American Health Information Community
Population Health and Clinical Care Connections Workgroup
Summary of the 24th Web Conference of This Workgroup
Wednesday, March 05, 2008

PURPOSE OF MEETING
The meeting was convened to receive an update on the latest iteration of a Clinical Decision Support (CDS) Draft Letter of Recommendation and discuss next steps for review and input; and to receive testimony on and to discuss the next steps related to Health Information Technology (HIT) and the Population Health and Clinical Care Connections Workgroup (PHCCC) 2008 Work Priority of Maternal and Child Health (MCH). Meeting materials referenced below are available at http://www.hhs.gov/healthit/ahic/population/pop_archive.html

TOPICS
1. CDS Draft Letter of Recommendation Update
Updating members on the latest iteration of the CDS Draft Letter of Recommendation, Kelly Cronin said input was received from the five Workgroups involved (including PHCCC) as well as from the CDS Ad Hoc Planning Group. Comments included incorporating chronic care and consumer needs in the requirements and inserting specific references to public health. Specific references to public health were added.

Major changes included:

Members were asked to read the revised Letter carefully and provide comments.

ACTION ITEM #1: Staff will supply a Word version of the latest CDS Draft Letter of Recommendation to members for comment, with comments due back to Laura Conn and Shu McGarvey no later than March 15.

Discussion
Key discussion points included: (1) the need for the Letter to address repository harmonization and an oversight process for deciding appropriate content, and (2) related to standardization, anticipation that the Alliance would develop model repositories. The Department of Defense (DoD) and Agency for Healthcare Research and Quality (AHRQ) programs will provide input toward development of a standardized repository or set of repositories. Language in the Letter on these two points will be reviewed for clarity but additional comments are welcome.

2. MCH and HIT Presentations

  1. As a former Director of Public Health for Illinois, Dr. Lumpkin provided an overview of MCH and provided specifics about MCH and HIT in Illinois. He commented that the structure of MCH programs may vary from State to State, though the content is similar. In the early ‘90s, Illinois instituted an integrated MCH information system that illustrates important functionality that we would like to see in the MCH environment.

Dr. Lumpkin noted that:

  • In Illinois, as elsewhere, Federal and State programs for women and children are clinically oriented but also non-clinically oriented, such as food and nutrition programs.
  • Many States have enhanced Medicaid eligibility for pregnant women, the U.S. Department of Agriculture’s Women, Infants, and Children (WIC) food program, and Healthy Start.
  • Infant and child programs include Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and well child care under Medicaid, WIC, immunization, early intervention, well water testing, metabolic screening and case management, and blood lead testing.

Dr Lumpkin provided an overview of Illinois’ “Cornerstone” system, and concluded that:

  • MCH information integration is directly related to good outcomes; i.e., in Illinois, integration of clinical and other determinants such as WIC has demonstrably lowered infant mortality for women who participate.
  • An integrated system must be designed to meet the needs of frontline workers and program administration.
  • Integration with electronic health records (EHRs) and non-medical service delivery is essentiala task that bears further discussion.

  1. Cheryl Austein-Casnoff, Associate Administrator, Health Resources and Services Administration (HRSA), Office of HIT (OHIT), provided an overview of what HRSA is “doing to promote HIT in the safety net community,” with a focus on Health Centers where clients are mostly children, emphasizing that HRSA programs are significant, providing a safety net of direct health care services to nearly 1 in every 15 Americans across the countrymostly minorities, many lacking insurance--with an FY ’08 budget of about $7-billion.

OHIT’s role is to provide HIT information to HRSA grantees, bureaus, offices, and other stakeholders to promote improved quality and patient outcomes and reductions in health disparities through effective health information technologies adoption. OHIT also awards planning and implementation grants for HIT innovations and provides technical assistance (TA) to HRSA grantees and staff. Grantees face a number of challenges in addition to financing and choosing products. Now OHIT is helping vendors understand the unique aspects of working with Health Centers. In fact, “we think we’re the future of healthcare” because, for one thing, “the Centers already think about population health.” With AHRQ, OHIT has also established an HIT Community portal for HRSA grantees that will, among other things, include tabs for MCH (Slides 22 and 23).

HRSA/MCH staff will present in further detail to the PHCCC in the future. (Dr. Lumpkin noted that HRSA has been asked to become part of the PHCCC.)

  1. Chris Kus, representing the Association of MCH Programs (AMCHP) and the New York State Department of Health, gave a brief presentation on AMCHP, pledging to provide more information about the association at PHCCC’s next meeting. Key points in his presentation included: (1) AMCHP has been in existence over 60 years, linked closely with Federal funding to protect the health and well being of those who are underserved, and (2) AMCHP, which has an Office of HIT Transformation, is interested in what PHCCC will do to facilitate the flow of information from public health to clinical health and vice versa, as different levels of this exist in different States.

  1. Jean D. Moody-Williams, Director, Division of Quality, Evaluation, and Health Outcomes, Center for Medicaid and State Operations, CMS, presented on Medicaid, the State Children’s Health Insurance Program (SCHIP), and the Early Periodic Screening Diagnosis and Treatment (EPSDT). She emphasized that PHCCC MCH HIT recommendations will impact Medicaid and SCHIP, as these programs are major payors responsible for the health care of more than 42-million low-income children, adults, disabled, and elderly, including 7-million children covered by SCHIP. Federal and State Medicaid spending for medical services is estimated to exceed $347-billion in FY’09 and $2-trillion over the next five years ($400-billion for children alone).

Presentation highlights included:

  • As of 2007, Medicaid and SCHIP have a new “Quality Strategy,” whose pillars include evidence-based care and quality measurement, support of value-based payment methodologies, and HIT.
  • This “landmark” strategy and effort involves: (1) working with States to measure, track, and improve care quality in Medicaid, and (2) moving toward a national quality framework for Medicaid (see ExpectMore.gov), for which HIT is “key.”
  • EPSDT is an entitlement for children in Medicaid and SCHIP. Medically necessary services and fee structure are determined by participating States. Medicaid provides a matched rate. Challenges include low reimbursement rates in some areas and lack of HI infrastructure to identify individuals and move them through the system in a way that “is not burdensome to providers or patients.”
  • Problems with data collection at a national level through Medicaid Management Information Systems (MMIS) (a group of subsystems) has led to system reorientation to a more beneficiary-centered approach through Medicaid Information Technology Architecture (MITA). This is expected to lead to many innovations, including CDS, quality measurement and benchmarking, consistency in definitions, and possibly regional and national data exchange.
  • Highlights of the transformation underway include a new incentives structure for the States to engage in HIT innovation. Needs include data exchange with programs, other public health agencies, and other private partners.

  1. Greg Shorr and Amy Groom of the Indian Health Service (IHS) presented on MCH and the IHS Immunization Data Exchange Initiative. Highlights of Dr. Shorr’s portion of the presentation included:

  • IHS’s Resource and Patient Management System (RPMS) is about 40 years old (but operates now with new technology). It is deployed at about 350 sites throughout IHS, serving about two million Native Americans. Each site maintains its own RPMS database, and a National Data Warehouse receives routine data exports using HL7 messaging.
  • RPMS is quite comprehensive and includes multiple bi-directional exchanges of data, including immunization exchange.
  • Two new MCH modules are being attached to RPMS for obstetric care and well child care. These are based on standards from professional societies and guidelines designed to support direct patient care. Data can also be aggregated to support population-based initiatives.

Highlights from Amy Groom’s detailing of the IHS Immunization Data Exchange Initiative included:

  • The Initiative involves a module that is very much like a registry, with an emphasis on bi-directional exchange between RPMS and State registries.
  • A pilot involving information exports (from six IHS facilities) to State immunization information systems (IIS) turned up some 38,000 individuals who were new to State IIS. What IHS received in return was over 490,000 shots for its patients.
  • he Initiative is currently operational either two-way or one way in about 40 sites in six States, with expansion planned to at least two more States in 2008 and eventually to RPMS sites in 35 States. Updated software will include real time capability and the option to include adult vaccinations.

Highlights of Dr. Shorr’s conclusion included: (1) that IHS now has the ability to build registries “on the fly,” such as through the ICARE module, and (2) that IHS is in the process of integrating prenatal records with the well child module.

3. MCH Discussion/Deliberations
Addressing what the PHCCC could do now, Dr. Lumpkin said the answer will depend on further MCH presentations and a decision on what should be delivered on this iteration, and to whom it should be addressed. Dr Lumpkin favors drafting a letter identifying issues and steps for resolution and sending it both to the current Community and its successor.

Data Sharing
Key initial discussion points included:

Addressing how existing efforts can be leveraged, Ms. Cronin said 45 States are in various stages of trying to facilitate HIE across regions or in a way connected to public health programs. She suggested that PHCCC could consider: (1) a State-based plan to integrate these efforts and learn from them; and (2) that the National Health Information Network (NHIN) is another opportunity to try to connect clinical care with various public health and other agencies. IHS in particular has examples to learn from that could be placed in the public domain, scaled up, and possibly used more broadly.

Key discussion points that followed included:

Ms. Groom suggested that PHCCC contact States with relevant experience to learn more.

Standards/Data Flow
Theresa Cullen raised the lack of standardization in some aspects of MCH programs, such as guidelines. Dr. Lumpkin said some relevant standards may be addressed through CDS recommendations; however, PHCCC may need to look at data flow and interfaces from public systems, such as IIS, with the private sector, through EHRs or other means, as well as data exchange involving traditional non-clinical MCH partners, many of whom are not Medicaid providers.

Letter Format/Recipients/AHIC 2.0/Timing
Dr. Lumpkin returned to the question of what form PHCCC action should take and who should receive it, clarifying that a letter on MCH would not be the traditional Letter of Recommendation, but rather, an identification of areas where work is needed, essentially trying to encourage AHIC 2.0 “not to forget about population health.” It seemed to be agreed that such a letter should go to the Secretary, the current Community, and also the Community’s successor entity.

Ms. Cronin said there will be public health representation in AHIC 2.0, but it is not certain AHIC 2.0 will continue PHCCC’s focus. Therefore, as has been alluded to, work already underway in Federal agencies and elsewhere could be targeted as PHCCC fleshes out the letter. Dr. Lumpkin noted that PHCCC faces two transitions, not only from the current Community to its successor but from the current to a new Administration. Given that, Les Lenert said the Secretary would like to receive a letter relatively quickly and proposed that it emphasize critical areas that translate into actionable, cost-neutral policy.

Letter Content
Dr. LaVenture asked whether the letter should address possibly tying MCH systems integration planning by States to receipt of program funding, and Dr. Lumpkin responded that the letter could identify barriers and encourage AHIC 2.0 to look at ways to overcome them. Some barriers can be overcome through standards development and routinizing decision support. Others may relate to public policy reducing Federal funds to encourage integration, use of standards, and information sharing.

Art Davidson commented that PHCCC has not learned much yet about MCH and the private sector, how that might relate to product certifications, and how to advance population health beyond HHS agencies. Dr. Lumpkin indicated that Dr. Davidson’s points and the concept of exchanges across the country should be included in the letter. What kinds of exchanges bears thought. At present, there are a number of different pieces to that equation, such as the value exchanges just announced by the Secretary, although that pertains to Medicare, not Medicaid. He concluded that PHCCC needs to identify boundaries, affected organizations, and go from there to address what the private sector needs to be aware of.

Discussion Conclusion
Dr. Lumpkin noted that members today outlined some of what will be addressed in a letter regarding MCH. After MCH presentations at the next meeting, the group should frame the letter’s contents and identify next steps in order to consider a draft letter by its May meeting. Discussion ensued on how to handle the PHCCC’s remaining work priorities in addition to MCH: Bi-directional Communications; Integration with Registries; and Integration with HIEs.

Dr. Lumpkin then proposedand members seemed to agree--that the PHCCC could use MCH as a case study for the other three work priority areas such that it would advance one letter with an MCH focus that uses MCH “to highlight ongoing priorities in population health.” Dr. Lumpkin also proposedand members seemed to agreethat the PHCCC draft a second letter summarizing all of its work to date and highlighting key issues still on the table.

4. Next Steps

  1. The next meeting of the Community is April 22, 2008.
  2. The next PHCCC meeting is April 3, 2008, and will include MCH presenters, including from AMCHP. As MCH work proceeds, staff will stay in contact with today’s presenters to assist. Today’s presenters will be invited to the April meeting.
ACTION ITEM #2: Ms. McGarvey will invite today’s presenters to the PHCCC meeting April 3.
  1. Members were reminded to review and provide comments on the CDS Draft Letter of Recommendation within 10 days.
  2. Dr. Lumpkin briefed members on the transition to AHIC 2.0, providing the url for a key Web site for information (www.ahicsuccessor.org) and planned activities, including public meetings in March, April, and May. Transition planning will be a collaborative effort between Working Group co-chairs, ONC, LMI, and Brookings. Additional information will be passed on to members as it is received.

5. Public Comments
None.

Summary of Action Items

ACTION ITEM #1: Staff will supply a Word version of the latest CDS Draft Letter of Recommendation to members for comment, with comments due back to Laura Conn and Shu McGarvey no later than March 15.

ACTION ITEM #2: Ms. McGarvey will invite today’s presenters to the PHCCC meeting April 3.

Meeting Materials
Agenda
Draft Meeting Summary (February 6, 2008)
PHCCC Workgroup Meeting Slides
Cronin: CDS Draft Letter of Recommendation
Lumpkin: Overview of MCH
Casnoff: Overview of HRSA MCH Programs
Kus: AMCHP Overview of Programs
Moody-Williams: Medicaid/SCHIP/ESPDT
Groom, Shorr, Smiley: Vulnerable Populations

Population Health and Clinical Care Connections Workgroup
Members and Designees Participating in the Web Conference

Co-chairs
Les Lenert (for Julie Gerberding) HHS/Centers for Disease Control and Prevention
John Lumpkin The Robert Wood Johnson Foundation
   
Office of the National Coordinator for Health Information Technology Staff
Laura Conn  
Kelly Cronin  
John Loonsk  
Sunanda (Shu) McGarvey Northrop Grumman contractor to CDC/ONC
Kristen Uhde  
   
Members and Designees
Michael Barr American College of Physicians
Scott Becker Association of Public Health Laboratories
Theresa Cullen HHS/Indian Health Service
Art Davidson Denver Public Health Department
Amy Helwig HHS/Agency for Healthcare Research and Quality
Michelle Jenkins and Laura Rosas (for Thomas Frieden) NYC Department of Health and Mental Hygiene (representing NACCHO)
Brian Keaton and Ed Barthell American College of Emergency Physicians
Marty LaVenture Minnesota Department of Health
Debbie McKay (for Capt. Richard Haberberger) DOD
Lisa Rovin HHS/Food and Drug Administration
Jim Craver and Paul Youket HHS/CDC
   
Presenters and Others  
Cheryl Austein Casnoff HHS/HRSA
Christopher Kus and Marilyn Kacica AMCHP/New York State Department of Health
John Lumpkin The Robert Wood Johnson Foundation
Jean D. Moody-Williams HHS/CMS
Greg Shorr, Amy Groom, and Clarence Smiley HHS/IHS
Dana Womack BearingPoint

Disclaimer: The views expressed in written conference materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of HHS; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.