Tuesday, October 27, 2009

HIT Policy Committee - 10-27

The HIT Policy Committee met October 27th and is scheduled to meet again on the 28th to take testimony on how recommended meaningful use measures affect specialists, non-physician practitioners, safety net providers, and small physician practices and community hospitals.

Below are the meeting materials for both meetings and the rough draft transcript of the October 27th meeting.

Meeting Materials:

Draft Transcript:

Good morning everybody and welcome to the sixth meeting of the HIT policy committee. This is a federal advisory committee because it's being conducted in public. We have members of the audience here in the room with us. As well as the public on the telephone and on the Internet. But please ask members of the committee to identify yourselves when speaking for attribution. The summary and the minutes of the meeting will be posted on the ONC website at a later date. And with that, I think we will go around the room and introduced members of the committee you are here in the room. I'll begin with Dr. Charles Kennedy.

Four with Wellpoint.

Del Carol from Arizona from the state of Florida.


Seven McGraws and, [Indiscernible].

Paul S. [Indiscernible] of Japan nor.

And Clark.

Christine., national partnership for women and families.

David Blumenthal National court ended up a.

Paul Tang.

[Participant's audio is faint/unclear]



And we are expecting a number of committee members on the telephone. Is anybody on the line, PS?

With that I will turn it over to Dr. Blumenthal.

Thank you Judy and thank you to everyone who is here. But in person and virtually. I welcome you all and thank you for being here. I want to say that unfortunately, I have to leave in the middle of the afternoon for a speaking engagement. So Paul will take over for me. And I'm totally confident that he will charge, navigate the ship without any difficulty. I want to take a moment to reflect on where we have come and where we are right now. And to pose for consideration some thinking that we have done within the Office of National court later on future directions. This is a watershed point for the policy committee. We had done an enormous amount of work, very time since the work. We've done it well, I think. But high-quality and with the necessary speed. And as a result, we in the office of the national coordinator and at CMS have been given the tools that we need to move forward on a number of very important policy and regulatory matters. We can't talk about the much in public, so it's not apparent to you. Your work has been extremely valuable in and forming regulations that are now in advanced stages of drafting. A meaningful use regulation, a set of regulations on standards and certification criteria and implementation specifications. And in regulation on certification. Those regulations will be out we have for comment within a matter of months.

We cannot have done those without your help and without the standards committee. I think that's a statement of fact. They are done though. Your work on those is done and this gives us an opportunity to look forward to the next set of tasks that we need. They are bony -- By no means the end or even the end of the beginning. There are the beginning of the beginning. And we have been thinking about what we need your help with next. And we've also been listening to some of you who have opinions about what we ought to do next. So we have the opportunity to take stock and develop a plan and discuss the next period of time. During which our work has to evolve. There are a number of areas and to highlight for you with slides in just a moment. One area that I want to call out for consideration is a topic that we never Billy paused to think about but which in retrospect could be extremely valuable for I think in going forward. That is the question how we organize our thing. What are the principles? What are the values? What are the guiding sort of navigational science that we use as we make decisions? Other common themes that we want to make sure are contained in the decisions we make. A number of members of the group both committees brought the possibility of thinking about that to our attention between the last two meeting. And wanted to raise that as it possible exercise to take on. It could be very much a part of something else we are thinking about getting your help with. And that is the development of a strategic plan. We are required under the law, under the high-tech law, to update its strategic plan that was issued in 2008. That strategic plan was put together obviously, before high-tech legislation existed. And in a different circumstance. And I think appropriately to be revisited. But it would make sense this seems to me to go into the planning process with the way of thinking about our challenges that we all shared in common. I know that as we have to move forward with a very rapid decision making, we have relied to a large degree on a meaningful use concept that we developed as a kind of set of guideposts for what we should be doing. And what we should be directing ourselves toward. And meaningful use will continue to be a very important sort of navigational and point. But the question is among the many methods the might be a vote to us to get meaningful use, which make the most sense, which are most cogent. I think this became, the need for these principles became clear to me personally when we were talking about privacy and security at our last standards meeting. And we are talking about different methods of ensuring privacy and security, but we realized we haven't said a set of principles around privacy and security the made a lot of sense to us collectively.

I'm going to stop there and ask Christine back [Indiscernible] who has brought this issue to my attention to set a few words about it. And what I'm going to do is do an overview of the various kinds of work we have in mind. Some of which is still short term work. But very important. Some of which of the kind I just discussed with you might be a somewhat longer term project.

Thank you. I couldn't agree with you more. A lot of our thinking was really formed back in the crafting of the ARRA legislation which by law action requires us to craft a policy framework that was covering the use of electronic hope the commission in the United States. And it there's a reason that they wrote that this committee plays in prioritizing standards development actually comes subsequent to the development of the policy framework and the law. And I think it's become increasingly apparent that we've already made a number of really terrific policy decisions. The work we've done around meaningful use, the hearings on privacy and security, the issues we've been done to consider around help affirmation exchange. And it is my view certainly that we have to come it's a great time to step back, to take account of the work with them, but to be more explicit about the key issues that are in place. The questions that we need to answer and make decisions on so that we can provide a some directional guidance particularly to the standards committee as we move both of these entities forward. That's in fact have the law is structured. So in my view, I think the question is what is the it of a policy framework? I don't think I know the answer except to say I think it's exactly as Dr. Blumenthal characterized that where we need to set back now and take account of what the key questions are do we need to answer. What we believe and what to recommend for a set of policies or principles that should govern the use of electronic sublimation and then translating those into a set of practices. Strategies and tactics and I think that's the perfect flank into the strategic plan that I know we are going to talk about today. And in fact the law requires us in crafting this policy framework to take account of the zero and six strategic plan. Meaningful use again I think was a great example where the policy decision we made was to align the goals of meaningful use with health-care goals rather than technology goals. And I think we can do that for a broader set of areas including Dr. Blumenthal talk about privacy and security, but I want to urge us to star that work immediately although not of course stopping any other part because we have a lot to do. But to begin to have these conversations simultaneous to of the of the work that's going on that I think we're going to hear about shortly. This is something that I know is pitifully important to Congress and to patients and families do we get to a set of policies that can then prioritize and guide the development of standards and in fact, if Dr. Blumenthal would suggest to except them, it said the policies that would impact do we use help the commission in this country.

Let me go through a list of activities that I think we could use your help with. Of which this is one, and then I to have a discussion about this list and the priorities we are assigning to it and what your reaction may be. If I could have the first slide? And go to the next one. These are some as we sat around at the national coordinator and brainstormed what we see as some of the things that are very much on our agenda. For the two major committees. And keep in mind that this committee to some degree sets the agenda for the standards committee. Think about what they need to do is very much a part of our agenda. These are some of the things that came to mind and the things and blue are the things that we think remain time sensitive. For the policy committee and we are already deep into this, thinking about privacy and security policy. And again, thinking about the 2013 and 2015 meaningful use objectives which we are moving into even today as we speak. Thinking about specialty measures. Working continuing to work on promoting the adoption of electronic health record and held in commission technology. Thinking about how we fill gaps in standards and how we develop standards. One of the interesting things about the [Indiscernible] is that in the past, it has been responsible for common is an existing standards and then responsible for commissioning the development in the standards. But that may be something that we need to take on to meet our goals for national health information network.

Another issue is very much on our plate right now and that is how we continue to development of what has been called the nationwide Health and commission of work which in the past has had a very discreet manifestation. Has been a conceived a network of networks of as a way of promoting exchange developed information. We are thinking about with that model is still exactly the right model or whether it needs to be refined in certain ways. Regardless of what that model is, we need to link the availability of an NHIN however defined to the work that states have been commissioned by us today. And the development of health information exchange. A mention strategic plan. We had gaps in measurement that we need to attend to. The gaps in the measures that we are going to be using for Quality Measurement and the measurement of compliance with meaningful use. And then at some point we will have to are could think about how Medicaid programs coordinate with medicare programs in the meaningful use criteria that they develop. The two areas and blue, all these are important, it's hard to choose among the children these are all vital the important areas. The the two we feel particularly pressed on our privacy and security and the NHIN and state HIEs. If you look to the calendar, it gets to look like all of them are pretty depressing. In the standards committee, we've already talked about to some degree about gaps in standards. We need their help in telling us precisely what standards need to be commissioned if we want to commission new standards. They're going to have to start thinking as we think about meaningful use revisions, they're going to have to start thinking about changes in certification criteria and standards. The last meeting with the meeting before last, the standards committee decided that there were going to create an implementation and adoption of standards group. Which I will say more about in just a moment. The standards committee as part of the standards work can play a very important role in supporting the NHIN for which standards are actually front and center. If we develop privacy and security policies, they need to be implemented their privacy and security standards. And they continue to work as we will be working on setting standards for quality measures are recommended by you all for adoption in subsequent versions of the meaningful use frame work.

Next slide. In order to tackle this array of work, we have thought about some work group are how to destroy this work across the different work groups that exist and perhaps what new work groups might be needed. This is what we've thought about at the first instance. We have a meaningful use work group. That has plenty of work still to do. And so continuing it makes a lot of sense a lot of the discussion in the next day and a half will concern things on the plates of the meaningful use workgroup for subsequent years. And work group that looks at adoption, we have launched a whole bunch of, we have an adoption is a vacation adoption work group. This is in a sense a slide change in the emphasis of that certification and adoption group to focus a little bit more on adoption. NAD we have a certification recommendations. We have a privacy, we decided that it would be helpful if we had a privacy and security task force or work group. At least to get us planted in this very important area. We mentioned previously the NHIN and HIEs. That would be a new work group and a strategic planning group that would address the issue of the framework that we've just discussed. There are a set of parallel new and existing work groups in the standards committee that we thought about and implementation and adoptions work group that we mentioned earlier, privacy and security work group the to the policies of the policy committee and turn them into standards. Clinical measures work group that currently exist and a clinical operations work group that currently exist. Next slide.

These are some of the prior to topics that we thought of for these existing and new work groups. And some cases, their shared across groups. And in other cases, that is shared across the Policy and Standards Committee. And in some cases, the fall within the boundaries of one committee or the other. In the area of privacy and security, we have come to the conclusion I think that at least for a short-term it would be useful to give intensive focus to the principles and practices that are essential to ensuring privacy and security. And we've asked the policy -- We decided we would set up a group, we'd like you are thoughts about it as well. And we'd like them, this group to react to titillate to the ongoing hearings that we've been holding both here and in front of the security committee. So the standards committee. Hearings of privacy in hearings on security. And we think that those seven recommendations on how to proceed in this area could be extremely useful to the office at the current time. And the NHIN and HIEs area, we have to actually by law, we are required to govern, to produce a set of government commissions with respect to the NHIN. And SEM have been so helpful and recommending the purchase to other areas in which we have to regulate, we think it could be extremely helpful to us in this area. We also were hoping that we could use your wisdom to help us to think through what the NHIN it should be doing and how the work of the NHIN should relate to the work of Health Commission exchange generally. And the idea would be to take in a sense, the health and commission actions were group reconvened that and build on it for that purpose. The meaningful use workgroup as this meeting suggests is going to be focusing a good deal on specialist measures. That's a topic of high priority for us right now. And we hope that with the hearing today and of the work on practices and specialties that we can make progress on the front. Next slide, please.

The implementation adoption work group of the Standing Committee is one that was proposed [Indiscernible] and a previous meeting. This is a very interesting idea of tried to reach out to the community and get feedback on standards and see which ones are working and which ones aren't and perhaps modify recommendations based on what we are learning from the field in terms of the usefulness of alternative standards. The next point that the HIT policy committee and the standards committee will get a briefing on what strategies I think is really a follow-up to this discussion. And to the extent that I think one of the things we want to do at some point is to take a moment to inform you about not just the agenda of issues we are looking for your help with, but the review with the office is doing. Across all its various activities. Because that's something we think could be helpful to you and thinking about strategic planning. We also need as a mention, which been thinking about a strategic planning work group that might consist of members of both the policy committee and the standards committee. They would consider a framework for getting principles as we mentioned would relate that remark to a strategic plan in a word of the zero and C and then begin work on recommendations for us. Related to a strategic plan. I don't know if that's a long enough list for you all.

It's tiring does to gutter with much less to think about doing it. I think that's the last slide. Is there another slide?

Okay. I guess that's a lot to ask you all to digest, but if we could just reflect for a moment on what you all think of as critical issues. Www.these tasks and work groups make sense to you do you have thoughts about the idea of a framework? And related to a strategic plan. I guess I'd like to take a moment to get your reaction this set of ideas.


[Participant's audio is faint/unclear] the area I worry about is did Management. I don't know if that's buried in some of the quality measurement activity you talk about. But what's the create interoperability in [Indiscernible] have you know which data is necessary for the ongoing management of the patient? Versus creating and was amounts of what I will call a did a dumpster that the doctor would have to sift through to get the Net it's he needs. I do worry about data management, it did a presentation issues that I think will continue to [Indiscernible] as we move forward.

Good thought. Dale?

I might go back to my favorite topics, privacy and security. And I think that is extremely time sensitive. Is to have it listed as time sensitive but I really think we need to have some overall strategic thinking about that. We are setting policy and indeed we are setting really that strategic level of thinking in a lot of the things we're doing with and is committed we've already done that. And compiling that together into those first principles, I think is very important. That happens at the onset. It should have been thought perhaps first, before we ever got established in defining meaningful use or looking at HIEs for certification. However that's passed and we've already done that. Now I think we need to take that opportunity to go back, pull out the essential policies that to we have been established, the first principles the waist up as without thinking about them. Put them into a free market and again go back to that over arching thing that in order for the public to accept what we are doing is privacy and security. So I absolutely commend you for coming back to that strategic thinking section and first principles first, looking at that, but putting privacy and security at the very pinnacle of that.


I think the list is terrific. I think we did an okay job of working as were Crips and tried to get our thoughts together some of the things overlap and in this was a lot of them overlap. As the band thought given to how we did that a little more seamlessly so that we have some synergy between the work groups?

In coordination across the group's?


But question. And always to better. We are trying to do better. At the same time we want to court ended you all. We're also reluctant to give you one even more conference calls.

We thank you for that.

In addition to meeting with their kids, we then had a meeting with other groups. And the escalation can go on almost [Indiscernible]. But we will make a note of that and, Judy, are scheduler and magician with work groups will try to keep that in mind.


I think to MAC points I think it's a good list, one is to keep in mind the work the [Indiscernible] is doing and how that integrates into some of the planning we are doing here. And also some of the conversations you and I have had about time and the administrative and clinical data it together and how we begin to build towards more integrated [Lost audio] that's a great thought.

I'm going around.

I also want to support the work on the the principles for Mark, values by a worker that would also consider tactics from a strategic plan. I think if you look at the breadth of the issues that have to get done in a relatively short period of time, the only way to do that effectively in the way that sort of put it altogether is to have some benchmarks by which to measure the decisions you are making on those increments of issues but otherwise it looks like a sea of things to do it and it's almost overwhelming. If you have those pencils when Ford, you can tackle it and you have benchmarks for measuring the decisions you are making. With respect to the privacy and security work group, since I was summoned to urge us not to do this in our early meeting come out what to say that you've beaten me down. [Laughter]. Wrong way to say it. I appreciate there's so much work to do on this issue that person that not having a group that's dedicated to it means that those issues don't get the proper priority. I'm persuaded that it's the right approach. I think we need to do to make sure that we don't consider those issues in isolation because they're always contextual, is to make sure that there is some what I've come to call cross pollination with some of these of the work groups that are working on the substance of Information Exchange, adoption, etc., so the privacy doesn't it make any backing. I think can work if we do it that way to go the last thing I was it is with respect to the creation of a new work group to do the NHIN and HIE I think I like to it that it's about what you see the IE worker doing, it's not those tax. And the those of us who are on the work group are looking at are charged a sum that that would fall into our bucket although its ambitious to do NHIN planning and governance and we just took on the last issue and we will talk about that in a minute ago and now that there's a significant amount of overlap and I just want to make sure that if we are creating a new work group to do that, I think they're a lot of members of the IT workgroup who want to put is paid in that. And edit we need to be clear about what remains for the separate IT work group to do. And maybe the answer is nothing and it just gets reconstituted.

I think we're mostly talking about a refocusing. I think the initial work that the HIE work group did I think was extremely valuable in conceptualizing our options. And I think we are not trying to get a little more concrete around a particular option. And that is the National Health admission at work which we have to develop regulations about. I think it's a slightly less global focus. And whether we do it in under the rubric of an old group or relabel the old group, I think is sort of a matter of semantics.


First I agree with everybody this is a traffic was. It gives us a great sense of direction. I was influenced by the [Indiscernible] coming at the privacy meeting where she talked about the importance of having, defining the architecture of NHIN as part of the entire privacy word pro I've given that issue a lot of thought and I think she's completely right when she suggested that. Perhaps it's when you were alluding to when you talk about states and the works of networks, but fundamentally, I think we really need to clearly define the architecture with this is good to look like but in short-term and long-term vision. But was unsure of the work of so doing that word that comes from you or where that comes from?

And not specific -- We had spent the last several weeks working intensively on NHIN options. And we would like to present some of that work to work group and then to the larger group. I'm not enough of a tacky to know whether what we're doing as classified as architecture or something else. It looks pretty to me, so in know, maybe we can, architecture. I think options begin about the NHIN and previous views of it just the kind of relook.

I think that would influence are worked tremendously. In terms of not been a sticky or quite fortunate. [Laughter].

Just a couple of comments put a little bit to echo what Bill had mentioned regarding privacy and security. Just the importance of this and I think the ONC can make a lot of headway in distinguishing personal versus Public Health and really try to define some of those measures particularly as [Indiscernible] report cannot addressing FSA and we really need to distinguish these. The second know and I certainly don't want to add to the list so I don't know if this falls under specialist or not, the area of clinical research and I know we will hear from Greg tomorrow. The really the FDA will and a lot of this is we are entering a new age of Madison, a pair of did Boston's with Therapeutics, we are coming on this rapid learning health care system and I think the committee Willie needs to try to address this and to bring the FDA and and I age into a lot of the measures for both to reduce the cost of developing new drugs as the start identifying patients of populations. But also to improve access to patients. And doing some of the site visits to certain cancer centers for they are in the grading patient profile in with clinical trial matching the are reducing the time for enrollment in these trials down to a third of what it is. So this is critically important to a lot of patience. I would hope that ONC would consider this and see if we did find a way to put it in.

IS for this approach as well. I do think the privacy, the policy from word is very time critical. In getting that initial document or an outline for it as quickly as possible with guided the rest of the activities that we have in mind. I'm concerned that the architecture elements of the framework that they be joined to the that we not develop a policy for a mark of here and then the standards and architecture of their but the decisions about the options reflect the principles and policy guidance that comes out of this dialogue we're having. Both coupling and staging those two things is important to me. The of the thing I want to mention, the topic is not quite explicit which is alignment but across implementation cities across payers. I'm concerned about Medicaid, Medicare and commercial incentives for IT being the line. And the framework whatever that is, address alignment in that respect. I'm also concerned from a health reform when the view that we at least anticipates with the without federal reform alignment across payment innovation, measurement development, and IT incentive programs beak understood. And it referred quite a bit in terms of our presentations from [Indiscernible] and others about the measurement pipeline. That also applies to the payment strategies that have been deployed around the country. I hope we can and maybe in the strategic planning process make sure that we have thought through both the horizontal line the cost of a pair types and practice since and the alignment across different functional areas like payment measurement and IT.

To point out I think everything that every person has had said so far has policy implications slide think as we look at refocusing and we imagining the work group structure for me at points to the need for the policy for Mark that takes into account these core issue areas but also the time lines your offices under, legislative language and out Sam is as interested in is well. And the strategic plan and the objectives of [Indiscernible] I think it is a way to your points to also help the worker coronate across each other that if we all have an agreement about a set of policies and directions than the work of the group's becomes easier because it is more focused at least at a higher level as they drove down into the detailed work that needs to be done.

I wonder if I get a bit of a context the, the policy for a. I completely support the need for a policy framework, I wonder if there's an unpleasant to mark do we bring to the table. We are familiar with the high up and wait, everybody is lined up and then charges the door. I think we've been in a wait and hurry up stage. [Laughter]. None of its anticipated the banking failure but it put this into the hurry up face. And the good news about that is there's been a lot, we've had over a decade to think about this, so there's been a lot of processing, a lot of essentially policy from art that's been constructed through various activities that almost everybody on this group has been involved in. That could be [Indiscernible] word, Connecticut, [Indiscernible] a lot of work has come before this. And implicitly I think we've been operating under some of the framework that comes out of that consensus work. While we don't have it laid out in writing, I think and presently, I don't think we should save we haven't operated without a framework. It's very important to bring that forward. I think that's expressed through a lot of work, we had to do in short order has carried with us the focus on health outcomes. And the attention to privacy, there's a lot of things that a big income I wanted to add that to the discussion.

Anybody else?

La [Overlapping speakers].

I'll make a couple of points. One is I'm not sure this is we mean by a policy framework, but to me, I think we have to get back to part of the basics of challenging ourselves about everything that we are doing to make sure that it's got some impact on either improving quality, reducing disparities come improving efficiency of care and really keeping that stuff in front of us. I know working through a lot of the details, it's really easy to lose that and I think that's what the public really it to the most folks would add as outcomes of your try to achieve? And think we're there and I think we've been doing a good job at that, but I think if we did that more explicitly, that would be great. The big issue the, in where I like to see a lot more focus is on state issues. And the Medicaid fees. I think this is a huge. And I think we really have been spending and lot of attention on the Medicare piece which we can control at a national level and may well come across the country on the Medicaid meaningful use and the Medicaid incentive dollars states are doing all kinds of different things. Some have advanced structures and placed the debt going to be able to jump forward and really get people who are the safety net for fighters and people will drink a lot of Medicaid to be able to really use these dollars quickly and word about what it means for the underserved populations and the people in the states where that from word is not that well developed and where there structures aren't that well developed and where their HIT development aren't that progressive. What's good to happen to the patients in the state's? What could happen to the providers in that state who would qualify under Medicaid? I think we need to pay more attention to insure that stuff is called out at the National little more consistently. The third piece I would mention is I think we need to keep a parking lot of these some of which are going to come out in the next to met the hearings of things that have been left out. For the legislation just doesn't work. I think we're going to need an adverse event reporting system as we start to blow things out to find out to be able to pay attention across the country to places where the things we think we're going to work aren't, where there are some adverse consequences that we didn't expect to go where people are shying away from adoption of the without your tried to incentivize said and all of those things go and with the special plight where there might be legislation the fixes are regulatory fixes and other things. I to understand the process a little better in terms of what happens once CMS comes out with the regulations and what happens if the fixes need to be made later on. I'd think it would be helpful if the panel could get educated about some of this process is a little bit more.

Tony has assured me the same as regulation will be perfect. [Laughter].

And I trust Tony.

If you can reach me at lunch. [Laughter].

The focus of a state issue is my major point.


But it's a good idea to focus on privacy and HIEs with a novel concept there. I do agree with that and the question does the HIE still need if we divide that up, those of the two main things. Maybe it is replaced by those. I wondered about that. One of your original slides you had HIE, I'm sorry NHIN and state HIEs and I'm wondering if we could change that to just the NHIN and HIEs because extremes goes over States and by putting it as a state HIE I begin to see it all subdivided into little pieces within the concept of exchanging across states. Of is also going to recommend when you said you add to the people to that that you'd consider adding some of the different vendors to the HIE subgroup because then it could talk about what do they each did so we can send things back and forth to each other as we did that.

Okay, thank you. Anybody else?


I think the point I'd like to make obviously you've done a lot of thinking at ONC about where we've come and where we need to go to. And its quick for us to react to your proposals today but I think seven that would be helpful is if we could understand a little bit maybe in the form of seven that would be helpful is a white paper that ONC may be could be due for each work group from this point going forward. Kind of outline on a summary form the issues you thought that were present that got that led you to this next series of recommendations and [Indiscernible] it helps us because sometimes we are not all clear about how you interpret what the law, the intention of the high-tech Act was, I think a white paper that summarizes your thinking for each of these were groups. And your interpretation of the mission under the law as it relates to that would be helpful at least to jump-start us going into this next phase.

Thank you. Good suggestion.

I too would like to commend you on taking this time for pause. I think that in our deliberations we actually have implicitly confused certain principles into our decisions. And this the opportunity to take pause and actually be explicit about identifying those values and decision principles is extremely timely and essential to move to the strategic planning which I would advocate having a greater priority. And that value and principal articulation, I do think that we have, that we could offer more attention to the best practices or successful innovation at whatever level they have occurred in the U.S. The more explicit and informing the strategic planning opportunity. And my last comment is that in articulating the values and principles and our commitment to better health care for Americans, the research and the translation of that research to the benefit of individuals and populations is essential. So I would see that becoming far more explicit not only in the principles but in the strategic plan.

There's been an excellent comments and then not going to repeat many of them but I wanted to focus on one small area. The strategic planning is essential, and it would be great, I think Devon's point about at least the beginning that we reduce this privacy and security as a foundational piece and thought it was going to be permeating all the work groups and know it seems like maybe we are returning to an idea that there be a privacy and security group to look at this. I'm still convinced of many to have it permeates all the groups and that coordination I need more to speaking to needs to happen. It can just the that the separate. The second point I will make just to be emphasizing that nil made the point he made was with regard to these outcomes that we should be looking at and have to make sure that these are overriding. He spoke to the issues as it relates to the underserved, I'll speak to the issues of how it relates to those who tried to the population health to the the public health and from it, we haven't had much experience or discussion around that. It's inside of the meaningful use objective, but it needs to be spread throughout this as well. Thank you.


I want to remind ONC and the policy committee that while we talk about everything on the macro level, we are going to come down to a health-care worker doing this. We have to bear in mind that the decisions we make have to be palatable for the work force. We talk about population health and somebody is going to be compiling this data. To slides earlier we had some of the work groups and a blue and black, I would say I think the adoption work group is an ongoing group that has been a factor to it we have to be concentrating on the work force today. Because once a decision is made, they're not going to be able to turn it on tomorrow. You're going to have to be doing our due diligence prior to that to mention the work force is engaged right from the get go.

Thank you. Excellent point. We are in the office, we are required under law to address work force issues. And we have been tried to attend to that requirement. We hope soon to be able to make some public comments about it. But that doesn't completely address your point. Jody?

Briefly on the strategic plan, I'm glad there's so much interest and that. It's something that we had wanted to focus on the other but with all of the tight deadlines, it's something that hadn't come there was no time to have that completed before some of our other work. It really is going to be important to get him put a folks on this committee and others we may want to bring it to the worker on that. It's something we are planning, we are already talking about internally and coming up with some plans for how to do that and where would be great to get your input so think of the discussion about both the principles and from work and the strategic plan will really help with our efforts and we are going to be looking to you all for a lot of guidance in that area. In order for us to make the statutory requirement.

Thank you for all those comments. We gave you a lot to think about in a very short time ago and I appreciate your sharing with us and of course, if you have further comments, we would like to hear them. And we will take them very seriously. We have an agenda of homework to think about from what you told us. And we will get to that, Judy and Judi will take care of all these issues for us. Let's now move onto the rest of the agenda for the day and Paul, I think I can pass the baton to to review the agenda.

Thank you. I appreciate this discussion as well. I think it was very helpful and shows a lot of thought and deliberation in terms of the work of the committee. Just to match the incredible pace of what was shown and which required of ONC. This next day and a half I think will match that in terms of the various topics that we are coming back to. We all know do we had a very short time line to put together the meaningful use of remark, and the initial criteria for 2011 and we knew we'd left out some of the details. I think Tony is good to fix the details in 2011. [Laughter]. Okay. You've heard about those. Now that we have a little time to try to come back to 2013 and 2015, we thought we were systematically going through and fleshing out some of the rest of the details. And this today and tomorrow is a reflection of that. We've started on this course last month when we had a privacy hearing that was done in the full committee. And there was a privacy Task Force that I guess will go into the privacy work group. That looked at that and characterized the major things upon which we will do some more additional work. And a little bit later on, Devon is going to cover that. The outcome of that and some of the plans going forward. The other thing we all know is that a laboratory result is a very important part of [Indiscernible] and Acre important part of care and it shows up in the 2011 criteria. Your we know how difficult it is to get those test results into the EHR in a meaningful way. The information exchange work group held a hearing with the lab vendors in the EHR vendors last week, and Devon and [Indiscernible] are going to report on that later on this morning. Finally, the work of the hearing, we knew that in the measures we have a lot of measures that were directed toward the primary-care providers. And we knew we had additional work to do with the specialist, people who are covered only on Medicaid, for example. We are coming back with is Harry to cover many of those topics and I will give a more detailed overview of the hearing right after lunch. But included in that we agree to hear about what is the current state of quality measures in the specialty area. What Sam as is currently doing with this incentive programs and we're quite here approaches to industries which is one of the ways the specialist participate in get an electronic the commission for benchmarking. A couple approaches, one is a centralized registry maintained by [Indiscernible] society [Indiscernible]. We will hear from both of those perspectives. We then have a panel on specialist of various kinds, metal quote specialties, [Indiscernible] which may fit in between those. But those are interesting perspectives and we're welcoming their input on how can we design the criteria to accommodate the special concerns.

A big group where most of Americans get their care is and the setting of smaller practices. Whether it's a smaller positions practice or smaller committee hospital said in a provider roll out sitting, we have a panel that's going to talk about special challenges that will talk about and how did we help with the measurement, the qualification for the mental use incentive without putting them over the edge as Neil talk about. Finally there are providers who are eligible only for Medicaid such as nurse practitioners or dentist some of the folks that we have not spent as much time on. When we consider the Medicare population but we didn't spend any time on the clinical research area. Of those things are covered in the statute and we want to flush out some of the perspectives of those folks. While I'm on Medicaid, Medicaid, we talked a lot about the Medicare side, we have not spent as much time on the medicates I. We are planning in the future to have at least a panel if not a hearing on the Medicaid issues. We can provide more if commission as CMS goes through its processes. That's just a preview. I will go into more detail of the panel we have set up after, right before that hearing. It's going to be a jam packed agenda, lots of ideas to bring up. We will have to figure those in as we develop our policy framework. Could ship Plan and the future of meaningful use criteria.

I will turn it back overcome I think what we will do is go to the first update in the work group and this is the information exchange worker that's headed up by Devon and we keep the and I think Mickey is on the phone, is that correct?

I'm here.

P4 I did that, Judy, you had an extensive set of minutes before you. Any corrections or additions to those?

If not, I will entertain a motion to approve the minutes. And second. And all in favor. No post or abstained. Thank you. Now we can begin with the information exchange work group update on their lab hearing last week.

[Captioners transitioning]I am quite comfortable in my chair unless --

If you are not on the IE work group, you were nevertheless aware we had a hearing, issues arose with exchange of laboratory had information as you recall, one thing we have been focusing on are what are -- a deeper dive into policies, technical requirements that need to be set in order to facilitate exchange meaningful use. We have put recommendations on the table. We need to do more in this area, one of the things we will endeavor to take on in the coming months. There are really two areas of exchange that are key for meaningful use in 2011 and one is exchange of lab data and the other is E-prescribing. We had hearing on lab exchange last week, thought about having one on E prescribing, might need to think about the time that occurs with other tasks on our plate.

Again, I thought it was a very good hearing, very informative. We had a range of folks speak to us about issues involving exchange. Electronic medical record vendors, small and large laboratories came to speak to us. We had a representative from a public health laboratory, providers, folks who are establishing health information exchange entities and organization at the state level. We also had a panel on regulatory and policy issues, including folks with expertise on the clinical laboratory improvement act, CLIA, as well as HIPAA, and forks who talked a lot about laboratory standards. In fact, that was the common theme of the day. We provided people to give written testimony, from all of the testifiers who addressed us on the lab hearing, and also issued invitation to folks to augment testimony or others who didn't have a opportunity to testify or weigh in, submit written testimony to be received ideally by this Friday. The work group goes through all of what we heard, distilled recommendations is next Tuesday. We are not letting any grass grow on this one.

There are a number of key issues raised, and I will turn it over to Mickey to go over those at a pretty high level, again. We haven't had a work group call to distill what we heard and establish recommendations. Go ahead Mickey.

Can you hear me okay, good morning everyone.

It's a little distant can you get closer to --

How's this? So, as devon described, this was a listening and discussion session to try to get all perspectives on the table to help inform discussion and recommendations going forward, and to educate the work group members about the various issues that swirl around the issue of lab results issue so we can have a better conversation going forward.

I will describe some of the key themes and issues that came up, and then talk a little about what policy levers might be available to try to influence some of these things to get us over some of the barriers to broader adoption of lab results, delivery and ordering. This is really just the beginning of our understanding and we will have a couple of work group meetings to dig into the issues and come up with specific recommendations.

Some of the key issues were, first, around who is authorized to receive lab data, a critical barrier in certain areas as relates to health information exchange, for example, and whether health information exchange can be entities that receive lab data, able to present in certain ways, either simultaneous with, or in addition to the ordering physician being able to have access to the information. So there's certainly CLIA and state law related to authorized person or delivery to person responsible for delivery test results. There's [indiscernible], and going forward having the patient come closer and closer to the fore with respect to clinical information is a key consideration for us to figure out, what exactly we're able to do within the current regulatory and statutory framework and what to do going forward with patient access and engagement.

As I said, access through the HI -- Es is a critical issue that came up over and over. Urn fortunately, we don't have slides --

You should these slides, there terrific -- multiple versions of the standards, too much -- the issue, as in most of these transactions, not about a dearth of standards, but many standards, and high variability in the enforcement. Lab quality is one area there's been a nomenclature standard around, one of the oldest and most developed we have in clinical settings, which is [indiscernible]. Still, it's not universally adopted and not consistently adopted across care settings, which is a vexing issue as it relates to lab results. Even where standards have been adopted, the messaging standards have the same issue with respect to high variability, so I think all of us know the issues around variability of HL 7 messaging and it becomes more and more pronounced as you look at the lab results delivery issue, and the HL 7 mess 7ages are highly variability -- there's 360-degrees of issues here. On source system side, as well as the receiving system side.

Variations in the standards, issues that came up, maintaining custom interfaces to allow any kind of rational aggregation of data to support quality measurements, higher level objectives we would like to achieve with health information exchange, more costly to implement, tends to leave small practices out of achieving higher level functions because it often requires a dedicated clinical IT staff to do that kind of lab mapping at the practice level, usually something only integrated delivery networks or practices have the staff to do.

Issue arising with respect to different parts of the market, payers may dictate the use of one lab or another. If you have standardization by one lab a particular practice finds works with their particular EMR, the payer [indiscernible] may be such that they are forced to use a different lab that facilitates against the kind of standardization they are hoping to achieve.

Finally, validation, testing of lab interfacing came up over and over with the, both sides of the transaction raising legitimate issues about how the other side was driving up costs. It's fair to say, sort of 360-degrees of issues that need to be resolved.

Another set of issues identification issues, across clinical transactions with respect to provider identification and the issues where we have NPIs, but those aren't universally adopted we still have issues with [indiscernible] identification of providers, and even more pronounced with respect to patients.

So, what are the various policy levers that might be available to help overcome some of these barriers. Certainly under IRA there are a certain number be of levers available. One under meaningful use criteria, particularly a recommendation from Jonah Frolic from California, to perhaps incorporate more robust set of certification and standards on the EMR vendors on the one hand, to have lab result certification be a part of certification going forward, and have some conformance testing via test harnesses, to make it a miter tighter certification. And to make the delivery of lab results, according to the same set of standards the EHR vendors are held to, being meaningful use criteria that drive hospital meaningful use incentive payments, where the thought there is that one of the facts that came out in the hearing is something like 8000 labs, results delivered by hospitals in small labs, some kinded of lever to hit that, 75% seemed like a important thing to do thinking about getting over the barriers.

The role of or ability of regional extension centers, as well as the state HIE cooperative centers -- [indiscernible] funding, driving implementation of standards based lab results delivering. Also under consideration are changes through CLIA where some of the more near-term but perhaps softer kind of approaches may be survey and cert letter from CMS providing interpretive guidance, one example the national labs report, their interpretation that CLIA requires they literally check how lab results are presented within every EHR deployed; not just a particular vendor or version model, but literally every single time a lab interface is deployed they believe the law requires they look at the way it's presented on that physician's screen, approve the way it's presented. That's not written in the law, it is their interpretation, the idea is an interpretive guidance from CLIA on this point could help rationalize. There are interpretation across the -- on the -- and across the states, their interpretation of CLIA as well.

The last thing perhaps, regulatory changes related to cli A will be a longer time frame, perhaps have deeper hooks into changes, but a longer time frame.

So that's devon and my summary of the issues coming out of the hearing. I would invite Devon or any other members of the work group able to participate to cover comment and perspectives.

Any comments?


Thank you, I think Mickey did an excellent job summarize. ing need input from small hospitals and labs, very important we encourage that written component period so people from the smaller communities, these small independent labs or community hospitals provide a significant amount of lab information and we have to make sure we have a way to facilitate that eh change of data without expensive interfaces.

It's Christine Bechtel. I thought I heard you say issues around who is authorized to receive lab data, how HIEs are able to -- I didn't follow it. Are there issues around -- what is the issue around HIEs and lab data with respect to providers. I get there's a separate issue with patients.

I will begin that, and ask Deven to comment as well. She may be more well-versed in the issues. I apologize for switching over that quickly. The issue, I think, is that CLIA requires the delivery to an authorized person or the individual responsible for using the test results. Delivering to an HIE as an intermediary raises the issue of A, whether that is in conformance with what the law says, since HIE is an intermediary, the question about the pathway that it gets there. The second question about is the HIE allowed to present those results to either that physician or others who are authorized to use it, either via CC facility or something like that, is that in conformance with what the law reads about authorized person or individuals responsible. As you start walking down that path you get to patients being able to access it, others, through the HIEs.

Deven, would you add anything to my description?

No, I think you got it exactly right. I apologize, Mickey and I pulled this together in less than a 24-hour period post hearing, why we didn't distribute to the group, we needed something that we were on the same page, given the distance.

My last question. Was there a discussion whether or not, you talked to end of results, changes to regulatory -- discussion about whether or not patients should be recognized as authorized persons to receive their lab data and would that strategically help enable some of the movement of lab data for HIEs?

Let me ask deven if she could answer that --

She's ready.

I am standing at the mic.

I thought you would be.

That issue was squarely presented by one of the testifiers. [indiscernible] Marshall from web MD. We had a opportunity to talk over his specific suggestion -- it's definitely on the table.

Paul, then Gail.

Can I also add that CMS was there, testified, and one thing they said they are considering is what they call simultaneous delivery quote-unquote, to HIT and the authorized person, they are considering the view of [indiscernible] Marshall and Web MD, having patient access, but need more details, not clear that would necessarily authorize patient access, but in a way they haven't seen before, thoughts about how the regulation currently stands.

I participated in the hearings, and I want to say Mickey and Deven did a terrific job of leadership, organizing this, it was really wonderful to see. We got broad-based opinion and a lot of opinion that's were contradictory. It was a lot of fun to sit through all the process. Having sat through it, I would also comment there are a lot of interesting issues, about patient access, and limit ourselves in the short time to the getting the results into the E EHR, the most immediate concern, we can put together a set of recommendations to significantly improve that. Certainly to address all the issues with customization, we can clear that up dramatically.

My other observation, as Mickey suggested, to do this right, besides handling from our side, the EHR side, some recommendations about some changes relating to CLIA will also be needed to clear up the results side, issues you raise, Christine about patient access, and a the lot of other issues that I don't see as pressing a need to address, but very important issues to be addressed, and interesting issues.

[indiscernible] to add as member of the work group, present for the hearings, it was very, very informative and essential those kind of hearings be held so we hear from the people directly affected and avoid some of the unintended consequences, Neal, that you so pointed out. If we can address these things up front, hear from the people, why I am pleased we have the specialists here today, and thank you Dr. Blumenthal. Another thing we need to consider, there is state law that impacts a lot of this, especially when it comes to patients having access to lab results. It's very specific state statute in Florida that prevents patients from directly getting results on HIV testing, other testing that goes on. It's a very complex issue that needs to be really thought through as we move forward. Our work group has a challenge in coming up with those recommendations, but it's worthwhile you hear directly from the people it will impact. Thank you.

Any other thoughts?

That was really very -- I can imagine how wonderful the hearings must have been based on the content of the presentation. This is an issue that is a core issue, and we have to have an approach to it, or we won't be successful. So we very much look forward to the work group's recommendations.

Now going to hear about another hearing, that was, I think equal stism simulating, Paul and deven are going to lead us through this.


This is a follow-up to the hearing that came in full view of the committee last month, and there was a smaller group, privacy task force put together this set of panels. We came up with a way of clustering them. Deven will talk about that and our plans for going forward.

Given the discussion we had this morning, this is almost a bit of a roadmap for a new privacy and security work group. But essentially, we weren't an official work group, but there was a need for some folks to help plan will hearing, and it was very informative. Essentially, the issues cluster in four buckets, generally. One being the issue of patient choice, and control, including consent, opt in, opt out, how granular is that, under what circumstances. Secondary uses of data, one could almost say uses and disclosures, particular second use, somewhat more problematic. If you are talking about giving patients enhanced right to control data, that raises the segmentation of data in the record issue that a lot of folks raised at the hearing. That forms one bucket, and we talked about some folks that would be interesting to hear from either as work group members or perhaps throughout reach, consumers, patients, of course, HIE operators, the technical side, providers, common use -- second or users of data, including research, but -- communities of sensitive data -- certain areas are -- with respect to patients who are part of those groups and the providers who serve them, it's important to hear from them.

Second bucket was personal health records, came through, obviously not a unique issue, raises unique issues that need to be considered. Obviously we want to hear from groups, vendors of products, cloud computing experts, and the 2.0 community that is very interested in the personal health record, personal health platform movement.

Third bucket is transparency and accounting of disclosures, we heard testimony there. There's similar groups of folks we thought would be helpful to have around the table, or again, that we would reach out to, to get further information. If we are moving all into one group, we don't have to create for, necessarily, though it occurs we might want simultaneous work going on to meet deadlines. Maybe there's a call for subgroups. We will leave that to further discussion. The last bucket is patient identification, which we talked about in the lab hearing. Came up in the lab hearing, comes up really in just about every context where you meet the need to exchange data across providers, data aggregation, and again those came out as the four general areas.

Some are attached to statutory deadlines, might need higher priority than others, but how do you choose among your children, all pretty important. So, having the one work group with some input from the other sectors so we are not making these decisions in isolation will help us to address these challenges in a more efficient way.


Question -- it struck me -- as we listen to that very informative hearing, first of all, of all the different point of view -- at some point, as we contemplate what our actions might be toward -- the controversy seems to be around health information exchange as a noun, exchange, the national health information network you speak of, it's going to behoove us at some point to define what we think, and the law thinks, the benefits or objectives of having such an entity or goal, as we weigh the risk, because we, and the public are going to weigh the risk of our -- such risk as might be acceptable to the general pop U lace, if the goal was worthy enough. Maybe defining for all of us, and the public, what would be the goal and benefit to society in general and to our task of those organization. Then, as we make these, what appear to be very difficult decisions, safe guarding, but nothing is perfect, we might gain more tolerance, understanding of those decisions. I just spell that out for thinking.

Very important observation.

The 100% rule, if everything was -- we have to at some point discuss where is the line we will deal with, that's going to drive a lot of our recommendations and decisions. If it's 100%, that's a completely different standard than something slightly lower than that. We heard that from several people who talked to us a month ago.

I think I make the same point when I say you have to consider these issues in the context of the other goals we are trying to achieve in building this infrastructure. That's, to me, underscores making sure we have membership on the new policy committee that has a leg in or also members of some of the work groups like HIN, HIE, meaningful use, adoption, they are all intertwined.

We are going to hear a lot more about this. So, I think there will be hard decisions to make. The policy committee will make, help make recommendations to the national coordinator, and I hope when you and we make the recommendations that it takes into account the benefit and risks and the trade offs, and specifies what's technically possible and what the technical constraints sort of require in the way of those trade-offs, because it is true; in a perfect world, everything would be possible, but last time I looked, it was raining. So --

Okay, let's move on, now, to the introduction really, conceptual framework, if you will, for what going to be hearing over the next day, this afternoon and tomorrow morning. As we have moved forward with meaningful use, the objectives for meaningful use, we have done so under a lot of time pressure and understanding that we won't get it perfect the first time necessarily, but wanting to make sure we keep track of issues that are not perfectly resolved. And two of those are how we account for the variation in the specialties of health professionals, and how we account for the variation in the capacity of providers to adopt meaningful use electronic health records.

George [indiscernible], who is, as you know, co-chair of the meaningful use working group, has been giving thought to this, would like to share those thoughts with us.

Thank you for the opportunity to present. Let me acknowledge my chair, Paul Tang, and the members of the committee. I will talk today about the framework, and later, after lunch Paul will set the stage for the testimony, we divided those in half.

This timeline, I want to remind you, this is more or less taken from what we published in August. The bottom line is we need to work on the 2013 measures with the idea of making them available in mid-2010, and in the process, working with the HIT standards committee, of course, conducting informational hearings right now, eventually looking at industry preparedness. This timeline is a flexible thing, in view of the morning's presentation this will be altered as needed.

So, the rationale, the work group experimented with how you decide what objectives and measures map to what professionals. There are about 60 objectives and measures for eligible professionals, say there are 60 sub-specialties. You do that cross product, you end up with 3600 decisions to make. As we experimented how you would do that, what it would feel like, and the reliability of such assignments within our work group I can tell you it would be a hard time to do the first time and even harder to maintain.

The first obvious thing was to group in some logical way, measures and effectiveness, and then map between the groups. How do you group professionals? Well, first, by professional, medical doctor,s on te owe pathic, nurse practitioner, physician assistance, so on. Different than Medicare, Medicaid, or primary care versus specialty. How do you group measures and objectives? One is to look at the metric itself, measuring process, outcomes, quality, efficiency, our do you group them by the part of care they are concerned with, preventive, diagnosis, treatment.

The work group's early emphasis is on primary care. I don't know we are sufficiently clear, not every objective and measure would necessarily have to be met by every professional covered by the law. That is something we knew in our heads, not written in any slide. Let this be the slide that says we recognize a mapping needs to occur. Why did we focus on primary care to begin with? The key role primary care plays, it's important effect on the health of the entire population, recognizing much of the quality measure development work has been in primary care versus specialties. If you see primary care the specialty, and there are 60, you have to start with one, might as well -- primary care is not a bad one to start with.

In looking how we would map the -- they have been recommended, but the 2011 measures to professionals, we started with a simple framework. We have our core measures, definition from is measures all providers eligible for incentives will be responsible for. If you are using an EHR eventually we want everyone to do computerized provider order entry, a process measure. For quality, I can't imagine there's a professional we wouldn't hold to the rule high-risk medications should not be used in the elderly. And for -- insurance eligibility confirmation via electronic means.

The first group is core. The second group is primary care measures, highlighted different kinds, adult, pediatric, hemoglobin in and -- child immunization and -- specialty measures which we, for now just lumped together. There's two sets, first the small set, generic specialty measures, the measure that's cross all specialists, for example, if you get a referral, you close the loop electronically, something we want all specialists to do. The larger book, specific measures specific to each specialty we have.

If you are going to go down this road you have to answer questions, who is primary care. Perhaps family medicine, internal medicine, nurse-practitioner, you go by profession.

If obstretician/gynecologist doesn't generally treat diabetes, except in the setting of pregnancy, perhaps some of the treatment metrics don't apply, but the preventive measures like mammogram would. Is that a partial use of primary care measures or their own specialty measures, kind of a detail we have to work out.

Then, if if you think, when are you a primary care provider? Because of your profession, family medicine person? Or because it's professional-specific, interventional cards cardiologist, you serve both roles in your area. Patient specific for some you are specialist and others you are primary care. We need to think about the implications to see the best way, how we handle that.

There are issues in grouping measures. For example, even primary care measures, adult, pediatric, we don't want to create a million sets of primary care measures. We should probably use the denominator of the measure to decide what the population is within primary care, not have a lot of group

Then the question of sub-specialties, the number could be 4000 or 12, but I will say 60, just made that up -- are we going to prescribe the specialty measures for each, or prescribe you need to be picking five quality measures and follow them? Are they completely up to you, or the national society, so on. Things to go through as we develop measures. Then, measures the only way to do it? Are registries an alternative. I won't talk to that too much, one of our sessions on that is coming up.

Hospitals for now, we have assigned all hospitals responsible for all objectives and measures, just where we are today, here to hear about -- I don't want this to be read as the decision, this is just where it is right at this second.

To say we have not yet differentiated -- the plan is to listen, number one to the upcoming testimony, editing framework based on that, create a matrix that does mapping, and circulate back for feedback.

Thank you.

It's that simple, huh?

I guess the question, what recommendations on some of these very tough issues we will come up with. Of course at this point we are talking about 2013 and beyond 2011 for this group's consideration.

The point you made about messaging with respect to the applicablity of measures, previous 2011 recommendations to specialists is a very valuable one. I don't think it's understood that we weren't intending to have those measures applied to all specialists, especially when they weren't relevant to the work of the specialists. I don't know if your work group had thoughts about the groups coming forward with measures saying please consider these measures. Did you have any thoughts off the top of your head about those, that activity?

I don't understand the -- I guess -- maybe I am asking for an opinion about something you can't provide. But it's been of interest to me to know whether specialists are anxious to have more measures in the 2011 framework, so they will feel included, or simply saying if you are going to have measures for our specialty, please include these as relevant measures. Gail, did you want to say something --

Yes, I would like to address some of that, you brought up a very valid point. One question to you, and perhaps to Paul, how do you see a specialist qualifying between 2011 and 2013? Can they indeed qualify? And if they can, what are the specific measures here that would allow them to do that? Simply the process measures or what would permit them to qualify. That's the --

That will of course be up to CMS, whether the group is allowed -- to offer public comment during the comment period, to include a matrix of what could look like to divide the -- specialists are responsible or not, we have that we opportunity through the public comment to give that advice to CMS. We can say this is a public meeting, never our intention for the specialists to follow all of them.

You made that very clear right now. I appreciate that comment being very clearly stated there; but, are you saying that CMS is the one that will determine whether or not there is any specialty that can qualify in 2011? Or are we recommending to them specialists do be able to qualify simply by meeting those process measures?

It was our belief that specialists would qualify and that they would not have to follow the measures that weren't relevant.

I don't think CMS is here to hear that. I hope they get that.

Embedded in that is it wasn't only the process measures that were relevant to specialists, so George mentioned there's the core measures, such as the problem list, specialists would be -- medication set -- things, process about the use of EHR, things that are across all physicians caring for patients and there are cross-cutting specialty measures like the turn-around time in returning, closing the loop.

But the understanding of the meaningful use committee and recommendations we did vote on were that specialties should be able to qualify in 2011, and would not have to meet all of the very specific measures that are really primary care measures.

I think that was the intent of the work group, as George said, not explicitly delineated and our good friends at CMS are making explicit.

Thank you.

That includes the process, quality and efficiency measures that are core. So anything that for now, it's CMS's job to decide are core, not just process measures may be relevant to specialists. My example was the high-risk medications in the elderly, something to apply to all specialists, quality metric, one example.

Perhaps not pediatricians, however.

Very good.

There's always --

In principle, I agree, we are probably talking about modifying the meaningful use measures for 2013 and 2015, but the depressing issue in Medicaid, how they will get their -- themselves organized throughout the states and what are the meaningful use measures that may need to be developed in a shorter time frame than 2013, 2015, some of the discussion we will hear this afternoon and tomorrow hopefully will inform, even though we said we have done 2011, I think there's a piece of 2011 that's still not complete.


I want to highlight one of the things that came up in the work group George sort of mentioned in one line in the slide, but I think will be one of the most difficult issues to face and to focus on that as the hearing proceeds. That is the issue of providers playing different roles with different patients. This is not just one of the things on the fringes, it's at the core of how medicine is practiced in this country. Even as a primary care provider, I have people who I take care of who come to me for all of their care, including all GYN, preventive, and people who have outside doctors, I have people I am treating their arthritis, people being followed by specialists for particular things. If you go to the internal medicine sub-specialties, that is rampant. You have cardiologist serving as primary care providers. I don't want to let them off the hook, if they are, making sure they take care of people's diabetes appropriately, other things they are supposed to measure.

On the other hand, there are people who are generalists, using the cardiologist only for cardiology of services. We have to think this through, not just a differentiation through people's specialty. A lot of people call themselves specialists and are not board-certified. Whether or not we will treat someone who does largely cardiology, but a lot of internal medicine, will they qualify as primary care folks. This will be a hard line to draw, we need to create flexibility. I don't think at the end of tomorrow we are going to have a way of drawing this line clearly. We will need to create flexibility at the patient and provider level as to what the expectations are in terms of quality reporting.


I really appreciate it, George, it's going to get harder. I will add to that pile. One of my concerns is that we not fall prey to the existing siloization of American healthcare, developing structures for integration. One of the two questions, where do you see opportunities that incent cooperation across the silos, specialty and individual characters Neal is describing. I am also interested in our thinking about the difference between technology products and information handling as our objectives. In the case of these specialists, for my point of view I am more interested in participating in information exchange for the better care of patient, rather than knowing they have an oncology EHR installed. The technology platforms suitable for each specialty, spins off meaningful use, I hope we don't end up going down the path, having to certify every GIHR platform. I would hope, on the other hand, we can specify physicians participating with a flow of information supported by a variety of technologies. A caught lab infrastructure, not that cardiologist's, but enables a lot of good information to be spun off to support patient care.

So, how do we give credit to a cardiologist participating in infrastructure spinning off the right data without necessarily saying we will have a set of cardiology products we have to inspect.

What are you thinking about how we drive this process to address those issues?

I think that's a great point. In my mind, ARRA is an incentive to get the nation forward. It's not the answer. We need to figure out what we need do so the nation ends up in the right place, sharing information and having good oncology systems, not necessarily with us making every decision that needs to be made across the nation and all specialties. What can we do to push it forward without making every decision? My answer is I agree we can't make all those decisions. We have to make the exemplar decisions that push the nation forward. Information exchange is one example -- where oncology system might get done without our having to stipulate it.


The meaningful use group has done a lot of work, you, George in particular have gone blind on spread heats I sheets -- one concept we talked about early on was this idea of measures that matter, getting to a parse money yous setting, subspecialties, getting in the weeds about micromanaging practice. At the same time we don't want 10 million measures, but we want measure that's matter, David talked about measures of integration, composite. That's right, but at the same time it takes me back to the achievable vision for 2015 that [indiscernible] originally drafted, and it reminds me we need to come back to restating what that is. The reason I think that is because if we -- I will throw this out there -- not what the vision said originally -- if we had a vision that our goal is in the next five years we will save 20 million lives or $10 billion, or eliminate health dissities. disparities. Those are huge. If we are not driving toward outcomes, we are in trouble. That would get us to a more helpful set of measures that matter in terms of thinking about, okay, so for each specialty, we will hear about this today, we asked them to talk about what are the measures you could contribute, your specialty could contribute, but I think we need to come back to the high-level goals pretty quickly and have real sense of agreement, discussion. I know there wasn't agreement in the broad policy committee. We have work to do.


Thank you. I want to follow-up on Neal's comment about the need for flexibility that reflects the complexity of how physicians care for patients. I was a general internist. What you say is true. We have both seen disasters that occur when a patient and physician have a misunderstanding of the role, the patient thinks the cardiologist is doing primary care, never check being the prostate, the logical extension of Neal's argument is you have to specify at the patient level the relationship with the physician? Is it primary care, sub-specialty relationship? You get then into incredible complexity in a practice where a physician has different responsibilities for different patients. It would be difficult to manage. You are right, but the logical solution is one I don't think is practicable.


One further thing we have to understand as well. As we establish various measures to drive the outcomes, is CMS going to have the where with all to do that evaluation and are we creating a problem that is not going to be able to be solved unless we have CMS as a partner that can actually use those measures created. I know having had my discussions at the office space level with CMS, their inability to deal with things, I want to be sure that we are going to not just be creating data for data's sake. That it's actually going to be useable and achieve something.

Yes, Neal?

I guess I am going to follow-up, what I said before, this is one of the places where there can really be an adverse impact. If we try to clarify something that's non-clarifiable, like at the individual patient level what the role of the particular provider is with the particular patient, I think we run the potential of doing something bad here. For example, if we allow somebody to define themselves as a specialist when they are doing a lot of primary care, start focusing on the specialty measures and we know already from all the quality improvement work as you focus on something, on A, you only have a certain number of minutes in the day people stop focusing on what's not being measured. We run the risk the at that level of doing this. One thing we ought to consider through the process is that, as you said, it might not be possible to get down to this level of measurement, specialty by specialty, person by person, and if so, I think it leads us to go back to the larger goals, see what we can do to measure processes of care that are sort of more general and that really strike all the specialists, all specialties, all primary care people in terms of what we expect them to do. You can look at that, for the medical home criteria, processes are not just about primary care medical homes, they are really about how should the healthcare system function, might find ourselves rising out of the weeds, one thing we should consider, looking at things that are measurable, and may be at a less granular level, but a more important level in terms of basic structure how the healthcare system needs to function to improve people's care.

Couple of other points. First, we are tasked with defining meaningful use of an electronic health record. That has to be consistent with healthcare goals, but doesn't define all the goals of our society. Focusing on those that are most pertinent to the legislative and policy mandate may be helpful.

We are not tasked with developing quality measures. There are plenty of other agencies and groups that do that. If health reform were to pass, a lot of what we are doing would have to be coordinated with work that's going on in health reform area.

We can't wait for our 2013 upon discussion to learn all about what will happen with health reform and what will happen with its implementation. But I think over time the burden of coordination will grow, and so some of what we might conceive of will have to be -- at least reconsidered in light of other goals that the legislation may create.

I did find it useful to go back to the idea of what outcomes we are focusing on. If you have to choose among measures, then you can't ask for all measures, you probably ought to ask is for the measures that are most relevant to the problems you want to address. >

One possible organizing principle in that regard may be chronic illness and the leading areas of chronic illness that have the greatest associated disease burdens and Lack clarity of purpose with this quality measures because some of the point we are making I think relate to profiling a practice. In terms of our practice performs, but at the door and the line going to mean for his criteria is improving the help of population. Those are fundamentally different needs for how you architect the solution. It might be able to pull the data out of one [Indiscernible] one side and the of the need to have original collection mechanism. I think our answer is both, we want to profile both the practice as well as the help of a particular patient or patient population. But I'm not sure. Is that kind of our thinking?

I can only go back to the free-market all endorsed. Which had both an individual qualities safety efficiency and disparities domain, but also a population health domain.


For primary care in my view, the issue is sidle its been done come. My view about specialist is that it is a really complicated for all the reasons that Neil has laid out. And that we don't necessarily want the perfect to be the enemy of the good, we want them to do certain things, we want him to prescribe, but is paid in data exchange and be able to read the notes. And there are not good existing measures for most specialties. All the hearings in the world won't let us find out about those, mostly, they don't exist. I'm a little nervous about focusing too much on chronic illness even though on a recognized that that's where a lot of the utilization goes. Largely because much of the word to date that looks at using electronic records to improve care of chronic Thomas hasn't demonstrated benefit, at least in the near term. There's some exceptions around diabetes and in the coronary heart disease. And I think that would be one lens to look at but I don't think we should leave out, for example, a preventive care word has been clearly demonstrated that electronic records can improve things even in the near term.


My observation is I look at the meaningful use matrix, there is this column that's called objectives. So when you look at some of these measurements like percentages of people that use the PHR, there's no objective which is gauged patients and families. And the mammograms, there's my objective as it relates to preventive care. As it relates to the specialist discussion, it seems to me that is specific measurement doesn't apply to a specialist. Can we find something else that's a substituted that really fulfills the same objective? And that would be the way I would approach this issue.

Yes, Judy.

I know that we began all of this because of the stimulus money. And to get funding into individual physicians and health-care organizations and at the same time, basic level of care for our population. But it strikes me as I'm listening to this that we may be focusing on the wrong thing. Which is the physician when is it really around the patient? And not the position? Isn't coming to the patient get the mammogram or prostate checked, did the child get wait and appeared to abuse the charts and is it about, the the patient care and which of the multiple physicians did its bid if and all of the place and never tried to look at its physician, we are missing the patient.

It's true what you say at the same time there's going to be some tens of billions of dollars flowing of the federal treasury rewarding mean full use. If we are lucky. And at a minimum, we have to respond to that requirement and it is an enormous opportunity, I think, to meet both objectives. And that is to focus providers on patients' needs. More than they have been in the past.

If however we think of the patient and the problems that Neil and Michael have been talking about, it may allow us to figure out a different path because of the one we are on now might be to micromanaging and to detailed.

We should explore that. I'm going to suggest we moved before lunch, but George off the hook and the removed before lunch to introduce the afternoon and I don't think you have time to actually be part of that hearing. But we are a little ahead of time so it gives us a chance to move the afternoon agenda up a little bit.

Thanks. We will get an overview of the hearing that we are going to be hearing over the next day. This afternoon and tomorrow morning. May be another way to look at the meaningful use from what is it considered as a road map. for HIT investment to further the health care transformation that part of the original charge the group to help reform. We are clearly when we set it up it wasn't to get data for data set, but we use these measures as exemplars of what things are in HIT systems but add and as David messing, prevention is one of those states that in June to be good at. Some chronic care conditions or others. So we're trying to focus the meaningful use criteria around the things that are that and we know or that and yet would move the health-care transformation agenda forward. Our first panel record to let the state of the arch really, this did the practice for quality measures and how big it created. [Indiscernible] has over 500 endorsed measures, the majority of them deal with primary care. Why? Because that's where the measures are. We want to understand how do things move to that pipeline and Helen Burstin from NQF is going to talk to a sabbatical and hear from CMS and how they use some of these endorsed measures as part of their incentive program. [Indiscernible] is an example, but how they use it and what kinds of measures are they looking for. AMA is calling to talk to us about how measures get developed to fully from the specialities aside the point of view. And what challenges and what impediments to arise and what do they think could stimulate more measures in the specialty areas that we are looking for. Not only for this particular project, but for quality measures in general. And then look at the current use of data in specialty care in the form of registries. There are a couple large registries that are in use. Never went to hear from them this afternoon, ACC is Quantico that model is to centralize the data so that you can aggregate it and compare and benchmark but it's almost right now, in the paper world, it's is a process by which to electronically submit information to these registries. What about in the new world we are trying to create where people have EHR, but the registry's integrated with those EHRs. We are going to hear that perspective as well. And the next panel we've asked representatives of specialties the society's. Medical specialties, surgical, mental health, etc., to talk to us about the problem of trying to design objectives and measures that would include specialists like Dell mention. And want to make a plea that we are not, when perspective they say once these measures in my specialty because I want the EHR vendors to do that, but that's really know we are here for. The little bit along the lines of what David said. We are not trying to develop yet another 54 every it specialist, we want to think about walking in our shoes the policy commissions and to choose in terms of how to stimulate and reward of the effective use of EHRs and to providing care. We don't want to continue of specialties different from the whole care continuum which includes the patience. Had to remove that agenda forward not had we address each individual specialist. It's also we've intended to be what measures would like to substitute for entering the problems on the problems. Reconsidered some of the things problems, men's, dealing with Mets and elderly to be but it was the all care providers, not just primary-care for several. We are not asking for what can use substitute to get out of such and such measures. I think we're looking for global things that we -- The specialist can bring forward to help us set meaningful use criteria for meaningful use of electronic health record in the context of a new health care delivery system. That's the kind of perspective we'd appreciate most from the panelist. Starting off tomorrow morning, we are going to look at the care providers who are providing most care to Americans which really is a smaller group practices or a [Indiscernible] practice on the physician said and smaller community hospitals or in rural health or the city that providers. How can we move the agenda forward without stepping beyond where they can go. Because they have a harder time taxing capital, both the monetary and the intellectual kind. And Edwards, the people with experience that can and have already implemented before, account for their lack of access to that kind of expertise. It move the ball forward. I think part of the legislation help because there is a separate Medicaid program where they get rewarded not after the fact, but actually in the Medicaid program, they can get money to buy into employment [Indiscernible]. That's a marvelous part of the program, but what can we use to reward that year. There exempted from the meaningful use criteria in the first year for Medicaid. Is used to implement that and then they have to follow meaningfully as criteria in years two through six. Captain re-address those needs in a sensitive way so that the most people can come out most of the Pied fighters can engage in this program? As the final goal of the program. There's a lot of practitioners and issues dealing with Medicaid such as the pediatricians. Most of them are not going to be eligible for Medicare just by design. But they are eligible in the Medicaid program ago had we deal with those issues? And how we deal with the providers do we haven't talked about to this point, the non physician, a dentist, a nurse practitioners, etc. That's what we have on tab for the rest of the hearing this afternoon and tomorrow morning. I think that this is a good time we can break for not go and be all set and ready to go by 12:45.

Okay. We will see you back in our.

-- In an hour.

[The HIT Policy Committee Meeting is on a lunch break, and will resume at 12:45 p.m., EDT.]

Please stand by for real-time captioning.

I think we're ready to begin if you could take your seats, please.

Turn it over to Dr. Blumenthal and Dr. Tang.

We have a terrific panel you are going to shortly hear from. People who really understand quality measurement and the capabilities of our systems to produce quality measures.

And, so, I think their biographies are in your background materials. So, I am going to ask Paul to call on them, he's probably thought more about the proper order.

Fine. We talked about it ahead of time a little, Helen might lead up, the inventory of quality measures as pertains to the specialists, CMS, how they are using the measures now, what more you need. And move to Karen, the supply chain of measure John, Fred to talk to the different registries.

Helen, you want to start out?

I believe the committee has the written testimony, more detailed. You gave me five questions to answer, even I can't do it in five minutes. One of the major questions, the current state of quality measures for specialists, and inventory I supplied to Paul, initial review to date, and how they can be automated.

We currently have over 500 measures, at least 100 broadly applicable to a wide range of clinicians, smoking cessation, experience of care, those lines. Numerous specialty areas have sizable -- in the surgical, 100 measures, cardiology, 100 measures, 30 related to pediatric, 20 related to a variety of specialties including cardiac surgery. There are about an additional 70 going through final stages of endorsement, clinically enriched adding a significant number of measures. How many can be retooled, something we don't necessarily know, based on logic don't seem terribly complicated. Important interim steps to think about clinical dwat a becoming interoperable with any EHR.

The second question, impediments to development, coming from the specialty societies themselves in collaboration with the PCI, NCQA, primarily related to role of developing clinical tabid lines, the bay skis for measures we see, and obviously health plans continue to contribute as well in addition to a fair number of federal initiatives, [indiscernible] impediments to you quality measures, first and foremost, specialty societies, the financial resources to develop measures, lack of available clinical data to meet -- data sources, electronic especially, and the fact there's limitations in what clinical guidelines can suggest -- don't lend them selves to branch point logic and a way that's measurable, we have measures that develop off of guidelines with a strong focus on -- the drunk looking for keys under the lamp light. We are taking that particular point because it's where we have the data as opposed to is that the most important for suggesting measurement.

The next question about the extent to which they are being used and the impediments to use. Certainly on the in and out-patient side, used by CMS, other plans, PKS, and impediments come down to the data burden, ability to capture the appropriate data for the specialty measures and when you want to get down to the level of provider, the difficulty of getting sample size and the ability to build in risk adjustment in a way people feel comfortable.

Fourth question, there possibilities for cross-cutting measures, I think in this case there are a fair number of broadly applicable measures that apply to specialists. As reflected in the meaningful use work to date there was a lot of focus on the national priorities partnership. We plan to fill out over the next 24 months, measures available like smoking cessation, medication reconciliation, patient experience, care, hard to argue, those are specific, the important ones to look at.

We have a series of measures to go through our process now reflecting transitions in care, coordination, appropriate to consider, and I think for certain specialties, surgical care, there's a real opportunity as is done with skip to come up with cross-cutting measures, returning to OR, surgically site infections. In this context, the most efficient, effective way to realize getting at these measures. I already mentioned the NTP, real opportunity to focus on that, have a set of measures, priorities, goals, and when appropriate, specialty-specific measures. Patient experience of care, development of caps, welcome measures like that. And the work being done, recently initiated effort to measure development, endorsement, make sure the strategic development of a series of different streams in, including meaningful use is -- appropriate calls, measure development pipeline we hope in the future. Gla



59 seconds.


That was terrific, Helen, appreciate that. On the website, all of the testimony is posted, and 9 written documentation is really outstanding. I inadd Inver tently -- inupon add ought stand --

Let's proceed, Michael. I am Michael Rap, health assessment group at CM is S, office of clinical standards and quality, my responsibilities include leadership for the physician quality reporting initiative, measures for the hospital program, as well as other areas of quality measurement and health assessment.

So, I would like to address the questions a little from the perspective of our experience with the physician quality reporting initiative, addressing the extent to which we have measures, to which physicians they apply and so forth. Also address to an extent the issue of the desirability of specifying measures for particular specialties or not, at least how we approach the question in the physician quality reporting initiative. We started off in 2007 with some 74 measures that one of the interest of Congress at that time was to have broadly applicable measures and to cover as many different types of physicians and also non-physicians as possible.

In 2007 we had 74 measures that we implemented and the results of the reporting for 2007 indicated that those measures applied to some 600,000 eligible professionals. All 600,000 didn't report, but as you can tell applied to a broad scope of practitioners.

In 2008 we increased the measures to 119, and I brought with me a list of the measures we did implement for 2008, that reporting ended at the end of 2008 and just this month we are making bonus payments for physicians for that, and making available to them later this week the reports to them individually so they can see how they did.

With regard to those measures, they cover some 900,000 eligible professionals. As you can tell, that's a very broad scope of applicability of the measures. Every type of doctor, we sought to make sure we had broadly applicable measures, covered every last area of practice we could think of, plus non-physicians including therapists, social workers and so forth.

Now, that's just theth of them. With regard to high tech and PQRI, nursing homes, hospitals, ambulatory setting, high tech is not constructed quite that way, there's an exclusion for hospital based -- applicablability of the incentive, hospital-based physician cannot qualify for incentive payment. Not that the scope needs to be as broad for the high-tech as for the on PQRI. Claims based submission initially, the easiest way, didn't have EHRs available. We all along were interested in the possibility of having EHR reporting for the PQRI program and have made steps to advance that Dan can address in his remarks with respect to registries. We have currently three methods of reporting in terms of what we have and have is proposed. One is claims-based submission, another through registries and the third, testing submission from EHRs, proposed in the PQRI portion of the schedule, not finalized yet, but we proposed that on a limited basis.

So, for that we have specified a number of measures for EHR submission. Those are mostly primary care type, chronic care prevention, set of some 10 measures. The rest over time could be re-tooled, electronic specifications be developed.

With regard to the issue of desirability of having measures specified for a particular specialty, we chose not to go that route in the PQRI program for a number of reasons. Medicare pays for services without respect to specialists. If you want to do a service, as long as you're qualified to do it, Medicare doesn't say we won't the pay you because you're the not this kind of or that kind of specialist. These are self designated ated attributions. For PQRI we sought to carry that forward, which was the physicians could pick their own measures, they didn't have to say I'm a this, can only report this kind of measure. If applicable they could report it. A little different than claims-based, there's no attribution. But the advantage was saying this measure applies to and I took care of this patient. When you report from electronic health record could be similar.

If we tried to divide up into different doctor groups it becomes quite unmanageable when you think of the number of different specialists there are. Nevertheless, we sought to have measures applicable and really achieved that in terms of 900,000 different eligible professionals having measures to report what denominator. The PQRI requires, we have different types of criteria, one is you report on individual measures. That was the initial start that Congress put in terms of criteria.

The difficulty with that, is the doctors could just pick any measure in terms of wanting to measure quality. That becomes a little happen hazards if you will. Based on another authorization that came down in subsequent legislation, we moved to measures groups and with measures groups it is there's at least four in each group. You have a much more confined area of measurement, but if you report one of the measures in the group you have to report them all. That might be a way to approach this interest, having measures that deal with certain scopes of practice, but that you -- so you want to sort of have a set they report on, but still not require one type of physician to report on that as compared to another. I think this potentially could be a way of approaching this for this type of reporting program, swell, as well, I think it's important to think what we would gather trying to specify from one versus another, what measures they would report. That's just the way we approached with regard to PQRI.

Can you wrap up your --

With regard to registries, alternative way of reporting other other than claims. Those who sought to report 50% were successful in qualifying for the bonus. There were complexities with reporting quality measures on claims, that's why we moved in part to registries. Dan Green is a colleague of mean, in charge of our strategy rei reporting, at this time I will conclude, turn it over to his him.

Thank you, can Helen do mine so we can -- I will talk about our experience with PQRI and the submission of registry date for quality measure reporting. We had a limited time to set the program up. Initially in 2008 we intended to test registries. However, Congress passed the [indiscernible] legislation directing us to receive information for, in a production capacity. We outlined two options we considered receiving the data. One is data elements reported through the registry to CMS, we calculate the measures. The second option was for the registries to calculate, report numerator, denominator, percent, performance percentages on behalf of eligible professionals. We selected the registries calculate, shorter time to stand the program up. We had 32 reg registries qualified, 31 actually attempted to report quality information to us in 2008, and I am happy to say all 31 were successful getting that information to us.

In 2009 we had 34 qualified and they just completed the vetting process over the summer. Involves self-nomination, we require them tho submit a "calculated measure flow." they accepted a diagram of how they intend to calculate a particular measure. There are seven different measure types, some patient-specific, episodic, procedure directed. For each type we required them to submit measure flows, as well as XML format, how we collect for the data type. We found, because of the experience in 2008, literally some of the registries reporting, 11th hour, not kidding, 11:00, one hour before the portal would close. Despite that, we had to open the portal twice for registrys to do minor tweaks with the data, we allowed them to correct. Had to stand this up quickly, wanted to be as -- we require the registries to be able to say PQRIs pay for reporting, we require the registrys to somehow establish that yes, that eligible professional is reporting on all his or her eligible patients or the number they tell us they are rchting on.

Despite best efforts with the vetting, and I encourage whatever goes forward the method be tested, some sort of testing, vetting process go forward. All the registries told us yes, we can -- we can do -- will have it done in six weeks. Well, that's eight months ago, and we are still, albeit in the final phases, still testing the HR the data submission. Some submit incorrectly in the form of [indiscernible] and looked to match up data, no charges for the eligible professional even though he or she may have earned incentive it was 1 half percent of nothing. The registries did send a corrected [indiscernible] and we were able to match it up. In one instance it was about $100,000 for a group of several practitioners, the registry was on the hook for paying. This was an error on the part of the registry, and professionals in providing the registry the information.

A couple other things I want to talk about, reliability of data. Registries are very good, cut above claims in getting quality measure data, but we have standardization of the specs in PQRI, but some use -- specs are slightly different. Medicare doesn't pay for well person visits, require one visit, specs 2, some registries using our spex, some use ago -- when we looked at standard deviations for the denominator we had a large discrepancy. If we ever use this for value based purchasing, comparing practitioner to practitioner you can imagine they want to be compared on the same playing field. There are instances they can be discrepant and something we need to consider when doing calculations.

Last couple things, registries collect data in different ways, some get copies of claims, some use Internet portal to accept information, some directly from EHRs and some REH vendors, and I will finish up, I am sure you are aware with registries, business model, some solely for submitting information for PQRI, cost associated with the reamingistries to the professionals, one is free I am aware of, most in the five to $2000 range and some specialty boards have registries, like the American academy of family practitioners, have their own -- and register in PQRI, I will have to forego the [indiscernible] now.

Moving to Dr. Edwards. Thanks.

I will go next, follows on with -- the previous -- hi, I am Karen -- vice-president for approximate performance improvement at the AMA and physician consortium for performance improvement. Thanks for the chance to talk with you. I speak from the perspective of a measure developer, PCPI, bringing together over a 100 specialty societies, medical boards and additional 13 provider organization such pod I at rei -- I wanted to share our goal and four steps in our model that might be helpful in your deliberations.

As you talked about this morning we step back, pause, remind ourselves of the goal. To improve the quality of care and the efficient use of finite resources. We think about that, then two strategies in EHRs, to get the data into the hands of those who can make a decision and improve care, take a hard look at resources. There's a poster on my door, the data from a few years ago, probably still true, says things like less than one physician in 5 ever sees data on outcomes, process of care, measurement data for patient population. Probably, if I remember correctly, one in three order tests based on -- trying to change those numbers with the use of measurement and EHRs. External reporting is a key aspect. I emphasize the first half, what's new and exciting about EHRs. We have a model with four steps. The development of the measures. You mentioned this morning, Mike mentioned, we start with the clinical area, not the specialty. If we are working on a condition called heart failure, we will think about both in-patient, out-patient care and think about who all touches the patient with heart failure. We will have the cardiologist, in ternist, thankings to Christine, David's colleagues, a consumer representative, purchaser representative, payment representative. We come from the standpoint of the condition. What is the desirable outcome for someone with heart failure? Is it not having a readmission? Is it functional status? From there we work backward to say what are the outcome measures, process measures and adding composite measures to that to come up with a complete portfolio of measures around heart failure to achieve the out come we identified.

With that, we advocate the use of sets of measures. When you pluck one out you are left hungry to know what goes around that? Is that contributing to the outcome. The second thing we are doing, try to quickly vet measures and specifications around those measures which are designed now for implementing EHRs with some experienced physician users of EHRs as well as the vendor community. We started a collaboration with the vendor community; I can't say enough about those who stepped up, we are able to go to that group, say here's what we're thinking, what seems to be clinically relevant, what other stakeholders told us is important, is that functionality there now? Is it a work flow issue? Coding issue? We can quickly identify the issues.

The third step in the model is what I call an incube ated group for lack of a better term. We want to know soon if there are adverse reactions trying to retrieve this data. We have a group for heart failure, coronary disease, give national specification from the QF measures we developed, and it's amazing what you can find out when you put them in practice. We are advocating to have a dozen of those type of incubated groups across the specialty areas. We are trying to figure out a path to make that happen to get rapid cycle testing of what we are trying to achieve. In my 28 seconds, the last piece of the model is tracking. I gave you a straw man example in materials for today. We think it's important to track this. If this is our goal, let's keep that front and center on the page for the patient and do we have the data elements we need to care for that patient in the EHR, the prompt complement of measures, have we vetted with the vendor community and physician users; have we tested into an incubated group and how is it rolling out in established registry or through other means?

I will share our model and hope it will be helpful in your deliberations.

Thank you, Karen. And Dr. Edwards.

I am Fred Edwards, cardiologist at the University of Florida, and -- the international database, founded in 1964, the largest professional organization for cardiothoracic be surgery. The cornerstone of the quality improvement program is based on the FDS national database rolled out in 1989.

I will use the [indiscernible] we have 1000 hospitals participating in the database, that makes up just over 90% of all the cardiac surgery centers across the country. We have more than 3.9 million records in the database, each record having a ton of clinical information on the hospitalization in which cardiac surgery procedure was performed.

Here's the way the database works: At three-month intervals data are harvested to Duke -- and DCI performs internal audit of the information, generates a pretty detailed quality feedback report, provided back to each of the participants. The quality measurement is pretty much centered on a set of 21 performance measures endorsed by NQF. The quality feedback report based on that allows the participants to really critically review local results compared to the rest of the country.

We demonstrated with a fair amount of evidence that this kind of feedback protocol really improve the quality of care.

In Dation to the internal audit DCR icon ducts we have off site audit conducted by an auditing agency. Information is collected in a manner compliant with HIPAA regulations, covered by DCRI by Duke University.

Our data definitions are standardized and updated at three-year intervals. We take care to harmonize with other specialties, American college of cardiology in particular. We have a three-day conference of database managers every year to have uniform training being applied in the database.

The general business plan of the database is based on the concept of voluntary participation. Participants will sign an agreement, business associate data use agreement with SDS, agree to pay an annual participation fee. The participants contract with commercial software to use certified software to collect data and have it transferred to DCI.

Pleased to report the database is approved as a clinical registry to report PQRI data and hopefully be able to collaborate with CMS in a similar program based on hospital-level reporting.

A direct link between EHR systems and the database has not been established in a uniform way. We have a couple of isolated attempts at this, that either embed our database into an EHR or are linked, but I have to say there's not a uniform way we approached this at this point.

We are serious about linking our database with other databases and have the link established, for instance, with the CMS med -- data, received NIH grant to link with the American college of cardiology database for effectiveness studies and plan to obtain long-term mortality data with the [indiscernible] file.

We were asked about various participation, that was pretty easy. It's cost and the administrative burden. I should emphasize the cost of this whole complex enterprise is borne entirely by the surgeons, money that could be used to hire a PA goes into this database. Comes out of the surgeon's pocket. Voluntary participation, far away the most important, improved patient care. We have the facilitated ability to compare local results, automatic transmission of PQRI data, research and maintenance of certification.

Thanks again for the opportunity to participate in this important panel.

Thank you very much.

I am Jonathan Ion binder, I manage a team responsible for taking data from home grown electronic health record, as well as other data sources, we use that for reporting to build local registries and for quality measurement. We do this at the level of the provider, practice, and institutional level. My comments will be based on my pragmatic experience on the provider side, dealing with electronic health record data.

Our users include doctors, nurses, other allied health professionals, administrators, primary care folks, specialists, adult physicians, pediatricians, the point made this morning, it's reality hard to tell who is a specialist doctor. We are trying to improve the quality of our panels, getting a clean list of who is a PCP, even with our own institution, turns out to be pretty quickie. We have to do it on a report by report custom basis.

In our current state, and Partners is not atypical in this way, we participate in national registries, the national -- improvement program, American nursing association, national database -- et cetera, things like that. The data collection for these registries tends to be somewhat electronic, but mostly, certainly, very highly manually curated and unmanually submitted.

At the same time, we do quite a bit of work internally where we take data from electronic health record, other sources, to build local registries, for patient care, decision support. In these instances we can pull directly out of our systems, less public accountability, less financial accountability for the measures that come out of them. Often an initial focus of these local registries is to highlight data quality issues in places where we need better data.

With regards to quality measures that pertain to specialists, we do, and have been asked to develop measures for specialists, usually internally. My sense is that while these measures may be informed by published measures and data sets, the rheumatologist, look at professional societies at the end of the day, there will be local clinical leaders who decide what the measures are they want to be measured by. This is a give-and-take process. One of my key messages for today is there's the issue of adapting the electronic health record to fulfill the measures the measure developers come up with; and there's the issue of developing the measures the electronic health record is capable of providing, and we go through a real negotiation process there.

An example of a measure, one we are working on currently, is defined by gastroen tear ologist at brig am and womens -- getting appropriate blood testing. To do that we kind of measure we have to -- external records from electronic health records from a data warehouse. Another message, an intermediate step for qual qual Tating registries, to get before submitting elsewhere. I wanted to quickly go through steps I think of as the key components required to produce a measure fully from electronic systems. The first is to actually capture the data in an electronic system. The data has to exist or you have to add them to your system. For example, for smoking cessation counseling, we are scrambling to see where that data element exists. They have to be coded, looking at my time here, coding standards must be considered, if the data is to be interoperability, and the semantics, use the code appropriately.

Second, you have to make the data available for reporting, getting the data out of the systems, extracting into a data warehouse. You may have to link with other systems. Not just using, in my judgment, data from an electronic health record, but combine with schedule data or patient demographics or billing, other sources. That's where a data warehouse shines. If you submit to groups, you need to make sure you use the appropriate standards, everything is coded, done the way it's supposed to be.

To finish up, the four key points I wanted to make sure I get across here. The first is that we submit data to both national and local registries, it's the local that tend to be automated, connected to electronic health records. The second, denominator problem, the specialist, and the third, issue of adaptors to electronic health record and measures. The fourth, externalizing data from our system, submission to registries. Thank you.

That was elegantly done, you got very close to the time guidelines, we appreciate it. Thank you for coming and giving your wisdom today.

I would ask you go back a few slides. To grownld our discussion going forward, this is from the report this summer on interfacing registries with EHRs, combining much of what we are talking about here today To separate the concept of EHR, we are under statute, obliged to assist in the way the committee proceeds with the concept of registry. They distinguish here the record of individual health information that can be used by clinicians and staff across multiple organization and registry of organized systems of data for a population. Given this rough distinction, I call attention to our committee's recommendation the 2013 for meaningful use, the specialist report to relevant external disease registries approved by CMS. We had as a group endorsed the notion. One way specialists in particular could satisfy meaningful use is by not necessarily conforming to the EHR language here, but by helping to populate a registry which in turn can be providing data to CMS or others.

I guess the question I want to start the discussion with, to each of you, to react to the proposal we put forward, one way to satisfy meaningful use for some disciplines or specialists may to be contribute data to registry perceived as constituting part of meaningful use. Do you think your experience with registries has been, and the state-of-the-art, challenges you identified already, we should proceed down the course of evaluating the opportunity for specialists to meet the meaningful use goals by virtue of registry participation? What are the limits? Or strengths of that approach we should contemplate? >

There are definite advantages to registries and I think one the you're contemplating here is that it can measure outcomes more effectively. And Fred talk about that. If you don't need to measure outcomes, then they may not be as necessary, but they're very helpful to measure out. Registries all have additional purposes. What Dan was talking about earlier is the about the registry more as they did it intermediary. [Indiscernible] then it doesn't necessarily have many advantages over Drexel mission. But if it's to bring together date that over time, episodes of care, out comes, posted together, then they're useful but and I think it's just limited to specialists.

I would echo what Mike said. The STS is a prime example, it allows you to look at one provider versus another. In you can compare the outcomes and if one provider is doing a lot better than another, the provider is not doing as well. The may be able to learn something from the provider who is having a good outcome. The registry doesn't just cut the debt but it does work and out of go some of the registry's we have reporting were simply almost data vendors. Some of the EHRs set up registries and that's great, they're getting the data into is. What I would caution or suggest is that by submitting data from the electronic health record, one directly, I think that will have to push the interoperability on below. It's one thing to transmit data to a registry, there are many different ways as we talk about the registry's can cut that data. However, if the registry has to be able to put the clinical information and to a close to report to data architecture, and made a rapid and an exit trapper, you guys want able to speak of America, if they have to go through processing that this will have to push the interoperability envelopes one provider would be able to speak to another provider rather than ever distraite perhaps collecting data in the way that they choose to do. I think that's an important thing to keep in the back of your mind.

I agree with what the SEC. Support the only additional point I would make is I'm also not commenced its owner and publisher of a. [Indiscernible] from a registry to get meaningful quality measure. My concern is the definition up there and I think we were seeing was a mention of the data is perhaps not sufficient unless there's also an expectation that the data is aggregated to [Indiscernible] quality measures.

This seems like a very valid concept. And one that deserves serious consideration. It's a win-win situation from our perspective and STS because it's a huge burden to go through the claims based data system. No offense, guys. In fact it is. To be able to spend data directly to the registry is [Indiscernible] to participate. And approved at the proper feedback mechanism in place, it should also improve quality as well.

Just to zero months. Had begun to challenge a little bit the EHR definition there and suggest that with an EHR, the physician practice site becomes its own registry first. Right, so if you have PHR and the committee's report to you on all of your patients with diabetes, track measures, you are a registry and I think we should support that. Second though the tremendous opportunities for sharing and Exchange and learning that come from the largest ridges such as [Indiscernible] are tremendous. In with a provide. I would say that I think we want those registries and EHRs to merge down the line. In terms of Freds, about there is a cost factor there, we would want to be having our eyes set on a day and registries can be fed by EHRs so that hopefully there's some efficiency.

I think I agree with everything that's been said so far. I want to echo what Karen said that I think of a registry as any list of patients with a set of common conditions. If you have an EHR and didn't generate a list of patients with rheumatoid have read this, you have a registry of patience. The real issue I see with, not a bad idea to give specialists alternative to EHR submission for meaningful use, the advantages are you have a tightly specified data set. And doctors and clinicians now exactly with the need to collect and how it's going to be used. The issues are as we heard with the cost and how much time is ticking for example for STS to develop the ability in value from its debt has to do with the validity and comparability of the data. If you go that route, I would encourage that you start initially with some of the first measures coming out of the registry. As the actual data measures. Have complete is they didn't come how valid is it and maybe some of the quality measures go and one last point I think there is a risk if each specialist submitted stated to its own registry that you're not a fragmented set of databases and you lose some of the ability to do crosscutting and Sherman.

Let me see if our committee has questions.

I hope you will consider this question unfair -- Won't consider this question and. Tells some stories about how people have used the data to improve quality. Because what we are talking about now is the burden of producing and that these. We have to balance those to tell us about some of the things that people have done with the various databases so far do we can use to be illustrative in the can use to stimulate people to do this because we have achieved these kinds of improvements about comes using these data bases that we have.

I will start with this one. The question as they understand is how when we provide feedback about the data we are receiving and people see that the date is wrong or lacking in some, how does that lead to changes in the quality? Or--

And talking about changes in improving care for the patience.

Using the data.

Given the fact there are flaws in the data and if that's going to go on forever. How are we using the data we have to improve quality now? I'm more interested in what's happening with these datasets that are being accumulated, how are they being fed back to providers and what are the providers doing with them today that have achieved good results?

From a provider perspective there's obvious ones for reproduce and you can call it a registry list of patients. Patients who are overdue for preventive care, who should get flu shots, mammograms, colonoscopy is, patients on meant to have and have appropriate lab testing. And those we to actual list that a case manager or some quality improvement person will use. And other specific projects there's a smoking registry being used now, in some of the report for a tobacco coordinator reach out patience with free ticketing the placement there because if that's an intervention to see whether that results in higher rates of quitting. We do the same sorts of things for diabetes, heart failure, the really tricky thing is to have been a factor alarm or receiver of the report or receiver of the registry. My experience has really been a tense that be the doctor. The user has to be designated individual into the medical director of the practice level or a quality person that tends to take that role.

Any was also the panel what to this on?

I will give one quick example. This with the situation will the physician marked practice group is themselves the registry. The first time, they are looking at national quality performance measures. We developed and [Indiscernible] and Dorris and they are using all aspects of those measures. CIBIC contract variations and I call it the if not, why not. They can print out and see for all the patients the condition, those who did not get these aspects of care, why not. And the can sit by certain categories, edition reason, the economic reason, and they can refer those to case managers if it's an economic situation they will have team meetings. If it has to do with the consideration of [Indiscernible] and have that impacts providing that process of care. To your point come in having that data at their hands for their patient population that they can't make some decisions on.

The premise of course is that to improve quality you have to measure quality. Step one is to activate the data come stick to is to provide the meaningful feedback report. Something that can really allow the practice your sitting at his desk to determine where its shortcomings my life so they can pinpoint where they need to make improvements. And they can assess the local results against national benchmarks. This involves not looking at trends but looking at risk adjusted outcomes. We provide this information back at three month intervals to all the participants in the database. We've been able to show that we are not only improving the scores in a different performance measures, but we are seeing improvement in outcomes as well. The only logical conclusion is that the improvement in the scores is being translated into the real improvements and outcomes that we see.

Sensible to I didn't have to destroy is, I did is also worth remembering that the measurement alone is never going to drive improvement -- You can't patent a bit by measuring it repeatedly, by way it repeatedly. The same time, to look to the structural measure we've and doors for registries with taking a look at. It has a set of criteria of what does registries are intended to do and of them is feedback to the provider and extended as manager with benchmark into other like providers. That's part of the way you get there. To simply having the quality measures themselves want it improvement on.


-- Paul.

And the meaningful use workgroup proposed registries as a place holder and a possible alternative to be assured drive measures, didn't really probably click that most of the registries are populated by hand and a sense. Are separate from an EHR and then mentioned, a couple times did you try and it didn't work so hot to directly feed the registry from the EHR. What you think of the idea of making that the commission so if you were going to use that as your pathway for specialist, we said not to talk about them specifically but if you do populate a registry from your EHR, that that could be one way you qualify any component of the meaningful use criteria. Does that make sense or do think that registry submitting to registry in and of itself proves that your the meaningful user of an EHR?

I would suggest that that's an improvement over the initial recommendation. Again because there are various ways that registry's currently collect their information. I think if they're getting it from an EHR the provider has the EHR at least at them a fair minimum. But again, as you know, there are different ways even with and the torrent of record that registry's can collect information. The provider can actively submit the information to the registry or in the case of some of our registries that are EHR vendors, the can go and data mind the providers EHRs with their permission and would have. And even cross reference with their billing information to make sure they have a complete denominator population.

I guess my question back to you would be what meaningful use are you or what criteria the statute are you seeking to address? If you are seeking to address and measure use that's not the submission of a clinical quality measure, I can't see anything particularly wrong with it, but what category is this under? Is it the exchange of information or what is it exactly? If it's a submission of information on clinical quality measures, that's a different subject. And simply sending data to the registry doesn't necessarily get one as far as one wants on that. So I think once again straight which one of those categories you are seeking to fit this into, it might be easier to address it.

One way to ensure that perhaps is it isn't basis. And the statute says it would become more stringent overtime. You can say that in enabling step is to even have kept to the data at the smack of care and then we can go retrieve it. But over time you might have to demonstrate that you used the data in ways that John was talking about. Immediate feedback to the providers and then see improvement.

It sounds like you're talking about something other than submission of clinical quality measure information.

That is a proposal to help accommodate measurement of meaningful use by specialist.

And that a question about what registries do, the idea of feedback I think the ` always drive quality improvement. Twitter certain extent, but in the physician world, at least the CMS level, we don't publicly reported to mention. But in other venues like hospitals and together, we do publicly report information. There's no question that feedback plus the public reporting has an additional element of it. And then [Indiscernible] then the base purchase in with is a financial incentive on top of it, so feedback alone is good. Of doctors respond to it. As do other providers of health care. But there are other possible incentives as well.

The comment about the thing that would be a good thing or would it be too disruptive for the current capability to have them requirement for qualifying in no way to have it go from and EHR directly into your registry?

To ask my [Indiscernible] question? In the context of thoracic surgery in our knowledge would have let me be one of the fittest and some to the registry data, an operating room system -- Dash the amendment is could contemplate it there from the data source is the EHR and other digital system better in the clinical and vermin that would Public registry as well as the EHR per se.

That's one of the ways the we've entertained incorporating EHRs into our protocol. It's a way to send a commission from it Friday places other than the operating room. And the example you gave is exactly what we've tossed around. Whenever major questions is should we have information from our industry could to EHRs o Governor from EHRs to the registry. We've talked about that for some time and stuff and have a conclusion because.

It's a concept that I think we want to embrace the we've not figured out to do it yet.

And David and Judy then Charles.

First let me think the panel. This is a terrific group of experts. And I wish we had time to hear from you earlier. Because you have so much to help us with in terms of the technical and practical problems. Even conceptual problems of the collection and use. And want to make one observation and as question. I'm wondering whether the term registry has become has lost its usefulness. It's almost more confusing than it is helpful. Its used here in several ways just on this panel. Some people see it as a Data warehouse or use it and had to undergo some people correctly I think Karen said see it as an adjuvant of an individual record because some people see it as a specialty specific outcome based reporting mechanism. And these are all used without distinction in common [Indiscernible]. Maybe what we need is a standard definition of a registry or maybe we need to start talking about is we're talking about other than using the term registry. And that spirit, let me ask a general question of the panel. One of the big questions that for Quality reporting purposes the federal government faces and we face, and the policy committee, is with the meaningful use when data is reported from electronic of record, whether for meaningful use purposes it should be reported directly to CMS. Or whether it can be reported through some other vehicle. Which some people started calling registers. I think we have acquired the general definition of some third party that collects the data, manipulates it and passes it on. And that is somehow more convenient for acceptable for the provider whether a hospital or an individual professional to report to. Can we talk generally about the pros and cons of those two approaches and whether they are compatible? That is and a battle over different time frames. But we've talked about is specialists important to registries. In the 2013 timeframe. The application been this might be a transitional step. An alternative would be to say they should report to CMS directly. Or they can report to a specialty, registry in 2013, but by 2015 they have to report directly. Either any inherent benefits and risks to third parties and this, and if there were, but their specific third parties we should consider and not others? What characteristics should those third parties have?

I will address a bit of that. Certainly no offense guys, it's sometimes difficult to deal with the government and CMS. [Laughter]. If you had your third party institution like to do clinical Research Institute and in our situation, we can have a lot of control of the kind of analysis that done and tailor the analysis so its are specific need. As I can see working with the Government Organization might not allow it that flexibility. One other point that you raise is whether or not it's compatible to report with their party as well as Mississippi, that's what we're doing right now. So certain there's nothing incompatible with it.

When I think about that question I go back to what is our goal. As I mentioned earlier, one of the things is to give data into the hands of those who can use it as quickly as we can because that's for enjoyable patient care, but it's also been able to benchmark with your peers. The preferred that is very powerful but the extent that intermediary with the registry are rebels because come to do it more efficiently, can provide the feedback faster in a more peaceful way, to me that's and vantage. I tried to hearken back and have these issues is what are we try to achieve and as a helpless get there? And a better way.

You were talking but the two options is that about four PQRI reporting to registries and first was submitting data and do all the manipulation and calculation standardization. And the ad was people do their own measure collation [Indiscernible] measures. And I think if there were an intermediary and data were submitted as opposed to measures then there's potentially a lot of value to beyond the feedback that Karen is talking about. Doctor gets and mission of his our practice or institution benchmark and [Indiscernible] against others. Now you could ask and ask questions and there's a database that has perhaps enough granular information to go the next that. Beyond just saying this is a measure and how you compare but can't say anything else. I sense is that a third party intermediary be more likely to support that functionality do clinical research and CMS. Another comment about terminology, I agree, and confused as to what the registry is. I'm thinking [Indiscernible] lawyer, the Quality Data warehouse different sites and updated to. And it measures, of that. Is that a registry, yes, but it's a term that might make more sense for we are talking about.

Dr. Blumenthal, he made an excellent point. We do use the term registry's very loosely in terms of the collection. When as a medical without registers as the cancer registry come on the patient had cancer, the courage you once a year or twice here would have the. For example of 50 as, obviously that's a registered. There are some better data submission vendors and intermediaries. The option that you are mentioning it, they did it aliments are provided us we certainly that is something that would be a viable option. The reason I think it's important to have one person doing the data calculation or analysis at least for a payment purposes, everybody is on a level playing field go even if CMS or Duke or whoever is, at least they are kept waiting for the providers in the same fashion. If the information were to be used ever in a public fashion were used in Valley based Purchasing, again, everybody is being compared to the same stand. The lasting element and is one way to consider this an sure you've done in your deliberations, has been a if a provider in a local community is reporting their information to a health information exchange, and that is sending that information to its EMS for the quality image report in, by virtue of the individual using an HIT, that's helping to push the interoperability aspect and I'm sure we would both agree that it's great to have quote to measure it and agree to benchmarks, all of that is important. But half of the improvement in quality will be the better communication among providers of information can be shared and I think you'll get improvement in quality by virtue of that.

One more brief response. I think one other consideration is that I think we cut and of which go to build a right data collection passive and concern if we put too much on the EHR to have the did pass the incapacity for cow with [Indiscernible] and may be more difficult. I think that if we start thinking about the measures you are envisioning on the meaningful use laws, some outcomes are not point to come out of the box [Indiscernible] you have to have someplace that can begin to aggregate that data streams and if you want to get official report and outcomes, and have to have the capacity to get piece reported in there. If you make of the calculations will potentially missed some important it is Jim's that to help us get to the next generation [Indiscernible] not to use -- Over use the term meaningful. [Laughter].

The question was posed as what is the best of several options. And perhaps another way to look at it is to allow several options. And not confined to one or another at this point. And PQRI we allow claims based reporting, reporting by registries and we seek to have EHR reporting. And high-tech legislation it has to do with the clinical quality measures, using an electronic health record to submit a commission on clinical quality measures because the statutory requirement. So what constitutes using an EHR. Could involve registry? When the? Could involve direct submission to CMS? Potentially that as well. We traditionally have collected the information in house and calculated it so that our current approach generally speaking both for a as RD, for home health, for nursing homes, and for hospitals and four physicians as of Friday submitted on claims. The registry was sort of an exception from that. Was required and the original statute authorizing PQRI [Indiscernible] which said Congress required us to address the use of registries for the submission of this information. And acknowledged that such as the STS for District so Congress originally was interested specifically in so far as the doctors are already submitted to a registry, why not take that and it applies the clinical quality measures that we use in PQRI, when not have CMS to the commission from the registry of the then have them separately report its on claims? So we certainly agree with that. And we sought to address it and said we will test that option and a month later, the past another statue in said like you do that actually next year. So that's when we implemented it very expeditiously and the way we sought to do it was to have the registry's calculated because that's really the only practical way we could to really work this out for that initial implementation. Another alternative would be to get the data source. I think possibly our experience there to think of a number of options and not necessarily block one down early in the process until we get more experience with it.

Thank you.

Some registries don't allow us to share the data that we send to the registry with any other registry. And there are two problems with that. One is as turn mentioned, [Indiscernible] itself, and secondly, if you have integrated [Indiscernible] your covering some many different areas. Some of those areas might require components that you might send to one registry might also go to another as well. At second, some creditors charge a person of sell. And I was going to ask Fred, I've heard that about FTSE and was wondering if you could explain to you allow us to send the same data to other registries as you do to STS and what did you say about that?

Our policy is that the aggregate data, our own by the sight of dress and surgeons, the local they did our own but the individual hospital. That individuals should go group. And what they do with the date that is their decision.

So you are saying we can send data to you and that same data can be sent to someone else?

You'd have to be a participant in the STS database in order to make a contribution for clinical data to go into the STS database. That's the protocol we have in place right now. If you don't do a con Mexico procedure, then there's no information to be entered into our database.

The missing five understand. If we have been asked by an organization acts to send it to STS, can we also send [Indiscernible] since the did it to another registered, can we do that?

Not the way the system is set up right now. That is one of the things like David said, were you have the advantage of an EHR that would have -- I you to have to medication like that. Even though we recognize that ago, we don't have that structure in place.

And you're saying that's a matter of structure, not policy? If the organization she supporting want to send [Indiscernible]--

The only organization it entertained that. Is with American College of cardiology. That has been discussed, everyone agrees is the right thing to do. That would be step one. If you are talking about another organization outside it that, that's a policy decision that would have to be made.

I think it may be in the Contra this is you can't send it to both.

The way it stands right now, that's correct.

Thank you.


Hopefully it's more successful and Health IT [Indiscernible] Register is will get more clinical feet to go along with existing claim feats. One of the things I worry about if it is dated duplication. Multiple transaction represented the same clinical the event. And a couple questions, one cannot do you think registries in their current form are wrestling with those issues effectively? And then, secondly, when you think about the registry as a data source or as an asset to influence care, can the registry be made to operate in almost will time? And other words, influencing the care as it occurs or is it better to look for that coveted decision support out of the EMR?

Great question. I will take a swing at that. To influence [Indiscernible] at the time that an intervention is made is a challenge. We provide feedback reports every three months and falls. That's getting pretty close. And before we could really interpret a trend, I would think we need not necessarily didn't that instantaneous but they did that goes back probably a couple of years to be able to decide whether we should make a change in the way we approach things.

On that, but occurs to me is if you have, it depends on whether you're dealing with processes or out comes. If you're dealing with the process cannot conceivably the electronic of record to the clinical decision support would really be better because it's there while you're taking care of the patient and it says you didn't do this or that. You should do it. So it seems to me that perhaps process measures will eventually become obsolete because if you have electronic health records to put that in your clinical decision support, there's no reason to report that in your about what you did six months later. And it might be nice for benchmarking but you Billy like to have that will time quality affects so that you do it right the first time just like to make your tie iota by the first time with it and bring it back for every call six months later. With regard to the outcome measures, if you unfortunately, there's no way around it. If you're going to do a 30 date of come for six months out, or one your outcome, you have to wait that long. And for that you also have to have list adjustment so that's the reason and the registry you have to bring that the debt to the other and have it in one place, do your risk adjustment and come up with your out comes.

[Overlapping speakers]

One small point which I think fit nicely into a. I think it's not just a question with the there's a duplication of distance in the clinical side and claim, just a hierarchy of quality and at the it's afford to recognize [Indiscernible] the classic example is ambulatory claim dated as Paul knows well from a work with the Health IT expert panel but you would not want to pull that NASA data off of that if you have a problem list. And Dick what we're trying to do is have to identify where in the EHR the data is comes from. It's important to say and the Tridacna system that cannot come from the [Indiscernible] codes it comes from billing and needs [Indiscernible].

First of all as much as it thank you to all the various people there. Secondly, when I look at the whole issue of registries, and the diversity of registries and the name certainly isn't a party and maybe we need to have intimate year at this point used as opposed to registered. There's different each registry seems to do is separate do their own hierarchy of how they evaluate the material they bring in, what did with it and how they create that decision support that's going to come out and assist physicians making better decisions. So if there is no unanimity among ministries and how you do things, how are we going to know that if you are used as perhaps that intermediary that evaluates measures and it really helps direct improved care of me going to get to that ultimate goal of improving care when you have a different criteria? Certainly AMA is set up what I consider a very valid mechanism for evaluating things. Did you see that as a problem in the long run? And also the second question deals with cost. Where are we going to, who is going to bear the burden of the cost of a registry? Right now if you are going to submit to PQRI, although I can tell you I have met issues with PQRI, and with only 50% success rate in physician receiving payment, there's no cost in doing that other than an administrative cost. Who is going to be the cost of maintaining those registries? And if you have vendors establishing registries as well. Where does all of that fit together?

Currently the costs are borne by the allies will professional produce bedding with the registry not in the 100% of the cases I think STS is a slightly different arrangement with their -- Fred you could speak to a better, but certainly in PQRI land, for the most part, the registries do charge a fee got there was one register that is offering the services for free. List of the registries are summer in the 500 to 5000 but as a couple of little bit more to the 2000. If you're an ophthalmologist in your bonus may be in the tens of thousands, it may be an option for you if your it internist, Turturro is maybe less. It's a decision that have to make. Your other point in terms of how do we know there took a leading measures the exact same way is a great point. Ministries are wonderful, don't misunderstand me. They can collect a debt, they're much improved over claims will have to fill in on the clay because you want to get paid. You did the patient's blood test we didn't go even if you or did it and comes back in three weeks which would be reasonable, it can report that on the claim unless you're going to hold for three weeks. It's an improvement over the claims process that we have. You can also search of a canal comes. Did the patient come back in 30 days to have another eye surgery after the attack Iraq surgery? There are advantages with registries. When you look at these measures, do you use the patient, there's a bag is measures that says you check the hemoglobin within the past year and level was a, B, or six ago -- You only have to do that once per year. Its in once per year measure. If the patient comes in in February and they have been of Levin, it reported as long as it's within the last of months but the registry also could cut that within 12 months but to use that gun you cannot do use the value in December with a patient comes back again? Which fell you do use? If registry a is using the first one, and that's legitimate, the registry is using the most recent rally, one is better than the other, you can start to see. It is a example of a true example. Registries have asked those questions on our monthly calls which wonder why use it. These are the kinds of things the face and when we are talking in PQRI with 153 measures, it can be quite overwhelming. I think you hit it on the head in terms of you got using the same did it if you're good to look at outcomes and results. Long would it.

And the question gets back to when we want to people to parts been registered in its in to the question what is the definition of a registry. You could say we want people to participate, specialists or other physicians because we believe that will drive quality. Or we could say you want them, we want use the registry to offer an alternative way of cementing data. Other than some other mechanism, other than claims space, I think one has to come up with that basic dichotomy and decide what one wants. Helen mentioned that NQF has a structural measure which is participating in a standardized data registry. We use that measure and the hospital environment. We use it for cardiac surgery measures and considered an indicator of quality whether a hospital participates in a cardiac surgery registry in hospitals today after reports that measure. If they want to get their incentive payment for that. That's a different issue and a different subject then uses of date it intermediary. With regard to PQRI, we specifically did not define the registry other than if the registry does the things we require of the registry is a registry. We didn't get into Canada -- Can it have the aspects that is to etch which is the hierarchy of registries I would say or is it simply sufficient to be a date it intermediary.

You see is getting into a situation where you have a certifying body for registries so if they're really going to attain the -- Or get to the quality measures that we are looking for that you wind up with a certifying body of registries. So they really are valid in what they are doing and I come from for this look at this whole fraud aspect. Where do we go with that if you have various registry's out there doing a variety of things and yet, and they doing an inappropriate manner?

I think there's a lot of potential merit to that. And Fred, I know was involved in an effort where they rode a big report on registries and so for. I think eventually probably one would want to get to that point. We haven't sought to do it just for our program but I think in the future when they want to get there.

I would add that yes you want some assurances that measures from here and images from their pull together in the same way. But on the flip side, I would offer that you did not want to stifle innovation in that queue I component. Just like to in a turban there we say you need to have a problem as their enmity is well with its blue or pink or green, we want the market to come up with the best way to adjust like a registry, if they have a certain feedback way of doing it or gathering of everybody to share results are what have you, I think we are in a stage in this country where we want to promote those right now.

I would really echo what Karen said. I think it bears the point that the care and we mean by registries I think groups like STS are in a category by themselves.

But there are others out there.

Especially registry's or databases with if you call them there used for much more for to buy and for learning which I think it would not want to apply the same stringent standards to.

Thank you. I think Paula has a question and I will summarize.

Of we have CMS at the table and probably this is in your department since you are receiving intimation from PQRI, there have been comments on the committee in terms of what CMS capable to absorb this mission for these meaningful use measures. I wonder if you can take the opportunity to comment on the capacity of CMS to receive measures submission and fulfillment of meaningful use criteria.

Which country talking about? The clinical quality measures? Been a clinical quality measures according to the high-tech legislation [Indiscernible] using electronic of record. So we have sought to develop the capacity, but we are not there yet in terms of I think a comprehensive capability of doing that. As Dan was reflecting, we feel its necessary at this point, which is the same thing we did for registry is to make sure that the system works. And not just to say, open for business and send it in. We want to make sure it works and there's testing and contacting and so forth that has to take place to be able to do something like that. We sought to develop the mechanism that was specified a set of ten measures that we published electronic health records specifications on our web site. We've had vendors volunteer to go to that testing process. We proposed for PQRI that we will accept that if the testing process is successful. But we I would sit this point, a limited phase and the measures that we currently are dealing with are just on a care and preventive care. Diabetes, heart failure, [Indiscernible] Prevention quite mammography and so forth.

So far would you been hearing is still consistent with the path you are on. And other words, being able to cement clinical quality measures either directly or through third parties. It seems like beer flowing into -- --

And want to elaborate but would be outlined as what we're testing is to aspects. F1 Direct oral submission and the other through health and commission exchange.

Currently we're able to was the information is entered or uploaded to TMS, we are able to to the data elements and put them in the respective measure buckets to calculate the measures. We are working with the EHR vendors and we have some that are quite far along. In the testing process. But as Mike said, one method would be to this portal, the poor will probably has some upper limit in terms of what they can accept. At some point, there would need to be the other mechanism and certainly, things that we are looking at testing would include the [Indiscernible] and working to help if commission exchanges.

This is an evolution and it's going to happen over time. When Mike and Dan are talking about is certainly the Medicare side there's also the Medicaid side as well. We also heard about the registries that if you've seen one registry, you've seen one registered. There's also the issue of retooling the measures to get them to work with [Indiscernible]. I think all of these different dispirits parts have got to start coming together of the next several years and that's part of what PQRI is helping move that forward. The word that and and my dream isn't perfect, we know it's not. But we are evolving this over time ago I think where we're at the fall of 2009 is going to be far different and where we are in the fall of 2011 were 12 or 13 as the whole industry as we move along here. I think some of the work done as they pointed out has shown some of the weaknesses of where we are at today as an industry, not just CMS. But I think we have a way to go and we are working to get there. It's not going to happen overnight.

Okay. Any other last words? I will wrap a separate letter to several points and Mike to Kuwait is some of the messages you brought and thank you for doing that. One is David's suggestion we may want to rethink use of turn registry and be a little more precise about what we mean by that for different applications in context. Said the way, we may not want to confine our discussion to register is relevant to specialist the specialities but the more broadly about that. Third, we should be committed to the registry would be an calling them. Have multiple purposes and add value and number of ways to we may turn out as a policy committee that the beyond the narrow definition of EHR. That may affect how we decide to incorporate registers into our criteria. Among them the data integration for multiple Petze, EHR been one of those and also [Indiscernible]. Third, that as Paul suggested, we may want to revisit some of her own draft criteria to include registry's been fed by EHRs and other digital data source as a refinement of how we are thinking about these before criterion. Another one we need to get an audit are somehow or receive the equality of the registry process itself. If we aren't using it to one of the criteria for federal incentive payments. And that itself will be a bit iffy back to the primary Data sources. Those are my intermediate takeaways goes if anybody else wants to add any last words.


One question for informational purposes. What do you call what you keep or accumulate the mid [Indiscernible] data in today?

From the existing hospital records that we send to you? With a recall that? That repository?

Its claims data repository.

But its--

It's kind of a hybrid. It's a hybrid billing Summary and quality document and quality reports are generated from it. I guess at some point, I would hold up for a discussion that there is precedent here and what's been done by using eight government agency to be the collector and the definition is a byproduct of participation in the Medicare program you have to cement it. And that's used a test run to a great number of people for a general purpose use. One could contemplate that something similar could be done and a clinical Data level if we wanted to. It looks like a database to me. If we look at it, but I was, I think you've done something already and there was a reason it was a condition of participation. One think we could talk about is as we expand high-tech come I don't know if it's in the legislation itself, but basically we are talking about what is the driver that would cause a physician to submit data to anything? Either a registry or to make government program and maybe we should contemplate a condition of receiving high-tech were talk about it as you have to submit data of some sort to this central database. Much unlike we require a mat part of a. Just food for thought.

I know we've got some work to do in terms of the definition of registries and maybe in practice the registry means the capacity to make a list. But in other terms such as the panel here, we see that it's very different than that. I have some concern about with this definition of registry will mean and what the infrastructure will need to be when we get to the point of developing meaningful use criteria for the states and for Medicaid. Who will receive the data that the providers collect? At a state level and where will that off it and how will people create the feedback loops we talk about? I'm worried that the state Medicaid agencies were laid just don't have that infrastructure.

With that I will turn the ball back to Paul.

Thanks very much David and thank you so much to the panel has given mentioned. It's been incredibly helpful. We always wish we had the information yesterday, but things very much for bringing it to us today. We're scheduled for a 15 minute break. I'd like to give that because we do lose the room at approximately 4:00. If we could resume back at to 40:00. With our final panel for the afternoon.

[The HIT Policy Committee Meeting is on a break, and will resume at 2:45 p.m., EDT.]

I think we are ready to begin now.

Could you take your seats, please?

Thank you for been brought. We're on schedule with their final panel of the afternoon. As I said, this hearing is split over to parts. This afternoon and we begin again tomorrow morning at 8:30. While I'm at it, we are going to be in a different go you're going to be in the entire room tomorrow morning. The moment we've all been waiting for this afternoon is to hear directly from the specialist and of course to all of how to speak on behalf of your whole community. I guess I will warn you ahead of time, we are eager to talk to you and may come up with some challenging and interesting questions for you to answer. Especially given the last panel. Which I think was very informative. The moderator for this panel is Neil Calman. And will turn it over to Neil.

Thank you. It's great we see all five of your seats go make sure that everybody is here. The next panel as Paul said is going to be listening to specialist talk about answers to some of the questions we posed to them, to review quickly, some of the questions we've put towards the panel. One is what is the best way for a specialist to be integrated into the meaningful use for more? What are the relevant national registries in your specialty? What role can the specialists and the specialities society is play and try to create the conditions for meaningful use in that specialty? And what might be some cost-cutting measures that you see that cut across specialities that might be included in meaningful use for specialist? And what are some of the things that drive better communication and coordination between specialist in primary-care? And what would the minister with it [Indiscernible] and if I could ask you to introduce yourself with maybe just two lines and say who you are and what specialty you represent.

If you could come at it, you heard we heard just with the last panel, if you can also address if you are in our shoes, try to write some criteria, recommendations for criteria but how to assess the meaningful use of HIT to deliver the transform health system, that's a perspective we are coming from. If you can help share your advice on that.

And it if you could do that in five minutes each. [Laughter]. And also pay attention to the lower right hand part of the screen that will warn you when there's a minute left. And we will count on your time. Dr. O'Toole.

Thank you very much. I appreciate the opportunity to speak. Trying to be to the point, I'm going to be the answers and go back and see how much of the five minutes I have to elaborate. I think as registries, the need to evolve to become more than just intermediary. That's the role for the medical specialties. In cardiology we're fortunately [Indiscernible] has been doing this for a while. And is very much interested. The second question is how would I do it? I think for the first and maybe second go round, there needs to be a choice of meaningful use measures to go it's going to be hard to dictate to the specialist who are going to overlap into a lot of primary-care, and I'm speaking for the medical specialties and particularly relish typical I think there's going to be a choice. There's two answers. Let me go back now in the last four minutes. As for is that gun, I'm a cardiologist, and many private practice, if the member group in northern Illinois. B to six hospitals. They use six different electronic have record systems. Much to my chagrin, as the CIO for the coup. We been using electronic of record system since 97. And have been involved with registry work mainly to the American College of cardiology, American Heart Association and then the code PII with care and who is just though. And cardio which is a very nice incubator model that is helping to raise as many questions and hopefully a couple of answers. That's a model of six groups, private practice, a University based, multi specialty chemical using different EHRs. Have successfully HIT enabled the PCPI measures and reported it to the data warehouse. And a local basis. That's taken a couple of years to do but we've been able to do it for coronary disease and are valid but that's my background. Going back to the registries, the specialty registries as I see it have a value added. I can tell the personally our group has been reporting the PQRI in 2007 for the half year we were 50% successful using category to cut. 2008, what with [Indiscernible] suspenders approach and figure out some of the coding issues. It was all technical things on the category to but we joined a registry and it was basically intermediary. It didn't cost much. They took our data which we were pretty comfortable with. Passed on to CMS and were able to get pretty close to a we had expected. When word got the check. I have experience of when there's [Indiscernible] assisted with both, at the center and we are submitting data to our respective specialty. ACC, a chick, the book have inpatient and outpatient registry's related to procedures, I see the and I see that as a value added. At the report cards back and I'm adding to the signs and hopefully the Quality Improvement benchmarking, compared to the effectiveness, etc., and I see of that as part of why I would want to report to and enhance registry and not just they passed through registry. The quality measures and what is meaningful, I want to switch around. This goes back to me, and related to many to choose because I think this is a physician center approach. It was meaningful to me. What meaningful to my practice, to the patient in front of me, and that's plenty very. It's a closer hopefully to a patient approach and something that Judith was talking about and talking about a physician centered approach and I need to try to figure out with the meaningful measure of that's going to vary depending on whether I'm an actor physiologist enduring cardiology with what we call primary cardiology. There's a very few patients [Indiscernible] the PCP for the patient. There's an awful lot where I overlap with the PCP and work with them and take care of the hypertension of course the heart failures, etc. Is a lot of overlap and not sure how you're going to give that are out in our area. This is a shortage of primary-care physicians in our area. Does a lot of primary-care physicians no longer taking CMS patients on a weekly basis I have piece is coming to me into my primary-care doctors now say [Indiscernible] culture on the practice can take care my have attention, etc. And the answer is [Indiscernible] and I will overlap an awful lot and then tried to get another primary-care doctor but there's a shortage. Part of the challenger is are we talking about meaningful use for EHR adoption, health care reform and there's a slippery slope and a lot of overlap there. And I think you need to have a fair amount of flexibility because this going to be a lot to be accomplished just in getting EHR adoption. My final seconds I'm going to talk about issues related to communication with primary-care doctors to go in these to the bi directional. We certainly need to communicate better with their primary-care doctors and vice versa. They do with us measures around the I sent a letter, they said the report, it seems to me digitizing the existing processes which positions love to do is to go into a different paradigm because I think a different paradigm is held and commission exchanges. In our area what's happened is all the hospitals are in line with various vendors offer for competitive reasons so now the health and commission exchange is occurring at a very local level. And a practice it goes to six different hospitals and looking to come up with a [Indiscernible] Index to handle all the master patient [Indiscernible]. And maintaining of those and faces is going to be an impossible to. So moving to where the specialist is putting something into the annuity of care record of HIT so that you send it to the primary-care and that or primary-care doctor can go directly to the middleman. The HIE makes a lot more sense and is touching their existing processes. TiMet.

To amend ramage.

Thank you very much. On behalf of the American College of surgeons 74,000 surgical physicians who are in college I am here to testify before you today and share with you my thoughts on the I am a Colin and rectal surgeon by training. Professor of surgery [Indiscernible] for clinical care and clinical affairs at the Louisiana State and diversity in the Orange Bowl and the chair of the National Surgical Quality Alliance. I to take a few moments to talk about the last two sessions of testimony cover much of what we are currently try to do with and all of the surgery and surgical Quality Alliance. We brought over 22 specialities together along with anesthesia as well. And our focus is to figure out how we bring together the pertinent clinical information to measure quality but not only measure quality specifically improve quality recognize the need for conspiracy and public reported. And within that framework, best [Indiscernible] the skill. How can we get all the data elements of of the surgery pulled together in the most meaningful way? And pulling of that, all the societies together and doing that under one huge registry which pulls from the various other registries into a common set. Much of the discussion you just had for the last to accessions is very important to us and it's a direction in which we are going to go in whatever way we can get that information meaningfully from EHRs and push that forward into these areas where we can apply analytics on behalf of the patient and pushed improvement, and push it to a learning networks, we think that's where we'll make the improvement. Specifically just a few comments because so much has been said, in the previous sessions that I want to direct you, I will highlight a few comments from the written testimony that are areas we'd like to focus on. This urgent want to participate in the meaningful use and under its current definition there's really a concern [Indiscernible] I think you highlighted that recognize that. Any effort you can move in that direction we applaud that. We are all for that. At the same time, as we do this, we wanted to be about quality and quality improvement. We want this to be about steady for the test. We have the test ride, but I really did learn what we needed to learn to improve patient care. Surgeons are faced with challenges about operating out of many facilities for more than one and a little is surgical centers and one hospital or another, how they get something meaningfully EHR that's realistic and scalable and something they can come it without the necessary interoperability? We'll looking for some flexibility in that interoperability. I heard your discussion about the value of how registry's could actually serve some of this purpose. But we know we've got to get to EHRs, that's an important component to cross to all the different and works with me to cross to. Public also have to appreciate it's difficult we've got some different interfaces for a given surgeon, which system you get to make of this requirement. That interoperability is key in relook for flexibility there. We do feel that surgeons should be held accountable for that. Behind question to, you'll see there's an array of clinical data bases that we currently collect. The flagship is pretty much the same as the STS and that's the National surgery quality improvement program. Curly it's been retooled so it can be much easier skilled and spread across more hospitals in a more rapid pace quote it's a risk adjusted outcome registry that's critically important. We think to improving care it's action that the business case cost savings and improvement of quality examples on multiple levels. Surgical data registry's typically clad complex data compared to the data that we currently have in EHRs. We have to think about how eclectic data and it may be easily collected the registries and then where it can communicated back to EHRs. Willing to ticket the opposite with if we can get that technology at the EHR level and push it back to clinical registry's by direction of flow. We are not opposed one or the other. It's getting the data to the point where it can be analyzed, create a meaningful action plan for quality improvement and get information out to the local regional warming centers. That's our primary focus. We have an array of these registries that mentioned it, and we think there's still silent as they are. If we pull them together through perhaps an EHR platform, we may see an expanded capability. We don't currently have good systems for looking at it. It does, we don't currently have good systems for providing patient to decision making. And had we take this information that's within the ASAs and pull this out and not just perform quality performance measurement or quality improvement, but ticket to the next level. That's down the road, but all of that I think we need to start thinking about now as a plot out standards for EHRs moving forward.

I will say that you can notes behind four there's a list of different measures that we are looking at including three at the top of that list better outcomes measures. They are new to surgery, we are pushing this through the NQF capital risk adjusted up a measures across the board that we think our important and meaningful. Having the information we need extracted for these is you go to or less than the current [Indiscernible] of the can get to the EHRs and brought into the areas where we can perform the proper [Indiscernible] and create performance improvement, we think that's important the company that are the PQRI measures which the Kremlin have the capability of turnkey, turning it on for all of surgery to the surgical quality alliances proposed national registry program. We see the future in areas like imaging and other challenges in imaging. Based on looking at aspects of coordination of care at the pre surgical level and Perry operative level and at the post surgical level. Pre surgery is an area where surgeons need to communicate to the special primary-care to the information about where guidelines would tell us what test order and what the to do and when to refer patients, when not to refer and put them in a proper path with. Post operative week, to return the patient from their acute-care state into their chronic care environment in communicate back to the appropriate caring physician what they're care needs may be or how they may change based on what happened at the time of surgery. And create a communication that doesn't currently exist. We think there's opportunities in clinical decision support both within surgery and across to primary-care and other specialities, and better use of clinical guidelines in real time and the appropriateness of surgery. I thank you for the opportunity.

Thank you.

Dr. Strunk.

Good afternoon. I'm Al stump the deputy executive vice president of the American College of obstetricians and gynecologists. A been a practicing obstetrician and gynecologist in New Jersey during my clinical career. I'm pleased to be here today on behalf of [Indiscernible] and to offer perspective on behalf of women and on behalf of their personal physicians, obstetricians and gynecologists who work mostly in small practices. For many women, the obstetrician gynecologist is the only position seen during most of their lives. Optician gynecologist provide lifelong care as they continue on. Involving episodes of higher intensity care during pregnancy and an ecological sickness. Superimposed upon a background of on going wellness and preventive care which maybe it's productive or not. Most of the current reporting measures do not apply to women of reproductive age. Historic we cannot [Indiscernible] has been supported of widespread adoption and effective use of HIT. We're currently working with integrating the health care enterprise or HIE on developing the film for extension clinical data for obstetric patients. The continue to work toward anytime, anywhere access to patient did it that will reduce the need for duplicative tests, an imaging studies and other examinations. We were one of the final measures of the get connected program. It began with a few [Indiscernible] to encourage physicians and pharmacists use electronic prescribe the and we work with the Senate focused on helping small group physicians Health and implement EHRs. Needless to say, we share the stated purpose of the auction is a national coordinator in the development of a nationwide HIT infrastructure and a cornerstone of that infrastructure certainly is widespread adoption of electronic medical record. We are concerned however, that the measures while clinical in nature and not related to adoption of the EMR Platz, the meaningful use measures for the ARRA should determine whether a physician has met the objectives shown in the meaningful use matrix out with the EMR is being used report clinical quality measures that often do not apply because sometimes barely apply to that physicians patience. Is simple reporting of such measures has not been shown to improve care. Additional reporting requirements will inhibit we fear whether that encourage adoption of EMRs. And the same vein, asking physicians to provide information for the sake of reporting with there's no effective mechanism to provide prompted meaningful feedback about the quality of quality of care is frustrating and discourages participation in the program. The help information technology Act requires that eligible professional submit information in a form and manner specified on such clinical quality measures and such other measures as selected. I emphasize such other measures because submitting clinical and commission will not be useful to either the patient with the physician, and effective acceptance use and feedback will probably not even be feasible by CMS for the next few years, we recommend that the requirements focus on those specified other measures that are related to the achievement of the policies priorities, goals and objectives identified in the health IT Policy Council recommendation. Here are four examples are ready in the recommendations of the indicators that HIT goals and objectives are being met. The percentage of all orders entered by physicians through computerized order entry. Percentage of lab results incorporated into EHR coded form of percentage of claims submitted electronically, percentage of reportable let results submitted electronically. There are other examples.

Single specialty obstetrician and ecology groups have an average of about six physicians per group. The high cost associated with EMR adoption, and certain return on this and not let of technical support, a lot of trouble with it and decrease revenue during implementation substantial barriers to adoption for small groups to go there for a small group practices have limited incentive for adoption. Currently as we all know list of 25% of medical groups have some form of EMRs. Finally, one of the health information technology that will not cover the full cost involved in implementation, it certainly can is that financial burden.

[Captioners transitioning]

Physicians who have already adopted EMR are undoubtedly using been in any meaningful way. Reporting are not reporting process metrics does not prove otherwise. A high-tech incentive is not expected to cover all of the costs involved in implementation as I said. Only after EMR are in most positions offices can we realize potential benefits such as widespread assimilation, interpretation, coordination, sharing of data which will rip apart proactive health and elimination of duplicate services and avoidance of hospital regressions. Thank you for the opportunity to comment.


This afternoon, I am a medical oncologist at the Palo Alto Medical foundation. I am happy to hear to represent the society of clinical oncology her I am a member of the board of directors. I am also a member of CCHIT clinical troupe as well. About a period before ARRA was born, the Society decided it needed to create some standards for what an EHR function not she should be. We decided to do this in partnership to the National Cancer institute. About a year ago we began a project called the core project which would define the clinical oncology requirements for an EHR. We divided into three subgroups, the first one which I cochaired looked at the functionality from a clinicians' point of view. The intent was to start from the end user and point. For us, that as one qualification at meaningful use. What did the boots on the ground need to have to get the job done? A second worker put that taking that and mapping it to the lexicon so we would have opera ability to pay the way for standards for the industry. The third group was to take the IT at interrupt our ability a step further and the project is just about now completed. A white paper has been posted. There are probably about 100 functionality is listed in there.

We plan to take that and use that in discussions with CCHIT to begin an oncology certification module that is an accepted by CCHIT. Work on that will begin in the next month or two. I know you don't want us to drive oncology issues to this panel, but I think we have a real strategy for doing that already. I am saying this to offer those as possible mentors. A second effort of the society is our project which recall [Indiscernible]. This is a project that is about six years old. There are 650 practices in the United States participating. That is probably about 2000 plus oncologist. This is a program that every six months practices self audit doing manual chart extraction and load data onto a secure web based registry. They choose from several modules. What is a required core module which covers basic psychology safe practices and then a choice of modules related to breast cancer, colon cancer, and of life care. This program has been around for six years. We are now stepping up and starting a certification program. There will be formal requirements to pass it a practice opts not as for participation but for certification. We believe this certification will take these measures and give practice is a target to shoot for to improve their quality. A third program with had is development of a treatment plan and summary document. These are important for communicating to the patients as well as to the health-care team. The concept is at the start of treatment before chemotherapy, a treatment plant would be put in writing which would have structured data elements talking about pathology, stage, intended treatment, a surgical plan, radiation and chemotherapy plans and given to the patient as an ongoing document. At the end of treatment this would become a treatment summary which would list what was done. I think those two time points looking at what was planned and what happened would be interesting from a health services perspective to see what went on. That December will also include a survivorship plan. It would detail an example for patient with colon cancer, in when you need to have a follow-up colonoscopy. Or for a breast cancer patient coming you need to have a follow-up mammogram done in so many months. It is clearly delineated for the patient with the survivorship plan is and they're not left hanging. I would say responding to a doctor tang's request for ideas, a secure messaging system would be very useful for the communication between providers. These treatments summer and plan documents are static documents. It needs to be ongoing communication between the health care providers throughout the episode of care. The system I have, we are fortunate the system allows secure messaging. The messages can be attached to a specific labs or X report and can be fired up to the other positions to say what you what to do about this. Or something that should not be attached to the patient's records. We have secure Internet communication. It is an ongoing communication of specialists and providers. I think the major enhancement in communication. A third effort that we looking at right now is common case report research. Clinical research is something that hops across all specialties. The FDA and the NCI have endorsed an idea of a public case Report form. [Indiscernible]. NCI working to develop an oncologist this a case report form. This is an idea of specialties could incorporate to enhance research efforts. Finally, the last measure that would be critical would be the use of orders that spirit for ecology, we think this is chemotherapy order sets. They have all the chemotherapy drug, the doses with various safeguards for proper dosing and supportive care medications. They should follow guidelines usage. They can serve the purpose of improving health quality and falling evidence based medicine. That is my time. They keep.

Thank you very much.

I am a psychiatrist and vice chair of psychiatry at Columbia university. The opinions that give our that of my own. The bottom line is something that Judith Faulkner talked about earlier was the focus needs to be on patience, not just providers. I will mention five issues that have to do with special contacts of psychiatry and mental-health substance abuse and in response to the five questions. A lot of my comments are by the recent Institute of Medicine report that it that the crossing the quality chasm concept to Mr. Delp and substance abuse. But issue number one is we should not be splitting the mind, brain and body. Psychiatrist and mental health must be part of the mainstream. This kind of dualism is something that hurts patience and wastes resources. All of the goals of meaningful use are the things that are intrinsic to what we need for patients with mental and substance abuse disorders. They're unique attributes with regard to the structure of care in mental health and substance abuse. There is a much greater [Indiscernible] of providers. The settings are more heterogeneous. Much more of a cottage industry than the rest of medicine. The at the issue is the separation both structurally and functionally has a specially hardened silos. Their must be a greater for the communication. Item number three is the issue of resources. Mental-health conditions are among the most costly disorders. They have the second highest burden of illness among all of the disorders get the represent a decreasing fraction of the health-care dollar over the past 20 years. The resources are much more stringent in this regard. If you also look at the office environment, most practitioners have a minimalist office environment and often don't have access to an electronic infrastructure. Number four is the quality of infrastructure. One thing noted is that there are effective treatments and an array of mental-health and substance-abuse quality indicators. [Indiscernible]. We developed dozens of indicators throughout the the see a system. New York state has developed a number of quality indicators. However, overall, the mental-health field is further behind with regard to quality measurement and I will talk more help about that. Their loss of gaps in really nobody in charge of developing mental health indicators. Number five is that trust is essential in terms of gathering the trust of patience and consumers. There are special privacy needs in mental-health and substance-abuse. From a statutory point of view and in terms of how people perceive it. There has to be special safeguards and special consumer authorizations. To respond to the to the questions, what is the best with a decrease psychiatry and mental health in Demetrius and health information infrastructure. Integrated from the start. Integrate metal and substance abuse orders into the process. Most people with mental health and substance abuse [Indiscernible]. Number two, national registries. Mental-health is further behind and beginning in the number of areas, but there are important developments. VA has developed a number of registries. Depression centers on a national basis including registers associated with bringing stimulation techniques. There are state registries [Indiscernible]. Locally, a number of registries have been developed. We are developing registries that incorporate Mental Health and substance abuse. The development of quality measures. There is nobody really in charge in terms of NCI [Indiscernible] in terms of being responsible for the development of quality indicated development. That needs to change. I just came off being the co-chair of the [Indiscernible] medication management committee. It is not just a mental health but when we had a call for measures it was disappointing. There were huge gaps and what was submitted particularly in mental health and other areas. One of the measures that need to develop, the areas in mental-health has to do with measures that incentivize system magic longitudinal assessment using standard measurements. So-called measurement based care. One thing I would suggest again is screening by itself. There is little evidence of screen without follow-up is affected. Finally with regard to measures that might improve coordination. One thing to consider is whether or not for people with depression or diabetes or schizophrenia that actually both sides of the issue, the primary care provider or other Specialist and the mental health provider share responsibility for those patients and for both sets of measures.

Thank you. Do we have questions from the panel?

The [Indiscernible] program talked-about, are they on medical oncology practices, how many surgical measures are included in that?

Those are Medical oncology practices. There 80 of them that comprise it.

I am not sure understood you point, you visit a variety of proposed need for use criteria and said they were not applicable to ob/gyn. Like the percentage of prescriptions prescribed electronically. Why would that apply any less to ob/gyn and other specialties?

I may have to miss spoke, I am recited this as examples that we could utilize.

Okay, thanks.

You mentioned it suggested integrating cyc mental-health from the beginning. Given the discussions you have heard, particularly related to mean for use, would you have any specific recommendations on how to do that now?

One way is that some of the current suggestions on the cost-cutting measures at any for use could be applied as psychiatry and mental health more broadly but also to look at developing specialties and specific measures in mental-health. There are a number that could be suggested in that area, but a particular, the issue about referral and referral tracking is an important piece of that. I think that also [Indiscernible] not just the refer went out from a primary care provided to Specialist, but that the specialist got back to the primary care provider.

Thank you. In the mental health arena, at least of Florida, we see a significant number of mental health patients are treated and Medicaid and we have a lot of [Indiscernible] within. Most of that treatment takes place not by psychiatrists, but more by psychologists. As well as a primary care physician. There is, but the integration in communication between treatments. It is a major column and cost driver to budgets in Medicaid. Perhaps this is a question for Paul or for CMS. I know there are no incentive dollars for a psychologist,mental-health workers. Is there a way to Medicaid to perhaps integrate the treatment that there could be some targeting of money to go into those other specialty areas to get some of that Medicaid dollars down there because it drives our budgets crazy. That is a significant amount of our Medicaid dollars, that go intomental-health. Is there any way to do that?

[Speaker Faint/Unclear]

Is there a way to do it through Medicaid?

It would depend on how it ties to some of the is 16 funding mechanisms. I would have to talk to somebody as CMS who has more of a knowledge of how the different funding mechanisms could try to something like that. I can't answer your question.

[Audio Faint/Low Speaker] there is an incredible integration of the physiology and the social aspects of care for somebody as a condition. Somebody who's getting a psychotic which induces metabolic changes that requires tracking and assessment [Indiscernible]. At the same time, on the behavioral health side, there's not only a prescription drug, but there's also the issue of self care. [Indiscernible]. There has to be that kind of integration.

I have a couple of questions. Dr. Pincus, you made a compelling case to start not only our care, but the measure of care as an integrated mind, body whole. One of the dilemmas we face as community practitioners is that the data is virtually by law. We would require that to be swallowed in our electronic systems. How can reconcile those kinds of opposing me contradictory purposes?

Part of it is, from the outset, patience and consumers have to be involved. It is how you present the information to the consumers about what kind of choices they have to make. To explain to them that you really don't want to tell anybody about this information. It is really important to provide as communicate and that there are ways to do this in a format that privacy is protected so that providing this information can a system allows for that and that presented in a much more even-handed way.

My question for the whole panel is, there are lots of issues we have been discussing with the previous panel and an example of attribution. We heard from Dr. [Indiscernible] and the registries are silent. We have talked about them all morning and this afternoon. It strikes me that maybe we are on the wrong track. We are smiling our measures. There isn't [Indiscernible] the most challenging, the biggest challenge we have is care coordination. That would apply from one doctor of any kind to another and it certainly happens with the primary and specialty care. What you think of the notion of trying to go towards a measurement of this care coordination. Doctor, you mentioned messaging. Doctor to doctor and with the patience as well as perhaps one of those crosscuting measures that would contribute to care coordination. What you think that approach in terms of focusing on the cost-cutting measures rather than specialty specific measures?

[Indiscernible] strikes me being consistent with the episodes of care. One of the philosophies being espouse is the concept that we look at a patient's illness as an episode of care and try to look at the cost of that episode of care. That episode of care would with oncology would cost over different specialties. I think that is in line with the presenter on the ANA of registries. I like their approach of looking at it from the diseases. This patient has congestive heart failure, that means we need to involve [Indiscernible] if we are going to impact outcome. All of the players have to be there. I think that is an appealing way to look at it. The communication for chronic diseases, we find that things change and not only do we need to shed the data, we need to share the knowledge. We just passed the data back-and-forth and they are numbers. No one is using it. If we communicate freely and do that through EHR and capture the communication to track it, I think it would be a great step toward meaningful use.

There is an important dimension but again, an obstetrics we are hampered because of the need picks of the abstract of record. Even those vendors who have created an obese specific record and to have that record be interoperable with other records. [Indiscernible]. The only situation in which I am aware of a good patient centric record is in some of the large vertically integrated health-care delivery systems such as Kaiser. Those communications are important. At this point, we are living in a world with an obstetrician and gynecologist in most hospitals in this country and being less than 200 beds is still faced with the pepper record. [Indiscernible] sometime during the second trimester of pregnancy and then again during the third trimester of pregnancy we don't have records that can talk to the hospital system or talk to the imaging center and talk to a laboratory system. The whole concept of be able to communicate while of the highest priority is one that seems far removed.

With regards to your comment, I don't think it is an either or. In thinking about the balance as across coding coordination measures which purchase special to measures, there are special to measures that might be most relevant information for the other side of the divide. Think of measures and specialty care that would be most informative for the primary care provider to know about that kind of information as well.

Your written testimony was interesting and I am trying to [Indiscernible]. You don't talk a lot about EHRs as a high value for most surgical specialties. You list a number of registries which if they could be a good platform to contribute meaningful use of information. What do you see as the relationship between the hospital based systems that support a surgical practice and collect data that is relevant and the longitudinal characteristics which talked about in this panel [Indiscernible] as the best way to get a profile. I am trying to wrestle an architecture that we could think about from the meaningful use point until that could take as [Speaker Faint/Unclear]. But reward meaningful use information. Do you have a recipe to think about and how to blend these components?

There is a lot going on obviously. I think from my perspective, I look toward what the end looks like and how we map our way there. It seems like we keep learning with each one of these new aspect of health care redesign or reform we keep learning and the and keeps changing. The objective keeps getting more sophisticated. This goes to Paul's last question as well. I think the end of this for patients and providers and surgeons and anyone who cares for the patient is quality improvement and to empower the patience to make the right decisions. It those two elements are out there, there aspects of this that are in the hospital, but that is only one aspect of the continual of care for the surgical patient. Some of them is prevention of them needing my services. Or if they need my services, what can I do to promote them from never needing them again? Inside that facility base environment, I am really concerned about getting the appropriate things done and getting risk adjusted out comes to tell me if we achieve it. Those are two key measures both for the patience and for the providersIt is much broader than the surgeons. On the prenup and postoperative experience, it is that moment we think a chronic condition or stable patient suddenly starts crossing into this world of needing an intervention. To pick that up at the right time and get them at your right place and get the right things done and get it done expeditiously, but don't overuse it. Sync when we lifted the EHRs and can they do that? Currently we are not modeling [Indiscernible]. Ultimately we live in a cloud environment. The other aspect of all of this which is an important of quality improvement is one thing is to give me measurement and opportunity to drill down. Everytime I get a set of measures I learn something. I see an opportunity for quality improvement and I need the ability for the data to go further. If that datasets in EHR or a government program, is not easily accessible for the innovators for those who want to get narrow and deep for an issue. You decide what ever it is we put into policy. [Indiscernible]. That is what we are suggesting and heading to and at the same time outlining pretty currently are as we try to interlace all of this together.

Just to summarize, the guidance to us seems [Indiscernible]. We need to think about criteria on our matrix which captures data in the hospital EHR that supports which you refer to as appropriateness and that may be indications of treatment. Then we have to think about interrupt ability as a strong earlier of our criteria to support this episode and long exchange of information. [Indiscernible] you group as specialists. We couldn't be more diverse. That is the challenge. Trying to come up with the crosscuting measure. However going to measure the one thing? I don't know if you can. You can't group of specialists and say you are in this bucket because we are in different buckets. I think you're back with coming up with a short a sportsman of measures [Indiscernible] the real goal is EHR adoption. Those of us that are believers have lots of examples on have improved our care and made me a better doctor. The physicians in the groups that are most reluctant, once they started measuring, they started improving. I wouldn't want to try to have too many bars.

As far as the ob/gyn is a trickle patient, that refers to the model that the doctor talked about. Even the obstetric patients, many at difficulties can arise in terms of issues acuteness versus chronic moving from a chronic condition to an acute condition unexpectedly and also the need to transmit the information among these various locations, whether office or hospital or ambulatory facility. I would also agree with the doctor's comments about the easier and more ready implementation of registries with respect to many of the issues we would like to track as opposed to the full-blown EMR.

I have a quick comment, and to say that I was delighted to hit the approach and the leadership that you showed in looking at the broader environment and doing put it takes to figure at which you need from certified products and your functionality requirements. With the approaches that this country and the direction to have been heading, we hear a lot of folks remarking about how it will not work for them. I appreciate you have shown the leadership necessary to figure out that would not work and that you could do something about it. I want to ask a question of Dr. Strunk, we at the [Indiscernible] have done thinking about the quality of reproductive health care in this country. The quality of health care at large, there is a way to go. We are looking forward to supporting that progress. We have also looked at measurements in particular in reproductive health care and you point to some potential measures in your testimony and there are clearly others out there that there are not a rich set of measures. I heard you say something that I wanted to make sure I heard and ask you to clarify that. I think I thought I heard you say that the submission of clinical quality measures would not be helpful to the position. I am not sure I understand what you mean by that. I would ask to expand little and address with you think that could be helpful for the patient.

It when I sixth came across as a broad statement along the line to test indicated, that would be not correct and not what I would communicate. Clearly that is important for the patient and for the physician caring for the patient. After all, the patient's health and safety is our goal. I was speaking primarily in terms of population of women taking care of by obstetricians and gynecologists. The fact we have a relatively small percentage of medications and that many of the clinical measures are not really [Indiscernible] to our patients. The materials you have in front of you, I cited a whole range of measures which would be appropriate including various types of screening from mammography to cervical cancer screening to HIV screening. I would not want to be understood in the way that you indicated.

Okay. That is helpful. What of the things you do talk about is figuring out how to align to be objective that been shown to be in the meaningful use matrix. We have heard today about a lot of different approaches, but one potential approach would be allowing specialists to choose from a group of measures that did apply to them to the extent that those measures to exist or would exist in the future, what you think of that approach for your specialty?

I think that would be a daunting task for you, but one one we would endorse. To the extent we can identify specialty specific measures which are meaningful and reflect accurately on the quality of care and assistance in caring for the patient, these are certainly to be pursued.

Maybe I can follow up on that. I don't know if you're here with George presented a framework for dealing with measures and the core that would apply to all eligible professionals. There is the primary care which is many preventive care, and then there is the cross specialty and specialty specific measures. To piggyback on what Christine was saying, where the rest of you would agree that this approach [Indiscernible] contributing to the problem list with a specialty specific diagnosis and is a with the medications are elegies. George mentioned not avoiding the high risk medications in elderly patients. Then some cross specialty might be closing the loop, and I understand this is by direction[Indiscernible]. Do you think we could or should adopt measures for the specialty specific measures?

Many of the things and spoke with respect to cross specialty datasets are things that we have been working on of the continuity of care record to incorporate for pregnant as well as non pregnant female patients and that record. Yes, those things are amenable to corporations and very useful. I would have to know more about the specialty specific criteria to respond on whether they would truly measure, but they were intended to measure and if they would serve to improve the quality of care.

I think this is important. We focus on the procedures we perform and the outcome, the patient gets lost in the shuffle. I could tell you many stories of patients that come to the hospital that even had complications to the procedure, their entire baseline chronic status is now gone. The medications shift dramatically. We send them home on a new set of medications from specialty consultant to care for them in the hospital and patients go home and open up the medicine cabinet and have the old and new medicines and now have the opportunity to take all of them. Not realizing that is a problem. Number one, medication reconciliation is critical across all specialties. I think it touches primary care as a specialty, too. That is something we go on behalf of the patient. We pushed different types of medications to patients in a much more aggressive fashion. If that comes out, we have an obligation to get that in there. Of particular interest is high risk medications and in surgery. High risk medications in surgery and the elderly patients are narcotics. We get out all of them. We have significant impacts. Post operative dementia is a real problem. Patients go home and a mistake the narcotics the give them. I really believe that this to quoted and along with closing the loop at least from resurgence perspective is important.

Earlier in this day it was said we might specify an overarching goal and had each Specialist measure AnnTaylor to that goal. - measure and Taylor to that goal. [Indiscernible] and would list the medications and follow up with other issues specific about that disease. The application could be designed, without the overarching principle.

I would like to ask a question.

It's not that you can't have crosscutting messieurs, there's certain things like medication reconciliation I was trying to argue against and how many of those who are going to have and how many will be in a menu driven this may pertain this may not pertain. [Indiscernible]. I wanted to ask a slightly different type of question. You all our leaders in your field and we picked you because you have been deeply involved in that space of working in IT and be interested in IT. One of the things we are concerned about as a panel more broadly is the extent to which the dollars and put up their are driving people who are not on the street and the providers who are out in the community and how well these discussions pertain in the field. Are people looking at the information that is coming out from the policy panel and the things that are coming out in the trade journals and saying these people are out of their minds or are they looking at this saying this is moving in a good direction? You all think it is moving in the right direction because you were deeply in the space. Within the organizations that you are involved in, what is the pulse of the communicators that you sit in front of and what are they thinking? Second, what could we do to further the extent to which the work that we are doing gets out there and becomes a real encouragement for people to adopt electronic health records and use them in a meaningful way?

For our population, I think it is a rather disturbing distribution. I think those who are working in a vertically integrated health-care delivery system or a large hospital system, they are enthusiastic about the use of records, about the benefits they confer in terms of patient care, in terms of improving patient safety, being able to get the kind of data feedback we need to get the measure of quality care. They're ready to run with this as far as it can go. Then there are those positions in those practices who are associated with perhaps two community hospitals who deal with two or more diagnostic Laboratories and three imaging facilities, and they feel like they have run up against a brick wall because anything that they buy will probably accomplish an interconnection between what the seven or eight different entities they have to communicate with to have an impact on improving patient care and improving efficiency and being cost-effective. That is the population that asks us for the silver bullet. What is the record that is going to be interoperable with these and other entities and what is the record that will capture the kind of data that payers and the government are going to ask is to provide. What is at record? We cannot give them a specific record.

Is there a particular recommendation you would have for how we could do our job better and getting out to that group of people? I'm not really as concerned with the people that are deeply invested in this. Many of us to sit in this room are like that. What do we do to get to the rest of them?

From our members perspective, they wish the government would be more proactive and directive in terms of interrupt ability among vendors. That is the pin the SEQ holding up their decision to purchase a record. While and is well and good for [Indiscernible] why hasn't the government set particular electronic standards that will in schul interoperability of the systems.

They think we are a Miss America pageant commenting on world piece. It is really a wonderful thing and we all wanted to. I really think that is where they are. They pulled back to say that you have got to show was that this is a deliverable and I will not have to reinvest. It is not just the capital outlay, but the time involved. We have looked at places that have put registries into the office and there were no quality improvement efforts in that office for 14 months because every single resource went into implementation. To learn there is as many being removed as there are implemented, that is with the belief. There are 200 or 300 EMR that they should be looking at. They are more than willing to wait until they know. It is not that people don't want world piece, they do. They just want to see what they're going to invest in and invest not just the money but investor heart and soul into getting better quality care. They want to know they are in the game. I don't know that is on the street today that you can go to them and take that to them. That is news to me. When they ask me, I to tell them to sit tight, it's not time.

In the oncology community we hosted a symposium last month in San Francisco. The purpose is to provide people who want to purchase the [Indiscernible] policy. What standards are being set and what they should look for. At the same time a communicates to the vendors the same message. I think they're both looking to say, what do we need to have? The position provider is looking at I only want to buy this once, what do I need to have to get a stamp of approval that a know I am getting? The vendors are looking for the same thing, what do we need in our development plan to move this along. Having these venues where we can communicate to both parties together is useful and having the society be your outreach to the different communities is also important.

From my point of view, the question is who is day? There are multiple different subgroups. The psychiatrist, psychologist, social workers, substance-abuse clinics for the bulk of the care is provided. Those are critical groups outside of this. They don't have a dog in this fight, but the really need to. Those of the groups in most need it. Many people in the cottage industry think they can go undercover. I think the real issue in many cases of the telehealth is how you bring in other providers from organized care settings that are dependent upon - and one into have more communication with the rest of health care sync.

I would say the employee positions of the hospitals, the larger groups have bought into it and that is kind of the case of cardiology. The smaller groups to work with on a regular basis, there on the sidelines and up off of the bench and looking. It is hard for them to pull the plug and make the decision. If you just have one hospital, it is easier. We have a local hospital vendor affiliations that are working at more than one hospital. [Indiscernible] there are competitive reasons to align yourself with one hospital, it does not make sense that those hospitals are not necessarily going to exchange information. I think work with health information exchanges would help. Why can't it be as easy as the ATM machine. Then you could find a product that was best for you. Interoperability is becoming a buzzword, not necessarily a buzz word. The average private doctor that is in a two or eight Man group that may be in specialty or multi specialty. They're waiting to see what is going to happen. If I invest in one vendor, it is the last decision and need to make for the next 10 or 15 years.

It sounds like the people that are in the integrated systems are the ones that are out there first. We know where we need to point our original extension vendors, away from those same places into the community more so that we can start to get [Indiscernible] in those places.

I want to thank the panel. You did exactly what we were hoping was to give us an inside view of what is going on within a number of specialty societies. I think it has been incredibly educational and I think you for your prepared remarks and I will turn his back over to Paul.

I also want to thank the panel for an of formative group. I only regret we were able to extract from Frank the answer he was holding back because I don't know that we got the answer. Thank you very much.

I think we need to figure that out. How do we handle the huge problem, how do we do it in an even-handed way. As a society, we had jumped from [Indiscernible] to hit something that is more discussed. If we go one direction with mental-health, to keep it hidden? If we go another direction, do we keep it more healthy?

Good point. At this point, I like to entertain any public comments we might have.

Thank you, if you have a question or comment, please press star one under telephone keypad.

[Audio Faint/Low Speaker] and also, managing director of the Central Jersey Health Information Exchange project. We have been working on this since May. We decided as the private physicians you're mentioning, the ones on the sidelines, that we have to implement and go with EHRs. We have formed a not for profit to be able to incorporate a health information exchange. The problems we are running into, there is no national health identifying number so that is going to be a big deal for interoperability. The interoperability, most of our positions go between them to hospitals. One, we spent five years developing a clinically appropriate system. Five years of time. The private physicians cannot afford five years of implementation before they get to the point where the patients are being taken care of appropriately and properly. I defer to the health care policy people, but we have to keep in mind that we are talking about patient care as well. All these systems need to have a common language. The reality, the hospitals, the EHRs. Without the common language will not be able to do what you want to do. When you talk about meaningful use, it would make sense for the physicians to talk to one another, and to talk about who should set the guidelines, it is a specialty guideline, the specialty people should set up into ever the position is that is dealing with the problem can't take care of those guidelines. Finally, again, we really need to have meaningful use Communication for the patients benefit. Thank you.

Thank you.

I am Richard [Indiscernible]. One of the most interesting things I heard today was the proposed an affirmation of the strategic planning work group. I would structure recommend that go forward. As our whole effort goes forward on EHR and [Indiscernible], it is critical to revisit the strategic plan because the success of this whole effort and the components of it involves different pieces and different stake holders including government, patients, providers and medical device and software manufacturers. I have been to a lot of these meetings now, both in the HIT Standards Committee and policy. It has been repeated recognize that the adoption of interoperability status is critical. Our association and our [Indiscernible]. Griffin the criticality of inoperability standards, [Indiscernible] has to be at the table along with the providers and the other groups and patience and government agencies. I would strongly urge you to cast a wide net to solicit input from all key stakeholders and allow them to weigh in and participate in revisiting the strategic plan. I think that is the key to success. Thank you.

Get afternoon. I am with the Center Research institute. A nonprofit work to discover the most effective research base practices for B. Hager health disorders and increase the dissemination of these practices with the community health centers including centers on which is the largest provider [Indiscernible]. I come to you as a family caregiver and a person with [Indiscernible]. I am personally familiar with the consequences of a lack of mental and physical and health records. It has been costly to my family and many families across the nation. I have two requests of this committee. And to define to work the meaningful use, I ask you consult with community mental-health centers to ensure these providers have health provisions that are specific to the tasks in providing and coordinating care for people with serious mental illness. I also urge you to recommend the inclusion of physician and not physician providers of that the health care and the definition of meaningful use. The community of mental-health centers to work with, only 5% of our providers are psychiatrists are nurse practitioners. To provide care to the people we serve a communicate with medical colleagues about patience, what better% are clinical providers need to be using health IT. Sync to start solving the crisis, all health-care providers need to have access. Without being integrated, we cannot prevent [Indiscernible]. We cannot track out comes and we cannot be held accountable for best practices. I solicit your support and ensuring the mental health providers are able to benefit from your efforts. My contact information is in the handout.

My name is and and and with America's blood centers. We appreciate your attention and help we are making clear how important it is that blood centers be eligible for funding. Blood centers are stakeholders in in the electronic health records network and as such should add access to HIT funding. It is the intent of Congress we should have access to that funding since we are both a part of the national response planned and under the ARRA which include several HIT programs which blood centers should be able to apply. [Indiscernible]. Including grant programs, technical assistance and hospital pro fighter incentives. The eligible recipients in the application process for the grant programs and the HIT sections of the ARRA are unclear. Blood centers have been stymied in applying for funding. In order to best protect the nation's blood supply, we are not for profit sector. That means real equity and no means of borrowing or obtaining investment money for capital improvement. It is imperative that bless has qualified for a federal funding program designed to enhance the health HIT infrastructure. Be allowed to apply for HIT funding will allow blood centers to continue with their work [Indiscernible]. The use of data miners ended data warehouse for benchmark blood use with other hospitals and nationally monetary disease markers and blood donors as early warnings of trends. In addition we are working to establish an interface standard that will allow data interface exchanges between blood centers and hospitals. We appreciate support as we work on these projects and we hope you'll take the needs of blood centers into account. Thank you.

I am not a position that I wanted to attempt to address the doctors question about the work of this committee is being perceived in the community, not just what was in the critically integrated health-care organizations. I think when it issues bear seeing is the impact on productivity for positions. The third negative impact can be the real deal breaker went physician practices are looking at acquisitions of EHR. I don't we to underestimate that because it is prevalent among smaller and larger practices that are not integrated. There were many references to date to be mindful of the impact on the health care work force, balancing the burden as I think the Dr. Mentioned and what is meaningful to physicians as a specialist Hal testified. I hope to Everett these seven comments that [Indiscernible] presented to you because they reflect a lot of the concerns that we are hearing in the community. Assuring specialists and that the meaningful use requirements for which delegate for it then begins to address their concerns but also worried about the impact the meaningful use requirements and the EHR requirements will have and the productivity. If you underestimate this impact will never see the widespread adoption necessary to produce the higher level also the legislation. We expect to hear more from the physicians in this regard at the adoption workgroup hearing on Thursday. Not only is maintaining or preferably increasing productivity critical to the physicians themselves, both specialists and the physicians, but it is also to the national health care agenda in general. There is a perfect storm brewing. It will be increasing demand for care by the aging baby boomer population as well as the additional potential 47 million insured patients to will be seeking care and will have insurance as a result of what ever health care bill is passed.

Excuse me, we have a two minute limit.

I agree with the doctor when he said the goal should be getting EHRs in the hands of physicians and that it and see the benefits for themselves.

Thank you. I hope you would not mind if I take this from a difference perspective. I am a neonatology is by train. I'm currently senior vice president for pediatrics group based in San RES Florida. We take care of more than 20% of the babies in the United States every day. We have a significant stake in this. [Indiscernible] we have struggled with many of the issues the panel has discussed or heard about today. We extract automatically everyday 560 data points from that electronic medical record into a data warehouse. That data warehouses used for quality improvement measures, not only getting back our physicians intermission, but we use it in a structured way to make sure we have a number of tool kits and other mechanisms for our physicians to see how to begin to approve the care for our patients. Our feeling is strong that it is the positions it simply give back positions intermission. When they see this information for the first time they have the same uniform reaction that third day is wrong. The next action they have is an interesting one. They want everything risk adjusted. We've heard about risk adjusting today and I think there is a downside to risk adjusting because it allows people to explain away some of the issues they may have with the intermission. We feel they need to see the core data itself. I think you need to have the tools a place to string the physicians a long as an important piece. You have to give them something with the data back. Another area that hasn't been spoken about too much is the fact that many of the special to organizations in the United States are adopting their own quality improvement measures. Unless this panel coordinates your efforts with some of the specialty boards, there will be as significant amount of chaos that results from that. Thank you very much.

Thank you very much and thanks to the committee and to the panelists who have delivered a lot of information. We will stand adjourned until tomorrow at 8:30 in the Empire room. [Event Concluded]