the Department's pride and pleasure in the reconstitution of the National Committee and the high caliber of its members. In accepting membership, she said, they became special government employees and took on certain ethical obligations that her office and others will help them carry out. She introduced Karen Norell, ASPE's Executive Officer.
Ms. Stoiber then reviewed the process for filing and reviewing Form 450 and disclosing other information relating to potential conflicts or apparent conflicts of interest. U.S. Code 18, Section 208 is the main conflict of interest statute. One type of waiver can be granted to address Committee members' institutional ties in areas that may give the appearance of conflict of interest; another waiver applies to investments under certain conditions. Individuals are sometimes asked to abstain from direct involvement in some discussions, although that is unlikely in the case of the Committee's deliberations. Ms. Stoiber's office and the Department's Ethics Counselor are both available to provide confidential advice. She encouraged members to ask if questions arise about particular cases.
Dr. Detmer called attention to the guidelines for speaking to groups about the work of the Committee, and Ms. Stoiber stressed the need to clearly distinguish in public speaking between personal views and the Committee's positions. Dr. Detmer welcomed Ms. Ward's suggestion that members generally refer representatives of the press to the staff or the Chair. Although NCVHS meetings and discussions are all open and in the public domain, it is also advised that in public speaking members only discuss Committee recommendations and decisions once they have been finalized, not while they are under deliberation. Ms. Stoiber cautioned against speculation or opinion about where the Committee might go on particular issues.
It was emphasized that these guidelines should not discourage the Committee from "communicating to the outside world" about its work, such as in presentations on the core data elements.
Dr. Detmer suggested that everyone send their resumes to Ms. Greenberg for circulation among Committee members, so everyone knows of everyone else's other involvements. He noted that many members sit on boards that relate to NCVHS topics, and Ms. Stoiber confirmed that members should excuse themselves from certain discussions of items related to an organization on whose board they serve. The CDC ethics counselor may call attention to possible areas of overlap. The basic principle is not to improperly mix public and private interests, nor to give the appearance of doing so.
Ms. Greenberg said the Ethics Officer will issue waivers where necessary. Forms should be sent to Ms. Greenberg.
Remarking that these constraints and precautions suggest that the Committee has some power, Dr. McDonald asked what effect the Committee actually has. Dr. Detmer responded that its advice has been explicitly sought and can be expected to be taken seriously, although not necessarily followed, by the Department. Ms. Greenberg said the question of impact is a longstanding one with NCVHS members, and she noted that the Committee is taken very seriously outside the Department. Although one vehicle is the Committee's formal reports and recommendations, Dr. Cohn and others stressed that much of the Committee's impact comes through its ongoing dialogue with the Department. Both Mr. Moore and Ms. Stoiber said the burden of proof is on the Department to solidly explain its reasons if it does not follow the Committee's advice, given its prestige and mandates. She characterized it as "enormously powerful advice."
Dr. Lumpkin observed that the Committee's work has been given impetus by the Department's legislative mandate to take action in certain areas; in the past, some NCVHS recommendations on things it thought were very important received no action, but the conditions and time frame are different now. Mr. Scanlon added that conditions in the Department are more propitious now as well, due to the creation of the Data Council and other changes. He reminded the group that it is the Secretary who will make the recommendations for the law, but the Committee will have an influence.
On the relationship to the Department, Dr. McDonald expressed concern that much is going to happen between now and the next NCVHS meeting. He asked what could be done to interface early on to maximize the Committee's contributions to the process. Dr. Detmer said a key point of contact is his participation on the Data Council; he also will talk to Mr. Ebeler and Dr. Vladeck about ways for Subcommittees to interact with the Department in the near term. He encouraged Subcommittees to address the issue of interface in considering their work plans.
Concluding the discussion of ethics, Dr. Detmer asked that members who are in contact with the Department not do so "wearing their Committee hat" unless the Committee is aware of it. He reminded members of the need to act as a group, and encouraged members to contact him or one of the advisors if questions arise. He thanked Ms. Stoiber for briefing the Committee.
Dr. LaVeist, who has agreed to serve as Acting Chair, reported that the Subcommittee developed a preliminary draft of a workplan and charge, the final version of which will go to the Executive Subcommittee once it has reviewed the final reports of the Subcommittees it is replacing and considered what unfinished business to pursue. The group decided not to have sub-units but to deal with all issues within the Subcommittee structure, and also to have input into the other two Subcommittees. All members of this Subcommittee are also members of one of the other two. The group agreed on a name, which Dr. LaVeist presented as a motion. The full Committee passed a motion that the group be named the Subcommittee on Populations at Risk.
Mr. Gellman reported that there will be six days of hearings, in three sets of two days with time scheduled for the Subcommittee to discuss the testimony following the hearing. A list of topics to be taken up and suggested dates will be circulated to all Committee members, and he asked for indications of interest in attendance and suggestions of groups that should be invited to present.
Efforts will be made to use technology in these and other Committee activities to mitigate the need to travel and facilitate participation, for example by using a satellite hookup.
Regarding the location of the hearings, the Subcommittee favors holding all of them in Washington, D.C. The knowledgeable people who are critical to the discussions either are there or can get there easily, and Mr. Gellman reiterated that "this is not a man-in-the-street hearing." The arguments put forward for moving the meetings around were that different locations bring out different constituencies, and that the Committee may give the wrong impression by not making such an effort. On the other side, Dr. Lumpkin pointed out that a Washington location would enable interested parties there to attend and hear the input. Transcripts and minutes will be available on the Internet and in print.
Dr. Mor recalled Ms. Leatherman's point about information as a public trust, and asked if this would be in the Subcommittee's purview. Mr. Gellman said it is an important issue that probably should be taken up after the first round of legislation.
Ms. Coltin suggested looking for opportunities for joint Subcommittee sponsorship of hearings, in various combinations. The Planning and Implementation Subcommittee will pursue this idea.
Dr. Detmer then thanked everyone for active and productive participation, and adjourned the meeting.
I hereby certify that, to the best of my knowledge, the foregoing summary of minutes is accurate and complete.
/s/ Don Detmer February 27, 1997
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Chair Date