Wednesday, October 28, 2009

HIT Policy Committee - 10-28

The HIT Policy Committee met October 27th and 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 28th meeting.

Meeting Materials:


Draft Transcript:



Welcome, good morning. Just a reminder, this is a federal advisory committee, being held in public. There will be opportunity for the public to make comments at the close of the meeting. A reminder to identify yourselves when speaking.

Let's introduce yourselves. To my left is George Hripcsak --

Columbia University.

Gayle Harrell, former state representative from Florida.

Mark props --

[indiscernible] Johnson Hopkins, school of public health.

[indiscernible]

Judy Faulkner, epic.

Gavin McGraw, center for technology --

[indiscernible], entrepreneur.

[indiscernible] group on health.

On the phone we have Tony Trimpgel, CMS.

Tony from CMS, other committee members on the phone, please?

Thank you, I will turn it over to Dr. Tang.

Good morning. Work to the second day of the two-day session. Dr. Blumenthal sends his regards, he is in California at the moment giving a talk, we will continue out him this morning.

I have heard all the discussion from last night based on yesterday's panel. I think everybody was duly impressed, and I think today will be no different, very simulating, informative about how we move forward with the criteria. The objective of the meaningful use and -- not to put a computer on the desktop of every provider, but to find a criteria where we can help the government recognize and reward those who effectively use HIT to achieve the goals of the transformed healthcare system, to improve access, quality, and efficiency of the way we deliver care in America.

Done right, the framework we come up, as well as the criteria can be a roadmap to get where we are today to where we want to be to accomplish the president's role of truly having all American's health records in electronic health records. That's part of the goal we are setting before ourselves. Today we have two panels helping us consider a number of important topics. In the first panel we will talk with providers that are in smaller groups, whether a smaller group of physicians or smaller hospitals, rural clinics, safety net hospitals.

In our second panel we will look at a number of other providers that may be covered in either the Medicare or Medicaid programs, such as dentists, nurse practitioners, the safety net providers, pediatricians in a special group, primarily covered under Medicaid. Another topic of other uses of health data, for clinical research.

So we have two very special panels this morning and will turn it over to Art Davidson who will moderate the first panel.

Will the next panel present themselves? Thank you.

Is Dr. Edwards going to join us? Do you know, Judy?

[indiscernible]

Okay, I hope she comes. I guess we will start, though the fourth panelist is not here yet. We have Michael A [indiscernible] from the national association of community health centers, Bonnie Britain, CNO of Roanoke community health center in North Carolina, and Marty Feddic from, the CEO of Nem aha county hospital in Nebraska.

We will start with Michael, a presentation, should be five minutes, stick to that if you could, so we will have time for discussion and questions at the end.

Thank you very much. I am Mike Lawsuiterer, the directer of health information technology and senior adviser for behavioral health for the association community health centers and appreciate the opportunity to present to committee.

NAK represents -- 1200 qualified health centers, make up different sites across the country, we expect that to grow to 2400. We employ over 100,000 individuals across the country, around 14,000 eligible providers under ARRA and the stism los package. The type of patients we provide service for all live in medically under-served areas. 65% are on Medicaid, 35% are uninsured, about 8% are Medicare, almost all the patients we touch, everybody is paying for one way or the other. We have 67 million visits per year. In terms of criteria, health centers feel the meaningful use criteria would be very helpful to them in furthering their mission, to provide good quality care on a population-based method to all the individuals we serve. We do that, many health centers receive some funds from HERSA, other payment sources.

In terms of EHRs, we think the meaningful use criteria will help move them along quickly and in some areas more quickly than what is identified. Yesterday there was discussion about disease registries. Health centers use disease registries already, have been for years. But they are at the practice level, so they use them, monitor their patients, trends individually, groups, use those to recall patients for treatment. These disease registry functions are not currently in electronic health records. We heard testimony yesterday about that.

The quicker we can get that functionality incorporated in EHR, the better, from our point of view, help us do our work much faster. Or [indiscernible] smooth interface with disease registry. Right now we have situations where we use disease registry, but the interface doesn't talk to, we drop to paper, have somebody type that in, not a good thing. The sooner we can have the disease registry functions incorporated into EHRs, the better, from our point of view.

We do very well managing patients using those disease registries, we provided some numbers. Issues are tracked by HERSA, we are audited every year and health centers need to report every year, report against regular practitioners. In terms of clinical measures we request that the measures -- we are already using clinical measures, we request they be harmonized across the government. The measure for diabetes specifically is identiffed as an 8, we use 9. We don't want to report on two different measures. We are working the patients, managing the patients, so we don't the two cohorts, we want to work with one.

HIE is an issue, may be an issue in terms of being able -- additional cost may be an issue for health centers and the last thing, a barrier that is going to be present, two things -- initial start-up cost for EHRs. You identified the money is there, Paul, we don't know -- we need the money up front to adopt. The area of regional extension centers that have put a Of 10 providers on the regional extension centers per tax ID, seems to discriminate against the health center model. We don't have individual MD, we work in a team approach, medical homes, actually doesn't work out financial if you have seven sites with 50 providers They are 50 files apart, you can't bring up sites with the amount of money you would be reimbursed for 10. Doesn't work financially. I tried to work that out in my mind, on a business model it just doesn't work. We recommend we change that immediately to bring up health centers more quickly.

Thank you. Welcome. Dr. Edwards. We are glad you are here.

Me, too.

We will save questions until after the four presentations, so we will proceed with Ms. Britain.

I am Bonnie Britain, the chief nurse and [indiscernible] for -- in Ahoskie, North Carolina. We are an FQHC, have 20 primary care providers that cover four counties in very rural eastern North Carolina, 70% of our population is African-American, large majority of patienting population is uninsured. We are averaging -- this is 20 primary care providers at three sites. We are now averaging 185 new patients per month. Of those, 45% of them are uninsured or self-pay. This number has dramatically increased since December of last year. I was here yesterday. One thing that struck me is that the primary conversation has been around electronic health records, and we really have not addressed health information technology that can be used in a meaningful way for our patients. And I am here today to speak about patients and patient's rights. The literacy patients we are caring for, primarily, a large majority of elderly patients. By providing them a handout when they leave the doctor's office telling them about diagnosis, medication, really does not assist patients as much as they can. Education alone cannot change behavior. One thing that we believe is that by reaching meaningful use we have to engage patients, we have to alter the way health is maintained, the way care is provided on an ongoing basis. The proposed matrix, as I said, almost totally focuses on EHR, especially during the first two years.

What we want to do is bring forward to the committee the use of health information technology, primarily remote monitoring and chronic care management. Our health center has been using electronic health records for 12 years. All our provider and staff use EHR. We implement remote care monitoring, chronic care management. We have 200 patients at community health centers and provider sites across the state North Carolina. I have given you the written details. I want to tell you about a patient. Think about what I am saying as if you were a primary care provider or specialist.

We have a patient, 37 years old, African-American female, diagnosis of cardio mi Op thee, in heart failure continuously. She also is diabetic, long-term, just received a kidney transplant and is on the list for a liver transplant. Provider lives in Ahoskie, or -- in Greenville at the medical schedule, and [indiscernible] in UNC, Chapel Hill, and [indiscernible] at Duke. She had four different providers telling her different things to do. We were able to put a remote monitor in her home and every day she monitors her blood pressure, pulse, weight, blood sugar. She could check pulse ox em tree level, all collected by the patient, answer questions related to signs, symptoms, medical, nutrition, compliance. That data is sent over the plain old telephone line, you don't need broadband, you don't have broadband. Our patients don't have computers. That information is sent to a secure server, where a registered nurse reviews. If the patient is out of the range determined by the primary care provider the nurse contacts the patient by phone, completes a nursing assessment, and provides education.

Then, through the electronic health record, we communicate the RN to not only primary care provider, but the specialists in the other locations. It's a primary care provider, specialist that then make the determination how to care, proceed with the patient. They make those, contact the patient, document in the electronic health record, and all of that comes back. So it's completing, starts with the patient, ends with the patient, and we really will have to think about health literacy. Are patients going to gain behavioral change and long-term care management when you are just providing education.

Thank you, miss Britain. We will proceed to Mr.Ed thattic, from Nebraska.

Thank you. I am marted thatted ed thatted thatly there are 2400 hospitals with fewer than -- beds. These offer primary care services, that is the focus of my remarks. From my experience in implementing health information technology, complete electronic health record at Them a haw in Nebraska. wewe chose to install an integrated system with software from a single vendor to meet HIT requirements, single database. We found this easier to maintain, install than one from different vendors. We have a complete EHR and are exploring ways to connect us to the nationwide health information network. We have been on the most-wired list of the hospital health forum. We focused on functions most likely to improve care, including generating accurate -- single view, computerized order entry and support systems. We have electronic medication verification system in place. Such things as electronic reporting of quality measures, access to records, reportable lab results are beyond the scope of our HIT system. Adding these aspects to the 2011 objectives would take resources away and be challenging to meet. These functions in the necessary supporting structures are not yet well defined and I doubt our vendor will be able to develop by 2011.

Adoption is incremental, varies across institutions, [indiscernible] must be in place before other functions can be successful. In recognition of this meaningful use use objectives and measures should be defined in the same order, by use of systems necessary to provide patient care.

Eventually EHRs have E should be able to provide -- however, hospitals need a clearer picture of information considering meaningful as more hospitals expand capacity to share data.

Needs of smaller hospitals are different; currently all vendors design product to meet [indiscernible] requirements, making them different from meaningful use requirements would cause substantiate delays in the development of products needed for meaningful use. Cost is a major barrier to HIT implementation, another is -- small communities don't have the large pool of expertise. Talent is hard to recruit and maintain. Supporting the hospital's mission of providing care, meaningful use measures requiring system modification, analysis, extending beyond the basic mission -- cannot be a one-size-fits-all proposition. The hospital and physician practices must be clearly defined as each provides care in different ways and each needs HIT systems that do different things. I understand the complexity surrounding this issue. I believe by defining realistic objective and measures for meaningful use EHR can be made available to as many providers as possible, improving healthcare in this country. We strive to do that every day. EHR will be a critical tool as we through heeling the care reform build a better system. We look forward to work other with you to that shared goal.

Thank you.

Dr. Edwards, national medical association.

It's a pleasure to be here in spite of the train system.

I am the president of the national medical association and I am happy to be here to talk about the quest to reduce healthcare disparities. Adequate as privacy and -- I want to respond to the question about how small practices or hospitals can demonstrate they are improving care. From a process as well as outs comes measures, reporting quality measures to CMS, tracking percent of improvement is an effective way to measure that. Cautioning concern that baselines differ among populations. One improvement in one population may not make a difference in another. All quality improvement measures should bear this in mind and [indiscernible] until we work out the kinks. Increased number of patient with access to their own EHR an objective means of determining patient engagement. The so-called digital divide keeps patients on wrong side of -- the outreach awareness, building and improved access to technology is necessary on this front. Outcome measures, one thing to have a goal, but achieving results is more important. The following are important: Redwuks in racial, ethnic disparity, reducing incidence of chronic disease, co-morbidities, [indiscernible] due to language or cultural barriers, empirical evidence that HIT care improved care among populations.

Reduction in the 30-day readmission rate rate. Saving the system money, it remains unclear how much this reduction impacts a physician's cost of services. Our members ask does the promised -- outweigh -- where is the cost benefit to the physician or is it possible they are running a risk of paying for major HIT investments and still being reimbursed less because of potential bad outcomes that are best documented by the HIT had to purchase. Information exchainches smaller providers, and health departments, disease surveillance, outbreak, vaccination rates, all vital public health imperatives better served when there's an easier -- public health app Pratt us at the local, state federal levels.

With respect to applying the use of measures, the following considered as we apply the measures. This is through no fault of the patients. Many patients are unable to comply because of doctoree instructions, health rite rase, money, transportation, social determinants of health, lack of adequate housing, nutrition, food within the community, safe outlets for [indiscernible] all of these contribute to success or lack there of prescribed therapies which impact our outcomes.

The resource restrictions doctors in smaller practices have in terms of time to enter lab orders and results, many cases lack adequate staff in order to support the data collection. Glierp the other measures we agree upon, we may not have considered everything, but our goal should be to orient these measures toward prioritizing prevention, primary care, integrating office practice with public health structure and track the reduction in health disparities. The barriers we see to adoption are number one, affordability, maintenance, we suggest grants, insetsives, no lower interest rates -- need to recognize the patient mix, small practice provider should be given EHR and health information exchange designed by the demographics based on the variation of the patients they see.

Lastly I wanted to say finally our role in improving HIT adoption, implementation rates, spread the word, second set example with a lot of fiscal support, and encourage minority vendors to get involved in the design and implementation.

We will open this with questions from the committee.

You said the economics don't work. As I understood, one reason is because a lot of the providers aren't physicians. Did I understand that?

Yes, under an [indiscernible] model, we have physicians, nurse/practitioners, nurse-midwives and dentists included, the 10 providers per tax ID, when you have one tax ID that has seven sites that may have 40 or 100 providers it is just no way --

It's the number of providers.

Last week we heard a presentation from a representative group of California, federally qualified health centers, deven, maybe you can help with this, the person presented a model, subscription model of 60 federal qualified health centers who had got even together, a very cost-effective model. Wondering whether you are aware?

Oh yes, we have a health center controlled network. What happens is groups of -- regulated under HERSA, three or more health centers come together, form another corporation, nonprofit it, or one takes the lead and then they provide the infrastructure, basically for the rest of the health centers, so it's a very efficient model. We did recommend the health center controlled network and primary care associations in the state do some of this work. The components of the regional center was accepted, however, once you put this 10-provider On a tax ID, that doesn't let the health center control the network expand be able to provide the service it needs to provide. That's where we get into the problem, it just doesn't work.

Where and the 10 had-provider Come from?

It was in the last guidance. Wasn't in ARRA, seemed to be in the last funding opportunity announcement. It wasn't provided at a time where we could have made public comment on it. To us it seemed arbitrary and discriminates against that model of care. The first funding round is coming up November 3. Some networks think they may have to back out of their consortium with regional extension centers because of this. It's something that's important we should try to change immediately.

Is it already a law or just something --

It just was in the funding opportunity announcement, not law, actually federally qualified health centers were in the law, separated out as a separate entity because of the way we work -- because of the multiple providers home we provide for patients. Seemed strange that it was separated out, then lumped in back with other non[indiscernible]

Funding opportunity -- trying to -- this is HERSA?

This is the regional extension center.

I will try to read between the lines. The RECs, regional centers were to give preference to smaller providers, presumly they tried to do it by the , so your message is being heard.

You have done a terrific job in a small environment Question is around physicians, what you are doing to share the -- [indiscernible] the second is around the issue of -- I come from a very large organization, we have security, privacy, all the issues that regulation placed on us and it's beneficial in a large organization. I can leverage a lot of people to do that across a large cost base. How do you keep up with that, regulation and what's the impact on you? Seems it would be significant.

Regarding physicians, how we communicate, we have one private practice clinic in town, a five-physician practice in town and a number of medical providers from Lincoln and Omaha that visit on a regular basis for specialty care. Our physicians have an electronic medical record in their clinic, separate from us, two separate systems, but our system has a web-based access for physicians, that is secure, so the physicians can access clinic records while hospital, we set up a VPN to dial in to their system that way. Physicians can see both records, we can't, but the physician z can. It would have been better to have it all under one system, but at the time the wanted to move forward and I didn't want to slow anything down. They are doing an excellent job, using CPOE in the hospital, made a big difference on education errors, as you know. You all know what the data shows.

As far as the regulations, security, HIPAA, now high it places a huge burden on us. What we have done is partnered with legal counsel, have a law firm Omaha that provides services to many in Nebraska, South Dakota, Missouri area, they sat down, developed a toolkit, plug and play type of system to help us adopt high-tech rules and regulations. The policies, you put in your own name, number, away you go. guys who will defend us in court if we screw up --

The changes, modifications to your systems?

Most of our system was developed by our vendor. By our contract, has to modify, make changes required by regulation or law, so we can move forward, stay in compliance.

Yes? Paul?

I have a couple questions. First, thank you all for your testimony, very useful. Dealing with very challenging environments, doing terrific work, fair amount from reading materials, listening to you, for meaningful use criteria is interesting, but not really the center of your radar screen, what you need to do to best serve your populations.

I have a specific question on the issue of patient access to the records. Some people call the personal health record, you have shown concern, the digital divide, issues. My question is what should we do? Simply have an expectation that you will have a lower percentage of patients accessing records or is there a reason federally qualified health center should not be -- that requirement shouldn't apply to you? Should we lower expect eliminate the requirement?

Lowering the expectation may be okay. Another area may be education of patients so that they are aware, know they should actually access their record, use it. Another is requiring vendors to do translation facility, provide in the language for the patient -- gets difficult, we treat everyone, no matter what language they come in with, we need interpreters. It's a very difficult issue. I don't want to penalize anyone, didn't meet it because your patients can't access --

I think the way meaningful use will probably be written, I don't think there's a specific threshold proposed. You have to report the percentage. I don't think there's a problem with reporting percentages, but down the road, hold you to the line, penalties associated with it. Wouldn't want to see penalties as long as people are making a good effort to allow patients access in the language they can understand.

That's helpful, that's reasonable. And Marty, you made a comment you had concerns about whether or not your vendor can provide that functionality, but you have to use certified system to get -- even beyond meaningful use, that functionality has to be provided by your vendor, isn't it?

It isn't required in the CC HIT requirements at this time, our system is certified. It is not required. If I could expand on that --

Go ahead.

I would like to see -- first you have get the data in the system. You have to walk before you run. Let's get the requirements, measures, objectives in place that allow small hospitals and other healthcare providers to build the system, to get a nursing system, where nurses are documenting, lab results are flowing, medical images are there, then start looking at providing a patient portal. Until we have the basics in place there's nothing to look at. Let's build that base, and accumulate data for patients to look at. Another thing is how you want patients to look at data. We can provide them with a CD, give data on a zip drive, but we don't have a patient portal where a patient can log in, look at data.

If I understand right, a portal in 2011 won't be useful, you won't have it populated --

Oh, we will, but the vast majority of small hospitals will not.

Typically the patient interaction is 90%, 99% ambulatory, so would it be required? Critical to have --

Excellent point. We can provide them with the data at this time, you but as I said, the vendor doesn't have a patient portal. As web access, at this time.

Who is your vendor?

CPSI, out of mobile, Alabama.

Any more questions, Paul? Neil?

This is directed towards Bonnie. I guess, first of all, thanks for your discussion about the disorganization of care for people. I thought New York was the only place people five organs treated in five different -- two questions. Sounded like you were putting down the EHR requirement piece of the work we were doing in favor of home monitoring, I hope not, and I hope you were [indiscernible], trying to follow-up on your example. The patient has the home monitoring device sending information back to an organizing primary care provider, helping them put all this together. You still have the issue of communicating with all the institutions, you are not taking over their specialty care. What are you doing now about that and what do you see happening in the future that in your particular community might help integrate the information that has to get passed around?

Okay, first, I would like to say FQH, C, we support meaningful use, I didn't mean to, to put down the work you are doing. We need to expand what we are doing, expand, rather than restrict, because there are a lot of community health centers and practices that have health records we at this point are either meeting or almost meeting meaningful use. For us, we want to take that a step further. In regards to communication with the specialists providers, the information collected from the patient goes -- is sent to a secure website. That website, for each of the specialists in Chapel Hill, Durham and Greenville, each specialist has access to the patient's information via the website. What we are trying to do now, in January, the vendor we have for our remote monitoring is working with integrating the software from the vendor side over to electronic health records, that's been occurring in California with this vendor. We are hopeful within the next six months we will have integration with all seven of the centers we are working with. Until we get to that point, we are making phone contact with the specialists in the different areas, and explaining to them what services we are providing, offering, for us to be able to give them access to that website. The primary care -- the specialists at this point not given us access to their EHR. However, the seven community health centers, our nurses have access to all those electronic health records. So it doesn't matter where the primary care provider is located, we have access to that electronic health record to be able to send information to the primary care provider, then be able to view the action taken.

Does that answer that question?

Thank you.

I might ask, how many different vendors do you have with those seven community health centers you are trying to integrate with?

Five different EHRs in those seventy health centers.

Gail?

Thank you very much. I have spoken with many of our local hospitals in Florida, quite a few of them, people think of Florida as being Miami, but it's not. There are a lot of rural area ins Florida. From what I am hearing from our local hospitals, the initial investment is very difficult to make. They have a large percentage of Medicaid, if you know what Medicaid pays in the state State of Florida, it's well below Medicare, and very little private insurance. The up-front costs are significant for rural and community hospitals.

There's not a large patient base that is a full-paying base. How did you access the original investment? What did you do? How did you leverage to get first investment? And secondly, what is your lab situation? The HIE work group, committee, had a discussion last week, many people discussed the interface situation from community laboratories and how difficult that, the requirements and difficulty of interfacing with a physician practice, whole nomenclature issue, a lot of issues, but if you could give insight on the laboratory situation in -- if you only have one practice is different, but servel groups, the interface, how you do that and if your laboratory in your rural hospital provides mostly laboratory work.

Thank you for those questions. Very good. The cost is of how we funded our system, frankly, I was very fortunate, the previous administrator had done a great job of leaving me a war chest. I had funds for that. That being said, critical access, a perfect vehicle to fund an electronic medical record -- simply because the cost associated with implementation, ongoing upkeep, allowable costs through the critical access cost report. Our in-patient volumes run around 75% Medicare, 75% of the costs of this system are allowable each year under Medicare, we are reimbursed for those. If I would not have had the war chest in place I would certainly have leased the system, borrowed the money, something, because I know the critical access system will pay for it. Where you can depreciate desktop servers and -- the turn-around is pretty quick. It simply works well for us.

The other piece of the question, I couldn't have, if I asked you to ask me a question, that would have been one, the laboratory thing. Laboratory is my background, I have been a administrator for a number of years, I have also been a laboratory information systems manager in a regional reference lab up in the panhandle of Nebraska. Incorporating laboratory data into an electronic medical record is difficult into a combined record from many organization, is a real involved task simply because you have to take normal ranges and everything with you when you go, you can't pull a number out of the area in a system, assume everyone knows everyone's cholesterol is the same as everyone else's, for instance.

That is a huge issue. What we have done, we have an interface with our reference laboratory, being a small rural hospital, we have limited testing capabilities, but we work with a deference lab in Omaha to provide the rest of our testing, we can order on courier comes by to pick up, results come back across an interface, dumped in our system.

What did the interface cost, using only one lab, one interface?

Right. That system was $2500.

We've had estimates locally of 10 to 50,000 for a lab.

I am sure different systems are different -- I know some, I worked with other vendors, at different organization that had higher interface costs. Also, the complexity, a lot of laboratory information systems out there today are actually developing interfaces on a pretty large scale. If done one interface they can interface with the rest pretty inexpensively, they share the cost. Those type of things.

I must admit, probably giving away the secret of our success, but that is, a 20-bed hospital can do what we've done much simpler than a large metropolitan medical center. We are the canoe and they are the Titanic. We can turn on a dime, they can't. That's just the reality of it. It'ss not --

[indiscernible]

Paul?

Thank you. This is a very interesting, informative panel. Thank you very much to everyone. I have a follow-up question for miss Britain on the remote monitoring, follow-up of what Neil is talking about. You made a plea for us to consider more than -- not putting down EHR, but more than part of HIT, how you effectively use remote monitoring for critically ill patients, particularly when far away from you. Is your point the from a policy point of view that there be consideration of remote monitoring in the reimbursement, stimulus package or reimbursement rules for payers to reimburse for that kind of monitoring? In the 2013 draft at least we did include incorporation of remote monitoring data into the EHR.

Yes, and thank you for that question. What we are asking is a couple things. One, we would like ONC to include remote monitoring as part of the strategic plan. And if the target is going to be 2013, then we would like to see or ask for OCN to identify community health centers that are currently have EHRs, near compliant with meaningful use, and to fund some more studies on the use of remote monitoring in preparation for the 2013 guidance. Because if we wait until 2013 to do that we are not going -- there won't be enough large-scale programs to look at what are the barriers to implementation, the barriers to the cost of being able to provide. All the same questions we have with EHRs, also with remote monitoring. One thing I want to make sure the committee understands is, in the past the majority of remote monitoring and home telehealth has been provided in a home health agency. We are not a home health agency. In home health remote monitoring has been semieffective, but they are usually not in with the patient days, the average stay with our patients are six months. Every day for six months we make contact, and the patients start understanding -- you give them a handout saying don't eat country ham, don't use fat back, all these things people still use across the country. They don't understand that when they get that piece of paper. What we do, if a patient's weight is up, we say okay, what did you eat last night? Well, I had Chinese food. Remember, if you eat Chinese food, a lots of sodium, why your weight is up, patient start making the correlation between the behavior and outs come. One of the thing that has really struck me the most about the program, I have been in telehealth 12 years and one thing that strikes me is that the large majority of these patients say to us, this is the first time anyone has cared enough to help me figure out this maze. It's not the patients want to be non-compliant, they have issues they don't know how to overcome. By being there, being there every day, delivering that information back to their primary care provider, to specialist secondary, truly makes an impact on behavior, as well as reducing healthcare expenditures. With patients so far we could obtain hospital admissions and readmissions and emergency room visits, we have decreased healthcare expenditures by 70%. While at the same time lowering patient's heesm glob in A 1 Cs and having patients that are compliant. This patient I told you about has had her electricity turned off three times. It's not that she doesn't want to pay; she doesn't have the money. We can go to the electricity company, saying you have to turn it on because she has medical equipment in her home. She has to have that access. So we have to get down to some of the social issues. Again, I am not criticizing at all what you are trying to do with meaningful use, I believe in it completely. What I am trying to do is bring a face to the committee of the patients we are caring for, especially in community health centers. Even if you have all the things explained in meaningful use, I still think there needs to be something in addition to that to make behavior change.

Can I just ask? Are you reimbursed for the home -- remote monitoring?

We are not, absolutely no reimbursement. We are in a three-year grant. Collaboration with North Carolina Medicaid, dual eligible patients, North Carolina Medicaid is going to provide the financial data, components, have a sample size of 500 patients in the end of three years to be able to say should have be an adjusted reimbursement for community health centers for this.

Reform is

If I could add also that your primary-care doctor and a lot of communities are unable to do that as well because of the fact that they need to have the financial support in order to be able to provide those services.

A couple questions. First one, maybe to everyone there is Mr. De we were discussing something interesting which was how deeply do we get into managing what we want to see out? Regarding to the discussion of specialist versus primary-care and who is supposed to do what and how do we know whether we are measuring the right thing for the right person. My question because of what you were saying about your hospital is do you think that all we have to do is measure that they are getting the electronic hearth record and using it to see POE, through alerts and decision support it, etc.? And not measure the outcome because doing that brings and those problems we discussed yesterday. It would take a lot more time and cost more. Do you think that that in the end is so likely to drive the results that to get into the outcomes is almost unnecessary?

Thank you for that question. That's exactly what I was going to ask. Some comments amounted to make. First of all, I think it's very important that we measure outcomes. And we have and everything we can to measure outcomes in our organization. We participate in hospital and compare all the results there that we have to. We beg to participate in the outpatient measures that initially [Indiscernible] weren't allowed to participate in. We participated in all of Dr. Barr weeks IHI programs and hundred thousand my campaign and the 5 million lives campaign, we believe now comes measures because I think the make us better. The problem I believe is again, first of all, we need to develop an electronic health record. Let's get the data in place and let's go ahead and submit measures the rate we are currently doing it with the that's electronically or mentally or ticks on a piece of paper. However we get that done, but continue to require people -- Equals us accountable, let's face it. Let's continue to do that and once we get this basic electronic health record put together, so we have the data, then let's start a trend figure out how we can submit that stuff electronically. Again, let's walk before we run. My concern with my colleagues again, I had this help and commission technology background when I became a CEO, I approach these things a little differently than most of my colleagues. But most of my colleagues are doing a cost-benefit analysis of the meaningful use criteria. And a lot of them are saying, I'm going to take the penalty and be done with it. It isn't worth it. And that does not benefit the patient and that's what we are here for. Is to improve care and make it safer. My thought would be let's get the system in place, and all for that, let's help everybody. It on the train and then let stippling in all of these other really important pieces. Let's do them at a later date.

We would echo that as well. We feel that measuring outcomes is very important. We feel that's how health centers have come to manage the populations that they treat so far. The have a long history of a PDS a cycles, plan to steer the X and redo it. And always striving to do better because of measuring the outcomes is very important to go against the piece I would want to add is when you get too down the road and at the measured for a while and people say, you didn't reach this level and so then your reimbursement is cut into my R fashion. I think that's where we would come at you can't do that until you look at all aspects of why you didn't meet that criteria. But measuring is important in having that review cycle Quality assurance and continuous quality improvement is very very important.

Judy.

Just a couple more things. When is that I know the community health centers qualified health centers, the safety net providers [Indiscernible] they are working on the margins if they are looking [Indiscernible]. Is it possible that for those who are the disproportionate share safety net providers that for them the money could be provided up front. Resident after the fact because they may need it differently than the rest -- Those who don't serve the a underserved. That's just a question that I am throwing out as we do this if that would be possible.

It's Medicaid money for it the [Indiscernible] hospitals.

That was made after the fact the. [Participant's audio is faint/unclear]

That's an issue because even for a qualified health centers I know Paul you mentioned yesterday the money is up front, but if you can tell me where that money is, I would love to know. There's nothing we've identified so far with the money is up front. For the adoption your from the family qualified health centers, you are eligible for adopting and that still we don't know what that means yet. But the money is not available to you until after adoption. So we do need to have some mechanism to have the money up front to get people to adopt and then here to begin to make meaningful use criteria.

When you say of front, Mike understanding and I will look to my own colleagues, that in Medicaid your reimbursed and the question is your definition of up front for the installation and the cost of installing up to 85 % in your first year and said the meaningful use criteria per se don't apply until after year on.

Correct.

When you sit up front, he made before you make the purchase?

I have 20 providers. It cost me at least $5,000 per year per provider for my software license. That's $100,000. And at a fairly qualified health center in the work of my .8% margin across the country. Have to have certain reserves and place to meet might person demands but I don't have another $100,000 I can put that. That's just for the soccer license and doesn't include the training you need, a decrease in time for a staff and billing that you might have during that implementation. To get the money to get you to adopt is really something that needs to be available up front.

I want to add this. This goes back to an issue we talked about yesterday which is that the Medicaid money is supposed to come to the state piece. And so you're looking at the [Indiscernible] model which is really a national model, health centers across the country and each of them is going to be dependent upon what the states are doing in terms of being able to figure out how to get this money and how to a implemented and how to get it out in front. And honestly, given the time line, it probably isn't going to come before 2011. To have to put their plans in place, the plants have to go to CMS for approval and I think there's a second round of plans to go and not totally familiar with all of the details, but then what did it come to have to figure out how they're going to qualify the centers. And NL and New York State is an issue about just understanding sort of what the denominated issue is. You can report on the number of Medicaid claims and the health centers have certified audits that put this in place, but for the rest of the Medicaid providers, there's no way to know how many privately insured patients they have so when you are looking to figure out of some in its percentage of Medicaid, to have to know what the the percentage is. And the is Clinton going all over the country to private insurers and so, the states are trying to figure out how do we validate that piece of it in order to comply with the federal laws. I think there's a lot of pieces that are going to have to come place so the issue of getting the money up front is even more complicated than just the time line in the legislation. It depends a lot on how the stapes Orel's out.

Dr. Edwards.

On that point, as far as I'm also the president of the Senate but also a private practicing physician and Baltimore. And my partner and I in our practice internal medicine, are part of the demonstration project that CMS has with respect to use of medical records, electronic medical records. And we became a part of the demonstration project, we were very excited about being that part of that and learning more about how we would access the information and improve the quality for our patients. And as we went to the discussion about what you do as a participant, we found out that there was no money for us in terms of accessing or getting electronic medical records but they would give us direction because they had already gone through several vendors giving them information and other electronic medical records, but there was no grant available, no funding at all in order for us to do this. We had to dig in our own pockets and find the 30 or $60,000 to invest and EMR and who was [Indiscernible] interoperable with whatever was going to be developed on a national level. So needless to say, we have been measuring the quality measures that they have asked for, we've accumulated that. Sent that in in terms of our reimbursement for patients, but we don't have a medical records at this point in order to be able to pull the information out easily. That is the problem that many single or private practicing physicians and primary-care that want to provide quality are faced with right now that they don't have that up front money in order to be able to access the good EMR. In order to be able to qualify for many of the programs that are going forward.

I would like also to into jet and I'd be remiss of if I didn't bring it up for my behavior [Indiscernible] there are many providers who are not included in [Indiscernible]. And to we need to interface with. This is of good behavior health providers, committed to mental health centers, even at 50% of patients but to a primary-care and get your behavioral health treatment, the other 50% are going to community mental health centers and behavior help provide is. They are not all psychiatrists, social workers, their community mental-health centers other and if we don't provide the funds to be interoperable with them, they were missing the whole piece of the patient and not really going to be able to to the patient and a total wipe go we also need to look at those providers and there are of the sinking of providers that we are not included in ARRA that some of us share those same patients across the spectrum. So we need to look at that as well. TiMet.

Christine is next to go to have a comment about this?

I don't know where to start. And the National [Indiscernible] for women and families. Michael, you actually started to address one of the questions I had put your testimony was fantastic and I appreciate it but the written testimony is really helpful because you pose a number of challenges, but you also offer your thinking on [Indiscernible], that's much appreciated. One of the challenges that you pose as a second a talk about which is behavioral Health patience. In your written testimony you said we would encourage the policy committee to make recommendations to ensure that providers for these populations have the tools necessary to coordinate care with the FQHC. CMS is limited by the log in terms of being able to add and reimbursement provided types. I just don't see that as an option. I know there's an amendment in the Senate Finance bill a century now around frequent [Indiscernible]. But right now, we are limited. So can you talk briefly about how can we promote a set of tools that might drive some coordination and cooperation in that area?

One way that might help and still the costs associated with it, but would be to allow health come encourage community health centers to participate to some of our house DePetro networks. I describe that structure a little earlier. It certainly drives down the cost of implementation. You have some licensing fees could be reduced because they buy licenses involved. And the infrastructure is there so you don't have to have every help Center implementing everything, all the back of the redundancy come all the extra pieces unit to have if they joined a up, so to speak. That might be one way to go the lowest of the cost associated with that, an usher, I don't know where that money would come from. I believe that the office of the National court and it has to come up with a plan within a year for those other providers is what I thought I read in the stimulus package. Until that happens, it's still going to be difficult. But I would encourage them to join the helps to control and network models to build on those economies of scale and those infrastructure is already in place and we have helped some typical networks across the country who are willing and open to do that. I think also the money from the states, when the state's oil down the Medicaid money, they should be encouraged to look at that as well.

I want to come back to the back and forth between Marty and Judy about verses' getting the EHR in place. And I have a question for Dr. Edwards that's going to come following that. One of the concerns that I have about 15 EHRs in place is the experience that a lot of providers have had and that I personally had with my own family doctor, would you have an EHR in place. They have data. But they are absolutely not using it to provide high-quality care, to engage patients and families, and these guys are applying [Indiscernible] the medical home. It's unbelievable. They have been EHR for some time. It's not enough to automate paper and I know that we all get that. But what we did in the meaningful use approach was not to say and what be clear about this, that somehow reimbursement depends on outcomes. It doesn't. What we did and I thought it was a fantastic approach was to evolve what we currently, the approach we currently take which is report in a process measures. But begin reporting only about comes. It doesn't matter with the measure says or how poor it is of how fabulous it is, if you report, that's what the recommendation was from this committee that you would be reimbursed. But it gets provide their eyes on the outcomes. It makes them start to think about getting beyond automation of practices. So that leads me to my question for Dr. Edwards which is in your testimony, I'm not sure I was under Standing. I want to make sure that I and a stand. You talk about tracking % improvement as effective a metric as any. But you cautioned that baselines differ across populations so improvement in one population might not make a difference in another. Can you clarify that? Did you mean a you talking about one disease conditions across different populations or talking about different disease conditions across one? I wasn't sure what you were recommending.

You are very aware of health disparities and the fact that various minority communities are more heavily impacted by almost every disease entity there is for you talk about cancer or HIV AIDS, diabetes, it's highly impacted. When you start talking about disease measures and outcome measures, the need to consider the amount of disease burden in that community as low as the social determinants of Health that may also affect their outcomes in the long term. And the treatment that you get. Running start talking about outcome measures, you've got to mechanize the difference in that denominator there as opposed to other communities.

Terrific, thank you very much. I have one last question of this is what happens when I get further down the list, the more I hear the Mark questions I have. That is for you on the, you have great fans in North Carolina, the major that I saw the press release but the fact that you guys have decreased hospitalization by 71 % and decreased the our visits by 69%, that's phenomenal. And congratulations. Paul started down the logic here that I have for the question I have which is that in 2013, we have what I think is a place holder now because we need to figure out how to do this. But we have it says upload data for bio-monitoring device. Are hope here is meaningful use, blend back to what I said to Michael earlier, we are limited by that and we have to leverage that. Can't bridge reimbursements time for remote monitoring. And it may be that the question I'm going to ask is just food for thought and let's come back. My question is, what is appropriate for a criteria for a requirement in meaningful use given the fact that by and large the majority of physician practices is strictly small practices across the country are not billion tastefully in remote monitoring and with that you are. But we want them to start down that path. And the fact there are no reimbursement streams. I'd like to ask you to think about and talk to us about we start? What's the first of that is a reasonable step because clearly the amount monitoring and patient engagement and having patients being able to track their own information and submit it to providers and really have more of that coordination, that's an enormous project late giving the aging of our population and a huge demand we have on family caregivers not go a think the question is where we ought to start and if that something your thoughts on now, fantastic, and if not to come back would be terrific.

Takes for that question because I do have thoughts on that. One of the things I hope everyone here is aware of and its if not, to update you, the Veterans Administration years ago in the year 2000, started doing pilots within their [Indiscernible] on remote monitoring. And now it is mandated that all Veterans Administration's side has to imagine that it 2010 which is right around the corner. There's a 35,000 veterans right now being cared for in the manner that I described earlier. What I see is the next logical a national transition for remote monitors is a community health centers. We are the second below the Veterans Administration you're the next highest federally funded even though it's partially funded. Health centers and I believe that we need to identify community health centers were the networks of community health centers that are currently participating in electronic of records. And what Michael was describing earlier, to focus and target on doing standardized pilots studies for community health centers in remote monitoring with the chronic care. Because I believe because of the nature of the patients we provide and the social issues we have as well as the high level of uninsured, if we just focus the monitoring and not on uninsured patients and keeping those uninsured patients and their home, of refocused of patients with of this bird is which that's what we've been doing, patients that don't have transportation, pigeons haven't paid $25 each way to get to a doctor plan. With think we need to start with community health centers and we started that in North Carolina. And we hope to expand that even further than we have right now. I hope that answers your question.

Thank you.

Jody.

Judy Jana, ONC. I enjoyed your test might. I think it's important to have your perspective. One of the things we are concerned about and interested in is making sure that our Health IT efforts are not increasing health disparities and in fact hopefully that there are activities and things we can do to help reduce that gap to the use of Health IT. I appreciate your thoughts on that. I have a few questions. Following up on Christine's last question, this is for Bonnie. You talk a lot about the need for behavioral change in remote mountain, but it seemed to me, that was very compelling and I agree with all of your thoughts on that and really appreciate your experience. The question is a lot of what you are describing sounded like it was very people intensive instead of technology intensive. A question for you is whether some of did the things we can begin and since we're talking about out of commission technology to help support those efforts and Paramount the behavior change through the technology since that's the letter we have that we're talking about?

That's a good question. With our program we have right now, it's not people intensive as it seems. Your current monetary 200 patients and we have to our ends. It is a skeletal model that can be implemented without a lot of up-front. One of the things we are finding is cannot [Indiscernible] to and it's a health center in Capitol Hill can to us and they said we want to to telehealth at the have a EHR and we want to integrate remote monitoring into this but we do want to go to the learning curve worth the expense of having to hire the staff to do that. Said they are contacting us to provide those services for them. So we have developed the model where if someone wants to start the remote monitoring program, we're at a very low cost, we are able to actually be the structure for them to not only, we have a telehealth manual for them -- We implement the policies and procedures and rewrite them and all of their training and we help them do their installs and we all the monitoring. WUD we ask of those community health centers is the amount of money it takes to cover part of that RN. We've got one at RN that is covering seven community health centers, all seven committee held system have to pay for an RN. They are paying for a portion of the RN. The other component that happened was initially told technology was extremely expensive. And I started in 1997 and and how much and was 20 does dollars to this is completely, people can do that. I now come the vendor we are using to purchase the technology and it proposes $795. And then on a monthly basis after the first year, its $20 a month. That's affordable. And that something we have to find affordable way to be able to meet the needs of these patients. If we are going to have behavior changed go and the number one, with the community health centers there's not competition. Between it and see how centers and that's why community health centers there can be a model per each state. As a matter of fact, I meeting tonight with the CEO of Blue Cross Blue shield of Tennessee. They're going to a limited program and what they're saying is we, the up-front cost. You want to pay somebody a set amount of money per year to manage all of this for us. Can you do that? We are getting it request like that of the time. I don't think every site pass to have implementation as far as all the staff you need to go with it. The difficulty is if you as a community health center, I can't go to the other private practice physicians and in our area and say we will monitor your patience. They see that as competition and stealing their patience. The approach we took with that is we went to the hospital. And we said, all these diabetic patients coming in, they now have a nurse in the hospital who is providing diabetes at it education and for patients that don't come to our practice our community health center, they're doing to monitor train of those other providers and patients because they don't see that as competition. I think there's a way for community health centers and local especially small hospitals to partner together to utilize their resources to be able to expand the bio-monitoring for the then and the models we had in the past. That's why I wanted to make sure that everyone understood our model is a medical home model. For remote one veteran, is not home held. We are there for the long term. We've got patients that have been on the monitor for 18 months. And the providers will let them come off because the patient continues to do so well. That's another transition we have to look at in the future as well.

Another question is you're talking about the disparity gap in health. My question is tied into the discussion of this committee and meaningful use. And there's certain things objectives are measures, that we should be considering for meaningful use to help with the disparity gap. I guess that the Edwards, if you could start.

That would be and put together what we are asking for as well that we be at the table to give you those measures as well. And that any measurement we talk about should make sure that we are trying to address the issue with help the spirited. I can't give you all of them right now. But certainly I think that needs to be primary in our measurements.

One more quick question and discussion about the up front money and one of the possible things that we are allowed to do under the high-tech at is loan program. And I wanted your thoughts on whether or not even if it were a modest loan program, how that would impact the ability to adopt? And what level that may work or may not work for.

I think the long program would be essential and with the caveat that you get the loan of front and when you get your meaningful use money, you pay back the loan immediately. I think that would be very helpful. In terms of what amount, is that what you're asking?

I'm wondering, my question is [Laughter]. As far as the total cost, if we are only able to provide a little bit of help, not full cost, is that you over the hump or are people not going to adopt unless they have all of the money up front to purchase?

I guess that gets to the amount because anybody who really wants to do it, if they have enough to get them over the hump to do it, they will be able to do it. I think any amount would be worth considering. And some of the executives a little more savvy would be able to make it work and some won't. It's hard to say what amounts. I think anything would be helpful.

I'm going to say that the primary-care a single petitioning physicians will need a lot more help than others.

Tony, if you are still on the line if you want to make any comments about this subject in terms of the up front or loan for the smaller providers?

No.

[Laughter].

All right.

Could you repeat that?

[Laughter].

I want to think the panel. It's 10:00 and it's time for us to take a break. I appreciate the panel coming here and sharing this with the committee. Very insightful and thoughtful comments. We heard about up-front funding, the face of the patient, remote monitoring. Social determinants and pound about a critical care access hospital can be but a canoe. So I appreciate your coming in and sharing that with us today. Thank you.

I thank you.

[Applaud].

We will have a break until 10:15.

[The Meaningful Use Public Testimony is on break until 10:15 a.m., EDT.]

We are ready to begin if you could take your seat, please.

The meeting is ready to start.

Welcome to the second half of this morning's presentation and hearing. We are now going to hear from a variety of folks. Having to do with [Indiscernible] cover only on Medicare as an example and other safety net providers and as a mentioned, other users of information that help [Indiscernible] capture throughout EHRs and in part it weighed such as clinical research. Dr. George is going to moderate this final panel.

Thank you. Our panel comprises Dr. Greg downing of a digest, Dr. Alan Zuckerman about Georgetown, Dr. Thankam Thyvalikakath of Pittsburgh, Dr. Melinda attendance of New York and Dr. Andy still of Denver. This panel continues our theme of looking at various contingencies and other affected in various ways be the providers or infrastructural of how that is affected by meaningful use. Again, quote the presenters we note notice we have the time at the front and we are asking for five minutes at most Dominica's you already put in your excellent written testimony and that the Valley of the session as more in the questions since we have that already. Let's begin with Dr. Gregory Downing of HHS.

Good morning. Thanks to the members of the panel put my name is Greg Downing and a pair from office of his Secretary at HHS. Crystal I. want to think of you for your hard work and efforts towards this picture of health enterprise help and commission technology. And looking at the future, one of the problems is its not the same as the past. We are trying to understand how health care system will work and bonds on Wall widely diffused and integrated electronic information. And won't be the same as the system we know today that runs in a bitter based information world. It will behave differently and that's sometimes difficult to conceptualize. Clinical research is one of the fields within the powers of electronic information will truly change the game. It may not change the nature of clinical research itself, but it will change and greatly influenced and enhance the role and potential and the contributions that clinical research itself can make. It will render clinical research and information and generates much more central to the total health care Enterprises and that's a huge opportunity. I hope today is that I can show you in a system change the Health IT and go research will be a variable keys to the new way of doing business and one that we should support at the earliest opportunity to meaningful use processes. I am here today on behalf of federal representatives who have been working to support the use of electronic a record systems to support clinical research activities. This testimony represents the input from the FDA, NIH, National Cancer Institute, National lepers of Medicine, [Indiscernible] and the Office of Minority Health and CDC and the recognition that the future for improving health care will come through a research. And here on behalf of the patients and physicians. Is there information that is relevant to the data needs the support the full range of health-care Enterprise Research needs. From clinical trials, the outcomes, research, population based epidemiologist it's, research and more. Patients should have and provided with a technical means to voluntarily participate in research studies and used their and commission to do so. In the past, I think we've had a binary view of the way in which health care and health research are looked upon. We know of course, the research leads to health care advances. But I think we've looked at these two aspects as occupying different spheres with different rules and in particular, if and information needs. The clinical research enterprise which is today hobbled by the kid's old information techniques will truly flourish once it can take advantage of leverage the interoperable held information technology real here talking about in the same way the contribution that clinical research makes today significant as it is, it will be drafted by the information resource that can be support not only our traditional types of research, but also comparative effectiveness close to measure and research public health safety and monitoring post market surveillance and more. And proposing that their basic elements of the clinical research enterprise repeat for application happen as a part of the meaningful use incentive for practical and that, I believe these are essential elements to include in meaningful use. If we are to use this process to help build a bridge to the future of an information based health-care system. And sensitive to the way that this area clinical research may seem at first glance to be too far reaching for the job we are here doing today. But in truth, their practical steps that we can take now in the 2013 timeframe that will provide near-term based benefits [Indiscernible] researchers benefits that are not only achievable through Health IT and adoption, and benefits that part and parcel of the way health care will be supported by integration technology. Chemical Research is the [Indiscernible] that Mexico is sides of the prize with the application that cost the progress of medicine. And mission has been one the world's leader in developing these innovations and using them to improve patient care. We need to 19 from and where clinical care information from electronic health record systems can be seamlessly integrated into clinical research and Commission Systems. We need a standard state Senate is set that can also help us from stopping the waste from intimation resources that are today isolated inside of be there in paper or electronic systems that don't communicate with each other. Integrated EHR systems and information for clinical research will help reduce the time spent on data entry, the time needed to customize EHR products, the increased did accuracy and increased data availability to the research community. Further, it will enable data integration from multiple sources and support long-term steady and reuse of did overall. These deficiencies will leverage billions of dollars of our current research investment and will expand the numbers of clinical studies. They will accelerate new medical knowledge and in a word, the will to the advantage of the opportunity the Health IT is giving us to change and improve the way we do business in health care. These improvements to not need to wait and the foundation for standardize clinical research and emission are already in place and they can be supported to the meaningful use approach. It is true that not every physician will take part in the clinical research activities, but many will welcome the opportunity that they cannot faxes today. And not all IT vendors will need to incorporate clinical Research elements into their products. But many will find this as a vital and growing market in this area and especially as clinical research information grows to serve a growing number of classes. The nature of the information on the IT age and the seriousness of nearer to build the prisons and opportunity for clinical research that can only be described as sweeping as the edge of change. In turn, it enables clinical research and mission to contribute any way to help prevent in an quality improvement that we all aspire for. Finally, in an integrated into mission resources for clinical care, we felt that this is an opportunity that we must engage now in terms of understanding meaningful use in its fullest extent. Thank you.

Thank you, doctors Zuckerman.

Thank you to the Committee for giving me this opportunity to share my concerns those of my colleagues about the plight meaningful use to the health of children. My name is Alan Zuckerman, and a general pediatrician and practicing in just 2 miles from here over at Georgetown. For a Medicaid provider in Maryland D.C. and Virginia. And receive about 25 % Medicaid patients in our practice. And we are pleased that these got it statehood under ARRA. Although I've been involved with EHRs for every three decades now, it's a lot of the last year that my practice forced by audits of our documentation has gotten serious about implementation and for the last eight months, our general pediatricians and entering every encounter into our EHR. I also served on the help of commission did exchange task force in the state alliance of [Indiscernible] held. Relook [Indiscernible] I am co-chair of the van's interoperability work group at CC HIT. And I also am a member of the executive committee of council on information technology at a AP. In terms of the primary impact of the 2011, 20 the original objectives, was visible. Is and that of immunization. And although the measures now are just going to count the losses that should have been given by 15 months at some point between two and three years, in the future, this has to accommodate response to epidemics and other important considerations. A want to think the committee for the wonderful free more that you put together the many of my colleagues fell to see its value because it hasn't been applied to pediatric situations such as an all important first transfer of care of newborns out of the hospital. And hopefully the first generation born under ARRA is going to have it in different experience with newborn screening and other events. I'm very familiar with the benefits of interoperability because in my practice, we have one EHR for all sub specialist whenever my patients go across town or to nearby city, we are still dealing with paper. It's a day ahead to new patients and was quite a project even though there were a computer-generated, to get them in. Some experience I have with the registry. One of the things meaningful use is going to do is give the vendors guidepost of what they need to do first by connecting to immunization registry. What's different about kids? They are not just small adults and it got to adjust measures appropriately. And a disease in children is totally different but the big things we deal with as [Indiscernible] is a deficit or chronic medication and self management issues. These early onset of adult diseases like hypertension or diabetes is not managed in the same way because children slivers wouldn't survive a lifetime and medications we use in adults. We've got to adjust our measures appropriately. Pediatrics is also have primary-care it's also have a specialist. Hemoglobin and once he is in the province of the and technologist. I used it occasionally in of these preadolescence to pick up their adult onset diabetes. Even hypertension it follows for different norms and the can just simply apply things the might of 19th of the most adults would up to see is profound obesity in many children. We paste Dustin has to be done carefully because we can very quickly exceed adult doses and get into toxic ridges. So AP does have some guidelines in terms of things to add, getting the newborn screening in by two weeks, hearing screening which is miss so often and getting reminder and there. We paste prescribing, all you have to do is add weight to the prescription and know what happened. Tracking quote by norms, blood pressure, documentation of assessment, and sharing in the decisions with parents and of course, having a family history context for both social and a genetic reasons go to forget colon number five about security and privacy which is special in kids in foster care, adolescents and other settings. Perhaps the most important issue regarding adoption remains cost. And pediatricians are really worried about the extent to which they excluded because of the tremendous turned in and out of Medicaid.

[Captioners transitioning]



By the time they hit 18, it's a much larger number. Right now according to our surveys over half of the small to medium practices can approach the 20% level, one-third cannot hit the 10% thing. We have to live with the law but maybe we can find ways to adjust for regional variations in Medicaid levels and that our goal is really equity that Medicaid patients are not excluded because if we cannot get by and it's a problem. We also have a major role of safetynet providers and they are concerned about the return on investment in addition to the Internet deficit they have a bigger deficit in personnel to help support their systems but one of the biggest concerns is anyone going to share the results of these meaningful use measures that will probably not look as good as SafetyNet providers would like to see so concerned in that area are also very much with the dressing. I have included a number of other things in my comments but I think the most important thing I want to emphasize is when you turn into your strategic plan picture we have some approach that applies to all children not just those that are receiving Medicaid today. Let's do something about immunization registries, newborn screening to prepare to send the data because most of the practices have no weight to communicate with us and myself and many colleagues would like to work with you on developing your mapping to your objectives and helping to constrain those to the special needs of children.

Thank you, the -- Dr. Downing.

I am an assistant for informatics and the department's at the University of Pittsburgh. IMA dentist and a biomedical -- thank you. I am a dentist and a biomedical researcher and my work is evaluating the condition and patient outcomes. Today I am here to testify regarding the appropriateness of using the objectives and measures for meaningful use and EHR in dentistry. I see great affinity is in a dentistry even though it's only partially feasible right now. For instance we maintain an active medication list and elegies to medications however dentists do not typically order, enter orders, therefore there is the need to define and develop measures to monitor all of the health outcomes, such as periodontal disease and other auto conditions. While there has been a did limited coordinated response I would like to say that this meeting has colonized the community and my recommendation would be to develop a criteria with the difference stakeholders in the industry such as the American dental Association, education is Association and dental informatics researchers. We have multiple barriers for EHR of adoption. The first to fall only. Few of the 160,000 practitioners will qualify for the EHR and this is because the vast majority are seeing in the major qualified centers. In addition, the providers will have great difficulty in achieving the requirement to qualify for the EHR initiative. We also do not have any certified EHRs until now and we do not have in the process to achieve that if right now in place. In addition, we have a lack of standards to capture patient information such as dental diagnosis and patient findings. There are patients informations stories in the difference EHRs. The current dental EHRs are not currently interoperable and therefore significant working to be done to facilitate information exchange between the different dental EHRs and the medical EHRs. This is important because we need to realize the object of improving care coordination across the different care providers prepared so in the near future there is the need to double up meaningful measures to measure it ought to health outcomes and there is also a need to work towards certifying the dental EHRs and work with government sticklers to determine the eligibility for the criteria -- government stakeholders to determine the eligibility for the criteria and continued to develop standards for catching patients informations, storage of all relevant patient information and facilitate the exchange of patient information across the different health care systems. Thank you.

Thank you, Dr.

Dr. Jenkins?

I am a family nurse practitioner biggest purse than one to say thank you very much to the Committee for your service, public service to us. In general I support it the meaningful use document, the matrix. I just have some comments to clarify and add to that. I you speaking from my own experience. I am not representing any national nursing group. I have had some helpful input from others that I acknowledge in mind some of the testimony. I have to say there are some errors that appear in my bio. I am no longer working with CCHIT or the primary Care Project in New York City but I did learn a tremendous amount from both of those experiences. I will give you a condensed version of my right up and I will be looking for a word to questions and discussions. Nurse practitioners are directly paid by Medicare, Medicaid, and many private assurances. We also call ourselves and pianist practice nurses -- -- advanced practice nurses and the quality of care is equal or better than that of physicians. We're shown to have increased patient satisfaction, increased time with the patient and increased patient education people we can substitute for positions of to 90% of the time. If you want to look at history, positions substitute for midwives -- physicians substitute for midwives. There is added value of the patient education that we do and the routine case management care coordination. It's important to record advanced practice nurses as such under the MPI because this is the way that we can track the work of the nurses and find out the best practices and provide a mix. This would be in spite of sometimes building that is done under the physicians name. We want to use the same primary care metrics and people to insure improvement in their work and encourage practice based research networks where we can share across eight improvements and process these that improve patient outcome -- and processes that improved patient outcome. The majority are educated in primary care specialties including family, adult gyro, pediatric and women's health. I could not find an agreement in the numbers of nurse practitioners but there are a lot of buzz, a hundred thousand or more and I educated at least 200 of those so I am happy about that pretty I echo especially the testimony from behavioral Health and the telehealth and the presenters here. We need team work. We have multiple professionals working together. We are working with the honorable patients that have morbidities' and a very large task in terms of the social needs and the care coordination that is important but there are new technologies coming every day that we want to be able to use to the fullest. I think my priority in terms of moving forward is populating the personal health record and accepting patients entered the debt into that -- data into that. And I would like to say I hope we will include the content of the CCD that the patient has a poll coming that they can transmit and keep in case they move or change providers and also measure the use of the PHR in the future. I think it should include links to a patient education and community resources for it to be useful to the patient. I have recommended additional measures and providers, and most importantly I want to say that nurses in the community, home health nurses and care coordinator nurses are the super glue for care coordination and holding things together as we just heard. Well from the rock band who was here just before me -- from Robin who was here just before me. I have in my testimony a model that has a ready vend generated by about 65% of nurses and it includes functional assessment and patient education and goals and time lines and follow up.

Just to point out in my written testimony there is a small amount about education that I think is very important and I would love to work further with this community and committee on anything that would be helpful in moving us forward.

Thanks.

Dr. Stell?

Thank you I have been an intern for 20 years at Denver Health isn't to set the stage, Denver Health is the institution it for Denver and the Rocky Mountain region. Thank you includes multiple link improvements of a system such as the 911 trauma systems, community health centers, the Public Health Department and a HMO 85% are below 185% of the poverty level. We are have provided $85 billion invested in the health information technology. Concerning the first question how proposed measures demonstrate that they're improving care? Our analysis demonstrates near current compliance of the 2011 measures. For instance we are already seen improved care by leveraging our data warehouse to manage outcome measures for diabetic patients and try compliance with the BT prophylaxis guidelines. We will need to expand a few areas such as high risk medications and the elderly, CPOE, and improving access electronically. In addition we are in close communication with our EHR vendor and are confident that their systems to support full compliance. I have two main comments. What are some special considerations? As the economy tends to decline we seeing a dramatic increase of uninsured patients and predict a total of $362 million, a 32% increase. Clearly this is unsustainable for the future financial strength of the to be given are large Medicaid population you're concerned that Japan's of the federal level, the amount and method will bequeath variable between the states. Second they have special needs. It includes the poor, uninsured, minorities, the homeless, mentally ill and victims of violence. Many patients have low literacy levels and thus have a limited access to or understanding of technology. For these populations many concepts such as electronic discharge summary have much less relevance to the basic personal connection such as relations with caseworkers. To improve health outcomes we see the integrated systems which include public health departments and the information technology which links them. Concerning the third question what other measures will be propose we will need to treat include quality they must reflect the development of new systems and the systematic approach in addition to the use of information technology. In 2004, Denver Health embarked on a health care redesign, getting it right and protecting the patients experience. It was the recognition that health care delivery processes have not changed substantially indicates what others have a transform their systems. When cornerstone focuses on developing the right process of care utilizing tools with lean principles to drive quality improvement by limiting waste. Coupling this redesign of our care processes led to both improve quality and financial benefits paid we are on target this year to attain more than $20 million attributed to this approach alone. Developing meaningful use measures to develop this approach such as comprehensive redesign of the patient care processes may lead to better outcomes improving patient care care and then we will focus on specific laboratory parameters. Specifically this could be addressed by the development of the 2015 safety measures. Concerning the last question, what are other EHR barriers? For now I would focus on one item and that is cost. One of the main barriers is the cost of the implementation of the technology and the are tillage by this because of a decrease of funding streams to support them. Just this week an article reports on in emerging digital divide among hospitals that care for the poor and further investment needs to be made now for substantial Culp reform which will not occur until 20004 or later. And we would support that strongly. In conclusion we would encourage the committee to consider meaningful use that incorporates the process of design and the strategy coupled with information technology and implementation. In addition, we need to remain cognizant of the unique characteristics of this population and how they will interface with the new technology. We like to thank you for the opportunity to participate and look for where to helping you anyway that we can.

Thank you all for your presentations and thank you for coming to agreeing to help us out. I open it now to questions.

This question is for Dr. Downing. On Monday I was able to go to the Moffett can Cancer Center and they have the total cancer care program and they have about 18,000 patients in their that the profile and they try to lanky with clinical trials but tracking throughout your life to look at some of the outcomes from the different types of treatment and the goal is what you illustrated in five or six or seven years down the road when a patient when they are diagnosed can talk with their physician and the will look for the matching profiles and actually see what the best outcomes work for that individual patient. They are bringing in very many regional centers for this. Many community centers for cancer patients, 80% are treated in a community center. What they're finding is that the committee centers are interested in being a part of it because they themselves cannot participate in clinical trials, a clinical programs. They do not have the expertise. So as to look at some of the underserved populations, racial and ethnic minorities and adolescent populations as Lance Armstrong foundation focuses on we see there are many axises already. Such as the 34 year-old spattered diagnosed with cancer is the only group that we have seen survival -- group has been diagnosed with cancer that is the only group that we have seen survival decrease and that might be the clinical trial issue to be keen to that. I was wondering if you could comment on the challenges that we are going to face as far as access if we do not incorporate some of the clinical research protocols into meaningful use for health IT.

Thank you for the question. The issue in terms of access I think is probably a key one particularly to patients who are either not aware of a clinical trial opportunities or live in remote areas or recede their health care in communities that are not necessarily linked in as a clinical trial enterprise. In the preparation for this we received many examples of trials that were not achieving recruitment goals and the cost associated with that as there is growing needs for much more evidence for care guidelines call around not only new therapies or interventions but those that exist today. It's a big question mark as to how those bodies of knowledge will be developed without participation from Cuban subjects that wish to participate in those trials and studies. I think there is a great deal of innovation in this space through the use of electronic technologies to identify potential populations within various EHR systems in which people have identified themselves as being willing participants and want to know information and that the ability to manage critical trial recruitment criteria to clinical conditions is something that is being done now in certain settings and certain vendors' products but certainly the capacity to expand on that exists and meaningful use parameters would provide a great deal of utility to and sent the communities to engage more in those activities. There is a great disparity from the context of many people who want -- many other groups have published data on studies that indicate a vast majority of people that were asked if they want the information used however, their access and ability to do so is quite cumbersome. And if, indeed, if you have been in Washington this week on metro or on a bus to work on the streets you have seen advertisements for federally sponsored vaccine trials and those are not targeted. Certainly very important but the access and ability to identify eligibility requirements probably can be more strategic in the future by utilizing known populations and inflammation of people who wish to engage in that. We can be more strategic and use innovation in this case and ultimately enhance the capabilities of improving care.

Thank you.

This question is also for Dr. Downing, Greg. In your written testimony you talk about various value propositions that EMRs could deliver and can you talk about what types of studies that you see EMRs being applied to in the short-term? Is it more retrospective observation base studies or good to be talking to prospective clinical trials as well?

Certainly the longer-term population base studies for safety assessment and outcome research but the knowledge will be not be turned on the investment made today. Much in the same context that we invest in education and other areas those gains will only come about starting today. In the short-term we have a great to let me know in terms of risk management and risk mitigation -- great deal of need now in terms of risk management and risk mitigation to utilize the outcome research to emphasize outcomes research and to look at the new avenues paved by comparative effectiveness research and that with in the two to three year time window that these opportunities are being planned funded and establish the infrastructure is a major component but this is where short-term gains could easily be chartered. The three areas that we have highlighted where technology can be best served is in the identification of eligibility and recruitment parameters matching the clinical trials of the the mud -- clinicaltrials.gov and the ability to look and track a vindication and uses of EHR systems for the appropriate people with the appropriate authorizations' using that information this is a privacy and security and confidentiality issue overall and the firm the third one is a adverse events reporting in the clinical trials.

And one follow-up. You also talked about a standard set of information from a patient's EHR. Are you trying to introduce a standard data model or standard extraction of data?

Thank you for asking that question. On the Standard component elements of that there are a core set of data elements that are currently going through HITSP and contributing to the standards activities and this is work that is ready to go back can be employed now and has been shown to be that way. I can only emphasize the areas where the standards exist and captured Chordata that could support broad needs that is feasible so hopefully that answers your question.

Thank you.

Thank you to the panelists for a very interesting set of the diverse perspectives.

This will be for all of you, speaking as a nurse backup provider, and I do not mean that literally, I think nurses are some the closest to patients that there are. Melinda did mention using patient entered data from the PHR and that has a lot implementations and we call that a category of in teaching the patients and their families and we have a number of criteria for a meaningful use but we would have to -- one way to interpret your comments is that we should work on it even more, further expand some of the meeting please criteria and we have to do with the privacy and limitations of that and to help information exchange as first-class participants. So there would be a lot of things that we could do. So I would be interested in your thoughts on is this an important area to continue to spend more time on to make sure that patients have a direct benefit and participation in HIT as applied to health care?

I would say yes especially because we are trying to change the health system and the patients -- giving patients more information, giving them control of what they know and what they do is just critical to that we know already that people can use a personal health record on their own and people are starting to do that. However, we do know that there are limitations in terms of the input of data that they do on their own. I have read research and have had people tell me you're not sure that they would put the right diagnosis in and the right exact name of their med. So if we could get them started and then they could enter other things that they think are important specific to their behavior is, a daily life their medication that I may not know about from seeing them at the Community Health Center, the vitamins that they take pity things like that are very important for the patient to track and share as they wish. There are other implementations in terms of the remote monitoring but if you have a machine doing the monitoring, that is fine. But if there is no machine there, patients may be able to enter their own blood sugar that the tape from their own stand-alone glucometer so that is a. Important piece.

I would say from the Denver Health perspective clearly patient engagement is one of the most important things that we try to do. Unfortunately right now, we need to get the providers and -- engaged first. But it is a changing landscape, we did a study, only one-third of them had access to the Internet and a good 70 or 80% had interest in using technology to communicate and correspond with their physicians and much of that interest was not from the patient but from a primary caregiver that came in with that patient. Typically end of string of an elderly person were quite interested in that approach. But trying to encourage them to enter data in the system about their own status of help would be jumping the gun for our patient population but clearly a nice long-term goal.

I mentioned this issue in number of different places with in my written testimony. Most important of which is family history. Most important, I also talk about some of these issues of consumer empowerment in the SafetyNet system and how we need to avoid this Digital divide which is getting increasing documentation. There is a strong idea to enable them to move a growth, development, immunization's data and we have a quality statement of using PHR to improve quality. And also one of the only ways that we will ever get out comes in the areas between care into the record. Typically when I start to see a patient I look first at the growth data and immunization. What I cannot look at are the other providers people are singing and other events that are going the up side of the office in this is where a patient entered the above who else they are seen in when they have been to the emergency room will enter our system so we have more effective health information exchange.

I think from the dental perspective I think it's moving toward to be really beneficial if the patient is given the opportunity to update their medical history, medication list and the preventive measures that they are taking. For example, now the dentists now have increasing [ Indiscernible ] and be preventive measures and getting input from the patients in providing that opportunity so that we that continued T of care is maintained -- that is the way I see.

Next of the questions from Paul and David and Scott and Neal.

To follow up on the last discussions, I have a question for you, in your comments about personal health record are you speaking in terms of the families or the child having electronic access to their record?

That is that Number five goal on security. Eventually there is a point of transition where its sheered and a few people have started giving the child access themselves. I meant mentioned that the NCAA want to have the college athletes aware that they have been screened for sickle cell. We want to prevent some strategies that appear in hot weather training so there is a point in which data such as many things in newborn screening need to go directly to the child and there's a critical area of children with special needs of transitioning into adult care. So we're talking about parents and children and a period of transition both between childhood and adolescence and the period of transition between independent status as an adult.

Thank you. I also have a question for Greg Downing. In your documents he talked about inconsistent Data Standards, all other things. Can you tell us more about what we ought to do about it?

For the most part the issue has been put from the standpoint of capturing data from a variety of different settings. I think the work is not insurmountable but needs to be done in terms of addressing ways to recognize different ways of character using disease states that will be important enough to get to the renewed there been -- granularity to get too specific enough disease catheterizations and be able to distinguish what stage of diabetes someone is in so there is some additional work that needs to be done in the disease categories as well as other clinical measures to enhance the utility of the information that is being captured. And the EHR is a perfect place to people to do that. I think there is right now out a fair amount of momentum in this area to be able to harmonize standards in laboratory records, other forms of measures and in many areas we have been working in the newborn screening areas for examples and the measures for outcome bichirs are not mutually agreed upon -- measures are not mutally agreed upon. So most people agree that there needs to be work done in those areas.

In my experience even if you have an agreement on the correct nomenclature there's a lot of local variation about how things are coded. So should the extension centers or HIEs play a roll?

I think there is a training and educational component overall. This is not a huge component, but familiar raising new trainees and people who are adopting EHR systems to be comfortable with you for measures for example and out comes measures. I think if our quality work will continue to grow out from EHR realization that should be a component of the extension Center programs and understanding research models and Data Collection.

Thank you, that is very helpful. I also want to make a comment to you Dr. Steele, your oral and written testimony was very well accomplished and what to thank you for that.

Thank you.

I think the thing that has come of this session, you may have heard yesterday that we will be working on a strategic plan in some broad principles and all of your testimony challenges us at the strategic level to think about whether there is the longitudinal patient record and if so where does it live in because of meaningful use we have been very focused on EHRs as the atoms of this network but I wanted to ask strictly Dr. Downing and Dr. Zuckerman to react to this question of where to the longitudinal patient record live and particularly from the point of view of both architecture and policy. We have someone in our portfolio of things some of the issues around HIE. Some of that we can in bed in the meaningful use requirements but some of it sits outside of that tool that we have provided interesting particularly Dr. Downing if you look at the work in greeds and Federated networks in the opportunity to create a real learning environment and the system in some of the bunch of atoms that are loosely connected what should we be doing as a committee to enable to their feet and network of linked the resources for continuous learning by practitioners prefer is there something in meaningful use or the way that we support HIE that would help us get their? And the second question, Dr. Zuckerman in particular, a long time ago we contemplated the idea of a personal health record from birth which essentially the hospital substantiated the record and handed it off to other caregivers in the family as the weight to -- But we to have the opportunity to have played lifelong record. Is that something that we should be contemplating or set the purge will thing that may emerge naturally by the virtue of people trying to do the right thing or should we be intentional about Pat? I wanted to put those two on the table.

That is a complicated question.

I think fundamentally and I cannot speak for all of the colleagues but I do not think that we know the answer and I would be that the strategy of this committee is to not necessarily define and not limit the possibilities in the answer may be in the clouds literally in for more specific data likely that we'll have to have more detailed data infected in other kinds of remarks and I think the key thing is trying to find the ways to lock that allow more innovative approaches to enable databases to work together and an able to be linked in some fashion to be able to answer complicated questions. I think we see this in many other types of are the settings, with its national intelligence or environments and whether or in the business communities that the ability to utilize information from a variety of different sets and intricate thus provides a great deal of power and we do not have that in health care. I want to emphasize from the testimony that the label mint of people to participate and use that information needs some incentive and from the standpoint of whether its the the uses of technology for the purposes of a PHR and electronic framework to participate and a network like patients like me or something like that that we do and others have written in the federal space in recent months about the importance of the contribution to the public could that people have to start to consider in their terms of the leanest to contribute information for understanding what help is about. We have not have that dialogue get and perhaps the community here can be a spark towards that -- how that is used in the broader community. The technology will find its own way but the policy is the big piece right now and you are in the perfect position to lead some of the dialogues that are needed and that particularly with the patient communities.

Thank you.

Again, I think without getting into any of the privacy or the Technical issues of these virtual records we have to be extremely cautious about relying too much if that approach because of the tremendous difference in time value information and the danger of information overload. Practicing here in D.C. I have had the opportunity to work with paper records with patients and other countries that have an integrated child record that carries things over time and I really think we should make a new approach to define the kind of data both for children and adults that are going to make a difference in the future. We need to recognize that while we are focusing on this adoption transition from paper to electronic today we will have the benefit hopefully for most of our patients over the next several decades. And as part of that we need to feel out a. Intentional course set of data that moves forward a and its value may change. We how many infections has a lot of meeting at one point in their life and with the air 18 years old and preparing to go to college you are not as concerned. I have special care is a need -- special cared name stepchildren and the record that I built both on paper and electronically that I will hold some of that back from their adult providers. I think being selective about how information moves forward in terms of privacy control so that things are revealed that should not be and also in terms of information overload and I keep hitting back to the immunization registry story which is a perfect example, let's get something that works right. When I go to our immunization registry I have to print the web page, and start keeping things in. As we build these systems we have to make corrections and make it available and to use that data with in the different electronic systems that the patients will see over their lifetime.

I just want to briefly speak in say that the time to start with that personal health record maybe during pregnancy because there is the incentive that the women has to take care of her health. She is getting frequent visits and then that can feed into the child's record afterwards.

Scott and then Neal.

This question is for Dr. Steele and I want to recognize that you are one of the few people to recognize trainings so I thank you and gives me a great segue to preach. It's a two-part question be what were some of the challenges that you found in the training? It seems like you had a wonderful installation and the second part of the question is what recommendations could you give to myself and the Committee on design and we recommend training programs for the greater good?

Personal biased first, if we do a good understanding, trading would become less of an issue. But we're not there. So it yes, it has been a long road, 15 years, lots of money. We estimate that its about two and a half years the beginning and we learned a lot of lessons do that. To start off with you need a vision from the top and a commitment from the top. Then you need to have a culture of change. We had a culture of change in the beginning but it was not nearly as strong as it is null. I have seen the benefits of not just creating when based programs for having the end-users say, I can use this comet take this on, getting engaged in make this work group that is a critical factor that you have to get paid if you are trying to push them into this is not going to work. In fact, now what has happened is that they have become so comfortable they are basically coming back to us with demand for a profound and enhancements that we do not have the resources to meet. So as long as you can get that cultural mind-set to adopt along the same lines the training becomes a pretty easy factor actually pay but I agree it's an important issue to figure out how you are going to do that in conjunction with your help care workers there.

Neil?

Also thank you to the panelists. This is an amazing group. I want to focus on dental for a minute. Part of the written testimony that you provided around dental was pretty scathing. There is a comment, EHRs are likely to delay and eliminate EHR incentives for dentists. Those are some pretty strong statements and I am concerned about that because the dental system seems to be buried this integrated with the rest of what we're doing in the electronic health records. The people who know who have implemented systems and the uplift two completely separate systems and they cannot even talk to each other in the same facility. That is a tragedy played one of the goals that we set forward was reducing an administrative burden. And if there's any place with that is not reduced, it's in the lack of integration in our systems because people can register twice and there is no cross over a family information, health information, elegy information. You have to build interfaces between these zero systems. I guess I'm curious, what is the more positive approach that we could take in terms of what really facilitating integration at some level of greed and are you aware of examples where systems have been implemented like that where information cross freely between the dental systems? More than just crossing freely, as interface, but where they exist as one system within one provider organization?

Thank you, again, for highlighting the problems in the industry. We are far behind when compared to medical counterparts. Regarding your question on whether there are many places where they are integrating information across different providers, there are certain non-profit health organizations where they have the luxury of having only one system which has been home grown in those instances. They are able to exchange patient information to some extent. But they are using ONE system. Even in institutions where they have just one system in place. However, we are still lagging far behind in exchanging patient information between different systems. So, I think, a positive direction to take would be having certain specified targets unspecified time periods so that we can basilic -- I don't think that we can facilitate Exchange overnight in the near future but maybe having certain milestones to realize that.

To me there's a parallel between this discussion in the one that we have about mental health.

Yes.

We are trying to integrate your and every year more and more data comes out showing the relationship between oral health and other physical health problems from winning problems to cardiovascular disease. You can go across the whole spectrum and yet here is another area where I think technology really needs to play a role in helping us integrate our delivery.

I just want to thank you for bringing this up and I regret not having brought into my testimony the American Academy of pediatrics health is a very big gap in their standards. I have never seen some training in oral health. But we want to make it part of the care and want to integrate data from more than the providers so that we are able to share with them. We have a death of a child with a dental problem that has shaken up our understanding but I do not see it moving into HIT yet. We may be able to put it in meaningful use soon but it's the kind of thing that should be there. I should know what is going on with my children's oral Health and I should be able to share of corporate medical data with dentists more easy. Many of them do bothered to ask.

We are fortunate that all of the dental primary-care is under the same organization as their primary care so I have access to all of those records and they have access to our records. Although I cannot read their records, next to ophthalmology it's one of the hardest notes to understand, but they have a complete list of medications and allergies and I like to know that I can understand the burden of their dental care and just a phone call away of beating any clarification puissant anything that you can do to bring us together I think would be very important.

Dr. Jenkins?

There is a system in New York that is making do with an EHR and putting their data in there. They have a template for the initial and follow up visits. So if one of my patients had been to the dentist I can see it right there and I also can see that metalist from primary-care -- the med list from primary care. And we have the multidisciplinary providers. There.

Mark and Judy?

I have been listening to the last couple of these and you guys have been terrific. I'm not sure that this is as much of a question as a comment. We talked strategically about giving a plan as a committee and we have been talking a lot of kidding standards, data, extracting that data so that we can use it for research and other purposes. It seems to me one of the real values of these systems, and Greg, you talk a little bit about knowledge sharing and this type of thing. That we have this great sucking sound of pulling informational out but we need to talk about best practice care and how we get that information back out. Because there is real knowledge being deemed and the best practice activities can be facilitated by technology and we need to build some of those concepts in.

We have a comment.

Although this is a little bit off the mark to the discussions around meaningful use but a lot around decision support aspects and there's a tremendous amount of research and development that is needed in here in understanding how people can use knowledge represented to them in a patient in counter for example so I think there is probably not sufficient -- I know that Paul and the others had been in caged in these discussions but there is a growing base of momentum here and perhaps some hope that additional resources and efforts can be made in that area.

My husband is a pediatrician in they SQHC and I hear about the dental needs a lot but yet as a HIT vendor I cannot hear as much from our customers about center and the reason is meant to help is typically under the scene on ballett and dental is separated out for most of our customers and separate organizations that are separately run and are not under the same umbrella so they buy their own systems and then we as the HIT vendor, the best that we can do with those situations is to interface to all of the myriad of different dental systems out there. Is that really the underlying reason that there is that problem? Because they are separate organizations?

Can you repeat the question? Are you asking isn't a problem?

Yes, because if the HIT vendor is going to sell to a health care organization of medium or large size and because the smaller ones are publicly -- either way, even if its a small one, the dental groups are separate organizations and they would buy their own systems where the mental health is in the organization and I wonder if that is the underlying reason.

Yes, I think that is one part of the reason because many are in solar or small group practices and they are in their own world. They are not connected to the mainstream and the providers and I think that is also one of the main reasons why we cannot have a lot of dental practitioners who are offering care for Medicaid patients because they are left of the group did I know that -- I note that lately they have been making a lot of effort in educating dental practitioners regarding the need to connect with the health care providers. Keeping in mind now we have a of increasing approach -- the map of chronic disease patients and so forth. So there has been information, and I do not think the dental community at large was aware of it. But lately there has been increasing awareness.

Thank you very much. I would like to go back to some practical things and where we're going with the cost of implementation and how is the best way to handle things. I would like to get an Andrew's perspective and my daughter lives in Denver and I am aware of what you are doing. And a lot of states, you have a lot of state money, what is your recommendation for other areas? Perhaps what your best practices and recommendations to deal with in addition to the money that is coming of ARRA, which is limited, how carriers serving the under Serb populations deal with the cost of implementation, equipment and also integration of the systems so that the best -- so that we do have a best practice model out there because most states do not have the kind of resources to do this.

In my testimony I talked about how much money we are putting into this, about 4.5% of Arco's net revenue which is about average but we have been doing that for 15 years. What helped us actually at the beginning was Y2K, we were the public hospital and did everything crashed we would be the last resort so we put a lot of money up to improve our system. That was a model, dragging the change in care and it did not work really well. We got through it but I think that the model has to be back to if you can start turning over the desire to improve care to the end departments, commissions, quality improvement offices and the implementation costs start to cool down. We have used a very strategic strategy, we took a lot of quality improvement bodies and move them around and give them training and by having the formal structure in place we have been able to drive down the cost and implementation by about 35%. So trying to learn from past practices is one week to do its. Some people have seen 1,000 EHR implementations and you have seen 1,000 did I don't think so. I think there are some overriding lesson to be learned. And many people actually on this panel here, and not from people who work in the American community hospitals, implementing vendor based solutions. So I think we still need to learn a lot more to make sure that some of the current publicized best practices can be replicated in other places. Now, specifically how can we get that done? I think the centers will bear a lot of burden on this. They will have to provide the technical guidance to the local hospitals on how to best implement the systems and it takes a combination of people. We use industrial engineers -- certified Project managers and people who are experts. Just recently in our most recent success with online nursing documentation we took the project over to nursing and they put over 7,000 hours of their time without any new net physicians and what they did was said, okay, we are in the business of improving care and we will use the technology into that and take the current resources. There is educators, quality improvement nurses to change their jobs to help implement the project. So you have to take a mindset to who is really in charge of the project and to engage the work force to get that done.

Do you see the rule of the regional extension centers to drive these things down to the local level so that we do establish best practices? We have a lot of money being spent right now and grants are being issued as we speak. Do you see an overall umbrella of perhaps some guidance coming down to that as this money is spent?

Clearly we will need some click guidance for the month and a quick guidance. I don't know how many practitioners are trying to make -- clearly we need some quick chitin's. About 25% have bought off on this idea. So we need to quickly learn from them but just as important, we are not clean to reach 80% implementation by the year 2015 so we should be able to put into place an evaluation methods of the next two years to really categories how do we get this done for the next 3,000 hospitals. I think we have ideas out there but we have an opportune time now for a lot of institutions will be embarking on this. If we do not take the time and energy, I think it's a lost opportunity to get the last 50% on track. Those are the ones that will need the most. So it makes a lot of sense of front. We need a more normal assessment of how it works.

Thank you, a panel.

We need to check on the phone, if Tony is there, do you have a question?

No I don't.

Thank you.

Okay.

Will comity to so much for coming and agreeing to do this -- Well, thank you so much for coming and agreed to do this.

Thanks so much. In the final half hour of Power meeting I wanted to open it up for some -- of our meeting I wanted to open it up before our committee members be this has been incredibly valuable and thanks to the meaningful use workgroup we are sort of shaking this and special thanks court making it happen. That is where the rubber meets the road. And the knowledge and experience and perspective from these things so much to form how we go forward with our strategic planning and the meaningful use criteria a word about sort of deliberations because I know we are anxious to be talking -- I know that certainly that will happen within the work group in this particular panel. The meaningful use workgroup will be incorporating the ideas into the process. I also have to give a tribute to David Blumenthal and the Office of the national coordinator for trying to keep up with a lot that was passed in just the three. A lot of us might think it's an easy job to give away money but there's a lot of process that goes behind that and 2.7 the initiatives on the ground and on timing is just incredible. So thank you so much to the office in David Blumenthal.

We have been drinking out of a fire hose, and that has been such a great part of this process and we want to schedule some time in the upcoming meetings to have times and talk among ourselves and clearly one of the special areas is the formulation and development of the strategic plan. I think part of the time allocated for deanery is to follow up on the discussion -- for January is to follow up on the discussion paper the next 20 minutes or so I want to give people an opportunity to share some insight that they have cleaned in the past statements and have a hearing it is to put people -- I know we will all be thinking about what has been happening and how we incorporate that into our various Workgroups. I want to give time to have people's inside. I don't think we have time to discuss our delivery at this time -- maybe I will be off and say as we work on the policies and a meaningful use criteria one of the things that we need to be mindful about is not to reinforce let alone encourage the cared -- whether it specialist and primary-care or mental health and physical medicine we to not want to widen the disparities of care and how people receive care in various parts of the country. So we think we need to focus a lot on coordinating care and the way that we cross our meaningful use criteria so that the courage the use of HIT to bring care to the other and integrate its regardless of whether they're physically together. We do not want to risk widening the disparities that.

One of the things I think we will have to think a lot about is this recurring theme especially from the palests that we have heard the last two days on small providers and as other issues come up as far as complexity with compliance to the proposed and meaningful use criteria. That maybe it costs too much and I cannot afford to do its out of pocket and maybe I will just opt out. If we get a substantial portion of the providers decide to opt out -- So the question I think we need to go back in our work groups and study is is it because of the cost of funds and may be this loan program that we talked about earlier? Is it the burden of ongoing administration and the incentive that we provide is not enough? Is a perception? These are questions that we need to ask ourselves that the benefits and the testimonies were. Well done and we heard people talk about the actual benefits that they saw that justified the cost but also, discern some who said that maybe the benefit was not worth the effort. I think as a QA methodology we ought to ask ourselves some of these questions as we go forward and give them a test and then talk about also if there are other creative ways we might overcome those objectives.

Gail?

Thank you. I think we also need to be looking at as we talk about costs and that is the real concern for me as to how we are going to be able to do things and take into consideration what is the best method to make things happen appropriately. I am a very concerned about people opting out P that is a tremendous concern. We are committed to making sure that we have electronic health records across the board. We also need to look at how distinct different states are and the different levels for which states come into this. Yes, we may have seen some very good success stories but in reality when you look across the landscape and look from state to state Medicaid is three different, the amount of money is different and most small critical access hospitals do not have nest eggs so we need to be to attuned to what the costs are and what the differences are. We want everyone to have the same opportunities to have electronic help record but let's be aware of that as we move the word especially when we move into strategic planning.

Adam?

If I could go back to the earlier comments regarding the physician adoption. One thing that will be a vested interest to meet, and three consumer advocates here on the panel I know that the Committee -- we were all given a very tough time line and Dr. Blumenthal did a fantastic job of moving us a long. I would encourage the committee and others to start looking to the patients and consumers more of what they want. Clearly we can only deal with the reimbursement incentives for mechanisms or the incentives down the road. But if the patients and consumers are coming in and demanding its service the communities paillette --will adopt it and educating them on how this will benefit them and how they can move the mission but word for the ONC.

Neil?

I have a list of a couple things that I think I come away with this. One is our need to continually rearticulate the vision of where we are trying to get. I see a need I don't know whether you want to call its direct to consumer advertising or some social marketing campaign will probably be a more PT kind of term. I think we need to get out to the community and people in the country on why this is a really important thing and do a better job of that because it's ultimately the demand. As Adam said, we are pushing things from the top but ultimately the demand also has to be driven from the consumer point of view where people have an expectation when they go into a provider's office that the test should not have to give their families' medical history all over again. If that becomes an expectation on the ground we have a very important powerful push from the other end. Something else that got specifically out of the last two days is how disintegrated our system is and how much work we need to do in all of these areas and you think about the different people and all of them coming in one way, shape, or form seen that there's a piece missing would that be have to connect better and I think that whole issue is going to be critical in order for us to achieve our goal and think about that. The third point would be, in the committee here we need to spend more time looking at the other parts of the HITECH stuff and with the regional extension centers will do and what policy will sort of cover in the process a little bit more. Some of the other that we heard Jodi brought -- up the loan program and we have not talked about the potential of that. There are lots of other resources in HITECH that have been outside of our purview. But in a letter to accomplish some of those things, we are going to need to bring all of those resources to bear. Some some survey of what those resources are and some discussion with in the committee would be really valuable for all bus.

Good point. And I will remind you that one of the things on our docket is that ONCE will update us -- ONC will update us on the strategic plan.

Next I have Mark.

I could not agree any more, if they are opting out, are the opting out because of money or because they do not understand the up side? The biggest issue is around piece, money is an issue but I think that ARRA does address money and how we can start getting some funds out but the pace is scaring people away that we simply cannot get there that passed. So maybe I just will not start. That brings up the next point as we talk about our strategies and that is priority in what are we trying to accomplish? Are we trying to get electronic systems please and extract that the out or what? I know that is built into the criteria right now but we might want to address it more because the real fear I am hearing is piece and we do not even have the rules out yet.

Good point. Mike?

I really applaud the Committee for taking this pause to think about what we have seen and to build into the future process more ability to digest and think strategically. I agree with everything that has been said. One of the things that has struck me over the last thing and have was the testimony from the American College of of statistics and gynecology there was no perceived incentive to go ahead and for dissipate in ARRA and electronic health records. participate in ARRA and electronic health records. We only heard from a small sampling and how many of the specialties feel that way? We have to get some data on how prevalent that feeling is and what the perceived barriers are and whether its pace or money or whatever because if we have people in the medical professions that do not see any benefit through ARRA or other reasons, that is a big problem.

David?

Two the ads both across the microns' the integration -- two thoughts across the integration issues and we're focusing on the EHR on with the money goes in the luck of the disintegration and flow across different tools and pop forms and settings. And I do not know that we yet have a mechanism here to think that the rupiah is there a longitudinal help record? Is a on demand record and how do we in the micro level permit their to be a longitudinal comprehensive record that includes dental and other services? So that is one thing. The second is that the alignment of payer incentives outside of ARRA. We heard about HERSA and dentail payers and what the commercial peers may be doing. I think we need some form by which we take Medicaid, Medicare, meaningful use, Commercial Papers, a dental payers, PBMs and think through is there anything that we can do to have convergence incentives that will give people the resources to achieve these larger goals?

Charles?

The things that have been in my head the past couple days the first with that comes to mind is focused. I am really impressed by a the scale and the ability of issues that have been presented over the past two days, be it quality measurement, clinical research, specialties, etc. although the are all valid to show value in 2015 when people look back and ask us what did we achieve I think it will be critically important to focus on some tangible things. I would say probably around common disease management that we get down. And perhaps in our strategic review process that will be part of those discussions. The second thing is the notion of Data Management and the notion of using this simple structure for clinical research data Management will be the currency that makes this a successful or not. I do not think today we have had enough of a focus on that I think about a EHR connecting with seven different electronic health records you have seven different representations and that is the data management problem. So we think we need to think that through and finally I was a very much impressed by Bonnie's testimony this morning about local innovation and about appointing a career management but we also have to figure out how to we empower individuals and organizations to do more of what Bonnie describes in aid systematic way. Promote this part respecting for this to be a coherent system.

Excellent.

I agree with all of the comments that Neal made about consumers. If you look at Technical logical change in this country it has always been driven by consumers paid anything that we can do to create and help increase consumer demand is very helpful especially as relates to the personal health record. Patients get involved and this can help create demand for these systems and I also agree with Charles' most recent comments about focus and the the importance of strategic plans because there are a lot of issues here and we need to be very clear what is your trying to accomplish in these states will come very past. And what we will consider success in terms of what we're trying to do. I know this has all been a very high level discussion but there is also something mentioned today that was also sort of very tactical. In the interface discussions which is the ten physicians on the extension centers and it does not apply to the federally qualified centers so what I am hopeful is that that information gets taken back to ONC that we figure out a way to do and a corporate exception for that small and a pretax credit by -- and important tax right way.

I would be careful of the academics because the academics are covered and what they are or not is questionable but they believe they are not so they're moving forward. Secondly I was impressed with the talk yesterday about privacy and abode to not to find the mines from the body but keep the two together. The third thing I want to see is that we cannot keep forgetting the technical side, whatever we do here we have to figure out is it technically doable by the vendors including the vendors, the smaller offenders be because if we authorized things that are unto blow it's a waste of time, we have gone the wrong way and it's not free to help -- not going to help rid I think the discussion about who is the primary care physicians, I think it was fascinating and I think that we have to look again perhaps at what do we require from the systems in the use of those systems. And if the system is not producing what it needs this should not be certified, and can lead to that by doing things like it has to be able to do CPOE and not just be able to you have to use the alerts and reminders. That led us into another discussion is, is that too late? That is the interesting question. There is no clarity of why we're still here and what is to lead and what is still on the table. What should we no longer deal with and what its future that we can deal with. And how does it work? How does it get from here to wherever it's going?

Christine?

This was really a good two days. I think on the meaningful use workgroup we have some hard work ahead of us to think about the various needs for the different provider types of. I think some of the key takeaways are really about driving care coordination as the basic level of coordination sharing. And I think it's the right concept, absolutely. I want to be careful how far we take it because a first of all, we can not put patients in the seat of been the one force of change that will finally get providers to do what we have been asking them to do. The health-care economic forces are do not operate in the same rate it has allowed consumers and other communities to be that to me and force and consumers have been demanding things like care coordination and better access. And we are not delivering still on a consistent basis. They are not going to walk into an office at the lead and we will see if I am right, they're not going to walk into an office in demand and electronic help record. They're going to say wait a second, you don't have the ability to share a business only with me or my information today from my visits that might OB/GYN okay thanks but no thanks. And those of physicians that choose to opt out because its to too hard because they do not recognize that values that patient get from it there will be left behind -- they will be left behind the I get the failure and the risk but there's probably a segment that I am okay with that. We have to get to a place with the conversation is different in the conversation about cost today was four in my view the same conversation that we have been having for years. Yet there is money on the table, this is not a rate, it's a privilege to get this federal support which I believe is a cost of doing business in providing care any way that this patient centered.

It's hard to avoid not leading that as the last comment.

I have one comment as well.

Going back to the start of this than two days of meetings, we have a lot to do. I think we all recognize that. I'm getting nervous about how much we have to do even if we were to be focused and to only those things in our power to fix. We have a lot of issues that I would argue no matter what we do we will not fix them. So having said that this would be a plea to Dr. Bloom in Fault in California and ONC -- Dr. Blumenthal in California and ONC there might peak -- it sounds like there's some more juggling going on with respect to others and I think the sooner that we get some clarity around this new structure and get started on the framework piece and the strategic plan we will all be better off because we have a lot of work to do.

So I want to close by acknowledging -- not quite close because we have not had public comments yet but acknowledging the thousands of hours that this group and all of the folks that we coordinate with and draw upon the volunteer efforts. Okay, Tony, you had a comment?

You might be on mute.

Or we may have lost him for a moment but if he comes back we will entertain his comment.

Really thousands of hours of time put into this effort and I know that everybody has got the heart in the right place. We are trying to do the right thing for the country and made into lemonade out of the fact that we did not have the time to do the strategic plan because I think these two days have been very thought-provoking and I think our strategic plan will look different, it has been that provocative and that an informative. So we will do that strategic planning process and start piece in Workgroups -- start these new work groups and we have all of this work to do. I think we're doing the right thing at the right moment in history. Let me see if Tony has joined again.

Just a couple comments although these were excellent presentations and you pointed out a lot of the concerns that small providers and others have. I think that one thing that should be pointed out that they have the opportunity to comment when the regulation goes out in the next couple months and believe they should take that opportunity to insure that their concerns to get hurt and become part of the comment process. Because that will help influence on how we look at this final regulation. It also brings up the need to make sure that before we update the 2013 that we really take into account what is going on in 2011 and what some of the feedback that we get from the extension centers are, because I think that is critical. The third point I want to make is that I agree with what David Lansky said about the payment incentives. That is a critical need that we need to be looking at to do a lot of work in that area as well. The fourth point I want to make is that the input also plans of the need for ONC to be very clear on the certification program and if the did move ahead with modulus certification that needs to be made clear to these small and will providers that as we have heard are overwhelmed by a lot of objectives and me please, criteria as it is -- and meaningful use criteria as it is and if they have concern that could make their disincentive to join even larger. So those are my comments.

Thank you very much, for a lot of those additions and clarifications. I think that calls upon to reinforce my comments on how much effort the federal government, ONC, HHS, CMS is pending in trying to move this agenda. I think that is what motivates a lot of us. It has been a lot of efforts. At this point I want to open it up for additional public comment and while anybody is getting up to do that the process of involving the public I think has been tremendous. Not only did we have a unusual step of the committee opening up for public comments but this whole process and as Tony just mentioned everyone including this group will have a chance to comment on the NPRM. I think we do have a line -- I will just remind everybody that we do have a two minute time.

Good afternoon, my name is Byron and I am with the National Medical Association and my comment is something that Dr. Steele was describing in his comments and working needed engineers and nurses to take over and get involved in the process could one thing I would encourage is to look outside of the Chamber of health-care. And if we need to do with information perhaps we should be speaking to some engineers or if we need to do with the consumer demand issue maybe we should be speaking to advertising or messaging people. I think it would serve a monumental purpose if we were to go upside health care and say, we have this problem, how did you deal with it in this industry and perhaps that is something for your strategic planning.

Thank you.

Okay, I am with the National Medical Association and private practices. I want to leave with them to point we have recognized the needs to have everyone integrated to the systems with nurse practitioners and other health-care professionals and we have opened our membership up to them as well and we really need every one. And we have always emphasized that. On the issue of opting out the recognize that we do not want doctors to opt out especially private practicing physicians. So when you look at all comes measures in meaningful use, not penalized it paid be more incentivizing as opposed to creating a penalty against the doctors and that we know that all physicians will see the benefit of using EMRs or HIT and our main concern is as you have heard of is the startup costs and the immediate costs so we appreciate you recognizing that but know that we want to do quality care and we think that this would definitely help us do that. Thank you.

Hello, Andrew from Central Jersey Health Information Exchange project and basically I want to comment on the fact that physicians are thinking about opting out. The issue is that when you have a group of physicians that what to do the right thing and look at the EHRs out there, the court need the care the issue that we're running into right now is we're looking at the offenders paid it goes from 1,000 to $50,000 in the upkeep costs are $300 to $800 a month that can come up to $80,000 for our practice of ten people and in addition to the amount of money you have to put in the price becomes an issue and the problems that we deal with is when you're looking at the high end product they do have the guidance. They do have the word means that be one to have included, the lower end products do not have that. And again the interoperability is the biggest issue. Having people listen to Wes is the other part of the problem. Thank you.

Hi I Kate and I represent am the National Organization of urban hospitals and we have private hospitals that do not have the support of their local state funding that our public hospital counterpart we do the same work but we are often in areas where there is no public hospitals. So these private hospitals have stepped up to filling the gap where no one else is taking care of these underserved patients. We have two concerns going forward, of one is as you look at any recommendations or any exceptions that you might make to these other SafetyNet providers in meeting meaningful use such as whether or not we might be able to allow for patient access to their information. Please remember that the private SafetyNet hospitals are in the same boat and we are treating the same kinds of patients with socio-economic barriers to care, chronic diseases, language barriers as the other public safety net hospitals are treating. The other issue we ask you to remember that if there is a way to come up with some up-front funding four SafetyNet providers they also need to be eligible. Thank you.

Hello my name is Tom Stevens, CEO of health care management systems and I am one of those smaller HIT vendors that to be talked about -- that Judy talked about and I want to echo some of the comments that were mentioned and comments that were made in your last session there did we service about 650 community and specialty hospitals and about 400 of those were county hospitals and 100 being critical access hospitals. And the issues that you reached around cost is a real issue. The up-front cost that they have to implement eight EHR is a real problem for them and that is something that needs to be considered. The piece that you mentioned is also an issue. You heard testimony that they started their implementation of the EHR around 2002 to 2003. Dr. Steele mentioned a five-year implementation of CPOE many of these small hospitals are not. Far along in the implementation of Chemical Systems to period much less than the EHR product. So the gap of 40 are to where they have to be is rather large in the piece together its screen them. And the pace as it relates to vendors like a mess is also an issue. We will spend four to five times the amount of the element to meet the me please, criteria that we spend to achieve certification with CCHIT in 2007 and that is a significant investment in a short amount of time when the criteria still is not finalized so I think the piece of it is an issue as well and I would appreciate your consideration on those two parts on the part of my customers. Thank you.

Hi, Rod P. from the American Hospital association. A comment was made that there is only a requirement to report quality measures and the values are immaterial and as early as 2013 the meaningful use Quality reporting requires a 10% reduction in the 30 the remission rate and that is in one year. As we have pointed out hospitals are engaged in significant quality reporting to Medicare and other organizations and do not seek to have any of that duplicated here. Furthermore, connecting these measures to incentive payments in penalties for use of EHRs forms the basis of a value based purchasing program were instituted a should be managed as a separate and distinct program. That is, in fact, part of the discussion of the current health reform discussions. At the intent of the HITECH components of ARRA is to increase the adoption of HIT as a prelude to will to improve safety, patient involvement and efficiency. As the committee has heard the structure of the incentive payments still leaves many hospitals and professionals in the difficult position of finding the funds required to implement health information technology. In the early years we should focus on getting EHRs and others supported HIT systems in place before we require improvements in quality measures that merely not be directly to people to the use of this technology. Meaningful use should measure initially whether or not systems are in place in use and are becoming part of the hospital's culture. Finally many hospitals will need additional help to accomplish these goals and the regional extension centers as correctly described will be primarily focused on eligible professionals, not the needs of hospitals. Thank you.

Good afternoon onion Kathleen Reynolds, the program specialist for integrated health-care and we represent over 1700 mental health and substance abuse programs across the country and you talked about the fact that we were not included in the legislation but nevertheless we are very interested in the committee and the definition of meaningful use and helping in any way that we can with the integration of that. One, the definition of meaningful use should underscore the need of health IT to eliminate the disparity in treatment and outcomes for people with persistent mental illness including individuals of chronic substance abuse and we cannot let the 25 year loss of will continue because it has been preventable chronic illnesses that we can do something about. Second the concept of meaningful use to include treatment planning for mental health and substance abuse disorders and they cannot overlook the critical linkage between Heathrow health and health outcomes. And finally they should be able to track standard clinical information. And we gave a consumer portal and integration that they work with and the first panel of consumers, she wanted to provide this input into the that her manager and said, is this a place I should tell you which of those medications I am actually taking? So the role of the consumer is critical to health behavior and health outcome.

Good morning, Michelle Fried and I have a brief comment to echo what Charles Canady said this morning I might have heard a lot about the data that exists and the critical piece that I would want to enforce with the committee is the importance of accurate and consistent patient identification. We can connect all of the EHRs and HIEs and sure of the data that we want but if you cannot identify the patient the data means nothing been so in order to achieve our goals and objectives assist you with meaningful use I would really ask the committee to look back and read salmon the use of the patient identifications so -- and reexamine the use of the patient identifications in this endeavor.

I work with the American dental Association I would like to offer the ADA support and exhibitions in any capacity that we might and I know that the ADA was mentioned in the last panel. Just so that you know, electronic health records is not something that the ADA is blind to prove we have had a working group for some time. We are in the process of trying to address some of the issues that you have raised about interoperability and connectivity in exchange of information and so on and I think that we would be pleased to help the committee understand where we are and where the gaps are. Over 90% of all dentists practice with less than four dentists and the practice so we do not have a large practice that even the medical practice that you will see. There was a question about are the systems out there that currently integrate medical and dental record keeping? There probably are. The two that I know something about is that you might look at the Department of Defense and the Department of Veterans Affairs systems. I do not know how well they work because I am not an expert in how those systems work but there has been an effort in both of them to provide an integrated system. Again, we will offer the ADA's assistance in any way that we can.

Good morning, I am Al, the CEO of [ Indiscernible ] and we are an application developer currently in use by over 500 hospitals throughout the U.S.. We provide some special the clinical decision support in antique we collation, diabetes and heart failure and we think that the support system should be included in me will use and the certification standards of that the continued to help health-care professionals improve outcomes and reduce costs. Specifically we think there should be a premier considered for the separate certification of the critical decision support disease management application and these some special the modules already are interoperable with generalized EHRs and registries and continue to improve outcomes and cut costs. So we think that they can be a valuable part of the solution in allowing health care professionals to meet people use measures in these of -- in these subspecialty areas. Thank you.

Good afternoon my name is Lindsey Haggle and I an independent consultant and I am speaking on behalf of -- the ADA is the largest with over 70,000 members. ADA appreciates the work of the ONC policy committee in establishing a strong definition of meaningful use as directed by ARRA and for moving forward with the adoption of EHRs we are encouraged by the potential for health IT to improve the quality of care, require aggregate data for population how the outcomes and serve as a vehicle for preventive care. In yesterday's meeting we heard from numerous specialist groups who presented many the first situations of care. As expected, the meaningful use definition focuses on providers as they are the primary designees of HITECH adoption and sent desperate we hope that the policy will consider beginning with the end in mind for meaningful use. That is to utilize it as a tool for quality health improvement. In doing so we encourage that meaningful use have an overly based upon patient consumer conditions. Which we think may facilitate greater cooperation of patient care. The ADA believes that Egyptian care should be consistent component of EHRs Patricia is known to be a sissy with seven of the ten causes of death and -- nutrition is associated with seven of the ten causes of death in the nine states and obesity which causes a unique figure in chronic disease management. The discussion this morning concerning telehealth inpatient success is inspiring. Consumers and patients often want to change but lack the understanding the resources and the support to do so. As our health system adapts to every aging population and nutritional care of the elderly remains a concern and one that can be impacted by the crucial of comes. This is particularly compelling given the identification of high risk medication. And maintaining health in the nation's elderly articulate, poor nutrition is the major problem in older Americans, inadequate intake a proxy 37 to 40% of individuals over 65 years age. The ADA has been working to ensure that the nutrition did this it is included in languages such as SnowMed CT we have developed a EHR tool kit in developing metrician care and EHR adoption could we thank you to the following comments in this area.

We have our final comment on the phone.

Are a question comes from Michelle from WI Medical Society.

Thank you, I am with the Wisconsin Medical Society and I want to comment to thank you for bringing up the issue of the federal tax ID limitation for the regional extended payments. We are applying with the cooperation of others to be the state Regional extension center and we heard about it being attacked to the tax ID on October 15th and we will be surprised. We have had numerous discussions to help providers to need the most help with our hands tied with granularity provider tax ID issue. In addition to having this issue and the state we have health care systems that might have one tax ID where smaller clinics under that mother ship tax ID are not getting IT or EHR assistance from them which causes a barrier for us to help them. We will not pull out our applications we believe state electronic health will improve patient care so thank you for passing that information on so that we can continue are in adoption of EHR to all physicians will need it. Thank you.

Thank you.

That concludes the public comment. I went to thank you again, everyone on the committee and the work groups and the public on behalf of Dr. Blumenthal and myself for all the efforts put into this. In recognition that even the committee should give thanks with their family we will not have a November meeting in the next meeting is December 15th, same place -- Well, I don't know with the place is in Washington D.C.

Any final comments? If not, we will adjourn and thank you very much.