[This Transcript is Unedited]
November 15, 2001
Hubert H. Humphrey Building
200 Independence Avenue
Washington, D.C.
Call to Order and Introductions - Dr. Friedman
Discussion of Committee's Response to Draft Report
DR. FRIEDMAN: There are four or five things that maybe we could try to do in the next 50 minutes, one of which is, very, very quickly, just review the comments that Mary Jo and Cynthia, Michelle and Susan will make on the report.
Second, go over the process and try to nail that down a little bit. Third, we will identify any other report issues. Michelle mentioned something to me that, for better or for worse, we need to at least put on the table.
Fourth, discuss dissemination strategy and then, fifth, follow up. If, in the unlikely event we get hung up on either comments, process or any other report issues, if it is okay with Mary Jo, maybe what we could do, if we do get hung up, leave dissemination to a conference call.
DR. MC DONALD: Just a point. I had assumed, voting anticipatorially, that I could still get some changes in, and I will never get them in if there is not some discussion of them. I have written up some paragraphs. Is that on the agenda?
DR. FRIEDMAN: Absolutely. I didn't think that we needed to suggest all the suggestions and edits we were going to make today, because it is going to be disseminated, but if you think you have something that is controversial --
DR. MC DONALD: I don't know. I have had the experience in the past that it is not a good thing that might be controversial if you don't have a chance to talk about them.
DR. DEERING: If I understand what we are going to do first, I will just as quickly as I can review what staff thinks they heard, and how we think we are going to address what we heard in the roles that we can take, and then the other people can add what they have heard. I want to raise one thing quickly, which is a suggestion that we remove the word final from the report. As many of our other suggestions have been to do something into the future, there may be other reports. With people's permission, I would take the word final off.
One of the issues was how to get the cost effectiveness quality value into the report. We heard the finality of the discussion to suggest that we might be able to handle that in the intro section through a side bar, that is not a scenario like the other side bars, but it in a succinct fashion raises some of the issues and assumptions of what can happen, without making an authoritative statement.
We would further include the sentence that John had given us about the committee beliefs that the HII can. Then we would add an end note, a reference to that, at which point we could put in any references that people could give us that they think are the most authoritative, plus we would preface any of those references with the statement that the literature and the research on cost effectiveness in ROI is evolving. We would just leave it and say it is evolving and add whatever we could. So, that was how we felt that we could address that issue, and that was our intention there.
DR. FRIEDMAN: When you do that, I would suggest you run it by Ed Sondik and see if he feels this now addresses -- it was he who first raised that, I think, and it would be good to get his sort of affirmation that we seem to have reasonably addressed that absence that he noted.
DR. DEERING: We then heard a call to insert next steps. I believe we are currently thinking that it would be added to what would be one of the last ages before the recommendations, which would be page 31, beginning at line 22. We would enhance, we would expand that paragraph. We had some comments on next steps depending on what has come out of the discussion today.
It would, among other things, make the request, as was in the recent other report that just went forward, the functional status report, calling for an annual report from HHS. So, that would be text added to address follow up issues. It is both work that NCVHS is considering doing and what they are requesting from HHS.
We further heard that, under the recommendations, that we would break apart the federal and all others, and our proposal is to introduce a new second level header that says, other stakeholders. I have drafted a couple of sentences that just state again the gist of what I think was stated before, the federal government can't do it alone, it assumes there is a role for the other stakeholders.
Again, you will see the exact language. You will have an opportunity to see it, but I am just trying to describe how we are going to handle it, and that that would constitute the sort of intro to the others.
DR. SHORTLIFFE: I had a thought about that, and that is that the discussion today added some important points that probably are not reflected in the document now. Somehow or other say, we held a lot of hearings, we asked a lot of people, and we heard time and time again that, although there are many others who can play a role, there is this fundamental important role to be played by the federal government, and even the stakeholders agreed with that and pointed back in this direction.
It seems to me that by really highlighting this consensus about the federal role, you can help assure that we avoid an outcome whereby the department says, hooray report, I am not sure about this federal stuff, but we should really encourage the rest of it to happen.
DR. DEERING: I think what you have suggested is a good idea. We have language somewhat to that effect at least a couple of places in the report. We have always thought that people would be looking at the recommendations as a stand alone, so I think it bears repeating.
DR. SHORTLIFFE: It also would explain why you separate out everything else as other.
DR. DEERING: That is a good point. Of all the comments, I believe those are the ones we heard that were the most substantive. We do have a variety of specific notes that we would be making editorial comments on, and of course, we are waiting to hear from Clem and others, and you would see those changes in the next draft.
DR. SHORTLIFFE: And then the issue of privacy.
DR. DEERING: Oh, thank you. I can tell you how we have already proposed to reword that. It would now read -- this would be page 52 line 39. The sentence would say: The office would promote coordination of activities within Health and Human Services relating to personal health information privacy issues, period, and then all the rest would be struck. Basically, it is promoting the coordination role as opposed to an operational role in privacy right now. Isn't that what people heard?
DR. SHORTLIFFE: I think that is good for another reason. I felt that some kind of role in privacy was important, because we hope this office will be extremely visible to the outside world and the outside community. Many of the questions that people are asking have to do with the relationship between the information infrastructure and privacy concerns and the like. Having us consolidate it with a sort of point of contact and HHS leadership that will be very visible publicly, I think, could be very valuable.
DR. DEERING: From a strict constructionist standard, the preceding sentence just says it is going to coordinate and oversee blanket NHII-related policies and activities. I think it is important to have the sentence as we have said it. First of all, it doesn't say it is overseeing. It just says it is promoting the coordination, plus it pulls privacy out as a stand alone.
DR. SHORTLIFFE: It does and that is good. My own question is whether it should be restricted to personal health information.
DR. DEERING: So, we could simply say privacy issues, strike out the personal health information and just say for privacy issues?
DR. SHORTLIFFE: Or privacy issues relating to the HII. Are there provider privacy issues that would be relevant? It is a very big set of issues.
DR. DEERING: We had one comment from VA, where they would always like us to insert the word security when we use privacy. Are people comfortable saying privacy and security issues?
DR. SHORTLIFFE: In this context.
DR. FRIEDMAN: Mary Jo, do you have any other comments, or should we move on?
DR. DEERING: I think all the others were small.
MS. COLTIN: I think you have moved from lead responsibility to just promote. There is an awful lot of room in between. I am wondering if you couldn't also say, promote and facilitate, to have a more active role. It is not an oversight role, it is not a lead role, but it may give the office some leverage to pull groups together and provide some service or whatever, just a suggestion.
DR. DEERING: You are quite right. It is a big step backwards. So, if people are comfortable with promote and facilitate?
DR. FRIEDMAN: Clem, my only question about your comments is whether or not we need to do a dramatic reading of all of them, or whether there are two or three that you think might be the most controversial.
DR. BLAIR: For my benefit, that is the only way I could grab onto it here, is if it is read through.
DR. FRIEDMAN: Everybody will be getting it as part of the revised report, too.
DR. MC DONALD: I worry about having a word or word. Let's try the big one and if people like that, I think no one would mind the little ones, and then we could do that by your other mechanism. The large paragraph relates to page -- actually, I would like us to do maybe a little one, page 16, first sentence, last paragraph. This is the second one.
MR. BLAIR: Clem, are these additions or replacements?
DR. MC DONALD: They are replacements.
MR. BLAIR: Then, could you give us some idea of what we are replacing?
DR. MC DONALD: Yes. The first sentence in the last paragraph says, one of the ways the NHII could be strengthened is through more rapid development and application of health informatics standards. I am proposing that we say, instead, one of the ways NHII could be strengthened is through more rapid and more compliant adoption of existing standards, and by more rapid development -- this I have just changed -- of other needed standards.
That is, I specifically think we keep ignoring the fact that there is a lot of history. It makes it read like this committee has been on another planet regarding standards and now we are going to get them going. You know that is not true, and Jeff is aware of all the activities. I am saying, more specifically we are saying, get cracking on the ones that exist to make sure that they are compliance standards, and also more rapid development of new ones that are needed.
MR. BLAIR: By new, does that mean advance versions of the ones we have now?
DR. MC DONALD: I wasn't trying to be specific.
MR. BLAIR: I was using the word more rapid development. I was hoping we could have the phrase in there that they could take steps to help us accelerate the development of a new standard.
DR. SHORTLIFFE: It is nit, but one of the problems with existing standard is that they are not disjoint, they overlap. They are competing in some cases. So, it does seem to me that just adopting existing standards leaves unstated this problem of selecting among them or harmonizing them. That is as big an issue, arguably, as developing them.
DR. MC DONALD: When we did the previous meeting on the marketplace, with some of these standards, there is not much question about them. I was just really trying to point out that we need to do something with the current ones as well as the new ones.
I have got a bigger one, and if that one won't work, I am going to have a lot of trouble with the next one. The actual wording on the printed thing, I changed the very end from, other needed standards, instead of the more obtuse final phrase I had there. I actually made a hand edit that you don't see. If you would read the end and then say where it says, development of the key, change that to, of other needed standards, and forget the last.
With some work, we could maybe wrench it into development and further improvement of existing standards. We are going to have recommendations on this more specific. I just didn't want these to sound like they weren't right. The bigger one here is on page 17. It is the first full paragraph on page 17. I basically restated all of it. It is not all changed.
DR. FRIEDMAN: Clem, I think it might be a good idea to read the existing paragraph.
DR. MC DONALD: It is the first full one which says: Clinical standards already exist to address many administrative and clinical processes within health care institutions. They include standards developed by DICOM, HL7, IEEE and OMG, the object management group. However, much work needs to be done to make these transaction standards more complete and more interoperable and less expensive to install and maintain. Similarly, many medical terminologies already exist, but few have achieved the level of clinical specificity necessary to achieve the significant improvements in effectiveness and efficiency described in the preceding paragraphs.
The systematized nomenclature of medicine, SNOMED, the logical identifiers, names and codes like in MEDSIN, the medical collaborations interactive network, are three examples of medical terminology that are leading the way to clinical specificity that we require by NHII. That is the current sentence, and I have made this a little bit more specific and separated some issues.
A number of US SDOs have developed clinical transaction standards for various purposes. I included in this ASTM, HL7, DICOM, OMG and NCPDP. I think that is a true statement. They all have developed those standards. Some of these -- HL7 and DICOM -- are in widespread use in the United States, Europe and Pacific rim.
I think with all these standards, we should put a citation as to what they are, reference, this is the address or the report or something, so that people know. However, substantial standardization of work remains, especially in regard to the compliance testing, to be sure of a uniformity in the adoption of these standards, and a realm of standards for codes that gives specific meaning to the content of these standards messages.
A number of medical terminology with important levels of usage and utility exist for various domains, but the adoption of the existing vocabulary standards is limited. The usage cost of some may inhibit widespread usage and existing codes for some subject domains do not meet the needs of clinical records.
For example, the national drug code does identify all drugs, but these have a granularity that is suitable for inventory control, not for prescribing. What I would almost like to almost do is get a bullet in for the FDA to do what they think they may want to do, namely, make that the code set, but that is a side issue. We could add a sentence or two here, but I really wanted to be more specific.
DR. SHORTLIFFE: I like that. I understand your motivation. In a way, what you are doing is avoiding having the SDOs angry with us. You are basically trying to better acknowledge the role they are already playing and the degree of penetration they have had.
DR. MC DONALD: I think it is especially important, if you give these letters, the average reader is not going to know what they are. If they are interested, there is no way to get to them from where we are now. If I have missed one, we will add them. I wasn't thinking about all of them.
MR. BLAIR: Clem, the only thing I would want to add to that, when we get the version in there, I would really like to make sure we don't lose the emphasis on what we expect the benefits of things like HL7 version III to be, so that we could wind up saying that we are hoping that the NHII would encourage and facilitate acceleration of things like version III.
DR. MC DONALD: That could fit in with, however substantial standardization, and maybe unified model based. We could work out some words. If you could start with this paragraph, I am happy. These other ones are really kind of small and I will just talk about them. On 18, the bottom of the second large paragraph, there is a statement about ISO and the tag. That seemed out of place, unless we also describe other international standards, like the internet engineering task forces and WC3 and EMCRI.
It isn't part of the national health information. I just thought I would take that sentence out. The sentence is: The U.S. national standards organization, U.S. technical advisory group, ISO U.S. TAG, coordinates the positions of U.S. standards development organizations for representation at ISO technical committees, 215's committee on health care informatics standards. We don't say anything else about it, and it is not the only one that is doing international standards.
DR. FRIEDMAN: So, you want to take it out?
DR. MC DONALD: Yes.
MR. BLAIR: I think it would be unfortunate to take out references to international. If you wanted to add additional activities that are being done with coordination of clinical data on an international basis, I would support broadening that. I do think it is an important message that, on the clinical side, whatever we do in the United States, is global on a clinical basis.
DR. MC DONALD: As it turns out, the United States is pretty global without trying.
MR. BLAIR: Right. I mean, HL7 is working internationally as well and DICOM is. I would rather add to that.
DR. SHORTLIFFE: Maybe the example of SNOMED and READ and trying to come with that. That is international cooperation.
MR. BLAIR: Clem, would you feel okay with that?
DR. MC DONALD: This is not a high issue.
DR. DEERING: Staff are admitted non-data gurus and standardization gurus. You will need to provide us the language so that we don't misstate what you are trying to say. That goes also with the previous paragraph, that if you want to add -- I have got that in front of me. I know Jeff wanted to add something about, was it HL7 III?
MR. BLAIR: Allusions to those standards. That would be a good example that is going to be able to provide a higher level of interoperability and data comparability.
DR. DEERING: But I am just saying we are going to need language on this. When we get it back from you, we will look for a suggestion as to what it should say.
MR. BLAIR: Tell me when you need it and I will run it by Clem and we will try to get it to you together.
DR. DEERING: Maybe just work on that paragraph and give us whatever you want the final version to look like.
MR. BLAIR: Do you need it tonight?
DR. DEERING: Well, we may indeed need it tonight or by tomorrow.
DR. MC DONALD: Couldn't you put that all in and then we would do that last second?
DR. DEERING: You could do it in the next pass through if you like. We have a difference of language here, that all the standards section is a different level of language than the rest of the report, which was very specifically lay oriented by designed, so that it would be accessible to the widest public. That is an issue that we may want to try and address, because this is not a technical report.
DR. MC DONALD: Except for the alphabet soup, I think these are all plain old English words in here. I don't think any of these are technical words.
DR. STEINDEL: Clem, there are some issues that are brought up that are technical issues, even though the words are issued. I am concerned about that coming into this report, because this report, in general, has been a lay report.
DR. MC DONALD: I thought we had just had a general acceptance of it. So, you are saying you don't accept it?
DR. STEINDEL: I accept some of it, but there are some of the details where we start getting into the nitty gritty that I question their appearance, like, for instance, usage costs, and some of the language that you have at the end of the proposed paragraph on the national drug code.
DR. DEERING: Maybe what we will do, we will put it in, and if you could look at it with a mind toward a non-technical audience, it is not the question that these are not plain language words, but this is still technical language.
DR. SHORTLIFFE: I would say that last sentence is almost a tutorial kind of thing for a lay person. There are national drug codes for every drug, and we can't use them in clinical systems because they don't tell us how to do prescribing.
That is not a very technical comment about a problem with some of the so-called standards.
DR. STEINDEL: I think there are a lot of other problems like that, too. I just don't think we have used this report in that nature.
DR. DEERING: It is a very simple thing, for example, and we don't need to really pick over it. Could the sentence simply read: The national drug code does identify all drugs, but these are only suitable for inventory control, not for prescribing.
It is just words like granularity. That is not a lay person's term. That is what I am talking about.
DR. MC DONALD: Then you could feel free to scrub it.
MS. BAUER: There might be a larger issue here, too, in terms of what is the message that you want that paragraph to deliver, because that is what we tried to be very careful to do, even on the standards section, was to make sure there was a message that was coming through in addition to the specific details.
DR. MC DONALD: I didn't see any message in it. That was my problem with the previous paragraph.
MR. BLAIR: Actually, the message, if I may add, was to say, while good work has been done with current standards efforts and medical terminology efforts, a lot of work is needed to be done if we are to achieve the levels of interoperability and comparability that bear the fruit that we are looking for with the national health information infrastructure.
DR. MC DONALD: I thought we had agreement that this paragraph, with some lay cleansing, was fine.
DR. DEERING: We will do a little bit of lay cleansing and we will send it back, and that will Jeff a little bit of chance to look at it and everybody a little chance to look at it, and we will handle it.
DR. MC DONALD: I am adding specificity. I may be going downhill now. Page 24, right after the first -- it is just an addition. When they are talking about the Canadian system, end of the first partial paragraph, end of line two. You say, indeed, in some provinces the Canadians have converted their plans into real infrastructures.
British Columbia, for example, has linked all prescribing and is in the process of linking all laboratories via HL7 message and standardized codes. We could take out the HL7 word, but I think the fact that they have actually built something is more important than the fact that they have this nice graph that says they have a plan. It is pretty amazing how far they have gotten already.
Then page 25, this is maybe also to kind of highlight the HL7, the HL7 standards and how far they have gotten, each of those countries -- Australia, Canada and Great Britain -- have chosen HL7 as part of their infrastructure, which is a U.S. standard. I am not trying to push all of these. Do we have a chance to put bullets in?
DR. DEERING: These are not in the recommendations. I think the issue is not whether or not they are bulleted. On page 33, we are actually into the recommendation section.
DR. MC DONALD: If we are not allowed to change the recommendations, I will leave that go, or add to them. This is a perfect opportunity, though, to kind of help FDA get something done that everybody wants to get done.
DR. DEERING: I don't think we have specified any individual agencies in here. I think that is the only reason that I think it might be a little -- you know, come to think of it, I noticed that in the chart under I think it is section five -- let me see what page that is on. On page 26, the bottom half of the page, HHS agencies' responsibilities related to the NHII. FDA is missing.
I had already drafted -- I don't have it in front of me. As you can see, there are ever-so-succinct clauses there after each agency. Clem, if there is a way that you can add something about FDA there, again, this is not a prescriptive box about what they need to do.
DR. MC DONALD: This is table three?
DR. DEERING: Table three, correct.
DR. MC DONALD: The other thing is that NLM is not mentioned, though.
DR. DEERING: Yes, it is, at the top of the next page.
DR. MC DONALD: Never mind.
DR. DEERING: In fact, they are mentioned several times throughout the text.
MR. BLAIR: There is one thing, and I am afraid I tend to slide down the same path that Clem does, and I guess in some of my earlier drafts I wound up having a lot more detail about the standards and all. I think it became clear that, really, the purpose of the audience for this report is one where we don't want to distract them with the details of what are the standards and what are the technical issues.
In order for us to get action and funding for NHII, we just need to make sure they understand the need for the integration of these information systems and the coordination, and that there be a government focal point. Beyond that, I think we risk the fact that we lose the audience if we bring them too much detail. Clem, I am reversing the position that I had a little bit.
DR. MC DONALD: I am going to fight that tooth and nail. I could find 40 paragraphs in here that you could do without if you want to really squoosh it. There are a bunch of empty paragraphs in here that are just waving hands. This whole thing says, what we have got to do is get it standardized. It just seems upside down to be saying --
DR. DEERING: The other thing it occurs to me we can do in the spirit of follow up and next steps, I don't know what the agenda is for the standards subcommittee, but it seems to me that beginning to use the NHII framework as you address other standards issues, and make a companion document, standards for the NHII, that is a more technical document, it seems to me that could be a perfect next step one, if you really want to be concrete, a joint report of the NHII work group and standards subcommittee. It is not that we didn't want to go there at all, and I do hear you.
DR. MC DONALD: In the telephone conversation, i had understood that it was going to be beefed up, and I just didn't look at it.
DR. DEERING: The standards section is considerably beefed up from what it was. It really is orders of magnitude beefed up.
DR. FRIEDMAN: What I would suggest we do is spend a few minutes just trying to nail down process, which we have, in fact, already done, but maybe if we could just go over it, be explicit about it, get some dates, and then spend, if we have time remaining, if there are other report issues to be raised.
DR. DEERING: I think staff will do their best to get this out to you by close of business Monday, perhaps. It may not have captured everything correctly, but we will certainly do our darnedest, depending on what we have left to hear. It strikes me we haven't heard from Michelle and maybe there is something else to come. That is our goal, is to get it out to you by close of business Monday. That is Thanksgiving week. Could we ask for it toward the end of the following week, which is about the 29th or 30th, like maybe noon on Thursday, the 29th?
DR. SHORTLIFFE: Could you make sure that what goes out on Monday has the changes marked?
DR. DEERING: Yes, it will be in a track changes versions. Then my understanding of process is that, as you give us your comments, you will not only edit and make changes, but you will indicate whether you think that substantively we are, indeed, within the scope that was approved by the committee this morning, and whether any further review if necessary. Is that my recollection of the vote?
If you think that the draft that you see with the mark ups is good to go, then my assumption is that we incorporate all your changes. We would probably then have to send it out to the full committee, to show them what it was, but not for a vote so much as for comments and tweaks and approval that it did, indeed, match what they thought that they had heard.
PARTICIPANT: To the full committee and then what I heard John say is that the executive committee looks at the full committee's comments and sees whether there is anything that needs action.
PARTICIPANT: I wonder if we can afford to give this work group 10 days. I think we need to give them five or fewer work days. There is a longer turnaround period that the full committee would have.
DR. DEERING: So, if we get it out to -- why don't we specify the number of working days that you need. There is a snowball's chance in you know where that by close of business it will go out to you. On the other hand, we have had technology glitches. How many working days, given Thanksgiving, do you need?
DR. SHORTLIFFE: The only time I do something like this is when I am not working. It is probably Friday after Thanksgiving that you would work on this.
DR. DEERING: So, you would probably work on the Thanksgiving weekend. So, close of business Monday after Thanksgiving?
MR. BLAIR: I have no way of doing that. I would have to hire somebody to go through that during Thanksgiving, and I need to be with my family.
DR. DEERING: No later than close of business Monday.
MR. BLAIR: Maybe I could do it on Tuesday before.
DR. DEERING: As I say, we will try very hard to get it out by close of business tomorrow. I think what will be hardest, in all honesty, is this side bar on cost and value. It is either going to say almost nothing at this point, and then you will just have to respond and give us some suggestions, or it would take me more time to work on it. I am inclined to try to do my best on sort of a place holder so you will see sort of what the flavor of it is.
DR. SHORTLIFFE: Did you hear the thing the Triservice fellow gave us today about the million days? That is the kind of anecdote you would like to have in that box. I would love to know where he came up with that number.
DR. DEERING: I have got the details from my meeting with him. I got it in my previous notes. It is so many dollars for each prescription renewal, for each scheduling appointing, and then multiplied by X.
DR. STEINDEL: It was approximately $7 per transaction and then he had just this absolutely astronomical number of transactions.
DR. MC DONALD: You will notice he was doing all this with a $2 million budget that, with eight million patients, is $.25 per patient, which is what they are giving him to work with. I thought that was interesting.
DR. DEERING: That is only to date. That is only for 2000.
DR. MC DONALD: I think Ed's point was cogent. I think if we spend a whole lot of time trying to defend this, first, there are a whole lot of things we can cite that have done that, with games or numbers or whatever. I just worry about, if that is going to be the major slow down in this, is that so important.
DR. DEERING: I have got to tell you, there has been text about cost effectiveness and we took it out. Again, we really couldn't reference it. I think it is the extent to which Ed Sondik could be made comfortable with the lack thereof.
DR. SHORTLIFFE: The reason we took it out was because we didn't feel that our numbers were very easy to come by. Another option is to leave it in and say the numbers aren't very easy to come by. That is sort of what I think we should do, and make the point that we believe it, but that we are not going to be able to provide the numbers to prove it. That is commonly believed. We are not the only ones.
DR. DEERING: Then what I would suggest doing, so as not to call so much attention to it is, we have the suggestion sentence from John that we were going to put in, the committee believes that. Our proposal was to use the end notes to make the statement that the numbers are not fully developed, they are hard to come by.
We could also editorialize, we could throw in the DOD figure there if we wanted to. There it is, appropriately more in anecdote than right in the center of the text. That means that all we have got to respond to end is a single sentence with an end note. Is that sufficient?
DR. FRIEDMAN: I agree basically. It is part of the motivation for the report, with as many caveats that you want, without overstating the evidence. Anything else on process or should we move on? We have got essentially 10 minutes left. What I would suggest is that we leave dissemination to a conference call or conference calls.
Then Michelle had an issue she wanted to raise. She mentioned it to me very briefly a few minutes ago. Let me just preface it by saying, it is a relevant issue. It is an issue that has been discussed by some of us in some previous meetings. The response to it could either be do nothing, totally reconceptualize the report, which I think is not an option, or it could be perhaps we could put in a sentence or a paragraph.
MS. WILLIAMSON: I will preface that with, I am leaning more toward a sentence or two. I wanted to share just comments that I received from Karen Trudell about the report. Her feedback basically was that, in reading it and looking at the dimensions, she didn't feel that the health care insurers were addressed at all.
You see them identified on the chart, on the diagram, but if you look at the details of the descriptions of the different dimensions, they really aren't touched. She felt that we have a good alliance with CMF and other health care insurers, and that they need to be recognized.
DR. DEERING: I think clearly they are within the health care dimension. If you could find single sentences here and there throughout the report, or sometimes just adding between commas, and insurers and payers, et cetera. I think conceptually it was within the view of the committee all along.
MS. WILLIAMS: I agree. Immediately, when she said that to me I said, no, that is in there. You are in the provider dimension. You are definitely recognized. She said, show it to me. We looked at each detail in the descriptions and it really doesn't pull it in.
DR. DEERING: If you have some specific edits, we could certainly -- you have until tomorrow to get them to me.
DR. FRIEDMAN: Okay, we are done. I don't think we should really do dissemination today.
DR. DEERING: There was this phrase about working in the role of the market, the role of the market in promoting the NHII. In my mind, it got mixed up with also then the discussion of cost effectiveness and value and what are the motivations here.
Staff were unable to decide what that meant, what the committee had meant when it said we need to address the role of the market, that was not already in here. So, we had a hard time interpreting that as an editorial charge.
DR. SHORTLIFFE: A fellow named Ross Ritchie from IBM, every time we talk about this he basically says the reasons things haven't happened is because the marketplace hasn't made it happen. He is of an opinion that the marketplace and its role have been undervalued in understanding why it is that some of these good ideas that involve technology and information management have not really made it out there.
MR. BLAIR: Could you get closer to the microphone? I couldn't quite hear you.
DR. SHORTLIFFE: I was hypothesizing about what the marketplace meant and reflecting on comments from a fellow very interested in the health care marketplace from IBM's perspective, who has made comments that we underestimate the extent to which the marketplace actually is determining this. There are counterarguments, I think. I think we have, in this document, pointed out lots of structural issues for why the marketplace is not working in this particular case, and why it needs different kinds of stimuli.
If you talk to the people in industry, they don't understand why this is such a hard market to work in either, although they point to things like the lack of standards and interoperability and not so much a failure to recognize the potential value of the technology, properly implemented, as we envision it.
DR. DEERING: In the meantime, draft some language like that and see if there is a place for it. You will see what you see when I get to it, I guess. I will do my best and see if we can find a good place for that.
DR. FRIEDMAN: Good.
DR. DEERING: So, you will hear from us about setting a new conference call. We will certainly try and see when we can all get together to talk about dissemination and next steps and what you would like to do about that. Thank you.
[Whereupon, at 5:55 p.m., the subcommittee meeting was adjourned.]