American Health Information Community
Electronic Health Records Workgroup #27
Thursday, October 30, 2008

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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.

>> Judy Sparrow:

Good afternoon and welcome, everybody, to the 25th and final meeting of the Electronic Health Record Workgroup. Just a reminder, once again, that this is a Federal Advisory Committee, which means it’s being broadcast over the Internet, and there will be an opportunity at the end of the meeting for the public to make comments. Workgroup members on the phone, please remember to mute your phone lines when you’re not speaking and to identify yourselves when you do begin to speak.

On the line today, we have Karen Bell from ONC, Bonnie Anton from the University of Pittsburgh Medical Center, Nhan Do from the Department of Defense, Peter Elkin, Samantha Berg from the Federation of American Hospitals. And in the room with us today, we have...

>> Alicia Morton:

Alicia Morton.

>> Rob Kolodner:

Rob Kolodner.

>> Lillee Gelinas:

Lillee Gelinas.

>> John Brand:

John Brand.

>> Linda Fischetti:

Linda Fischetti.

>> Judy Sparrow:

Okay. Did I leave anybody off? (Pause) Okay. With that, I will, first of all, correct myself: It’s evidently the 27th meeting of the EHR Workgroup. And I’ll turn it over to the Cochairs, Jonathan Perlin and Lillee Gelinas.

>> Jonathan Perlin:

Well, thank you very much, Judy. And welcome, everybody, to the 27th and final call of the EHR Implementation Working Group. Thank you very much for all the work that’s been put in today. And today is an extremely important meeting, because it really consolidated a good bit of the work the recommendations that would go forward to the committee of the whole, the American Health Information Community. And today we’ll also discuss our summary of the work of this Group. So we’ll have a document that summarizes the accomplishments and really, that’s kind of a sort of selfcongratulatory, selfreflective sense, though I do congratulate everybody on board and our colleagues from earlier times in this committee but a document that really helps to lay out a vision and with structural implications, process implications with policy implications for realizing both the broad and narrow charge that Secretary Leavitt set out for us over 3 years ago in followup to the Executive Order that seeks to make health records available to most Americans.

We have a good bit of work to do in terms of going through. And I hope this will be very interactive in terms of getting your input on both the summary to see if it paints the division as accurately and effectively as you’d like to see that portrayed, and that that vision is articulated in a very actionable way that could be presented in the final meeting of AHIC.

Let me stop there. And before we move to opening remarks from Dr.Robert Kolodner, of course, the National Coordinator for Health IT, I’m going to ask my terrific Cochair, Lillee Gelinas, if she has any introductory comments that you’d like to offer.

>> Lillee Gelinas:

No, I think that I’ll just welcome everyone. I’m glad to see good participation for our final meeting, and I look forward to high productivity. Thank you.

>> Jonathan Perlin:

Then without further ado, let me turn the microphone over to Dr.Robert Kolodner, and appreciate your charge to this final meeting of the EHR Implementation Workgroup. We thank you, and I think it would be remiss in the introduction if we didn’t acknowledge both your leadership, the leadership of Dr.Bell, Alicia Morton, and the entire ONC Team that has really lived the lived and breathed this work breathed life not only into the work that’s been done, but helped to inspire what is our charge of work within government, importantly outside of government, public and private sector, and across all categories of people involved in the health and improvement of the health population in the years ahead. Thank you for that great leadership, Rob.

>> Robert Kolodner:

Well, thank you. The thank you especially for the praise for the Team. They have done a terrific job and glad that we could help such an excellent Group to help us and to help the nation. And I’m going to keep my remarks very brief, because you’ve got a lot of work on your plate. But I did want to come to this final meeting of the EHR Workgroup and thank, Jon, you as and Lillee as the Cochairs who have been extremely strong in terms of leadership. And I think that a lot of the productivity of the Group actually traces to the leadership the two of you have shown and helped to move things along in some areas that aren’t always those where there’s full agreement.

So I appreciate that, and I just want to thank you for the work that you’ve done on this summary, which really does provide the comprehensive but succinct review of that enormous amount of work. And the fact that it’s succinct and yet, even so, is 25 pages, I think, just testifies to how productive this Group has been. And there have been some things such as the recommendations that led to the August2006 Executive Order and was the basis for the EHR demo and the recommendations regarding clear guidance that, you know, have been ones that have been important in moving things ahead.

There’s still, as you know, a lot of work to do, and you’ve got left us a wonderful legacy that we can be operating on moving forward. I think everybody knows that despite the fact of whatever happens next Tuesday, both candidates have been very exclusive about their support for health IT. And we’ve seen some articles in at least the Washington papers recently that they’re bipartisan and very strong for the need to move forward and look forward to continuing to draw from the recommendations that you’ve made and use those as the basis for moving forward in this area.

We certainly have had we started at a very low point in the nation as far as EHR use, when we finally got the surveys out and saw just how low it was. But we’ve also seen a rise last year in at least the hint of a rise that we hope will be documented with this year’s ambulatory survey. And we’ll be having the inpatient survey data at the last AHIC as well.

So there are some great opportunities in the future. The AHIC Successor is something that both of you helped to contribute to. And Jon, you’re serving on that first board of directors, and I know that you’ll continue to champion that taking the appropriate recommendations from here or the continuity from here as well to the things that haven’t yet reached recommendations in moving those forward and we look forward to working with you in that new realm. And hopefully, those who are Workgroup members will also find opportunity and will choose to engage in the AHIC Successor as that next entity that is meant to take the work here and move it forward and continue and actually increase momentum. So look forward to participating with all of you in that new realm while we’re continuing to stay busy with all of the things that you’ve handed us to work on. Thank you so much.

>> Jonathan Perlin:

Well, thank you very much, Dr.Kolodner and Team. I’m glad you mentioned the AHIC Successor, because they we do have our work cut out and a really terrific opportunity for continuity on the one hand and also forging new ground on the other, as provided by the transition document and transition leadership. Cochair Lillee Gelinas, as I think people know, chaired the Transition Working Group to help make sure that the best of this work is not lost as we forge forward in developing what will be the artifact of the successor organization, the value case, which hopefully brings together both the technical response to a reallife challenge improving health care and provides insights into the market incentives to propel that forward amongst all of the actors that need to participate to realize the vision.

Well, before we move to realizing the vision and that will be the first part of the summary document that we’ll talk about we have one order of business that I want to ask: Everyone have a chance to review the minutes, and there are any comments, amendments, or other input on the minutes? (Pause) Okay, so that’s hearing none, the record will remain open for 24 hours to get additional inputs from the members on the minutes. Otherwise, we’ll adopt our consensus of agreement.

Let us then go to discussion, acceptance, and finalization of a number of documents first the AHIC 1.0 EHR Workgroup Summary. And we’ll go through discussion, and Dr.Bell will subsequently lead on the blueprint for delivery system adoption, and that Ms.Gelinas will lead on the final AHIC recommendations.

So we have the first general slide up there, but in this instance, it’s probably best to turn to the document itself. And the document vision sets forth really a reflection of our collective aspirations. And you know, I hope people are logged onto the Webinar version of this. But the vision really reflects the belief that better health care delivery is a product of interoperable health information. I’ll let you read that as we refresh ourselves on both the broad and sense-specific charge, the broad charge being a way to achieve widespread adoption of certified electronic health record, minimizing gaps in the adoption among providers; and specific charge really focusing on standardized, widely available, secure solution for accessing. And we’ll be starting we’ll focus specifically on the laboratory results interpretation for use of clinical care. But I know in the intervening work, as Dr.Kolodner alluded, that was one of the areas that we’ve also moved focus to secure transmission of other information such as eprescribing and their role in prescription.

Are there any comments on either the summarized version of vision that’s presented on the slide or on the document itself? Does it set forward the aspiration in a way that this Group finds acceptable?

>> Linda Fischetti:

This is Linda Fischetti. First of all, I would like to reflect what someone said earlier about, when you read through this document, just being impressed with ourselves as to what we’ve been able to accomplish during this period of time. I also recognize the amount of work that has gone into the creation of this document. And I appreciate those that did pull this together. I think this is a wonderful artifact to summarize what we’ve done at this moment in time, capture our progress to date, and to handle the activities of this Group to the next.

>> Jonathan Perlin:

Well, thank you for those comments. I think our online participants have any input there. (Pause) If not, let’s move to the next slide. And we’ll also follow through indeed 26 meetings to date, 85 public testimonies, 38 recommendations. We’ll move up towards the next slide. It’s really informational. Okay. (Inaudible, multiple speakers)

Okay. Let me focus in on the key issues. And this just gets a little bit out of synch from the just the layout in the written document. But let’s start with what is foundational and hope that the Workgroup received a document that I’m sure we’ll reference later on what is foundational. But I think there is the general understanding that there is nothing without the foundation of appropriate acceptable privacy security. And I’m going to assume people are logged in, but I know some people may have had difficulty. “Privacy policies, principles and procedures, standards to enable the exchange of health data using adequate security protections for accurate patient identification, authorization of those generating and using this information, authentication of individuals permitted to access.” Bullet 2: “Query accepted guidelines for disclosure, particularly for secondary purposes of health information.”

Either on these points or on points that they may be elaborated more in the written document any input that any members would like to provide?

>> Karen Bell:

Jonathan, this is Karen Bell. What I’m hoping is that the Workgroup members will point out anything that may have been missed or, if there is something they feel was important that we didn’t highlight, that that might come up to the fore at this point. So I think the real intent here that we are hoping to hear is that either there is agreement that these are, in fact, the key issues and enablers or, if we’ve missed one and someone feels it belongs on the highlight page, which is what these are, that we’d like to make sure we get them there.

>> Jonathan Perlin:

Well, I think(multiple speakers)

>> Lillee Gelinas:

In light of that, the second bullet we have really fell under “Privacy and Security” on the slide deck. I’m looking for that quickly here within the documents, and I’m not seeing it. If you could just orient me, because I think it’s (inaudible)

>> :

Yeah. They don’t match up perfectly. So it’s definitely a summary. So I’ll make sure that that’s in the document.

>> Jonathan Perlin:

And I think for the discussion of the committee as a whole, as my cochair has just done, is numbering these bullets so that we can reference them easily for discussion at the committee of the whole.

Okay. If there’s anyone else have any input on privacy and security? And appreciate Linda Fischetti’s input on that, because I think there is interest in that, particularly related to, you know, the emerging situations, the bioterrorism, biosurveillance, and the less emergent policy situation of creating health information to help improve health care.

>> :

Does it jump out adequately? And I just ask the Workgroup this because when we were talking about privacy and security, it was such a foundational issue such a I don’t know any other word other than “foundational.” Is that because we have it at #1, if I were reading this, perhaps it might not jump out to me the discussions that we’ve had as a Workgroup of just how important it is.

>> Jonathan Perlin:

Maybe I can ask a question for Dr.Bell, which is that the pyramid that’s been put out has some privacy and security as a visual representation of the foundations. Would that be useful in terms of orientation, even for the board?

>> Karen Bell:

Well, I thinkthat and thank you so much for the question, Jon I think that it would be. And perhaps the problem for us to solve is how to present that. We have this we have that in this discussion. We have it in the diagram a little bit down the line, and maybe it might be helpful to present that up front a little bit more.

>> Jonathan Perlin:

Well, I have an idea that if we usethat and thanks for going to that slide if we use that as the orientation if we use that as the index, then as we go through our recommendations, we can start, for example, (inaudible) basically your colors may be different on the Internet, but the sort of reddish base of privacy and then, you know, orient that to one section of recommendations with that the products that the key to the next payments and resources orientation to what we’re just about to mention financial incentives and alignment there but essentially as an orienting framework or index. And then conclude with the roadmap or the arrow slide or whatever we want to call it.

>> Karen Bell:

Okay. I think that actually might work quite well.

>> :

I just I want to make sure that we are acknowledging that some of the testimony we had and that we heard that and have it mapped in some way where it’s clear. But the word “foundation” just didn’t, in all the words, jump out, as much as we have heard it in testimony.

>> :

The categories that we had here Privacy and Security and Financial Business Case those came from how we structured pretty much all of the Workgroup’s testimony, and it was from the adoption report (inaudible). So it doesn’t quite match up perfectly with the pyramid with the categories, but...

>> :

But it could. I mean, we just need to spend a little bit more time, but it certainly could.

>> Jonathan Perlin:

We’re going to use that as an explanatory image, then, where we can create a sort of framework. It may be useful. (Inaudible)

>> Karen Bell:

And I think we can do that. We have some time tomorrow. Alicia and I can work on that to bring it to its final format.

>> Jonathan Perlin:

Okay. And any other inputs on this?

>> :

I just want to make sure that we stay true to 3 years of work and how we did structure the testimony and so forth. And so, this work informs the pyramid, okay, rather than the pyramid informing this and changing 3 years of work. That’s all I would ask the staff to take a hard look at.

>> :

And I do think we have had them. We had the structure with the Privacy and Security, Financial Business Case, the regal you know, this structure is something we’ve worked on for 3 years, not only here, but actually in other workgroups. I think the pyramid just emphasizes it a slightly different way than we’ve done it in the past, with the idea that we’ve looked at each one of these areas almost within a silo as a separate piece of information. The pyramid actually puts it together in more of a strategic way. And I think that’s the real difference between the two. So that would be the perhaps one of the reasons to include it up front. But if any of the other folks on the Workgroup feel differently, I’d be happy to entertain all thoughts.

>> Jonathan Perlin:

I thought I heard somebody trying to make a comment.

>> Bonnie Anton:

Yeah. This is Bonnie. I think the pyramid is fantastic for a person like myself who’s very visual. It gives me a very good basic understanding of what we’re saying and going to the print in the text to get more explanation. So I commend you on that. I just both visuals.

>> Jonathan Perlin:

Good. We take that as good feedback that it helps orient strategically. The strategy is, you know, essentially developed from the work, but we don’t want to be so (inaudible) again that we lose, you know, the actual fidelity to the work that Lillee Gelinas really reminded us needs to be in place. But the orienting framework, particularly since it parallels with the other workgroups, may be useful as an organizing feature. And Bonnie, I appreciate that.

Let’s go back to the slide that we were on, and then we’ll talk next about the financial and business case. And I believe Lillee and I are of like minds in really wanting it to be clear and (inaudible), but in the absence of incentives for adoption that this case that, I think, works for multiple players. It will be very difficult to achieve the vision. This bulletin states the potential that this model can sustain adoption implementation maintenance of electronic health records in multiple settings.

Any comments on this? I haven’t just awkward that you’re saying this, because I think this is so profoundly fundamental to the progress that, you know, there is a singular bulletin to and similarly sized font it may lose some of the emphasis that I understand across a variety of sectors is necessary.

>> :

Let me ask my government colleagues. I don’t know the financial business case may be different in the private sector than it is in the government sector. And we’re talking about the entire landscape, so I would just ask that you have Jon, you’re in a unique position, having been in government and in the private sector as well. Does that adequately cover, you know, the entire landscape of financial business case and honoring the issues in both the government and private sector?

>> Jonathan Perlin:

I think it does a good job, Lillee, of transcending both government and private sector. What I think we need to make emphatic is, we have to work across all categories. It has to imply that patients, as consumers, understand that they’re want to tend to say a “value” in a health care system and health care providers who are supported by electronic health records that employers have consumers, and ultimately payers in the private sector understand that government, as a purchaser, understands the business case the value proposition, but the vendors who are making the different technologies understand and support and, in a sense, create an economy that in turn creates a pull for electronic health records.

So I think your framing it is terrific that it (inaudible) and I would offer that I believe it does work, but perhaps more subtly that all actors, you know, from population to personal to the three P’s of patient, parttime payer, provider; vendors all actors in the marketplace have to understand a value proposition. And I think that to many of us, this may be it may feel selfevident, given what we understand from president information technology advisory committees, that, you know, some number of lab tests, some number of hospitalizations, some suburbs, some certain amount of activity essentially occurs, because data doesn’t move from point AB and that health care is not delivering perfect value. I just think there is an emphasis that we have to be able to articulate. And certainly, I think we’re reminded of this economy.

>> :

And it helps that that you know, if that question passes the screen. It is interesting to me that a financial business case is one of those issues. As you may recall, our testimony was around misaligned incentives, because those that implement it may not necessarily reap the reward of the implementation. The payers get it. The patients get the reward, whatever, but not the provider setting. And it’s the only one of these key issues and enablers that only had one bullet. And yet, without the financial case, the rest kind of go away. So just I’m really pushing on this to make sure everyone on the Workgroup’s really comfortable with it.

>> Peter Elkin:

Hello, this is Peter Elkin commenting. I think there are a couple of additional things that could be added to the financial business case. One that’s obvious and stands out is secondary use of clinical data. This could be used for any number of activities: quality improvement projects, federal reporting, public health reporting, use for automated recruitment to clinical trials that have a financial reward back to the practice that generates the data. And then I think the there’s probably another potential angle for using the EHR to do automated coding. And that also has a return on investment for practices. So it’s possible that we might be able to highlight those things.

And then the other thing that I didn’t see there that’s fairly obvious is that electronic records mitigate the need to ship physically records around to locations where patients are being seen. And each time you transport a physical paper record, it costs money to each organization. And I think most of the EMR implementations are, at least in part predicated, and justified on the cost savings that goes into shipping, you know, for these organizations to ship these records around to the individual physicians who are seeing the patients at that moment, then to whoever the consult is or their studies or however else they need to be treated within the practice.

>> Jonathan Perlin:

Exactly. Yeah, secondary uses of data is this increasing administrative efficiencies and reducing the cost of transport physical storage of a paper record.

>> Karen Bell:

This is Karen, and I really do appreciate these comments. What I’m wondering, though, is, they all support the need for a financial business case model that will sustain adoption. And whether or not we stay at the high level and indicate that there are multiple things that could or multiple steps that could be taken to do that and then try to list all of them out, at this point, or whether we should just keep it at the high level is the question I guess I would have of the Group. And when we get around to the other colorful slide that we included in here, we have some things that we’ve outlined that would certainly in addition to what was just mentioned, would certainly help sway the business case as well.

>> :

Karen, I think one way to compromise is just to put secondary uses of clinical data as a line item and not necessarily to enumerate all of those, but to at least I didn’t see in the list that there were secondary uses of the clinical data weren’t mentioned in the list here. And I think that a lot of people are aware of those secondary uses and are counting on them.

>> Karen Bell:

Right. Okay.

>> :

And I may offer a slightly friendly amendment to that, which is that I that we do enumerate, in the body of the document, some of the specific types of values that can be derived from increased efficiency, transporting lab data, secondary uses, etc. but that, you know, this bullet has sub-bullet is that wordsmithing can be done later, but indicates that a specific understanding of the value proposition to different better words than “actors,” but different actors in health care needs to be created. So deriving fromthis, more than just developing a financial and business model alone, is that that model needs to convey what the potential value proposition is to each of the different entities in health care and to (inaudible) a personal relationship (inaudible).

>> Peter Elkin:

I’d like to second the friendly amendment.

>> :

Thanks, Peter.

>> Peter Elkin:

Welcome.

>> Jonathan Perlin:

Anything else on this? It really strikes me as just closing a bit of a circle to our first meeting, I remember Secretary Leavitt very eloquently spoke of the large gear and clock at the Governor’s mansion in Utah that, you know, turned all the wheels and standards. Certainly, we’re one of those large gears, but I think you know, over the course of our 26 prior meetings, I think we’ve heard that this is also an extremely large gear in terms of providing a lot of leverage in moving everything else forward.

Okay. Related to that, the legal and regulatory framework here and I think that this does get at some of the opportunities or challenges that we do have: review of both federal and state statutes and regulations to address those that impeded appropriate and authorized sharing of information; mitigation of medical-legal liability from accessing and maintaining large amounts of clinical information beyond that of the, quote, “standard” medical documentation that constitutes today’s legal medical record. In my mind, this takes us right back to a terrific session we had with a number of attorneys who were able to look at this issue. And for those of us who’ve sort of grown up with electronic health records only thought of the opportunities for mitigating litigation, in terms of having information. But I think that they opened their eyes to the challenges that information itself presents, both in terms of the employed necessary response as well as management of that information.

Thinking back to that session, any input on these bullets? Do they richly enough capture both the challenge and, more importantly, the path forward? (Pause) Okay. We won’t beat this to death, but thank you. We’ll go on to the next slide, please. Okay.

This is a, you know, theme that, of course, has pervaded our work from the very start under technology’s need for welltested interoperable vocabulary messaging implementation standards for clinic care, which are incorporated into the EHR certification process, Point 1. Point 2, incremental technological progress towards improved functionality, usability, and interoperability. So the first my own impression is that this is a very friendly way of communicating some of the more technical aspects of semantic interoperability, but in a language that’s more accessible and broadly understood, the second really simply applying a progress of increasing everincreasing functionality.

Do these adequately capture to use Karen’s challenge to us, are there any omissions in terms of what we’ve heard in trying to summarize both the sort of thread of use case standards development to certification and increasing functionality? And here, I think that the document, page 7, bullet 7 you know, are fairly explicit in terms of other documents and recommendations that gave rise to these particular bullets.

>> :

You know, the only thing, Jon, is that I sometimes take the word “incremental” these days, because it implies slow. And “rapid” is our new normal. And so, I hope you know, words mean something. You know, when we use words, they are very, very important. And that’s my only comment (laugh).

>> Jonathan Perlin:

I think you raise a great point here. If our goal is allowing is assuring that health records are available to most Americans by 2014, boy, that’s feeling just around the door, and I think the word “incremental” really adds value. I think the text I think there’s an understanding, you know, of another document that the Office of National Coordinator has promulgated: The Four Stages of Evolution of Health Records with different degrees of functionality implies an incremental functionality. But I think what we want to avoid is anything that seems to justify an incremental pace. And so, I would support removing the word “incremental” and say that the sentence would stand

>> :

Without it.

>> Jonathan Perlin:

Without it.

>> :

I’d be satisfied with that. I just don’t want you know, there are those that would really like to just throw the boat anchor out there and slow progress down, and it almost gives permission when something like this is vetted: a process with a large group of professionals (inaudible). Okay.

>> Jonathan Perlin:

Okay. Let’s go to the workforce issues next. And again, you know, this takes us back to terrific testimony across a variety of professions, across a variety of administrative roles categorization of workforce. But the preeminent theme was that, just as we need to build an architecture technology for health information technology, so, too, do we need to build and a competent workforce and a greatly extended workforce to support this. So Bullet 1, then: “Creation of a welltrained workforce development and/or use help IT effectively.” Bullet 2: “Culture change in both professional workforce and patient populations with respect to new and different approaches to care in an EHR/PHRenabled environment.”

I’m sitting here looking at Ms.Linda Fischetti, who the Chief Health Information Officer at VA. And you made a very silly point, I think, about the need for job classification that would allow us to have some measurement. To my left is Ms.Gelinas, who reminds me again if you can’t measure it, you can’t manage it. Are we leaving to Karen Bell’s Dr.Bell’s challenge are we leaving something out? Let me ask Ms.Linda Fischetti in terms of not specifically identifying the Department of Labor or, on the federal sector, job categories that we can measure against.

>> Linda Fischetti:

Certainly. So Alicia, I’m going to go ahead and reference to you as well the conversation related to the Department of Labor. Alicia, you’ve been in the conversations with them?

>> Alicia Morton:

Well, I tried to engage them on the work that they had put out for public comment, but it was a little too late, so it was too late to change that process, but we’ll engage in the future.

>> Karen Bell:

One thing I might this is Karen Bell. One thing I might just add is that here we’re trying to identify the key issues. And perhaps we should not maybe I should we should strike the word “enablers,” because here we really are just defining the key issues. And then we’re talking in the next couple of slides about some of the key recommendations and the status of those recommendations that have come forward. So maybe one of the things we should do is highlight a little bit more about where we are with the workforce recommendations when we talk about the status of the recommendations that were made to address the key issues. And I would just go back and just ask everyone if this is because our intent here was to basically say, “These are the key issues.” And then the following two slides after these two were to say, “Okay, well, these are the issues, and these are the key recommendations the Workgroup had made. And what is what’s in the sta what are the status of those recommendations?”

>> Jonathan Perlin:

Okay. I think your point’s well-taken, and I see some nodding heads around the table in agreement if we do capture that.

>> Karen Bell:

Okay.

>> Jonathan Perlin:

Do weneed to challenge more time? Do we need to be more specific? We’re asking for culture change. And that is broad. Are we really asking here is an expectation among the professional workforce and patient population of the safety, effectiveness, and efficiency?

>> :

Is it really more, again, the workflow change, perhaps, that we’re trying that should be articulated here? Because workflow is such a huge issue. You can have the IT, but if you don’t change the workflows to use it effectively, you will not be able to get the outcomes that everyone’s hoping to achieve.

>> Jonathan Perlin:

Okay. So there’s a bullet there on efficient work an expectation for enhanced and efficient workflow among health professionals and, frankly, patients in the environment of personal health records.

>> :

Mm-hmm. Okay. We can change that, then. Thank you.

>> :

I really liked where you were going, though, in terms of pulling in the IOM language, because we had such a need for alignment in this industry, and I think that every single place where we can just have this even in vocabulary, the smallest amount of alignment. It helps everyone.

>> Jonathan Perlin:

Maybe, then, with respect to the workforce and workflow that we should actually includethe it’s not about the technology. It’s about better health care. And better health care can be defined many ways by many individuals. But at the same time, really effective, efficient, equitable and patient centered are really the aspirations, I think, we have certainly used in our framing of the work for this Group. And perhaps the introduction might simply include that division toward realizing the care of those attributes.

>> :

Okay. You know that I love the sick things. So I’m more than happy to put those in there (laugh).

>> :

At the end of the day, when you look at it, the President’s vision achieve the island vision the railroad tracks to get us there.

>> Jonathan Perlin:

And it aligns with every component. Patient care is more efficient adver avoidable adverse drug events. That gives the medicinal offer (inaudible) technology aren’t not only expensive perhaps the most profound ways to the patient, but they lower the value for every purchaser of health care.

Okay, we beat that one enough?

>> :

Mm-hmm. Thank you.

>> Jonathan Perlin:

Okay. We’ll go to the next (laugh) the next slide, #7.

>> :

And what was the recommendation, Karen, that you had? (Inaudible) you said, you know, if we take out the word “enabler,” and then on the next slide...

>> Karen Bell:

These two slides are the key recommendations and their status that fit under those enablers I’m sorry to fit under those issues.

>> Jonathan Perlin:

Okay. And now we’re moving to a conjunction of the recommendation with status. And this is really more factual, in terms of less philosophical: EHR demonstration project launched by CMS and it relates to a number of recommendations made in June 2007; collaboration with malpractice insurance industry and CCHIT; encourage premium reduction for physicians who adopt, again relating to Recommendations 3.0, 3.1 of April2007; and eprescribing recommendations in progress, very exciting, to create a lot of movement lot of alignment.

Is there anything that’s missing in terms of the marquee bullet points? Because as we mentioned at the beginning, there are quite a number of recommendations in toto. (Pause)

Okay. While those are being considered, we’ll move on to the Technology Health Information Technology Standards Panel EHR laboratory results reporting interoperability specifications. CCD were recognized by the Secretary January2008. Executive Order 13.410 that all agencies contract for health care services on behalf of Federal Government to ensure consistent language on health plan contracts.

>> :

Hard to believe that that really did come forth as a result of the deliberation of this Workgroup way back in May 2006.

>> Jonathan Perlin:

That’s right. That really was one of the earlier emergency response EHR use case developed to analyze harmonize the HITSP standards, accepted January2008.

>> :

Came right out of our postKatrina work where we were coming together.

>> Jonathan Perlin:

And you know, as a reference point, the eloquent testimonies at the National Governors Association, particularly those individuals from the Belt states who could not have been more poignant in describing the inadequacies of noninteroperable or simply an absence of information.

>> :

You know, just at first blush I know we have the other three areas to cover just for staff, it helps me I guess as a clinician, I just think of a critical pathway in my brain. But if these could be lined up just like 1-2-3-4-5, like in the previous area so that they have they’re easy to track back to back. But at the end of the day, in terms of the content, it that is extremely impressive work. If you don’t look back and see the impact that this Workgroup has had on this in this landscape, it’s extremely impressive. And listening to Dr.Kolodner, he was so correct. I want you to think about the couple of these that did not have universal alignment initially and what it took to get national consensus. So I just want to commend the Workgroup, because I just hope you’re seeing the impact of terrific work. And I sometimes hate this word “status,” again, because it’s such a clinical word, but is it too are we stretching it too much to say

>> :

Accomplishment?

>> :

key recommendations made and accomplishments?

>> :

Not at all.

>> :

That word “status” isn’t strong enough to me.

>> Jonathan Perlin:

Yeah, I think that’s fair. This recounts what has happened, and I think it’s extraordinarily powerful to relate it to the specific recommendations. And without being overly selfcongratulatory, I do think, you know, this ship has turned. There is momentum and not to say that additional energy will not need to be applied to not only continue the momentum, but to move forward to a more integrated form of the aspirations. But this is substantial.

Okay. Anything else that’s marquee level under accomplish recommendation accomplishments? (Pause) So we’ll go to the next slide, please.

And organizational cultural. We’ve discussed that a bit after discussions. And planning for continued support for and additional development of Docket University is under way. Recommendation all workforce recommendations in progress. And Linda, did you...?

>> Linda Fischetti:

So, Dr.Bell, is this where you wanted us to speak to some of the progress that’s taken place to date?

>> Karen Bell:

Right.

>> Linda Fischetti:

So, to enhance what Alicia was saying in terms of her activities with the Department of Labor that we all looked at and a number of private-sector folks as well requested that it include informatics as they were putting together their labor codes in preparation for the next census. And it was decided that we just did not have a high enough quorum and would not be included until next time. So we’ll have to come back into that. But what was impressive is the amount of private-sector folks the AMIA (inaudible) and actually a particular number of others, as well as the number of federal entities that made direct contact into the Department of Labor and made this known. So if nothing else, now, they certainly know that there’s an active informatics group out there. While we may not get the numbers that they expect, I’m sure we will next time.

The other workforce recommendations that you mentioned, Dr.Perlin, related to the Office of Personnel Management we have gone through and done an assessment of all of the existing OPM theories where there is, in fact, a representation of informatics that people are hired within informatics that we use different theories across FDA than we do at CDC than we do at VA. Of course, we also know that those different theories are touched by many different pay authorities. So we’ve come up with a plan in terms of how can we go forward to OPM to be able to incorporate informatics into the scope and practice and would recognize as part of the theories for all of the relevant theories and (inaudible) being posted out of the Office of the National Coordinator. Of course, Alicia is the center point for this. And with this, we will be able to we have come up with a strategy which we need to execute on, which will not get touch pay authorities but will recognize the practice of an implementation.

>> :

(Inaudible) presented all that work to the Health IT Policy Household to elicit support from the other federal partners. Then we would have broad support (inaudible) on working together collaboratively with OPM to rectify that.

>> Jonathan Perlin:

Let me thank (inaudible) thank Alicia Morton for her leadership on this. And thank you very much for your work on this. And I think we need a bullet on here. I spoke incorrectly earlier when I said “OMB,” just because I passed OMB this morning coming into town. But indeed, personnel management is really the authority that I meant to reference but I think a bullet that, you know, describes the multiagency was it called “task force” or “working group”? that

>> :

Oh, right now, it’sa handful of interested folks that have come together that are looking at this across the different departments. We are about to become a formal entity, but then we’re engaging with them (inaudible). So I don’t know how much yet there is to report, although we have done our homework. We’ve done our research.

>> Jonathan Perlin:

I think multiagency discussion to align it.

>> :

Self-forming workgroup. Good for you.

>> :

The recommendations are still to be formally accepted by the Secretary (inaudible). There’s a process. So we’re kind of doing the behindthescenes work. We’re going to have to (inaudible) and hit the ground running.

>> :

Great.

>> Jonathan Perlin:

Okay. Anybody else with input on organizational aspects?

>> :

I’m sorry. Before we move on, I should also state that the value of having the Federal Advisory Committee make the recommendation, even though it has not been formally accepted that there should be an evaluation in informatics professions within the federal sectors, has been incredibly important and has allowed all of us from our different departments to put the time and the energy needed to come together and have these discussions. So I want to thank from the federal workforce, thank the Federal Advisory Committee for looking at the importance of and recognizing the importance of adopting an official recommendation of this Group. So thank you.

>> Jonathan Perlin:

Thank you for that work.

>> :

Can’t underestimate that.

>> Jonathan Perlin:

And it’s such an enabler to a great deal of workforce development. And the absence is not only a barrier, but potentially problematic in terms of not being able to identify health IT workers who, by virtue of need, not role definition, are hired in the Federal Government into other series, as with land titles and data analysts and the like. So this is an area where your work will be, I’m sure, greatly appreciated and greatly supportive to the effort.

Privacy and security is the next bullet Confidentiality, Privacy, and Security CrossCutting Agen Workgroup is foreign, and that’s true. And I’m going to assume, Dr.Bell, perhaps our or Alicia, we shall will this be reported out from the CrossCutting Workgroup, in terms of a parallel report on the specific recommendation?

>> Alicia Morton:

I believe they did that at the last AHIC.

>> Jonathan Perlin:

I’m sorry?

>> Alicia Morton:

That workgroup.

>> Jonathan Perlin:

So we don’t need to reiterate.

>> Alicia Morton:

(Inaudible), no.

>> :

And it’s been interesting. When I talk about AHIC 1.0 and the Workgroup, because we’ve come so far, it was not clearly seen that in the early days of AHIC 1.0 that it was our Workgroup that said that quality and privacy and security were so important that we needed two different workgroups that were working in concert with what we were trying to do, because the landscape was too big and, you know, it was feeling like we were a flea on the ankle of an elephant. And so, the fact that these workgroups were spun off by the good work of this Group is also an important achievement, because it was not only recognized, but just look at the tremendous work that came out of the Quality Workgroup as well as the Confidentiality, Privacy, and Security Workgroup.

>> Jonathan Perlin:

Legal-regulatory National Coordinator and CMS continue to work on CLIA HIPAA guidance. And indeed, that was very important. I remember a good bit of testimony, too, about agreement around the needs, and Office of National Coordinator has engaged the National Governors Association to employ and develop guidance for state leaders on variations and cleared to authorized personnel, so something that really is a great enabler across the jurisdictional authorities.

If there’s no input on or no additional comments on these, we’ll move to the next slide, please.

And this is indeed where we begin to change. I’ve been referencing a pyramid, but I should be more specific. This is where we actually talk about a blueprint for delivery system adoption. And obviously, I think you can tell by my alluding to it earlier I do think it is a very useful granting framework strategic framework. And again, we do absolutely appreciate Alicia (Inaudible)’s comment that make sure that in our exposition that we’re true to the testimony of to the FACA across these last 26 meetings.

And with that as segue and the understanding that we really focus momentarily on the foundational nature of privacy and security, let me turn to Dr.Bell to take us through the rest of the blueprints.

>> Karen Bell:

Well, thank you so much. And as I say, we’ll probably move this over bring it up a little bit forward in the document. So if we could go to the next slide, that gives me an opportunity to point out that this is color coded. HIPAA obviously has to do with privacy and security, and that’s the very foundational pieces of the pyramid. The next piece of the pyramid is getting the technology right. And then the third part is the issues around reimbursement and then moving into the more organizational kinds of things.

The but as we’ve talked about before at the previous workgroups and at the last one, when this concept was introduced, we have a lot of recommendations, all of whom which are outstanding, all of which are important to move forward. But the piece that we’ve just started to do is talk about how they all fit together. We have a goal: 50 percent EHR adoption by 2014. That was set for us quite some time ago, and that is where we’re moving towards as a nation. We are we know where we are right now. We’re at over 50 percent adoption in very large integrated delivery physician offices, which is very good. But we’re not very good in the smaller physicians’ offices. We’re less than 9 percent there. Hospitals, we’ll find out a little bit more about in November, but we also know the skilled nursing facilities are very, very low on their adoption rates, too.

So we thought we would try to put together and this has been through so many iterations and so many sausage processes that it looks very different from the last time you saw it, but we felt we would at least try to put together, along a continuum, without any definitive dates in it because at this point, we’re not absolutely clear about when all of these things will happen. But at least we have a 5year continuum here. We saw that would that expresses all of the big chunks of work that need to be done in along the pyramid and tries to do it in a way that acknowledges certain interdependencies and certain priorities. For instance, just as one example, going below the arrow, we have HITSP interoperability standards that are being developed for transfer of care, referrals, and consults, which will go into a certification process in 2010. That’s going to be of particular value to hospitals. The earlier HITSP interoperability standards, the ones that we already have now that are going into this year’s certification process, are helpful for hospitals also but are primarily most useful for the large physician offices and the small physician offices. Transfers between hospitals and nursing homes, again, will really when that comes forth in 2010, will really, I think, help push EHR adoption in those two settings, particularly the skilled nursing facilities, from 2010 on.

So we have some dates here on this slide, but not very many. And you’ll there’s one other point I’d like to make, and that is that we do have a strategic plan that was put forth by this office a couple of months ago. And a number of the strategies of that plan are represented here on the diagram, so that when you see, for instance, Strategy 1.3.5, and that reflects on the workflow improvements, that reflects back to our strategic plan.

In looking at this, what I’m asking for us to do now is to have some really good discussion about how these fit together. Is this reasonable? Does this make sense to all of you? Is it too busy? Is it something that, again, we could use as a strategic blueprint that others might find useful that brings together a lot of the discussions we’ve had and a lot of our recommendations? Or is there some other way that we might want to depict this? Before I ask you to open it up for discussion, I will say that in our sausagemaking process, I’ve just noticed and this is thanks to you, Peter, because you brought up the payment for secondary usage of data that we initially had on this reimbursement for secondary usage of data.

It seems to have fallen off, and we will absolutely get it right back on there again, because it is going to be a very important driver, we believe, for moving the adoption agenda forward in the delivery system.

So I’m not sure I would have caught that, Peter, if you hadn’t just brought it up a few minutes ago. So thank you very much. But it had been on here. It’s not now. It will be back on here (laugh).

>> Peter Elkin:

Thank you, and you’re quite welcome.

>> Karen Bell:

So with that in mind, Peter, is I guess I should turn to you is there anything else that’s fallen off here that you think we should put on? Or what do you what I would really love is to have the various Workgroup members on the call comment on it on in terms of its usefulness, how it could be made better, any other glaring omissions that we have, or anything that you think might make it a little bit more focused maybe a little bit more less busy. So...

>> Lillee Gelinas:

Karen, when we talked previously, there were two things, again, referencing the term “large physician offices” and “small physician offices.” And I believe it was Robert that had wanted change there, correct? Or does this reflect the change that he wanted?

>> Karen Bell:

It said “MD,” and he wanted

>> Lillee Gelinas:

Oh, it said “MD.” Okay. So his input has been incorporated.

>> Karen Bell:

Right.

>> Lillee Gelinas:

And we also noted that this particular arrow starts at 2008, and yet this Workgroup began in 2006. And we had talked about some kind of way being able to depict that. And I know we never landed on what that would look like, but if I were just looking at this as a summary of some of the recommendations that we’ve made and what the roadmap is, we’re missing 2 years of time here.

>> Karen Bell:

Well, the reason that it is this way, Lillee and I’d love to have your input on how we might be able to address that is that the recommendations that have been made basically are either being implemented in 2008 or will be implemented over time. So this is really the strategic blueprint for implementation of the recommendations, rather than when they were actually set forth. And that maybe there would be a different way we have of capturing that.

>> Bonnie Anton:

Should that be this is Bonnie. Should that be reflected in the title?

>> Karen Bell:

I’m wondering.

>> Bonnie Anton:

Because if you adopt something, you may agree upon it, but you haven’t implemented yet.

>> Karen Bell:

Right.

>> :

Is just a this roadmap is a roadmap that articulates how the delivery system adopts interoperable EHRs?

>> Karen Bell:

Well, I think it’s more looking at all of the things that have to be done in order for the goal of adoption to be reached by 2014, recognizing that we can’t do it all in 2008. There will be things that have to fall in place over the course of the next 5 years in order to get to that goal. So this is a depiction of all of those things that are critical. And it does read from left to right, so that given how things work and when we know interoperability is going to come in, and we know it takes 2 years, for instance, to do re-in legislative reform, but we also know that there’s an administration change, so maybe there’s going to be different things that will happen in terms of federal support.

But I think the real concept here is that it there is a progression. It is unlikely that there would be any type of significant federal support, whether it’s loans or tax relief or grants, without a really good, methodologically sound ROI analysis, or at least a way of knowing that you will get ROI out of it. And the Congressional Budget Office has been quite clear: We don’t have that right now, and so that they’re loath to support putting forth money for EHR adoption. And then the other part of that is that, if there were to be a lot of federal support coming forth, we certainly want the EHRs to have the features in them to really achieve, through maximum usability, the best outcomes. We certainly know that having a certified EHR will get us to some interoperability. But at this point in time, without real good attention to usability and those features that are most likely to improve care, there’s no guarantee that having a certified EHR is actually going to get us to better outcomes. So that’s why we have those two things, one a technical solution, if you will; and the other a financial solution, or something that will feed into the financial solution that are going to be important before any type of state or federal support would come forth.

And these are things we’ve talked about in the Workgroup, again. And this was our attempt to take all of those discussions that we’ve had around all of these individual pieces and individual recommendations and put them together in some sort of a strategic blueprint so that people really get a sense of not only what needs to get done, but when it needs to get done and how.

>> Jonathan Perlin:

Well, I think you’ve done a terrific job of framing the sort of strategic threads on the pyramid the color coding those sort of integrating them. I think the Group got my my comment is that this really is integrated. I mean, if this were a cylinder, I’d totally agree with the depiction that what’s going on in the office environment ambulatory environment and what’s going on with the institutional environment need to coalesce. But it’s just a difficulty in that depiction. I think it’s very true to the testimony that we’ve received in the recommendations that have gone forward. I think one could argue that it’s not exhaustive. It’s probably necessary but not sufficient in terms of stating all realities and contingencies, but that graphic would be probably impossible. But then, as a set of conditions and activities that need to occur, my own sense is, it’s a reasonable depiction of the way forward. And that, in fact, is respectful and honors the input and testimony that we took.

>> :

Karen I agree with Jon, by the way. We’re just trying to make sure that this is going to pass all the screens. Under the hospital piece, I see incentives for small hospitals and incentives for skilled nursing facilities. What about other hospitals?

>> Karen Bell:

That’s what I would love to get some input from you and whoever’s on the line from the hospitals’ associations: whether or not the larger hospitals need more in the way of financial incentives to drive adoption.

>> Jonathan Perlin:

Let’s I’m it’s they’re I’m not sure that we should want to necessarily (inaudible) record as qualifying (inaudible).

>> :

I just you know, again, to the point if you leave it off and this is a final framework that comes out of this Group and we don’t call out I don’t recall in any of the testimony that we said that there wouldn’t be incentives for that we talked about incentives for physician practices and incentives for hospitals.

>> Jonathan Perlin:

And let me use an example. I assume the implication is a small critical access or rural hospital, but does that mean we shouldn’t incentivize a large, urban, you know, safety net facility? So I think we I think (inaudible) hospitals (inaudible) remove the modifier “small.”

>> Karen Bell:

Okay. That we can do.

>> :

I’m fine with that.

>> Karen Bell:

I’m hoping that we will have information will certainly will be presented at the November12 AHIC on adoption rates at various different levels of hospitals. And I really don’t know what the difference is right now. But I think that might help also help inform us moving forward. And you’ll be at that meeting, Jon, and we can make changes (laugh) if we cho if we choose.

Any other comments from the folks that are on the phone? Bonnie, Peter, anyone else?

>> :

I think when you talk about incentives, I think a couple meetings I guess it was the last meeting, when we all did presentations. One of the things came up that a lot of us had not really talked about was cost when it came to hospitals. It was like it was a given. And when you said to include it here, I think that’s it’s really important. We all assume large hospitals can make use of the funding they’re going to get, but maybe they can’t. So I agree that it maybe it should be added here.

>> Peter Elkin:

The only other thing I this is Peter that I would at least consider and it’s a strong link between our Group and the Quality Group is using EHRs to drive fully automated electronic quality monitoring, because I think that as we implement these, there are these initial adoptionbased benefits that we’re hoping will push EHRs into the practice. However, our longterm vision has always been to improve the quality of care that’s delivered for patients. And so, just putting that somewhere on the timeline so that we know that our goal is to take this interoperable data and use it to improve the quality of care that we deliver to patients would, I think, you know, make the story more complete.

>> Jonathan Perlin:

Can I play devil’s advocate on a point?

>> Karen Bell:

Go. (Inaudible) Would the Group feel comfortable if we were to include that up around where the EHR features support maximum usability and quality?

>> Jonathan Perlin:

Sure.

>> Karen Bell:

That might be a good place to include that without it getting more busy. Thank you, Peter. That’s a good point.

>> Peter Elkin:

I no, I agree, too. Thank you.

>> Karen Bell:

Yeah. Good point. Thank you, Peter.

>> Jonathan Perlin:

A short, terrific contribution, Peter. Thank you.

Karen, I’m going to play devil’s advocate on a point, and I’ll preface it with what we know. (Inaudible) and others have provided data that there’s higher penetration of adoption in large physician offices. And on this diagram we show, indeed, that you know, slightly to the right of 2008, large physician offices. Then we have we’re struggling. We’ve acknowledged that finance is a key driver. We’ve also acknowledged realities that oftentimes, an efficiency doesn’t improve the doesn’t offer an incentive to the provider, but to others. In fact, it may even be counter to not that anyone would do it, but counter to the interests of the provider. I’m talking here on physician offices. We identified incentives and have an arrow pointing to small physician offices. I think that the logic that would follow is that “Gee, we don’t have the adoption there.” But a natural response from our physician providers down in the absence of some sort of parity might be that “Hey, we’re out of the game. Why would we invest any more?” And do we really want to I’m a little concerned about even implying winners and losers, but I’m absolutely positive about implying a need for, you know, incentives in the broadest sense to create interest in adoption. Should that arrow should there also be an arrow off are we stepping into more policy than we intended, perhaps, than a roadmap?

>> Karen Bell:

Well, I’d yeah, I’d love to hear everyone else’s thoughts. The re I can assure that the reason we didn’t put the arrow in that direction is because the adoption rate was already so high in large physician offices, and the rate was so small (laugh) or so low in the small physician offices, so that it seemed that we already there are a significant number of incentives and enablers to drive the large physician offices forward already. And they may be and they can find ways to find a return on investment. The small physician offices can’t do that, and so, that’s why there was the additional incentives there. But again, I’m you know, certainly, I’m very, you know, cognizant that we certainly don’t want to look as if we’re punishing early adopters here or, in some size, shape, or form, chilling the any further adoption in the large physician practices.

>> Peter Elkin:

And I guess the point that’s been made about large physician practices is that they’re not a homogenous group, either. It’s really the large practices that have been integrated into delivery systems. But there may be administrative structures with large practices that are actually probably distributed models in rural areas that (inaudible) I’m worried about that punishment of early adopter and implication of policy beyond what’s intended.

>> :

And it’s not only punishment of early adopters, but I worry about sustainability. And sustainability is frequently an issue as well that requires additional resources or continuing resources, I should say.

So we need to make sure we’re testing that, and especially in this economic climate, where we just don’t know the real impact of Wall Street’s collapse on health care. We really don’t. And just making sure there’s a safety net for any of this work going forward, we have to be visionary. We have to consider all of the points here a really important place for all the Workgroup members to weigh in on this one.

>> :

We need consensus.

>> Peter Elkin:

Maybe instead of pointing to a particular practice, I’d also be comfortable with changing the arrow to being a bidirectional arrow to CCHIT-certified products.

>> Karen Bell:

Yeah. One of the other things we might do is blend the two gray boxes, “Large Physician Office” and “Small Physician Office” make them one box with just a small line between them and then one arrow coming down so that

>> :

That’s a better idea.

>> Karen Bell:

it looks like everything is coming down to both of them

>> :

Better idea.

>> :

okay with the large physician office already being in the forefront, and then the small physician office coming in a little bit later on. Okay. I think we I think that might get that message across a little bit better.

So everything above the gray bar comes down into the gray bar and supports large and small physician offices.

Any other comments? (Pause) Hello?

>> :

Yeah, I’m thinking.

>> :

Mm-hmm. (Pause) I think I’m every now and again, I’m afraid I lose you.

>> :

Well, I was thinking, Karen, that are we so we’re changing I think I heard we were changing the slide the second slide to “Implementation of Interoperable” rather than “Adoption,” because the hierarchy says “Hierarchy of Implementation.”

>> Karen Bell:

Right.

>> :

And then that’ll get to Lillee’s point of “What about pre2008?”

>> :

Well, when we look at roadmaps and timelines, I just want to make sure that our depiction is our intent and am very cognizant of that, being in a large system, that what goes here and cascades down gets interpreted different ways as it’s disseminated. And Karen, I just kind of drew lines where the years are. If we just drew where 20082014 is and you do it equally, it’s interesting that it would hospitals would be 2010, and skilled nursing facilities would be 2012, and small physician practices would be 2011. I’m not saying that’s right or wrong. I’m saying the way we have the years depicted here could be interpreted that if you divide this line evenly, it may give rise to a notion that we made a recommendation that these points occur in these years.

>> :

So we put a nursing facility I should hold off on doing anything 2011 is my year.

>> Lillee Gelinas:

Yeah, and not worry. So is there another way to depict the timeline, then?

>> :

Should it have a start date?

>> Lillee Gelinas:

Yeah, if you took the start date out, you wouldn’t know the interval. If you didn’t have “2008” there, then you wouldn’t know what the interval was to 2014. That might help.

>> Karen Bell:

We deliberately took out anything to suggest that it was a regular interval. It just it we are “2008” now. This is where we have to be in 2014.

>> Lillee Gelinas:

Yeah, but if you do take I like the idea of taking “2008” off, because I still know the work that this Group did for 2 years is not anywhere on this timeline.

>> Karen Bell:

Well, we can just take off “2008,” then. That might solve all the problems. That’s a great idea.

>> Lillee Gelinas:

And where it says “2014,” take that off and just have an icon there that’s the President’s vision some kind of way have the Executive Order you know, some kind of way showing that as an end goal, but getting away from time definitions.

>> Karen Bell:

Well, we do need, I think, a line in the sand for 2014.

>> Lillee Gelinas:

Oh, I agree (inaudible).

>> Karen Bell:

Yeah. So if we can find some way to hold the “2014” and maybe but I love your idea, Lillee, of just taking off the “2008.” Then we can, you know, understandit’s implicit that it’s work that’s ongoing and we have a goal of 2014.

>> Lillee Gelinas:

And I want to ask this one more thing, Karen. I recently was in a discussion around My HealtheVet, which is the I guess the VA homebased...

>> Karen Bell:

Personal health record.

>> Lillee Gelinas:

Personal health record. Okay. We’re only showing hospitals and skilled nursing facilities here. We’re not recognizing home health, hospice the other care entities. Is that was that did we intend that?

>> Karen Bell:

We only have those here for now, because those others are coming in through other ways. We have a lot of homecare coming in through hospitals and skilled nursing facilities. So we did leave those off. And we also have a companion slide to this one that enga is around consumer engagement patient engagement. And so we bring that in there.

>> Lillee Gelinas:

Okay.

>> Jonathan Perlin:

You know, that gets back to my point. And this maybe we should have that slide or whatever is that you know, my initial concern was that there was an implied disintegration between the hospitals and the practices, but, you know, don’t and that’s not intended, nor is there intended nonintegration with the personalized health record aspect as well. And I don’t think we have to present it, but I think the implication should be as part of a continuum of development of interoperable health information.

>> Karen Bell:

Maybe we could put that someplace in the goal?

>> :

Or maybe (inaudible) that companion slide that the (inaudible) Workgroup will actually present the same day at the AHIC their version. Maybe if we just put a notation on the slide that there was a companion slide and about the (inaudible) perspective...

>> Jonathan Perlin:

Yes. That would work for me.

>> :

That works for me. As long as it’s noted, we’re good.

>> Jonathan Perlin:

And but they would probably want a reciprocal notation.

>> Karen Bell:

Right.

>> :

I notice, Karen, we have two really other big buckets of work that this Workgroup needs to get done today, and that’s our opportunities of future as well as our recommendations to the Secretary that are the final ones. So, you know, I certainly don’t want to cut this short, but are is there any are there any other decisions that we have to make around this?

>> Karen Bell:

Well, I think that this is a very good input. We’ll work on this. We’ll send it around to everyone for their interest so that you’ll see it before it’s at the AHIC. But I think the only other thing that we may do is, we may play around with the title a little bit, so that it’s also clear that these are the interdependencies of how the recommendations might roll out, or something of that nature, in order to get adoption across the delivery system.

>> Jonathan Perlin:

Okay. Well, thank you.

>> Karen Bell:

So we’ll play around with that. But thank you very much. This has been a very helpful discussion.

>> Jonathan Perlin:

Okay. Well, thank you, Dr. Karen Bell, for that. And we’re just going to look we’ve gone from the status through the roadmap to the opportunities for the future. And let me not try to read everything out. But again, this follows the technology, organizational, cultural, financial business case, and other I think we’ve alluded to a number of the implications in our discussion our iterative discussion. So let me just stop and ask if there are any amplifications, amendments, etc. on this aspect. Perhaps the singular piece that hasn’t been specifically articulated (inaudible) with National Health Information Network.

>> :

Let me just ask the staff: Is there anything new in this that we haven’t done in this Workgroup before?

>> Karen Bell:

No, actually, we’ve so this is the slide that’s going to probably go to the AHIC. And so it’s I’m asking for the Workgroup to see it one more time. But we’ve gone over these before, and it was what we had passed on to the Transition Team as, you know, work we hadn’t yet completed and wanted to see completed by A2.

>> :

That was one of my keys. This is what we used at the Transition Working Group, so little worried about consistency.

>> Jonathan Perlin:

Do we think that you just mentioned A2, and Lillee just mentioned that this was really an output transition group. Do we want to specifically identify the handoff, or at least the path forward to A2 in this?

>> Karen Bell:

Well, that’s what this was. (Inaudible)

>> :

We probably should. No, you’re right. We should note that.

>> Jonathan Perlin:

(Inaudible) on this document.

>> :

On the title that this was handed off to the Transition Workgroup for A2.

>> Karen Bell:

For A2. The only other piece, though, that I would add is, there are some things that may not go to A2. There are some things here that may go to a different body. Maybe they’ll go to a FACA or some other organization. So it might not be an A2, but we didn’t want to lose it just in case A2 doesn’t pick it up.

>> :

But you know, I the Transition Workgroup as you know, one of the, I think, great pieces of work that came out of that group was the screen that identified what needed to go to A2 and what needed to stay with the government, because it was inherently governmental. And so, this particular slide helped us develop that screen. We recognized some of those issues. So I think that staff could just work with that.

>> Jonathan Perlin:

(Inaudible) “opportunities for the future for” “opportunities for future work byA” “opportunities for the future,” parentheses, “inherently governmental,” comma, “A2,” comma, “elsewhere.” I mean, it’s just missing as to “Okay, whose future opportunities were” and maybe we could simply state that, but I think we need to give some consideration as to what the continuity or transition life path is.

>> :

Linda, you were on the Transition Workgroup, too, and I’m just not so sure I have to go look back at my slide deck. I’m not so sure that the word “opportunity” was there. It was a little more concrete. These were “A1,” “EHR Workgroup,” “Recommendations to the Transition Working Group” and then we were making it to “2.0.” I mean, if you look at the process here, “1.0 EHR Transition Working Group,” “Transition Working Group” creates the screen, here’s what goes to A2, and here’s what stays with the government. So the title’s even incorrect.

>> Jonathan Perlin:

Well, I was just going to say, maybe we’ll resolve it. Instead of articulating where things go that this is not simply sort of ephemeral opportunities, but these are recommendations for future work.

>> :

And then it would be the responsibility and the story almost of the TPT group to say, “These will go to A2,” whereas from this Group, I’m not sure we have the platform to do that. All we can say is, “This should be done.”

>> :

I think when the Workgroup(multiple speakers).

>> :

We said what we thought needed to stay with the government.

>> :

And when the Workgroup made them, they weren’t

>> :

No.

>> :

The filters weren’t there, so they weren’t considering who might do the work, but just that the work had to be done.

>> :

This needs to be identified maybe have a date at the bottom that it was I want to say was it July?

>> :

But it predated the finaloutput (inaudible).

>> :

It predated the final output of the Transition Planning Group, yes, particular someone in the field trying to follow all this.

>> Karen Bell:

The and I think that, Lillee and Jon, I will defer to both of you, because you are very much engaged in this. But one of the things that has occurred, as I know you very well know, is that the individual opportunities that each of the workgroups set forth have been looked at from a different point of view. Some of them have been realigned. Some of them have been folded into other opportunities. So what is actually or what is likely to go forward to A2 might not look very similar to some of the work that you see here. And that was, I think, the reason we thought it would be important, because this is how the Workgroup this Workgroup set forth the ideas. How the Transition Planning Group how the A2 actually takes it up and redistributes it or redefines it is what the future will bring. But this at least was designed, and, again, we can change it. But this at least was designed and again, we can change it, but this was at least designed to reflect what this particular Workgroup suggested as being opportunities for the future. What will happen, again, down the line can’t predict.

>> Jonathan Perlin:

Do you suggest this as opportunities, or do you recommend it as future work?

>> Karen Bell:

Well, we basically talked about the future work that needs to get done. This is work that

>> Jonathan Perlin:

Okay, because I think I would rest all concerns with a change in title to “Recommended Future Work.”

>> Karen Bell:

Okay.

>> Jonathan Perlin:

This (inaudible) amenable to...?

>> :

You have two CCHIT members right here on the phone who remember it, so (laugh)...

>> Jonathan Perlin:

Great.

>> :

Got it.

>> Jonathan Perlin:

That’s okay. I mean, that it’s not overly constrictive or prescriptive, but it’s more than opportunities for some things that relate to each of these baskets that the (inaudible) honoring the history were indeed recommendations.

>> Karen Bell:

That said, this is a Workgroup. It’s a FACA is that this then becomes a formal recommendation to the AHIC. The one of the reasons we call it “Opportunities for the Future” because is because these are this is work that the Workgroup thought needed to get done. It was sent off to the Transition Workgroup. Transition Workgroup worked with it. And this is a way of codifying the original pieces of work that the Work this Workgroup thought were important to move forward. If it becomes a recommendation, then it has to go through the recommendation process.

>> :

What about, like, remaining work to be accomplished or something that doesn’t make the work into “Achieve this mission,” but still important to continue on?

>> Jonathan Perlin:

How about simply “Future Work,” period?

>> Karen Bell:

“Future Work.” That could probably do it. Yeah.

>> Jonathan Perlin:

Yeah. You’re getting increasingly minimalistic.

>> Karen Bell:

Yup (laugh). I love it.

>> :

I do, too. This is work, and that’s how we considered it (inaudible).

>> Jonathan Perlin:

Okay. With that, we’re going to turn over to my Cochair the next component for two reasons: one, the meeting with AHIC Secretary; and two,you’re on the agenda for this. (Laugh) Let me apologize for the early exit, but I, you know, thank everybody again for incredible work. I think one thing of this format lots to be proud of a lot ahead. And certainly in the context of the last discussion, not only is it something we don’t want to lose momentum on, but just the opposite: It’s something that we want to add fuel to, to really achieve better health care that is visible. Thank you.

>> Lillee Gelinas:

And for the (inaudible), it’s been delightful working with you.

>> Jonathan Perlin:

And you as well, Lillee. I think we’ll have an opportunity to do some work together.

>> Lillee Gelinas:

I agree. It’s not over. (Laugh)

>> :

It ain’t over.

>> Lillee Gelinas:

It ain’t over. (Laugh)

>> Jonathan Perlin:

Thank you.

>> Lillee Gelinas:

We’re going to move to the draft recommendation piece. But before we do that, because Jon’s just walked us through the summary of activities and accomplishments piece and I have two quick questions for the staff. On the Workgroup member list, we had a number of members of the Workgroup, but there were also alternates. You know, there were times when, for instance, Chip Kahn couldn’t be here, but Howard Isenstein was. Do we not acknowledge those in the alternate delegate? Or we only put the formal members of the Group in?

>> :

You should put the formal members (multiple speakers).

>> Lillee Gelinas:

Okay. I’m just looking for what the protocol is.

>> :

But (multiple speakers) on a question I didn’t know, Lillee, if we wanted to typically, we’d just (inaudible) state people’s names and not their credentials. Do you want everyone’s credentials?

>> Lillee Gelinas:

I have this note to you that I believe that, in the spirit of noting many of the health professions that are around the table and making these decisions that the credentials are extremely important, especially for physicians and for nurses to the degree that you have them, I think, for the physicians and nurses. That may be easier.

>> :

Yeah. I’ll have to send them in, then. I don’t really I don’t want to miss

>> Alicia Morton:

Well, I’ll attempt this is Alicia. I’ll attempt, because this document is going to go out for one quick turnaround again. Everyone will know if I got it right or not.

>> :

The other question would be some of the folks on the membership have been on from the very beginning, all the way through. Others have had terms of service that did not extend the entire time. Is it important to reflect that, or is that not worth it?

>> Lillee Gelinas:

That’s an excellent point.

>> :

I included both the first group original group and the current group. But it doesn’t(multiple speakers).

>> Karen Bell:

Well, that’s an excellent point, because I do think we are missing a few people who used to be on the Workgroup but are no longer there.

>> Lillee Gelinas:

Maybe there’s original Workgroup members.

>> Karen Bell:

Or maybe we just include everyone.

>> Lillee Gelinas:

Everyone or everyone? (Multiple speakers)

>> Karen Bell:

Yeah. Just put everybody on there who served at some point.

>> Lillee Gelinas:

Okay.

>> Karen Bell:

Thanks for bringing that up. (Inaudible) on for the entire time.

>> Lillee Gelinas:

I think those who have been able to hold the course have been amazing. And the if you say we’re going to send this out maybe one more time, then maybe we get the you know, just a couple of the other comments to save the time.

>> :

Sure. Sure. I mean, do we want to add the (inaudible)? I mean, remember we asked we had changed the focus from outpatients to inpatients about a year ago, and that some people elected to drop off and

>> Lillee Gelinas:

Well, we the specific charge around outpatient and lab had and physician adoption had been accomplished, and we’re moving to inpatient and hospital, and we needed more expertise.

>> Karen Bell:

And I think it would be maybe it would be helpful when the Workgroup member list goes up. Jonathan, just because he’ll be giving the presentation, basically will mention the fact that there was a change in direction in the Workgroup, and many of these the folks that listed here have served two terms, essentially but that there was some change as we moved from the hospital from the physician sec or from the outpatient sector to the hospital sector. So everyone gets some credit here.

>> Lillee Gelinas:

Yeah, just a little bit of an explanation around that, and then the credentials. I just don’t know why, a lot of times, we’ll see a lot of MDs, but the RNs after the names aren’t there. And it just is important or the PharmDs, lab or anyone that hasa, you know and I would say, not getting into the nano-details, that anyone that has a licensesociety gives.

>> Karen Bell:

And that’s what we did with the other Workgroup list as well. So I think that’ll be consistent with the other presentations.

>> Lillee Gelinas:

Any of us with public domain licenses that need to be transparent.

Let’s move to the final AHIC recommendations. This is a document I’d like for you to be looking at that I’m not sure where our slide is.Oh, here we go. I’d like you does everyone have a copy of the letter to the Secretary, or are we they only going off the slides? Do Workgroup members have a copy? I’d like you to take a look at that. And I think we’ve already talked about consistency in wording.

And so, in this very first section, when we talk about “Throughout the Workgroup, continue to structure its work in the key enabling areas of” and those should be, “(1) privacy and security, (2) financial and business case” strike “alignment” “(3) legal-regulatory, (4) technology, (5) organizational workflow and culture.” And on the first page, just in this opening, right under “Dear Mr. Chairman,” making sure that the five areas are consistent that we’re noting so again, “(1) privacy and security, (2) financial business case” strike “alignment” “(3) legal-regulatory, (4) technology, (5) organizational workflow and culture.” And that way, this document flows with the PowerPoint and the Word document. Everybody with me on that?

>> Karen Bell:

Mm-hmm.

>> Lillee Gelinas:

Okay. I had some suggestions for the staff and I’m not going to belabor the call here very consistent with credentials at the top of page 2. Margaret Robinson is a registered nurse. And we note the title of the CIO, but we don’t note the title that she’s Vice President of Patient Care Services at Midland Memorial Hospital. So I would just ask that we be consistent with credentials and titles, however which way you want to do that. Bonnie, what is your title?

>> Bonnie Anton:

I am the Electronic Order Set Coordinator.

>> Lillee Gelinas:

Because I noticed your title and Margaret’s title were missing.

And then just a couple of the key themes the themes are certainly there; I think the staff did a great job with that around implementation, bottom of page 2. And then we will get to the recommendation. I want to just point out, when we talk about mandated use of the EHR system, we heard from Midland Memorial, if you remember the CPOE adoption curve that they showed, and when they reached the 40 percent level in there 30, 40 percent it took off. And I don’t recall that they necessarily mandated or at what point they mandated, so we might want to get clarity around that. But when I see the mandate use of the EHR system, some of the testimony we heard is that if you mandate on the front end that everybody’s got to use it, it’s not as effective as if you implement, and you get those early adopters going, you kick the tires, you do what you need to do, and all of a sudden, it takes off, and then you say, “Okay, 40 percent is implemented by 2009, then 80 percent or 90 percent or whatever.” So I thought this was a little strong for what I thought the intent of our discussion was. Anybody tracking with me on that, or have I just lost my mind (laugh)?

And then, at the top of page 3, “Recognize the time commitment needed to learn a new HR system and perform documentation as daunting, and incentives for physicians may be needed to learn and use the system,” did we only mean for physicians here or all clinicians?

>> :

Clinicians.

>> Lillee Gelinas:

Just physicians?

>> :

Well, I mean, the presentation was purely for physicians, but we can put clinicians there.

>> Lillee Gelinas:

So what’s the recommendation of the Group?

>> Karen Bell:

It’s the entire health care environment, Lillee. It involves clinicians as well as those that maintain the business processes to support the clinical environment. So when you’re doing that implementation, it’s a great deal of time and training (inaudible) support staff for, yes, the physicians; yes, the nurses; but everyone else within that environment as well.

>> Lillee Gelinas:

Am I hearing, “Strike ‘physicians’; add ‘clinicians’”?

>> Karen Bell:

No, I think it’s you know, I think it’s a trasmi transition here. We’ll just put in “clinicians” instead of “physicians.”

>> Lillee Gelinas:

Okay. Those are just a few of my comments. Are there any other comments about the body of the letter before we get to the recommendations? (Pause)

Well, the first recommendation, if you recall, that came out of this tremendous testimony of our last meeting was that we needed to convene an expert panel to investigate and clarify documentation requirements. I had a suggestion here, and for the sake of time, since we only have 15 minutes left, I’d really like to throw it out to you guys. I did pass this by Jon before our meeting started. But it seemed to me that in Recommendation 1.0, we actually had some sub-recommendations. And I liked the way that we had made those recommendations to the Secretary in the past, and the also that you know, the terminology around put forth. I was going to recommend wording that would go like this: “Commission an expert panel to investigate and clarify documentation of requirements mandated by regulatory licensing and payer entities, such as CMS and the Joint Commission,” simply because there are a lot of organizations that are collecting data and thinking that it’s mandated, but it’s really not. So we need clarity around what is actually mandated through regulation or legislation.

>> Karen Bell:

Well, Lillee, this is Karen. We talked about this a little bit earlier, but a thought has just occurred to me that the Joint Commission actually isn’t really a mandate, I don’t think. If you want to have accreditation by the Joint Commission, then you obviously do these things. But not every hospital chooses to do that.

>> Lillee Gelinas:

You have to to have deemed status by CMS to get paid for Medicare and Medicaid patients. There are only three deemed organizations in the United States. The Joint Commission covers 85 percent of all the hospital beds in the United States.

>> Karen Bell:

So the interpretation here is that the mandate is essentially a mandate for payment?

>> Lillee Gelinas:

That’s right.

>> Karen Bell:

(Inaudible) if we’re going to put “mandate” in there, it might be “mandate for payment purposes,” as opposed to other forms of business.

>> Lillee Gelinas:

Okay, let’s see: “Commission expert panel to investigate and clarify documentation required by...”

>> Karen Bell:

Maybe that would we could put it, “documentation required by the regulatory licensing and(multiple speakers).”

>> Lillee Gelinas:

Period. Don’t list anything else.

>> Karen Bell:

Yeah, okay.

>> Linda Fischetti:

And so, “licensing” versus “accrediting”? I mean that (multiple speakers).

>> Lillee Gelinas:

Oh, you (inaudible) no, you’re correct, Linda.

>> Linda Fischetti:

Are you looking at licensing or looking at both?

>> Lillee Gelinas:

No, you need to add that. So it would be, I guess, a very good catch: “regulatory, licensing, accrediting, and payer entities.”

>> Karen Bell:

Okay, that’s good.

>> Lillee Gelinas:

All right, and then strike the example. And then 1.1, I would recommend, would be “Determine how those requirements can be met with electronic health records without posing undue burden on clinicians documenting information for patient care.” You see what I’ve done here? I’ve broken it into parts. The first is to convene the panel. The second is to determine how those convene the panel to determine the requirements. The second activity is determining how those requirements can be met with an electronic health record. Everybody following me here?

>> :

Yes.

>> Lillee Gelinas:

Then 1.2 would be to launch a national effort to develop templates based on the requirements, because if you go to the second recommendation, it’s all about the expert panel and a template.

If we could move the slide to the next slide and I can help people that are following us on the Web because Recommendation 2.0 had to do with identifying and clarifying those external documentation requirements after that had been done, then creating the standardized and structured template using the requirements. So I was trying to cluster the recommendations around requirements. So 1.0’s convening the panel, 1.1 is determining how those requirements can be met, 1.2 is the national effort to develop templates based on those requirements, and then 1.3 would be “Establish a clearinghouse for the dissemination of those templates.”

And then what that would do is and where I think we need the good discussionis, we don’t want to confuse the development of standardized templates based on regulatory licensing-accrediting body requirements with the clearinghouse, Alicia, that I think we talked about at the last meeting so much of the AHRQ clearinghouse for guidelines, where there’s a clearinghouse for all this good work going on out there in the United States, and we’re capturing that as well. So there’s templates around requirements, so we’re not duplicating. And you go all the way back to billing and coding in the private sector UB82, and look at what the version is now. But it’s standardized. But whoever brought that up earlier really made an outstanding point that it’s not just the templates around those required to capture the mandated information: It’s the clearinghouse as well for capturing the right stuff.

>> Alicia Morton:

So 1.3 you intend to be broader than

>> Lillee Gelinas:

No, 1.3 is the clearinghouse for this work. I was trying to keep the mandated stuff in one recommendation. You see what I’m saying? And then

>> Alicia Morton:

Yeah. (Inaudible) as far as this testimony, they talked about the mandated requirements. But when they were talking about having to recreate these templates for every instance, it was broader than that but was really just about(inaudible).

>> Lillee Gelinas:

I agree. And then 2.0 captures that for the clinical care part of it.

>> Karen Bell:

Well, that’s where the clearinghouse concept comes in.

>> Alicia Morton:

When you divide up 2.0, you want us to make the first part of 2.0 actually not on Recommendation 1.2.

>> Karen Bell:

Well, no, I think what she’s saying, Alicia, is that there’s a piece of that that will go into the recommendation that has to do with mandating the reporting requirements, but 2.0 is a standalone around the clearinghouse that allows information to be shared around best practices for templates that are being used strictly for clinical care.

>> Alicia Morton:

Okay, I’m just trying to get a handle how we’re going to divide that in the current recommendation.

>> Lillee Gelinas:

Well, let me just I’m probably not making myself clear. Recommendation 1.0 would be commissioning the expert panel to investigate and clarify documentation requirements required by regulatory licensing-accrediting and payer entities; 1.1 would be “Determine how those requirements can most efficiently be met utilizing EHRs without posing undue burden on clinicians documenting information for patient care purposes”; 1.2 would be “Launch a national effort to develop standardized and structured templates using these requirements,” period”; and then 1.3, “Establish the national repository housing these structured templates for distribution.” And then there is a whole new 2.0 that is the...

>> Karen Bell:

Clearinghouse.

>> Lillee Gelinas:

clearinghouse that contains structured templates and its you know, its better practices.

>> Karen Bell:

You know, what we haveon our just I don’t mean to interrupt you, Lillee. But what we had on our summary was “to set up a national clearinghouse with information about evidencebased, structured templates for hospital EHR systems for clinical use.” And maybe that’s we could just shorten it to something like that.

>> Lillee Gelinas:

That clearinghouse was meant to be like our guidelines clearinghouse that all of us go to. You Google it, and it comes right up, and you find all kinds of stuff there. You don’t have to reinvent the wheel. And so, that’s what this was intended to do. I remember Margaret Robertson Bonnie, I know you gave testimony. It just seems what I heard after hearing all that testimony is, all these organizations out there implementing EHRs are creating all these documents, forms, templates in silos. And we were trying to break down some of the silos and encourage sharing. And that’s to me, that was the spirit and intent of 2.0.

>> Karen Bell:

I think we can work on that one a little bit, Lillee, because it’s just a matter of probably focusing a little bit more and really stripping it down to the clearinghouse concept for clinical use.

>> Lillee Gelinas:

Does do we have consensus around taking that approach, where we’re trying to cluster the recommendations that all have to do with mandated requirements into one and its subsections and separate that out from the clearinghouse function of leading practices? Guidelines, templates? Bonnie, Peter, anyone? Linda’s shaking her head “Yes.”

>> Bonnie Anton:

I you know, it’s Bonnie. I agree. I just think that we’re going through some issues now at UPMC where, gee whiz, we wished we had, like, a clearinghouse to go to and give some of the general, standard types of information that we could use. So I’m in agreement certainly with that.

>> Lillee Gelinas:

Okay, great. Thanks.

>> Linda Fischetti:

Absolutely. This is Linda. I wanted to offer (inaudible) comfort. We could probably also, whoever implements this, look at doing it in conjunction with the licensing-accreditating group so that, in fact, they get their Good Housekeeping Seal of Approval for the (inaudible) confidence of the (inaudible) going in there (inaudible).

>> Lillee Gelinas:

That’s a great point.

>> Linda Fischetti:

I also think, beyond the intent of the original goal to help the implementers, it’s going to have incredible value to begin to look at standardized templates (inaudible) interoperable environment (inaudible) from the beginning to see the same patterns for the clinicians presented in a similar manner. This has a great deal of benefit beyond the initial (inaudible).

>> :

I agree.

>> Lillee Gelinas:

I just want to commend the staff, because I know this was done very rapidly after all that testimony at our last meeting. And I think we did a great job capturing what we were trying to recommend.

Well, if we can go to the third recommendation, then “Identify and develop a standard methodology for measuring both the direct and indirect costs of EHR adoption in various types of hospital settings” it’s a little bit more of the business case as well, but really is at the cost point. One thing that I know is a really key issue in my system is the number of staff that are taken out of direct care that are extracting data from charts manually to meet these regulatory and accrediting body requirements, especially at a time of a nursing shortage. So to the degree that we really start to quantify costs, it’s almost not just the direct and indirect costs of ER EHR adoption, but it’s the cost of not implementing EHRs. And it is quite substantial.

>> Karen Bell:

You know, one of the things is that we have heard that the actual cost of the hardware and software and the EHR itself is only a small proportion of the total cost of the implementation. We should probably capture that in the discussion.

>> :

That’s right.

>> :

I have it down as 25 percent. (Inaudible) gentleman from Hopkins(inaudible).

>> Lillee Gelinas:

And Bonnie, I think you emphasized as well Linda has certainly emphasized it I think I heard it in almost every one of the testimonies Cleveland Clinic all of them that the cost of workforce adoption is always greatly underestimated the people side of the adoption.

>> Bonnie Anton:

You’re right. We just assume that. We don’t bring that up and emphasize that.

>> Lillee Gelinas:

Right. The Nintendo Generation gets it a lot quicker, as my 21yearold son would say, and us Baby Boomers take a lot of mentoring. Did you want to say something, Linda?

>> Linda Fischetti:

Yeah. The one thing that might be interesting, again, for whoever does do this analysis who when you look at EHR adoption actually split that out by functions, not at the level of the agency, but more in terms of the order entry, bar code, medication administration, imaging you know, some of those documentations consultation some of the major functional categories that are that you have with electronic records. So it would be great to know which of those would provide the most cost avoidance for the community as they go to adopt.

>> Lillee Gelinas:

I don’t know some of the great work of HIMSS and the Alliance for Nursing Informatics and other groups. Is there not a standard methodology already out there for capturing the cost of adoption?

>> Karen Bell:

There’s no standard methodology for looking at cost or cost savings. So this is a this is just a wayof because so many different pieces can go into it. So this is an attempt to at least get half of that part of the equation in place.

>> :

Because this isn’t even addressing the educational process of the hours that go into preparing for these classes and pulling people off the units. And so, there’s a lot I mean, it’s such an important recommendation. It’s s they all are, but I mean, there’s a lot that’s going into this behind the scenes for this recommendation. (Inaudible)

>> Peter Elkin:

This is Peter Elkin. I know there’s no standard methodology, but there are some lessons to be learned from other industries. And for software implementations in general, I remember there were some figures from IBM that said that a third of your total budget should be for education. And I don’t think that substantively that that proportion has changed over time.

>> Karen Bell:

Peter, do you know if that actually translates to what actually happens when you do an implementation in a hospital setting?

>> Peter Elkin:

No, I don’t think I’m aware of studies that have been done that looked at specifically costs of implementation, although let me try to do a quick search see if I can find something. But I do remember that federal IBM gestalt, which I think was published probably, you know, a decade or two a decade and a half ago from them. But I can’t imagine that our systems are that much more usable that we decreased the proportion of cost significantly.

>> Karen Bell:

Good point. Thank you, Peter.

>> Lillee Gelinas:

So do I hear consensus around this particular recommendation? And I didn’t hear any wordsmithing to this particular one. (Pause) Okay. Alicia tells me that because of the timeline of the next AHIC meeting being the 12th that changes to this particular letter to the Secretary have to be done by tomorrow, so they go to Judy, and, you know, we go into our regular approval process. So I just want to emphasize that to you on the phone. If there are any other comments about the letter, then I’m going to ask the staff, “Do you have enough just for the wordsmithing and the recommendations?”, and keeping it as crisp as possible, as Jon says. He and I are both about brevity, and so less is more in some cases.

>> :

I think we won the AHIC award on the shortest recommendation letters.

>> :

Well, if you look at the other AHIC(laugh, multiple speakers).

>> Lillee Gelinas:

I want people to read them. No, I don’t want us to become credenzaware. You know, it goes in your credenza, and it collects dust. So we really want people to read them and use them.

Judy, I’m just looking at the agenda here. Are we at the closing comments portion now?

>> Judy Sparrow:

I think we are, yup. I think we are.

>> Lillee Gelinas:

Okay. As we are wrapping up our activity and the next AHIC meeting was moved, and it’s on November the12th as you reflect one more time on our summary of activities and accomplishments, I hope that you do give that your most utmost priority. Please remember that goes into the public domain. It will be referred to for many, many years for those in practice, in research, in policy. And I know that we all have a lot on our plates. I think you’re all getting to know me know one of my favorite lines is, “The urgent drives out the important,” meaning what we have to do right now gets down, and the important gets pushed to the sideline. And I would just ask that this be considered an important document and that you do give it your utmost consideration, given the long shelf-life that it’s going to have that will reflect the real work of this Group.

Jon also noted the very active practice with AHIC 2.0 under way. And just as the current administration is trying to put a process in place to assure a smooth transition from one group of leaders to another, it is very important for you to recognize that all of us that have been Workgroup Chairs and active in 1.0 are trying to do all we can to assure a smooth transition to AHIC 2.0 as well. I think that’s everyone’s goal so that we keep the momentum and we keep the interest going, because we know just how high the stakes are, as we know it is about quality and safety. It’s not necessarily just about health IT.

And finally, one more time, we just want to acknowledge I can’t imagine the hours that have gone into your individual contributions to this Workgroup, whether it’s been meetings, phone calls, recommendations, presentations, preparation or not. If you’re like me, you know the angst goes up if I haven’t been adequately prepared, so there’s a little visceral response every now and then. But I do want to really acknowledge the tremendous work of the Workgroup members, of the staff, Alicia, Karen, Judy I cannot imagine any of this work getting done. Folks that are not in this room Cindy Reed I know every time I see her name on my email, I know that I’m going to get the MIS “Your email is over its limit” and quickly pay attention to it. But there’ve been a whole lot of people behind the scenes that have certainly made our work visible. And I know we have some members of the press here, and I just want to acknowledge and thank you for helping us getting the word out, because we certainly can’t do this without you, and I want to recognize your contribution as well.

Are there any other final comments from members of the Workgroup before I bring in the public comment section of the agenda?

>> Karen Bell:

Lillee, this is Karen. I just have one final one from the staff as well. And I know I’m speaking for everyone to say it’s been a privilege to really be part of this Workgroup. You guys have been phenomenal in terms of focusing on what needs to get done and getting it done. However, what I would like to just share with you is that we are putting these packets together and having them printed up. And yes, they probably will (laugh) be credenzaware, Lillee, but we will assure that each and every one of you has a printed version and copy of the summary with all the recommendations and everything that goes along with it for your own records or library or, as you say, the credenza. And we’ll be distributing those after the AHIC. We’ll get them to the AHIC members first, and then we’ll send they’ll come to you. But thanks again to everyone from us as well.

>> Lillee Gelinas:

Karen, will we get a final electronic copy? Because those of us in large systems really need to cascade this electronically.

>> Karen Bell:

Oh, yes. You’ll get them electronically, too. I obviously, you will definitely get them electronically. And the paper is just a simple little add-on for anyone who likes to have something in a nicely bound format.

>> Lillee Gelinas:

And is there a master copy that is a summary similar to this AHIC overall?

>> Karen Bell:

Yes, we’re going to do all of the workgroups.

>> Lillee Gelinas:

All right. Okay. So it’s nice, neat, tied in a bow, and... great.

>> Karen Bell:

So Lillee, because I’m sitting in the room, I’ll take the opportunity to thank you for your leadership as well as Dr.Perlin’s (inaudible) leadership. The fact that the two of you have been here since the beginning you’ve made such successful strides in what we’ve been trying to get done here. The recommendations that have been accepted I think the percentage is really high in terms of what has gone to AHIC what has been considered to be useful. I know that it’s very hard with the remote, distributed group. We’ve never met as a full team face to face.

>> Lillee Gelinas:

That’s a good point.

>> Karen Bell:

(Inaudible) the constructs of the Federal Advisory Committee. Sometimes things just have different processes than what we’re used to, and we do work naturally. So I wanted to thank those of you and (inaudible) for your leadership for this Group.

>> Lillee Gelinas:

Thanks. I really enjoyed working with Jon. I don’t think you any of you see behind the scenes how much we go back and forth and cover for each other. And of course, he’s going to be doing his testimony on November 12, since I have a previous commitment.

All right. Let’s get public comment.

>> Judy Sparrow:

All right. Chris, can you see if we have anybody from the public or if there’s anybody in the room that has a comment?

>> Chris Weaver:

Certainly, Judy. For those f you that have been following along online, there is a slide on your screen now that gives the number to dial in if you have a comment or a question. Once you’re connected, simply press star-1 to get in the queue. Then, following along on the phone this time whole time, just go ahead and press star-1 to ask a question. You guys can go ahead if you have any final thoughts while we’re waiting.

>> Lillee Gelinas:

Anyone in the room that has a question or a comment? (Pause) Anything you’re

>> :

I’ve got a lot of work, but I do have one question. I talked to (Inaudible), and I don’t know if this is something(inaudible)

>> Lillee Gelinas:

Can everyone hear on the phone? You might want to (multiple speakers) and just introduce yourself (inaudible).

>> Jeff Dan:

This is Jeff Dan, reporter with the (Inaudible) Health Care Policy Report. They one of the things with the certified electronic health systems is, they’re certified for privacy and security (inaudible) AHIC. And yet, the many of those functions can be switched off by the doctors’ offices. Doctors say, “Now we have to be able to do that, you know to this idea that I have to log off and log on, and this stuff gets in the way of my clinical care.” That will also what they want turned off so it’s just open. So anybody can use it, theoretically. It does not create a good log of what’s being done. It’s an example of one of these things you just switch off that log process. The question would be, how you know, what is that sort of an issue from a technology standpoint that needs to be addressed?

>> Lillee Gelinas:

You mean single signon?

>> Jeff Dan:

Well, just the whole thing of this that there is these that these tools in the systems that allow doctors to actually to sort of turn things off temporarily or again and again and again. What’s her name Lisa Gallagher with HIMSS said two things. She said, one, “We it has to be we have to have those, you know, switches, or doctors would never buy it.” And she also said, “I worked in the financial industry on, you know, privacy and security systems for many, many years, and I never heard this come up.” So(laugh)...

>> :

So your question is about (inaudible) or...

>> Jeff Dan:

Or what you know, what needs to be done.

>> :

I think part of it is that (inaudible) is that every clinical alignment has vastly different workflows. Some people can handle a 1-minute timeout, and some people need a much longer space. (Inaudible) people running around there trying to save lives (inaudible) it’s vastly different. There’s a lot of technology out there RFID and things like that that can handle some of this. But again, they’re only they’re never really thus far (inaudible) in this environment. RFIDs have (inaudible) interactions with (inaudible). Other ones such as fingerprints, for example, (inaudible) the same problem, and you need to have people wearing gloves. (Inaudible) But some of that, I think, is (inaudible).

>> Lillee Gelinas:

So site-specific

>> :

Site-specific allows you to (inaudible) flexibility (inaudible) and things like that, in terms of log-in/log-out. (Inaudible)

>> Lillee Gelinas:

Peter or Bonnie, do you have a comment to that?

>> Bonnie Anton:

We have not we’ve not that issue has not really come up with us. The physicians don’t seem to have a problem with that, as far as you know, from our experience.

>> Lillee Gelinas:

And she’s at the University of Pittsburgh Medical Center.

>> :

Yes.

>> Peter Elkin:

Well, I understand this is common in s most common an issue in the in smaller doctors’ offices. I can imagine it would be it would may be that hospitals you know, big hospitals have a ways to(inaudible).

>> :

(Inaudible) You have to talk with your group just to find out, you know, what you do have the sort of timeout with privacy and security (inaudible). This is more about, you know, what’s good for that environment (inaudible) have the flexibility to accommodate for (inaudible), like the financial systems. The financial systems are much more they don’t have that kind of variation in what they have to do. But they are part of the practice of medicine, so (inaudible) varies just from hospital to hospital (inaudible) way, but (inaudible).

>> Peter Elkin:

Well, she’s a technology person. But I think she does understand that there’s differences between them. But nonetheless, you can understand what I’m saying. It’s frustrating. I one of the things that was said by Dr.Braithwaite, when I asked him about this, is, they really need to he said, “What we really need to do is not you can precertify things with CCHIT. What we need to do is certify the way it’s being used in the individual setting place.”

>> Lillee Gelinas:

Very much some of our workforce the people side of the issue there’s the technology side, there’s the people side, and you’ve got to consider both, just like you have software and hardware. It takes both to make it happen.

>> Judy Sparrow:

And we have one more comment on the phone.

>> Lillee Gelinas:

We have a comment on the phone? Chris?

>> Chris Weaver:

We do. Ryan, could you open it’s Angela Jeansonne’s line from AoA?

>> Angela Jeansonne:

Hi. Good afternoon. Can everybody hear me?

>> Lillee Gelinas:

Yes, we can. Thank you.

>> Angela Jeansonne:

Great. Good afternoon. Just a very quick clarification: Our member could not be on the call today, and I noticed that you said that you were going to send out information electronic to Working Group members. Do you have a sense of when that will be? I know that you did a lot of things on the call today, including modification of some of the diagrams and stuff. Will they will Working Group members see that information one last time? And if so, when will that be distributed to folks?

>> :

Yes, it will. And we have to have this all wrapped up by Monday. So between now and Monday, you’ll get it.

>> Angela Jeansonne:

Great. Thank you very much.

>> :

And Angela, (inaudible) if you’re going to serve as Bob’s alternate, I can make sure that you get a copy of it.

>> Angela Jeansonne:

Yeah. I’m on I usually get a copy of that information. I just didn’t hear a time frame. That was the only reason why I asked the question.

>> Lillee Gelinas:

That’s great.

>> :

Thank you.

>> Lillee Gelinas:

So just to be really clear, I want to clarify: It’s not just the recommendation letter to the Secretary. It’s all the documents. It’s the summary, the slides, the letter to the Secretary, where that feedback has got to come in tomorrow to you.

>> :

And I’ll turn it around, I’ll share it again (inaudible).

>> Lillee Gelinas:

You’ll turn around, share it with everyone the beginning of next week, and then what’s the hard deadline if we get it Monday from you?

>> :

Monday (inaudible) I’ll have to send it out this weekend, because by Monday, close of business, they need it to the AHIC.

>> Lillee Gelinas:

Will you make sure if it in the subject line of the email, “Time-sensitive; comments by end of business Eastern Time, 5p.m., November3.” Monday, November3, is what I’m hearing. (Multiple speakers)

>> :

(Inaudible) okay, like, noon Monday so I can have it by 5.

>> :

Okay, so that will be any additional comments that folks have once they look at it for the final time, that will be the deadline. Is that correct?

>> Lillee Gelinas:

Correct. It’s almost like the minute it hits our inbox, we’re going to have to look at it.

>> :

No, understood. Okay. Thank you.

>> Lillee Gelinas:

Just hope I’m not on an airplane.

All right. Is that the only public comment?

>> Chris Weaver:

That’s all we’ve got.

>> Lillee Gelinas:

It is 3:15 Eastern Standard Time, and I declare the AHIC 1.0 Electronic Health Record Workgroup meeting adjourned and the tremendous work done over 3 years done. Thanks, everyone.

(General thanks and congratulations)