The National Committee on Vital and Health Statistics was convened on Wednesday and Thursday, November 5-6, in the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Present:
Don E. Detmer, M.D., Chair
Hortensia Amaro, Ph.D.
Jeffrey S.
Blair, M.B.A.
Simon P. Cohn, M.D., M.P.H.
Kathryn L. Coltin,
M.P.H.
Kathleen Frawley, J.D., M.S., RRA
Daniel J. Friedman,
Ph.D.
Kathleen Fyffe, M.A.
Robert M. Gellman, J.D.
Richard
Harding, M.D.
Lisa Iezzoni, M.D., M.S.
John R. Lumpkin, M.D.,
M.P.H.
Clement Joseph McDonald, M.D.
Vincent Mor, Ph.D.
Barbara
Starfield, M.D.
M. Elizabeth Ward, M.N.
Marjorie Greenberg, National Center for Health Statistics (NCHS),
Executive Secretary
Lynnette Araki, NCHS
Harvey Schwartz, Ph.D.,
Agency for Health Care Policy and Research liaison
Bob Moore, Health
Care Financing Administration liaison
James Scanlon, HHS Executive
Staff Director
Gail F. Fisher, Ph.D., NCHS, Former Executive
Secretary
Jackie Adler, NCHS
Dennis Melamed, Health Information Privacy Alert
Donna Pickett, NCHS
Larry Watkin, Medic Computer Systems, Inc.
Gary Dickinson, Medaphis
Chris Bergsten, AAHP
Bill Sobaski,
HCFA
Mark Epstein, Sc.D., NAHDO
Mike Galdun, Northrop
Durwin
Day, BCBS of IL
Maria Ward, BCBS of IL
Gale Carter, Anthem BCBS
Patricia Vaive, NCHS
Jeanne Gilliland, CDC
Robert Mayes,
HCFA
Michael Tate, American Dental Assn.
Michael Kremer, NCHS
Karen Sealander, McDermott Mill & Emery
Robert Iadicicco,
Gordon & Barnett
Michael Strazzella, ASCP
Theresa
Cendrowska, ASTM
Jean Narcisi, AMA
Mark Gordon, Thomas Boyson
State College
G Moulton, BNA
Brett Baker, ASIM
John
Geisser, Int. Billing Assoc.
Susan Joan Mauriello, Wexler Group
Doug
Peddicord, Washington Health Advocates
Caroline Glowacki,
ConnectiCare, Inc.
David Berglund, M.D., NCHS
Lois Schein, HCFA
Kepa Zubeldia, Envoy Corp.
Kathryn Foxhal, St. Anthony Publs.
Luis Kun, Ph.D., AHCPR
Carolyn Rimes, HCFA
James Kuhn,
Consultant
Andrea Hatch, Washington Health Week
Barbara
Mayerick, Dept. of Veterans Affairs
Donna Shelton,, NACHRI
Leslie
Cooper, Ph.D., NIDA
Colleen McCabe, Assn. of American Medical
Colleges
Susan Phillips, Nortel
Jim Klein, EDS
Brenda
Gillum, Consumer Product Safety Commission
Helene Guilfoy, Catholic
Health Initiatives
Henry Heffernan, EDPNS
Phyllis Doulaveris,
NCHS
Mary Emerson, HCFA
Robert Tennant, MGMA
G. White, NCHS
Frank Pokorny, BCBS Assn.
Mary Lynn Burhman, Xact Medicare
Julie
Meehan, Xact Medicare
Dr. Leslie Cooper, NIDA
Melody Cathey,
IAIABC
Robert Beck, MultiState Associates
Tom Montgomery,
College of American Pathologists
Bob Sargis, Admin. for Child and
Families
Gary Friend, IMS America
Cathy Brady, ACLI
Kristin
Steward, Amer. Assn. of Health Plans
Grace Escario Birch Davis Assoc.
Eric Stas, Multinational Business Services
Michael Lynd, Reason
Elizabeth Gibbons, CD Publications
Brett Baker, ASIM
5. Dr. Sondik asked the Committee to think about two proposed meetings or workshops, which he briefly described. He also asked for guidance for the National Center for Health Statistics on meeting the need for local data and for data on specific racial and ethnic groups, and on the privacy of genetic information.
6. Ms. Humphreys noted that the National Library of Medicine may need the Committee's advice on an emerging legislative issue regarding copyright of databases, which could restrict access.
7. Dr. Jencks said HCFA hopes to work in partnership with the Committee in developing an integrated data strategy for post-acute care. This point was later reiterated by Mr. Mayes.
8. Dr. Simpson noted the potential roles for the Committee in 1) facilitating a public-private dialogue on creating clinical systems that generate needed information as a byproduct of care, and 2) challenging researchers to assume greater responsibility for data security and privacy.
9. Dr. Sondik stressed the Department's need for the Committee's help in identifying the values and principles on the basis of which the contribution of information gathering to improving the system can be assessed.
10. Dr. Amaro called for an ongoing mechanism within the Department for developing and pursuing an agenda around data on vulnerable populations. Dr. Sondik agreed, but also stressed the key role of the Committee in this area.
11. Subcommittee chairs were asked to review a list of outstanding Committee activities since 1990 that have been referred to various subcommittees, to be discussed at the Executive Subcommittee retreat.
12. Future meetings: The full Committee's March meeting is March 3 and 4. The 2nd and 5th are reserved for possible Subcommittee use. A hearing on the unique personal identifier will take place on May 4-5 in Chicago and in Washington on June 15 (the day before the full Committee meeting).
13. Ms. Freedman said she would supply the Committee with a description of the birth record as currently specified for automatic collection. She also said that NCHS could compile an analysis of the privacy protections for birth records at the state level.
(Note: Subcommittee work plan items that were mentioned in the Subcommittee reports are included in the summary below but not listed here.)
14. The Committee passed a motion approving the draft annual report on HIPAA activities and authorizing the Executive Subcommittee to make final revisions before sending the report to Congress and putting it on the NCVHS Web site.
15. Regarding post-acute care, several actions were taken:
· The Committee asked HCFA for a list of its activities in this area.
· HCFA asked the Committee to help conceptualize its data gathering in this area.
· A Committee liaison to HCFA for these activities was proposed, a role in which Dr. Mor will be asked to serve.
· The Committee will talk with the Data Council about coordination of legislatively mandated data collection and reporting.
16. Mr. Moore promised to bring to the Subcommittee the results of HCFA's work on an encounter data set for managed care.
17. Members were asked to inform Ms. Greenberg of their public presentations and to give her or Ms. Ward their ideas for public education (i.e., for the general public). Ms. Ward asked that this topic be discussed at the January Executive Subcommittee meeting.
Dr. Detmer introduced and welcomed two new NCVHS members: Daniel Friedman, Ph.D. and Kathleen Fyffe, M.A.; a third new member, Paul Newacheck, Dr.P.H., also has been appointed to the Committee.
In recognition of Dr. Gail Fisher's 18 years of service to the National Committee as its Executive Secretary, Dr. Detmer read a letter from former member Karel Weigel and presented Dr. Fisher with a plaque from the Committee and a certificate of appreciation from the Department. Dr. Fisher stressed her pleasure in working with the Committee, its importance in achieving comprehensive and useful health information, and the significant progress it has made in the last year.
The Committee was briefed by Data Council Co-Chair David Garrison and Dr. Bill Braithwaite. Mr. Garrison focused on the Department's work on strategic planning and performance evaluation and noted the strategic role of data in this effort. Dr. Braithwaite described the status of HIPAA implementation. The Implementation Guides for the transaction standards have been published on a Web site, and the Department hopes to publish its first NPRM in November. Decisions about maintenance will be deferred until after the standards are released, and then worked out with the SDOs.
Janet Corrigan, Executive Director
Introducing Dr. Corrigan, Dr. Detmer stressed the Committee's long history in the area of assessing quality of care. She affirmed this history and the fact that the Committee is a resource to the Commission. Dr. Corrigan gave an overview of the Commission, its time frame, and the current status of its work. It will release the Consumer Bill of Rights, its first product, this month. The next part of the mandate is to develop a quality framework for the health care industry. It has one year to complete its objectives, using four subcommittees. The approach assumes incremental change and reform. The group, which is co-chaired by Secretary Shalala and Secretary Herman, operates by consensus. Its final report is due at the end of March 1998. It is giving special attention to quality of care for vulnerable populations. Another theme is the need for a set of national aims for improving health care.
In the discussion period, Dr. Iezzoni expressed concern that the Commission subcommittee with which she met seemed unaware of HIPAA and the Department's movement toward standardization of data elements. She noted that conversely, the National Committee should keep in mind the need to use data to evaluate quality. The relevance of the core data elements was also noted, and Dr. Starfield urged the Commission to make a strong statement about the need for certain data in order to look at quality of care. The group discussed the balance between a patient- centered and population-centered orientation in the Commission's efforts.
The Commission will address the issue of the unique patient identifier early in 1998. Dr. Amaro suggested that the Committee look at the commission's thinking on this issue.
Dr. Corrigan promised to provide copies of her slides, the Consumer Bill of Rights, and a draft outline of the final report.
The Commission's Web address: HTTP:\HCQUALITYCOMMISSION.GOV
In conclusion, Dr. Detmer stressed the Committee's interest in continuing to track the Commission's work, owing to their overlapping concerns. He noted that the Committee's role in this area particularly relates to the development of an infrastructure for standardized data collection and reporting -- a precondition for quality measurement. He asked for a follow up briefing when the report is out, and proposed that meanwhile the Committee consider giving more attention to quality issues in next year's work plan.
Lisa Simpson, M.D., Deputy Director, AHCPR
Dr. Simpson gave an overview of AHCPR-sponsored research related to quality and of some of its data collection efforts, notably MEPS, as well as its infrastructure work. She highlighted the need to move toward automating the patient record and the need for further action regarding privacy/confidentiality and researcher access to data. She also noted the importance of balancing the roles of the public and private sectors in data collection.
Ed Sondik, Ph.D., Director, NCHS
Dr. Sondik reviewed several initiatives from the standpoint of where the Center particularly needs input from the Committee. He noted the work on HANES and SLAIT as well as the study of the information needs for understanding a changed health care system. In all of these areas, he asked for the Committee's input on issues related to quality. Noting that he was "kicking off" the Committee's new advisory role for the Center, he proposed two meetings or workshops that he asked the Committee to think about. The first would address new directions in health statistics in general; the second would focus on NCHS and what it should look like in the coming years, given the trends identified in the first meeting. These meetings would include participation by several agencies and would be held in collaboration with the Committee on National Statistics.
In addition, he asked for guidance on how to meet the need for local data and for data on specific racial and ethnic groups. He also called attention to issues related to the privacy of genetic information, which he predicted would inevitably become part of individual medical records.
Betsy Humphreys, Assistant Director, National Library of Medicine
Ms. Humphreys gave a brief general overview of NLM activity and noted that the Department may need the Committee's advice on an emerging legislative issue regarding copyright of databases, which could restrict access. Other issues she highlighted included anticipated NLM- funded studies on making the Internet safe for routine health care and on what would be reasonable security practices, and the Library's continuing work on the UMLS meta-thesaurus.
Stephen Jencks, M.D., HCFA
Dr. Jencks described some of the guiding principles of the HCFA reorganization, which is intended to make it a value-based purchaser. The agency is working to align Medicare and Medicaid, address issues of quality and accountability, and work with industry and other agencies and consumer groups. He called special attention to performance measurement as an issue of common concern between HCFA and the Committee, noting that HCFA pursues it through internal studies, partnerships, contracts, and requirements on providers and plans. The agency hopes for Committee leadership in the future in several areas, notably working in partnership to develop an integrated data strategy for post-acute care. It is also interested in extending core data sets into use in the broader range of care.
The panelists were asked how their agencies view both the role of the Committee and its core data recommendations. Dr. Simpson said the Committee can play a key role in facilitating a public-private dialogue on creating clinical systems that generate needed information as a byproduct of care. She noted that this is a good time to leverage the private sector's capacity- building and to consider the optimum use of agency resources and programs. Ms. Humphreys agreed, but recommended caution in framing the discussion of core data elements so they are not perceived as imposed on providers, but rather in terms of their clinical utility.
Dr. Mor noted that the agencies represented share with the Committee a concern about how to simultaneously protect individual privacy and get the greatest use out of data. One response was a reminder to learn from the states in this area; another comment was that researchers need to "step up to the plate" and address their responsibilities in this area, something the Committee can help spur them to do.
Dr. Lumpkin reminded everyone to stay mindful of the purpose of information gathering and the consequences for providers and patients of increased demands for information. The question is whether the system is being improved as a result, and answering this question depends on clarifying fundamental principles in order to test whether they are being achieved. The Committee can help agencies think outside their bureaucratic boxes and define health more broadly and more as it is pursued at the local level, such as by community health agencies.
Dr. Iezzoni raised the issue of language in respect to getting information from consumers, and the panelists agreed that this issue and its resource implications need to be addressed head on. The need to prioritize the use of scarce resources brought the discussion back to values and the question of what is most needed to improve the system. Dr. Sondik stressed that the Department needs the Committee's help in addressing this question.
Dr. Amaro called for an ongoing mechanism within the Department for developing and pursuing an agenda around data on vulnerable populations. Dr. Sondik agreed, but also stressed the key role of the Committee in this area.
Mary Ann Freedman reported on various activities of the Vital Statistics program at NCHS, including the electronic birth certificate, the electronic death certificate, and plans to revise the standard certificate. Concern was expressed about the transition to ICD-10 in 1999 and a feared loss of comparability in the nation's statistics, and she described the efforts to assure comparability and smooth the transition. Variations in state practices in regard to protecting records led to the comment that the idea of not preempting state law should perhaps be revisited in proposed federal confidentiality legislation. It was noted that efforts to automate birth and death registration, and a special effort to link the birth certificate to the OB clinical record, should be coordinated with broader standardization activities in which the Committee is involved.
Dr. Bill Raub spoke on the Department's activities related to genetic data and confidentiality. Generally, genetics information is regarded as a subset of health information and is covered by general health information policy. However, he discussed four important exceptions that are receiving special attention: genetics and discrimination with respect to health insurance, access and coverage; discrimination in the workplace based on genetic information; genetic testing of stored human tissue samples; and response to a recent report of the Task Force on Genetic Testing, commissioned by the Human Genome Project. Dr. Raub is part of an implementation group that is preparing recommendations for the Secretary in response to the issues raised by that report. Reports and recommendations are being developed in each of the other areas as well.
Subcommittee on Privacy and Confidentiality
The Subcommittee will probably meet in January to address the following topics:
Subcommittee on Health Data Needs, Standards and Security
· Claims attachments: Work on this will begin with a February 9-10 hearing, the goal of which is to identify the core issues and decide how to deal with them.
· Data standards, ownership and maintenance: Work on this will be deferred for about six months.
· Unique patient identifier: The Subcommittee proposes several hearings on this, with the participation of other Subcommittees or the full Committee.
· Computerized patient record: The first step is to read the 1997 update of the National Academy IOM report.
· Core data elements and their applications: The Subcommittee will routinely revisit this issue.
· Annual report: At the Subcommittee's request, the full Committee passed a motion essentially approving the draft annual report on the Committee's HIPAA-related activities and authorizing the Executive Subcommittee to review and revise it as necessary before forwarding it to Congress. The report also will be posted on the NCVHS Web site, along with a summary of other Committee accomplishments.
Subcommittee on Population Specific Issues
· Medicaid managed care: At hearings on January 12-13, the Subcommittee will start hearing from the field about its questions about Medicaid managed care. A contractor will then develop a report on the findings from that hearing, Medicaid data reporting requirements, and gaps in the ability to answer the questions that are identified. The Subcommittee will make site visits to Phoenix in February and Boston in April.
· OMB Directive 15 rules: The Subcommittee will follow up on the recent OMB decisions by focusing on the issue of tabulation and getting continuity of data reporting around race and ethnicity. They hope to follow up with NCHS on this in the spring.
· Data on health services in the Territories: The December meeting has been canceled, but another will be scheduled on this topic.
· Uniform identifier: The Subcommittee recommends that the full Committee address this issue.
· OASIS: The Subcommittee's letter to HCFA about OASIS has only recently gotten to the right person. The Subcommittee has subsequently learned more about the multiplicity of HCFA data reporting initiatives for post-acute care, and it hopes to draft a letter to the Data Council that Dr. Detmer can submit on its behalf, expressing concerns about this matter.
The last item stimulated a lengthy discussion with Mr. Moore about the demands on HCFA, with Dr. Iezzoni stressing the Subcommittee's desire for better communication with HCFA on this subject. Mr. Mayes said HCFA would like the Committee's advice on conceptualizing data collection for post-acute care. The Committee asked for a list of what HCFA is working on in this area. Mr. Moore promised to bring to the Subcommittee the results of HCFA's work on what will be needed for an encounter data set for managed care. Dr. McDonald urged that the Committee be brought into the process early enough to be able to advise before everything is decided. The group agreed that a Committee member, possibly Dr. Mor, should be a liaison to HCFA for the post-acute care project. In this context, the Committee agreed to talk with the Data Council about the coordination of legislatively mandated data collection and reporting.
Ms. Ward suggested that in January the Executive Subcommittee discuss what the Committee might do in the area of public education, as distinct from educating people in the field.
All members were asked to let Ms. Greenberg know when they are doing public presentations that touch on Committee activities.
Ms. Ward also asked members to let her or Ms. Greenberg know of any ideas they have for public education.
Ms. Ball asked for the names and addresses of organizations that should be targeted in the education effort directed at the health field, including the presence of mailing lists and newsletters.
Dr. Detmer introduced and welcomed the three new members of the Committee:
· Daniel Friedman, Ph.D., Assistant Commissioner, Bureau of Health Statistics, Massachusetts Department of Health. Dr. Friedman, who directs the Division on Health Statistics and Research, has been a leader in the development of public health data and methods for data dissemination.
· Kathleen Fyffe, M.A., Federal Legislative Director, Health Insurance Association of America. Ms. Fyffe is a member of the National Uniform Billing Committee, the National Uniform Claim Committee, and WEDI.
· Paul Newacheck, Dr.P.H., Professor of Health Policy and Pediatrics, Institute for Health Policy Studies, University of California at San Francisco; Professor of Health and Medical Sciences, School of Public Health, UC Berkeley. Dr. Newacheck is a health services researcher with a special interest in the health care and access issues of children with special needs. He was not able to attend the meeting.
Following introductions of everyone present, Dr. Detmer reviewed the agenda, noting that the work plan for the coming year would receive a lot of attention.
Dr. Fisher retired earlier this year as Executive Secretary, after serving in this capacity since 1981. Dr. Detmer read aloud a letter from former NCVHS member Karel Weigel, expressing appreciation for Dr. Fisher's contributions and noting her commitment to forging public-private partnerships, her diplomacy, and her "gentle guidance" to the Committee. He then presented her with a plaque expressing the Committee's appreciation for her 18 years of service, and a certificate of appreciation from the Department.
In her response, Dr. Fisher stressed the Committee's importance, her pleasure in working with it, and her satisfaction at its progress in the past year. She predicted the eventual achievement of the goal proclaimed 35 years ago by former Chair Dr. Kerr White: a comprehensive system of population-based health statistics that is useful at the program and community level. She praised the Committee's current membership, leadership and staff.
David Garrison, Co-Chair of the Data Council, acknowledged the excellent work of this Committee and welcomed new members. He reported that the Secretary has implemented a policy requiring, as of November 1, the inclusion of information on race and ethnicity in virtually all HHS data collection systems, using at least the minimum standards for reporting.
In the privacy area, the Secretary forwarded the Department's recommendations on medical record confidentiality to Congress on September 11. Departmental staff have begun working with Senator Jeffords' staff to draft legislation to establish national standards to protect medical information and further the quality of care for all Americans.
The Department has complied with the Government Performance and Results Act, which requires all federal agencies to submit a strategic plan to Congress by September 30. It developed its plan through extensive public consultation. Annual performance plans establishing quantifiable performance goals for the strategic plan will be submitted as part of the President's 1999 budget by early February 1998. Agencies are required to issue annual performance reports beginning in the year 2000. Mr. Garrison noted that this process forcefully introduces performance-based planning into the Department's procedures. The Department has concerns about data gaps, timeliness, and the difficulty of attributing program causality to changes in complex outcomes. The shift toward accountability, results and evidence-based decisions points to new investments in data, and the Department looks forward to working with the Committee on this effort.
In response, Dr. Detmer expressed appreciation for the solid hearings the Council gives the Committee's input as conveyed by its representatives.
(The update continues below, with Dr. Braithwaite's presentation.)
Dr. Detmer then welcomed Dr. Janet Corrigan, Executive Director of the Commission. He noted the National Committee's history around issues of quality assessment, particularly through the work of the Subcommittee on Ambulatory and Hospital Care Statistics as well as through meetings of the full Committee with NCQA, JCAHO and others. He observed that although there is considerable interest these days in the quality of care and concern about the variance in care around the country, we still do not know how to measure it. He stressed the Committee's interest in this issue and its availability as a resource to the Commission.
Dr. Corrigan explained that President Clinton created the Commission last March to address the concerns of consumers and professionals and other workers. Co-chaired by Secretaries Shalala and Herman, it has 34 members encompassing business, providers, home health, insurers, and the public sector. Recent NCVHS member Sheila Leatherman chairs one of the subcommittees.
The group has a year to accomplish its objectives, which it sees as part of a broader, incremental process of reform in which many are engaged. It will produce two reports: the Consumer Bill of Rights and Responsibilities, to be released in mid-November, and a final report, due out at the end of March. The goal of the co-chairs is to operate by consensus so that the group's decisions represent something everyone can agree on. Meetings are open to the public, and there is a Web site ( http:\hcqualitycommission.gov).
The mandate is two-pronged: consumer protection and developing a quality framework. Work in the first area has focused on the types of information people need to make good decisions and to drive the marketplace toward quality improvement. There are four subcommittees: on Consumer Rights, Protections and Responsibilities; on Performance and Quality Measurement; Creating a Quality Improvement Environment; and Rules and Responsibilities of Public and Private Purchasers and of Quality Oversight Organizations.
Dr. Corrigan briefed the Committee on the status of the Bill of Rights activity, in the context of which a new issue has arisen about an ombudsperson program. She then described the activities of each of the subcommittees. The one on Quality Measures, chaired by Ms. Leatherman, will report to the full Commission in December or January. Among other topics, it is looking at whether current quality measurement activities adequately cover the care provided to vulnerable populations. Dr. Corrigan added that vulnerable populations are a theme throughout the Commission's work. (She later defined this population as including the disabled, the chronically ill and the poor, particularly Medicaid beneficiaries.) The Subcommittee on the Quality Improvement Environment is looking at issues of leadership and at various work force issues because of concerns about low worker morale.
In the discussion period, Dr. Detmer expressed appreciation to the President and Secretary Shalala for creating this Commission and predicted that it would make a valuable contribution to the nation.
Dr. Iezzoni, who testified before Ms. Leatherman's Subcommittee, said she was impressed by their thoughtful approach but surprised at their apparent unawareness of the Department's work on standardization and administrative simplification. Conversely, she reported that former NCVHS member Dr. Risa Lavizzo-Mourey, a Commission member, asked her whether the Department and Committee are keeping in mind the need to use data to evaluate quality.
Dr. Starfield asked whether the Commission was taking into account the core data elements, and she urged that they come out strongly on the need for certain data to look at quality of care. She also wondered whether the Consumer Bill of Rights would only support reactive stances by consumers, but Dr. Corrigan said it goes further than that.
Mr. Gellman noted the tension between the patient's right to know and the provider's interest in keeping some aspects of operations confidential. Dr. Corrigan said the Commission has heard testimony on that, and the report will address it.
Asked to expand on her comment about work force morale, she said the focus has been not on administrative burden but on what organizational characteristics and models of care lead to higher morale for staff across the spectrum from physicians to aides.
In response to another question, Dr. Corrigan said she did not know if the Commission would comment on the unique patient identifier and its impact on consumer protection, but it will look at the issue early next year. Dr. Amaro suggested that the Committee look at the Commission's thinking in this area. She then asked how the issue of access for non-English- speaking populations is conceptualized, and was told that the Bill of Rights calls for culturally competent networks.
Dr. Corrigan promised, upon request, to provide the Committee with copies of her slides, the Consumer Bill of Rights document, and the draft outline for the final report.
Dr. Starfield pointed out the need for a population-centered approach in looking at quality of care, beyond simply looking at health plans. Dr. Corrigan said the Commission was not charged with reforming the health care system or addressing the problems of the uninsured, but it does have a population-wide perspective in considering quality measures and covers all types of health insurance, not just managed care.
Dr. Detmer noted Len Ethridge's observation that the country is at the same stage with respect to health care systems as it was after the 1929 crash with respect to financial institutions; in both cases, standardized measurement tools were and are needed. He also noted that a health systems approach in looking at quality clearly deals with populations. The Committee's role is to help build the infrastructure for this effort. He asked Dr. Corrigan to report back to the Committee when it completes its report, and suggested that the Committee include quality in its work plan for the coming year.
Lisa Simpson, M.D., Deputy Director, AHCPR
Dr. Simpson said advancing quality in health care is central to her agency's work. She called attention to the importance of system safety for quality, and to the recent expansion of child health insurance through the Balanced Budget Act. She then highlighted aspects of AHCPR's research portfolio, which seeks to know what people want and how they are going to use it, what works and what doesn't, and how to get this information to the decision makers. She gave examples of investigator-initiated and targeted research sponsored by AHCPR, noting that the unit of analysis needs to be the provider level, not just the plan level.
The agency's data collection efforts also contribute to improving quality of care -- e.g., the Medical Expenditure Panel Survey (MEPS) and the Health Care Cost and Utilization Project, the latter in partnership with states. MEPS surveys access to care, a key facet of quality, as well as patients' experience of care. It covers nursing homes.
AHCPR's infrastructure work is aimed at standardization, which is necessary for comparisons. It works closely with the key private sector groups, supports broader initiatives on the health information infrastructure, and provides technical expertise to Departmental committees. It is also working toward development of the electronic medical record.
Finally, Dr. Simpson called attention to the need for balance between private and public sector roles, and to the overarching issues of privacy, confidentiality and researcher access to data.
Dr. Ed Sondik, Director, National Center for Health Statistics
Dr. Sondik extended his good wishes and thanks to Dr. Fisher. He said his remarks would focus on areas where the Center needs the Committee's input and guidance. First, it is designing a new, continuous HANES, which in turn has significance for Healthy People 2010 by providing hard clinical measurements to supplement self-reported data. The Center is also looking at ways to make HANES more portable. In addition, it is currently testing the State and Local Area Integrated Telephone Survey (SLAITS) for use in gathering information on topics that may include health care quality and welfare. This is seen as an adjunct to the BRFSS.
A general issue is how to collect data on a changing health care system, something the Department is studying extensively, with results expected in about a year. Dr. Sondik noted that the system is no longer based on edifices, but rather on networking. NCHS is collaborating with AHCPR on quality issues in a few areas.
He invited the Committee's input on any and all of the aforementioned activities, and mentioned a recent meeting held to discuss how NCHS can get guidance from and work with the National Committee as its advisory body. He asked for guidance on the major directions the Center should take in health statistics -- e.g., on the use of administrative data and the tension between data dissemination and privacy. Specifically, he asked the Committee to think about holding two workshops in collaboration with the Committee on National Statistics. The first, involving not only the Center but other Department agencies, might focus on the major directions and changes in health statistics; a second would focus on the implications of these changes for NCHS.
A specific area in which the Center needs guidance is in meeting the need for better minority statistics and for local data, despite scarce resources. Dr. Sondik also expressed concern about growing issues around genetic information and privacy.
Betsy Humphreys, Assistant Director, National Library of Medicine
Ms. Humphreys said NLM is interested in patient record systems that generate clinical and health services research and public data as a byproduct of health care delivery, and that also support sophisticated integration of knowledge-based information into the process of care. The Library supports work in all of those areas, along with a strong focus on evaluating telemedicine systems. It also works on infrastructure issues in information access, including privacy, security and standards.
She called attention to the possibility that legislation and treaties on intellectual property might be extended to protect electronic health data in ways that could restrict legitimate access to them. This is an issue on which the Committee may need to advise the Secretary.
The NLM is funding a study by the National Research Council on what would be required to make the next generation Internet safe or useful for routine health care. It is also making sure that privacy legislation does not have "a great chilling effect" on the release of public use data sets. The thrust of its recommendation is that if people do malevolent or inappropriate things with data, the onus should be on them, not on those who released the data following reasonable practices. The question of what reasonable practices are may be addressed by another IOM study.
NLM continues its work on vocabulary through its Unified Medical Language System (UMLS) meta-thesaurus. This will further Kennedy-Kassebaum implementation by serving as a vehicle for distributing standard code sets and specific clinical vocabularies, for mapping between levels, and for distributing information about which vocabularies are valid for which types of clinical messages.
Dr. Stephen Jencks, Health Care Financing Administration
Dr. Jencks stressed that HCFA is reconstituting itself to become a value-based purchaser with accountability for value and thus for results. It intends to integrate its approach for Medicare and Medicaid, with a goal of evaluating managed care and fee-for-service on a level playing field. It has been an active (but not dominant) participant in the HEDIS process, and plans to publish for public comment a set of desiderata for managed care plans. It also is taking a special look at dual eligibles. He invited the Committee's help in bringing together the interests of the agency, providers and plans to help HCFA create a workable system of accountability. The agency is setting priorities for what it wants to improve and thus needs to measure, as part of an overall strategy that begins with assessing population needs. Dr. Jencks stressed the critical role of data in this effort.
In regard to quality, he noted that HCFA is one of many players working on such things as performance measurement. It uses contracts to get its desired results. The new Center for Beneficiary Studies is developing information and technical assistance to help beneficiaries make health care decisions.
Dr. Jencks praised the Committee's leadership on administrative data and noted that there are many other places where it might be applied. Development of an integrated data strategy for post-acute care is a priority area for HCFA. He noted the possibility of extending the notion of core data sets to the broader range of care.
Dr. Starfield noted the shared interest in integrated data that is useful as information, and asked the panelists how their agencies are thinking about core data. Dr. Simpson stressed the need to think more about how to achieve the goal of having information be a byproduct of the process of care, something the Committee could help with. With the private sector building capacity, the timing is right for a public/private dialogue.
Ms. Humphreys stressed the need for a strategy emphasizing the common interests of those who want good clinical information systems and those who want core data elements, avoiding any sense of imposing core data elements on those working on clinical information.
Dr. Mor noted the emergence of a paradigm that is already operative in the nursing home world, of information being valuable first to the person generating it. He observed that the panelists' agencies and the Committee have a shared interest in finding the balance point between the optimal use of information and protection of privacy/confidentiality. Dr. Sondik suggested looking at state approaches to finding this balance. Ms. Humphreys pointed out that researchers themselves have a professional responsibility to address confidentiality issues, and NCVHS could help spur this. In response to a question from Ms. Ward, she described some of NLM's initiatives with other agencies to facilitate partnerships and generate more data for public health uses. She noted that NLM has a database of full text guidelines.
Dr. Lumpkin challenged his colleagues to keep in mind the burden of information gathering on providers, and the need to evaluate this in terms of whether it is leading to any improvements in the system. For instance, are local health departments, the front line of service delivery, being provided with useful tools for carrying out their public health mission? He noted the need to bring together diverse data sets, broadening the definition of "health" to encompass environment, nutrition, socioeconomic factors, etc. -- a process the Committee might help the agencies accomplish.
Dr. Iezzoni raised the issue of language, with growing proportions of many state populations not speaking English even as statistical agencies rely increasingly on consumers as the source of information. The panelists all agreed that this contradiction must be addressed head-on, and that it will require resources to do so along with a clear set of priorities. Dr. Sondik observed that this points to the need for a set of principles for evaluating progress, including the basic question of what is health.
Dr. Cohn asked if the Data Council was coordinating the diverse efforts of the various agencies, and Dr. Jencks said it was unrealistic to expect an overall integrated data strategy. The key question to ask is whether each agency is using all the information and potential partners at its disposal. Dr. Simpson and Dr. Sondik said they have seen much more cooperation and coordination within the Department of late, especially around the priority area of quality.
Dr. Amaro observed that there is a good deal of talk but not much progress about collecting data on vulnerable populations. This suggests the need for an ongoing structure for developing the agenda in this area, with a broad array of people at the table in that discussion. She proposed that the Committee help set up such a mechanism. Dr. Sondik agreed on the need for Departmental work in this area, but he stressed the importance of the Committee's guidance on it.
Finally, Dr. Harding observed that without trust the data collected will simply be "baloney." Dr. Jencks responded that HCFA is very sensitive to this issue and is aware that the health care system is not doing a very good job in measuring things. Dr. Simpson observed that the benefits and value of health services research for the public need to be communicated more effectively.
Dr. Braithwaite reported on the implementation of administrative simplification standards. Decisions about all standards except the personal identifier have been made. Implementation Guides for the transaction standards are available on the Web site of the Washington Publishing Company (http://www.wpc-edi.com/hipaa/) while the Department continues work on the Notices of Proposed Rulemaking (NPRMs). The final rules must be published by the end of February 1998. The nine transaction standards and various supporting standards have been aggregated into six NPRMs, most of which are drafted. In the process, the Department has encountered and resolved various legal issues and wording problems. The goal is to publish at least one NPRM by the end of November.
On the personal identifier, the Department believes that the Committee's recommendation that nothing should be done until Congress has passed privacy legislation does not meet the intent of the law. It is therefore laying out the options and deciding how to elicit public comment prior to a Department-level decision. The final rule will probably be delayed beyond the others.
The Department is also working on the infrastructure for maintaining the standards, and talking with the SDOs about a fast-track process to keep up with the business needs of the community. The development teams have done good work on developing consensus in each of these areas.
Dr. McDonald noted the desirability of flexibility, which can be achieved by keeping rapidly changing material out of the standard. He asked about the possibility of a subgroup that could more quickly manipulate fast-moving codes that are left in a more public area. Dr. Braithwaite said the law separates the maintenance of the code sets and of the transmission standards, and indeed some code sets are maintained by other bodies (e.g., CPT). This principle is being embodied in the standards. Asked about the broader question of updating and version control for the standards, he said that most maintenance decisions are being deferred until after the standards are out. They will then be worked out through an industry-wide consensus process. Eventually, the maintenance process will be discussed in NPRMS, but not initially.
Dr. Detmer asked the Subcommittees to consider the personal identifier issue in their afternoon meetings, in view of the Department's desire to make a decision. The key question for the Committee is what process and time line it would recommend for developing the recommendations. Ms. Frawley said the Data Council has suggested that a notice of intent would be useful, and the Committee could help elicit input from industry. The Council has concerns about cost-benefit, utility, and privacy, and has proposed that the Committee hold a hearing. Ms. Greenberg added that there was also talk about the need for public education on this issue.
Dr. Lumpkin pointed out that the Committee's role is to gather input and promote discussion; once the NPRM is published and the Department receives comments, the Department is charged with summarizing and responding to the public comments. Dr. Braithwaite noted that HIPAA does ask the Committee to keep tabs on implementation.
The group then recessed until the following day.
Dr. Lumpkin chaired the meeting this day, in Dr. Detmer's absence.
For the Planning and Implementation Work Group, Ms. Coltin called attention to a list of outstanding Committee activities since 1990, with referrals to various subcommittees. She asked chairs to review the lists prior to the Executive Subcommittee retreat.
Dr. Cohn noted that the National Conference on Terminology for Clinical Patient Description would take place November 12-14.
The Committee confirmed that its March meeting would be March 3 and 4. The 2nd and 5th are reserved for possible Subcommittee use. They agreed to hold a hearing on the unique personal identifier on May 4-5 in Chicago, and another in Washington on June 15 (the day before the full Committee meeting).
Ms. Greenberg invited comments from members on the reformatted work plan.
Ms. Freedman explained that legal authority for registering births and deaths rests with the states and territories, while NCHS is legally required to collect data from the states. This collaborative effort began in the early 1900s and is now formalized as the Vital Statistics Cooperative Program. Computerized data are obtained from the states, and NCHS works with them to develop the program and determine the data content.
Recently, the Preliminary Vital Statistics Series has allowed the release of detailed data a year earlier than previously. In addition, the Center is working with states to speed up the production of final files. It is also revising the software it provides to states for death reporting so that is ready for the implementation of ICD-10 in 1999.
Regarding the automated registration systems, Ms. Freedman said capturing and reporting information in electronic form is relatively new. The first electronic birth certificate was in the early 1980s. She described recent changes in the birth registration systems. At present, 85 percent of births in the U.S. are registered electronically, and over half of the states register virtually all births electronically. The Social Security Administration helped fund the expansion of the electronic birth certificate (EBC) as a vehicle through which parents can order a social security number.
In the future, NCHS envisions a computerized labor and delivery record, with the birth certificate being a byproduct of it. Ms. Freedman described a recent collaboration with the American College of Obstetrics and Gynecology (ACOG) and other bodies to sponsor a workshop on options for computerized OB records. The meeting generated a coalition to further the effort, with a steering committee and a staged plan for proceeding.
Electronic death registration has been slower to develop because of its greater complexity and the large number of players. To steer the evolutionary process away from incompatible state efforts, NCHS and NAPHSIS set up a steering committee in 1994 to look at the process and recommend the optimal system. They issued their report in December 1996 after two years of meeting. They recommended a state-based system and two phases of reporting, with the fact of death reported within one day and the cause of death and demographics within four. This provides more time for information gathering on the cause of death. The steering committee also recommended that NCHS convene an ongoing oversight group to encourage efforts in electronic death registration. Ms. Freedman described a few state activities and said New York may provide a model for the nation. It hopes to implement its system state-wide in the spring, following beta testing.
She then described the Center's work in regard to standard certificates, for which it will probably recommend a revision in the year 2002. The standard revision procedure is for NCHS to appoint an expert panel which reviews and refines current documents and considers what information is needed, ensuring that the system meets legal requirements. This time, the recommendation will be not for a paper document but for a data set and a mechanism for obtaining it. The Center has surveyed some 1,700 individuals and organizations, including NCVHS members, and it is building a database of the responses. The panel (which is now being appointed and will meet first in January 1998) will also receive written and oral testimony. It is expected to make its recommendations to NCHS by the summer of 1999.
In response to a question from Mr. Blair, Ms. Freedman said genetic information is neither explicitly included nor excluded from the scope and expertise of the panel. At Mr. Gellman's request, she described the state policies on disclosure and those of NCHS, noting that at the national level they do not deal with identifiable data. States vary widely, with 18 "open record" states imposing virtually no restrictions on access to birth and death records. Some open record states restrict access to the medical and health information. She said she would supply the Committee with a description of the birth record as currently specified for automatic collection.
Dr. Lumpkin noted that even in closed states, there are referrals of pertinent information when intervention is indicated. Mr. Gellman said his concern was that proposed medical privacy bills say that state vital statistics laws should not be preempted, and this should perhaps be reexamined. He urged Ms. Freedman to ensure that the privacy community is aware of these issues and that the Center benefits from their input as it develops policy. At Dr. Lumpkin's request, Ms. Freedman said that NCHS could compile an analysis of the privacy protections for birth records at the state level.
Ms. Coltin noted the many parallels between the vital statistics activities described above and the National Committee's work on standardization, and the potential benefits of coordination and broader thinking. For example, the data elements in vital records and in other transactions should be captured, defined and formatted in the same way. Also, the OB clinical record could be linked through the computerized patient record to the death certificate as well as the birth certificate. Dr. McDonald reinforced the point about standards, and Ms. Freedman said the Center is in touch with SDOs. Mr. Mayes added that ACOG's plan is to act in the HL7 context as a content specialty group, rather than doing its own technical work.
Dr. Cohn expressed concern about whether the character of data stores would remain consistent through the transition from ICD-9 to ICD-10, and whether the mappings are adequate. He wondered whether there would be major comparability problems before and after 1999. Ms. Freedman described some of the efforts to minimize the likelihood of that, and she said NCHS will not publish anything without publishing comparability ratios with the 1999 data. She acknowledged, however, that implementation is a major challenge, one that it is complicated by a NCHS tentative decision to revise the standard population for age adjustment in 1999. She and Ms. Greenberg said the U.S. has been doing most of the work on a crosswalk, and WHO will release one soon.
Ms. Coltin asked about efforts to improve cause of death statistics, and Ms. Freedman described several including a tailored exhibit that is taken to major medical meetings, basic how-to worksheets, and a study of what hampers accurate cause-of-death reporting. She said there is no standard audit of accuracy.
Dr. Raub said the general approach to genetics issues is that genetic information (including test results) is a subset of medical information, and therefore falls under the guidance on medical information. There are several exceptions, however, and he focused his remarks on four of them.
The first is genetics and discrimination with respect to health insurance, access and coverage, an area for which the Department had the lead in developing themes for the Executive Branch. The major concern is that when genetic information is used as a predictor of disease, especially for asymptomatic individuals, it can be abused in the health insurance system. The President has outlined principles to address that and encouraged Congress to pass laws to assure fairness.
The Department of Labor took the lead in the second area, discrimination in the workplace based on genetic information. This is a more complex area, partly because of safety and health issues. Several bills have already been proposed to address it.
The third area is genetic testing of stored human tissue samples, which is being studied by the National Bioethics Advisory Commission, which Dr. Raub serves as acting executive director. It is concerned with protecting human research subjects. In studying this issue, the commission has encountered very complex ethical, legal and social issues, among which informed consent looms large. Opinions vary widely on this question, which links to complex ethical questions.
The fourth area was addressed in a recent report of the Task Force on Genetic Testing, commissioned by the Human Genome Project. A work group in the Department has reconstituted itself as an implementation group to consider the issues raised in this report and make recommendations to the Secretary. The report discusses the need to balance the fostering of this technology with protection for the individuals involved. It identifies three key issues related to genetic testing: analytical validity, clinical validity, and clinical utility. The commission challenges the Department to find a regulatory schema to protect human subjects without hampering the appropriate development of the technology, and it cites the tools at the Department's disposal, such as the legislative authority for the FDA.
Dr. Raub offered to brief the Committee again, if asked, and he invited its comments.
Mr. Gellman observed that attempts to impose restrictions in this area are complicated by the difficulty of distinguishing among types of players. Dr. Raub said there is sensitivity to this fact, and the focus is on the potential for misusing particular information in particular contexts rather than on the collection of information per se.
Dr. McDonald noted that risk is not only predicted by DNA but by smoking and other factors, and he suggested not singling out particular measures. Dr. Raub agreed that this is a complication and said this issue is "well engaged by very knowledgeable people." Asked by Mr. Scanlon whether IRBs are equipped to deal with disclosure issues, he said most are not, partly because their knowledge of genetics is limited and partly because their traditional orientation is to protecting against invasive risk, and they are less sensitive to other "secondary" risks such as to privacy.
Dr. Harding observed that the core issue is discrimination and it stems from the current disparity between science's ability to diagnose using genetic information and its ability to treat. Dr. Raub agreed and said that because of this disparity, the task force has focused on "high dial" tests that should be subject to stringent scrutiny and also suggested criteria for that scrutiny. It is also "alarmed" about the absence of an educational and regulatory framework, given the prospects for abuse and misinterpretation. He stressed, however, that the task force does not regard the development of treatments as following easily from the diagnostic breakthroughs, because of the multifactorial nature of genetics and health. On the other hand, simplistic efforts to "wall off genetic information" are unworkable because it is implicit in much other health information (e.g., a child's cholesterol level). Dr. Lumpkin observed, as well, that states already test hundreds of thousands of children for genetic illnesses, as required by law.
Subcommittee on Privacy and Confidentiality
Mr. Gellman reported that the Subcommittee would meet in mid-January to address two topics: 1) defining "identifiable record" and 2) defining and exploring aspects of disease registries.
Subcommittee on Data Needs, Standards and Security
Dr. Starfield reported that the Subcommittee reviewed a draft annual report to Congress on progress on administrative simplification, prepared in compliance with HIPAA. The Committee passed a motion that the Executive Subcommittee finalize the report later in the month and forward it to Congress after the first NPRMs are published.
The Data Subcommittee also has looked at claims attachments and concluded that there is no standard definition for a claims attachment or its contents. It will hold a hearing on this matter on February 9-10 and try to identify the categories all of them have in common. Subcommittee members agreed to defer the large issue of data standards, ownership and maintenance for six months or more. They propose several hearings on the unique identifier involving several NCVHS Subcommittees.
The group will start its work on the computerized patient record by reviewing a 1997 IOM report, which revises a 1991 one. They will keep core data elements on their agenda.
Following up on the comments on the annual report, Ms. Greenberg called attention to a summary of the Committee's 1997 accomplishments, prepared for the Committee Management Office of the Department. It will be published on the Web site as a supplement to the aforementioned annual report. She invited comments on the summary.
Subcommittee on Population Specific Issues
Dr. Iezzoni reported that this Subcommittee started on its major initiative of looking at Medicaid managed care and data systems with a hearing on September 29-30 at which it heard from researchers. Next, it will elicit from the field what the questions are around Medicaid managed care, starting with a January 12-13 hearing. It will contract with a research organization to tie together what is learned at the January hearings, Medicaid's data reporting requirements, and where the gaps are in being able to answer the questions identified. The Subcommittee will do site visits in Phoenix in February and Boston in April.
In other areas, it will be looking at the issue of tabulation and data continuity in respect to the revised OMB Directive 15. Its letter of concern about HCFA's OASIS reporting system has only recently reached the right person. Dr. Iezzoni said the Subcommittee is finding that "administrative simplification has not yet hit the post-acute care world" and it has learned of five or six different initiatives to develop data reporting standards for post-acute care. The Subcommittee is drafting a letter to the Data Council calling attention to this situation, which Dr. Iezzoni described as "a mess" and something that has received little attention as the Department has focused on HIPAA-related work in the acute care and standard outpatient care arenas.
The Subcommittee also plans to hold a meeting sometime in 1998 on data on health care and health services in the Territories. It agrees with other Subcommittees that a hearing on the unique identifier should involve several Subcommittees or the full Committee.
Mr. Moore responded to the comments on OASIS and other HCFA activities on post-acute care data. He pointed out that HCFA is required to address "certain tactical initiatives" such as prospective payment; for example, it must start gathering OASIS data by July of 1998 in order to promulgate a rate in October 1999. Dr. Iezzoni acknowledged these pressures on the agency, but stressed that nevertheless HCFA's activities are running counter to the administrative simplification effort. The Subcommittee would like to understand the issues and offer advice as appropriate, but it has not received the kind of information from HCFA that would make this possible. In fact, the Subcommittee has had trouble getting people from HCFA to report to it on this topic.
Mr. Mayes observed that HCFA "lacks an overall framework," and he invited the Committee to help HCFA develop a model within which the pieces of post-acute care data can be linked and made comparable. Dr. McDonald and Dr. Iezzoni asked for a list of HCFA's activities in this area. In addition, the Committee agreed to designate a member, possibly Dr. Mor, as the liaison to HCFA on this project.
Dr. Schwartz noted that the Balanced Budget Amendment contains language that may authorize reporting of encounter level data to HCFA and that this has implications for the Medicaid managed care inquiry. Mr. Moore said the agency is starting to look at what would be needed for an encounter data set, and it will report to the Committee on its thinking when that process is complete. Dr. McDonald "pleaded" that HCFA share its thinking in all these areas before it has hardened into program decisions, so the Committee can offer suggestions when they can still make a difference.
Dr. Cohn expressed a desire to know more about how the Data Council works to coordinate data activities within HHS. This comment prompted considerable discussion. It was pointed out that inevitably, many activities that are a function of various legislative mandates are buried deep within single agencies. Many do not reach the awareness of the Data Council unless/until there is a problem. Part of the National Committee's role is to raise issues when it becomes aware of them, and then to work with the Data Council to resolve them. Mr. Scanlon pointed out that the Data Council is not a clearance body, and it only deals with interagency issues. Some problems should be resolved elsewhere than at the Data Council level, such as by special work groups.
Noting the limited resources of the NCVHS working group on public education, Ms. Ward said it set as its first priority preparing the industry for understanding forthcoming HIPAA regulations. This is being done mostly through the Department's outreach work and is not designed to call attention to or elucidate the role of the National Committee. A powerpoint presentation has been developed on HIPAA, and it was demonstrated prior to the end of the meeting.
The next task will be public education, which Ms. Ward hopes the Executive Subcommittee will discuss in January. She asked members to offer their suggestions about the public education campaign.
She also asked them to inform her or Ms. Greenberg about all public speaking engagements in which they are identified as NCVHS members, even if they are not speaking for the Committee. Specifically, Ms. Greenberg asked them to enter their information in a matrix that will be e-mailed to them, and also to comment on the headings, if desired. She said NCHS staff are collaborating on public information activities with a Departmental work group co-chaired by Judy Ball and Mary Emerson. It has developed a press release on the National Provider ID and a letter about HIPAA that will be sent to the NCVHS mailing list and others. A tailored version of the letter will be sent to public health constituencies. The Data Council has asked for help on public education on the unique identifier. Ms. Ball stressed that the entire education effort will be done "in waves," not "in one fell swoop," and she welcomed suggestions of mailing lists and newsletters. The press release will go to the mainstream press, such as The New York Times and The Washington Post.
Mr. Scanlon urged caution in talking about privacy and unique identifier issues, as they evoke a range of strongly-held views that will not necessarily be changed by "education."
On the administrative simplification education effort, Dr. Cohn encouraged that the outreach as much as possible be tailored to the audience and delivered through vehicles that are familiar to them (e.g., newsletters), to maximize their effect.
Helene Guilfoy, from the audience, stressed that workers in the information system side of the health care industry and vendors are not getting the message from their organizations about the coming regulations. She urged a more aggressive effort to reach them.
Following a quick review of the powerpoint presentation, Dr. Lumpkin adjourned the meeting.
I hereby certify that, to the best of my knowledge, the
foregoing summary of minutes is accurate and complete.
/s/ Don E. Detmer March 3, 1998
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Chair Date