June 23, 1999
Department of Health and Human Services
Hubert H. Humphrey Building
Washington, DC
DR. COHN: I am going to review the agenda for the meeting to make sure we haven't missed anything, and the good news is we are not on the Internet.
First, I would like to ask Bill to update on the status of HIPAA implementation and issues. It was mentioned earlier. Following that, I have prepared a draft that is meant really as a draft to update the work plan and it is really not necessarily a work plan draft, but it begins to identify the activities that I believe we need to be responsible for over the next 16 to 18 months.
Really what I am trying to do is to lay out what needs to happen as far as the overall subcommittee, and I would distinguish that from the work group only because we have a very involved work plan already going for that, but the question is what else does the subcommittee need to be doing which is not part of the CPR work group activities so that then we can put these together for a total work plan for the Executive Committee to be reviewing this summer and figuring out costs in relationships to tasks.
So, that is the intent of that. We will spend from 45 to an hour talking about that as well as some issues about the items that we have identified, are there other pieces of the charge that we need to be involved with over the next 12 to 18 months.
Finally, I have asked Jeff to talk for a couple of minutes about computer based patient records and the meeting yesterday. Most of us were there already and talk about the outline of the letter to the Secretary which I think we will probably discuss at the overall committee tomorrow just as a bit of information and then hopefully we will adjourn, and if we are all lucky this won't take until five-thirty. How does that sound? Is there anything else we are missing?
PARTICIPANT: It sounds like a plan.
DR. COHN: It sounds like a plan, okay. Bill, would you lead off by just sort of talking about any of the other issues.
DR. BRAITHWAITE: I pretty much blew my wad in the meeting this morning, everything that we can say publicly about what we are doing, unless you have got anything, Karen that you want to tell people. We would be happy to answer questions about what is going on and where we are at as best we can.
DR. ZUBELDIA: I have a question. What about the NPI?
DR. BRAITHWAITE: National Preventive Identifier is one of the NPRNs from last year, and we are drafting the final regulations for that, and it will be out by the end of the year.
DR. ZUBELDIA: And the national identifier system, how is that going to work out? The national health provider identifiers as reported by national health provider file and national provider system, is all that going to be in place?
DR. BRAITHWAITE: It will all be in place and deployed by HCFA, yes, but as we heard this morning or at least this afternoon, the Y2K effort is making it difficult to do that before January of next year. So, our plan is to, although we are going to publish the final rule before the end of the year we plan to make the effective date probably July of the year 2000 as the earliest date at which we could start actually assigning provider identifiers. So, although the rules will be out before the end of the year, the actual assignment of identifiers will be delayed
MS. TRUDEL: I could add something to that. The team that is working on the NPI is developing issue papers on large issues just as the group that is working on the transactional role is developing issue papers, and there are several papers that have not been finalized yet that really would significantly affect the design of the system itself, like addressing the comments in terms of how much data, what data we should be collecting when we enumerate a provider, what would be the mechanism for that to happen. We don't have a final take yet on who the enumerators would be and how that whole process would fall out, and so there are a lot of design decisions that need to be either made or revisited with respect to the system that are based on requirements that haven't been defined yet.
DR. ZUBELDIA: But HCFA has no funding for it?
MS. TRUDEL: HCFA has funding in the 2000 and 2001 budget.
MR. BLAIR: These position papers and the decision to accept these position papers, can we assume that this is all within the context of the current time line, that this is not something that you anticipate any delays?
MS. TRUDEL: That is right.
DR. BRAITHWAITE: Is this part of the process of drafting the final regs?
MS. TRUDEL: Right.
DR. COHN: Any other questions about current status?
Okay, let us take a look at the draft document in general. I will apologize for not having sent this out earlier. We were trying to put this into a better format, but I think that this will serve to identify the activities, and I will read them as we go here.
Now, this is called responsibility and proposed activities for the Subcommittee on Standards and Security for 1999 to 2000, and really what we are looking through is the end of the fiscal year 2000, so, through, I believe that is October 1, of the year 2000.
The first item is referenced in one of our charges which is to produce recommendations for the full Committee's annual report to Congress regarding the progress of implementation of administrative simplification, issues related to implementation and provide timely advice to the Secretary regarding any issues associated, and the actions include prepare report for year-end 1999 and each year thereafter. This is an ongoing responsibility of the subcommittee, if you remember, to advise the full committee on that. To date one of the issues that we need to discuss and decide has to do with the desirability of independent metrics to assist the tracking of communication progress. The issue is you have an initial baseline evaluation upon which to base yearly updates, and our observation was that such work would likely require a consultant resource, and maybe I should just stop there for just a second.
I think we are all aware of the charge to produce the report. The question actually was a discussion that Bill and I had. There are qualitative metrics based on our testimony that might be sufficient for us to identify where are as a starter or we could actually go and do some work to identify independent metrics. This obviously does require additional resources. So, we sort of identify the year zero status.
Thoughts, comments, otherwise?
MR. BLAIR: Is there any idea of either what it is we will measure or at what point in the system we will measure it or is that basically what will be part of our discussion?
DR. BRAITHWAITE: That is part of our decision basically. We are sitting now overlooking the whole health care system and how it currently deals with transmitting these transactions from one place to another. The question is is there some quantitative metric we can either get from some resource that already exists or ask a consultant to get for us which we could then do again each year in the future to see if there has been any quantitative change that we can use to help evaluate the implementation of these standard.
The only one that I was able to come up with as a sort of first thought was that there is a Faulkner and Gray report that surveys the industry to find out how many people are doing what kind of transactions and what proportion and that sort of thing.
MS. FRAWLEY: Health Care Informatics does, also. When they did their survey this year at their meeting, they found that after Y2K that is the issue that people identify in complying with the standards. So, there are different survey mechanisms out there in industry that there might be a way to tap in.
DR. BRAITHWAITE: So, one cheap way to do this might be to tap in or ask others to provide the data to us as a means of getting a baseline and following up.
Another might be to actually contract with them to add some questions to the survey, for example, and give that data to us rather than publishing as part of their report. If we can figure out what questions to ask of whom that would get at this issue, then that is a possible other way and then we could look to our consulting resources to see if there isn't someone there who could do something different, but we would have to be very precise about describing what it is we want them to do before such a contract would be productive. So, that is what this discussion should lead to.
DR. COHN: Certainly I think it is going to be very valuable to develop some baseline metrics. I mean if all we do is to rely on our testimony we are going to be especially in subsequent years relatively confused about whether we are making progress or not, and we certainly won't have a very good sense of the issues. I have been grappling with the issue about whether or not the work that is already existing would be sufficient to help us with that, and I am sort of sensitive that probably one of the initial activities is to evaluate that.
MS. TRUDEL: And in the process of doing the impact analysis for the proposed rules what we found was that there was information, and it was all very fragmented. It came from different sources and it didn't all quite fit together, and I think if we had some sort of comprehensive baseline we would be in much better shape.
DR. BRAITHWAITE: There has been some feedback from groups like Health Informatics that do surveys on the people who show up at meetings. From a scientific perspective it is not a very unbiased sample, whereas an organization like Faulkner and Gray that actually sends surveys out to places where they answer them in place seems a little better although I don't know what the response rate is on that and how representative it is. We would have to investigate that aspect of the data as well
MS. FRAWLEY: Do they send that to every organization or not just to people who subscribe?
DR. BRAITHWAITE: No, it is not just to subscribers, but I don't know how they decide who it goes to.
MS. TRUDEL: I think with Falkner and Gray they send it to high-volume clearinghouses and vendors on the assumption that it gets more of the industry that way.
DR. ZUBELDIA: I think, in fact, last year they had listed 50 clearinghouses, and the lowest one had like 1000 claims a year. So, they send it to everybody, and they do follow up to make sure that you fill out the survey and return it to them, and if you don't, they will keep calling you until you do return the survey back to them. I have been filling out that survey for a number of years, and they do a very good job about getting the reports back.
MR. BLAIR: The thought that I had on -- the first thing I try to say, "What is the simple," you know, if there is a single point where we could do it inexpensively and get good data, you know, and avoid complexity. So, I thought for 12 payers and what are there about 400 or 450, quote, you know, payers other than Medicare and Medicaid, and so I thought maybe that is a manageable number and then I --
DR. BRAITHWAITE: No, it was more like 4 million, Jeff.
MR. BLAIR: Payers?
DR. BRAITHWAITE: Yes.
MR. BLAIR: There goes another theory. So, I still --
MS. TRUDEL: If you include the ERISA plans.
MR. BLAIR: So, I still have the one figure out for the payers and then in addition to the payers I thought, well, then another one is the clearinghouses but not everything goes to the clearinghouses, and then the other piece that I thought of was okay, we have the payers and the clearinghouses, but on the other hand the providers are the ones that I think in large part wanted relief from being able to have to send to all of these different payers. So, you know, I think measuring the relief that the providers have, to be able to send things electronically; so, I thought of all of those, and then I, also, wound up saying that nobody is required to do this in the first place if they don't send it electronically. So, it would be kind of interesting if the only folks that adopted this were the folks that are already doing it electronically anyway and that this didn't broaden the base.
So, my last thought was the patients to see if they are getting their reimbursement any faster than they did before. So, I am up to four.
DR. COHN: Jeff, I think it sounds like you are recommending the census.
MR. BLAIR: Pardon?
(Laughter.)
DR. COHN: I agree with what you are saying. This is unfortunately not simple.
MR. BLAIR: Unfortunately, I couldn't keep it simple.
DR. COHN: I think we are all sort of coming to the need to develop a comprehensive proposal and I guess the question is does everyone agree that we should be developing this baseline metrics?
Jeffrey, do you support it?
MR. BLAIR: I am reluctantly supportive of that, yes. It needs to be done.
MS. FRAWLEY: I just worry about how we are going to accomplish it, and I think that is my immediate concern because this could be, I mean it is important, and I think we need to know this information, but from a pragmatic point of view and without it being a lot of money, you know, I am getting the impression from the way Bill is talking that we are talking about a modest effort.
DR. BRAITHWAITE: Yes, this is not a $10 million survey.
MR. BLAIR: Guiding principle, keep it inexpensive.
MS. FRAWLEY: And so with the small dollars I just don't know how much we are going to be able to accomplish, and I guess the other is how we get to the right people and if you want to get to the clearinghouses you want to get to hospitals; you want to get to physicians and managed care organizations and payers and when you start to think of all those populations, you know, people that are affected by these regulations, it seems somewhat enormous, unless you are go the approach of going to the professional associations.
MR. BLAIR: I think CAPA(?) may have given us a little bit of a clue in that if certain data is already being captured which could reflect the acceptance of this where we are not creating a new survey but we are winding up instead tapping into existing surveys or measures, to the extent that that is possible that could keep our costs down.
MS. GREENBERG: I would say going where Kathleen did to some degree is that maybe some combination of the Faulkner and Gray with obviously some staff consultation and what they collect and whom they send it to and so, see what the coverage is and a hearing with professional associations, giving them quite a bit of lead time and asking them to find out what they can from their membership because I mean we are in no position to do our own survey, and by the time we got OMB approval it would be 2010 probably.
The Committee can write letters to people and ask them to, but you really cannot conduct a systematic survey without going through the entire approval process. So that doesn't seem realistic, but it seems some of the major provider groups, the AHA is certainly going to want to know what is happening with the hospitals. They communicate with the hospitals regularly, AMA. Just think through the professional groups we have been working with and kind of the outreach and see the extent to which, do a hearing with them maybe and ask them to provide information and see how well we could do.
DR. COHN: And certainly as things move along there are going to be lots of groups across the country that are going to want to be involved.
I was talking to somebody from the California Health Care Foundation. He is interested in understanding better what needs to happen in California, for example. I would expect the other state organizations would become similarly involved.
I think what I am hearing is that, you know one of the early questions that Bill and I had was do we want to make this qualitative or do we want to make it more quantitative and what I am hearing is everybody has a desire to make it quantitative. At the same time nobody has a desire to spend a lot of money.
MS. GREENBERG: Again, it almost goes beyond money.
DR. COHN: I don't know that I believe this is an HHS survey nor is it a consensus. So, I think we need to somehow scale it. I guess what I am thinking of as I am looking at it, and Bill is here to help us and I think that what we are trying to do is to identify an appropriate direction.
I think it probably will at some point require some consulting support to help with all of this stuff, but we do meet between now and September to evaluate perhaps better what Falkner and Gray give us and then identify how to handle those areas where we aren't getting that help and sort of begin to put it together and I think we could look, with perhaps both of you to assist us with that as well as I think the question will be for the Executive Committee which needs to meet this summer at some point and probably will need to at least postulate some resources not only to assist with that identification but, also, how much we think it is going to be. I would expect that this issue would come back in September here as we, hopefully, by that time will have fleshed it out pretty well.
Is that a reasonable expectation? Then rather than us doing the work we can evaluate where there are holes that the two of you haven't identified.
MS. TRUDEL: I would like to just informally sound out reading the work group for electronic data interchange because they have a very broad-based membership and they may have some ideas about other either existing data or ways to get it and their survey, the famous 1993 and 1994 survey which was pretty much the only thing we had when we went into doing the impact analysis.
DR. BRAITHWAITE: So, if they decide to do the survey annually for us then that would be a very good input.
MS. FRAWLEY: I know having been a member at that time when we did the survey there was nothing out there, and we realized that we were trying to make a case for administrative supplementation and we had no data. I mean that was an important tool and probably something they would be interested in doing, particularly with their role in the legislation.
MS. GREENBERG: Do you think they would need resources to do that?
DR. BRAITHWAITE: I think that they would volunteer to do that. It is part of their charge to do that sort of thing.
MS. GREENBERG: Without additional resources?
DR. BRAITHWAITE: Yes.
MS. TRUDEL: They are having a work retreat right now, and I am going to be there on Friday. So, I can take that up with them.
DR. COHN: Actually I do think that there would be probably some, I mean knowing that organization, and I was on the board until last year, I think there probably will be expenses that they would need some help on. I don't think we should expect them to perform a full-scale survey completely out of their own cash flow.
MS. GREENBERG: I was just thinking maybe we could think of, if there were some resources needed, some creative ways to assist them without contracting with them to do the survey which has the same requirements for clearance, etc., as doing the survey ourselves, but we could --
DR. BRAITHWAITE: We could, for example, hire a consultant to do the analysis of the data.
MS. GREENBERG: That is exactly what I was thinking.
DR. COHN: Or even to assist them with drafting the survey.
Jeff?
MR. BLAIR: I do think that we should focus the data that we are gathering to answer two basic questions. There may be more, but because I am thinking that you know, WEDI(?) may be opportunistically a good professional association that we could take advantage of, and they may be able to because of their membership show us those folks that are already involved in electronic data interchange that they are switching over to new standards and adopting them, but there is a larger part of the universe which hasn't adopted electronic data interchange yet that we, also, want to measure, and we want to measure that they, in fact, are being attracted, I would say, that I hope being attracted because the standards are in place and because vendors can produce these systems now with the standards that there would be more attractive prices that more and more folks that weren't involved with electronic data interchange are now moving to it.
So, I think those are the two major focus areas.
DR. BRAITHWAITE: Issues of implementation for those people already doing EDI and converting to the new standards and the other issue is what proportion of people who aren't doing EDI now are moving toward it as a result of issuing the standards.
MR. BLAIR: Exactly and as a matter of fact the latter one is probably more important to us because if 80 percent of the universe right now is not on EDI and we have expanded this at the end of 2 years to reduce that down to 50 percent, that is a tremendous success.
MS. GREENBERG: And of course we will take full credit for it.
MR. BLAIR: Full credit. It might make a difference in the election.
DR. COHN: I think WEDI actually still becomes a very good group for that since as payers they are painfully aware of what is coming, at least for that particular transaction. We may have to think a little further as we begin to think about for example, enrollment, so we can get the number right and other such transactions because they may not be quite as obvious. Many of them may be primarily people or, actually it is not people, but there are other pieces of that that are still primarily people. So, that would be part of the question and the charge that is coming up with the solution but I would be curious to hear what part of the solution they can look at and I think in all these transactions how many they could help us with metrics on.
MS. BALL: I don't know Falkner and Gray is with the methodology. I think we probably ought to make a pass at them to kind of get their methodology so that we can evaluate what they have.
DR. BRAITHWAITE: So, we will get into that. Karen will get to WEDI.
DR. COHN: And see if we can have a plan that responds to our stated objective, and obviously we will review it in September and see where we are.
The next bullet --
DR. BRAITHWAITE: If there were any other organizations that anyone knows of like Falkner and Gray that do a general industry survey, that might be useful to, also, contact.
DR. ZUBELDIA: The MGMA reaches to areas that are and are not computerized and that may address some of Jeff's concerns and WEDI is everybody that is and MGMA reaches people who are not computerized.
DR. BRAITHWAITE: All right. With your permission we will talk to them as well and see if they have any input into the data sources.
DR. COHN: Anything else on that bullet item?
The next bullet is a piece of this and this will be sort of a recurring theme which is called barriers. The final piece we described in terms of trying to prepare these yearly reports, at least that I saw was to hold yearly hearings probably in the late spring, early summer time frame regarding implementation progress issues. The idea is we would have our first set of hearings in the year 2000 to elicit public comment on how well the system is working for standards developers, users, content committee, code set developers and other interested parties, recognizing that by that time it will be out, and we probably want to understand that there are things we need to do to help improve the standard for full-scale implementation in 20002.
DR. BRAITHWAITE: That will be very valuable for the Department, too, because as I mentioned this morning we have this sort of emergency clause that we can bring out a modification of the standard if we get feedback that something is impossible to implement without getting it tweaked. We, also, have to continue the input stream for the annual -- it may not end up being annual, however, long it takes us to get these things cleared but we will attempt to do something as close to annual to keep up with the business needs that have been expressed through the consensus process. So, it would be valuable.
DR. COHN: Comments?
DR. ZUBELDIA: I would like to include in the agenda something about the 148 personal health and injury because that has been kind of postponed, and the implementation guide was approved for publication. So, there is now an implementation guide for personal report of injury in compliance with HIPAA.
DR. COHN: That is actually good to hear.
DR. BRAITHWAITE: Also, now we can add to our plate writing an NPRM to adopt that.
DR. COHN: We were actually wondering what had happened to that transaction. So, thank you for the update.
MS. GREENBERG: Simon, on the issue of hearings I think the subcommittee needs to think about and revisit periodically whether some of those hearings could be held outside of Washington or --
MR. BLAIR: Albuquerque?
MS. GREENBERG: There are additional resource issues when hearings are held outside of Washington though we know there are benefits as well. They can be more difficult, also, to -- the Pacific insular islands. You go to one, and I will go to the other. We don't have to decide that now.
DR. COHN: Part of the question is that. Part of the question is how many hearings do we really need because if we are going to do late spring, early summer which by the way is meant to be after we have done most of the work on the CPR report, and we are in big trouble if we haven't gotten that done by that time, but it is meant to basically tail that, but we saw it as actually helping us with annual report. We saw that there was another activity which was called providing ongoing federal public advisory committee input into yearly modifications of the administrative final rules. Remember every year there is an update of the final rules and the committee meets to be part of that activity and then the whole issue of evaluating and making recommendations regarding proposals for new HIPAA administrative standards, and so we sort of saw those three things all sort of happening during -- I mean they are different activities but they are all very much overlapping.
Now, as we say that, do we think that that is 2 days of hearings? Is that 4 days of hearings? Is that hearings in Washington or where?
MR. BLAIR: The suggestion I have is something that we probably wouldn't want to put into our documentation as a purpose for those hearings, but I feel like it may be a very valuable silent objective that we have.
MS. GREENBERG: We are a federal advisory committee. There are no silent objectives. I am teasing.
MR. BLAIR: And that is that any time you come up with a new system, a complex system that involves new standards, new systems, new implementations, clearly the implementation process is especially during the first several months, is going to be a struggle for a lot of folks, and there are going to be frustrations, and one of the benefits of having some of these hearings for feedback, as much as the feedback may be valuable to us in terms of what do we need to correct, it may, also, serve as a venting system, as a place for people to vent their frustrations. They know they are being heard, and from that standpoint if we look at it as serving that need as well as providing us with information, we may want to characterize them and schedule them slightly differently than just to inform us.
For example, we may want to alert the professional associations that they should consolidate some of the concerns and frustrations and communicate that to us in these hearings, but do it with a certain degree of publicity so that the health care community is aware that this feedback system is in place for them as much as for us.
So, that is my story, and I am sticking to it.
DR. COHN: Other comments?
I the question here, the issue you are bringing up is what in the first and second year are going to be different than year 7 and year 8, we believe, and it may be that we may want to consider having some hearings sort of spread out over the year based on your comment to make sure that -- not everybody is going to be implementing in the first 3 to 6 months, but there is going to be sort of ongoing things, but we may want to capture a couple of times during the years input. Is that sort of where you are going?
MR. BLAIR: But in particular, to advise the American Hospital Association, CHIM(?) and CHIME(?) all of these other associations, WEDI that we in fact are setting these things up to get feedback so that as they go through the frustrating periods they know they have got a vehicle, an avenue to be able to communicate where they are having difficulty, you know, to diffuse the frustration somewhat because we know we are going to have some of that, so that it doesn't blow up because somebody feels like they don't have a vehicle to articulate their concerns.
DR. COHN: I think we are in agreement about that. I am just trying to think of what you are indicating is to set some hearings throughout the year or do you think one set of hearings well publicized in the spring-summer is enough to satisfy that?
MR. BLAIR: I see what you are saying. However we set it up I am just saying that we publicize the fact that we are making them available. That is all.
MS. BALL: Are you entertaining outrageous ideas? The new contractor who is taking over, making something into the HS web site raised in one of our initial meetings the idea of using the web site as a way to let the public communicate with the committee.
DR. COHN: Excellent.
MS. BALL: This perhaps might be a place for that.
MS. GREENBERG: Yes, in an interactive way. I think the real question here is the extent to which responses, you know, what type of response capacity would be expected.
MS. BALL: From what Jeff was saying there may be value simply in providing a forum for people to exchange information.
MS. FRAWLEY: You might, also be able to set up a survey on the web site and have people do the survey and get responses that way.
PARTICIPANT: That I don't think we can do.
MS. FRAWLEY: I know that we did that on our web site. It is an easy way to pick up survey data from people who are interested in that topic. I mean that would be really nice to be able to do something like that.
PARTICIPANT: We are not flexible enough to do that.
MS. FRAWLEY: That is unfortunate.
DR. BRAITHWAITE: There were two aspects to this that you mentioned. One is to have a constant input source, and we would have to set up a procedure and staffing and so on to handle the answers.
MS. GREENBERG: And the collating obviously.
DR. BRAITHWAITE: And collating and so on to fit into the committee what sort of input we have been getting and the other is to allow as we are having meetings where we send our audio out on the web we allow at the end of each meeting for people from the public to stand up and ask questions or make comments to the committee. We could in turn allow those comments to come in over the Internet during the meeting, and it is an outrageous idea.
DR. ZUBELDIA: Even over the telephone people could call in with questions.
MR. BLAIR: This is another not fully thought out idea, but it is like when you buy a new software package and just the fact that there is a help desk or an 800 number that you could call if you run into a problem gives you some degree of reassurance as opposed to you bought something, and it has been thrown over the transom, and they don't care if it works or not, you know. So, you mentioned on the web site being able to have some vehicle to be able to capture concerns or questions or have people share stuff. Whether we call it a help desk or I don't know there may be other phrases and titles we could use, but in a sense what we are really doing is we are winding up saying,"Okay, now, that you are implementing the standard there still is some place you could go for help," and it may be WEDI. I mean some of the stuff may get routed to WEDI or to CAPA and what is it APHIT(?) and they have the ability to provide help. We may not have to provide all the help.
MS. GREENBERG: I don't know if the committee really can provide much of any of it, but I know there is a process in the Department that is part of the implementation team. I think it is the infrastructure team, isn't it, looking at the whole issue of implementation and what type of help desk or clearly working with the industry and I don't know you two could characterize it better than I can. The general principle though is that obviously you don't put out your regulations and go home, and I don't know the committee might have an interface there, but --
DR. COHN: A HIPAA triage center.
Do you have a comment on that?
MS. TRUDEL: I think in terms of, I am not sure what you mean by assistance, Jeff because there is a level of technical assistance in terms of I cannot build this transaction that I don't believe the Department could ever want to begin to try to provide, and one of the things that we wanted to do as part of the implementation process is try to figure out where the Department's role stops and where the industry's role starts and how we can use what we have and what we know here to leverage what the industry will do implement HIPAA itself, and I don't think we have gotten to the ultimate conclusion on that yet.
MR. BLAIR: Maybe some of the things would be like if we do have a web site that it have links to ASCX12 links to APHIT, links to maybe even some consultant firms that are specializing in assisting these things or professional associations or just a set of other places they could go for assistance.
DR. ZUBELDIA: There is already such on the technical side. A Washington publishing site follows some discussion groups that have been used by the implementation teams to discuss different implementation guides, and it is open to anybody who registers. Anybody can go there, see the thread of previous discussions and see the answers, pose their questions and the questions are sometimes answered by the chair of the group, sometimes answered by any of the group participants. Anybody is free to answer any questions. It is a free and open discussion group that today is working very well for the implementation guide's technical issues.
Now, there are other HIPAA topics that are not delved into, but they could be built into Washington publishing site like security, NPI issues, and that would be a very good forum to discuss the issues and get answers, and it could be monitored by some of the Department people. It could be monitored by some of the professional associations and they could answer whatever they feel they need to answer. It is an open forum.
Another thing that worked very well for us about 8 years ago when HCFA was moving for the first time from NSF to X12 there was a big HCFA symposium on X12 in Baltimore, and they sent invitations to practically all the practice management vendors in the country and all the clearinghouses to form this informational session. It was a 2-day session and it was more like ask the expert. It was a big panel of five or six experts on each one of the conditions. They would make a short presentation on the guide and people on the phone would ask questions, and I think a lot people see it as a distant entity out in DC, and they are afraid of coming to meetings, and if they see there is more room, maybe having some large forum like that as focus forums on the implementation guides, but they have a forum like that on the non-implementation guide issues like security and identifiers and code signs, and invite the industry to come to a forum sponsored maybe by the Department or by NCVHS and with the experts from NCVHS and the Department answering questions. I think it was excellent about 8 years ago.
DR. COHN: I think certainly somebody needs to handle that. I don't know that the NCVHS is really the group to do that, but I think it may be part of the implementation plan for HHS. The question is where the line is, but what needs to be done by business versus what needs to be done by HHS versus what needs to be done for NCVHS.
Now, I am hearing a number of things, and I am obviously hearing that we need to have hearings, and I am, also, hearing that we need to really leverage web technology in all the ways that we can. There needs to be, I think, a whole set of meetings that you can sort of think about as you think about implementation planning, and that is probably something that we need to, later on this year as it becomes clearer to you, what briefing we need to have to better understand the whole spectrum of implementation planning. We don't need to do it, but we need to follow along, identify the issues and help uncover them, and I think what I am hearing at least in this conversation is that at least for the first year it may be that my previous views of just 2 days of meetings in the spring to uncover all of these issues may be a little naive or perhaps understated, and I think we need to look at that and sort of potentially come up with something over the year in ways that are staggered and maybe even get out of Washington so that we are hearing from people because that really is our responsibility to make sure that people are feeling heard in whatever medium they want to use, at least that they are speaking of their frustrations and otherwise or their successes which would be nice to hear, also.
Karen?
MS. TRUDEL: Would there be a possibility of trying to coordinate a hearing at the same time and in the same city as an X12 meeting because it may be that the same people who have problems are going to be attending those meetings to participate in this forum.
MS. FRAWLEY: That is a great idea.
DR. COHN: So you are indicating that at least one of the meetings we ought to try to do it in conjunction with an X12 meeting?
MS. TRUDEL: Yes.
DR. COHN: Okay.
DR. ZUBELDIA: I would recommend that it be done after the X12 meeting or before and not during the X12 meeting.
MS. TRUDEL: Right.
MS. GREENBERG: They go on a week, too, don't they?
DR. COHN: Yes, but I think that that is actually a very important group to hear from though equally one worries as much about people who aren't making it to the X12 meetings. I think in some ways Jeff commented that that is a group of real concern that we had better start looking at.
DR. BRAITHWAITE: Of course, all of the STOs are now thinking about coordinating meetings with others. So, it seems to start the ball rolling when somebody sets a date and a place, and all of a sudden there are five STO meetings all one after the other in the same place, and everybody will be out of town for 2 weeks.
MS. GREENBERG: When is that X12 meeting in Hawaii?
(Laughter.)
DR. COHN: I think on the basis of this discussion probably Bill and I will come back with some more definitive comments at the September meeting. What I am hearing is probably more than one set of hearings and probably at least one set of hearings outside of town and trying to do something around an X12 meeting.
So, once again a little more effort than we had initially thought, but I think that is what I am hearing.
MS. FRAWLEY: And we are, also, going to do this after we are sure that this work group has finished its work.
DR. COHN: Yes.
PARTICIPANT: What?
MS. FRAWLEY: I am just making note of the fact that the work group on computer based patient records and the subcommittee are the same five bodies, and we have a lot of work.
MS. GREENBERG: They do look a lot alike.
MS. FRAWLEY; It is a pretty ambitious time table for that activity. So, I am just concerned when you were mentioning you know late spring-summer because we, also, were using some of those time lines for our report to Congress for that activity.
DR. COHN: You are right. I think we are hoping to have that report done by the March meeting, at least in advanced draft form. So, we hopefully will be providing as opposed to developing.
MS. GREENBERG: And when you present it you are not going to disagree with it, are you?
DR. COHN: As long as you present something unambiguously I am in favor of it. Anyway I think we will finish off that schedule, and we will come back with recommendations around dates and places as we look at some of the opportunities.
Now, there is another set of activities regarding the new administration final, actually the NPRM which is the next act. It has a slightly different tenor to it which is that I think it is our responsibility to propose letters during the 60-day period responding to the NPRMs and comment on them and so, this fall we should be expecting to see some new NPRMs. So, once again it is just something that is on our plate having to draft letters and respond appropriately based on our views of the NPRMs.
MS. GREENBERG: And basically to do those letters for the full committee.
DR. COHN: I am sorry.
MS. FRAWLEY; Yes, you have better change that to the full committee so that people don't get concerned that you are trying to do an end run around.
DR. COHN: Thank you. This is why this is draft. Advise the full committee.
MS. GREENBERG: And hopefully by then, by the fall we will have a process that we have agreed to for doing this, if it cannot be coordinated with the meeting.
DR. BRAITHWAITE: Although right now it sounds like the December meeting would be an ideal time to address the next round of NPRMs.
MS. GREENBERG: Late November, the last week in November is one of the alternative dates, and actually in the spirit of the document that was discussed today ideally we will plan ahead so we will in fact schedule our meetings to take advantage of when the committee needs to respond.
MR. BLAIR: Could I get in sync on this? I think I thought that the November was the last full committee meeting and December was our, the 2 days in December were reserved as the subcommittee.
MS. GREENBERG: That is true.
DR. COHN: Yes, and I think that what they are counting on is a time for us to consider them, come up with the agreement ourselves on the letters and then the question will be if there is a process for expediting.
PARTICIPANT: Simon, have you told them about doubling the amount of time we have available by using parallel universes and quoting?
(Laughter.)
PARTICIPANT: Excuse me, Simon, do you have an extra copy of the draft?
DR. COHN: I think what we are thinking is if indeed, I mean if you will remember, Jeff, we had already identified that we needed some time for a subcommittee in December or November or somewhere around there, and so this might be well timed depending on when this comes out. I mean if it comes out before it may be something we could do during the full committee meeting in November, but that may be a little tight for coming back with comments, but anyway that may be the sort of thing we might do for half a day to a day in the December time frame.
I think the other question was that there may be some value in eliciting some focused input on issues related to the NPRMs. That is something I think we could --
MS. GREENBERG: The new ones?
DR. COHN: The new ones, yes.
DR. BRAITHWAITE: Particularly if there are some really hard issues that we are asking for comment on but we really don't know what is going to come back or know the best solution. We could propose that as a subject for a hearing and get more input that way.
MR. BLAIR: Is it reasonable when we solicit feedback on the implementations that we don't invite individual companies or vendors or providers, but we invite the associations so that we are not winding up having 4, 5 or 6 days worth of hearings? We could wind up getting the feedback consolidated into an afternoon or a day?
DR. COHN: And that is in relation to what now, the NPRMs?
MR. BLAIR: You know, I may have been out of sync. My mind was still thinking of the hearings on feedback of the implementation. So, I am sorry.
DR. COHN: I wasn't sure what you were talking about. I think we don't actually have to do any hearings on NPRMs at all. We have already done our hearings on most of these issues. The only question gets to be if there are some focused areas we may choose to invite selected speakers to help us focus our thoughts on things to gather some input and recognizing what else we have on the plate I want to be careful. I do not live in Washington, DC. I have not bought a house here nor is it my intent this year to do that. So, I think we need to be careful in terms of the time line.
One issue that we thought might be of some interests except that may be resolved by that time had to do with the issues around maintenance of code sets. This is really going from claims attachments, but it was unclear to me whether or not there may be something already determined by that point, and I don't know, but I think at a minimum we would take some time to take a look at letters and otherwise.
So, anyway that is what we are talking about sort of at the end of this year. Now, I have a list of items A through G which are other things that we could think about and decide if we want to do anything about, and they are actually from our charge, and the question is is there anything we need to do about any of these areas, and so the question is what other issues or activities do we need to consider for 1999, 2000 either for us or for the full committee, and Item A has to do with revisit of unique health identifier issue or other routine mechanisms.
MS. GREENBERG: Next?
MR. FITZMAURICE: Vice President's permission on that one?
DR. COHN: I think the only question is whether or not we might want to hear, there are many states that are actually doing things around linking mechanisms.
MS. FRAWLEY: You see what I am worried about is the fact that we are not supposed to be using any funding on the issue and the reason why I bring this up is because even with the committee members travel to attend a meeting where there is discussion on the topic does that violate --
DR. BRAITHWAITE: No, it doesn't.
MS. FRAWLEY: That is what I am trying to figure out is what are the parameters of what we can do.
DR. BRAITHWAITE: Parameter-wise the specific rule of law is that we are not allowed to use any money to promulgate a final rule. It doesn't say anything about leading up to it, getting input, even issuing an NPRM. So, putting everything on hold until a prior issue is better resolved is more of a political than a --
MS. FRAWLEY: Right. So, I mean my understanding was the committee couldn't do anything.
DR. BRAITHWAITE: It is not that you cannot do anything. The department has decided not to do anything for now. That may change next year. It may change after the Secretary issues regulations or Congress does something, and the interesting issue here is while the federal environment gets pretty much paralyzed all the states are out there doing things, and it might be interesting to understand what is happening.
Now, I would not in any way propose this as an early year 2000 activity. The question is whether we leave a placeholder around it sometime in the September time frame or something like that.
MS. GREENBERG: You are talking 2000, but I really would recommend you think 2000 and 2001 because the fiscal year for 2001 starts October 1, and what John was suggesting at the executive subcommittee meeting was that the committee try to do some more focused budget planning and budgeting around the fiscal year or the budgeting period for the department basically so that I wouldn't limit it probably to --
DR. COHN: Just to the fiscal year.
MS. GREENBERG: Yes.
DR. COHN: Okay. So, I think what we are hearing is maybe fiscal year 2001. I am sorry this was not discussed with Kathleen. This would not be something that is just done by this particular subcommittee. It would need to be done in conjunction with the subcommittee on confidentiality. So, maybe we can get their views on it, also, and see what time frame makes sense.
Item B is other code set issues and needed activities.
MS. GREENBERG: There will be issues. I think the committee is on record talking about movement to possible uniform framework, whatever for procedures, for moving potentially from 9CM to 10CM, other issues that have come up in the process, you know, the comments, etc. I got a call yesterday about a concern about the dental codes. I am sorry. I gave him your name after I talked to him for about half an hour.
So, I mean I think this subcommittee is the --
DR. COHN: It will be our charge which is why I am bringing it up as an issue. Certainly the work, the CPR work group has I think been modifying the focus areas to include the concept and terminology of framework. Within it though the question would be how far we can get by next year recognizing that we are going to start writing something at the beginning of the year, and so I think based on that it will tell us whether or not the other -- this may be something that goes beyond where we will be able to take the first couple of steps. Would the CPR work group have to continue it on?
I think it is an activity. I don't know whether it is -- it is probably not a summer 2000 activity.
MS. TRUDEL: It might be helpful to have that as a placeholder though because if we continue to get a lot of issues and concerns about the proprietary code sets, you know there may be a need to revisit exactly what is happening with those maintainers that is causing this concern.
DR. COHN: Okay. So, you think that might get substituted actually in some of the issues having to do with the overall hearings about what is going on?
MS. TRUDEL: Yes, probably.
DR. COHN: And I think the other piece for action will depend on how far we get with the CPR work group in some framework discussions.
Okay, security.
MS. FRAWLEY: I see it as an implementation issue.
DR. COHN: Okay, I look at it as the electronic signature. I don't have any specific agenda item on that one.
Mike?
MR. FITZMAURICE: There might be something on security if the Secretary's privacy regulations come out. There might need to be an analysis between the consistency of the Secretary's recommendations and the security requirements of HIPAA. Somebody might want to look and make a judgment. If somebody raises an issue, we want to analyze it and say, "Yes, we know that there is some consistency."
MR. BLAIR: The piece that I don't know clearly if the Department of Health and Human Services goes forward to promulgate regulations for privacy and confidentiality that may generate some more security issues, considerations,topics. I feel like we have so much on our plates I am hesitant to suggest anything. So I am doing this reluctantly because I feel like this is a frustration and an issue because I get telephone calls on this all the time and I cannot answer them very well and they are -- is Bob Mace here or anybody from HIPAA here?
DR. COHN: Karen.
MR. BLAIR: Okay, the calls that I get are folks have read the HIPAA regulations on data security requirements over the Internet. You know, this is a growing area. It is a hot topic, and I have read them through several times and they are just really hard to understand, and I have tended to ask folks for clarification and I haven't understood it, and I don't know whether that is our role or not. Maybe we don't have to spend time on that. That is an issue though, and I think we need better -- is anybody else running into the same --
MR. FITZMAURICE: Are you talking about the Internet policy.
MS. FRAWLEY: That is not HIPAA. That is HCFA's Internet policy, and people are mixing that up all the time because I get phone calls from people, and I have to stop them because they start telling me all this nonsense and they are mixing up the HIPAA security regulations, the NPRM there with the HCFA Internet security policy which is totally different and has a very limited application, and people seem to get very confused about that, but that is not HIPAA so it wouldn't be the jurisdiction of this group.
MR. BLAIR: I don't think it is totally different in the sense that if they are going to accept security requirements set forth in our NPRM which is part of our administrative simplification provisions and if they were to attempt to send it over the Internet then those HCFA guidelines are the only guidelines that are out there or do I not understand this clearly? Is that not correct?
MS. TRUDEL: The HCFA guidelines at this point apply to Medicare and Medicaid only and to federal identifiable data, in other words data that comes under the privacy act, and as an example, what a provider would send to a private health plan is not covered by our Internet security policy. It is only covered when the provider attempts to send it to a Medicare carrier fiscal intermediary, and our carriers and fiscal intermediaries are told that they are not to accept identifiable data over the Internet at this time and at this point we are working with WEDI and AFEC(?) to participate in their interoperability pilot before we go further.
DR. COHN: Without trying to solve this one, actually I thought it, also, included beneficiaries as opposed to just communications. It may have been an earlier version. I am actually wondering if this is an issue where there needs to be a briefing to the full committee on the relationship of the HCFA Internet policy to the security NPRM or the HCFA security regs, once again not as a hearing but as an update in September or November and that that may be our recommendation around this one. It isn't a hearing issue, I don't think. It is really more of an update and certainly --
MS. FRAWLEY: There is a lot of confusion in the industry. People are getting that all mixed up and people are even extrapolating that policy now to the use of e-mail and patient identifiable information. So, it has gone from HCFA Internet to cover just about anything that is transmittable and patient identifiable.
MS. TRUDEL: We have been trying to on our own web site to draw the lines around what the policy applies to and what it doesn't. Perhaps we could be doing a better job of that.
MS. FRAWLEY: I think what you did on the web site is good.
MR. BLAIR: Maybe that is where I need to look to understand it better. Okay, so, you have something on the web site recently?
MS. TRUDEL: Yes, it is out there. In fact, I just referred somebody to it the other day, and I know they found it helpful. They had a client.
DR. COHN: What I am hearing on this one just to make sure, I think where we are on this one is I think Jeff is obviously going to look at the web site, but I think recognizing that if Jeff doesn't have a good handle on this one, that is something. There is a concern out there, and probably a briefing in September or November depending on what the NCH's schedule is for a discussion of the difference and how they relate, not hours and hours but a briefing would be useful.
Marjorie?
MS. GREENBERG: I did have a question although first I have to backtrack because I guess it is with the Department looking at the 2001 budget. I am in the wrong years here, but the November meeting this year, the year in which we are talking about a late November meeting of the full committee is in 2000. This year the November meeting is actually in the beginning of November in conjunction with the National Academy workshop. I think it is the national committee is meeting on the third and the workshop on the 21st century vision for health statistics is the fourth and fifth, and the committee members are all invited to it. We have discussed this, but maybe it has been forgotten.
In any event, so, the November meeting is really only going to be 1 day of the committee meeting.
DR. COHN: Oh, so, you are talking about September better than November?
MS. GREENBERG: I am just saying that we have to keep that in mind that we are not going to have that much time at the November meeting and, also, it is going to be difficult even to have subcommittee meetings in conjunction with the full committee meeting in light of that plan and that is in 1999. I had already leapt ahead to 2000 I think, but my question was these hearings that we had talked about on the first page or we have been talking about up until now and about using Falkner and Gray, etc., and those are in 2000, but were you thinking that -- or the information that the committee has to provide to Congress also has to include implementation of the security policies, as well or regulations and is that something that Falkner and Gray, do they collect that information as well or do we need a different approach for that?
MR. BLAIR: I am glad we are talking about this. That is a good point.
MS. GREENBERG: I think it spells that out, doesn't it even in what it says in the legislation, I mean not all of it, not the CBIs but, also, --
MR. BLAIR: It would be very nice if we could combine them, but I am afraid that since a lot of the clearinghouses are on value-added networks they don't have to deal with the same data security requirements that folks might be using over the Internet. So, we may have to do it a separate security -- there is overlap. Clearly there is overlap, but it is not 100 percent overlap.
DR. COHN: But, Jeff it may not overlap. I mean security includes all --
MS. GREENBERG: Everything electronic, I think.
DR. COHN: It is electronic. So, it means inside a facility. I mean it is a very different sort of survey process.
MR. BLAIR: Thanks for opening up another can of worms there.
MS. GREENBERG: You are welcome. That is probably off in 2001.
DR. COHN: Without a solution I think it is something we need to put into use as where consulting assistance might help us and so if anybody has ideas about how we can gather that information it would be useful. It reminds me of a lot of the work we have done over the last couple of years, how much is there.
Having said that, electronic signature, is there an issue that anyone -- do we need to be --
MR. BLAIR: Wouldn't that fold into data security?
MS. FRAWLEY: No, it is actually an implementation issue. It is both security and --
DR. BRAITHWAITE: But there is no requirement that anybody use it.
MS. FRAWLEY: Exactly, there is no transaction right now that requires an electronic signature.
DR. ZUBELDIA: There is one problem and that is even if they did require it, we cannot do it.
MS. FRAWLEY: That is a separate issue. That is why we are having the hearing on implementation issues so you can come and tell us about it. We will have a chair waiting for you so you can come and tell us.
DR. COHN: Item E is data content. Anything else on electronic signature? I don't think there is, is there? Good.
DR. ZUBELDIA: Yes, I would like to mention something on federal regulation and federal legislation on electronic signatures. It seems like there is a proposal to have federal legislation on electronic signatures whereas now there is state legislation only to those signatures and all the states have an electronic signature act and in fact Florida last month repealed their digital signature act and now there seems to be a movement to have federal legislation on digital signatures. So, that could affect the HIPAA digital signature NPRM if there is a preemption clause of any kind in the federal legislation.
DR. COHN: So, I guess that will be an issue that we will follow which is probably the best way to describe that one.
Anything else on electronic signature?
Now, E is data content control and ownership issues and I think it is actually going to be handled mostly as part of ongoing hearings. The only question is really whether there needs to be a briefing towards the end of the year or whether it is just sort of an issue that we follow along.
MS. TRUDEL: Actually that would be good timing for the September meeting because we have been just sitting in while the different SDOs and traditional content groups have been trying to coalesce on a way to make all of this maintenance work and they are shooting for August when there will be meetings of the NUBC and the NUCC to have a protocol ready to look at and we could basically share that with you hopefully at the September meeting.
MR. CONWAY: I am Tom Conway, AMA, and secretary to the NUCC. I was just on a conference call earlier this morning. I left the meeting for a while, not with the groups, the STOs and the content committee and they have looked at a draft of the MOU as that is called and they are definitely planning on having a draft ready for the NUCC, NUBC in August. So, it is good timing for the September meeting.
DR. COHN: So, a briefing on that would be an appropriate thing in September.
Item F is basically anything else, any other issues for subcommittee or full committee attention.
Karen?
MS. TRUDEL: Enforcement.
DR. COHN: I knew I forgot something. Okay.
MS. TRUDEL: Talk about a can of worms.
DR. COHN: Dr. Braithwaite will come up with a solution on enforcement.
DR. BRAITHWAITE: You are going to hold me to that one, huh?
MR. FITZMAURICE: Are you going to operate the rat mines?
(Laughter.)
DR. COHN: Karen, what do you suggest we do in terms of the enforcement piece? Is that a briefing issue? Is it something that we elicit comment on next year? Is that a hearing?
MS. TRUDEL: That was an unformed thought actually, but I guess if I had to follow that up, I would say that those of us who are thinking about this with the exception of your suggestion this morning don't feel comfortable that we have got a real good sense of what our options might be and what we might be running into. So, that might be a hearing.
DR. COHN: That might be a hearing, okay.
DR. BRAITHWAITE: Particularly since we have committed to put out an NPRM in the year 2000 to describe how we are going with enforcement actions under HIPAA. A hearing to give us input on it as we are writing that would be very welcome. It depends on what happens. That could even be part of the December discussion or sometime later depending on what it is we --
DR. COHN: I think later than December this year. As the industry starts to get into implementation and sees what some of the issues are they might be much more informed about what kinds of enforcements might or might not work.
MR. BLAIR: We are giving folks 2 years to be able to implement and comply with our HIPAA standards. So, I would assume that that means that we wouldn't expect to put in place any enforcement prior to those 2 years. Is that a correct assumption?
MS. FRAWLEY: That is correct. The concern that has come back to us is that people want to know what the enforcement provisions are going to be like while they are still in the process of implementation. They want to know beforehand.
PARTICIPANT: So, they can figure out how to get around them.
MR. BLAIR: My thinking is that while you may have said it in a cavalier manner about squealing that really may be a very efficient and effective vehicle because if a payer is trying to wind up getting their claims or a provider is trying to get their claims to a payer and they are not complying, you know, they know. There is the frustration, and there is the incentive to wind up getting the other party in the transaction to comply and you know, I would tend to think that the self-enforcement concept you articulated earlier might work pretty well.
DR. BRAITHWAITE: We would hope to direct most of that into self-correction mechanisms as well, when all the 1-800 matamania(?) lines and all other variations have failed.
DR. COHN: Without trying to solve the problem, I think we have identified it as an issue. The problem is we want more than just the people at the table commenting on it.
Is there any other issue that needs to be dealt with by the subcommittee or by the full committee that is not a CPR work group issue and there is a bunch of those but in relation to the pieces we have already talked about?
MR. FITZMAURICE: Have we talked about the process of issues and the process of updating those standards, data concepts?
DR. COHN: Yes. I think we have pretty much filled out our work plan. It is actually a lot of work, and I think there are going to be a couple of hearings next year as opposed to just one.
Now, the next item, Jeff is an update to the work group on CPRs recognizing it is pretty much the same people in the room and we are talking to ourselves. Is there any update aside from agreement on the outline that you want to just mention to the committee tomorrow?
MR. BLAIR: I can't think of anything that we didn't cover yesterday and like you say, virtually everybody was here. I think we are just simply going to try to get moving on a lot of these issues during the next several weeks and keep everybody informed as we go along so that some of it will have to be done by conference calls and we will just let everybody know when they are so that interested people can participate. I don't have anything else unless you want me to review what the agenda was.
DR. COHN: No, I think probably the pertinent things are that there will be another set of hearings in September, that we are planning to do a letter to the Secretary and that is actually a formal item that we sort of raise our hands and approve since we all saw it yesterday.
It doesn't need to be approved by the NCVHS tomorrow but we just need to inform them that this is going forward. Beyond that I cannot think of anything.
Mike, do you have anything?
MR. FITZMAURICE: Just that one of the lead staff operating in this field crafted a new set of guiding principles for consideration from the CPRWT that will be circulated by e-mail.
DR. COHN: Okay. I am not sure we need the data per se but I think we have agreed that we will mention to the committee the intent that we will be bringing forward a letter for September. Our work group part of our full committee meeting will be to finish off that letter and get it all set up for the committee.
MR. FITZMAURICE: I think for that letter I have it pretty well all in my mind so you can see it, except for the set of issues that we want to highlight in the letter and so will probably discuss that in conference call and circulate it around the CPRWT to make sure that those are the right issues.
DR. COHN: Any other items for the subcommittee meeting, for subcommittee consideration?
With that we didn't quite make 5 o'clock which ruined my plan, but we will adjourn the meeting.
Thank you very much.
(Thereupon, at 5:05 p.m., the meeting was adjourned.)