Saturday, October 31, 2009

ICANN Bringing the Languages of the World to the Global Internet

The first Internet addresses containing non-Latin characters from start to finish will soon be online thanks to today's approval of the new Internationalized Domain Name Fast Track Process by the Internet Corporation for Assigned Names and Numbers board.

"The coming introduction of non-Latin characters represents the biggest technical change to the Internet since it was created four decades ago," said ICANN chairman Peter Dengate Thrush. "Right now Internet address endings are limited to Latin characters – A to Z. But the Fast Track Process is the first step in bringing the 100,000 characters of the languages of the world online for domain names."

ICANN's Fast Track Process launches on 16 November 2009. It will allow nations and territories to apply for Internet extensions reflecting their name – and made up of characters from their national language. If the applications meet criteria that includes government and community support and a stability evaluation, the applicants will be approved to start accepting registrations.

" This is only the first step, but it is an incredibly big one and an historic move toward the internationalization of the Internet ," said Rod Beckstrom, ICANN's President and CEO. "The first countries that participate will not only be providing valuable information of the operation of IDNs in the domain name system, they are also going to help to bring the first of billions more people online – people who never use Roman characters in their daily lives."

IDNs have been a topic of discussion since before ICANN's inception. It's taken years of intense technical testing, policy development, and global co-operation to prepare the Fast Track process for its coming launch.

"Our work on IDNs has gone through numerous drafts, dozens of tests, and an incredible amount of development by volunteers since we started this project. Today is the first step in moving from planning and implementation to the real launch," said Tina Dam, ICANN's Senior Director for IDNs. "The launch of the Fast Track Process will be an amazing change to make the Internet an even more valuable tool, and for even more people around the globe."

More information of the Fast Track program is available online at:

New GE eHealth Business Better Connects Patients, Hospitals, Doctors to Critical Information

BARRINGTON, Ill. -- GE Healthcare has announced the launch of eHealth, a new business unit offering enhanced connectivity to clinicians and patients designed with data privacy and security features to enable health information sharing that can help increase efficiency, reduce error and improve health outcomes. A part of GE's healthymagination initiative to improve quality and access while reducing cost, the eHealth business tackles one of healthcare's most pressing problems - fragmented clinical information trapped in disparate IT systems across multiple institutions, without the common framework to connect to other care providers and their patients.

"Connecting healthcare systems is challenging," said Dr. Brandon Savage, chief medical officer of GE Healthcare IT. "Wide variations in clinical terminology, patient identification methods and systems architecture makes integrating health information exceptionally difficult. Turning that information into value for the care provider is a second, even more challenging hurdle, requiring deep understanding of care provider requirements and clinical workflows."

The eHealth suite of solutions enables the secure sharing of health information that can help lead to improved care by equipping providers with timely patient data, help reduce costs by eliminating redundant procedures, and empowering consumers to make more informed health decisions by providing health histories and wellness services. By providing infrastructure and clinical support services that support physicians, GE is helping to improve the communication of health information,and helping to reduce life-threatening medical errors, twenty percent of which currently occur due to the lack of immediate access to patient health information1.

"eHealth provides the next level of connectivity," said Jim Younkin, IT Program Director, Geisinger Health System and Project Director, Keystone Health Information Exchange (KeyHIE). KeyHIE utilizes GE technologies to serve 31 counties in central and northeastern Pennsylvania. "More than 345,000 patients have registered for our exchange and those patients have given their healthcare providers at eight hospitals and other regional health facilities timely access to relevant information through a secure connection," noted Younkin. "This, in turn, helps ensure these patients receive optimal care."

GE's eHealth business is delivering value to clinicians and patients in four fundamental ways:
*Patient Health Records - As consumers are increasingly engaged in their healthcare decisions, secure and reliable access to medical histories is critical. LifeSensor® patient health record provides a web-based system designed with privacy and security features that allow consumers to access their health histories and to collaborate with care providers. With LifeSensor, consumers can now better understand and direct their own health and wellness plans and leverage the LifeSensor tools for managing chronic disease, nutrition and fitness to help promote lifelong well-being. LifeSensor patient health record is the result of seven years of development by GE's strategic partner InterComponentWare (ICW) and integrates with GE's Centricity HIE solutions.
*Health Information Sharing - The heart of the eHealth business, GE's standards-based Centricity Health Information Exchange (HIE) infrastructure helps enable clinical data from disparate information systems, including medication history, laboratory results, radiology images and referrals to be shared between clinicians in a secure and private manner, helping physicians gain a more complete picture of a patient's medical history. Today, GE's Centricity HIE solutions are helping states, Regional Health Information Organizations (RHIOs) and healthcare systems aggregate data across information silos.
*Structured Clinician Views - Information is only valuable if it is organized, accurate and logically conveyed. Leveraging a deep understanding of caregiver requirements and workflows, the eHealth Clinical Portal structures and displays information so that it is clear, understandable and useful to the caregiver.
*Robust Patient Identification and Matching - It is essential that physicians and patients trust that clinical information is matched with the right patient. GE's Master Patient Index (MPI) technology provides a comprehensive solution for matching patient records from diverse organizations. This technology helps to ensure that information is accurately matched, and is designed to maintain patient privacy.

"With eHealth, we're working to develop standards-based infrastructure, a ground-breaking suite of collaborative services and clinical decision support tools that will empower providers and patients as never before," said Earl Jones, recently named vice president and general manager, GE Healthcare eHealth.

"Integrating disparate data into a single, accurate clinical picture, turning this integrated clinical picture into insight, and making that insight available to caregivers across offices and institutions in real-time will transform the way healthcare is delivered."

GE eHealth solutions are driving value for customers today by providing customers collaborative charting across institutions, patient medication histories, and centralized services such as physician referral, and laboratory, radiology and image information exchange.

eHealth Business Leader Earl Jones joined GE Healthcare IT earlier this month from GE Water & Process Technologies, where he served as Global Commercial Leader, leading global sales and partnership activities. Prior to this role, Jones served in GE's Corporate Initiatives Group where he led Lean Six Sigma for supply-chain and manufacturing. Jones also served with distinction as a submarine officer in the US Navy.

GE Healthcare provides transformational medical technologies and services that are shaping a new age of patient care. Our broad expertise in medical imaging and information technologies, medical diagnostics, patient monitoring systems, drug discovery, biopharmaceutical manufacturing technologies, performance improvement and performance solutions services help our customers to deliver better care to more people around the world at a lower cost. In addition, we partner with healthcare leaders, striving to leverage the global policy change necessary to implement a successful shift to sustainable healthcare systems.

Friday, October 30, 2009

Understanding ARRA and HITECH

On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act of 2009 (ARRA), which, among other things, created financial incentives for physicians and other providers to adopt and utilize electronic health records (EHR) and penalties for those physicians who do not.
Over $60 billion in healthcare funding is included in the HITECH provisions of the ARRA for electronic health records.
  • $46.8B for Medicare & Medicaid Incentives to doctors & Hospitals for "Meaningful Use" of certified HIT
  • $2B for HIT infrastructure, especially Health Information Exchange (HIE)
  • $4.7B for the National Telecommunications and Information Administration's Broadband Technology Opportunities Program
  • $2.5B for the U.S. Department of Agriculture's Distance Learning, Telemedicine, and Broadband Program
  • $1.1B for Comparitive effectiveness grants from AHRQ, HIH, and HHS
  • $1.5B for the Community Health Centers through the Health Resources and Services Administration
  • $500M for Loan Forgiveness and Workforce Training
  • $500M for Department of Labor for Workforce Training
  • $500M for HRSA Workforce Training
  • $85M for the Indian Health Service
  • $50M for the Veterans Benefits Administration
  • $ 25M for Chi ldren's Health Insurance Program Reinvestment Act (CHIPRA)

Meaningful Use of certified EHR Technology:
To take advantage of these incentives you must be able to demonstrate "Meaningful Use" of Healthcare IT.

The EHR must be certified, and you need to use the EHR for:

  • ePrescribing
  • Sharing clinical data with other certified EHR systems (interopraability)
  • Reporting on specified clinical quality measures
Medicare Incentives
  • Incentives will start in 2011
  • Available to all non-hosptial physicians who see Medicare patients
  • Eligible physicians can receive up to $44K over a five-year period
  • Minimum for Medicare participation: Provider must bill 125% of the total incentive received over the five-year period of incentive distribution.
  • Must prove "meaningful use" of an EHR.
  • Physicians who have not adopted an EHR by January 1, 2015 will be penalized by reduced Medicare payments.
  • CMS has extended full Medicare ePrescribing one full year until the end of 2011
Medicare Incentives Schedule
Year Eligible in 2011 Eligible in 2012 Eligible in 2013 Eligible in 2014 Eligible in 2015
2011 $18,000 $0 $0 $0 $0
2012 $12,000 $18,000 $0 $0 $0
2013 $8,000 $12,000 $15,000 $0 $0
2014 $4,000 $8,000 $12,000 $12,000 $0
2015 $2,000 $4,000 $8,000 $8,000 $0
2016 $0 $2,000 $4,000 $4,000 $0
Total $44,000 $44,000 $39,000 $24,000 $0
Medicaid Incentives
  • Available only to non-hospital based clinicians, including dentists, certified nurse midwives, and physician assistants practicing in rural health clinics or FQHCs
  • Medicaid incentives range up to $63.5K over a five-year period.
  • Minimum for Medicaid participation: 30% of a clinician's patients must use Medicaid, with the exception of pediatricians, who only need to have 20% of their patients using Medicaid.
  • Startup incentive up to $21,000 in state loan funds will be available in year one to ward the purchase of a certified EHR.
  • After receiving startup funds, providers who can prove "meaningful use" can receive up to $8,500 annually for an additional five years.
  • No penalties have been defined by Medicaid for lack of adoption.
Medicaid Incentives Schedule
Year Eligible in 2011 Eligible in 2012 Eligible in 2013 Eligible in 2014 Eligible in 2015
2011 $21,000 $0 $0 $0 $0
2012 $8,500 $21,000 $0 $0 $0
2013 $8,500 $8,500 $21,000 $0 $0
2014 $8,500 $8,500 $8,500 $21,000 $0
2015 $8,500 $8,500 $8,500 $8,500 $21,000
2016 $8,500 $8,500 $8,500 $8,500 $8,500
2017 $0 $8,500 $8,500 $8,500 $8,500
2018 $0 $0 $8,500 $8,500 $8,500
2019 $0 $0 $0 $8,500 $8,500
2020 $0 $0 $0 $0 $8,500
Total $63,500 $63,500 $63,500 $63,500 $63,500

To stay informed, you can always go to the ONC's FACA Blog site for the latest news and updates.


Posted via web from ahier's posterous

Close to a Health Reform Score

I was wrong when I thought that President Obama would be carrying th ball much on health reform. It seems that Harry and Nancy making all the plays, and Obama is staying mostly on the sidelines. And it looks like health reform efforts are inside the ten yard line and driving in for a possible touchdown. The recent CBO scoring of the House health bill (see below), while only preliminary, gives some momentum to advocates. However, the devil is in the details and with almost 2000 pages to read, that is a LOT of details.

However, the CBO report's conclusion raises doubts about promises that the public option would provide a lower cost alternative for consumers. It also raises doubts about the effectiveness since only 6 million people would enroll in the plan (hardly a government take over).

On page 6:
Roughly one-fifth of the people purchasing coverage through the exchanges would enroll in the public plan, meaning that total enrollment in that plan would be about 6 million.

That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges. The rates the public plan pays to providers would, on average, probably be comparable to the rates paid by private insurers participating in the exchanges. The public plan would have lower administrative costs than those private plans but would probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)
At the end of the CBO's summary is a strong a warning from the usually cautious CBO that this bill will only be deficit neutral is if it's followed strictly to the letter:
Those longer-term projections assume that the provisions of H.R. 3962 are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation. For example, the “sustainable growth rate” mechanism governing Medicare’s payments to physicians has frequently been modified to avoid reductions in those payments, and legislation to do so again is currently under consideration in the Congress. The bill would put into effect (or leave in effect) a number of procedures that might be difficult to maintain over a long period of time. It would leave in place the 21 percent reduction in the payment rates for physicians currently scheduled for 2010. At the same time, the bill includes a number of provisions that would constrain payment rates for other providers of Medicare services. In particular, increases in payment rates for many providers would be held below the rate of inflation (in expectation of ongoing productivity improvements in the delivery of health care).
It really seems more like politics as usual with healthcare reform, and it is only going to get worse as the the House and Senate versions get amended to gain votes and then are eventually reconciled. Whatever finally lands on the President's desk may be a far cry from what we had been expecting.

In Support of Health IT


Paulsen, Erik [R-MN]

Text From the Congressional Record

Mr. PAULSEN. Thank you, Mr. Chair. I yield myself as much time as I may consume. I rise today to offer an amendment that I am hopeful will help to strengthen and accelerate advancements in medical technology. My amendment would require the SBA to conduct a study that would determine the feasibility of a program that would help bring funding to startup medical technology firms. The amendment would also require the SBA to report its suggestions on how to best structure such a program. It is my hope with this information, Congress will be able to strategically implement a program to help fund medical technology.

Programs of this nature are already in place and exist for renewable energy and for rural manufacturing. This amendment would simply look at also expanding this to medical technology. Medical device companies face startup costs that are very steep, and a program under the SBA would help bring funding to these companies and allow them to get their products to market quicker. Mr. Chair, we know very well that the development of these new cost-saving technologies allow patients to lead longer, healthier and more productive lives.

These technologies also improve the quality of health care in America while helping to fight rising health care costs. Furthermore, the medical technology industry is a proven job-creator. According to one study, the medical technology industry nationwide employs more than 350,000 people. These are good, high-paying jobs. The average salary of a med tech employee is higher than the State salary average in 49 of the 50 states; and in some States, medical technology jobs pay nearly 25 percent higher than the State average salary. Many of these jobs are also often in the area of research and development, which keeps America in the forefront of innovation. It should also be noted that these companies are truly America's small businesses and success stories. Of these companies, 71 percent have fewer than 10 employees. It fits right in with this bill, Mr. Chair.

A week ago, I held a field hearing in my district on the issue of medical technology, and we heard firsthand from small businesses in my district about the work that they are doing and the jobs they are creating. As cochair of the Medical Technology Caucus, I would ask support for this amendment so we can have Congress spur additional advancement in medical technology. I urge adoption of my amendment and reserve the balance of my time.

Small Business Health IT Financing Program: H.R. 3854 amends the Small Business Act to establish a new small business health information technology financing program. The SBA Administrator would be authorized to guarantee up to 90 percent of the amount of a loan made to a medical practitioner for the acquisition of health information technology for use in medical practice and for the costs associated with the installation of the technology. The maximum amount of loan principal guaranteed could not exceed $350,000 for a single medical professional or $2 million for a group of associated professionals. The Administrator may impose a guarantee fee on the borrower for the purpose of reducing the cost of the guarantee to zero. The Administrator may also impose annual servicing fees on lenders not to exceed 0.5 percent of the outstanding balance of the guarantees on lenders' books. Loans guaranteed would have a deferral period of one to three years. The bill authorizes such sums as are necessary for the cost of guaranteeing $10 billion in health IT loans.

Summary of H.R. 3854 - Small Business Financing and Investment Act of 2009
  • Supports public private partnership aimed at channeling investment capital into small business start-ups.
  • Expands equity investment to low income communities
  • Makes microloans more affordable for budding entrepreneurs
  • Provides greater support by the SBA to help facilitate small business lending
  • Maintains fee reductions and increased guarantees on 7(a) loans that were established through the Recovery Act
  • Takes steps to encourage smaller lenders to participate in SBA programs and to help rural businesses and veteran-owned businesses obtain loans
  • Raises loan amounts for both 7(a) and the CDC loans to help small businesses access larger amounts of capital.
  • Provides financing options for small health care practitioners to afford new health IT technology
  • Altogether, the bill is expected to support $44 billion in small business lending, annually, helping to create or save almost 1 and a half million jobs a year.
Amendments to H.R. 3854 – Small Business Financing and Investment Act of 2009
  1. Velázquez (Manager’s): Would make technical and conforming changes to the bill, including clarifications of legislative intent. It also would incorporate provisions that would enhance investing in veteran-owned businesses in the New Markets Venture Capital program. It would direct the SBA to conduct a study on the efficacy of the Business Stabilization loan program that was established under the American Recovery and Reinvestment Act, a study on the existing loan size limits in the SBA’s 7(a), CDC, and Microloan, and a study on the state of private sector lending for small businesses over the past four years. It contains provisions that would enable franchises with temporary workers to qualify for SBA lending programs and would enhance the ability of small firms to use 7(a) loans to purchase unoccupied manufacturing centers or equipment. The delivery of capital with Business Stabilization loans would also be improved, with provisions that will make more loans in cities with unemployment rates that exceed state rates by 25 percent. The Health IT Financing program would also be expanded with eligibility for home health care providers.
    (20 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  2. Schock: Would require the SBA Administrator to pay the claim of a lender who demonstrates it followed the applicable requirements of the National Lender Training Program (Sec. 106), unless the SBA has clear and convincing evidence demonstrating that the lender failed to comply with regulatory requirements.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  3. Schock: Would require quarterly reports on the SBA Administrators progress towards the expansion of the Renewable Energy Capital Investment Program. It would require the SBA Administrator to establish regulations necessary to carry out the program within 180 days after enactment.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  4. Bright: Would require each of the SBA district offices to establish a marketing plan for rural businesses regarding financing and investment alternatives, designate an employer as a Rural Business Outreach Specialist, and host at least one annual outreach seminar.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  5. Flake: Would prohibit the earmarking of grants made available through the Small Business Early-Stage Investment program.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  6. Kosmas: Would add "photonics technology" to the list of targeted business sectors qualified to receive grants under the Small Business Early-Stage Investment Program.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  7. Gingrey: Would increase from 5 years to 7 years the period to participate in the Small Business Health Information Technology Financing Program.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  8. Kratovil: Would give the SBA Administrator authority under the 7(a) program to guarantee 100 percent of loans made to veteran owned small businesses.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  9. Paulsen: Would require a study and a report to Congress by the SBA, within one year of enactment, to determine the feasibility of a program to increase investment in the research, development and commercialization of medical technology by small businesses in a similar matter to the renewable energy program currently administered by the SBA.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  10. Massa: Would create youth entrepreneurship programs in the Small Business Administration to assist the development of new businesses by young people who remain in their local area.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  11. Foxx: Would result in the termination of the SBA small business lending programs in two years.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE NO.
  12. Kissell: Would amend Section 7(a)(7) of the Small Business Act to allow for repayment of SBA 7(A) loans (granted to small businesses after enactment of this bill) to be deferred for a maximum of 12 months from receipt of final loan disbursement if that small business concern is classified in sector 23 of the North American Industry Classification System.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  13. Peters: Would increase the maximum amount of stabilization loans in high unemployment areas to $75,000 and delays repayment of stabilization loans in high unemployment areas to 18 months for new loans made after enactment of this act. It would give the SBA administrator ability to designate high unemployment areas as eligible for operating assistance grants under the new market venture capital program.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  14. Brown-Waite: Would require individuals directly engaged in loan application analysis and/or underwriting under the new Capital Backstop Program (Sec. 111) to have at least two years worth of experience in those activities.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  15. Brown-Waite: Would clarify that the Capital Backstop Program (Sec. 111) is authorized to start immediately and to operate through 2011, regardless of whether the recession is declared officially over during that time or SBA loan volume drops another 30% next year. It would restore such requirements after September 30, 2011.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.
  16. Nye/Buchanan: Would allow the SBA Administrator to make loans to homeowners to be used for the repair or replacement of toxic drywall manufactured in China.
    (10 minutes)
    Chairwoman Velázquez recommends that Members VOTE YES.

Thursday, October 29, 2009

CBO's Preliminary Analysis of the Affordable Health Care for America Act

Posted October 29th, 2009 by Douglas Elmendorf

CBO and the Joint Committee on Taxation (JCT) have just issued a preliminary analysis of H.R. 3962, the Affordable Health Care for America Act, as introduced on October 29, 2009. Among other things, H.R. 3962 would establish a mandate for most legal residents of the United States to obtain health insurance; set up insurance “exchanges” through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage; significantly expand eligibility for Medicaid; substantially reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law); impose an income tax surcharge on high-income individuals; and make various other changes to the federal tax code, Medicaid, Medicare, and other programs.

According to CBO and JCT’s assessment, enacting H.R. 3962 would result in a net reduction in federal budget deficits of $104 billion over the 2010–2019 period. In the subsequent decade, the collective effect of its provisions would probably be slight reductions in federal budget deficits. Those estimates are all subject to substantial uncertainty.

The estimate includes a projected net cost of $894 billion over 10 years for the proposed expansions in insurance coverage. That net cost itself reflects a gross total of $1,055 billion in subsidies provided through the exchanges (and related spending), increased net outlays for Medicaid and the Children’s Health Insurance Program (CHIP), and tax credits for small employers; those costs are partly offset by $167 billion in collections of penalties paid by individuals and employers. On balance, other effects on revenues and outlays associated with the coverage provisions add $6 billion to their total cost.

Over the 2010–2019 period, the net cost of the coverage expansions would be more than offset by the combination of other spending changes, which CBO estimates would save $426 billion, and receipts resulting from the income tax surcharge on high-income individuals and other provisions, which JCT and CBO estimate would increase federal revenues by $572 billion over that period.

By 2019, CBO and JCT estimate, the number of nonelderly people who are uninsured would be reduced by about 36 million, leaving about 18 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under H.R. 3962, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 96 percent. Roughly 21 million people would purchase their own coverage through the new insurance exchanges, and there would be roughly 15 million more enrollees in Medicaid than the total number projected for Medicaid and CHIP combined under current law. (Under the bill, CHIP would no longer exist in 2019.) Relative to currently projected levels, the number of people purchasing individual coverage outside of the exchanges would decrease by about 6 million, and the number obtaining coverage through employers would increase by about 6 million.

Although CBO does not generally provide cost estimates beyond the 10 year budget projection period (2010 through 2019 currently), many Members have requested CBO analyses of the long-term budgetary impact of broad changes in the nation’s health care and health insurance systems. However, a detailed year-by-year projection, like those that CBO prepares for the 10-year budget window, would not be meaningful because the uncertainties involved are simply too great. Among other factors, a wide range of changes could occur—in people’s health, in the sources and extent of their insurance coverage, and in the delivery of medical care (such as advances in medical research, technological developments, and changes in physicians’ practice patterns)—that are likely to be significant but are very difficult to predict, both under current law and under any proposal.

All told, H.R. 3962 would reduce the federal deficit by $9 billion in 2019, CBO and JCT estimate. After that, the added revenues and cost savings are projected to grow slightly more rapidly than the cost of the coverage expansions. In the decade after 2019, the gross cost of the coverage expansions would probably exceed 1 percent of gross domestic product (GDP), but the added revenues and cost savings would probably be greater. Consequently, CBO expects that the legislation would slightly reduce federal budget deficits in that decade relative to those projected under current law—with a total effect during that decade that is in a broad range between zero and one-quarter percent of GDP. The imprecision of that calculation reflects the even greater degree of uncertainty that attends to it, compared with CBO’s 10 year budget estimates, and the effects of the bill could fall outside of that range.

Those longer-term projections assume that the provisions of H.R. 3962 are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation. For example, the “sustainable growth rate” mechanism governing Medicare’s payments to physicians has frequently been modified to avoid reductions in those payments, and legislation to do so again is currently under consideration in the Congress. The bill would put into effect (or leave in effect) a number of procedures that might be difficult to maintain over a long period of time. It would leave in place the 21 percent reduction in the payment rates for physicians currently scheduled for 2010. At the same time, the bill includes a number of provisions that would constrain payment rates for other providers of Medicare services. In particular, increases in payment rates for many providers would be held below the rate of inflation (in expectation of ongoing productivity improvements in the delivery of health care). Based on the extrapolation described above, CBO expects that Medicare spending under the bill would increase at an average annual rate of roughly 6 percent during the next two decades—well below the roughly 8 percent annual growth rate of the past two decades, despite a growing number of Medicare beneficiaries as the baby-boom generation retires. Based on the same extrapolation, Medicare spending per beneficiary under the bill would increase by roughly 4 percent per year, on average, during the next two decades—compared with a 7 percent average growth rate (excluding the effect of establishing Part D) during the past two decades.

This entry was posted on Thursday, October 29th, 2009 at 4:39 pm via

Affordable Healthcare for America Act

This summary was prepared by the House Committees on Ways & Means, Energy & Commerce, and Education & Labor. I am posting it without comment...

The Affordable Health Care for America Act provides quality affordable health care for all Americans and controls health care cost growth. CBO estimates that it will provide coverage to 96% of Americans, that it does so under the $900 billion threshold outlined by President Obama, and that it reduces the deficit within the budget window and beyond. Key provisions of the legislation include:


I. COVERAGE AND CHOICE: The bill builds on what works in today’s health care system and fixes the parts that are broken. It protects current coverage – allowing individuals to keep the insurance they have if they like it – and preserves choice of doctors, hospitals, and health plans. It achieves these reforms through:

 Immediate reforms. Includes immediate reforms to improve today’s health care system as we implement full‐scale health reform. These improvements include the creation of a new national program to provide affordable coverage for those who can’t get health insurance today because of pre‐existing conditions (including the use of domestic violence as a pre‐existing condition); implementation of insurance reforms to enforce an 85% medical loss ratio, coverage of young adults on their parents’ policies through age 26, limits on pre‐existing condition exclusions, protections for treatments for children with deformities; implementation of new programs to protect retiree health benefits; enactment of administrative simplification; and creation of a new federal grant incentives for wellness programs and early advancement of reform by states.

 Health Insurance Exchange. The new Health Insurance Exchange (starting in 2013) creates a transparent and functional marketplace for individuals and small employers to comparison shop among private and public insurers, including new health insurance co‐ops. It works with state insurance departments to set and enforce insurance reforms and consumer protections, facilitates enrollment, and administers affordability credits to help low‐ and middle‐income individuals and families purchase insurance. Within three years, the Exchange will be open to employers with 100 employees as another choice for covering their employees. Over time, more employers will obtain that option. States may opt to operate the Exchange in lieu of the national Exchange provided they follow the federal rules.

 A Public Health Insurance Option. One of the many choices of health insurance within the Health Insurance Exchange is a public health insurance option. It will be a new choice in many areas of our country dominated by just one or two private insurers today. The public option will operate on a level playing field. It will be subject to the same market reforms and consumer protections as other private plans in the Exchange and it will be self‐sustaining – financed only by its premiums. The Secretary of Health and Human Services will administer the public option and negotiate rates for providers that participate in the public option. The public health insurance option is provided startup administrative funding, but it is required to amortize these costs into future premiums. Providers are presumed to be participants in the public option unless they opt‐out of participating.  Guaranteed coverage and insurance market reforms. Insurance companies will no longer be able to engage in discriminatory practices that enable them to refuse to sell or renew policies today due to an individual’s health status. In addition, they can no longer exclude coverage of treatments for pre‐existing health conditions. The bill also protects consumers by prohibiting lifetime and annual limits on benefits. It also limits the ability of insurance companies to charge higher rates due to health status, gender, or other factors. Under the proposal, premiums can vary based only on age (no more than 2:1), geography and family size.

 Essential benefits. A new independent Advisory Committee with practicing providers and other health care experts, chaired by the Surgeon General, will recommend a benefit package based on standards set in the law. This new essential benefit package will serve as the basic benefit package for coverage in the Exchange and over time will become the minimum quality standard for employer plans. The basic package will include preventive services with no cost‐sharing, mental health services, oral health and vision for children, and caps on the amount of money a person or family spends on covered services in a year. Within the Exchange, there will be four plan levels – all of which cover the essential benefit package, but have varied levels of cost‐sharing. The “Premium Plus” plans will offer additional benefits such as adult dental or vision and private hospital rooms.

 Ending the Antitrust Exemption for Health Insurers. By eliminating the antitrust exemption for health insurers and medical malpractice insurers, the bill increases competition in the insurance marketplace. It will remove their shield that has allowed them to price fix, divide up territory, and effectively create monopolies in particular markets.

 Helping address long‐term health care needs. Creates a new, voluntary, public, long‐term care insurance program to help purchase services and supports for people who have functional limitations. Individuals determined to need assistance because of functional limitations would qualify to receive a daily or weekly cash benefit to help purchase the services and supports needed to maintain personal and financial independence. CLASS would supplement, not supplant, traditional payers of long‐term care (e.g. Medicaid and/or private long term care insurance).

II. AFFORDABILITY: To ensure that all Americans have affordable health coverage the bill:

 Provides sliding scale affordability credits. The affordability credits will be available to low‐ and moderate‐ income individuals and families. The credits are most generous for those who are just above the proposed new Medicaid eligibility levels; the credits decline with income (so premium and cost‐sharing support is more limited as your income increases) and are completely phased out when income reaches 400 percent of the federal poverty level ($43,000 for an individual or $88,000 for a family of four). The affordability credits will make insurance premiums affordable and will reduce cost‐sharing to levels that ensure access to care. The Exchange administers the affordability credits with other federal and state entities, such as local Social Security offices and state Medicaid agencies.
 Caps annual out‐of‐pocket spending. Will cap annual out‐of‐pocket spending at a maximum of $5,000 per individual and $10,000 per family to prevent bankruptcies from medical expenses.

 Increased competition. The creation of the Health Insurance Exchange and the inclusion of a public health insurance option and health insurance co‐ops will make health insurance more affordable by opening many market areas in our country to new competition, spurring efficiency and transparency.

 Expands Medicaid. Individuals and families with incomes at or below 150% percent of the federal poverty level will be eligible for an expanded and improved Medicaid program. Recognizing the budget challenges in many states, this expansion will initially be fully federally financed then transition to include a 9% contribution from states starting in 2015. To improve provider participation in this vital safety net – particularly for low‐income children, individuals with disabilities and people with mental illnesses – reimbursement rates for primary care services will be increased to Medicare rates with new federal funding.

 Improves Medicare. Senior citizens and people with disabilities will benefit from provisions that fill the donut hole over time in the Part D drug program, eliminate cost‐sharing for preventive services, improve the low‐income subsidy programs in Medicare, increase access to primary care providers, and make other program improvements. The bill will also address future fiscal challenges by improving payment accuracy, encouraging delivery system reforms and extending solvency of the Medicare Trust Fund. Companion legislation will permanently reform Medicare’s payment formula for physicians.

III. SHARED RESPONSIBILITY: The bill creates shared responsibility among individuals, employers and government to ensure that all Americans have affordable coverage of essential health benefits.

 Individual responsibility. Except in cases of hardship, once market reforms and affordability credits are in effect, individuals will be responsible for obtaining and maintaining health insurance coverage. Those who choose to not obtain coverage will pay a penalty capped at 2.5 percent of modified adjusted gross income above a specified level.  Employer responsibility. The proposal builds on the employer‐sponsored coverage that exists today. Employers will have the option of providing health insurance coverage for their workers or contributing funds on their behalf. Employers that choose to contribute will pay an amount based on a percent of their payroll. Employers that choose to offer coverage must meet minimum benefit and contribution requirements specified in the proposal.

 Assistance for small employers. Recognizing the special needs of small businesses, the smallest businesses (payroll that does not exceed $500,000) are exempt from the employer responsibility requirement. The payroll penalty would then phase in starting at 2% for firms with annual payrolls over $500,000 rising to the full 8 percent penalty for firms with annual payrolls above $750,000. In addition, a new small business tax credit will be available for two years for low‐wage, small firms who choose to provide health coverage to their workers. In addition to the targeted assistance, the Exchange and market reforms provide a long‐sought opportunity for small businesses to benefit from a more organized, efficient marketplace in which to purchase coverage.

 Government responsibility. The government is responsible for ensuring that every American can afford quality health insurance, through the new affordability credits, insurance reforms, consumer protections, and improvements to Medicare and Medicaid.

IV. PREVENTION, WELLNESS AND PUBLIC HEALTH: Prevention and wellness measures of the bill include:

 Community Health Centers. Funding for community health centers is significantly increased, allowing for the creation of new centers and growth in the number of people served.

 Prohibition of cost‐sharing for preventive services. Cost sharing requirements in the essential benefits package, Medicare and Medicaid are specifically prohibited.  Community‐based programs. New programs are established to deliver prevention and wellness services at the community level and to support grants to small businesses that promote wellness programs.

 Prevention research. A dedicated funding source is created to support research on clinical and community preventive health services to determine which services are most effective.

 Data Collection. New data collection efforts are required to better identify and address racial, ethnic, regional and other health disparities.

 Public Health Infrastructure. New investments are made to strengthen state, local, tribal and territorial public health departments and programs.

V. WORKFORCE INVESTMENTS: The bill expands the health care workforce through:

 National Health Service Corps (NHSC). Increased funding and greater flexibility in meeting service requirements are provided for the National Health Service Corps.

 Building the nation’s health workforce. Increased funding and other improvements are made to programs targeted on training primary care doctors. Similar expansions are made to encourage more health professionals, including nurses, to choose primary care. A new Public Health Service Corps (modeled on the NHSC) is created to ensure an adequate and qualified public health workforce.

 Workforce diversity. Greater support is provided for workforce diversity programs to help ensure that the nation’s health workforce reflects the population it serves.

 Scholarship and loan repayment programs. Scholarships and loan repayment programs for individuals in needed health professions and shortage areas are expanded.

 Training for primary care physicians. Puts in place steps to increase physician training outside the hospital, where most primary care is delivered, and redistributes unfilled graduate medical education residency slots for purposes of training more primary care physicians. The proposal also improves accountability for graduate medical education funding to ensure that physicians are trained with the skills needed to practice health care in the 21st century.

VI. CONTROLLING COSTS: The bill reduces the deficit and will reduce the growth in health care spending in a numerous ways. Specifically, it invests in health care through stronger prevention and wellness measures; increases access to primary care; implements health care delivery system reforms; creates a Health Insurance Exchange and a new Public Health Insurance Option; improves Medicare payment accuracy and makes additional reforms to Medicare and Medicaid ‐‐ all of which will help slow the growth of health care costs over time. These savings will accrue to families, employers, and taxpayers.

 Modernization and improvement of Medicare. The bill implements major delivery system reform in Medicare to reward efficient health care, rolling out innovative concepts such as accountable care organizations, medical homes, and bundling of acute and post‐acute provider payments. New payment incentives aim to decrease preventable hospital readmissions, expanding this policy over time to recognize that physicians and post‐acute providers also play an important role in avoiding readmissions. The bill improves the Medicare Part D program by creating new consumer protections for Medicare Advantage Plans, eliminating the “donut hole” and improving low‐income subsidy programs, so that Medicare is affordable for all seniors and other eligible individuals.

 Innovation and delivery reform through the public health insurance option. The public health insurance option will be empowered to implement innovative delivery reform initiatives so that it is a nimble purchaser of health care and gets more value for each health care dollar. It will expand upon the experiments put forth in Medicare and be provided the flexibility to implement value‐based purchasing, accountable care organizations, medical homes, and bundled payments. These features will ensure the public option is a leader in efficient delivery of quality care, spurring competition with private plans.

 Improving payment accuracy. The bill eliminates overpayments to Medicare Advantage plans and improves payment accuracy for numerous other providers, following recommendations by the Medicare Payment Advisory Commission and the President. These steps will extend Medicare Trust Fund solvency, and put Medicare on stronger financial footing for the future.  Preventing waste, fraud and abuse. New tools will be provided to combat waste, fraud and abuse within the entire health care system. Within Medicare, new authorities allow for pre‐enrollment screening of providers and suppliers, permit designation of certain areas as being at elevated risk of fraud to implement enhanced oversight, and require compliance programs of providers and suppliers. The new public health insurance option and Health Insurance Exchange will build upon the safeguards and best practices gleaned from experience in other areas.

 Administrative simplification. The bill will simplify the paperwork burden that adds tremendous costs and hassles for patients, providers, and businesses today


HIT Standards Committee - Implementation Workgroup

The Implementation Workgroup of the HIT Standards Committee will hold hearings to identify enablers and barriers to the adoption and implementation and standards. The HIT Standards Committee has inaugurated an Implementation Workgroup and charged it with bringing forward “real-world” implementation experience into the HIT Standards Committee recommendations, with special emphasis on strategies to accelerate the adoption of proposed standards, or mitigate barriers, if any. The Implementation Workgroup held a public hearing October 29th on the topic of Adoption Experiences.

Meeting materials:

  • Panelist Process and Questions for Comments
  • Presenter Biographical Sketches
  • Agenda [Revised]
  • Welcome and Introduction
  • Non-Healthcare Industries Panel
  • Providers Panel
  • Vendors Panel
  • Quality Measures Panel

  • Draft Transcript:

    Good morning, everybody. And welcome to the HIT standing committee implementation work group. This work group will be operating as a federal advisory committee which means its operating in the public. We have public in the audience as well as people listing of the telephone and of the Internet. Proceedings from the meeting will be made available at the ONC website in a week or so and there will be opportunity at the close of the meeting for the public to make common. Just a reminder for work group members to please identify yourselves when speaking for attribution. And we will now go around and introduce members here in the room.

    And Castro from the Cross Blue shield of South Carolina.

    Linda Department of Veterans Affairs.

    Tim Ferguson.

    Reset command.



    Judy Murphy.

    David McCallie.

    Liz Johnson.

    Are there any worker members on the telephone?

    Chris Ross also joined us today at the table. Our chair Aneesh Chopra is running late SAA and going to turn the meeting over to Dr. Halamka.

    And look for today. It's going to be a great opportunity to hear from multiple stakeholders about issues of adoption and implementation of do we I think about adoption and implementation imagine that your company and you need to make streaming media that goes to some kind of player. And you think, there's this 8 D, DVD, bluey, DVD, I know exactly what one to use because the standards have plant agreed upon by my particular stakeholders for my industry. The notion of the standard I want to use, that's adoption. Everybody pretty much agrees. They know. Of course implementation that its widely the servitude in people using it in a variety of settings it has become mature. We are here today from folks outside of the health-care industry and that will be our first panel. And then we will hear from folks who are providers who actually have to use standards and of course, one wants to hear about it it actually cut in the morning saying, I saw a patient with a 420.3., maybe they don't. What are the issues of meet the standards and as David Blumenthal said as from a car, a Trinity and magic happens. Providers will of course tell us a bit about how adoption impacts them. We will hear from the vendors and how they have to implement products that contain standards better interoperable and we will hear about quality measurement. Quality Measurement been one of the more challenging things to do because it requires the notion of semantic interoperability. What is it the data means when you compare it for multiple sources and institutions? And that as we think about meaningful use, is going to require a lot of effort on the provider side to make sure the data gets placed in the standards. It will be a very rich they. We've assembled and Judy husband worked in assembling the team and during all the organizing a really diverse array of opinions. The format will be five minutes of discussion by each participant and the panel. And then we will be opening and up to Q&A. We have a set of standard questions we asked each of the discussions to reflect upon. Our first panel is going to be on the non health care industries and I will go change hats and become the moderator of that first panel.

    Adam Bosworth will be joining us by phone. To introduce the panel, we have David Miller and Skip Best from the Vincent and the this and for folks who don't know them have integrated the supply chain of the entire auto industry and have now begun to work in health care with the AMA. Undoing such things as automated systems to identify credentials of individual doctors and licensure. Adam Bosworth today he is CEO of [Indiscernible]. A company that provides decision support for a decision based and how did it has a rich history of working with standards and his roles at Microsoft for you worked on sequel ODBC, your Don XML, who worked on the Internet explorer four. And Microsoft access. He will tell us his experience from the Microsoft base of his career. John Trustman has a variety of experiences and he's been in the financial industry, he's been in the customer relationship management industry and he's dealt with various types of the Minister of transactions. He will talk to us about his experiences outset of health care. We were supposed to have since forced it, but unfortunately do an emergency, we were unable to get testimony from them. There's still a possibility when my kid Colin, but I'm thinking probably not. What Mr. With the prepared remarks from David Miller and Skip Best.

    Good morning, I'm Skip Best from Covisint. In addition to the things we're doing with the American Medical Association just briefly, we are also operating to statewide health care information exchanges exchanging both clinical and administrative data on a statewide basis in Minnesota and in Tennessee. I've asked Ed Miller to join me here today. I'm actually the health care guy on the panel. With the 30 years of experience. But David really was one of the founders of our company. Prior to our purchase by CompUSA five years ago. With that, I'd like to set way of a to David for his remarks.

    Good morning everyone. I like to thank you to be given the opportunity to address this issue and we've talked about this at Covisint a lot before as skips it, we were born out of the automotive industry. I used to be back to the '90s a GM guy. And now I may Covisint. It's a wholly-owned subsidiary of [Indiscernible] of the nine it's it's covered. Not ago from subsidiary to a subsidiary. The interesting parallel here which I think people have seen come this idea of other industries is this parallel but in the late 90s when automotive was going very well for the customers that we have, what you had it is 75,000 suppliers whose basically supplied supports about the large six GM, Ford, by March, Delphi, those large companies. Their issue was an interoperability issue. Very complicated vehicle to be able to assemble and electronically they decided how to manage part. The issue from interoperability is have you get a very complicated supply chain to be able to communicate in any effective way with this whole new concept of just in time. Which was the parts come to the line at the time when the vehicle is actually being built. If you looked at health care today, it's just in time type of thing. You're patient comes, and when a patient comes you have to have all the information cubicle and necessary to provide the health care you need to just-in-time. Having information above the patient as I've looked at it and having information about that patient five weeks before it comes to visit you may not be appropriate information and having that information five weeks after he comes probably isn't good either. It's a just-in-time system. What we learned in automotive and I like saying one of the advantages of working with the company that solve the problem that is similar in another industry is not that he found that over the smartest, he found the people who've already made all the mistakes you don't want to make. We made lots of mistakes and I think that's really what this discussion is about. Is kind of with the things we did you shouldn't do. Here's an a nutshell what's we saw. The first thing is an automotive there's a standards body, multiple but one of the largest ones is the AI AHA which is a standards body for the creation of interoperability standards to allow organizations to communicate in an effective manner. One of the issues that came up is when you come up with a set of standards, would you like to do is believe you get one shot at it so you try to make a standard as all encompassing as possible. So you work really hard on it but the standard oftentimes become so complicated that unless you are a Ph.D. or work for one of the big companies, the small guys can implemented. Not because the cancer understand it, they're just huge. The other thing is nobody wants to implement a standard that's going to be obsolete at the time it's implemented so you pick the most cutting edge technology also. You don't pick the oldest technology. To pick the technology is a little bit more on the cusp, cutting edge technology. That puts the implementer heirs, the guys who have views in a quandary. I think health care systems are much like automotive systems in that the standards that were created were gray, but the required you to be on the latest release of technology and a lot of the larger companies said, I'm three releases behind. And my budget does not allow me to update to the latest release so I can support the standard that you proposed for another year or another two years or three or whatever that was. With these two things ended up occurring in the '90s, people didn't adopt the standards are with it did which was worse, you're better off having people ignore them and say I'm not doing it. What happens oftentimes this they adopted the standards but they did in a way that they could say they check the check box. The state of a box that would accept the standard, they did a set of proof of concept standards, they did one of the small plants, they said I do the standard. They moved on and said and done. They weren't done. There weren't its allies in or adopting. When we came around we were task, Weaver owned by GM and Ford and this guys and they said you fix this because we want you to be an independent third party that fixes this and allows us to the top rate in a common way. And we don't want you to both the standards. We want you to be a message to move towards the standards. What we did it is we took a look at it and we came up with this concept of a this made them where they are. Don't try to push them where they can go. So the idea was I was going to start by interacting with them exactly with what they currently have. I went to a company I said, here's the standard that we wanted to migrate to. But I want to know where your at and you get to connect exactly what you do today. As a broker, and I will take care of doing the interoperability between organizations. And the model we came up with who move them that way interestingly enough is we charged for what we called mapping. If you could send me the standard then there was no cost two because you sent me the standard. If you could not send the standard, I would map to the standard for a price. If you could migrate to the standard, then your cost went down. If it chose never to migrate and they're always organizations to set, I only send 50 messages a month. I don't see any purpose right now to pay $300 a month to do that and I'm never going to move to the stand. That was okay. Larger organizations move in the other technology started to support it and you it's a move towards standards. That was the original plan. The other lesson with one because we've been doing this now for ten years. It's been in the business of being this interoperability. This relates to other things that we've noticed. One is this isn't just about computer computer messaging. So that thing there's a lot of folks out there that do that. You have to look the other technologies. This isn't all about, this is about users to log into web systems. Redoing the the icily produced a Web e d I screen. I have a guy who say what you do and how deep the messaging and they go I don't know if you are talking about. There are suppliers and automotive to go to the public library and log on to the Web in order to interact with General Motors. To had to give them and meet the when they are. In health care, we have a particle provide a link that faxes staff to positions because some physicians have nothing. They don't have that kind of [Indiscernible] really the. The second thing we learned is standards don't and there's the 1.0 standard and the 1.1 and two-point know and the three-point those standard. The idea of having in interoperability of allows you to agree that standard so as people get to 1.0 you have the ability to migrate into 1.1. You are always chasing that standard. That's okay. Because a really the lessons we've learned in automotive. We've moved that lesson to the health-care industry. Being independent action and I think one advantage we have is not a health care company. I don't provide health care so an independent. It's one of the reasons the Department of Justice chose us to the interoperability broker between them and local law enforcement. Because of the idea we are not one of the players. That's one of the advantages that we learn. It's one of the reasons that are almost sold us because the recession people who weren't part owners who didn't trust this because we were owned by the competitor. Is said we have to make them more independent of those early kind of the lessons we've learned in ten years of doing this.

    Thank you very much. Next we will hear from Adam Bosworth. Are you on the phone?

    I am.


    [Participant's audio is faint/unclear]

    Can we dial up the volume on the phone?

    Is that better?

    Yes, we can hear you now. Of course, Aneesh to drive.

    Before you speak of wanted to apologize for my delay. I was addressing a Cyber Security summit with a banking sector and the research community said, cuts were about one standards, and wanted to remind us We haven't already, this is a very important session to get the stories from those on the ground with experience so that we can remain tethered to what actually is happening and therefore, informing the work the group is to undergo this particular panel to to the end of what you are saying, resonated well with the theme of the event. We are for those of you on the phone and watching over the Internet, we are simultaneously launching our online form. And the website the expected to give away? That reflects us. The standards body I'm assuming the policy committee would benefit of the blog but we are first and the use of it. We would welcome of the next two weeks your remarks, comments, reactions to what you heard in today's session. The Independent use on this subject and will be reporting the findings of this on the November 19th session. One final point before I turn back over to you add them, and wanted to pay special thanks to Chris Ross who helped manage the online form. And Judy Murphy who arranged today's session. With that, I will turn back to Adam Bosworth to hear your thoughtful comments about experiences and out of industry.

    I interest you with your experience and sickle and XML and Microsoft access and Internet explorer zero and I imagine your current role.

    A thank you for inviting me. I appreciate the opportunity to testify. Secondly, I want to say I got into standard accidentally but I was building a product called access and it was clear that I cannot talk to all the databases out there and access was a way to help you understand and manage your data. I ended up wandering around the database standards say we need a standard way. To communicate from product like access or Excel to products like yours. In the final result was an uncalled ODBC. And it worked pretty well. It was basically the same thing. I learned quite a bit from that. Then later, I was building Internet explorer and wanted away to build AJAX. Much more interactive than the old pages for night demount. Again, I wandered out to the Internet and found some partners and today we have a new generation of web that's because if that. Lastly, some of the NOI help make XML a standard. Was perfectly well it designed but is figured out how to make it popular in standard as we for applications to share did it because it was clear to me that applications of the web at data. They needed to talk to other applications and there was no standard way to do it. The some lessons I learned from all this. That's really what it wanted to talk about the book the first one is pretty well described by the players could -- Speaker. The lessons of Lipper is to the standard as simple and stupid as possible. The shorter of respect, the better. In the XML spec one of the things that the team was part of is the corporate had to lead was only a few pages. That is a really good sign. If the core standard can be read and understand in a food pages the odds are high that the standard is comprehensible. I have a rule that said the odds of failure at least the square of the decrease of complexity of the standard. Actually for the size of the square of the size of the committee writing the standard, very few people, three people came together to build the XML standard and only five for six initially on ODBC. That's the key issue and of the mark and mentors, busy building the implementations with an going to get to in a minute. In the health care will I think what this means is be very careful that your standard is very focused. Don't try and write one standard for everything you've ever we want to do -- I have to use the right to offer the job. Second thing space and this was a very surprising lesson for us in the industry. A good example of what happened in the car industry as well. If possible to the exchange should be human readable. This was not an intuitive thing at the time that we were reading dash front building standards. It was essentially of stuff only a computer to read and what that meant is it that the organism when your first of a meeting zander's things the market and just I bought as an engineer. And see what was going on. Engineers are people like everyone else to go to make mistakes like everyone else and often small companies that have a lot of back up. If they can a document and set that looks like, my looks different, why is that? They cannot figure out what's going wrong. As soon as standards started to be in text and the first was Tim Bernard [Indiscernible] the standards took off like wildfire. They took off like wildfire because every single person tried to implement than could see at a glance with Iran during and with [Indiscernible] and will look XML all standards can look at this open of the text editor and get the data going to. That's not entirely true. It has to be intelligible. And give a simple example not from the help world. The purchase order. If you have a standard for a purchase order that looks like a purchase order, engineering and and can see who the order to into the shipping to and what of the goods being shipped and so on. That engineer can figure out why the person on the the side can read that purchase order or vice versa. They can see it includes because they can get the head around it. It however they read the XML and it incomprehensible to them even though its in text, but you are reading it in France and you only speak English then they don't do so well. Because they still can look at it and understand why it's not working. And this happens in quite a few XML grammars and it happens because the grammars are very general model of knowledge. Of the first most famous of these was called RD F. There are still in its in the health-care industry that do the same kind of thing and the industry has spoken to this. Was extended for how to include blocks which was now much more widely used. Twitter feet, clicker, accused by go for a lot of their feet. The standard was called for SS and the first one of days that was tried be standardized and was very abstract and a general model. In a difficult guide called David Weiner wrote a different standard called RSS which a board all of the obstructions and brought the stand back to help him to read in the what caused it to be successful because anyone who was a publishing it correctly configured out. I think it's a key issue is that if you are building the standards and at all possible of the content that's been shipped from a vacation day to application be, whether its automotive or health records, something a human condition and said and Stan Getz listed medicines or that's an order, and pick up the left. If they can not look at that and see that, the odds that more people will be able to do it are very high. I bring this up because unfortunately, one of the things the health-care industry has picked up in this space is some standards that [Indiscernible] encompasses that violates this role. The third issue about standards this was addressed by the prior Speaker, don't build an 18 wheeler to drive a city block. The standards often fail because committees were very complex goals come together without any actual working implementations. And the intelligibility, the second point. Standards work best with their simple and focused. Part of the genius of the what is that [Indiscernible] separated to different standards. One the protocol, how did the figure out what browser, which server you're talking to from this of the browsers should display. It's like separating an envelope from the letter in side in its basic and necessary. And standards would include all the levels, all layers or all jammed into when they began to fall because you have to understand and then when they only needed to understand one thing in the boycotted. Find some other way to share data. In health care, this means the including once tended how to include health did it and decide who to get it and how to the sites could be and how to decide something else could do decide to to get settled. Duet protocol works for a while for that. Don't make program as one a new one. This is a key issue that stand as relation not address anything they don't have to. It's a man of principle and again, that goes back to my first point standards should be sent in do you can describe in a very small number of pages. If you look at the XML specs, it's more pages than I said but if you read it, that's because it includes the [Indiscernible] code -- If you took out the specific in coding, the rest of the XML standard is tiny. I think that a standard for sharing medical data should be very similar. The actual standard for users meant an lab and conditions and basic demographics, should be tiny and the rest of the state did should be a long list appears develop in coding or how you find the valid and coatings. [Indiscernible] have you know they're valid? One of the things the team understood is that cocaine's do matter. It doesn't do good to exchange [Indiscernible]. You will think someday the next point that we went on most of these tenets was always have to go will employ of his opinions as part of the design of any standard. It is really hard for anyone to know whether something apps the works are can be engineered in a practical sense until you do it. And SRS are not geniuses with the can simply build this entire incredibly complex edifice and had come a tested and it works. ODBC was built by many of us as we went along with the head of petitions and references Weaver using. And the health care will come to a lot of us have now built [Indiscernible]. When ever a standard doesn't have the people who are define in action living and breathing with real implementation that they're raising, that standard tends to be much too complex. It tends to be much to abstract because as did you have a group of people saw the problems they don't know. As a said earlier, complexly an abstraction to debate the death of standards. Lastly, we learned one thing that I think was very unexpected. We learn to have to put into a standard history for the unexpected. I was to buy one of my people last night that this is something called the sales law. And going to put a big block linking to it. Fundamentally the way I've always faced as if there's something that the receiver does not understand commission not break. It simply ignored. The reason this is important is there an issue that the press because talk about a burgeoning. It's a very hard to get people to upgrade our versions. It's much easier to get people to simply add data to an existing standard. Some people may not understand but others may. That works very well. That was built into XML and there was one thing I did add to the XML stand. Was probably this concept do you could interlace into a document that you otherwise understood come elements of the receiver might not understand and, which ones they were. Called names basis. So that that would still work in the way to think about it in normal terms is so you have an envelope and the is a little understood but there other things a test that you could either understand or not. If he did in you could ignore them and throw them in the garbage. If you do understand them, great, you could take advantage of the. This works well in standards because what it does is provides [Indiscernible]. In the EPI standards that the automotive industry's use before XML, there is really not out there. They thought they knew everything up front and define it up from exactly what they needed and that would happen is the standards would cheat. Since there was no room to add new did it as they realize there is no data, they would cram into old places the wasn't appropriate. To understand this disenrollment exit means why in this case. The problem with that was that only worked with everyone everywhere quote I did go code and that never happens. A much better model is to make sure that this [Indiscernible] in the standard. Basically you need to assume the unexpected. Those are the fundamental lesson that I learned trying to build successful standards. Keep it simple and release want to go to the stand for any kind of thing you're doing and in our industry and the most basic thing we're trying to do is get a quick list of men's Orangeman's conditions and test results and demographics about a user or just get an order placed. Would ever we are trying to do, don't try and have one-size-fits-all. Have a small sample standard. And then have a lot of precision about the encoding. The semantics of the data being shoved around in the standard. That's a place for the health industry is not involved as far. We don't have an ambiguous and coding. Looking back at XML, the was part of XML standard which is specific and coding called Unit code so you could handle XML constant coming from China or India or England -- We knew what they were. And what you were getting. When we do the same thing for medicines or the lab results or the condition, we don't have the government supported free open to use standard. In the same way the [Indiscernible] system was and that hurts because that really does cut down in -- Interoperability. Those are the real lessons I learned from implementing the various standards I worked on.

    Thank you very much at and. Let us turn now to John Trustman for a final presentation and we will open up and have a general discussion.

    Good morning. And John Trustman in speaking this morning about and limitation of a standard base connectivity in the property and casualty insurance industry. John and I have knowledge of the for a long time and I'm an ex health care guide. I put up on my FaceBook blog this morning that I was coming and I got in responses within an hour from people who said, with that you're going to try to stay out of health care, none of us believe you'd ever do it. On the former CEO of Aetna Health Plans and also the last chairman of any I see what some of you may remember. As being an interchange standard set up by the big guys to try to make some of this work which were about as well as you think in an industry which has a lot of little guys. Applied to in that context tackle the advice to health care question right up front. We have in our industry or in your industry, this belief that the industry is unique, more complicated and more sophisticated than any other. And in some respects it is. But in most areas of information technology, it's not. I'd say my experiences as a CIO in banking, insurance, securities of Fidelity investments and health care, has convinced me that from IT perspective, there's a whole lot more similarity there are differences. As I listened to the presenters before me talked this morning, all of our lessons are a across a range of industries which could be more different are almost identical. The major requirement and adopting HIT standards and what I'm going to talk to about this morning is much more about process. It's about the drive and commitment to do it and to do with quickly. And it's certainly my belief that you are facing and tried to accomplish can be substantially completed in a lot less time than you probably think. In 1999, the independent agent sector of the property and casualty insurance market was a technologically naive and fragmented market. We have participants ranging from one end to pursue independent agencies literally mom-and-pop, pop would sell the policy and Mom would service the policy. With no computers, completely on paper to national and international scale agencies like a on adventures, Harvard, nationwide, travelers, who are household names with thousands of people in their IT staff. In that market, delivering a consistent quality product efficiently and quickly was just not possible. We also have the burgeoning of the Internet and customers in this case the property and casualty agents as well as their customers were demanding more. They were expecting a policy that they be able to understand the policies, God forbid, there were expected to be able to get a quote on the policies and hours if not days, not weeks. And it was clear even ten years ago that technology might offer a solution and the industry trade association in independent insurance which is called the big guy or the II a come and its Technology Council, the city were committed to moving forward. They're having a meeting in my living room, my then wife was actually part of the ACT and they were discussing what it was great to take to get insurance agents to adopt and invest in new technology. And all of a sudden this expression came up. Meaningful use. [Laughter]. I was struck again by the similarity here that you had to provide a meaningful use to get these people to buy computers and make them work in their office. And what we proposed coming off the back of the couch, was in New approach to transactional connectivity in the industry. At the time, the industry had a standards body accord and a well-defined EPI standard. It had been in place for 30 years and at that point, it there're grand total of 30 insurers and almost I believe, 45 insurance agencies. Who adopted that standard. In 30 years. For those of you who are map challenge, that's about one a year. It was a standard that was again, to paraphrase Adam and David, it was onerous to the point of pain. It took a Ph.D. to read it and it took a forklift to move it around. The standard was geared at the largest participants and it missed the need for universal connectivity. Sound familiar? The industry in a few large for this pens were experimented with an object oriented approach but that appeared headed in precisely the same direction. Instead what we proposed that day was a new effort based on XML and open standards. Delivered on tight timeline with meaningful success criteria and designed specifically to be useful for the little guys. We said all participants but we met the little guys. It took us six months to convince the standards group in the industry committee that we had a viable approach. With their agreement, we listed a couple of senior technologist participation from a few representatives of leading in middle-market insurers and agents, and participation from several technology partners including Microsoft, one of the [Indiscernible] in the hapless as well as several of the industry software vendors. All of and had a lot use and often had their own agendas. This will shock everyone but Microsoft actually had their own standards that they were pushing. We listened for those of you who don't member. We listened to a lot about how the task was impossible and it was certainly couldn't be done defining the standards and promulgating it in the 90 days which targeted and that was never going to get any adoption. As it turned out, through its discipline decision making process, and the hard work of about a dozen motivated professionals, which she but we set out to do. The definition and implementation of the key core standards in 90 days. I will talk a little bit more about some of the technology but you've heard it again or heard before from Adam and David. We had extensive billeted, we kept things simple, really define what we had to. It's all you could do in 90 days. The standards were open, accessible and easy to implement. Which gave us some really nice documentation. Again, probably sounds familiar. But what it also gave us was a court committed team who implemented at their respective companies as we went along both to prove it to ourselves that what we are doing was correct, but also to prove to everyone else that we were suggesting was possible. The standards were lightweight enough, there are enough and extensible enough so we are able to meet the objectives and prevail in the standards were implemented in deployed at insurance agencies and in the industry vendors offer companies. And when they did, they created a significant advantage for the companies which adopted, that were quickly seen and followed. Within 180 days, of the adoption of the standards, we had the publication and adoption of this then is, we had over 1,000 insurers who had implemented at least some portion of the standard for meaningful transaction said and within two years the standards have become universal implemented from the smallest to largest industry participants. That's 1,000 insurance companies and 180 days to be contrasted with 30 insurance companies in 30 years. The math is harder. But it's a better result. The work transformed the industry enhancing accuracy, timeliness and radically lower in cost as the percentage of automated machine processing has gone from nothing literally, to a significant portion of the work in the industry in a significant portion of all of the simple work. If you wonder how is that the cycle and other companies that advertise they can give you their raids on the quote as well as everybody else's? It's a direct outcome of this type of work. It wasn't a [Indiscernible]. Extends ability which was a requirement to quickly support given additional and Commission requirements so if travelers needed to know the paint chip colored by their standards, and some else needed a verbal description, there were places in the standard to permit that. That stability is credit some predictable challenges and much work is continued in terms of application guides in subsequent releases of the standard. And better and better documentation and better and more automated implementation. The core transaction sets emerged very quickly. CUR insurances car insurance. Some of the more esoteric transactions for example, which the standard definition for ensuring a carnival? When we think we have a complex industry, think about what's the core information you need to right carnival insurance? How do you even approach that one? Every industry has its complexity.

    Our imagine [Indiscernible] is the key factor.

    How sharp the blades are and how many knives? And with the wait is of the nontarget? It's a problem. [Laughter]. But the standards of it and vault and expended over the years to cover most lines of insurance now. And universally implemented and used. The critical success factors. Intelligent and aggressive goals with phased incremental adoption, granular deliverables, and no OSHA boiling. I don't think I'm adding there anything that you haven't heard from Adam and David, let me reiterate. From a process perspective, a ruthless decision making process was a marked preference for delivery over consensus. If we got there in the committee in the implementation committee and we hit something that was going to slow us down, we just decided. Consensus is wonderful, it is not quick. Consensus is something that can be achieved over multiple releases of the standard but without someone taking a leadership role, distended will never be adopted at all. And talented and committed team which went fast enough to outpace any naysayers. Property and casualty has a that's a bit of insurance and sure some of you are familiar with the health care. Which is people like to slow things down. Nobody says no, they have concerns, and they have issues. With this team did was to be fully implemented or enough implemented so when people came back and said, we are not sure you can do that, we said, sure you can, we already did. They said, we have issues how are you going to approach this problem, we said we approached it this would go a talented and committed team which went -- Billed as a dove again something that I think and talk about. Design the standard and then implement it. Find people who will build as they go to work with people who I've already built around standards. Leadership which believe in the importance of practicality of the undertaking, not just that was important, but that it was doable. Design for the little guy. It's really easy to build a standard that [Indiscernible] can implement. Finding a free person -- Building is tenet that a three-person bought back.

    Of it suggests that employment since then it was easy but they got a few more programmers than the three-person EMR the implementation shop who really does make -- Need the three pages that. We used to joke and business that if you negotiate with the firm and have more attorneys then you have employees, just do whatever they want. [Laughter]. Kaiser had probably more people assigned to read these back and a lot of these constituent companies here have in the entire company. We have to decide the little guys. Finally, it's not really about technology. It's really much more about process. But make appropriate Technology choices. And I think both Adams and David had spoken to that more eloquently than I can. Thank you.

    Thanks to everyone on the panel. A very rich discussion ago we heard, things about the importance of process and government go at it from what you have to what you want to go aligning the incentives we move folks to the standards. We've heard a lot of interesting comments from add them. I reflect Adam unsub they heard about the early and implementation of the email standard which is send e-mail precisely, accept anything. And this is what fostered an ecosystem of people eventually getting it right because the had the history they described a they accepted stop on the receiving and promised them to send any. Keep my way. There was this notion and portents of vocabulary, of giving precise terminology in and an ally with standard is something you can do. Do this incrementally. Do in a phase fashion and start to implement and get better. A open it up to the larger committee and please, questions for our panel. David.

    What you -- What is unique about it to presentations is that they are driven by learning outside the health care industry but all three of you now have or have had or will have the practical experience with the health-care industry. The logical net step is to say how would you take the lessons you of three clearly laid out and apply it to the health care issues in front of us as a part of the next five years of meaningful use? And maybe add them if you are still on the line, I would be curious to know how you would approach that in particular around your critical point about the separation between the descriptive content and the messaging standards. Because I think health care we may be troubled that up a little bit. What advice would you have from your learnings to health care specifically?

    But may stipulate first that might bias to which I see this is consumer oriented. And may not address all the issues that [Indiscernible] has to deal with. With that, the thing I have discussed both with John in a meeting with the Marco Foundation here and with others and I'm action going to publish, is I would focus first on the simplest possible document that could be used to exchange the current state of health. Of a patient in those areas where we can have unambiguous in coatings. I would focused first and put differently on the demographics of the patient, the medicines that they are on and have been on, the test results they have and when they receive them. The conditions that have which as you probably know better than I is a very famous a problem right now. And it really stop there initially. Most people say analogies and I hesitate there because allergies open up this Pandora's box because of your allergic to be a better how do encoded and that's not a trivial problem. I think the government has the power and ability to not only write a standard for when I described where the actual standard could be tiny. If you think about what it would take to write a standard that would say here's our and code the basic demographic about this user, the basic medicine, the basic test results, and the basic conditions which is enough for most people who receive that did it to start to reason very intelligently about that user. That doesn't require much, the actual and codings are going to have to be blond and dynamic about their new medicines coming out every time and no conditions. But the specific standard would be tiny. I have used personally the [Indiscernible], but I don't have a religious affiliation to one grammar over another. I'm just answering your question. This goes back to my hysteresis expect the unexpected, have a way where you can have other sections to the document as New vocabulary's become available. Whether it's allergies, whether its procedures, and of the things that would be valuable to the receiving party. But with those parties that don't understand it, don't have to pay attention. Because a lot of them as a no, much better than I, the vocabulary used in health care is used more for claims and for billing them for clinical decisions about what this means for the user. If you have a bad shoulder, maybe 15 ways in which it was fixed, but really it only matters and what is the shoulder is bad and fixed. That's usually much less complex than the various surgical procedures that were used. To actually address the problem. For the consumer side of the business, you don't really care. I guess that was my point. It is of the care that it's understood and what is your health status. But I've spoken to many doctors and and as factors within want to know and if they only went about patience they said tell me the medicine is not wrong. They said giving the test results. This it give me any cagey and would be great if that could be included in the standard [Indiscernible]. And then I say for, then is it a condition, nothing else has come in and they say at this point and a lot and probably figure it out myself. The one be my very simple message co-star with something really simple, really achievable that could be deadly fast and solve one of the basic problems which is a lot of the encourage could use are not open [Indiscernible]. Standards should not require for you to pay royalties to a monopoly company. In order to use an encoding. For example, no one had to pay unit code Tuesday in coding coding for XML. Don't have to pay anyone for the encoding and ODBC cement the coins used for medicines for test results which I would urge you [Indiscernible] for basic conditions whether they are, who should be an open and free standard. Everyone can safely use because again, the small shops your hearing about are how standards adopted. And the small shops don't have the wherewithal to get the people [Indiscernible] even if the had the money in the time. If you want them to appear to stand, you want them to know that all they have to do is write the code.


    Och one of the things and I think this mirrors a lot of what's been said, but the first part is be willing to take 80% success. Don't shoot for 100% success which means define the things that everyone agrees upon. And the Chiefs to the officer for Covisint and one of the standards would been pushing is this idea of provisioning of users. It's complicated as can be. But we've said is I've been in meetings like this that we can define what the user is. And I'm not coming this weekend, do we agree people have for Sams? Yes, but. We have one field. We agree people have last names? Yes. Rollerson that are complicated but if I can hurry is then that takes care of the 80% that's good. The other thing is that you can try to block what reality is. And the reality is that every organization and vendor believes that they had specific value to transactions. And standards will find that. If you adhere it completely to the standard then when you are saying is I'm no better than anyone else. That's not human nature. The best example of that I used and I know of people know this and not, but there is a define standard for infrared communication between devices. And yet, nobody here has one remote control to to their television set and the VCR and that. The reason is because everybody thinks that their unique little button that the something is more important than everyone else's. You can either fight that and you define the stand because you're the most brilliant people in the world and you tell everyone that what they do is unimportant, in which case you'll lose. In what will happen as was part of an automotive, is that people who decided that the field in EDI was an important, and so instead they would put another call in there because there are much smarter than the standards guys were. Or what you do is define, to find [Indiscernible] to solve 80% and make extensible. And encourage people to come up with new things that extended and what will happen is those will become the effective standards. Someone will come up with a great idea, it will be adopted by the majority of the community, and then that will become part of the standard. That expense ability gets added on little by little bit as opposed to the let's listen with this and hope it's right. That's why something that we've seen again and again. Civil and extensible.


    I have a one word response which is [Indiscernible]. I think have 29 to 30 specific uses the one for disinformation coming out of sources including yesterday's. Grab a bunch of people and start implementing. You will very rapidly discovered what works, what doesn't, what simple to abdicate and what's complex, the based on the table and at the end of what I would suggest to be a very short period, you have made a tremendous amount of progress. And you know you did the progress when it is said of that group of coming to say where is going faster? You're going back to them insane, we can do all of that stuff, what else you want us to do? The only way you can do that from the only way you could never did have them is starting to go and all standards there's this huge desire to get it right and that [Indiscernible] the desire to start. I suggest start.

    Thank you.

    I will ask a couple questions and it. Adam, when you did ODBC, how many RD BMF as is were there in the world?

    And weedit ODBC there are only about six or seven in the world police that we were politically focused on.

    So basically they're all in the room and all implementer is?


    Thank you. David, I thought that was one of the best plan language presentations on the whole process of getting standards to work I've ever heard. Thank you. One of the things I think I heard was that he used EDI, the underlying standard with EDI for those transactions and that you had to deal with portals and other things as well.

    What we found is we started with where they were in 2000 it was 26. Computers talking to computers. What we learned is at the time there was a huge move toward saying, part of the problem with the standard was the technology was sometimes we need is a person looking at a screen making a decision but said it had been the epitome of those decisions Sapporo's for getting bid for web applications written a big. Is less and less the area where I will send you my inventory, and going into the tax system in a mature system. That created the same issue. Which was instead of having to either send my dated ten places, I now have to go ten places to go this that made ten separate IDs? Ten separate LaChance? Ten places to provision myself? Ten Ways and sets of security rules? So that also becomes a standard of interoperability. Your interoperability is not just the computer to a computer, it's a person to a computer and all of the things around that have to also be decided and determined.

    So a couple comments now based on this. And lot of the operational problem of making standards use is less to do about formats or transports mechanisms and more to do about the operational business of keeping a registry of participants, keeping its authentic, keeping it verified and so forth, would that be correct?


    Second comment, you found that where the standard was being used it was being misused. And that your solution rather than to define a new standard as an independent group was to develop customized mapping create an economic penalty for doing that.

    Yes. Our idea was to basically allow people to be on standard. And make them so that they would end up conforming to the committee by mapping. And the concept was people want to communicate via the standard, that they will get there when they get there. And if you allow them to get there when they want to, there will get there faster. Then if you force them, if you force them than they believe they're smarter than you and the right, you're wrong in your standard is ridiculous and I'm never going to do it. If you say it's a little bit like dealing with your kids Governor if you tell them you have to have to do something in the long -

    If you throw in the car keys, it works better. [Laughter].

    I want to comment that would David described is exactly the core competencies of an HIE today which is to say it manages the trust relationship, in a community setting, and it does mapping to create some standard interactions. [Indiscernible] that's probably 80% of the drill, but it's even communication style and format as well. I would suggest that as the committee we have to think carefully about whether our model is what David described which is starting from where the industry is and moving forward. Barbara Adams described which is starting with, creating a new stand in getting a small group of people together, get them and their room and make sure its own and lamentable and things like that. I think there's room for both approaches and the business we are in. And of the weekend, we have to be careful to know where we apply which approach. And a personal basis, I'd like to point out that in 1995 when I read the first HL7 spec, I built in hysteresis. The rule was if you don't want a field, don't give me an error on a. Just ignore it. My intention was for that to be an evolutionary process for adopting new standards. It was used that way in the official standards of HL7, but in terms of the implementation, people did the same things that did describe ago they would use a different field for they would add on. Hysteresis is as hysteresis does. We found in go into XML that one might have been ill-advised decision which was to adopt XML schema made histories is virtually impossible. And it's been a problem for us going forward. I do think one of the other decisions we need to make as a committee for we need to advise the government on is is it possible to support this notion of a small group of empowered employment years writing the standard behind closed doors. It has been my concern for some time that the nature of what the government expects of and as the bow in terms of process and open forum works against the principles that John and David and Adam described. That we have not the ability to do that and if we can find a way to support it, and create specifications that the government can accept as standards, we can make a huge leap forward.

    Carol and then press and in Jamie.

    I want to thank the panel for your comments. I think I agree with Wes and we really have to reflect on some of what you shared and think about what it means for this committee and our deliberations. My father was a very wise man once said if you don't learn from other people's mistakes, you won't live long enough to learn everything you need to learn by making them all yourself. And up to this day, I think that is an important thing to keep in mind. I'm interested in going back to the things you said about, and I heard this and all three of your comments, it was something to the effect of design for the little guy. And other words, don't ignore the fact that most of the people we want to have adopted standards won't have the infrastructure, the support, the technology to understand complex of the or to implement it. I think that is a very real issue in health care. And John, your description of the mom and pop versus travelers or whoever, is clearly the variability, the range of variability that we are grappling with. My question for you is this, and it rolls down a little bit on the process that you described, but I'd really like to understand how you got the discipline? Not to go any farther than you needed to because very often in this process is, whether it's in a C or group that comes together to try to define a stand, the people who come to those forms are people who can deal with complex today because they have the resources to show up at the meeting and participate in these things. I'm wondering if there is a process for a mechanism that you used to have the discipline to make sure that what comes out the other end is in fact designed for the little guy with the little guy isn't always there designing.

    It's a really good question, Carol. And let me be rolled up from. We use the most simplistic approach any of us could think of it to assure that. We make sure that half of the in place implementation team was coming from little guys and the that the big guys to find it. Literally, I think five of the ten people who did the work on a day-to-day basis came from people with fewer, from organizations with fewer than a dozen people. In the development organization and returned to the larger guys and said, instead of you putting 12 people on this because the most it can put this one anyway, give us some money so we can find the little guys participation. Because the little guys couldn't have afforded it to send someone on their own. There were, full truth of the 5 I think two or actual full-time employees and one case it was the founder and CEO. Three of them used the money to hire consultants, to work on their behalf and we used an acceptance on to the committee techniques that we used to use in hiring top developers which is the rest of the committee had to approve that anybody coming on in terms of [Indiscernible] to work and technical confidence. So that if someone should have wasn't going to cut it it didn't work. And the last thing was we had a lot of meetings. People got together in that group on almost a full-time basis. If you missed to meetings in a row, you were gone. It went back to the organization and asked if they could do something about it, and we allowed them to correct, but it was fairly harsh discipline. The last piece is we had a set of really nasty people who were willing to break ties. A tithing anything that would prevent us from going forward. And written both at the beginning that all decisions would be published as the group's decisions come not that I was tried to [Indiscernible] anybody, that I was a nice person. Because that would have been hopeless anyway. But at least that way we all stood behind the decisions of the group. And we were able to do that.

    To ask a crisp fall one? You all also emphasized this issue of implementation that favored implementation somebody doing it at all cost over trying to perfect the standard, if you will. How did that factor into the process. Was there an indication threshold that you used before people decided?

    If someone wanted to object to the major scale with the major thing they did bring to the tip of wasn't a petition that demonstrated the problem. And some haven't implementation that demonstrated the solution to the problem, we opted for the implementation that demonstrated the solution to the problem. To try to solve everything on a what's the practical business problem, what's the practical technical solution, and there were actually very few instances -- If you have a good technology group understands the business and you establish a working group like that come you get a lot of problem solving going on. We always had the ability to say this will be an extensible field that companies can use as they will and we're basically going to let it go as a free text and we will do exactly as been described. As to what evolves. And there were a lot of those. For pretty much everything else and everything that was necessary for the core transaction, we came up with a solution. And the group liked each member it the right to be the solution provider or some associated with that. It's not magic. It's just creating an environment where that success was preferable to failure.


    Thank you Remic for your comments, there were terrific. I think if there is a cup, then that you're suggesting we ought to think big, start small and move fast. I'd like to ask to questions. The first is the idea of little standards for little guys is pretty appealing. At the same time there's a lot of health care organizations that have been problems typically would have complex relationships with each other. Clearly that happened in the insurance industry and auto industries as well for example. Can you tell us what happened with the big guys and their big problems of your original guys a little standards?

    And automotive, it was the big guy so we were the big guys. We were on by the big guys and we defined that standard. The interesting thing was the standard was specifically defined for the purpose of solving a real business problem. That was costing the big guy's money. Their impetus was to get the little guys to support it. The wasn't very hard to get them to design for the smaller organizations because there was real money. You could really apply real money to it. To be honest about it, the big guys in many cases agreed to continue to communicate nonstandard for a while. In order to be able to focus on the smaller group. Standards are good for getting 5,000 people on board very quickly to meet a business problem. And the five guys who have it into committee can make enough of a standard for a bit. That's also worthy of model command. So the hub or broker got to broker those transactions to kind of make them stand for a while until they could get there.

    Second question would be to was his point about the role of federal government and so on. And I'm curious about that because your successes were done at the private industry or in a collaborative fashion. In this instance, the file government is [Indiscernible] and has a significant step in this. If you were to advises, where should the federal government draw the line and stop at the water's edge and leave other issues to the private sector or collaborative or nonprofit efforts?

    In my opinion, this is where the idea is the federal government needs to be deleted by actually adopting a single standard across all of its agencies. The federal government is not a monolith, let's be real here. If you want to be the leader, it's the define a standard, anything. But then implemented everywhere. You can do the thing that says we've and lamented it, but the VA has decided that interested in using it. If you can implement, as a single monolithic organization, in you cannot expect industry to be able to follow. That's really what needs to happen.


    Thank you. My question is to some comments that were made by Mr. Trotman and Mr. Miller, two related questions. One is you both talk about the role of a central clearing house for the industry to perform the mapping and other services that we've talked about here. And then I wanted to extend that a little bit and ask what is your view, the role of a SPs and other service providers to make it easy for the little guy is essentially to wrap up to the standard that's going to work for the whole industry?

    Sure. Ltd. The second question first. In 99, the notion of an ESP was not in the vocabulary. Today I don't know how you could even think about delivering sophisticated services to smaller players without starting with an ASP model. Finding ways to make that available even to the extent of perhaps the government going back to the prior question, asking some of the larger players to make what they felt available to some people who otherwise wouldn't have access to it. And it's absolutely the right model. Asking a small position is more a small physician practice for the physician is more than five for ten years out of medical school, to implement this top technology and connectivity is counterintuitive. It's not necessary today, it's asking someone to stop doing things they love to do things that at best, they are afraid of -- I think that something I've hardly introduced. As far as clearing houses go, I think there important in this environment as standards because they provide a central ability to actually see what's going on. Finding, taking data from the clearing house on compliance is going to be a whole lot easier than taking data from multiple transaction processing environment and tried to find out what's going on. And I think that to the extent one of the closer is in fact understand national compliance, national issues in health care, you have to build into the not coding standards, but into your implementation plan. In your implementation standard mechanisms that will deliver against those things. And also hopefully reduce those costs.

    We are at a time for this particular panel. I want to take all the panelists and Adam, thank you for getting about 6:00 a.m. your time to join us. Your doing God's work every bit. Various full.

    Thank you.


    We should transition now to the providers panel. And I would ask if Judy, are you going to stay here?


    And leave it to you to introduce the folks who are going to participate.

    Let's get started. We have our provider panel assembled. We have organized this one in a way that we've got a combination of the folks and Little folks. And use the same term that we are using in previous session. You're going to go a bit out of order with what's listed. Dr. Wiesenthal has just landed and will be coming here so we will probably settle back and do him last rather than doing him first. I would draw your attention in your packets to the company bio for the folks we are doing the abbreviated introduction this morning. There are full bios available in the package to have received along with all of their submit comments which are a bit like your even then we are allowing them for the physical presentation this morning. Thank you all again for joining us. Let's start with Dr. Dick Taylor. Pediatrician who is currently CMIL and Providence Health and services in Oregon.

    Thank you. Good morning and thanks for the opportunity and I get to the first which is all the pleasure. Providence is technically one of the big guys. PRN integrated delivery system with an Oregon the service multiple acute-care facilities. Has dozens of smaller clinics and a health plan and a home care service. But we're also very much aware of the problems the little guys because we do not own most of the physicians on how we rely. When we look at our history of interoperability, one of the first things that the parent is we have to figure out how not only to integrate data within a large health care delivery network, but also how to bring in the specialists that we do not apply which is virtually all of them. The small primary-care physicians and the physicians and the critical access regions of the state. And Providence has been doing this for a while. We've had -- We've had an aggregating physician portal for at least the past ten years. We've brought various kinds of data into it. And we've fought the option battle. We have brought credit data into the portal. And then fought to give providers to look at it in the hospital. We made the portal available to the clinic providers in their offices and then fought to get them to log in and use it. As we've done that, we discovered we are not making the grade. So the interoperability story for us and adoption story for us really came down to understanding what we are doing wrong. Because when you have to fight a battle for ten years, there's a device between technology that new and technology that is wrong. And sooner or later if nobody is adopting it, you have to ask why. There's a concept and medicine recall their pivot noncompliance. Which is when you don't take your medicine and it's a good thing. And there's been a lot of therapeutic noncompliance with did it aggregated across organizational boundaries. Because it takes a physician longer to read it and longer to understand it, then it does to actually just ask the patient and do your best, it may be inappropriate to not used interoperability. Starting from that, we decided rather than try to do what we did and which is to bring clinical summaries from various places, the clinic and when I said the clinic, we have patients that are seen by 12 different providers. For 12 different last clinic visits. And knowing what's going on with a patient can be very challenging the. Rather than try to bring it all, we said to Adams, P4, what's the one thing we want? Is the medication list. The allergy list turns out to be easier to work with than you might think because it's a list of medications. The peanut butter elegy is a great question, the answer is we don't care. You will take that as uncoated and we will code it later go very much an implementation strategy that I endorse. We said how do we bring this across organizational boundaries? How do we do this for the small providers that either don't have an EMR or have a very bare bones EMR and have no IT Dept.? What we've said was this has to be a capability that big in sued the EMR. This can be something that you asked to provide a to implement. When the kids about the standards is just as we don't ask them whether they want Oracle or sickle server or my sequel, we also need to say, ultimately if the date is where it needs to be, how it gets there should not be something that's transparent and obvious and unnecessary problem for the provider. So we said, concentrate on the condition. What is the commission need at the point after? If there are 12 different medication list out there, how many are there really? The answer is one. It's whether the patient and out of the medicine chest this morning and took. Saw what we need to do is to find a way to aggregate that medication list and put it into a form that the provider can look at quickly so that they can talk to the patient and understand what the patient and out of the medicine chest and took. With the analogies, if there are told the phonology list and all have penicillin on them, the patient is allergic to penicillin and nothing more. What we said was we need a standard approach that has the semantic interoperability necessary to understand that penicillin is penicillin as penicillin. And at the same time, to break that down and put that in a useful form from the physician. Our biggest problem, the business problem we try to solve is fragmentation of care. The fact that as a patient moves from one environment to the other, they may be getting terrific care in that environment, but when I walk across the hall would drive across the city, the minutes will be from Pluto. Because the provider doesn't know enough about them, the registration as a no but then, this is a new area for them. In that moment of great risk to the patient because we know this has been widely published, transition points, and transfers between level of care of the places where we heard patience. We need to get information to the provider at that moment and it's a difficult moment for the patient. They may not be conscious. They may not be old enough or Senate enough to participate in their own care so we need the system to support it. We let hard when Weaver implementing our new approach. At taxonomies and standards and the great thing about standards is there are so many to choose from. You have HL7 and HL7 the point X and CR and CCD and have [Indiscernible] with which you can do anything. To have a variety of suppositories standards, and what we decided in the and is it needed to be very core, very straight forward and again to the point raised earlier, it had to be extensible enough that we could do almost anything with it but at the start with this basic core set of data. And we also said do we have to honor the current clinical workflow. The point is not how do I make physicians practice medicine the comments had wide support what they're doing? If they are doing something wrong, what we discovered, we mapped the work clothes in many of our clinics to look to see how the medication reconciliation is today. What we discovered is there's a curve. The amount of time span I medication reconciliation increases with the number of medications on the list until you reach between six and ten at which time drops off, and. But happening is the blood in addition to a level of growth in giving up -- We don't want them to give up so we need to support better behavior and need to understand what's happening and who is doing it. Is it angers, a physician, when we talk providers and the small offices -- We have to support the work flows that exist. We're focusing on our core data and focus in on a high degree of success with the core data. The greatest triumph we've had is over the past year we've created a prototype system which is coming to production. Which produces a summary of key documents, a coded vendor neutral summary of can document from our vendor's core Systems for every visit of care. For every change to a clinical test. And every time a clinical list is populated, the court HIE suppository [Indiscernible] it's bought in integrated without the provider having to ask for having to interfere but then discrepancies in the data are presented to the provider for confirmation or rejection of the have control over their own record. The bottom line is this is a small piece. Folks to say I want to medication list, you dig into that and it's complicated in a hurry but in the end of day it's just a medication list. It's just the allergy list. We needed to be shared across multiple environments of care. We are doing and bring into production literally within the next few weeks is this capability for all of our patients, for every transition in care. And that we think is the proper ID way to use the standards. The providers will never see the standards. One of the woes we sat down for our vendors was a few may not say HIE, it may not say it's become the main not say HIT anything except English and clinical English. And it's critical because if you were a provider in you have 50 minutes a patient your scene for patients, if you are busy asset but he did have time to sit down and buy your way through a second coalition headed for something as simple as a man or allergy list. With that, I will be done and pass it on. Thank you so much. That is a great example of both work and what didn't work. We will move right on to record and. Who is the VP CIO at allegiance held in Michigan. And he is an example of a community hospital. Thank you, Judy.

    We are a smaller scale than what Dick is doing and a very impressed with what he's done in Portland. Last night at 6:00 p.m. our senses in a hospital was 249 patients. This morning it was 259 patience. It gives you a sense of scale for us. Today at like to share our experiences in working with other providers and to many to representatives to beverage packaging to improve a 1/2 -- Outcomes and a 20 -- From the College of Health and

    In 2005 our local physician organization, created the Jackson community medical record organization. In so doing we implemented and probability across organizational boundaries with a mission of leaving our community to better health and well-being in every stage of life. To accomplish this we used HL7 standards available to us from our vendors. As you have heard several times their implementations and interpretations of the standards are different. We have had to use our limited resources to translate between the vendor interpretations. We only measure the number of providers using our EMR and the number of patient visits. In the future we are warning to measure population and progress such as diabetic patients with diabetes Control. The role of Standards and in accomplishing interoperability to achieve our goals is critical. The exchange of information between providers and with Allegiance is vital for their work load efficiency and care. We are working to standardize how and where did that is documented in the EMR, how flashy it display and capture data for efficient workflow, [ indiscernible ] opera ability and care coordination and the use of data for future analysis. From our experience, changing technology is the easy part. Changing workflow is the hard part. Dick talked about this. In our experience is that adoption is about workflow, behavior modification and perceived value. Standards must facilitate more simple workflows. One example is aggregating data from multiple sources into a composite you rather than just compiling lists that does not have have to open up. They will not use it, from our experience. As standard all the data should be used to determine the most effective treatment methods [ indiscernible ]. Will design Standards [ indiscernible ] correlations and interventions and outcomes that such capability will consolidate the learning needed to treat diseases as well as keep people healthy. Before we solve important loftier goals we should start with a National-[Audio interference].

    The records we exchanged our for the correct patients. The single biggest thing in my experience in accelerating adoption is to clarify the timing and method of payment for the incentives. One of the things we are doing it as we are using our internal standards within our database we tell physicians if they put it in is right and document the field we will do the automatic reporting. There is not lot of skepticism around if those payments are ever going to show up. I encourage ANCHA to pursue public standards to achieving these type of benefits. By setting as expectation early well ahead of implementation deadlines the vendors will have time to build the software that will operate better in the future while requiring less effort for implementation. Thank you.

    Thank you. I think we will have some questions about that, especially the National patient identifier. Moving on to our other Community Hospital, Lisa is the CIO at regional West Medical Center in Nebraska's because you are on the phone, right?

    We are here. Can you hear me?

    I believe she had no is no issue and had intended to be here. Here we are before Halloween and whether issues still to take it away, Lisa.

    Thank you for allow me to take part this morning. I am sorry I could not be there this morning's. The first is my perspective as a CIO from Nebraska and to give you background we are not made 184 bed hospital and provide them wide range of services for the size of our hospital because of our location. There are not a lot of options. We had them lot of technology installed in our building and have been [ indiscernible ] four out of the last seven years and have been able to achieve Stage five EMR adoption through the [ indiscernible ] scale. I will talk about a problem we have the required interoperability. Our radiology group gave us about three months' notice to change our practice because of this impacted us but we provided radiology service for several critical access hospitals within the regions because of the most attractive respondent we had to the RFP which was from Colorado which is about [ indiscernible ]--We needed to send them orders and images and get results back. We have been providing lapper radiology transcription results electronically to our physicians and providers for years or more. That is functionality we did not want to take a step backward on is because the biggest party during this whole thing was to have uninterrupted high-quality service. That became a challenge because we had such a short time frame and had to implement or rounds for radiologists that were suboptimal. We managed to move forward fairly well but it happens in process because of the short time line. I am not sure we could have done anything about that. It was frustrating. As far as standards we use the [ indiscernible ] and use HL7. We were able to get results into our EMR, data repository and [ indiscernible ]. The biggest challenge we faced was that many times when you are trying to get data sharing among system should have to manipulate the messages and these required a tremendous amount of manipulation and we have done lot of programming time and this was our first foray into programming interfaces and was very difficult. We managed to get it done but now have to support it. That is a lesson. We are a small fish in a big pond and do not have the resources because IT is not big issue in role Nebraska. We have financial constraints that most small providers have and there our vendor costs associated with customer interfaces, as well as. It is a challenges because we are fortunate to have access to a interface engine to pass those back-and-forth and do that at the interface levels because that is not an option for many, many providers. More standardization is imperative. From a regional perspective--we are now may enter--I feel like I have some context for this. Got one of the biggest challenges we see out here is that small providers do not have any data yet. Data sharing is phase two when we have not tackle phase one yet. We have to get the systems did not place to have the data to share it. The other thing we see our smaller systems and home run systems that do not have the sophistication or capability to do the exchange of data. The smaller hospitals and providers like even more IT expertise and resources than we have and lack of fresh capital to subsidize. And of the Medicare incentives are coming but they have to put the capital of front. From the state perspective, I am sitting on the board of the Nebraska health information initiative is because that is NHI for short. Riverwill to five hospitals and several clinics and are in the process of rolling that statewide. It has been a privileged to work on that and get one of the biggest challenges we saw during that implementation was the privacy, confidentiality and security issues because we not only have federal mandates but state laws an individual into the policies and procedures and is very, very difficult to reconcile those and find out what will work for everybody. Another thing that helped was the Consumer Advisory Committee. We had to get the patient the table and find out that they were educated and see what we're doing. Interstate exchange will be even more challenging and complex and a need for standardization is important. I would echo what Dick and Rick said, lessons learned, best planning, training and support our vital. Thank you.

    Thank you, very much, Lisa. I did not make this note at the beginning, but she is also a nurse and exact and ended exactly on time as nurses know they need to do.

    [ LAUGHING ].

    That hit zero and she was dubbed. Moving on to Dr. [ indiscernible ] who is our next presenter, family practice physician in Whitehall and board the purposes of our panel, representing small practice.

    To present for Europe listening enjoyment a short-story in three very short parts.

    [ LAUGHING ].

    Part one.

    Ann is a patient of mine and it middle aged and as medical and social issues, in a Family Medicine patient population and in is eight we are including hypertension, diabetes as well as social issues. She takes care of her elderly mother and worries about her daughter and two grandchildren and until recently she also worked full-time. How she obtained her care from our office is very cutting edge and reveals a plans of how primary-care anybody effective health information technology should work. Before her or her mother comes our current account-[ CHEERING ]-[Captioner has lost audio. Cpationer will redial.].

    The Electronic health records are the same electronic health records but did not communicate with each other in anyway. Part three, Lou. Like many physicians that have made the transition to electronic health Records, there is no way I would go back to paper records because my worst it with an electronic health record is better than my Best it with a Park and tepid record. I have been thinking about this since the late 1990's and if you would have told me back then that in 2010 we would still be in a position to communicate mostly with paper would have laughed. Additionally as I have become more connected to my patients, I have not needed to see patients as much within the office setting. This is an effective and somewhat interoperable technology solution, since I am only paid for CA patients in the office, some days I think this will run me out of business because of the message is that full interoperability is the a laudable goal but will have a profound change in the medical system. The development and rollout of communicating Systems does not operate in a vacuum and will incur press down changes, as well. Finally, we have a minute or a minute and a half Left. I am earliest because I came up with this with the health Information Technology haiku that could solve summarize this problem. Health Information Technology, effective, and interoperable, expensive [ indiscernible ].

    [ LAUGHING ].

    I did thank you ever before and listening. Appreciate it en thank you for my five minutes of fame, which I assume is after inflation, the original 15 minutes I was allocated.

    [ LAUGHING ].

    Thank you, so much. I am sure we will have questions or get you the end. We will move to our other small practice provider, and Dr. Tripp Brad.

    I am family practice because and I am another little guy I would also like to have the seven handicap for time, if I may speak as I speak slowly.

    [ LAUGHING ].

    Lisa must have been an auctioneer in for previous life. I have a hard time keeping up with reasons I am from the south in. Are divided thank you the implementation where group and the HIT standardization committee. Most of the testimony follows the written testimony I have provided any names I will mention our real persons that have given their permission for this testimony. I will tell you about how I came to this meeting but what you to know that I am connected to many physicians across the country. Some parts of these responses not only present my perspectives but those of many. I thought I would have the greatest impact if I gave my real life experience and using computers in the healthcare field for over 26 years. You would not want to see that old PC. I am the one of three physicians located in Virginia 7 miles west of the seat. We have over 12,000 registered patients. We have hard wired PCs in every room accepted doctrines and reception area. We use the 2009 version of practice partner, which is a McKesson Product. And not like other well implemented offices we use all aspects of our folly it under an integrated EHR. Please see written testimony for get those details. Let me ask you a question. Who believes we can attain a paperless office. Please raise your hand.

    Well, I am here to tell you that we cannot do it.

    [ LAUGHING ].

    [ Audio/Speaker not clear].

    We are a paper light of the. We have a dynamic website not only for our patients but also for physicians that are trying to implement a EHR. With regard to this and the interoperability with our patients, let me give you a breed examples. A patient of ours had a reset [ indiscernible ] and was able to log on, answer a set of questions that allowed me to review the case adequately and I made the diagnosis. He was able to remain at is important job without losing much time. Received secure instructions on the care and later picked up the prescription that was sent electronically to his personal pharmacy. A lot has changed with regard to interoperability back to 1993 and 1994 when it was, essentially, non existent. Wouldn't it have been nice to have the standards that then? I think so. Today the interoperable of the potentials are there but unrealized but most practices. That is to represent today. I'd like to see the small practices are given the resources to make it happen. That is what the American recovery and reinvestment Act is all about. I would ask that you make sure that the ones with the least are put at the front of the line, at least with health IT. Large Systems to have the resources, both human and financial to develop IT solutions but the small practices do not receive much attention. Let's talk about two physicians at the opposite ends of America. In Arizona and New Jersey. These and two excellent physicians have a fully implemented [ indiscernible ] within their walls but both said to me this week that their prospects of interfacing with their hospitals and Labs was a pipe dream. They are not hopeful for the short or long term. To have talked about the paper conundrum that we deal with, except in Catherines and faxing in Mike written testimony, but [ indiscernible ] is a real problem and I have a article about that. I also talked about the insurance interface with the electronic claims and how a [ indiscernible ] was implemented differently across different carriers and caused as merely to go bankrupt. Please read the testimony of. Silos, this is a [ indiscernible ] but breaking down those silos through interoperability by having a standard communication interface that they actually use for the interchange of clinical data would become great starting point. Let me talk about eScripts. This is how a written single standard can look well for all parties. As requested you have asked for examples on how interphase improves quality. The Electronic prescribing has led to increase quality by reducing errors. In the written testimony I described them good friend and patient of mine who have an incorrect medication filled by a pharmacy. By using eScripts we could identify and error by the pharmacy that we would not have known otherwise because this was picked up on. Request and he got a heart medication for several months for his leg cramps. We joked about it and I said at least his heart was doing okay over those months because you can see the electronic interfacing help avoid a significant mishap. You have mentioned outguns in the questions because in 1995 practice for research was formed. It is no collaborative effort between Medical University of South Carolina, McKesson and participating practices. They have 152 physicians practices--And approximately 1.8 million patients across the United States. Batch-research activities, designed and protect the confidentiality of the patients and physicians and minimal time commitment from the busy physicians. I think you have heard that. We are busy. We have been about in multiple research studies over the years and are involved in one now. And other ongoing process is the quality quarterly reports that each practice gets to. These quality reports-and this allows us to measure up to fellow members and national benchmarks for get quality care. This reporting that each PPRNet receives improves the quality of care and delivery. For physicians I would say as far as mitigating the problems of implementation, it is best to talk to champion for physicians and other champions in the office. I think that the victim mention behavior modification in. I think a lot of Xanax would help that. Cultureit implementation for lunch. I think you know that. To help this process of creating a culture for fellow users I created an online database does-it was formed in 2003 and comprises 580 practices and is International in the scope, diversity max size and type of practice. Oncemember of the database you can query it to see how others implement their EHR PPRNet closing, let me make a few remarks. In my experience and interaction with multiple physicians, any standard for change should be one with which the physicians do not have to worry or think about it. They just want to plug and practice. They do not need further distractions from delivering excellent healthcare. Almost all physicians--As has already been mentioned. Ideally, physicians would like to have interfaces that do not require significant configuration or set up. It is my understanding that a heart attack harmonization effort under the auspices of HHS has already been developed and makes sense to me and others to no longer delay this process. A harmonized, widely available standard, not subject to interpretation can only help prevent problems in the future. If we keep physicians focused on their patients and delivering good medical care without having to worry about health IT interchange standards, our healthcare system would be better for it. Time is of the essence. I know. I have been waiting since 1993. Such a standard would help lead our country and all stakeholders towards better health for our patients, our families, communities and the nation. Thank you.

    Thank you. Doctor and the Weisenthal has right. Accused is associate director of bass-clinical Information support. Go ahead.

    Thank you. I represent the opposite pole, sitting the opposite end of the table with these large medical health group's. We have lot of things in. I am here on behalf of Kaiser Permanente--I want to thank you the workroom for allowing me to testify this morning. In implementing standard-based HIEs, our primary goal is improving the safety and quality of care which is managing data care what Kaiser Permanente and many healthcare organizations with sculptors facilities, laboratories, public health authorities and others. We must do this in all of the vocations that we deliver care. Second, we must have seamless coordination of care with patients the receive some of their care from Kaiser Permanente and some from other organizations. Is central to this court nation is interoperability based on national and international standards for data problems, drugs, imaging results and other defined categories and clinical information. HITSBY stands have been good bass-which, by the way, my organization uses and HL7 standards across our multiple geographies and jurisdictions. These are required for clinical coordination within the Kaiser Permanente. HL7 messaging helps us move records between clinicians and consistent vocabulary based on SNOWMED CT--Clinical documentation is understood in the correct context and all patients--Like my colleagues referred to link to these data elements. We must ensure the same high levels of patients day Quality of Care in any location at anytime. Because we operate in different states and jurisdictions, national and international standards are extremely important to us. HIT standards implementations - - cost and complexity and diverse resources from patient care investments. The opportunity cost of variation in HIT implementation should be seriously considered by this committee. If our long-term national goal is to implement interoperability standards that are for all patients to the city and benefits of HIT, allowing for variation even if it seems expedient will delay and undermine that goal, reduce efficiency and [ indiscernible ] the total cost of implementation. Claiming alternatives are easier to implement is misleading but can increase safety risks and the disparities of Care. HITSBY HHS standards - - actress ability to read an original source and alternative solutions do not. As a clinician I am more likely to use the data that I trust. When it comes from a HIE or any source less reliable than a belive chemical record the patient might be less--I cannot see the quality. Suspicion about the reliability of information [ indiscernible ] what are the acknowledged as costly and unsafe. It would be tragic to miss the chance to improve data test readiness by failing to appropriately standardize HIE, perpetuating this damaging practicing in a EHR World. Our greatest success with Kaiser Permanente Best as starting with several partners like the Veterans Health Administration and using standard already recommended for meaningful use. We have repeatedly demonstrated that our production ready systems are able to exchange CCD including public demonstration with several operational [ indiscernible ] in California. Their different approaches represent alternatives in an emergency under an emerging market-HIT solutions are reproducible everywhere. Our frustrations too implementing standards are common in clinical data 15 Projects, competition for scarce resources and difficult decisions about investing human and capital resources--Could mitigate these problems and exhilarated options because training the detailed reports on various standards could result in or data integrity of the clinical records being exchanged and scarce resources will be further diluted. It will take much longer and cost more to achieve the same benefits in Chemical Safety. Funding standard implementation is another factor speak meaningful use for hostels and physician clubs will accelerate adoption. In some HIT and HIE standards will have the greatest impact--to providers and the ability to use that data to include healthcare activity and patient safety with consistent adoption and implementation of the standards, the substantial benefits of HIT and HIE will be realized more rapidly by most clinicians and patients.

    Thank you, very much. I would like to thank you all six panelists for a very robust and sincere presentation, particularly I enjoyed the patient and provider stories that you all shared.

    The haiku.

    Yeah. We have about 45 minutes for questions.

    Thank you. All are want to share with you, Tripp, I was pocketing as a nurse-that was documented as a Norris. When listing to your stories, I did not hear how long it took you to implement. We are working together to get the standards and what we need to do, that would help was a great deal in terms of understanding the baseline. If you could see what you implemented and how long it took you, that would be very helpful.

    Do you want to start?

    We have implemented an electronic health record across the entire continuum of care, 14,000 doctors and 150,000 some other staff of using electronic records. We are operating the hospitals and all of our ambulatory settings, pharmacies, imaging departments, everywhere. It took us five years to. The bases, the core of it, all of our data is encoded in SNOWMED CT, etc. and any messaging that goes back and forth between the systems is HL7 standard messaging. We have developed, as I said, the capability to export CCDs to anybody-it is like having the world's first fax machine. Nobody is ready to receive the fax.

    Just to clarify, you do create CCDs, but no one is accepting them?

    We have the capacity to create them and exchange them. We have shown that we can do that with the Virginia which is a completely different system.

    Got it.

    Our story goes back more than 20 years and I will not give you the full implementation details other than it is a ongoing process but not specific event. The interoperability we are talking about, the integration took about six months to create using a non-standardized approach, customer implementations become the prototype we created, which is a CCD exchange between two vendor systems using our own HIE was 12 weeks from goat to delivery. Since then, we have spent the better part of this year in taking the prototype system and making it into the core of the vendor's EMR systems and that is subject to their stock for development cycle than the actual amount of coding required. That was relatively modest.

    I will take moderator-I will ask the question-Your clinic [ indiscernible ] was something outside of the workflow and what you feel is so different with this new process is that they are importing that, if you will, into the native EMR and seeing it within the context of the regular record.


    When they go to [ indiscernible ], in the clinic system, or in the McKesson system in the hospital, what they see is a composite view of the medication lists that have been given from the HIE with distinctions highlighted where there are disputes in the data, we resolved as quickly and that is where we implemented the prototype last year.

    When you talked earlier-you are talking about medication reconciliation, but you do have a EMR. Do you have a EMR in your hospitals?

    We have McKesson in the Hospital. Those are the two systems there. We have two more vendors implementing their own prototypes for integration as year.

    Thank you. Dick?

    We started with the portals use of for labs and other information from inside the hospital in 2001--We have been doing the rest since 2000 by.

    Your up next, Lisa. Any comments?

    We started our EMR in the Hospital about 10 years ago and it has taken us about 10 years, but we are almost completely electronic on the back and. The exceptions to that are any written orders, written progress notes from physicians and anything that requires the patient signature speak otherwise we are completely electronic, but it has taken us 10 years. The actual integration that I talked about with the radiology group took us about 60 days errand from the [ indiscernible ] perspective, that was about a three month implementation, if I recall correctly, it might have been four months to get the pilot going for the health Information Exchange for Nebraska.

    My learning curve has been 10 years. I started 10 years ago to start in another office to do electronic prescribing and we did that and learned a lot. In 2002 the hospital allow me to start a new office so I could do a full electronic health care record implementation. The ideal with that, I liken it to cross the a Desert. If you do not feel you can get rid of the paper, you do not start because you must get rid-I tell people the goal is to get rid of the paper. You might be totally paperless, maybe paper light, which you probably will, but you need to get rid of the charts and it has to be one interface. If you end up with a mixed system you are worse off than you are when you began. It took our Office 12 to 15 months to transition from paper to everything on the computer. I would reflect on what the first panel said that the enemy of the good is the perfect. Implementation is an ongoing process and that is the fun part is that it never ends. Once you do that you start thinking about your system and what else can I do. Instead of faxing prescriptions we can do ePrescribing--If you think about it, there is always something you can do. Our main thing is to get it so that we could [ indiscernible ] on the computer interface. It still amazes me now after five years that during lunch, if I wanted, I could get into my record and write a prescription for someone or answer their question, absolutely impossible in the paper world.

    Your first patient story was about Ann. Was the a Personal health record involved with that?

    We do it through relay health. That does not even transition. I cut and paste that. That is not perfect. I always think, what is the ideal situation that could happen, and then we back off from that as to what is the situation we have now. It works out okay with her. Eventually, that is the paradigm. How do we get people to help physicians? Who will help the doctor and the office to this? What is the source of the help? The source, ultimately, will be the patient.

    Thank you.

    To answer your question about the portable health record, I remember back in 1995 a patient wanted to go to another place that had a EHR and I was able to put it to our a 3.5 the floppy--Unfortunately not lot of doctors what to do everything, all of the sudden, and it's like drinking from of fire hydrant. What is good enough? Eventually get better at it. That is the key. In 1998 we started a lack interface with our regional lab and even the National Lab and used the ASTM and had translation files to deal with translating it from their ASTM to our electronic medical record. That took a year and we had to use it-talk about the written testimony, we have sneakernet Mac. It was a floppy that they printed all the files on and had to bring it with the courier because they were so worried about HIPPA and did not want to do that over the Internet. The security standards were not as good as they are now. It worked. Now we have a bi-directional interface with them and can do more entry with them. The eScripts is a good example of a single standard that everyone uses and even as mom-and-pop pharmacies that had to set it up on their end of the equation, and I must say some of them went to this kicking and screaming, actions of the efficiencies. I talk to you about the quality initiative and that has happened several times since then. Of the insurance industry is a good example. I speak without money lot of experience, I must admit. Electronics emissions took as a year to set up and then carriers decided to interpret the standard in different ways and there was then period of time where we had no income Electronic submissions. We also intend almost went bankrupt. Oh, you did not fill all that field, oh, you will have to resubmit it. Are really plead for a Common, single interface. [ indiscernible ] does not give a flip about what his, as long as it works and we do not have to pay our EHR vendors a lot to reduce something which we will if we have to change things around much.

    Let's go to a question from David.

    Yes, hi. Dick, you errand Flloyd mentioned that it should be same as or invisible or transparent. I want you to elaborate on that and, Dick, I will start with you. You said is automatically imported into the record but requires an acknowledgment. I am curious to know about the acceptance of the physicians of that approach and would also like to know how that might change as the source of the HIE data gets more broad and in particular as it includes consumer control repositories, personal health records or health banks and on the reverse, it does the data that the providers add to their own record automatically flow out to the HIE, or does that require an acknowledgement or something like that? If you could just elaborate on that?

    Sure. The technical details first, data flows in whenever it is available in the HIE and cons of in a semi-trusted way. It comes in and if you consume an allergy, the allergy and allergy is coded and it will place the coded ology into your list and the deposition support. If you are having to write a prescription for a medication for which the patient is rumored to have an allergy, you will be warned about that. It is not truly in your record and tell you if confirmed it. This answers concerns we have had from independent, private practitioners about losing control of their own record. They want their own judgment to drive what they believe to be true. When I say it is not truly in the record, when you sign the note, when you leave the charge, it is automatically published back to the HIE. This is the other technical details. Publication is automatic and is at other [ indiscernible ]. Application publishes only that which you have confirmed. You cannot convict --The issue personal ... records is interesting. The patient is the ultimate source of truth for the record. This is all historical data that comes from the patient. There is a great deal of discussion about how you integrate this data. As long as you label the source and is labeled in our system, not by the system that produced it but by the person that authored it. It is Dr. Smith that enter this into the medical record, his name is on the prescription or allergy. The patient is identified as the source of truth and if the clinician is given an opportunity to confirm that information or rejected as untrue, that has been in our usability testing in the prototype and very well received. Similarly, colleagues that do not know information from across the country, it is different if you know the physician. As long as the sources identified and you are given the clinical choice to make, this appears to be well received. Thank you.

    Any other comments box.

    I agree with that. Our physicians and others to in our system what the exact same thing to be true, that it can be traced and you know what the source is. Patients are giving us information all the time. I would add that the standards, currently available, allow for that to be traced and identifying the source and that is why the CCD, to me, is a very important standard.

    I could not agree more. This is that one of the standard details,--Each individual element of the document makes it possible to preserve that risibility across time and republication.

    This is a technical detail, is it digitally signed so that I cannot be reputed or are you taking it at base value entrusting the sources listed.

    We are not doing digital signing of that document. We will probably go to that in the future. Right now we use the circle of trust and we know where it came from.

    Thank you.

    Can I respond, briefly? One of the things as far as the Personal health record, from my perspective, where is that information-and like you said, how old is it? Which [ indiscernible ] did the patient get it on and where is it hiding? Would talk about paper metastases in our practice, but these would be the - - of one to get to the concept of the patient-centered medical home. We are family doctors, and we would like to think that we control them lot of the information or that the patient can come there for their care or be funneled out with everything else because I think you would agree that medicine is dispersed across many different places. It is hard to really get all of the information. This interchange stuff will help us, but I can tell you, as Lou will tell you, frequently people have their personal care neurologists and might have their personal care podiatrist, if you do not know what is going on with those patients because they do not understand the concept of the patient-centered medical home. Especially family doctor or pediatrician or turn is that like to take care of their patient, it would be nice to have all of that information.

    I will second that. May be the arbiters should be the primary care physician, as long as there is enough of them to accomplish that function. I do not know about that. When you are in larger groups, we are starting to grapple with that McKesson if you are in a large System and have, for instance, you and myself and my wife is a neurologist, who has the ability to change the record? At some point there has to be some test involves. To me, I will be trusting my colleagues and if they changed the seizure medicine, I am not sure I want them to send it back to me and have the check a box doing something that has already been accomplished. That might be more work than I want to do. I want to hear that they have done it and it would be nice for get them to send it back, but there needs to be a lot of interaction.

    Go ahead.

    The notion of a trusted circle is what we are all alluding to. Our live inside of an organization where that is barely gender large as we have every specialty represented. We are lucky. We will have to come to grips with the finding would be trusted circle of information is across specialties and institutions and time. I do not think we have figured that out yet outside of the multi specialty group practices like ours.

    Thank you.

    [ Audio/Speaker not clear].

    Eventually, it really has to be the Mark, how we act as an a team with the patient being involved.

    I will second that. Got one of the key features, key things that we believe is that, ultimately, the arbitor is not the primary care physician but the patient. You are trying to figure out what they are taking if they did not take the medic vacation or maybe it made them feel funny so they stopped taking it, ultimately, that drives the clinical decision. That is what we are aiming at.

    I call that the facto information.

    Thank you. That was a Good discussion. Wes?

    Thanks. I enjoyed the fact that while Dick was telling us about his experience, or a little bit after, Andy came down and then Dick represented the middle organization. Dick, I want to ask you got one question and get you to agree or not agree with the comment. In doing this war, trend that you have done in forward-looking statement year or so with GE and McKesson, what standards did you use?

    The standards we are using-the documents we are using are the HITSBY, [ indiscernible ] and CCDs. -as an for medication coding and allergies. We are using both SNOWMED CT and ICD9 for problems and because of the 2.3 version-it does not directly allow-there is an a translation tag that can change that information's because we are working through that in the 2.3 Standard. Hopefully in the 2.6 standard we can move forward. This is going into a repository and we have an independent [ indiscernible ] from Initiate that has interfaces' and we are doing our identity management--sleeving the HIE to that structure.

    I would like to make you more numbers.

    [ LAUGHING ].


    Can you talk to doctors that way about medicine, too?

    Yeah, unfortunately, it is a character flaw.

    The point I wanted to draw out is the pioneering work, I will talk more about that, but also that you did the work relying on the HITSBY standards and protocols, rather than feeling the need to pull together a group to define that stuff.


    The two comments I wanted to make, and you correct me if my interpretation is wrong-1 is that the biggest challenge you faced in the interoperability was not the standard for transportation, wasn't security. It was dealing with the functional issues in the EHR on how this information was introduced, the point of view of the physician, what were the status of here is some raw information and to define a functional solution. And assigned a note you were verifying information that was important to the record.

    That is absolutely correct. The critical piece to that is at the clinician fingertips and how they interact with this without creating something that cannot be.

    It looks like you want to say something, Louis.

    That is an enlightened view point that not everyone shares, from my experience. That is very enlightened.

    Will be looked at the barriers for interoperability, I think what Dick and his colleagues have done is recognized that the real barrier is that the standard support that kind of workflow, and as a medium size organization had to work with the vendors to get them to make that functional cobbling to Information interchange that is required. I think we have a tendency to in this committee to think of interoperability and functionality as being two separate discussions. There might be a need to do that, but this is an example of why it is difficult. We have heard in various comments throughout the day two statements that I think we all nodded our head and said, oh, right. One is designed for the little guy and others are learned by other experiences. I think that those are both true just as ying and yang and have to exist in the world. 15 years ago, the big guys recognize there was not a good way to code the last tests, only the outcomes and the big guys worked-this is the academic, they developed LOINK and that became a resources that the little guys could adapt later on. I would urge us to recognize that the real thing about designing for the little guy is not always to start with the little guys conception of the world in terms of the informatics, but to get to a perception of the world, to get to an implementation that they can absorb. For example, we say there was a time that the simple design for the electronic medical record was to have one column in a Table for garbage and another one for sodium and so forth. The big guys, when they got together in that crowd, they recognized that that had a limited, there is a practical limit on how many rows you can have in the Table And they went to putting the code in a column and having fewer rows. That was not comprehensible by the little guy at the time. It was, where is the blood sugar? You have to go through all of these bits --You have to go through all of these rows. It was a balance issue. Ultimately, everybody now does it the way that the crowd figured out how to do it and the little guys, the vendors for the little guys have accepted that as an approach. We need to embrace this approach of making our-what we offer, usable by the little guy without adopting it as a religion of not looking beyond what their sixth contract for experience base is.

    Thank you, Wes.

    Lisa, sorry. This is a? For [ indiscernible ]-does this is a question for [ indiscernible ]. I tried to use my primary care physician as the keeper of all clinical knowledge about Mia. I go to a specialist and try to have them send something, paper or fax or something. It would be great if I could say, can you ship that one of those over there. Do you envision-you talked about the LOINK and you mention the lap and I am envisioning those as services outside of the EHR as they evolve perhaps the interfaces are not having to be updated in the EHR software itself. --If my specialist was to send my primary care physician a document, the only thing they have in common is that they are probably all paid by my insurer which does not make this network usable. Use the to the notion of having a HIE or how specialists and you all, the small guys, can share information. I am sure you will not have an open Web service on your EHR rating for Information.

    Let me explain. One time there was a patient the move to Arizona and wanted his health Information sent and he knew I did as. At the time I was using CCR which is now CCD. They can do both. I sent that and scented by e-mail to the guy because I got the approval to do so by HIPPA standards. It came over pretty well. That is what Lou is talking about. He does not want every nuance of many neurologists note sitting in his charge, perhaps. As far as the lab interfaces, they exist, but, unfortunately, for instance, some of the lab companies have different standards by region. If you have to deal-that is the one of the problems that Wes alluded to, every time we have an interface, it costs us money to get them to develop it for us. We are the little guy and too expensive and very hard to develop that and there is the process that you have heard about that takes so long as the Coke how we can ever remove those boundaries and all of those problems-I had a CIO that said, please have them come up with a standards so we can push it out to our practices.


    Let me approach it from a little different perspective. I like the thought experiment. That is let's say I am primary-care doctor and you are seeing an endocrinologist. What is the ideal thing? I have an electronic health record. I do not know whether the endocrinologist does or not. The ideal thing that would happen if in order of preference, the most ideal thing is that I would open my Electronic health record and received a message from your endocrinologist that says that he saw you and that here is your information. He might be part of my group or maybe even modifying your medicine in. Isn't that wonderful? I opened it up and it is there and I have acknowledged that I have seen and I received the information. It rarely happens, but it happens sometimes in my hospital. There our two specialists on the same record. The next less ideal saying is that they will fax your information and come to in electronically into an electronic fax and we have to do something to put it in the record. The next up which is less ideal that it comes in the mail and we have to scan it in and that is even more work. The amount of collaboration goes down and the Part of it speaks to was his comment about HIE that if they're not in your group, but the have electronic capability, they have to somehow get to you.

    I don't care how it happens. If it happens, I'm okay with it. Life is good. As long as I don't have to someone says, you're going to be paid $20,000 for this for the endocrinologist go beyond the cardiologists as low, the will be another $5,000. It's a matter of money and work. You'll have your program as work on it.

    The other thing I think he could selectively decide we want to bridging to your EMR is relieved if you got the message, what do I really want in there? It may be the meds, it may be the lab, it may not be the lab. And have the more frequent, more recent lab work. I have and have bred to in capability -- It's very helpful.

    For my own organizations perspective, I'd like to suggest that there is it and where to look at this problem. And that is recited my medical groups we don't have a record in the neurologist office and a record in the family doctor's office, and erected in the car in August of this, you ever record. And its of those specialists has a view of that record which we can configure if you want to so that it presents them with the information they need to clinical decision making and kind of mix the rest of the information present a subsidiary to in their office. And I don't think this is out of the question for the United States. And not suggesting Aneesh is Greg Everett one record and is going to be stored in some wonderful place without the citizens of and all of that. But I think we can solve the issue technically in a different way but a means thinking about doctors physical ownership of the record in a very different sense. And making it clear -- Actually don't on the record, you own use of the record in the patient owns the record and it has all of the important stuff about them and you can look into it to do the things you need to do.

    I want to echo that a little bit differently which is to say I think the doctor wants a piece of the record. It's the piece they have pressed my offer to take responsibility for. And I come at it differently because I do have an affiliated with my system and a variety of small physicians that believe firmly they on the record. And the fact the record is not unitary. The record is the composite of the information centered around this patient it's visible everywhere and a ventricle and I think one of the things we're seeing is these changing view from the EMR as the place sort of the volume for the patients information in to the EMR as the browser and the interface into that larger record which is underneath the piece will have to have local control over. And that's really how we are trying to approach this. The HIE is a vehicle for getting at the larger truth. There's been a recent discussion about the Health Internet, the whole idea that you quit the Internet stored. And think where is the records stored is exactly the same kind of question. It does make a lot of sense but it says is have you see it. Have your with it was his point? How the set down and get your day knowing we need to know about this patient? Wheeler seen the turnaround of the HIE.

    If I could piggyback it a question on to this excellent branch of the discussion. Some of us have been having conversations about how to position this problem of moving the data to the right place at the right time into two bought. One of which is that provider to provider notification and should be the secure messaging. It essentially replacing the fact with and the trauma of and in the form of a CCD and then that a copy of the message be sold automatically into the lifetime personal health record of the patient. Where successful for future query by people who didn't know they needed it so they weren't sent it originally discovered the need to go back and reference it. With that address, with an approach like the ribs to messaging for the endocrinologist know you need back and then a copy spilled into the HIE or EHR?

    Exception that many of those messages are going to determine the concern messages. Which is to say it's not just a message from an endocrinologist to the primary care physician, it's a statement to the world from the and enologist and this is what I believe to be two don't be in the EHR which would be a valuable by a standard.

    I think the EHR is a browser as well.

    There are some aspects of the patient's history that a want anyone to know. Except perhaps their personal physician. Psychiatric things are a big thing. And Do you want that out there for everyone to see? Let's say they want their sexual orientation to be specifically kept private. Do you want that to be out on the thing? Those kind of things, you can have in the HIE. I'm saying is only as a counterpoint only.

    I should be very clear that in the conception I just throughout, the PHR would have access to controlled by the consumer and if they wish to restrict that information, they could do so. Absolutely take that as a premise.

    Of what we are saying really is bowing to have to cope with the concepts of privacy and security and protection portions of the record -- That's a multi month discussion in and of itself. But the technology needs to me there enable that needs to enable the free exchange of information on the patients' behalf.

    Thank you.

    I follow up on that. Did it and I have been having these discussions and I think all of you would agree that once the endocrinologist has sent back the report, the endocrinologist doesn't want to receive any more information about the patient until you send the patient back to the endocrinologist. Is that right?

    I would potentially take issue with that.

    It specialist as their own personal style. Sometimes they want the whole record before they even make an appointment.

    When the consultation is done.

    The consultations have a finite life span which they also the life span of the patient. The problem is as the endocrinologist, what I know is if I never look at the record again, I don't care happens to a. If the patient comes back in to me again whether they are referred or whether it's a follow-up I've arranged for them to come back in, I want the complete record. Functionally, depending on the technology you choose, either I need to be able to complete update record from what's available from when the patient comes back with a steady push to be. It depends on the technology issues.

    But the fundamental thing is the endocrinologist and many physicians want to spend any of their time looking at information about a patient unless they are actively involved in taking care of the patient?



    Let's go to Aneesh and then and.

    If I may ask a few questions down the line. I'm fascinated by the conversation. Just to clarify when you sent the message to the doctor in Arizona, was a sufficient information from the perspective of the Arizona physician? Would ever the information you sent over was he or she happy, any feedback on a wanted more the was not in that particular messaging?

    This was the same EHR, we both recognize it as an experiment. And it just basically was a skeleton of information. It didn't have everything they wanted to go we ended up sending them the other information by CD. But that's how it actually happened. The technology is really not easily there yet. At all to answer your question.

    For I was going is identifying the value gap of what the physician in Arizona wanted relative [Overlapping speakers]

    When we get a record we have to basically be entered everything.

    Got it. Last question on that. When you did Senate, since it was in the same family, was the vendor essentially brokering that message or did you go to a third party are was a basic email?

    Email with a file attachment.

    Thank you.

    I would validate what was said before -- I think doctors can agree on what is more important, that's part of being a professional is to say you have all of this chicken we and what's the week. The things that definitely more of partner medication must as far as before you see the patient, are why you're there, to me was born poor in this have the patient is doing. But that's a non could file thing. Other than, it's medication list, allergies, past medical history, family history to go doctors can agree on anything, I think it can agree on what's important and what's the very core basic data set and in my story, if I could have gotten that basic data set in automatically or abetted, it comes up and says here I see that Jack said your on these medications to be for an automatic transfer it into your record and I want to go over it with you and we will automatically transfer them.

    If I could ask you a question. There is a fundamental and you listed your key things you wanted to get from the endocrinologist, there was a presumption that basically the and ecologist sending you a message and then you were describing what would find useful in that sent. But you didn't present the scenario and opposite which is nobody said you anything, patient showed up, and you wanted to query the world to find out whether or not the patient had been seen by an endocrinologist and a fine. I didn't hear that in your answer. I'm curious how does that make you a set of priorities.

    The would be great. That's science fiction. That's almost a lesser with a larger group and -- I can say that. We have a larger group and that has happened. It's now in the database. Is w want to know?

    The reason we are having this conversation is there's a whole set of standards and processes and algorithms and rules and so forth around a question of how does one find Jane Smith information more broadly in six caraway and water the to standards that govern the process which is there is the question of the scenario you a line which were basically send me what you know and in order of priority teachers were allowed to be able to import into record or ridden validate or whenever push, pull, press. The point is, there's a world you about made it easy for me to send from A to B and there's a world view of help me find what might be available about patient in the world and let me work on that.

    I can only tell you what I do because we're part of the hospital system. I do have that. Defense in at the hospital and I can get that. It's not an is an record but I have access to the price declines as of that which a very nice. I'm not getting it -- I have to go after it. And not getting it in a format isn't that would be pushed out to me automatically which would be really nice. That would be very very nice. May be personal health record, that's the Holy Grail for a patient says I have my personal health record on this website and guess what, it will download everything space. If you'd like to go over with it, the first time they come in, we open it up and see what's there. Is that--

    That's where I wanted to go with the of the question. Your giving me a great scenario of your priority list and it's a useful thing to know what you value.

    I vow almost anything the patient values. When I see them I estimate the value and if ever they value and whatever information they have, I can get, in a format that makes it easier for me to get my work and, and okay with capital and that format now is a digital format. If they bring me and I still get paper, it's nice, but it's not incredibly useful.

    Very helpful. If my re -- May Rick and Lisa, representing the committee hospital setting, if you could hum a few bars for me on the investment path as you move to some of the standards questions that were grappling with. Did you face the need to buy new core systems or were you investing mostly in middle where for lack of a better term? How may get a flavor for investment path towards achieving the ability to produce and/or receive a standards based message.

    May be in a pilot or a the direct the first and Lisa.

    It's a mixed bag. Some of vendors that in the event of the products on evolve. The Domi the standards if they don't upgrade. Will try to stay away from us but we have systems that we've invested in 20 plus years ago. In general, the answer is we by mid aware of the custom design it based on a particular need and our particular environment for the tracking of the implementation of a standard for the different vendors.


    I would agree with that. I think it's a mixed bag as well. I think that our interface engine has really helped with the exchange of data because we been able to manipulate the messages in the engine and that programming to be able and it acts as a traffic up. And passed the message to multiple systems and printed in ones and reformat it three different ways that that's what we need to do. Again, that's very resource intensive and once you get them running, then one side or the other doesn't upgrade in your back to square one with starting over to support those programming changes. It becomes very difficult. I think vendors are stepping up to the play an understanding that they've got to help us. That to become more standardized. They've got to take a look at how they exchange data and how they map that data into the software so we can become more standardized. To decrease the cost. I don't think there's another way to go about this. I still think that, I would reference to a step back -- I think you've had it toward a really important point with the physicians. Providers, they need all of their information in one spot. They need it not all together. And if they need, if they want the hospital results, they need to be able to go and find as patients they have hospital results on and those results they to be there and presented in a way that they know that they're back. If they need their clinic messaging -- One of the challenges I had as a CIO, we now have an office as to the clinic that we are trying to integrate and we agree to install a [Indiscernible] master it and it's likely we will end up with this vendor from the hospital sides the clinics had. And getting our physicians and stop shopping to be able to get off that data still find records of, still signed hospital records of, still send home care records of, still see their packages as well as debt of the clinic messaging and get that in is to mind format so they don't have to go log into four different systems and it's all viewed in one place. It's a huge challenge with the technology much less with financial and resource constraints that if that. I do not that answered your question.

    It very much did. NB for NT and Dick [Overlapping speakers]

    I want to ask John and [Indiscernible] the question.

    [Overlapping speakers]

    Short answer because I want to tag guns with a sitcom how much is it going to cost institutions to convert from ICD-9 to ten?

    Do we have a budget yet. This is a huge project because we are going to have to do not just deal with edge systems because some of the standards we been talking about, we use proprietary systems internally and translated the edge. We are going to do a complete writing as low as is a given region of our clinicians. We are doing which many of you have done, SNOMED, mapping, it's not the whole clinical system but its a multimillion-dollar project.

    We don't have a budget yet. We're doing the discovery to figure out where this. Its multimillion dollar investment in new revenues cycle systems and reporting systems. And like John, we are also looking at [Indiscernible] as part of this.

    They're thinking in a way that's different from most of the rest of the country which is poised to make a multibillion-dollar investment in converting revenue cycle in clinical systems from ICD-9 to ten which matter is not a whit in the clinical role. It's not going to of equality or say or anything. It's not that we shouldn't do it, what should -- Their all applauded go to the point I want to make an M.A. in Iran stuff but I couldn't resist the opportunity to say it. We plan should be converting something that is clinically useful and match the background just as John suggested that Manson the background to the financial classification schemes. And if everybody were thinking about that and taking those billions of because you are talking about an investment that. We are talking about a tiny wedge of money to get stuff going in interoperability and you're going to waste a couple of billion dollars in the country over the next four years so we can have a financial system that's based on a city ten as opposed to nine.

    [Indiscernible] your the answer?

    We're out of time.

    We can go a few more minutes.

    You compare for me what you anticipate the investment path to be to achieve the standards capability as we proposed it in the last weeks. I'm asking Dick and and a sense you are furthest along and this prescribing you're largely there. In the context of what in the set relative to where the other investments are, any feedback you could give us in terms?

    Getting the and to Robert building about we have an electronic health record in firemen that is a HITSP stand based is cheap. And actually fast. If we could devote to read it into it there a number of things that a kid and as politically and culturally from devoting dreaded to join but of weedit, would focus bid get it done in six months.

    So clinical interoperability based on the standards [Indiscernible]

    It's an order of magnitude smaller than invest in respect to put into ICD ten. From an operational perspective there's an operating [Indiscernible] assistive with a book standards themselves was there a implemented in the EMR, the actual implementation into a facility and no use our example, where the total training is about two hours. To explain what this is and what these boxes mean and how to get them. So this is not an insignificant investment is modest. It's smaller for example than CPOE or other things that we are doing as part of this. Again, if replace the [Indiscernible] reps on, the vendors will give you a different answer because they have more work to do. It's worth it should be doing in its work we intend to exploit widely.

    Last question if I could for Lisa and Rick. I did hear if you're producing CCDs Today, as you look to the marginal investment over you're gorgeous and your dollars given what we've talked about in terms of the billing versus the clinical, any you a little bit about how your planning to think about that invest in road map?

    As we look to the future we will be looked into integration vendors to provide those services for us. What we've got we're a medium-size community hospital and so the committee understands we probably have 200 systems. We've got 75 or 80 vendors. So as we are trying to do standards based implementations, the Polish reports not consistent with basic lab, the mammography reports not consistent with the other radiology, the Dictaphone prescription system, we are dealing with different vendors and insistence that all have to get on board with the standards.

    The investments will be in the middle work column. Lisa?

    We are on the of the side of things. We've tended to go toward a single vendor partnership. So we have similar challenges where we've got some systems but most of them are single and. We are looking to the vendor to get us the versions of this software up-to-date and get us compatible and then we got the engine to be able to pass those transactions.


    I don't mind.

    I'm fine, thank you.

    Come on. [Laughter].

    This has been incredible information.

    With that, thank you again and for the great dialogue. We have a break until 12:30. Cracked, Judy? Thank you very much.

    Correct, and Judy?

    Thank you very much. [Applaud].

    [The Standards Workgroup Public Meeting is on break until 12:30 p.m., EDT.]

    We are back from a very lively morning. And again, Judy for helping arrange a uh huh, that was a really robust conversations. If these defenders of this done, I'm going to be relieved of. And hoping they're born to be equally compelling. Tried to get to Chris, I want to make your mind to those of you on the phone and watching on the live Web cast, to give the food, we're going to be heating. You're welcome to begin blocking your feedback on the Health IT Web site. For those of you who can remember on that,[Indiscernible] I can see if we are getting Clive [Indiscernible]. At red John for your connectivity. Crisscross, take away.

    Thank you very much. If not come to that thing is going to be the heavyweight card on today's event. Where the rubber hits the road. First thing this morning we heard from three emeritus professors from the school of hard knocks of auto, Internet and finance about how standards both helped and in some cases, impede progress. Then we heard from a terrific panel of six providers represented everything from the largest private health care organization the country down to almost as solo practice to go around with their issues are. Now what we have in front of us is the five vendors who are going to solve all these problems for us. [Laughter]. And we have arranged a vendors that includes Rick Ratliff from Surescripts, the nation's ePrescribing network. To talk about what they've been able to do. Arian Malik from RelayHealth [Indiscernible] that and talk about their experience in automating practices as large and small. Sean Nolan from Microsoft that's involved in both the provider and consumer side of health care. The risk, from the clinical works. One of the reading EHR vendors that again has been touching both large and small practices. And Chris Stevens with an information company that to give us experience from a wholly the U.S., but from outside the U.S. You're going to try and stick your five minutes to meet and we will start with Rick and move to the left.


    Is this on? Very good. My name is Rick Ratliff and thank you for having me here today. And executive vice president for customers and Markets for Surescripts. As the chief operating officer of the legacy SureScripts organization is that your family with, and the [Indiscernible] of the newly merged organization with [Indiscernible]. In May 2008, I been involved in the development of an operational national health information exchange for prescription information specifically the now called Surescripts. So the combined organization is now named Surescripts. As most of you know, and Chris mentioned, Surescripts is the operator of the nation's the prescription Network which connects prescribers in all 50 states did it was of ePrescribing Software. It's a very important when I will talk about standards and certification in a moment. To the nation's leading player to pharmacies and it confirms is again this is an exchange where we are exchanging information for the protection the average between prescribers and pharmacies and health plans. Your work in standards certification, education collaboration and a national, regional and state levels, we've established a national digital health infrastructure for exchange of prescription and commission interoperability is really the core of this. Space to thank you for the time today. And going to make some comments on the front end about our experience with electronic prescribing answer to answer the specific questions based on this experience of the last eight years ago I'm going to go through the questions and I may skip some of the questions just give to the timing. Because I think I probably have about the damage with until at a very minimum. First, I think it's important when we talk about interoperability to establish the definition of ePrescribing from our perspective and this will help support the comments and answers to the questions as I move forward. EPrescribing from our perspective supports the shift from a paperless and more informed way for prescribers, payers and pharmacies to communicate. EPrescribing occurs when a prescriber uses a computer for handheld device and software that in our case is certified to connect to our network that enables the individual to electronic access the patient's prescription benefit information. Or formulary and I will talk about that later. In more depth with the patient's consent, we can electronically provide access to the patient's prescription history from not only their physician but other physicians that that patient as well as other prescribers that patient may see. It's Electronic rap patients prescription to the interests of pharmacy and when they're out of prescription refills, we've enabled a two-way communication between the physician and pharmacist for prescription renewals. And begin talk about more death. Our network delivers these capabilities 33 core services. I want good for each of those, you can see them there. Prescription benefit, prescription history and prescription rounded. We released earlier this year a progress report on ePrescribing and you can see that electronic prescribing is taking off. We do have a great deal experience in operating in network with a large number of physicians and a large number of pharmacies both retail and mail order as well as delivery of prescription benefit information and history as it is right. You can see the statistics there, I won't go to those. Our network is grounded in a focus on neutrality transparency, and the use of industry standards. This is the foundation. As a result, the network is now able to support other opportunities for interoperability. I think that's key. We started simple and started with a very focused effort route electronic prescribing, we deploy an electronic prescribing as to concede to the statistics, we are now starting to take information on the network and deploy that information to other constituents in hospitals as an example. We are starting to share information using con [Indiscernible] care record or document types of standards. That is our business. Just to touch on a few of the questions. Let me go to the standards questions. Was standards did we use and why? We current use the [Indiscernible] script standard. This is the standard of the is adopted by the Medicare monitors stationed at. And is utilized in our network for the prescriptions and renewal request as I suggested and will be expanding beyond that. We will be moving from 8.1 version to 10.6 of that standard assuming that is a standard that is adopted by CMS. It's important point because it does require some of from notice and some planning to get from one version of the standard to the new version. We'll have over 150,000 physicians and 50,000 pharmacies and six of the largest mill orders, etc. Migrating from one version of extended to the new version is no trivial effort. We also use the an CPT formulary and [Indiscernible] for the from an affirmation, that we utilize the standards for eligibility transactions that you can see here from another standards organization. Given the timing, Chris, I do not the best way to go through the comments from here. You have the written comments and good-bye.

    I think we have a lot of questions.

    Let me finish up if you go to the last part. I think it's important when that it be noted that standards are the foundation but standards are not it. Our success is based upon taking the standards and putting together the implementation guidance and printed in the process the certified systems to come into the network but driving adoption and utilization goes beyond the standards them we can talk about that more if we have an opportunity. I will leave it at that.

    Great, thank you.

    First call and want to thank you for inviting me here today. I really enjoyed the first panel sessions and I've been scribbling seriously a couple things I want to endorse from the first panel around standardization. Keep this simple. Number two, choose the minimal set that it possibly work. Build on what works and without their right now and design for the little guys and I come as a part of [Indiscernible] reform a startup company. My wife and both camps of having the the little guy and now having been part of a larger organization. My I fill the needs of the little guys. From the provider panel, this is not about exchanging documents back and forth, that's really not that interesting. This is about being able to integrate data into a chart. And make good clinical decisions. That's the one tick away from that and the second one is that metalist are the key thing that we need to drive toward. Medication elegy is a problem and secondarily. So lets not try to solve every problem all at once. If we can get in trouble metalist in committee we are making a big star. As I said, we offer Software Service platform. We see the world in a different way. From a suffer based vendor. We currently do HIT interoperability as well as physician productivity, EHR applications. We do a whole host of standards including HL7, [Indiscernible] with Surescripts, with Surescripts and also of pears, web services and the like. We launched also a CCD based patient data interchange in the to a pilot project with the zero d using the [Indiscernible]. And getting us to stay where we can do that easily and transparent is something I heartily endorse. When I look at the current recommendations from the HIT standing committee, to the ONC and CMS, I see a lot of things like [Indiscernible] the whole host of standards, a bunch of HITSP transaction [Indiscernible]. And I worry. We worry, we rebut the petition cost of conformance. Be wary about the implementation cost of a small practices. And what's interesting for us is we are not been asked to implement the standards right now. We are being asked to share medications, Lab Data, and to share critical information across [Indiscernible] care. When I look at the set of recommendations and business needs, I'm seeing a disconnect between what's the business problem we see and what's being asked of us in terms of standards conformance. A lot of the standards conformance things we're seeing coming out of as the recommendations the purchase of enterprise needs and are naturally attuned to the needs of smaller practices. What both enterprise in small practices are looking for pretty basic, let's get the mentalist, but get the electronic results, and let's share clinical documents. The secondary that might come in on is the use of HL7. Specifically, to point x, the current set of recommendations of the need for a summit over constrain for 2.5 per one. If you look at what's happening there's a lot of very good exchange that's happening on HL7 to point at the others will the flavors here in the that's what helps in the interoperability mechanism for s record from the non health care interoperability panel. We're currently doing it a crime everyone to create [Indiscernible] would make our job a little easier. But at the cost of a lot of implementation effort across the provider community. Likewise for clinical documents that a text is reusing an BMF, using HL7 two -- 2.X. You can get it comes to consummate from hospital to primary care practitioner. We don't need to do a lot of reinventing of the will to solve the problem. It's already out there and works. Also to endorse what was said earlier, terminology is incredibly important. The terminology standards that exist right now aren't of the box usable. I can pick up the manual for how to use SNOMED Connecticut, it's a huge standard pickerel weed that the [Indiscernible] subset and the course of said and we need to get something that we can actually used their. Likewise, RxNorm is further had but still has area to move to go particularly in the area documentation. And point out is today. When need usable once subsets and most critically, we have no leverage over the people providing labs, the clinical lab providers to get them to conform to the standards so we are going to making the adopters of a EHR to [Indiscernible]. But results and put the final point is that I believe that this group should constrain the standards of the minimal set that's necessary to exchange data. In the past CMS has been a great job about this. Constraints standards to exactly was necessary to exchange data with the federal government. And I think that should be one of the core policy drivers is what's the minimal set of standards that's available to exchange data with [Indiscernible]. And use that as to solve the basic problems out there and to build on what works. FISMA commentary. Thank you.

    [Captioners transitioning]

    I want to thank you guys for allowing me to be here. Solutions group. Microsoft has tremendousuated two products -- product health vault lifetime family health department records that they can use with an ecosystem of tools and they can share with recipients in whatever format is aprepout for those recipients. We actually are listening and taking them from kaiser today and to help them. [ Indiscernible ] Enables folks to create a -- as share that information with folks in the forms that those folks are accept it. Both of those problems with the diverse entities and certainly standards are an important tool we have in our kit. I do believe our policy efforts need to create -- for exchange that are going to be require today support the common use cases that the market is asking for. Many of the questions the committee asked about relate today standards adoption to large versus small enterprises. Clearly small practices are looking for -- current approach of pressing full scale EMRs hasn't worked. Just like they're not interested in HDTP or other protocols. They're happy to adopted technology when it helps their work flow. Creates satisfaction or creates new business. The large versus small question magfifies this question but at the end of the day it's the same dynamic. Allow our desire for system 46 wide quality to align with the business imperatives that are the first priority of the organizations. If they don't, they just get ignored. Dr. [ Indiscernible ] Said in the past that CCD hasrevolutionized the [ Indiscernible ] Snapshot in time care document has a dramatic accelerate. The key is people get it large or small. The paper base provider can print those documents out an get use for them. That speaks to Adams point of readability. Uses the Social Security administration health vault uses them with PHRs. As we work with these documents we think three observations that seem meaningful. We believe you should accelerate the concept of continuity of care by -- the challenge that is not a specific document format. It's really about working to assemble [ Indiscernible ] Many vendor haves made investments in CCR over the past few years. We have done both. We have the luxury of being big and doing that. It just doesn't seem worth the fight. I would urge the committy to endorse the CCR and the CCD and move on from there. great job of balancing the desires and needs with the reality of the way that information exists in the world today and allows a sliding scale to exist. I hope that we'll continue to stay focused on the art fact rather than the -- arty fact rather than the transition. How you can use the CCD or how it can be sent over in network. I also think there's an opportunity around the standers committee around quality measures. There's been a lot of come entear about being core to health reform sort of push. We agree with that. We think they are special because actually measures actually can indirectly influence the type of adoption that we've been unable to force using standards and certifications. When you have to report on numbers IT helps and people understand that. While the standards committed doesn't define the specific measures there's ways they can help. That are quantified in a way that maximizes analysis and reusability of information. This is a place where vocabularies and structured data really do matter. Actually encourage adoption but also allow that glide path. We believe the commonty accepted standards do play and must play an important role in delivering that value. We need to pull standards rather than push them at people. We need to concentrate our efforts on smaller number of scenarios where the business need has -- embrace standards that are working and not create negative momentum. I think we should ensure that -- not just our system wide goals but with those with the individual businesses that do the workday today. With that I look forward to your questions after other folks have had a chance to speak.

    Good afternoon. CEO of E clinical works. Thank you for the opportunity this afternoon to present on an important topic. What I wanted to do is talk with some background that sheds light into real life experiences of mass scale base deployment on EHRs with interoperability in mind. What's more important is one extreme they work with the leading hospital systems both in terms of size and reputation and on the other extreme we work with solo and small practices. It is not the size that has dictated the interoperability needs of the physicians. Whether you work in independent practices or whether you are an affiliate at large hospitals seem to have the same need for interof ability or information that you need for clinical findings to provide quality care. Neither does the size dictate whether a small physician practice can avail of that technology as much as a large physician can or physician large group practice. What matters more is the technology the whether there's 15 or 500 oaf them without requiring retesting or recalibration to deploy that interface down. Large hospital system. The same example we do in reference labresources or worth sides. Of 235 session at the point-of-care happening for the core -- we have to schedule a second round of testing and second round of cleaning to have that happen. The point being is when we look at standards we should look at policies for deploying them. Policies that need to essentially come in to play in the digital world believe the paper world behind and allow us to start focusing on what can truly allow us to go to scale. End up at 70 to 80% adoption. That what we need is scale based standards and scale based policies for deploying them on size. The second point that I'd like to highlight is that it's not the standers that concern the clinical works but the vendor. It's us more. We believe it is -- that's the one time capital cost that you need to absorb to have that in place. But challenge comes down to is can we in repeatable fashion again deploy that technology and implementation without adopted in the first place.

    The reason I bring this up is we've all been concerned about physician at the adoption a notion that sometimes I might not agree with you looking at the growth we've had as a company but nationwide it is a concern that we are all trying to wrestle with. One side of that equation we're asking vendors and systems to become'ier to use easier to implement and havelesser -- sofa sessions can spend less time implementing those systems in their practices. One they can quite familiar with. Asking them to follow the old paper processes to review every lab that comes in to the system trying to sign off on every [ Indiscernible ] Exam.

    Alleviate those processes saving them time which can be spent on better quality of care for the use of EHRs. The point being we need to try to stabilize [ Indiscernible ] Limited in size and scale that we can indeed deploy so we shouldn't have any -- shouldn't have 20 different [ Indiscernible ] Codes. What we need to do is standardize on ones that I work.

    The root of this subject matter. What you are dealing with is sometimes vendors that cooperate and sometimes vendors compete in that same market segment. In practices and communities that we have deployed we've had tremendous success. There's been a governance structure in place. The hospital system or from projects like New York City PCIP or [ Indiscernible ] Many others. Implementing operability was not an option it was mandated. For small practices that don't have that kind of affiliation or program it sometimes becomes very difficult to deliver even the standards that are in place a discharge summary from the community hospital. That comes down to governance. What we want to started asking the question is it optional for a hospital physician to display or give away a discharge summary to noonty doctors or is it mandated that is part of standards and policies that should be in place? Thank you.

    Thank you very much. Cress Stevens.

    Thank you. My name is Chris Stevens. I'm the CTO. For those that aren't aware of us, that better? For those that aren't aware of us oary January house is an integration vendor. We provide tools for integration including Health Information Ex changes and in fact we've deployed Health Information Ex changes in over 6 countries including the United States and Canada. Canada we have four preventable wide exchanges and one of our flagships examples in theist is the state of Maine. I'm going to share with you some experiences around the world. Make you feel like you're not alone. Other countries have been through the same sorts of pains and having been in the health care system I can attest to that. Fundamentally most of our clients are trying to achieve the same thing. They believe that sharing of clinical information between physicians nurses and other health care professionals helps inprove clinical decision making and improve patient outcomes and those that are worried about the dollars and sents control the costs. That is a fundamental belief. Expertise to allow them to share the information both within their organizational walls and of course across organizations when we talk about Health Information Ex change. So that when a patient [ Indiscernible ] Regard less of where they are, all the information is available. Some of the challenges that we've spaced are what you -- face redirect examination what you'd expect.--faced are what you'd expect. Country of New Zealand it doesn't matter. We arrive there. Although there various hospitals and clinics are attempt places in terms of their IT strategies and IT employment. HR72.1 to HL7.2. Manage that in a cost effective way. It's not ideal but we manage.

    Challenge of course is the update of the EMIs. Both of those countries have very high penetrations for EMIs. It was a long and regard use task. But they still have a high uptake of EMRs. Both of those things can be addressed. Ironicically probably the biggest challenges we face is when we turn up in a region and we're talking to a hospital or clinic and they've got an EMR, captioning all this great information and there is absolutely no interface. This speaks to your point about whether or not interoperability is mandatory or optional. The challenge that we've got there. This provider is doing all the prescribing but they AOR not transmitting. There's nothing we can hell 7 with that. We can't share that. That is something that technology -- tieing the functionality to the improper ability. They are not separate but they are the same. If you are going to allow people to do discharge or progress notes they have to be interoperability as part of the requirement. That's probably one of the biggest challenges that [ Indiscernible ] Faces in an organization. One Health Information Ex change it needs a critical mass. The thing we heard before being by yourself and one fax machine is no help. Even two of you it's -- that's still not a lot of help and Health Information Ex change is put in the same category. They only add value once you reach a critical mass. I don't mean the large hospitals. Getting in smaller practices and -- these problems that I've outlined ring a lot of bells for everybody in the room about the United States experience. New Zealand and Canada, Australia where the health systems are wonderful. They faced all these challenges and they still do. Bringing to the conclusions. There was a question about supporting older standards versus new standards. From a Health Information Ex change I don't believe there's a choice. In Canada they mandated these HR7 for the paying Canadian health record. The Health Information Ex change use the HL7. The pea sore ten of EMRs -- very low. So you need the ability to somehow take into account the fact that hospitals spend a lot of time and money get an EMR in. There's going to be this lag factor. It's longer than you think. It could be 5, 6, 7 years where you have large scale organizations that want to contribute. They want to be involved but they've somehow got to get into the latest version and in the meantime they're going to be using those old versions. I'll wait for you questions.

    I imagine that we have a number of questions that folks might want to ask at this point.

    John you're first up.

    In 2011 meaningful use is requiring four different kinds of data exchanges. E previbing, laboratory exchange, quality/immune nation registries and administration transactions. From my point of view as a provider, I think prescribing, I've got sure scripters and thestandards are mature. Lab, you've highlighted it. The implementation guidance is quite variable -- unfortunately aren't quite as concise as you'd like. Quality immunization is actually harder work because I support a thousand different data exchanges out of my institution because every single trading partner measures quality differently. My barrier is get me a fine identity set of measures and I'll get it to everyone. Administrative transactions. We have 4010, 5010 it's pretty well set. For you guys, if those are the four big data exchanges, what is your view of our adoption and implementation barriers and enablers and E prescribing, lab, quality administration and administrative transactions. Simple.

    [ LAUGHTER ]

    That's it.

    So I would say that's actually an interesting order. Clearly the administrative actions we're pretty good on. CMS has done a good job about enforcing there. E prescribing we're good there. There's clearly an adoption challenge but there's no question about what standard do I use? There's not a question about what intermediary do I use that standard with. Lab as I mechanicsed you can get electronically EMRs today. We can do millions of transactions we have a problem of se [ Indiscernible ] Are these two really an A1C. They come from different lab vendors. I forget -- quality and immunization. I look at that one an I don't know what to do. I have no idea how to hand somebody data. I don't know how to hand an immunization registry data. I don't have any idea how to [ Indiscernible ] That they can actually take it in a way that it means anything. I'd willing note that -- we require transmission of information at episodes of care. Reconciliation. Those are much more problematic. Right now we can get documents back and forth using MDM having the enabling technology formed reconciliation outside of what sure scripts does. We need to do more work on.

    I can go next. I think probably take it in the same order. Labs I think the challenge remain. There's policies that we need to resolve o so we can get lab out of the box. Technology exists and we need [ Indiscernible ] So we can then have 100% success ratio and not having any errors and emessages that relies on labs. In terms of quality measures, I'll take that on separately. We've got some good experience having done this for 1500 docks in New York City trying to get quality measures submitted every month to where physicians actually get financial incentives to do it. Similarly we get a call from Rhode Island. They have their own measures. We get one from blue cross an they get another set of requirements. If we don't go ahead and standardize on that format now if we don't physically put this thing back in the box of defining what measure reporting period what the numbers are going to be we'll make the same mistake with HICFA. Resulting in millions of lines of software being written just to try to prevent that mistake from happening. We need to try to look at this box right now and have measures defined in a way that implemented -- not interpreted.

    Very similar things. I would say quality is the one where we have to do hard work. Where we get the most benefit and there's shared objectives for people to understand under the long term. From a point of view of sort of physical standards we have largely everything we need in the other areas with exception of vocabularies and we can use in a reasonable way.

    Just a quick comment to build on what's been said first of all I'm glad to hear we have the prescribing thing solved. [ LAUGHTER ]

    Thank you. Thank you very much. There is still a little bit of work to do there. At the same time, I think that what we should make sure that we do is learn from that experience. Most of the people -- aspect of making prescribing work. Why it works and where the opportunities are as we move forward. Principles to the lab world and you look at govern than you look at standards. You look at what is required to create interof ability -- some opportunities there. There's obviously some work to do on the Norman claytures that we described. There's some.

    Lekythi that's also a bit of a challenge but I think it's straightforward. On the quality piece, I probably don't have -- I don't think anybody has a magic bullet there. I think however that let's learn from what's been successful and let's focus in on where those biggest bang for the buck is to some extent. Let's start with something and let's show some progress. I think again, it's keep it simple is most people have said. Let's find some ways to show that we can -- other areas of quality. So if there's any risk that people were going to leave after this panel an not stay around for the quality panel.

    Audits, all the other things besides the major topics that are also included?

    I think there that we have the benefit of having our VP of engineering came out of the security auditing world. We have a security officer who does this for a living. Implementing standards isn't going to make our system more secure. I can implement all the standards I want. Something can still get in and download a bunch of records. Security auditing is the internal audit controls is the code quality standards, the testing standards, the code inspection standards that get the stuff done. Most of that exists within the walls of the information within the walls of the hospital or the physician practice. I had the experience in previous life of being under FDA regulation and there's 21CFR part 1 is which regulated how a functionality software being used for the conduct of:calltrials being done. They weretough standards. They were policy standards not interoperability standards. I think that's what make security and privacy work -- laundry list of acronyms and letters.

    Have you looked at our current staid ands that we have documented?

    That's what I was reacting to when it's a little enterprise heavy. To me it looks like a ton of work for not a lot of actionable value. It's not driving us towards where we need to be to solve the business problems that we're trying to solve it's driving us towards check the box kind of standard implementations. As I said, if I had to choose I would have something similar to 21CFR part 11. Or the standardization process as a rigorous security auditing component. That works extraordinarily well and drives strong security and privacy requirements. At the appropriate levels.

    I just want to mention that not only have we identified standards but we have identified required use of standards of proof of meaningful use. It's not just a check box.

    I understand that. I'm just being truthful here.

    One quick example without commenting on the standards, the thing like we'd -- comment on the standards [ Indiscernible ]

    I'd like to see --

    [ Overlapping Speakers ]

    I think if you look at the current state like New York state, you have -- decide whether you get to view the data. You actually have to opt in to share the data. I think if we don't [ Indiscernible ] Not know whether we need to share the record before the [ Indiscernible ]

    Respond to who made that call between New York and Massachusetts. Was it the state government?

    Yes. It was state government. 7 months of leg work and [ Indiscernible ] It was legal that decided to lead the state HIPAA laws whether con consent was required. That was back and forth we figured out an acceptable solution for the currentimplementation or the understanding of the law.

    I'd second that.

    Very much so.

    I've had conversations with people which amount to you tell me what patient privacy you need an I'll do the work. I'll guarantee you'll disappear for two months and we'll do the work in a week. It's done by state by state legal. State of Maine is an opt out. It has a number of variations on it. The biggest [ Indiscernible ] Region to region isn't necessarily the technology and support that it's getting someone to write down the rules around what happens under what circumstances for whom. It gets a little more complicated when I have patients that are moved from main to Massachusetts. We haven't crassed that bridge at this stage.

    It depends on what you are opting out of.

    Chris is moderating here.

    Just a brief follow up to Ann's comments. With security our big challenge -- we have inside the organization and we have between organizations so we have a mandate for example an ARRA where you have a disclosure log that you have to share with the patient. Inside the organization, do what is necessary to keep those data elements but from the border of the organization you should have some means of reporting standards based audit trail if a patient requests such a thing. This is really a question for the group, our challenge here is sometimes security can be policy driven. Absolutely. That's going to give us great security but if we're mandated presume we can do an audit trail on a standards based way. Force a patient cob sent preference -- we've had to at least try -- for that purpose.

    I think that's a great example. I think it's a non-objectable requirement to expose an audit trail to a patient readable way. If I expose [ Indiscernible ] Log, I can guarantee you I can expose it. I'm not sure anybody's going to look at it. I've already got an audit trail that any patient can look at their history across multiple providers. It's something we're already doing. Implementing the [ Indiscernible ] Technology isn't going to move that ball forward and it's not clear it's going to actually be used by anybody. Just an example of where I believe policy oriented approach can drive to the same outcome. It's not clear that we need -- at least not clear to me a technology driven or standard driven approach to expose that log in a certain way. If a health system wants to access [ Indiscernible ] That's a business reason for me to do it. I'll do it.


    All right. So I think it's actually a really good example of where the boil the ocean strategy [ Indiscernible ] Which don't know the allocations that are going to be asked for. We don't know these things and yet somehow we've put a requirement on the committee oritises. Here is the document for exchange. It must be auditable with this type of policy oversite. Maybe later we can get to that computable audit trail when we need it but we've been doing good exchange for a long time.

    We're going to go to Aneesh, Bess then [ Indiscernible ]

    Ladies first.


    So one comment and then the question. I heard in the last panel that the providers did not want to.

    Investment as a capital investment. So I'm sure the providers were applauding that. I wanted to follow up on what Chris has written in system related to the lag of when standards are available an when they go in. You mentioned the lag in the commercial environment. You have here that you already done quite a bit of work to get up to May 2010 initiation of a new standard roll up that's going 12 to 18 months. Looking at the timelines we're facing and when incentives start, what is the one thing that's keeping you up at night that we as a committee could do to help with this time that's needed to roll out and implement these standards?

    You want me to comment first?

    . The key is to the definitive of what the standards are and ensure that we don't try to as been described here and discussed this morning that we're trying to boil the ocean by making the standards too extensive. As an example we want [ Indiscernible ] It was about new prescriptions and prescription renewals it was automating a part of the process. It's not part of the process by the way. Just doing that part in my statements, at the point we're at now an you can take any of the standards we're looking at, at the point we're at now to move all of the participants in our network today that are processing 20 plus million prescriptions a month looking at 20 plus million eligibilities a month. We're doing a lot of exchange of information in a secure way, by the way. That to move them from one version of the standard to the next is an 18 to 24 month process. For some on the network they can do it in two months. For some like a major pharmacy cheap -- that's a lot of heavy lifting not only to get the software changes but getting deployed. The challenge here is not all systems are ASP base systems software service. We have a lot of client serve ever based electronic medical systems still in the market. Just to debt your software to the point that it supports a standard is one thing. Then to get it deployed in to the market is a much different thing because you have to upgrade the software and you have to test it. This takes quite some time. We've done this once before a few years ago and it did take 18 to 24 months to get there. You have to make the software changes. Those have to get deployed. You have to have a network that can help manage that migration. So we know how to do that. This is not a technical issue necessarily but this is a timeframe in making sure you are keeping focused on what the standards should be.

    Honestly I'm really hoping that software service is going to help bring this drag down. When you have software as a service the service gets updated. If it's an interoperability version -- but looking through the landscape there's a lot of hospitals out there that have some big -- we aren't talking small money to upgrade. We're talking 10s of [ Indiscernible ] For the CIO to go to the board and say I need upgrade and I have to spend $300,000, the question is going to be what does that give our organization? A list is a driver aside from interoperability that he can turn around and provide that. So coming back to that point even if all the major vendors implemented the standards as they stood right now we'd look at a strong timeline until everybody got to the same version simply because the natural enear sha. Somebody has to pay for these upgrades. A lot of vendors have good pricing. But a lot of testing and internal resources [ Indiscernible ] Big thing that keeps me up at night. Look at those systems that exist right now that don't see any type of data because they are going to be left out in the cold.

    One more comment. I'm sorry. There was a statement made earlier, a couple statements about our standards command tire or are they optional? What is happening in the market is that software products are certified through CCHIT or sure scripts etc. to meet certain requirements. The majority of the systems in the market aren't those certified products just so you know. We may see in a given vendor doing a really nice job 60% of their install base meets that standard. That 60% may not meet all of the elements of the standard, even with electronic prescribing, some systems are installed and have not implemented eligibility checks or form lay chicks checks. What is the standards what is required to be do ployed.

    You have to deploy what's certified.

    I want to thank the panel for your remarks. I have a three part question. Ask folks to respond. The first is I think at least I speak for myself an not the excite de. We are very interested in your thoughts on how to improve and accelerate the adoption of standards. You mentioned that some of the standards that have been developed or recommended are trying to self-enterprise needs and don't meet the needs of the small practices. If we talk about ultimately why this committee is tasked with doing standards it's about the meaningful use crater. Where interoperability is necessary they are in fact the things we've been talking about. They are in those key areas. So the first part of this question is, tell us what would work? In other words what would work better than some of the recommendations that have been made in the best case scenario. The second piece of this is on terminology. We had some discussion about technology. What I heard you say was, in fact, what the key problem is right now is that some of the terminology sets are not usable or readily usable. Advice us on what needs to be done there. The third piece relates to privacy and security recommendations. What I'm hearing you guys say, which is something I truly believe, for a lot of the privacy and security issues, you really need the policies. You need to know what the policies are for handling those situations. How urgent then are the policies in order for the implementation of the meaningful use criteria in the timeframes that are set?

    That's excellent. I'd say the policies go in back ward order. I think they're incredibly urgent. Policy what keeps me up late at night is not what standards do we support but can somebody break into our data store and retrieve a bunch of data? That's no amount of standardization in terms of transaction sets is going to prevent that. Within the organization that we need to do that's driven more by policy than technology standards. With respect to terminology, I can not right now, question not right now hand a developer the manual that says the implementation guide for RXNorm the implementation guide for KPVA or the subset of [ Indiscernible ] Or anything really around the link and say here it is. Here is exactly how to get at it. Do this. We have a really strong [ Indiscernible ] Consultant that we use. Now we've got two that we use. So we spend money for that because they're the ones that research all this stuff.

    It's well mandated. Well clarified well maintained subsets. It's documentation. It's implementation guides. It's examples. How toes. Those kinds of things that you can hand a developer and go do this. With respect to what you guys can do to help us, again I go back to what the first panel said. Keep it simple. Keep it focused. I think what happened was we've got this wonderful work that HITSP has done. We need to focus on the core requirements and focus on the minimal set of standards required to get there.

    [ Captioner transitioning. ]

    The condition that a second standards and which to reduce, documentation for example part of my job is to try to sell to my board by many to implement the standards. And I cannot give them the documentation and set. Go and there was a go ahead and let now. Anything that helps provide not only the technical documentation but the reasons for it and the abstracts is of great assistance become a second thing having an engineering background, talking about interoperability here, I can see any reason why there isn't [Indiscernible] available that lets software vendors as part of the Delvalle process [Indiscernible] which is developed and then [Indiscernible] to around and said by the way we need to support HITSP developers turnaround so we can go to some of addition and get it working. [Indiscernible] are available online, 24 hours that we can use as part of our normal the of unprocessed--

    When you mean tools to mean testing interfaces?

    Can we seem it protection a transaction to as a Vermont start what developers are with, is it error % of go and we may want to [Overlapping speakers] what is the main?

    Those types of tools and it's about lowering the barriers for vendors for some of the organizations and can afford to have guys who look to the standards and figure this out for a lot of the smaller EMR vendors, and if you can provide them that makes life easier. We not talking about stuff that complex want to understand it, but I need someone to read and explained to me first. Those are the things that really I think can help the adoption standards become the third thing is really indication on what is the most points standard. If your and EMR vendors in the with the standards, some of Vice. Did this one than this one than this one. Because when them, although we know it's a meaningful use, but look at the HITSP standards and go across the meaningful use and make the decision about what to do first. The privacy and security, I agree with everybody else typically think it's more about policies than anything else but there's a lot of technology out there available that can help assist with privacy and security and it's not really a big challenge in terms of interoperability in terms of making sure these things are there. A policy stating the [Indiscernible] must contain this information and you must transmits in a way that is secure, it's going to go a lot further in tried to standardize a single model especially since most vendors already have done some stuff and the thought of taking it out and doing something different for no real benefit is a bit of a tough pill to swallow. Terminology, yes, [Indiscernible] is back with that puts of nationalized reporting networks and realize that the elapsed on all news when it weren't [Indiscernible] and what they've gone through an done is create a subset specific for the countries of the White laboratory. We will find is terminology becomes more important, this is a given the more information shipwright not difficult to tell people to do terminology because they say what does give me and tell your sharing it and it becomes a major driver.

    The couple comments. First look on the standards I think the key is to the simple and focused as has been said several times. We have standards and we are seeing growth from electronic prescribing. I think we can do the sames but let it begin December sharing of information to transitions of care because there are some standards that are being deployed. But make sure you don't make the definition of meaningful use as an example so burdensome relative to the inclusion of standards in certain systems as small practice can never get there. The small practices in any event, the need labs and they need a certain standard set of documentation and communication in the market. I think keeping it simple is key. I want to reemphasize a point, we do have tools to help vendors for going to the process of testing the software on a real-time basis as they're doing the development and deployment of the Kingdome is deployment. If you're going to talk about interoperability, it's very difficult to drive it interoperability just in a hospital. And Reg. tried to drive interoperability across 50 states. Across physicians, hospitals, payers, pharmacies, etc. Don't get too broad. Don't try to create some of the standards you can never get there. Number one, and never to, you'll never be able to evolve because you have to be able to evolve as we talk about a couple times. Testing on security, policies definitely keep. We have to be very careful though that it doesn't it in the way of driving to the benefit. You have to have the right balance, there's no question about it, security is critical, technology is there, but policy could get in a way of us effectively sharing defamation. We've seen this happen in the past zero weeks and have fun and state basis, we saw happen in her ticket and go have disinformation now to help improve care. Don't let some of these issues get any way of sharing information where it needs to be shared.

    The first one in terms of how to get standards implemented sooner this is tactical answer and a strategic one. Great not only the standard but [Indiscernible]. CIBIC contest against the. This strategic win is also simple, every vendor I think at least I can speak to some lenders perspective, is to define which go faster and why there. What can we do, if you can and told us that we interoperability and the hospital system [Indiscernible] make it to met month, it would cost us to the consumer. And the would probably jump on that given its required for assistive 24 hours writing code. I would say that your time to greet the standard but also create the clear and you proposition and when the standard needs to be implemented around time and money. And trying to make interoperability work through market forces forces go ahead and have a for the sake of interoperability. Or have it tied to some kind stimulus. At the end of the day if a physician can [Indiscernible] that is in place unless it's the creates market competition for [Indiscernible] that would be my strategics an emblem of standards [Indiscernible]. In terms of terminology, I would say let's go back to the physicians office. It doesn't matter whether it's small or large. Of vocabulary have a fine but sometimes we get caught in the lab where they define them and kiss of labs, the electronic machines that and if [Indiscernible] it's not important right now in terms of ambulatory it [Indiscernible]. What's important is with the blood pressure reading is. Because that would reduce and make the workflow of adopting that at the point of care that much trouble. Lastly in terms of lack time for implementing the standards, we live in both worlds. A lot of our customers live in a fast model were repulsed a minute dissenters and [Indiscernible] it is less about with the system is hosted an axis that dictates the timing. It comes down to the end users want to take that upgrade at that moment in time. We need to tie that to something very teach it for them to create the reason whether it's more functionality [Indiscernible] plus then but needs to be driven by market forces or else it won't happen.

    Last year we were at a discussion about EHR adoption and had the question asked was how would we get people to adopt EHR. One of the recommendations was that getting guidance from interested folks about what they should expect in privacy goes a huge long way. I think that our policy question of security is the same view which is that we very often say we create pilots. We create integrations and we see it works and the technology is easy. And then the seven month delay happens to but then we have the seven months of the the lawyers are worried about it and what is really the policy definition. At the end of the day, they say this is it worth it. And not going to take the life of typical if we could help define those policies, that yes when it's ready I can turn on, that's something they're going to do and I think it would be helpful to go and wanted to add to the vocabulary a little bit, that I think are important, subsets and terminology are super important I think to action getting this. May receive this in consumer space in spades begum consumers are really confused by some of these. But licensing is a huge but of that piece as well. Many of the vocabulary is that are being proposed for standards are either too early proprietary and cost is a fair amount of money or have been licensed an awkward ways to be used in novel settings. We think about using a patients entering the labs in health of for example and what terminology we are able to use their. It's a really challenging thing, many of them are licensed per user, this that mean every of the Mellon people that use it, that's a scary thing. That's it challenged go and live to see the committee make some progress with this already been great work done on do you M.L.S., that's a resource that is remarkably great for translating from one vocabulary to another in helping the legacy problems and challenges as we say I have a body of data that's very valuable, can I use that and migrate that up without a huge no effort. It's a wonderful asset, it is very machine driven to go and people have run comfortable using that formats translation. If there are ways to create an advance, to create easier upgrade paths, I think that go along with.

    So now we're going to Aneesh, West and hopefully have time for David.

    I'm going to make mine brought questions and not for an immediate answer but for some Mexican debt to the others. Maybe for the response to be on the block available of Health IT [Indiscernible] [Laughter]. I would like to ask if you are willing to share the data, the marginal capital contribution necessary to achieve the various recommended standards, and other words, and try to understand if you have to spend a third of your capital going from eighth to be, I really want to understand the level, in a fixed pie world, where is your capital plan with respect to the standards we've recommended? And then I want to ask a little bit of a physically or maybe from your customer base, with the marginal value is of those component parts because I think one of the inputs to me and grappling with in our work is it sounds easy to say keep it simple, versus complex. But that has no translation to me in terms of the work we're doing until I have a clear perspective -- Babysit tree privacy aspect tends to be one of the marginal value relative to the technology you have to rip out and put in, relative to the merits of the alternative being the Paula system in a timely fashion, I'm hearing that message and want to understand that better. If you'd be willing to not just you, but anyone listening on the phone and available on the block, the share with us what you think the share of your capital with the dollar value to hit the different component parts sobriquet a little more granular. That's my statement. My question is brief, and maybe more if a [Indiscernible] question than the others. One of the areas that has me interested is to the extent to which once we achieve a standards based interoperability, how might that enable more of application development platforms for new ideas, I'm curious if there are lessons in the experiments on ePrescribing that say, now people are developing apps on top of what is now a fairly normal lives to team for how information should be shared so that they could come up with their own creative way of engaging and ePrescribing transaction. I don't care if it's a customer facing interface to the pharmacy it link back to -- I have no idea. Allows me to one of others are drawn and cement, can you give me a little bit of flavor on this the standards efforts you've done helped enable or completely irrelevant to the idea of application development. May be outside of the Surescripts world, other an ecosystem building because that now is a double and a standardized format.

    Will give you a couple of examples. The answer to your question is absolutely. We've been able to the implementation of this national infrastructure built on if you standards. It's just a few standards. We are enabling wide scale interoperability as I described before. What we've been able to do now is weekend take the same infrastructure and someone says I want to send a continuity care record or a cut knew the care document which ever standard you choose, patient summary format in store clinic to a primary-care physician. Because we've created the yellow pages for the directory on your network, we understand every and points on the network. We can now take a different standard and a given piece of information and transmitted over that network electronically and we can do like that. The incremental cost to do that is a very minimal from our perspective. The value is used in that we can and document a transition of care from an in-store clinic to your primary care physician. That could be a discharge summary that goes to a primary-care physician as well. It could involve referrals on the network, etc. Messaging capabilities that cannot be built on top of a transaction of Rick is kind of interesting. That's one piece, the of the thing is we have health plans and p.m. and pharmaceutical manufacturers that are very interested in the fact that now there are and points on this network, those being physicians that are writing a prescription and at the time you're writing the prescription, it would be interesting to know if there are potential gaps in care for that particular patient. Because we understand what is happening at that point in time, we have an eligibility transaction that says that that patient is on this particular plan that can then trigger another type of transaction. It could be a constant [Indiscernible] format the goes to the physician of the time the writing prescription to suggest when not to talk to this patient about these particular aspects of the health care and make sure they're having these teston, etc. Does your application status started to do be deployed to go and it is because the platform is there. It's also because there are standards that are of interest to the and point to build applications around to go.

    Very helpful, thank you. Was?

    Thank you. There are numbers and splitters in the world. I may splitter quote I consider all lumpers to be [Indiscernible] and I'm anti completion. Sow completion is slumping two things together. All right. So I'm going to try to anti conflate a few things that have happened here. One, we have talked about the challenge of getting that data transmitted. The big labs don't always use the same codes internally themselves much less across interfaces some and often takes on the job of mapping. There are 20,000 white codes for labs that makes [Indiscernible] very difficult if not very time consuming at best. HITSP a year ago put out a list of 700 LOINC codes. And endorsed it as what we need two at the edge in order to send one of data. I wonder if the folks on the committee have looked at that and have an opinion about whether that is a reasonable subset is it too big or small? Are we on the right track or not?

    Directionally, it's definitely on the right track because your simplify the subsets to 700 versus eight randomize number. Or import may, if every lap then starts using that format, the key concern here is not just meta and, that's the point I to hype code mapping is one concern, or one obstacle in hurdle we need to cross, the second obstacle in the [Indiscernible] manages that is small physician practice, if he or she signs a reference lab tomorrow, and we set them up, they will start going live with this new weapons to using it. And if that lab is not giving you that same 700 the clinical decision support will start going wrong. And that small practices and have the IT resources to keep up. With thinking through and St. the new source of data that I just bring in to my EHR follow the standards.

    And to follow up with [Indiscernible] before anyone else talks. What you were saying is either that every lab should map at the edge to some subsets that's universally agreed on. And we have a mechanism for continually updating. Or that -- What happens now is that the responsibility of the integrator, that's what HIEs to all the time do not -- Now.

    I think we're going to need to call time pretty quickly. [Overlapping speakers]

    We heard a lot of concern expressed all day about the small practice. Three important -- Very important. We've heard about the difficulty of a small practice and it at the LOINC. And putting up the new standard when it comes by. Except for that rare [Indiscernible] Christie's of all my writing code, I don't see it as a problem for the small practice. I see it as a problem for the vendor of the small practice. And we've also heard a lot of talk about some standards been better than others in terms of adaptability for the code it. Does that mean we are concerned about the small been there? This isn't a good panel to ask about the small vendor unfortunately. But where is the balance between requiring value-added over and above writing basic code and terms of the interface, and therefore requiring more investment on the part of the vendor. Rick, I think has the most experienced with making the standard work with a lot EHR and a petition. I'd like to ask him that question.

    Sure. Currently we have over 250 plus vendors better certified into the system and they range from the large, major players to the very small organizations that are deployed in brand new EMR solutions. The key again from our perspective is that you keep it simple, and you keep focused on the standard, and you are very clear to your documentation as it's been suggested earlier. As to how you implement the standard. Because even and NCPDP script new prescriptions standard has a lot of information that it can hold. And if you are not careful, you will really negatively affect interoperability by creating too much flexibility. You have to narrow your definition, you have to be specific and implementation guidance and have the right tools and then with your a small vendor for a larger vendor, you can a woman those capabilities. Annual differentiate York capabilities within the workflow and the user interface is of his performance, etc. Can be done, we have 100 plus small EMR vendors coming through the certification process right now. These are organizations that are deploying the new systems. It can definitely be done but again, you have to be very focused.

    Europe and the user interface, right? To see if that represents the data so you go beyond did just the data get it through?

    The workflow is critical to enabling the popular level of utilization and also to ensure you have the right quality control of information moved through the different points of the network. We do look at the display of formulary information that [Indiscernible] history information and the prescription data with it its in a prescription or renewal. On both ends of the network and in the pharmacy as there is some cost to the been a?

    There is no cost to the vendor for certification. Their cost is related to the implementation to the specification. There are -- There is a question about capital cost, there's no question, this the costs for implementing the standard and there software and for deployment and support and training and it comes to a interoperability. And I can emphasize this point enough, the standard itself is only one piece, the workflow is critical. If you don't do the workflow right, we are not going to get the value that we want. The workflow is where -- I'm not a developer of the systems, the workflow is where most of the work goes.

    This conversation will continue at health IT [Indiscernible]. We appreciate the time and effort that these vendors put into coming here and look forward to the work you are going to do to help us take health care to the next level. To a mad River much for your time. We appreciate it.


    Thank you very much for your time. We appreciate it.


    We are going to turn to David to help us say hello to the quality panel. By design, we learned today that the quality space is the one that has the most room for opportunity. And it is we knew that in advance which is why we set this thing up, right? Of that testimony reinforced this. NB David, while folks are is something you could make sure a few words and set up and we can get started.

    Okay. Best on the agenda but certainly not least, if for no other reason than in order to qualify to receive the actual stimulus' funds, one has to submit a credit quality measures. So we're the final common path between interoperability as the goal and actual stimulus as a result. Let me introduce the panel while we are settling down. We have a good selection, to be interviewed together a great selection of groups that have experience with capturing and reporting quality measures begum from different perspectives. We will let the differences emerged as the testimony occurs. Let me introduce everybody first and we will do the five minutes a piece presentation and then have the questions as we have for the other panels. We have Janet Wright who is senior vice president for science and quality with the American College of cardiology. We have Richard Gliklich who is president of outcomes Sciences. We have Jesse on the phone, it Justice center who is going to be on the phone who is with the Department of Health and Mental Hygiene of New York City. Executive director of development there. We have a Barbra Rabson exec elite director of the Massachusetts Health Quality partners. And Jack Bowhan who is manager for performance measurement with the Wisconsin collaborative for health care quality. A lot of expertise and Janet, will you prepared to lead off?

    I will be happy to.

    It's an honor to be here. And I'm going to want quickly into my comments. And what I'm going to say will basically try to make four points. The first is that the program that I've been involved with is founded in science, founded in the evidence. It was built to improve quality. So far in its in life its proved incredibly valuable to the participants in the program. And the final point is it has been darn hard. So I'm hoping that the working right wing will make it easier for those who follow. I think I would speak for the team that's been working on this we feel like we've been bushwhacked -- Bushwhacking. [Indiscernible] has been in the registry business for a little over a decade ago we have about six registries. About 10 million patient records to go until we decided to move into the ambulatory space, all of our registries have been procedure based and hospitals based. And about 2007, recognizing all the games to be made in quality in the ambulatory world, I think with a little bit of Cuba's and I was involved in it at the time we thought we will just pop in and out there to the addition of in and do what we do best. Said the registry. And you can imagine we hit not only hurdles but buckets of hurdles. All kinds of things. Over that period from 2007, we made tremendous progress. The configuration of our program which was named improving continuous cardiac care try to link inpatient and outpatient and look more at chronic disease management been a key procedural studies, and giving so we depended upon the science. We picked the AC AHA PCPI and U.S. endorsed quality measures. That's where the sides is and that's where we went. Weedit measures that reflected the major cardiovascular conditions. Coronary artery disease, her village, hypertension, [Indiscernible] and also referral to cardiac rehabilitation. Does a 29 core measures. When we approached and said this up we decided that our early conversations with practices that we would have to take practices where ever they were. We would offer them a multitude of options of collecting the elements that would allow us to calculate the measures. We offered them a paper option, we offered them a web based tool and our strategy was to work with the major EMR vendors to get embedded the data elements that would allow us to collect those and constructive measures. The rest surprised that a large number of our practices really wanted to do this on paper. We know that's not the option for the near future, but as it turned out, the form we created past served as wonderful decision support for practices. And in reviewing the data from the various options so far, we've discovered that the data quality is highest in the speaker practices. Duet based will turn out not to be a good choice. We are working on that. Our EMR strategy also was problematic multiple meetings and multiple vendors' difficult for them to see the business case. And then in August, we learned of and deployed a systems integrator. Service that was able to link the data elements out of and EMR agnostic clique allow us to cut the lead the measures. Since then, the program has gone. We have about 170 practices over 600 SiteScope we have a 380,000 patient record and that took a huge boost officially the chart, in August when the system integrator started to work. The thrilling part of this is we've been able to generate for set of performance reports back to practices. And not in my 23 years of working cardiology have I seen such excitement around a piece of paper. These practices for the first time see their practice pattern. They actually know how they're doing in the major areas of their career. We also hope this will be a great value to primary-care who of course the care of a huge number of cardiology patients. Would have been encountered difficulties? In terms of IT, the most difficult challenge has been in EMR mapping. We learn that not only are there different versions of EMRs there are divisions within and EMR. In a practice with multiple sites their different versions of electronic medical record go where we need help is in standardization of the data elements and definition. Would help us would be embedding the of rhythms that allow us to collect this data elements in a constructive measures. During that in the standardized way. And then minimizing the customization that is so frantic. Thank you.

    Well said.


    Thank you as well for this opportunity to go I'm going to be following the questions that were provided. Question one, health and science has worked with territory medical and surgical professional associations the suspicion organizations and government agencies and quality measurement and a proven programs? We currently work with over 8000 U.S. hospitals and actress several thousand physician office practices and implementing quality measurement and reporting. These quality registry's but regional and national clout and confidentially but are close to measurement across organizational boundaries. In addition to standard physician of definitions as was mentioned, to challenges abroad is quality measurement of the work effort required to collect the debt and ability to do so across multiple care settings -- To date we have primarily utilize standards to adjust the first of these issues. The group of standards that Shunra is promising our experience [Indiscernible] between organizations are the integration and content profiles such as HITSP and C 76. Response to question to first, and all of these programs [Indiscernible] across our between organizations and that the core component of quality improvement is Clinton's Mark is a crucial piece of the QA process. As an example, a client from American or disposition of the data and traditions in coronary heart disease have been the mystery to improve care numerous studies and publications beyond what has been achieved and institutional programs that do not have representation in comparison affirmation. Said in quality measurement between organizations will become more important as we eventually develop next-generation quality measures those that focus on longer-term outcomes because patients move between organizations. And third, quality measures are not and will never be is that it. There based on evidence and continuously developing evidence. There for many of our clients are actively developing a test in future quality measures, these measures need to be tested across multiple organizations to better understand performance, characteristics and and said its disparities in care and opportunities for improvement. Question three, the Ford subscribing success may explain key challenges faced by these quality registries bear on these [Indiscernible] have the list curtly endorse national standardized measures is relatively short. Was to these measures focus on process. Our clients are developing a implementing and benchmarking both new and next generation quality measures. The latter measures focus on outcomes rather than information process requires the collection of condition focused Information and risk factors, treatments and longitudinal outcomes including Payson reported information. A portion of the data required to generate the measures currently exist in most EHR and since this Kaiser testing or actively modifying the measure specifications, the measure definitions are subject to periodic change as frequently as a times per year. To date are records of standards implementation of focused and automating the process of data collection and this is the most expensive and burdensome part of the current paradigm. We tried several different standards based approach as to this problem that of have it should restrain the Q&A the by far the most promising results in our experience to multiple implementation has companies in Standard integration profile suggests HITSP and the country profiles suggest HITSP C 76 to go in become the standard integration profile opens this circuit to allow in [Indiscernible] to send definition with a registered when an eligible to return patient identified, the data collection form is retrieved and service within the EHR and content profile that is used to be populate that form with the data contained within the EHR typically the CCD. But as noted earlier, this typically additional data required for the quality measure or their changes in the measure from time to time and both of these cases can require additional data and tobacco using the set of standard if there's additional data entry not content within the EHR, the data can be entered directly by the provider [Indiscernible] is a session which is important. This approach has been successfully deployed for several quality measurement programs, including for example the American College of rheumatology [Indiscernible] the American Society of plastic surgeon talk program and the outcome [Indiscernible] Register. Uses of the EHR that meant one to the standard package is inevitably proved workflow and reduces burden of did caution. For example, in the rheumatology rigid focused on some that approximates seven % of the data element can be completed from the CCD and remaining elements played by the commission during Dan. Frankly the greatest frustration to these professional associations and addition to participate in quality measurement programs, this level of standard based interoperability that is and will demonstrated is available in a very limited number of EHR. As a result these have [Indiscernible] such as the lack practical impact until the majority of EHR have a nibble their systems to use such standards and provide determined way. I will stop now.

    Thank you. Jesse, are you available on line? If so, you may start.

    I am here. Can everyone him a okay?

    Speak up, your it a little bit late.

    How is this?


    Thanks also for inviting me. I greatly appreciated. My name is Justice in the Knesset and with the primary care information cermet of in York City Department of Health and Mental Hygiene. We Kermit oversee the Lotus community EHR the implementation in the nation. This seemed a little of which a similar mission of this project is to improve the quality of health care for the medically underserved to the use of health information technology. Three project Kermit over 50 dash providers and York City are using this prevention oriented electronic health record and a book with what we call public health functionality. And we anticipate that by the end of 2010 your program, we will have over 2500 providers in York City life on this type of the EHR. I talk about public health functionality within EHR, especially to this, what I'm talking about are targeted quality measures focusing on those measures from the public health perspective that have the grid is potential to impact the greatest number of the spotlight save. Number two, actionable clinical decision support to a special clinical visits for the to the drug within and provider workflow. At the point of care that's based on the status of those sacks in quality measures. The primary care and fresh product has been with commercial EHR vendors to not only create and integrate the public health functionality into their EHR but also to report this quality measure [Indiscernible] every month. For every provider for public health the volition and analysis. Quality measurement and reporting has been a critical design principle that we believe is necessary to transform the delivery of primary care to put this on population health. Many of the providers we work with your project have limited experience with quality measurement and reporting. Must have had experience the the process last unfavorably. The look at it as burdensome, and waited and disconnected from their day to day care of patients. They don't really see the connection. The main challenge facing providers and quality measurement embedded decision support and reporting to could potentially be a to help the commission technology but we need to focus national agenda that addresses quality measurement based upon clinical priorities and information technology to further exacerbate the bare trees and as for careful -- As a city for providers traditionally have been [Indiscernible] or dismissive of information is for performance measurement are attractive because reports often don't accurately represent what they see on the patient record. Of the providers to use an EHR it need to cut data elements December they did when they're back with. Automatically the measure requires that the commission is recorded in a structured field of in is a residual format within the record of human providers are using an EHR, they're not necessarily recorded the commission in the structured fell as any to become this could biased report in reporting -- And some of using the structured Phil, this will call a huge disconnect between what they see other measure of reports and with the done. Quality measures towards the more believable and that creditors were negative impact of Freddie's in light of the EHR freshman and report. In our expense we've had to show provider step-by-step how this information is documented to go and have at information is reported to go without this coaching and additional feedback measurement the for clinical quality or buyers of areas is often ignored and is not integrated into clinical workflows. This can result in a disconnect. P2 reported results in provider perception of the measure of performance to go with EHR it's tempting to ask providers to address every gap as everyone has begin about with the large numbers of quality measures that are flowing around out there. Be looked around and estimated that time required to deliver in a parameter is the most good times with the Volvo prepositional but it's almost 22 hours per day if you include acute and chronic and preventive care of this leaves little -- Leaves little time. For example 31 recite this is too small practice, it took a provider almost a full hour to address just a subset of all the recommended preventive services. In primary-care doctors who work in small practice environments many primary-care doctors it's the small practices that deliver aid % of primary care in the U.S. But these practices are without resources of large integrated healthcare delivery systems and a small businesses. Time occurred to does all quality measures are [Indiscernible] is an impossible task [Indiscernible]. Understanding this challenge we reduced the measure said to focus on areas of the greatest [Indiscernible] mortality -- In York City we've had the opportunity to amend it difficult to program sponsored by private donors. However we've learned that even with monetary incentives provider engagement quality measurement and Plan given activities a slow. Implementing Health IT is a huge disruption and providers of is primarily on billing for improving their documentation within the EHR in order to the business afloat. The three recommendations of the one, want to prioritize and standardized measures. A special focus in on condition that have the greatest potential to acid the greatest number of lives -- Number two, we want to build measures the the LAN Data pulled directly from the electronic health record collected in use as a number part of patient care embedded within the clinical workflow. CUR and quality measures as they exist for credit is Sunday that available such as retrospective claims and administer the death. Is excluded of populations with the greatest medical need, the uninsured. The last point, plus from my first point some what we want to standardize structured data. That used to detect a quality measures and enforce the dimensions of the level of the jar venture -- This and consistent in its quota measure analysis on scalable across multiple EHR vendor measures, expected health care Valley from listed it as it needs to be consistent. Thank you very much.

    Thank you. Blogger Rabson.

    Thank you very much for the opportunity to be here today. I've observed the world of HIT in the world of quality measurement operate in parallel and at this meeting just today we need each other. It's a great opportunity. The Massachusetts house quality or [Indiscernible] as an organization that's been measurement physician performance in setting it back to physicians and to the public since 2005. Report statewide comparable performance reports on primary-care physicians at the Medical Group level for over 250 trips across Massachusetts. And then report back on a website but the private report to the physician at the Medical Group level up to the network level and then below that at the practice that level down to the individual. Report at all levels. We also report on pension experience across the state and similar comparative way and have been doing that since 2006 and we did this every year. And 2006, but hired by the mass [Indiscernible] collaborative to create their quality data center along with CSP as our technical partner. And the idea was to establish equality datacenter to capture the data from the three pilot communities project and capture the quality data and turn into a quality metrics and feed it back to the physicians and those communities as well as have it for research purposes to look at the question of whether the implementation of EHR and HIT action improve quality. That was the charge. In terms of selecting measures, what we did was selected there's been a lot of discussion about what kind of measures to use and we went with scientifically endorsed measures we use some measures from the AMA PCPI the most of the measures were [Indiscernible] measures that had been developed for claims based reporting that is the kind of reporting we've done until then. Just a quick sense of quality measures to get everybody on this at page to develop a quality measure to have to have a did, didn't that divide the population in question. The puppet kilometer Solomon over for have to get mammograms or 50. Of seven quickly get the idea and people have different standards. The idea is you have to have a population that you are looking to and how many of those target populations that the service in question. It's not that different when you're working with claims did or clinical data, the idea is unique in and writer and denominator to pull this out. What we did our experience was surprising to us because we are all excited that we regard to working with the gold standard which is the clinical data. After working with claims did that and what we found was when we compare the measures on the clinical side with the clam side, and the clinical side the practice did worse. The reason for this was undocumented issue. We lost a lot of patient activity because of documentation. Part of it was the data leakage, even though in the three communities we had EHR and the HIE what we had in one committee we had one hospital and physician practices but some of the patients went to the other hospitals that wasn't part of it. If it patient had a test at the other hospital, it didn't show up in the HIE of the physician didn't get credit for doing that test results. We lost some because of this kind of leakage. We also lost there were lots of inconsistency in documentation errors across physicians that we talked about a perfect example is smoking status and the idea of having to put in a box did you ask about some of his desk. And one of the physician said I didn't fill up the box because I said how much they smoke. Which is better information, but you can capture it so they don't give credit again on a quality measure. There were tons of coding issues do we ran into that were really frustrating. One of our major vendors didn't codify his store full information. In a way that we could captures so for example, if you have hypertension you are not told every visit you have hypertension. It didn't show up than you did not have hypertension but if you had a woman who had a mastectomy, so should be part of the numerator and breast cancer screening, if that wasn't in the history notes, but the history you couldn't pull it out so we weren't able to exclude those people from the thumb -- Denominators a source of capital we had to challenges dash front of talking faster and faster because of time to go and talk a lot that and the drug cut the huge problem you made great progress so I would talk of that. I think in terms of our greatest successes that we were able to create a comparative performance reports for these providers based on the clinical data. And more important, we had a process for providers we give them a list of patients when they didn't do well on that measure, which patient didn't get it to the records they were able to look back at the data flow and data entry in say, I did this, what's the problem and then identified by their data wasn't getting into the record which reported in the wrong place or it wasn't easily catchable format. We also identified these did it changes to practice data entry we also said that back to the vendor so that that was sometimes a vendor issue rather than the provider issue which was important to go in terms of advice to others, clearly the national standard code sets will be tremendously helpful. We've got to all of this and there's a lot that we will have to do, however I say it's necessary but not sufficient Coca-Cola to world that I live in, there's so many other issues to creating valid and reliable quality metrics that hasn't even been brought up and I tend to be more to bring it up because it dealt with so much of it. There's a whole slew of issues having to do with documentation and attribution and phasing in a college reports I guess that's a really key thing that think but when you first issue your college report as reports of the quality of the documentation. It's not the quality that is provided, it's really just the documentation and you shouldn't expect more than that the first go round because there's so much work to do to clean that up. I think another important thing is performance reporting from the EHR is not happening in a back in. There's a lot of organizations that have been getting performance feedback for years whether it be from an organization and a lot of times financial incentives tied to the measurement that's been fed back to folks. It's absolutely true that those will not reconcile with the data coming out of the EHRs. There's this whole process to say what is truth. I'm getting paid on this, get your telling me I have this. And I now have this. Summer and there there's truth so it's incredible challenge to really grapple with that. Finally, as I started out, we need to marry the expertise and experience and the trust earned by organizations like [Indiscernible] and other regional coalitions and the performance measurement and feeding data that to doctors and believing it and be willing to use it. I will stop there.

    Thank you. That was very good. Screes that in. Jack.

    Thank you for the invitation to share the story and expense of reporting quality for 48 health systems in Wisconsin. Back in 2002, chief executive and currently is from five Wisconsin healthcare organizations gathered to confirmation of the collaborative and extend the partnership to health care purchasers and state medical society and representatives of state government. What we had formed the collaborative and started to publish our comparative performance measures, some of the goals we've achieved a the following. And first, and cullet altruistic may be na&ï;ve, but participating organizations they to public accounting of performance with focus each opposition leaders of team on continuous improvement ago and in public reporting ensuring improvement strategies would raise both. Organizations will compete on price in various aspects of service but none of the organizations believe they should compete on quality or patient safety. Consequently participation and collaborative specifically excludes the use of public reported results for purposes of marketing. Second, the collaborative methodology provided a valid and reliable means to compare ambulatory performance for clinics previously look at their own results and isolation of other systems. And third, the burden of health care cost to employers and government [Indiscernible] was no less an issue in 2002 than it is today. Hospital and clinic CEO clearly and as to the Paris request for accountability and the public reporting is at least part of the solution to that problem. Internal Business School for WCHQ members was to create reports with minimal burden up to the reporting organizations. Health plan in hospital measures were easy in that the replicated [Indiscernible] or measures. Development of ambulatory care specifications has been more challenging and continues to be fairly resource intensive process. Nonetheless, to success of ambulatory measures effort is acceptance of the results by from nine clinicians and leaders who currently use the information for improvement and strategic planning. Additionally purchasers use it to build consensus and their provider contract in. The release and the person of performance measures has resulted in the simple but important question from clinicians and health care leaders. What are they doing to get those results? Clinician confidence in the repeatable and valid comparison of performance and by questions related to process change and improvement by the then excuses to deny or ignore the results. 50% our primary care physicians practicing in all regions of Wisconsin and reporting through [Indiscernible] one can begin to see the potential impact of improvement for the residents of the state. Aggregation of the WCHQ member results for chronic disease management and which and care shows slow but ever increasing trend of improvement. So far and preclude clinician acceptance of the results but I think this can be overemphasized and that without their believe in equality and fairness of the reporting of results their not going to change or make the effort to change based on those results. That's crucial. The of the piece for us was reporting on all patients and zero pairs. Are connections had been receiving reports of population subsets from Kissinger of that ensure that often resulted in small bands and serve more frustrate the physicians than to enlighten them about their process. Major frustrations from the collaborative side include the development and implementation of the validation process of the results that were being reported. A lot of energy had gone into that. Additionally, the resources in time and people the required to develop the and it toward performance measures specification and aggregation of data for testing and reporting. Which has been alluded to before the real doing the same thing. As for recommendations to ease adoption of the health information technology for quality improvement, first made easy, full commissions to do the right thing in terms of coding, result entry in care documentation. Information in the EMR is not necessarily the table because it is an electronic format but many felt can be scattered across hundreds of behind-the-scenes tables additional information from type and Dick joinmack [Indiscernible] easily retrievable. Second, provide guidelines for attribution of patients to systems, clinics, specialities and providers. This is a challenging problem being addressed by multiple organizations. As with much of the performance measurement development and reporting their significant event work for each public reporting body to develop its own processes. A tradition will be difficult and never perfect but similar processes across organizations will make and product more usable. Thank you for interest and attention.

    The finished exactly on time. As the panel chair I will take the prerogative to make an observation and turn it into a question. It seems clear that the Holy Grail is that these quality measures are automatic be captured at the side effects of routine process of care and that your almost invisibly and unaware that of the extra burden you the provider to capture those measures. It sounds like we are not area. What I heard were a variety of approaches and want to enumerate what I heard in heavy make sure I didn't miss anything. If you want to comment on which of them makes the most sense to you, roll up across the group, please do so. We heard about claims based capture and I think we all said we want to move past that. So I will list it as maybe the ground floor that we'd like to move past. We heard about paper based forms that could be completed. We heard about a web based tool where someone could go and fill out the form essentially on line. We heard about vendors attempting to embed the form and its associated out rhythms into the EMR which apparently Janet described by with some success but perhaps limited success. We heard about the approach where it third party pulls the data out of the EMR and applies perhaps deeper expertise around the algorithm and extracts the measures. Richard described an approach where a remote system can actually fond of a form effectively in the process to capture what ever was missing from the care process itself. Is that a fair statement of how that would work? It describes as having good acceptance and is an interesting approach certainly. Then we heard -- I think that's about it. What did I miss? And there any other purchase of getting the data out of the record that should be on the table for discussion?

    I want to comment because it comes up so often when we are talking to our physicians is that when an organization says the reaction to implement electronic health record and it altogether organizations have been to this there's a tension between San I'm going to give the dog flexibility an unsolicited and with the court to do. Because I want to get this off the ground go and then that's totally destroys your efforts in having all standardize in very structured. So I think that that's -- In terms of its part of policy. Local policy but what are the rules won't be in terms of how we are born to all this out and start to restrict and get what we get or be more flexible and then move over time?

    Any of the comments on the general question of how to get the quality data out of the EMR and into the quality reporting system?

    Richard, I'm curious to know you described good acceptance of the form that's delivered from a remote system. Intuitively to me I'm surprised to hear that. Could you elaborate on how providers receive that?

    Limited questioning to before and then answer that one. We've been doing this for about 12 years. I've been participating in about 150 different registries. We've seen paper and paper was good before there was electronic. That there's electronic, we went to the Web and everybody wants to use the web. Once you have an EHR in place, people don't want to duplicate the work. If we did this wrong, we're glad to be worse off in five years than we are today. Now we come to have we pull data from the EHR and we tried standard transfer. We tried CCD, and those methods are good except the still require provider to go back into another interface to complete the missing data or definitional issues. I tried to stress in my talk clear is that we are and evolving phase of quality measures and we will before long time ago that will always be the case. This alert assembly of standards from HITSP what it does is allows you to leverage what ever is prepackaged and you can get you do, and the form it services within the EHR, it's not it's in the context of the EHR itself. So if there's anything left that needs to be completed can be completed and submitted. I think this gets to an issue that far raised is it gives the physician a moment to check and there's a lot of comfort and been able to check as opposed to begin at the end of this is something magical is part of of your system and your be measured on that and pay for that.

    Just to present another side of that if I heard correctly that something would pop up on a screen in front of a physician to double check something?

    Maybe it's different where I've been, but any interruptions in the workflow and pops are something that we've heard a lot not been very welcome particularly. Unless it's absolutely crucial, life dash type situation. So the whole discussion that has been I think occurred at a number of the panelists about workflow, is a crucial issue about being able to capture the right information as part of the normal workflow is critical to getting some of this done.

    I'm struck by the attention because I've heard certainly Jack, what you've described many times in the sessions and from our own users. And Richard, your stories compelling as well. It's an interesting tension.

    If I did say one thing. I miss seeing the facial expressions. I think forms are definitely counter intuitive and physicians about get them but what we found what they've been good for it if it's stated that the physician needs or wants to capture, what form based capture is good for is delegating that work to ancillary staff. To see a provider time to access to patient care. If forms can be. It's a structured in a way that other staff can fill them out, the providers are actually pretty good at delegating that to their staff.

    Can I add points. One is that the idea of physicians and all the injury did what we found in some of the health committee was physicians would be faxed information from physicians outside of the HIT in some would enter them in. So that information would be in there and others wouldn't.

    You have the apples to apples problem. Not everyone has.

    The other point is that a lot of us think the integration of claims and clinical data is action even better than either one. The idea that claims did have the universe of what's going on for a particular patient if everything they bill for and if you're talking about different HIE to have the information of the care in that committee annually don't see the total picture. Integrating the two is very challenging, but that's better than having one or the other.

    That's a good points. Aneesh, your next and then Carol.

    Thank you. I really love this panel by the way. I love it in the beginning because I'm struck by the definition of quality measures as being relatively different things as I hear the conversation behind one. There's a compliance component quality measures. Where there's this notion that we want to report the results and presumably this report that comes out some monthly, quarterly, an elite and some, but there's a compliance major which is someone else's conspiring the care giver is providing the answers. I'm struck by that person's the I action want is to provide me support so I can provide greater care which spoke to the notion of a real-time actual combat the notion that the paper actually gets you what you need to make the right judgments. I'm struck because our end game is to improve decision making at the point of care. And I'm struggling with the following, and the latter, first of all I'd be curious if there was a way to identify what are these physician initiated physician wanted physician quality measures activities, what's that subset? And within that subset, how might the standards committee work, make that process basically available on steroids so that everybody who is in that ecosystem can benefit? If I did segment for a moment the compliance discussion from the point of care decision support feedback discussion, if we could take that latter scenario, help me understand in this example, is the CCD sufficient Richard Committee said 7% is what you need? Help me understand what the gap is and what's the right role if we go back to the very first panel they may not have been here for, we had a group of folks from out of health care talk about the need for stability in the standards. And the idea was there's a base set of data everybody should share. But then over time, smaller communities may add more sophisticated elements that others in the community can ignore because it's not relevant to them but those who understand it can benefit from it. I not tried to the words in the mouth but that's what I remember hearing. In that context, what can we do so that smaller niches of communities can and on to help gather this information? If you talk about rheumatologists, I don't even know if this were the 20,000 of them in the country. And me understand that. That universe of people, how much of this data if you had a magic wand could be built into the requirements process of being able to provide that and then -- I will get to to in a minute.

    A lot of the goods that aren't looking to develop these measures are groups like jennets group. The professional societies that are trying to get their scientific knowledge of a disease area linked to the quality measurement of how providers do. And that gets engagement of the clinicians in those groups. Pretty much all of the groups that were associated with are working at some level towards getting to be developing their own quality measures but that's happening, there is this community that you are describing. The measures that they're looking at utilize information that isn't necessarily defined within and EHR even if you go in and try two, you have difficulty getting there. Some of you will get, you'll get the demographics and--

    Just give me one example.

    Let's use down. You can have, you can get the demographics and you can make a mapping that says if acid level is about acts that that would say that patient has meets the criteria and you can have an answer out of the CCD that way. But then there will be of the questions that will come out was the patient given instructions on how to avoid X why and Z. So patient instructions are not part of the CCD. At least for these particular things. You just want have just got you need to ask a question to be able to get that information to go that goes across for surgery and even when I have to different specialty organizations in the same room, and they are talking about something like transients scheme of attack which is a pre stroke type of thing. There definition is different. So the definition they want to display it may be slightly different. As you described, there's tremendous interest among professional groups, some groups in refining measures involving the measurement to outcomes, and getting it right. And if following the logic to believe there are still gaps in what you can do. A think what we're trying to get to the best we possibly can given where we are. And good will be better than perfect, I think where it --

    Or am going is I'm thinking not having an experience in specific areas you're describing. The question I have is the output of the ten doctors or their representatives in a room saying what we really want is this field equals that, this and this, is there a method by which the output of that becomes an extensible component of the CCD?

    My comment in saying that is of the intellectual property of that design making it fictionalize so that everyone else can see, I'm thinking of the ad Store here were some has, this extensible feature set into your EHR if you want to participate in the society of such and such. Is that what tapping underground in if not, what can we do from a standards perspective helped enable what's the right level of intervention to enable that type of fiction as capability?

    In a word, what you just described is exactly where we want to go. And what I describe using the form paradigm of partially filling and still having additional questions, if you could have immediately have those elements into the CCD, you'd never have to see the form. It's kind of a way station. What you describe is wary that we want to go. If we could get there, without this intermediate step, great. And we cannot, there's intermediate step a.

    We are here to be -- Dream big dreams to the.


    This one is it patient safety concern. Quality but it's really all patients in the. One of the things that attracts physicians to electronic medical records is it's always there. You can tab into it from home and so they can call you can look it up online and withdrawn and it sounds fabulous. In our work with the performance measures, one of the conditions we attempt to measure, we found in 90% of the cases you cannot find the blood test that is used to regulate the dose of the blood thinner. You cannot find that in the medical record of this was standardized place without lives. In a very practical example I'd be covering for a partner of mine and find out a patient is on, then, they don't know with the austerity in. And might be able to find that but I cannot find the last blood test. This implications for the care, do they need more or less of a stoppage or a first drug. It's not available.

    Clinician and would want to know what the eye and are is. Tell me what it is? Doctors are not thinking maybe you know a population of doctors, but my doctors are not thinking about performance measures. They're not in a quality improvement. They're the good of care they deliver and what enables the care. The week it seems to me for all of us is in a still play record these performance measures and give them back to reports and allow them to practice care according to their training and their confidence level. And now that's what you're trying to do is get the eye to enable that not to tell them up or obscure data when they need it. The I and our is a very specific example of how even with this ticket it system and people know what they're doing the can get out of a 20.

    The last one and I will show up. What I'm more interested in it than anything else is a process question and the process question is, let's presume ten doctors in a neighborhood want to do engage in this conversation. And then wanted to share their experience, we really would do on this particular niche, and only 50 people in the country need to worry about this but as I figured it out and want to share with the 50. From a process standpoint, would you share that into some Ethernet? Would be the universe of people that would say, let's now but that into every EHR that is working with those of other 45 folks that may or may not supporting the. How does one take the thinking of what you've described from I would love that blood test in the context of this scenario, how is that then fed up as a matter of process in terms of figuring out either systems that have the data and are they transmittals through a standard? And are we in any way shape enabling that without getting into every minute you're born to vote on the [Indiscernible] but this standard reporting from Mark.

    Are you following me? Where do the two of you are for a view which you report your ideas to? For folks to been billed stuff against?

    There's a parallel universe, there's an organization called a National Quality Forum. [Overlapping speakers]

    To come up with measures themselves and they would of this specialty societies of evidence comes up with it. I think what's not now is we don't have measures before a lot of specialists. We primary-care started and it's been this slowed drilling to cardiology and breast surgeons wear a hat of the game but there's a lot of special this would not even have the measure is four. In terms of knowing which dated to put in, but it really depends on and has to follow with the measures are. From a process perspective I think that--

    I'm asking if it's happening.

    I'm going to be calling you.

    I don't it is happen. I think what's happening is there's some level of performance measured specification as written through PQRI or where we have our Wisconsin and Massachusetts and everyone is doing this so you've got that. And even if you did a group of organizations in Wisconsin who all agree to do it, the of go into their own system and do it differently. The different stages of their maturity with it some of them are still doing paper things and we have different methods which is also addressed earlier today. Everyone is going after the same information, but they may be going at it differently. If you can setup a standard such that it ends up and electronic systems and a similar way with the specifications are made it will be easier for everyone to do that. I don't know that we have any answers here on how to do it. I know I don't. But that's what we did is a similar way for it to be in the system so that people are spending so much time hunting ground for the same pieces of information.

    Thanks to Carol, you've had your hand up for a while.

    Yes. I'm a sort of going to this the place that Aneesh was going but my question is a little different. I think historically we've dealt with quality measurement as compliance issue. And there have been a lot of efforts over the last two decades and the data, the measures, and the reported. That's basically how we think about this arena. And I think it is really important for us to think about the other paradigm which is what is the point of care feedback, quality, what does that look like? Because a lot of the quality measures that exist today don't do any of that. Is all about the reporting and the provider gets retrospective maybe sometimes no, action. But some retrospective report. But Keegan, one of the things that was to about all of your testimony was always the challenges of even what you're up against today in terms of getting the data it and measures in being able to report for the same things that you are trying to do. And I think Barbara you mentioned initially, your advice is the initial reporting is about the quality of the data. As opposed to the quality of the care. That there's so much that needs to be sorted through. To ask him a question which is if there is an infrastructure that parallels the technology extends ability of standard to develop those measures, shouldn't there be, I want to say a parallel infrastructure to share what you are finding, what providers are fighting, what's happening out in the field and what's working and what isn't. One of the things really are struggling with is how do you improve quality? It's one thing to worry about the measures and data, and another thing to say how do I move this meeting. It seems to me if there's a dearth of place for those kinds of questions to be learned, and given we are going to be in this space worry we're providing incentives for EMRs, it seems to me it's imperative. That we figure that one now. And I wonder about your thinking on this and if you have any advice from a process standpoint, not much on the technology side, but rarely on the process of what we are after him.

    I will take a stab at one perspective. And that is that as a mention, we embark upon this adventure thinking this is going to be a registry in the outpatient arena just like in registry in inpatient and fanned out there is definitely not what practices made it but they need help with workflow and Office redesign and when the practice who collects data? There's nobody in the practice collecting data now. Not really go only beginning to be concerned. And Esther with a much more physical physician and as we did, we started to realize that this was not a registry, it could be eventually a quality improvement program but what we're trying to grow was a trinity of people. And the idea was that once we got someone else they're signalling that they found a solution to something or a better way to do it, though we have a rapid fire way to share that. So the really strong for most notable benefit of the early phases of this program has been to capture, collect and disseminate that information.

    We've actually change the concept from a registry to a program and now a network. And a work of practices we hope there will be connected to the hospitals where there is also data sharing so that wherever the patient goes, there will be within this realm where doctors and nurses are sharing their information appropriately. And everyone is committed to moving that quality.

    Effective follow-up, is there any integration of those findings or those lessons with systems providers with the EHR vendors because all its might come it's not religious about the standard by the transmission, it's also about how the system supports the provider in achieving with the quality benchmark is.

    You are exactly right. ICD EHR vendors and a model as been the narrow network. But there needs to be policies and standards which is what you all are doing. The past be the will also and part of my fear about this measurement stuff especially when we are measuring stuff that people might not care that much about, they don't yet a second outcomes is that there will disengage. And they back away.

    Chris, was and John. Chris, are you first of?

    I will be brief. How to follow up a bit on where and age was going. Other than cost of care and access to care it's hard to think of anything more important than quality of care. But it's hard to think of anything more complicated than quality of care. Earlier we have people talking about how we can even get systems to agree on how to report an level and here you guys are doing metal levels on top of that. Plus your measuring things that population to get your denominator's that are recorded in systems in place to go really complicated domains they were having to act in. The editing we heard earlier is this going to be a lot of conflicting demands on practices and on technology vendors of the next couple of years. Example earlier was the cost involved in the move from ICD-9 to ICD-10 and that's going to be happening at the same time that some of the meaningful use a are a stuff is going on. And a perfect world, we will be able to have the things that Janet was describing about we will be able to put it in a still play and the quality data will be a cost less byproduct of all of the other activities we are doing. But I think there's a pretty good chance that that won't happen so magically. If that's the case, I'm about to ask this discussion I've ever last -- Ask. These to the question I've got is if you look ahead to an environment where physicians and the vendors supporting them are incredibly constrained, and will be able to do everything they possibly could to support your quality agenda, what would be the one or two most meaningful things that we could do to push things forward so that once they got to that period of turmoil, there would be the most fertile ground and most stable foundation to build on. That may be a complete the unanswerable question but I thought I'd give it a shot.

    I will take a first crack. I think everything you say is true in terms of people being resource restraint and over want and we hear in our community, we try to unload positions and improving patient centered care from the patient's perspective and they said I'm implementing EHR, I can do anything else it seems to me because of our experience in fighting how important it is to document is now awaiting documentation that if he started out with even one of the above measures around diabetes. And said everybody has to do these that these measures and it there's five and everybody is concerned but I did is because it's an important disease that leads to very costly care if you don't get care to go these measures have been fed out to a number of proportion of physicians over the years of have something to compare to some you could actually say, you can grapple with what is truth to go to space on a very limited universe. I think that would be a very constructive thing to do. But then you have to look at other audiences like to help plan and they said with a minute, we've dealt with diabetes, what we care about is X or why and we're putting our money here so I'm free to do that but what really need is the scope and it all starts piling on. Sort of evolves into this wave and is complicated. It's hard to turn the world and say stopper looking at this. I think from the perspective of what you are trying to do I think that one be a very constructive way to do it.

    I think the key thing is to give the accessibility so that can be given any provider given way so if there's a way to extend the standard for its an into a CCD or having a form popup, it doesn't matter. But those the documents be able to run their product -- Quality program.

    Chris, if you have a follow-up.

    No, I'm done.


    Generally review in what the committee has done today if we divided ourselves into the clinical quality work group which is really focused on the definition of data types. To this point of it's really challenging to understand what the numbers and demonic side, the NQF and high-tech panel, here's action will we have to wrap go [Indiscernible] at the process of the care is gathered in who gathers it and so it all the workflow and the who and how, that's a whole set of work that was done. And Jamie scripters it is say, assuming you have that in the EHR and how do gather it, aggregate and transmitted? And we came up with a couple of paradigms' for you could imagine it goes from EHR to a culture registry for EHR to an HIT or EHR to Richard and Richard escalation and reporting and submit it to CMS. The whole variety of standards to do summary and detail and patient identified and the identified. To the point you ask me, I don't recall in any of that a form pops standard. Clinical Research is working on the form of a standard. Their work should be done in January, February so you may actually start seeing the work of the [Indiscernible] and clinical research group. Some capacity to say, what if there is did it that's not part of the clinical process or care they want to gather, how might you get that? Long answer for we've for down one part of the problem, this is a slightly different part. My question to you, this morning we heard in the auto industry they look at the a [Indiscernible] that existed out there and said, we think we can be and ended thereby creating a bunch of mappings to would ever exist today and creating some registries and bringing value. Each of you I think has probably slightly different models of how you work with clinical data or administrative data with you are a registry, would you do it. In your view, is there a similar exercise in your industry you could exercise could be to help enable and accelerate quality measurements by serving as these registry's analyzers, transformers, taking uncommon to lamented stuff screen, scrapes, administered did it come in doing your best. To this whole sort of point of today with talk about how do a dance the industry without waiting for it perfection. I'm interested in your take on that.

    Could we start with Janet. The city hired an integrated. [Indiscernible] with give it we however you can and then -- Is that a fair statement?

    The integrator extracts the data elements and we do the performance measure technician and construction and send it back in the form of a performance report. When I thought you were suggesting is where you also were going, maybe I misunderstood, a place where the interested parties, the relevant parties confer and problem solver at a level where that's not yet occurred.

    That isn't what the NQF has tried to do. At a high level health information technology expert panel the NQF but together a dozen of these interests and partisan tried to say, had we tried to simplify the definition of the data that forms the enumerators and denominator's and then they're going back to all the quality measurement authors and same, retool all of the stuff. Because it focused on paper and perfection. If we could just have a hemoglobin and it was defined this way and had one LOINC code and as we need, like it better for everybody. That's what height [Indiscernible] are written on.

    We are trying to draw on that work.

    I think there's great potential with friends a little bit about that is the rare fried breed of people who take the clinical practice guideline and create performance measures from those are coming at it from the other side. It seems like to me there is to be a merit in the middle. Because the perfect measure is probably not capture all. If that's a word.

    , an acceleration.

    I want to comment the [Indiscernible] collaborative and when the communities that three hospitals but they hired [Indiscernible] two to the LOINC codes because it was such an incredible mess. This morning when the guy said that you have to pay -- Gives a big help everyone to give you have to pay to have this mapping then because I thought that was an incredible model to encourage people to get to the standard because I thought that was a really neat idea in something that is within the more about.

    There are people that will do it if you pay them. And then if you keep paying out, then there's an incentive for you to get with the program.

    You all these rabbit challenges of clinical data it and administer it did it, I've had my own experiences with the administer it did is actually quite poor but then clinical documentation isn't perfect go so neither is exactly silver bullet. One hopes the work into a variety of models sometimes it will be the vendor, the aggregate, sometimes you guys will be the aggregate is, sometimes [Indiscernible] will perform the function. We will be able to a accelerate the industry taking Friday were exist today. And tried to make it better and simplify the number of metrics we have to support and the number of numerators and denominators seems to me as folks have said, this is a one bytes of the elephants and eventually will get it down and there'll be a bunch of strategies to accelerate as.

    Was, would you like to have the last word?

    I know the answer to that question. [Laughter].

    Any word would be okay.

    [Participant's audio is faint/unclear]

    Was that again? [Laughter].].

    We talked about the various ways of looking for the nickel where the light is better. One of which was payers to have a more data about a person then providers to. That works well for acute episodes less so for chronic diseases because I've changed payers three times with the same doctor. As you begin to plug holes and go forward, are you going to be challenged by having a patient IT, have resolved this, and have an idea of how to solve it, given how complex the question is, is there anything we can do in terms of standards or so forth that could help with that issue?

    I will comment because I dropped off in my discussion. Patient identity management and some form standard way is critical for the next generation of quality measures which will cross care settings.

    I completely agree pickled standard is outcomes and we would love to be able to link what happens to a patient in the hospital to what happens to the person and a primary-care for knowledge office, we all would. But it's impossible to do with this point.

    It also goes out to the dedication of both provider and patient. Patients can be a problem as much as the provider Patinkin and up with multiple identifiers and to make those attributions after while we want to report this is how you're performing at this clinic or down to the physician level, if you don't have a good match vision process, again use the physicians and that's how you start getting to the point of improvement is by their by believing in the data. You have to have that.

    We've done a little bit of work with patients where we don't have the patient identifiers but somebody else does and so you do this across and it, some. But given the privacy and security concerns, it seems like this only a to miss some way to do it.

    Do you get funds from payers for doing your work?

    As of December 9th, they can no longer collect family history before enrollment because that's genetic information. Is that going -- I don't know if I have a question. [Laughter].

    The genetic information something at.

    -- At.

    Restrictions on how payors can collect of the [Indiscernible] is going to continue to be a problem.

    Don't throw out the baby with the bath water. [Laughter]. And the last questions for our panel. We are right on time.

    I want to go back to the comment and Janet, you hit it for me at the beginning when you were talking about the fact that what we are doing is making it easy for clinicians to do the right thing. The purpose of quality measurement is not to measure quality, its to improve quality. It's to ensure quality. So I sit here and it about the stop measures and I'm thinking, they did everything right in the first place, but otherwise it's not helping our patients to measure the fact that they didn't do what they're supposed to do 30 days ago or 60 days ago. So I the Internet as all that there's really not a lot of difference in my mind anyway, between what we're doing when we provide patient care and how we measure it and we've got those two things he might possible concurrent as possible. Said that the right thing is to and from. That's what I like to pop up for because it's reminding them what they didn't do.

    I couldn't agree more because I have a colleague who for years now has had a homegrown electronic medical system worked beautifully. He's very deeply IT conscious and knows how to make it work. It's a big practice to open all of this business of measurement and transparency of public reporting can about, he's completely non but. A point of care, I'm doing what's right for my patients to show the world, I don't care. And to be able not just to inoculate someone against public reporting, the Thomas of that, but to actually insure your delivering the right here at this time and it happens almost automatically. That's a good system.

    I think the sense that most doctors think they're doing the right thing every time. Because they're well-trained and the intent to do the right thing every time. And it's only when you measure something you find out that I didn't realize, I didn't know she was diabetic or did know this or that. It really is a helpful tool in improving care that the whole measurement world if you don't measure, you cannot improve. And we all know there's improvement to be had in our health care system but I think it really is part and parcel to delivering good care it is to understand and I want to mention that the commonwealth's funded a study not -- In 2005 and the repeated it, how many physicians in Canada back about the care they deliver. And a bidding want to guess what percentage of physicians, this was in 2005. Got any kind of feedback about their performance?

    [Indiscernible] [Laughter].

    This was a wide. Nationwide. It was a third. It's the physicians had any kind of performance feedback.

    By the way, my point is that do we should measure and playback. I think you get a behavior changed from that play back. But you did not get enough be for change to get where we need to go. I'm back to the concurrent making sure they're doing the right thing at the time they are delivering the care. Because we are going to take some behavior by giving them feedback.

    The way you did at that at the point of care is in my workout for this physician and he or she does that all the time, but to the point you can use the same standards for the point of care improvement and doing the right thing, you can also use it offline because in the midst of the busy day, you don't have time to think about had widely change this process? Is not really because it's all about reporting on the physician been good or bad, that's not going toward. It's the system that there were again and that's where it can use the same standards to develop this in college report to can sit back as a team and say how do we change the process so next time and at the point of care, the process automatically pushes me in the right direction.

    David, if I'm a ticket [Indiscernible]. And use this to and and the waiver exciting panel. My question is this, let's presume the standards we've recommended are universally adopted tomorrow. What one or two quality measures in your world has the highest degree of having operational reality of going to 70% limit housing, there may be in a dissenting board of data one could call from a CCD [Indiscernible]. May be here live or on the post afterwards, if you could suggest a the one most impact will quality measure assuming Universal adoption of the standards we've described, would we really, I'd love that feedback. If you could think of it. Jack, you're nodding your head?

    A question with asking?

    It's been going on for years, I don't know if it's worth watching a quality measure or not. If you can get people to stop smoking it would eliminate a lot of health care problems and a lot of expense but that's a big one. But pressure, if you're going to the conditions, this won't satisfy Richard, but the rest of us, diabetes and heart related disease.

    Elements within the CCD could be sufficient to x to on this of quality measures around diabetes



    That's my gut but in terms of body mass index to that I would add. That's a huge issue. And also we want it to the pediatric population and that's part of it is its only diabetes and heart disease which populations do about and what about those doctors don't see those patience. Out to think a little bit more about that but that's, I agree with Jack.


    I would ask cannot to narrow it to a specific set of color images because of your patient with the disease does not in that group, you lose.

    I probably would go with the diabetes but I would love to pull the brains that I have access to. And to get back to.

    That would be very helpful.

    Jesse, we forgot you because your on the phone. Any thoughts?

    That's okay. It's hard to jump in. I would say what I was talking about in my statement, Aspen, but pressure, cholesterol and smoking. Slogan probably the hardest is to capture because of the unstructured way it's collected. If we can get standards around that type of unstructured data and make a structured and make it mandatory as implemented in EHRs I think will go a long way.

    I think we need to look at from a public health point of view and I agree some people will lose up I think if you're looking to move a needle, and the biggest classes, the greatest classes of mortality, I think we have to take that approach.

    Thank you all.

    Let me think this panel first four the pioneering work that you are doing in this incredibly important space. And second for being willing to come and share with us today. Thank you very much.


    I have had a blast. Listening to all of these stores to go I want to speak for anyone of you, but what I thought I might suggest in the next ten to 15 minutes is to throw it open. I do want to tell you my perspective on a summary of the I'm happy to. I would love to just the with the producing what have you learned today free-form brainstorm will continue this conversation in advance of the 19th go but to kind of tease out some of the top two or three things we might have heard today. I'd love to throw some of that fertile information on the ground for dial-up ago would like to start?

    I would say if I heard one thing over and over its keep this simple. And very focused. And I think that's going to be a challenge for us. If you look at meaningful use, it was do we lost our way in didn't understand, we should simple. But I think going back and religion, I think about the word that we've done in the standards could put the and we Village tried it to search for right standards but now it goes like its more than half to. We have to do less.

    Very simple, very focused.



    I've learned, I think I've learned that there's not a lot of knowledge of these to scope of what we are working on. Because I think in the long run, and I don't know that timeline, there's going to be a big impact to providers, to vendors, to health care, to efficiency of cost, to all the things, but not and a noninvasive cost. To the constituents and vault. And I hope everybody is really looking at what we are looking not -- Working on. And start the process of helping us figure out how to do it a step at a time. Good questions with whether the top three, top five, we are going to get to the 22nd one. [Laughter]. By 27th one. So I really think that, I want more people to know exactly the death of what the vision really is. But then help us get to that. In the appropriate time frame.


    One of the observations I made and I learned today, we would love standards to be simple. I did one of the challenges I need to be a core opportunity to get it right is as we go forward looking at what standards and I am somewhat lean also toward a smaller set of standards as well. But finding the balance between, I want to be too specific with the standards necessarily right now, that's going to wipe out the good work that already got on. For example if we get too specific with a given standard, and all of a sudden, the lab network out there for some of the other networks that already in place, we now made a decision about a standard gotten too specific, it's now with the implement for example, HL7, something or other. If we get to in depth and require too much, now we forced people to go ahead and do modifications when the had a working solution. I don't think when we pick our standard, I think we want to be careful that we are not going to pull out of the water and the stuff that's written out in the communities and HIE and networks with cannot but think we need to be careful about how specific maybe we get in the standards.


    Reacted to leases,, I'm not sure that I heard that's an issue with the standards. As opposed to the adoption and path to get to the standards. What I heard was that there's a need for allowing variation to accept what exist and what has been implemented and what working locally on the path to adoption of the standards.

    [Overlapping speakers]

    I think that's what I heard.

    And that's from some who implemented many different versions of version two. And didn't want to do another one perhaps. And then--

    It's a road map in.

    It's a path to implementation and adoption of the standards not necessarily essentially allowing a lack of standards.


    I think we heard a couple things. One, as Janet said, [Indiscernible]. [Laughter]. In other words, the notion that we will get the National scalability associated with fully interoperable standards in our lifetimes is suspect. The notion that there's already a lot of good data exchange going on to the core competency of some HIEs and things like that, those are the two polls. There's not know the exchange going on. There's a lot. It's our job to move as between those polls, reduce, put the systems integrators out of business may be. Will have new problems for them to solve them. And also learned that a lot of that work is based on some of the work with HITSP. And I think we have a challenge to tease out more than we have so far. What are the things about HITSP that creates so many antibodies because they haven't been implemented [Indiscernible] and they don't need the business case for us is what are the things about HITSP that face the inevitable I'm already doing it one way, now you want me to do with a giveaway but we can get beyond the interoperability of the don't buy that political.

    Did you learn anything about that?

    I think so. I think the discussion on 80 TA for example, was initially I got angry because what I heard someone say is it's not right for three physician offices. We are not talking about three, we're talking but the country. But the real question was -- How is the benefit of having an interoperable audit log but is that benefit important enough to impose a TTA. Of a lot of times we talk about the interoperable of gridlock as being a key to trust. If I put my trust in that organization, to share data, but I have, I want to know I can examine an audit logs. So I've always thought it's important. That carry the conversation today, it's not is it important, it's how important is it? I think we could do it in some reexamination of [Indiscernible] in that regard.

    Before I go to the next one, [Indiscernible] last, was so much of it was developed by whether I'm simply sending you a message verses' given you the right to look into my knickers and I think the question about the need for the interoperability was tied to the perception of what's the scenario. So that -- And nominal a summary on that. Do we want to go round in order? John, you did the last word.

    That will be fascinating.

    We will go around this respect a couple things. I didn't hear anybody say that keeping it simple would get in the way of making a complex for people who need it to the context of the was lots of chances for people to say that if it wanted to, I think we try to tease that out and we didn't have that so that was sort of one. The second was was the role of government versus private or collaborative activities. I think we heard a little bit of that in the first two panels and to the. And the topic in the vendor panel. And one interesting piece of advice was for the government to eat its own cooking. But implementing all of the standards--

    They are looking right at Linda. You make this happen tomorrow.

    And she didn't blink.

    [Participant's audio is faint/unclear]

    You said it better than I possibly could. I thought that was a big deal about what should we do and turn over to others to accomplish in a different kind of way.

    I will leave it at that.


    And with the key principle and let perfect the enemy of good enough and I think it would sometimes with all this trying to nitpick and match and take apps of everything and account for every member around the HITSP standards. I think we get much of the little bit with that. The biggest message was implementation guidance. And testing tools would be in there. And working examples. As well said, we've got people doing some good examples. Let's get those documented and let's get those put around some very specific implementation guidance. With each of the big standards that we're talking about implementing.


    I heard a couple of things, and there reinforced it already believed. But sometimes it's nice to be reinforced -- I believe to keep it simple and the quickly is incredibly important. I don't think anybody would call the CCD simple but what was interesting to me is a breeze objected to. There was a plea for it [Indiscernible] around the edges but people are using CCD as complex as it is, to do useful things.--

    To ask a question? What I heard and give me the technical [Indiscernible] of this. One can transmit the CCD without and lots of data that might require some complexity to transmit and still transmit. The CCD and it may not have the full [Indiscernible] on each individual did element. That would still be transmitted. It's simpler version of it is what I'm trying to ask.

    I'd think it is already. A fairly simple version as specified in the various documents all the way down to it a completely uncoded textual version of it is illegal.

    That's right.

    We have to be careful about what level of coding. Maybe the good news is that the complexity has already been mandatory complexity has already been accounted for in the agreement on CCD. We now have a problem which is had we use that CCD effectively? And where I think there's two things I heard consistently. What the cowherd and one which is just I didn't hear anything to counter my own personal [Indiscernible]. I heard the nomenclatures we specified for CCD on the right ones but they need subsets. So LOINC is too big and it needs subsets, SNOMED is today, a need subsets perhaps needs to be mapped to ICD-10 so people can use it instead of ICD-10, etc. I heard a lot about constraining the nomenclators we've already paid. And the second thing which I think Adam made the point which was one of the things that made the web succeed was the distinction between HTML and HTTP. If we look at CCD has been our HTML, we are missing the HTTP. We've got a bunch of specs on the table better complex and can be built, the next PS sweet, but they're pretty complex -- And hearing is this is for people have made the work but I think they'd be more powerful way to move CCD around that would get us much of the benefit of sharing structured data without some of the complexity of [Overlapping speakers]--

    Has anyone designed a very simple HTTP to move the CCD Brown? And tried to get my arms round it.

    It's called HTTP. [Laughter].

    Captioner says: . I think there's more opportunity to take advantage of that [Indiscernible]

    I see you down there talking at the bit.

    I think one of the fundamental lessons in their is we can figure out what minimal born during the above the [Indiscernible] and it's more about services. We need a D and as for health care that includes more than just do you are right, it includes some authentication that you really send it to a doctor and not to other people. Still we can oscillate that issue and deal with it. Just combining that with what window was saying, right now, people in various [Indiscernible] particularly HL7, have come from a culture when there was no HTTP, there was no -- Nothing that was widely adopted but the first and we had to fight with is [Indiscernible] as opposed to asking. What I hear is it's important for us to create a clear message to the ESD up to get out of the HTTP business. To spend their time in the business of giving the medical information that we need to interchange.

    Very powerful.

    [Overlapping speakers]

    It. I didn't hear anything to push me away from the belief that the central point of aggregation for all of this the death still should be the patient. The person. I was pushing to see if there are cases when that failed quality measures is one area where it may fail, but I didn't hear anything else, and I sure as and quality measures. And still think we should be when we start moving this data around we should be moving in the context of the person rather than the region of the State or provider or do whatever.

    A man.

    To continue on the simple part, two things continue to come up, medications with that medications others we have that information at the point of care. It's the best decision and we've heard here and referred before what can We Do about royalties go people are paying lots of money to get the standards what timid about that to make that open source.



    This summer, it's happened great but I do want to raise the issue of cost because at the end of the day we are all here because of the recovery Act which was enacted basically to address economic issues in this country. And I think we have a responsibility in our recommendations to make them in a way that they're not only simple but also that we are really careful about doing only what minimally necessary to put that was another comment we heard today. I think everyone of these requirements given everything sauce that's going on, just adds to the complexity and we start doing the math, where it takes to comply with x and why and z, across 750 dozen providers, across hundreds of vendors and thousands of implementation, I think we do have to think about doing what's minimally necessary and factor in that in and prioritizing it. I will also said that one of the little worries that a half about the issue of complexity and then the mapping and integration and all those other, to worry about complex because we will have mapping and integration and all of this is that that's who it cost. In its cost that its board in the system and some mentioned [Indiscernible] Lawson and I think this is again, the same lesson. There could be a lot of cost that unnecessarily late on the system. I think the reason it works in the auto industry, because it was subsidized. The big guys have a lot of incentive to make sure the little guys is the standards because they basically subsidize the adoption of a dome that we have that situation. And I don't think we want to get--


    And your point is well taken. Maybe not, we will see.

    To that point, I think we should have a discussion [Indiscernible] talk about the country, I think we are talking about a lot of three and four and 510 Dr. Practices. Or we should have a discussion about how to figure that into a our deliberations. Target to be all things to all people but I do think that's one of the key reasons for this recovery Act and invest in Health IT was to really the accelerate adoption of Tripoli in places where the as glad. And has been slow and I think we have a responsibility to think about that.

    John, I like. You're not the last go I think when the, we missed you. I want to put you on the spot.


    Remember and also the one that represents long-term care [Overlapping speakers]. That's why I'm a little bit quiet most of the time. Because we are not and meaningful you use yet. On the cost part, let's not forget the vendors and sometimes we forget the vendors and I'm a provider as well but the vendors have a large cost and sometimes we keep throwing it on the vendors. My biggest [Indiscernible] which I really appreciate from our point of view is of the CCD was mentioned a multiple times. And the third sector in health care being long-term care post to care, we get everybody at 40 on Friday afternoon and that CCD would be immensely helpful for us on medalist and everything else that comes. I did like the little comment though below the OSHA. I've not heard that before. Focus and focus on a few things but the most important ones and that process and implementation are as important as technology. You mentioned the little guy, that cannot many times today that. And to move the quality measures from compliance to really doing better quality of care especially at the point of care. And a couple of standards we should have extra room for extension. And designed standards to achieve real clinical problems and business problems and not just because we wanted or because of compliance. Another one that's important to our sector is that the government be a leader of but the all the other pieces of the government to comply like CMS, were about to have an M.D. s three given to us next year and there's a different set of standards.

    Can you describe that is?

    In our sector we have two things already that our assessment. A lot of what we talked about pulling the electronic quality measure from an EHR, we can pull from it and be as that's a minimum data set to go we do everything multiple times on any resident patient that comes into a nursing home. We have to follow up this electronic form in order to get paid. In home care, we have to fill out an Oasis form that it's paid. Oasis C comes out in January. And that's a first change in a long time and MDS to appoint a comes out next October. And that's a radical change.

    Has anyone mapped either of those to?

    I'm taking that chart [Overlapping speakers]

    Because we did Janet and I and the rest of the guidance [Indiscernible] said for our sector, which is not on meaningful use, we are shadowing that so I'm doing quality measures with the people, with the association's I work with a hospice, home care and skilled nursing facilities. When you all decide that we are a meaningful provider, and I know it's hard to do incentives to a sector that really gets paid for Medicare and Medicaid. That's different than the rest of the sectors. But we're going to be ready to work and look at the time you make this one.

    To the extent there are new requirements in MDS and Oasis at the require any information, could you substitute a CCD.

    I have no idea. I'm trying to get my arms around from our perspective knowing [Overlapping speakers]

    We can harmonized a CCD with MDS and Oasis because.

    Last thing I have, on the security issue which always bothers us a lot was interesting, let's not over standardized security to a summit in hat into our big security. We have so many deaths of security, it's on real. But really, someone said policies for auditing and things like that.

    Linda, last for.

    I heard today which of course triplex again what I was pay most attention to is -- Tell A surprise.

    And terms of once the standards are available this really going to be a different adoption rate. And the rate is going to be influenced by whether you are nimble [Indiscernible] service provider or if in fact have major legacy systems where you're going to have to go back and if you want to do anything other than mapping at the edge and you really want to internalize it into your system, getting rid of mapping which of the wide because it produces toys in the data legacy and cost. We have to get away from that mapping. The adoption of the standards will be on different time frames based on what your technical, the legacy system is what your model is. To come back and what [Indiscernible] roadmap, and we sought in one of the written testimony is, exactly the communication strength that goes out that says, may 2010, we all go to start and this what we're going to start on. And this is how long you're going to have to do in here are your resources and maybe there's a testing and all that sort of stuff. I think that something that this committee could probably spend a lot of time on is that broad communication campaign once we have pulled all those moving pieces together. Is there anyone Alice was working on that? Is that the job of ONC or policy committee? Or is there a space within the standard communication that of do we are going to have a provider that this committee should spend some time on?

    Phenomenal comments. Let me ask if I may, we are going to check again probably by phone conference between now and the 19th. We are voice and but all of you Tupper's be an online form at the website pot. I mean that in services but there are a lot of questions that came up that will likely lead to some further which conversation about this topic. The biggest theme not summarized yet but one because I wear a policy that is just the sheer magnitude of the policy judgments that are still to be defined that weigh in on the status questions and I don't mean just in the narrow scope of Health IT, we learned a great deal about a variety of other whether it be Clea, the work going on at the ICD-9 and ten and so forth. I've got a litany of policy questions that I'm going to be taking back to make sure that we are getting the right guidance to inform the technology specificity that we're describing. The chat ahead with less about privacy, the level of technical confidence-building measures required to the reforming of the policy question. We should turn now to the public. And invite our friends who are here to share two minutes each thoughts on this subject matter. And while we're doing that, I want to give special things, do you want to go first? Why don't you come first the goalie's first to go and I really wanted to draw attention to what I think is a phenomenal document. Could you please describe it for as?

    And Robin from the HITSP. [Indiscernible] kah ha -- It mimics the [Indiscernible] the absolute intent is to work to the governance and the next couple of weeks through HITSP to make this an official HITSP document the begin of the biggest of it. And get out and recant through the [Indiscernible] the HITSP Web ago Reebok -


    Can I share before we make it official.

    This HIT policy committee, anybody lost in each building this part of the poster, it's all about good stuff. [Indiscernible] I don't know any of the stuff was to is the other reason is automated posted as I had to make myself learned. What's out here is what is service collaborative and what's in capabilities. What exactly is the speaker is an epochal and in over here this is actually, this piece here is Jamie Ferguson workgroup [Indiscernible] there summary that says [Indiscernible]. Here's the meaningful use criteria and here's what you said in a column was supposed to be in there was the vocabulary and standard and the alternative which is marked in great. Probably the most the pointing of is able to do polling this out of Excel and putting into with detail format, I am here is how Ms. Times that standards showed up. And meaningful use as a whole.

    Twenty-five times CCD showed up. A richly waste of time on it [Indiscernible] it has to be HL7 to buy one because Clea's says you have to have OEX 2024, 25 to put in the lab director name and address discreetly and jiggles says, EHR people in [Indiscernible] was be able to support the [Indiscernible]. I wasted time,.

    Does anyone know this in the world.

    The right this minute if you don't upgrade not unto .1 and take will come to your organization you get a violation of your sure that information discreetly.

    Why do you think we selected it?

    Deploy your making is the ability to communicate in simple terms to the external market, I have no idea. The externalities' involved and what you just said because that's very helpful.

    From that piece and then down here is how many components there are of a capability for but never. This is Dixie Baker is a spreadsheet here which says the privacy and secure [Indiscernible] this is just 2011. I couldn't get any more on there.

    I have to be careful, we have a two-minute rule. Can we say thank you for the working done. Thank you.


    My name is Larry I'm with Siemens and a practicing physician. I'm Mike, and where to acknowledge the fact that HITSP and a lot of the other standards organizations, HL7 have done some great work and we beat ourselves up but we've done some fantastic things and I think we have to take advantage of that. On with it, there are a couple things I'd like to make mention of. One is, the timeline and the governance and to reemphasize the fact that you need time in order to anticipate what's good to happen in the future. Probably one of the biggest things that this organization can help with is setting that with definable goals of where we need to be at what particular time so that everybody is in sync and knows what went to happen. The of the thing I'd like to say is on the measure of making it simple. Making it simple can either before the senders of the did it or for the receivers of the data. There are different things. They have different trade-offs and cost. If you make it easier for the center, it has a low initial cost but as a high downstream cost. If you make it easy for the receiver, then it requires that you do something up front. And usually that has lower downstream over all cost. And the development of your standards, think about what the impact is and sometimes the least expensive solution is not necessarily the easiest first pass. In require some effort up from.

    Thank you.

    Richard medical imaging and technology alliance. Medical imaging information is important to realize in the goals of [Indiscernible] given how the diagnosis and evaluation of patient condition has been revolutionized by images of the past two decades. Driven by the potential of medical limiting, industry and health providers coverage of the created a collegial environment in which medical imaging now represents the largest body of standardized medical information existing today. And medical images have been exchanged using the DITE comes standard for over two decades ago the first large-scale radiology department having become virtually famous in 1994. Implementation of the DICOM standard has gone from early demonstration in 1992 almost Universal adoption today by imaging vendors worldwide. In addition to what is the end [Indiscernible] cardiology department, hospitals have adjourned so images using DICOM over networks and on CDs for a number of years. [Indiscernible] the success hospitals have and reading images the zero images [Indiscernible] accordingly, we strongly current the committee to accept DICOM as a standard for medical imaging data and ticket mentors of the interoperability possible between hospitals and machines centers and clinics today. Mind is the medical division of the month, the national and local manufacturers association with 80 years of experience in standards development, managers develop a deployment, testing and stability of the DICOM standard and promotion of its widespread use and adoption. [Indiscernible] there have been involved in the implementation of the DICOM standard and to provide this work group with real-world information on adoption and implementation experience is related to DICOM. [Indiscernible] intends to provide additional and Commission on this lines and its common to go [Indiscernible] would like to become more actively involved in providing the conditions regarding adoption and of an intention of interoperability standards such as DICOM. Refill this work group is a unique opportunity to measure rate of adoption and meaningful use in health care sites to go to these ends, [Indiscernible] members would welcome the of eternity to meet with implementation remembers for more detailed discussions about the adoption of imaging within the broader HIT in from. Thank you.

    Thank you.

    The order [Indiscernible] on the phone, please stay on a.

    Stephen Walton from American Academy of Family physicians.

    Thank you.


    Good afternoon. Thank you for opening up the HIT Standards Committee to have this jury important discussion. We appreciate that and until they know I've posted on the block and [Indiscernible]. A couple of points. One, in the summer about no comment about the complexity of the CCD. What I would put it to is the project age did which was a group was started from some of the folks that did the test harness work for the CC HIT around the CCD but they talked about not been able to use a lot of the standard XML tools better off the software with that because of the way that it implements backs Amal. And they've created an El 32 [Indiscernible] a live version so they could work off of. Based on testimony and would say the CCD is not complex although I did hear that it has been implemented which is great. My main point, I hope we can continue toward a separate a nothing layers in the standards, the one of the things we can do for simplicity is make sure we separate those things that deal with passport and again in the management and the content and keep them separated and I think one of the great things we been able to do on the Web is keep [Indiscernible] all separate and began aggregate those together and if you want to use FTP and not [Indiscernible] you can still do that and still use the underlying standards, and predicted that something similar in health care come I think it would be fabulous to make sure we don't to that. The other thing is the notion of dependents and how it's great, head up to see that diagram that was presented in the public.



    [Overlapping speakers]

    That's one of the issues is just the dependency and if you say that we want to see x number of components within sight of HITSP and you may find a standard and there that reference is what the other standards, so being able to understand that if you guys pick a particular construct from HITSP or standard, what is it your action required people to do? The last point I want to make is around extends ability. If you take the notion of separating things out, I think it's more important to be able to allow other standards to participate as opposed to expanding. There's a lot of discussion about extending the CCD standards to represent these other things and other pieces of data but one of the problems is it being set up as a document and not did that and it's hard to do that. You separate out the did and document, you have the ability to add more standards and do that by extension of opposed to taking it to the standard [Indiscernible].

    I have to cut you off. That's free helpful. Please post the project link on the blog, is the dominant.


    [Indiscernible] we've given to the our full statement and I will focus on a few key points. We really appreciate your interest is on practical implementation and this was a terrific hearing. Refer to focus your time on effective rollout of the standards that have been adopted to recommended to date by the standards committee. Which is really done a very good job of assessing the readiness. I think a lot is on the chart and billing of a multi-year adoption roadmap. What to call off the critical role of I [Indiscernible] and hits be in harmonizing standards for pilot use cases. Third, to emphasize the importance of a single set of standards for exchange of clinical document goes something we've heard a lot about it. And fourth, with fiscal year 2011, less than 12 months away, the number one standard implementations priority of the next four months or so really needs to be the clarity and consistency and what we vendors and customers are expected to implement. Beverage in the huge investment that had made to date in the HITSP harmonize standards. Once until application is to not be open settled standards. Notably that of CCD, as the harmonized headed for clinical summaries. Such a single standard is central to data liquidity, vendor neutrality and interoperability. The CCD is fully billable and immature and been widely lamented as referred, and as Dr. Taylor said, the use of CCD is fully transparent to fundamentally to physicians and also to reference the final discussion you had. I think the talk about the value of standards based transport. Using the STS model to action move the data into the records. The extra cost to support multiple clinical summaries standards and we heard about cost at the end, [Indiscernible] the second major priority here as per today is to ensure that vendors have a clear understanding of how to implement the ARRA designated standards without a written statement before refocus proposal to meet this urgent need under Standards Committee coordination. This approach involves collaboration amongst an alphabet soup are familiar of a soup of IT. HITSP and the ONC connect Program. Emphasizing technical support documentation, identification of applicable open source tools, and in our focus for the upcoming IT connected on. On behalf of it the [Indiscernible] I think you for this opportunity to present the views and we stand ready to help you in the to provoke a new will post on the block.

    Two the.

    Eyes, is.

    Go ahead. My name is Kevin and I work for [Indiscernible] and on the board of [Indiscernible] representing the radiology demented but I think--


    I think the integration healthcare enterprise familiar to people is the basis of a lot of the HITSP particles. And wanted to hide your desk and a connected on. And in terms of we've had a very good presentation from the vendors with a thing speaks to the value of the we've already talked about in terms of testing tools and in terms of the implementation guides which is essentially what the IT profiles are. To help the vendors get the right sort of material is out there. I encourage you to take a look at the database we have an online database which has ten years of connected on refills. Which the conducted both in U.S. and Europe so ten years of Senate test results on the different profiles. Covers over 300 vendors now. In terms of looking for patterns of adoption, speed of adoption, hot from giving a spread of disease something in private, those sorts of things, we are current and working on a registry of the integration statement. The connected on lets you test prototypes, the integrations them is when you actual release pot, it's smart one page we support this and this. To do you have to go Google or from around everybody's Web pages. We are trying to do is set a central registry so you can essentially going antiquaries and get a map of how far as industry on in implementing these. I think we've got that side of a pretty well covered. Hopefully that will be useful. We'll give for this you do, but the terms of looking at the of limitations side and hospitals. We think that you're asking about obstacles and I think that's where some of the biggest obstacles are going to turn up. As you heard on here, getting some code written, there's cost and things to deal with the we've demonstrated again that on a lot of fronts. River and into a bit of a foggy days and we are not sure how far we get. In terms of having the people and organizations understand how to apply these and getting them turn on and getting them put to -- Meaningful use. I think the green out that cited the implementation Guide and I know there was a suggestion and setting up regional centers of expertise best practices and things, I can say that's necessarily the best way but we are looking for to see how that goes and perhaps we can do some collaboration.

    Thank you very much. Post those lines on the block to your summary data.

    Will the.

    Thank you. I'm Tim [Indiscernible] we been a member of HITSP for years to go John knows all about this. Would I want to talk about and I think the slides were handed out to the committee ahead of time ago but want to talk about is second-generation XML. The Nobel Prize in computing goes to XML and 1998. [Indiscernible]

    That's correct. There's better things down. Second-generation XML, unfortunately the people who developed it telehealth in business and, extensible business reporting language. This two versions of it. When is for financial reporting, the other is GL, general ledger our global ledger as the College internationally, and that's for health care and intelligence law enforcement etc. And it requires not schemas and extensions because the kitchen in trouble, because everybody is [Indiscernible], everybody [Indiscernible]. That is pretty straightforward work. That's plumbing work as far as I'm concerned. I'm a plumber. If you look at and the slides there's one slide I think that's useful in the interest of time. Where ever is. There's two things. Two parts to taxonomy. One is a semantic and in our political with the agreement on the definition. The other is a computer interoperability. My view is that John [Indiscernible] who ought to get his own Nobel Prize has given us semantic interoperability. We are there. There's more work to be done for sure. But we don't have one computer standard for this is pretty straightforward and that's the kind of work that needs to be done to make it work. If that happens, and basically, that was the August 28 meeting for [Indiscernible] blog. Does a couple of printers that are possible. We suggest using a URL for every patient record. There is a national identified. It is an out of box solution. But there's something called XM HEL for web site for medical records but you can clinical administrative, financial. We know that the Government Printing Office is going to do a pilot, doing what a petition on that for next year. And I think we will switch to that shortly. It's going to become quite widely used to go -- Saw the the updated your help is available for the next physician. Where ever they are. Down the hall quote, or around the world. It works quite well. There's a lot of issues to resolve typical privacy issues, security issues, the verification issues are the same, the legal issues may be different. And each doctor can specify what they want when they want it.

    Thank you very much.

    Did you want to wrap up?


    Say if you is the customer I'm Larry with the health care and [Indiscernible]. The of what ever is going to say is HIE several folks have spoken about a. What we'll do is post two items on your blog, one related to attended the integrity and what people with this completed and deceptively on an EHR usability white paper. Being a policy, the one item the window appreciate is 30 % of the administration exit in orders for a return by the Bush administration and is, about 25 to the % of the administration administration go Executive Order 13 for ten requires the federal agencies to build a up to the bar regarding standards. That's one that this industry doesn't want you to overturn.

    Thank you.

    Anyone else on the phone?

    I can believe we made it. Thank you all very much for your time. Thank you for everyone showing up with all this work we have to do. As relaxed and absorb this stuff and reconnect and we will see you in a couple of weeks. To an average much.

    Thank you very much.