[This Transcript is Unedited]
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington DC 20201
MR. ROTHSTEIN: Good morning everyone. We are now on the record. I want to welcome you to the meeting of the Subcommittee on Privacy and Confidentiality of the National Committee on Vital and Health Statistics. My name is Mark Rothstein and I'm the Chair of the Subcommittee. And before we get to our business, as is customary we will go around and have everyone introduce themselves for benefit of the reporter. Richard?
DR. HARDING: I'm Richard Harding, I'm a member of the Committee and the Subcommittee. I'm a child psychiatrist for the University of South Carolina. I have no clear conflicts of interest. The only possible conflict is that last year I was the President of the American Psychiatric Association and continue to serve on their Board of Trustees.
DR. LOCALIO: I'm Russell Localio, I'm a new Committee member. I'm from the School of Medicine, University of Pennsylvania. I have no conflict of interest except that my organization, like others, is subject to the proposed forthcoming privacy rules.
MR. ROTHSTEIN: Welcome to the Subcommittee.
MS. GREENBERG: I'm Marjorie Greenberg, National Center for Health Statistics, CDC, and Executive Secretary for the Committee.
MS. HORLICK: I'm Gail Horlick from the Centers for Disease Control and Prevention, and staff to the Subcommittee.
MR. HOUSTON: I'm John Houston, I'm with the UPMC Health Systems, I'm a new member.
DR. HUFF: I'm Stan Huff, I'm with Intermountain Health Care and the University of Utah in Salt Lake City. I'm a new Committee member and visiting here for the first time in the Subcommittee.
MR. ROTHSTEIN: Welcome. It's nice to have you.
MS. KAMINSKY: Stephanie Kaminsky from the Office for Civil Rights and beginning to reexamine of the definition of the Board's conflict of interest.
MR. ROTHSTEIN: Our guests are invited to identify themselves as well.
MS. BEEBE: I'm Suzie Beebe with the National Center for Health Statistics, for Disease Control and Prevention, and I am staff to the Subcommittee on Standards and Security.
MS. LEON-CHISEN: I'm Nellie Leon-Chisen, American Hospital Association.
MS. MYRECK(?): Cathy Myreck, Quadriment(?) Corporation.
MS. FRASIER: Chris Frasier from Salt Lake City, AAPC.
MS. TRUNTE(?): Nancy Trunte, Magnum(?) Psychiatric Association.
MR. BRODY: Ken Brody with American Health -- Association.
MS. OLSEN(?): Michelle Olsen, National Center for Health Statistics, CDC, and staff to the NHI network.
AUDIENCE: Comment off microphone.
MR. ROTHSTEIN: I want to welcome all of you. Today's agenda is one dimensional and we have one item on it to take care of and that is to consider the revisions to the draft letter based on our last two hearings. And I want to thank Richard and Stephanie for presenting our draft and for making revisions to it as necessary.
DR. HARDING: Stephanie gets the credit for that one. Wonderful job.
MR. ROTHSTEIN: So I think the first thing that we should do if there is no objection, is to go through the letter. And the letter is virtually unchanged and maybe, I think there were a couple minor things that I picked up and maybe Stephanie might want to call those to the attention of the Subcommittee members just so they know where they are.
MS. KAMINSKY: Actually, I didn't bring a red-line, so it will be a little difficult for me to pick up all of them. I guess what I can do, I should have red-lined it, when you say you wanted to go through the letter, did you mean you wanted to read through it again?
MR. ROTHSTEIN: No, just note the changes.
MS. KAMINSKY: Note the changes.
MR. ROTHSTEIN: There were just a couple very minor things.
MS. KAMINSKY: I'll do the best I can here and then I'll refer back to my notes. Obviously the biggest thing was the reorganization, if you call it that, or the so-called clustering.
MR. ROTHSTEIN: Start with the letter and then we'll get to the other stuff. I think there were just a few things on the actual letter, right?
MS. KAMINSKY: Well, there was the change that I think Marjorie actually had suggested on page two in the second full paragraph at the last sentence. Someone has said that they would like the system of certifying vendors and consultants, or I added some other way assisting covered entity in determining when services are needed.
MR. ROTHSTEIN: I think that's an excellent change.
MS. KAMINSKY: And I think that's it for the letter actually. Did you see something else in the letter itself?
MR. ROTHSTEIN: No, I don't think so.
MS. GREENBERG: Didn't someone suggest that the letter itself, in addition to, it says here, the last sentence says the additional information, da, da, da, but unless prompt vigorous action is taken to ensure that implementation goes smoothly the public acceptance and viability, didn't they recommend an additional sentence that was sort of like from the first letter?
MR. ROTHSTEIN: Of course that sentence, what you read is a direct quote from the prior letter.
MS. GREENBERG: What?
MR. ROTHSTEIN: What you just read. We could put that in quotes.
MS. KAMINSKY: Are you talking about, Marjorie, the last comment that was made about having something about marshalling resources?
MS. GREENBERG: Yes.
MS. KAMINSKY: I added that to the very end which may not be the appropriate place and of all areas that is the topic I wanted to have the most discussion about. But I put a paragraph at the very end of the whole document.
MS. GREENBERG: Oh, I thought they really wanted that in the letter.
MS. HORLICK: I actually think they suggested putting it at the end of the attachment but I think it belongs in the letter.
MS. GREENBERG: Maybe we just heard them differently.
MR. ROTHSTEIN: Ok, well let's that issue up now. If you'll turn to the very last page, which is page nine, there's a new paragraph that was added to replace the one sentence explaining the bolding, since we've been de-bolded, we don't need that. I think this is an important paragraph and seems to me that there are probably two, at least two places it could go instead of where it is. We could try to work it into the letter itself or we could move it at the top of the recommendations, which would be sort of right before the organization, Roman I, we stick in something like this explaining the recommendations. Or conceivably we could do it both places, we could have a sort of one sentence reference to it in the letter and then more detail at the top of the recommendations. So what do the Subcommittee members think? And we can play around with the wording later.
MR. HOUSTON: Since this is my second day here I guess I'm allowed to speak right? I think you have to make sure that any important points are contained within the three page letter even they're reproduced more substantively within the specific recommendations. And I think it was an important part of the recommendations was that discussion, so if you don't contain it within the letter, the fear would be that some people would read the letter and stop there. So if you don't put it there, I think you're going to regret it, we're going to regret it.
MR. ROTHSTEIN: Well, I think that's a good suggestion. Personally I wouldn't put the entire paragraph in the letter, I would maybe just include the first sentence.
MS. GREENBERG: I had written down here I guess right before we appreciate the opportunity, just a phrase here, resources need to be marshaled immediately, which I think is going to be said, so I think some kind of sentence like that and then as John said, I agree with him, I think something like that should be in the letter. And then this whole paragraph could be as you suggested at the beginning of the recommendations.
MR. ROTHSTEIN: How about if we do this, take the first, is everybody in agreement that the place for this extra sentence or two should go in the letter, is right above the we appreciate? So suppose we take the first sentence, after the egregious is where the Department and OCR in particular have limited resources to accomplish the extensive recommendations, and maybe we'll change it a little bit, set forth in the attachment. And then add a second sentence, something like nevertheless, we believe it is important to set forth a full range of implementation strategies that we think are most appropriate, or something like that.
MS. GREENBERG: Well, and we urge the Department to marshal whatever resources are possible to address them.
MR. HOUSTON: You said right above we appreciate is where you want to place that?
MR. ROTHSTEIN: Yes, you have a better place?
MR. HOUSTON: I think you need to above that paragraph preceding that, because then you say our recommendations for implementing the privacy rule are detailed in the accompanying attachment so I would think you would want to have discussion on that particular point, above the point where you reference the attachments --
MR. ROTHSTEIN: Ok, that certainly is, Marjorie any thoughts?
MS. GREENBERG: Yes, it would work there, and then in the last sentence the additional information derived to reinforce this view, we expressed, you say you need to marshal resources, etc., and then you say unless this is done, basically, you're going to have a problem.
MR. ROTHSTEIN: Any comments? Stephanie?
MS. KAMINSKY: I have two, one is wordsmithy, and one is substantive, and I'm sort of hesitant to even share the wordsmithy because there's a little part of me that's like, so maybe I'll just pass right over it.
MR. ROTHSTEIN: In those three sentences?
MS. KAMINSKY: It just doesn't matter.
MR. ROTHSTEIN: We're going to have a chance to, here's the plan. This meeting will end and then we have to go into the full Committee meeting, you and I will perhaps skip the first hour or two of the full Committee meeting and make the changes, you can do it unilaterally without anybody --
MS. KAMINSKY: I am curious just by way of thinking through what we've done here all the way about people's sense about what it really would take to implement these recommendations. What amount of staff? What would be the reality of what we have proposed here? I just want some thinking from you about what we have said and what we intend.
DR. LOCALIO: Just a question. What is the size of current resources available? Yesterday the number came up that OCR had eight people, eight FTE's assigned to this particular issue.
MS. KAMINSKY: In headquarters, it's something like, I'd have to sit and count, but it's under ten and one's a half time, so I don't know, it's something like that, I can take a moment and do that.
MS. GREENBERG: I have to admit after the hearing in Salt Lake City we spent some time together and when I discovered how few people there were I was kind of shocked, I thought there were more people.
DR. LOCALIO: That now sets baseline so if you recommend that you want more people, I would suggested you do it in absolute terms rather than relative terms. In other words say you need 40 more people, rather than four times as many.
MS. KAMINSKY: I'm not necessarily suggesting that the Committee come forward and actually put a number down, I just wanted to sort of raise for thinking sake what it is that is actually being proposed here because you've got to think about the folks who are going to get it, read it, and have to either take action on it or feel that it's beyond what is really possible. So I'm just trying to do a reality check here and just think a little bit about, we can talk about in the ideal world, but in the ideal world or in the real world, what's being proposed?
MR. ROTHSTEIN: Well, I think what we're proposing is a combination of people and money and they sometimes trade off against each other because if there were enough money then you could hire contractors to do certain of the things that we're proposing. I don't know that it's our position to even, it's interesting speculation to think about how many bodies we need and what budget and so on. I don't think that's our role, I think we are being measured in our recommendations and I think that everything that we have suggested is totally defensible and in fact essential to come up with compliance and it may be, if the Department doesn't have the resources to shift over to HIPAA enforcement, then they need to go to Congress to get more money. But I think we are basically calling it like we see it and there is a big problem out there and we've heard about it repeatedly and unless more is done it could be a major problem. Marjorie?
MS. GREENBERG: One thing that would be probably, maybe we've already done it, but we're talking about greater coordination with CMS. Some of the recommendations that are here for OCR are already being done by CMS in the transactions. Like they have a hotline, and how many people it takes them to man/woman that hotline, but I mean that would be kind of a reference point. I think they've used their regional offices, we heard yesterday, they actually have training in every state and now you're starting to train your regional offices. I don't know how many people there are in each regional office so that would have expertise in this area, one.
Part of the problem it is that it's not just people putting in to stuff envelopes, you really have to have people who understand the regulation well and that's a little harder to get up to speed. If you doubled the staff it would obviously be helpful and I could ask every agency to send one more person over, but if they send their most knowledgeable person then they're not going to be able to implement for their agency, so it's difficult. But I do think maybe some of the CMS experience would give some benchmarks as to the number of people needed for some of the resource intensive things like the hotline, the conference calls, some of the things being done by CMS.
DR. LOCALIO: Let me give you the other half of my comment. I also thought I heard yesterday the denominator, in other words how many covered entities for at least, in additional to covered entities, how many potentially affected organizations there are out there. I heard a very big number.
MS. GREENBERG: It's somewhere between 500,000 and two million.
DR. LOCALIO: We take 500,000 as the low number, you have ten people, you're talking about one per 50,000. That's not the kind of ratio that I would like to word under. Sometimes I feel I do all the time but I don't think I'd like to.
MS. KAMINSKY: I guess I just wanted to put that on the table as we go through and as we're thinking because that is sort of, those are the numbers that we have now and the reality of what's being asked for, I'm just trying to make this received in a way that will be --
MR. ROTHSTEIN: Richard?
DR. HARDING: We were asked by statute to monitor the implementation and make recommendations, I'm not sure if that's in the statute or not, but that's implied. And certainly all of us, and I'm sure I speak for everybody here, we want this to be helpful. We want this to help this thing work and that's our job. So if we bombard OCR with all the good things that could be done and there is absolutely no way any of that, I'm sure that OCR is going to feel like we're piling on with eight people working on it and so forth. If we can be helpful in some way of getting resources to increase implementation, to increase, just increase it, not perfection, increase it, that's what I would hope that this would do. But if that isn't the case, then I don't want to be part of piling on OCR if they're not given additional stuff, so that's the bind that I feel.
MR. ROTHSTEIN: Well you'll recall that when Rick Campanelli spoke at our Arlington meeting, the last full NCVHS meeting, he asked us to provide him with specifics. And I think we are. Maybe he didn't realize to the degree to which we would do that, but we had five and a half days of hearings and we heard it from all these witnesses all over the country, and they had some very interesting and disturbing things to say and I think we are just reporting those back and trying to do so in the most constructive way that I can find. And I would hope that through our personal interactions with the folks in the Department, they realize that this is not a personal criticism of anyone in OCR or at the Department, but it's a sort of a plea for more institutional support. John and then Simon.
MR. HOUSTON: Anecdotal evidence coming from a very large integrated system we probably have as many people in this capacity within our system working on HIPAA as OCR does.
MS. GREENBERG: HIPAA privacy?
MR. HOUSTON: HIPAA privacy. In terms of specific guidance, we've brought in three or four people that if you would add up their time, it's sort of on an FTE basis, we're probably providing high level guidance on our implementation of HIPAA, and that's just within one organization. That doesn't take into consideration all the people that are charged with performing implementation itself out at the individual facilities. While I think we provide good guidance, and I'm one of the people in that capacity that has to provide guidance within the organization, clearly there are cases where I either hear something internally or externally which is at odds with my thinking, and there's often a very good faith difference of opinion. Obviously you want to be able to vet those issues and understand, I'm right or the other person's right, or whether we're both wrong, in our interpretation of the rule. And clearly if OCR is not positioned to provide, just simply don't have the resources to be able to respond quickly to those types of questions, which are often very, very weighty questions, you're going to have non-uniform compliance throughout the United States. And that scares me because even though that supposed there's not a private rate of action, I believe there's going to be a standard of care established which is going to be actionable under state law.
My fear is that, so we're going to, though OCR may not enforce it I think we're going to find ourselves having to defend our HIPAA position immediately following April 14. I think that there is a lot of good faith difference of opinion about certain provisions and how to implement them best, whether its positions are sufficient and I think that we do need to have the capability to get very good guidance very quickly. And again, it's often the very meaty substantive issues that we need to drill down into and have clear guidance on.
DR. COHN: Good morning. I also work for a very large integrated health care organization, I don't know which is bigger, I think ours might be. We also actually have more people working on privacy than OCR. But having said that, of course we're implementing, we're not developing policy, so just like you. There's a difference there.
MR. HOUSTON: We're in the implementation phase, too.
DR. SIMON: But policy is a different issue. As I understand really, the question is what sort of resources does OCR need and I think we need to think about this in sort of two separate pots. And at the risk of having this already said right before I walked into the room I will apologize. Knowing how quick the government gets staff on, I'm just reflecting on our recent new members of the Committee, that if what we're doing is recommending staff, that has nothing to do with implementation, that is going to be a year from now we're going to get a staff on board. Because let's be honest about this all works.
MS. GREENBERG: Maybe we don't want a lot of staff for enforcement.
DR. SIMON: That's it, I was going to go there, you've already jumped to my thought on this one. I think there's a real piece for funds for consulting help, I mean you'll need consultants on board, that way it gives you the flexibility to get guidance written very rapidly, things up and going very rapidly. And that doesn't take all the bureaucracy that typically exists with getting new hires. Now then there's the question of, and that's the only way you're going to make it between now and mid-April. Then after that, the question is does OCR need some additional staff. They probably do, but it's probably a much more modest amount than we might be talking about between now and April, so if you're going to make a recommendation I'd suggest you might frame it in that sort of way.
MR. ROTHSTEIN: Well, I think there are various ways, I mean use of contractors, having people detailed to OCR from CMS, from wherever on a temporary assignment, there are all sorts of things that I think probably can be done but that's their call how to do that. I think where we would be most helpful is to just tell them what needs to be done and let them worry about how to do it.
MS. GREENBERG: You're meeting today with the Privacy Council?
MR. ROTHSTEIN: Correct. I can't tell you where or when or --
MS. GREENBERG: In an undisclosed location. I think you could engage them in some conversation on this topic.
MR. ROTHSTEIN: I assume that's the agenda. What realistically can be done and what as a Subcommittee and full Committee we would recommend based on what we've been hearing around the country.
Let's see if we can get closure at least on the letter. What Stephanie and I will do if you approve is to, page four of the paragraph that begins complete versions on page three, we will add a sentence, probably two sentences that reflect the tenor of what's on page nine in the added paragraph dealing with resources.
MS. GREENBERG: I thought you were going to add it after the sentence on recommendations for implementing the privacy rule are detailed in the accompanying attachment. You wanted it before then?
MR. HOUSTON: Yes, you typically close with saying what's in an attachment.
MR. ROTHSTEIN: I'll let you ponder that for a second.
MS. GREENBERG: I'm not sure since, I thought it might work there, but I'm not sure if it would make sense completely before this last paragraph, but work on it and see what --
MR. ROTHSTEIN: And of course everyone is going to have another shot at it this afternoon.
MR. HOUSTON: The other way would be to just say as sort of the opening that the recommendations in the attachment require immediate marshalling of resources to, or something so it ties together.
MR. ROTHSTEIN: You mean put it in the middle of the last paragraph.
MR. HOUSTON: I was back to putting it, yes, right before we appreciate.
DR. SIMON: Mark, I would actually refrain that conversation about having another shot at it this afternoon. If we're wordsmithing this significantly this afternoon, it's not going to get passed and we're going to be going to the Privacy Council later on today with a draft letter from the Committee.
MS. GREENBERG: Actually, he's going to the Privacy Council before the Committee addresses it I think.
DR. COHN: Oh, good, isn't that interesting.
MR. ROTHSTEIN: The Committee is taking this at like 2:00 or something.
MS. KAMINSKY: The Privacy Council meeting is like at 5:00 this afternoon.
MS. GREENBERG: I'm sorry, I thought it was at lunch. I misunderstood yesterday then.
MR. ROTHSTEIN: Ok, so you'll have a chance to vote on this later, but it's going to be in such wonderful shape that no reasonable person --
DR. COHN: You'll have taken all prudent comments in --
MS. GREENBERG: We have every reason to be confident that the two of you will come up with something.
MR. ROTHSTEIN: Ok, let's move now to the recommendations section and I think Stephanie did a wonderful job of reorganizing them and maybe you'd like to take us through it.
MS. KAMINSKY: So, took out the bolds as you can see and tried to cluster recommendations under more general headings. And also obviously took out the note that was at the top of the other draft about explaining what the bold was about. Under organization, I added a second bullet based on just Lare's(?) request and I'm not sure if this is worded correctly because I'm not even familiar with what this, I'm afraid to say, recommendation was. So maybe folks could take a look at that little bullet and see if they agree with it or if there's a better way to word it or what.
MR. ROTHSTEIN: Simon, what do you think?
DR. COHN: I don't know. I didn't agree with Jeff's recommendation so it's hard for me to figure out how best to put it in place, I just think that HIPAA, and I think this particular piece and NHII are sort of different things, at least in my mind. I guess I have a real fundamental question on organization, which I will apologize since I jumped into the conference call a week ago, made a couple of comments and then jumped back out, you had already gone through this. And obviously I brought this up a little bit yesterday during the session, but didn't want to just dwell on it. Is this really what we want to do? And I just bring this up, we're in a weird situation right now, where agencies have been designated as lead agencies.
MS. GREENBERG: You mean this particular --
DR. SIMON: Yes, the HIPAA Office.
MS. GREENBERG: I'm sorry, I thought you meant organization of the whole thing.
DR. SIMON: No, I think the organization, the whole thing is fine. As I looked at this thing about the issue of a HIPAA Office, I was reflecting that we used to have a HIPAA Office and it's name was Bill Braithwaite. And we now have CMS that's really responsible for everything other than privacy and who is responsible for not only doing that but also coordinating whatever, it is the lead agency for that.
And then we have OCR responsible for privacy and it is also I think responsible for coordinating with everybody else at least as I understand. And then the question is does a HIPAA Office at the Secretary level designate things work better or does it just get in everybody's way? And I absolutely agree that we need to be promoting mutual coordination. As you commented, there's lots of ways to do coordination. And so the question is, I don't mean to have this take the heart out of things, but considering a couple of weeks ago Tommy Thompson and John Skulley(?) gave CMS, have created a HIPAA Office at CMS, and they've already sent out a memo saying OCR is responsible for this other piece, does this do something with --
MR. ROTHSTEIN: Notice the difference in the language. Number one says Secretary should consider establishing, whereas number two under covered teams it says OCR should establish and so we're being less directive in number one and I think for good reason. I think it's worth raising it because I think it emphasizes our view of the importance of collaboration and if the leadership at the Department feels that they can get the collaboration more effectively some other way that's fine. I think this is a possibility and I don't see anything wrong with saying the Secretary should consider establishing.
MS. KAMINSKY: What if instead of what we have here, point number one was more of a focus on the incredible importance of collaboration and coordination and then underneath that what they should consider?
DR. SIMON: Thank you, that was actually where I was sort of trying to go. This comes really, even though there's a consideration here, it still comes away as number one is terribly strong, it feels like a strong recommendation.
MR. ROTHSTEIN: In other words, in the text of number one we state the need for collaboration and coordination and as an arrow we put one possibility might be.
DR. COHN: Exactly. And then at that point that other arrow which is that obviously there should be coordination and collaboration also with the NHII, the Special Advisory at NHII, I think that begins to potentially make some sense.
MR. ROTHSTEIN: Ok, is everyone comfortable with that?
MS. BEBEE: Marjorie I just wondered, the Health Data Standards Committee that used to meet once a month that Bill led the discussion, maybe you bring out the mention of some of the resources that were already in place.
MS. GREENBERG: I had said yesterday the Data Council, the Data Council only meets once a month and though, I mean they're the ones that should, should through that there is coordination and I guess going back to the resources issue, if you're going to have more resources do you really want to put them in like an overhead HIPAA Office or would you rather see them on the ground. But I like the way it's being, because I think this point that problems in coordinating agency efforts are already beginning to surface, are likely to intensify, I mean I think that's a good point and it needs to be made. So I think the way you talked about reorganizing is good and then the Department can come back, just like the Committee recommended an NHII Office, well the Department didn't do that but they did create a Special Advisor which is a start.
Actually the problem I had with the second bullet which now maybe would be a different bullet, is that the Special Advisor is not really what was recommended by the NCVHS. I think the NCVHS actually recommended an office for NHII, but the response of the Department was a Special Advisor, which at least is starting addressing the coordination issues, or visibility issues. So I think the way you've recommended it is fine.
MR. ROTHSTEIN: So we should change the language at the end of the last bullet in that section because that was not previously recommended by NCVHS.
MS. GREENBERG: Well not the Special Advisor, no that was the Department's response. You could just say --
MR. ROTHSTEIN: Could we put period after the word infrastructure?
MS. GREENBERG: Probably, with the Special Advisory on the National Health Information Infrastructure, period.
MR. ROTHSTEIN: Is that ok with the Subcommittee?
DR. HARDING: I'd rather leave that whole sentence out.
MS. GREENBERG: Well, it's not a bad point though that there should be, someone could be at the ASPE level basically where Bill is and where the Data Council and Health Data Standards Committee are coordinated, where Jim Scanlon is, so I think, I don't know.
DR. HARDING: A minor editorial point, but the first bullet, if it's going to be moved up in some way, I'd like to see the wording read something like, instead of OCR needs to work with CMS, I'd like to say CMS and OCR should, putting it on both instead of OCR needs to walk across the hall and get, it's both. CMS and OCR should coordinate.
MS. GREENBERG: Right, I think that's definitely good.
MR. ROTHSTEIN: Ok, anything else on Roman I?
DR. SIMON: So I just want to make sure that I'm understanding, what we're saying is that coordination and cooperation, basically this title is a need for increased coordination and collaboration, period. And we're talking about the need for, I guess the one piece, which maybe will even further downplay the HIPAA Office, I'm sort of thinking that, sort of saying that there needs to be increased coordination and cooperation between the parties, it may be that something like a HIPAA Office at the Secretary might help with that, and you should consider that, sort of on that level of recommendation. I just don't want them to throw the whole next 28 recommendations out because it's going on in their mind, well, we don't want to do that, so everything else goes out. So we just need to have it sound like an option to improve coordination and collaboration and then another type of collaboration, as appropriate, should occur with those involved with the NHII.
MS. GREENBERG: Do you think maybe the same solution that they came up with for the NHII, rather than an Office, which again does start conjuring up a Special Advisor, somebody to coordinate, who can have staff? I sort of agree with Simon in one sense, we've already figured out how we're going to organize HIPAA and now you're telling us to put in a new Office. But there does need to be more coordination at the top level which could be to a --
MS. KAMINSKY: It doesn't necessarily have to be at the top level, it just has to happen.
MS. GREENBERG: Well, if you stick it in CDC or something, the other agencies aren't going to listen, that's why it has to be at the Office of the Secretary.
DR. COHN: Do you think if CMS says something, CDC won't listen? I don't know the politics on that particular, if CMS is in charge of something and tells CDC something, they won't do it unless it comes from the Secretary's Office?
MS. GREENBERG: No, I'm not saying that, but if you're trying really to coordinate CMS and OCR, it's probably got to be by someone over them. You're not going to stick it in --
MR. ROTHSTEIN: Well one of the things we could say is that as a bullet, the Secretary should consider any organizational modifications necessary to enhance coordination and collaboration.
DR. SIMON: Ok, that sounds good.
DR. HARDING: This is the homeland security of HHS.
MR. ROTHSTEIN: That would take care of the budget problem. Ok, Stephanie do you have that? On to number two.
MS. KAMINSKY: The only, the Roman II, covered entity teams, I put together the issue of the teams for the industry, the state government, and then I actually put the fragile providers under that grouping, I'm not sure if that was correct or not but I thought it was close enough, I don't know what others think. And then in addition, actually somebody from the public came up to me after the session where we reviewed the letter with the full Committee yesterday and suggested that Advanced Nurse Practitioners should be changed to Advanced Practiced Registered Nurses in Rural Areas in that third bullet, and also even suggested that we put something in about complementary and alternative medicine providers, which I guess are also active in the areas that we're talking about. And I did delete the word primary from the last sentence which now says health care providers treating indigent populations lack the time and resources to achieve compliance and should be a focus, instead of a primary focus, of OCR assistance.
MS. GREENBERG: We could either I think correct the spelling of complementary or leave it out. I know who came up and I understand, but I don't think that they are really among fragile providers.
MS. KAMINSKY: Ok, well that's why I have it in bold brackets. I wasn't sure what I was dealing with here.
MR. HOUSTON: Being new to this Committee, this sort of assumes that the big providers, or the reasonably situated providers, the non fragile providers, are fully capable of moving forward and implementing without technical support.
MS. KAMINSKY: Bullet one.
MR. HOUSTON: I'm sorry, I thought we were down to bullet three.
MS. KAMINSKY: But bullet one addresses the sort of mainstream, whatever.
MR. ROTHSTEIN: So there would be theoretically someone assigned in integrated health care delivery systems or academic medical centers, or whatever. But in addition to those, then we also should focus, or OCR should focus technical support on fragile providers.
MR. HOUSTON: Then I would say take the word its, then its confusing.
MR. ROTHSTEIN: Take the word its out of the --
MR. HOUSTON: Right, it should focus technical support, its sort of assumes you're going to take all of its technical support and you're going to throw it at these fragile providers, and I think that is not what you're intending to say.
MS. GREENBERG: So there was a place in this letter, should that move up into that first arrow? Or was that under structuring the web-site?
MR. ROTHSTEIN: No, it was on page two, right above number six, the bullet before that. OCR should tailor FAQ's to be more responsive to the needs of specific entities, professions and groups, such as long-term care facilities and academic medical centers. Is that what you're referring to Marjorie?
MS. GREENBERG: Where is this now?
MR. ROTHSTEIN: In the second bullet under number five.
MS. GREENBERG: I'm just thinking, if you take out its also maybe I'm just thinking if it wasn't fair to John, but maybe this is clear now that the first one is more mainstream.
MS. HORLICK: Is this on that?
MS. KAMINSKY: Yes, well it's on this whole segment on covered entity teams.
MS. HORLICK: Well I was just thinking at the last sentence now where it says that the providers treating indigent populations lack the time and resources to achieve compliance, and since we took out the word and should be a primary focus, I don't really know if we need after compliance --
MR. ROTHSTEIN: Just put a period?
MS. HORLICK: Yes, or even move that after, because we've said they should focus their attention on this so I think that's sort of redundant to say --
MS. GREENBERG: Maybe to achieve compliance without assistance, without further assistance, it sounds like we want it to say they can't achieve compliance.
MS. HORLICK: Well where we say above it large health care entities such as large hospitals have made considerable many, maybe something else. I just don't think we need and should be a focus of OCR.
MS. GREENBERG: Yes, because you've already said focus.
MS. HORLICK: We need to strengthen that or --
MR. ROTHSTEIN: Alright, let's take out everything after the word compliance and add the word often, because Richard mumbled, health care providers treating indigent populations often lack the time and resources to, how's that?
MS. HORLICK: Achieve compliance --
MR. ROTHSTEIN: Yes, period.
MR. HOUSTON: Why couldn't you just include health care providers treating indigent populations in your list of providers farther up in the paragraph as being fragile?
MR. ROTHSTEIN: Well, we are.
MR. HOUSTON: My point was that this is almost redundant --
MS. GREENBERG: Well the reason though that they need to focus some technical support for them is because these types of providers --
MS. HORLICK: But they all lack resources.
MR. GREENBERG: Lack the time and resources to achieve compliance.
MS. HORLICK: So maybe put them up in the top and then say something about how they all lack the --
MR. HOUSTON: You could say OCR, if you look at the first sentence, OCR should provide technical support to fragile providers and then including, and then put the health care providers for the indigent populations as part of that list. And then further down just simply globally say these fragile providers lack the time and resources to achieve compliance.
MS. GREENBERG: Yes, that's good, because somebody mentioned not just focusing on indigent --
MR. ROTHSTEIN: How about OCR should focus technical support on fragile providers treating indigent populations?
MS. GREENBERG: Well, it's not just those, that point was made yesterday though, they don't just treat indigent populations.
MS. HORLICK: It's on fragile providers including community health centers --
MR. HOUSTON: Comma, health care providers, treating indigent populations, and then at the bottom then you say these fragile providers lack the time and resources to achieve compliance. Put that somewhere in there because that's what you're really trying to say.
MS. HORLICK: And then it's more generic.
MR. ROTHSTEIN: And you would want to move that before the sentence that begins large care entities?
MS. GREENBERG: No.
MR. HOUSTON: I don't think it matters, I have less of an opinion there, I just think you're --
MR. ROTHSTEIN: Where Marjorie?
MS. GREENBERG: I thought we were just keeping it where it was, although maybe it flows better the other place because you just described the providers and say these providers lack, then you wouldn't even have to use fragile again, you could just say these providers lack the time and resources to achieve compliance. I don't know, I defer to you on that.
MR. ROTHSTEIN: Stephanie, do you want to redo? Alright, let's go over again how we want to have it.
MS. KAMINSKY: What was that point though about it's not just indigent populations? I have a note about that but I didn't understand what that was.
MS. GREENBERG: I think they're saying these, like rural physicians, they don't necessarily just treat indigent people, but they still are, they don't have much depth there, one person, or three people.
MS. KAMINSKY: I think I understand the gist of what's being asked for in the changes here, so I'm not asking about that. My bigger point that I want to try to draw attention on is the very first sentence of this whole segment. Again, OCR should establish covered entity teams to assist the various industries and professions. Given our staff, what does that sentence mean or what are we advising?
MR. ROTHSTEIN: Well maybe a team of one. What we really are more concerned about as opposed to a team are representatives, people who have the assignment that, Stephanie is responsible for coordinating with the dentists and maybe two or three other groups as well but that's what we're trying --
MS. KAMINSKY: Can we use the word representative or designated specialists?
MS. HORLICK: Teams would be ideal but we're really talking about designating somebody for the particular groups.
MS. KAMINSKY: I'm just calling your attention to that because it could be like again, this is outside the range of what's --
MR. ROTHSTEIN: Ok, instead of OCR should establish covered, should designate staff to, specific staff --
MS. GREENBERG: I like the idea of teams, I mean you can have a team of two people.
MS. KAMINSKY: I like the idea, too, I'm just concerned about the way it's going to be received so I raise it as --
MR. ROTHSTEIN: Staff could be two people.
PARTICIPANT: It comes back to your question about how many people we really think this will take. If you think you need 16 people then you should say teams maybe, but if you think you're going to have four people, each of which cover five groups, so one does the dentists, then one does something, then it will probably be better to say individuals.
MR. ROTHSTEIN: How about OCR should designate one or more staff members to assist each various industry?
MS. GREENBERG: It could even be through a consulting group, or through a technical assistance contract.
MS. KAMINSKY: Leave it teams, leave it teams, teams I think is strong, I'm just, designate one or more staff and then you start getting into micro managing.
MS. GREENBERG: Yes, that's too micro managing. I like the idea of the teams.
MS. HORLICK: But do you think that the way it's written now, covered entity teams, really clearly shows that we want a specific team for industry and for help, and it may be that one team does all of it in the Northeast and one does it in the West, I think we need to get that sort of that somebody is responsible for a particular industry.
DR. HARDING: That's in the first bullet.
MR. ROTHSTEIN: Do you want to change? Are we ok with the way it is now after deconstructing and reconstructing?
MS. GREENBERG: That's true, there it does just say a designated staff person for each major profession and industry.
MR. ROTHSTEIN: Ok, you've failed in making more work for yourself, but I still think so we're now going to move on to number three.
MS. KAMINSKY: Ok, so number three you see the defensive practices. The main comment which came was it Jean or someone, about the last sentence that I added to that first paragraph, such defensive practices might result in adverse outcomes with respect to treatment and data collection activities for research and public health. Because there was a request to tie this defensive practice recommendation to the general point that was made in the cover letter about problems with, the chilling affect of this whole implementation effort because of misunderstandings.
MR. ROTHSTEIN: I think that's an important addition. Russell, does that extra sentence satisfy your concern?
DR. LOCALIO: Yes.
MR. ROTHSTEIN: Now do we also then need to add that bolded bullet?
MS. KAMINSKY: That was Russell's suggestion.
DR. LOCALIO: I'm not sure how the powers that be want to address this. My position is that unless there is some program underway, it doesn't have to be a huge program, for continuing evaluation of this particular initiative, you're not going to ever be able to assess how it's working, positively or negatively. For example, in education, there's a new initiative on testing, accountability, but there are also some evaluation components that go on. Again, it's just my opinion that there ought to be some formal evaluation apart from people getting complaints.
MR. ROTHSTEIN: I would say, I mean that's an important point, but it's a more general point than just the defensive practices.
MS. GREENBERG: You weren't just talking about research, you were talking about the impact --
MR. ROTHSTEIN: The hard educational programs, working, etc., so we might want to add like number 15 before we go into enforcement, something on the issue of evaluation.
DR. LOCALIO: I think that might be better. Because also I don't know has anyone asked for an evaluation on whether the rules are working? We have a candid population, are patients going to be assessed as to whether they're happy with this? Whether they feel their privacy? Do they know whether it's going to work? Why do we have the rules? We might be able to put that in.
MR. ROTHSTEIN: And for this one should we suggest that OCR work with AHRQ?
DR. LOCALIO: Sure, NIH, whoever is the most appropriate.
MS. GREENBERG: I wouldn't say who, I mean NCHS could put something in the health interview survey, a module about --
MR. ROTHSTEIN: But this sounds like -- grant program --
MS. GREENBERG: There are all sorts of different ways.
DR. LOCALIO: I just wanted to say there are a lot of different groups here who are affected, patients, providers, researchers, public health, and there has not been to the best of my knowledge a proposal to evaluate the impact of the rules on the various people who are affected. I think there's been a lot of emphasis on what we're saying here about the impacts on covered entities, I think that's a very important focus, but there are other people who are affected. Non covered entities are affected.
MS. GREENBERG: I think Russell made a very good point yesterday, the hearings. I think we did hear from, well we heard from individuals, but we heard from groups and a lot of the stuff we heard was somewhat anecdotal, although we had reason, in particular some of the speakers because they represented a broader constituencies. But, and that's inevitable at this point, and people are looking forward and saying this could happen and all that. But then you don't want to just continually have anecdotal evidence, you want to actually have some systematic evidence that in fact things are, because often the common wisdom isn't true. And we want some way to do it and frankly, the national committee is supposed to report to Congress annually on the implementation of HIPAA, we do, we do an annual report and up until now we've pretty much talked about the process of getting there. Well once the implementation dates are passed, we're under much more obligation to be reporting on how it's going. And we can't obviously do it alone.
DR. LOCALIO: How would you do that if you didn't have some evaluation? I think it's much easier to go and say somebody has done this work and it doesn't have to be HHS, it doesn't have to be OCR, it could be somebody who has a grant, some organization at least you could point to it as formal assessment of the impact of the rules on X group, that group, A, B, C, or D.
MS. KAMINSKY: I would actually not even move it above 15, I would move it to the end under Roman IV, resources needed to implement the privacy rule. If we're talking about an impact study --
MR. ROTHSTEIN: But those are all things where it's the Secretary is being asked to go to Congress basically.
MS. KAMINSKY: Well, ok.
DR. LOCALIO: You might not want to ask for money, you might just want to ask for people's attention so that AHRQ or NIH or a private organization, Robert and Johnson Foundation, now hears that this may be an important issue so they're going to add this to their list of RFA's for people to apply.
MR. ROTHSTEIN: Markle.
DR. HARDING: So we're asking who to assure that the evaluation and so forth be built into this whole process?
MS. GREENBERG: I think that the Department should have an evaluation component. Others may pick up on it as part of the evaluation component. It could be even grants.
DR. HARDING: It's not OCR.
MR. ROTHSTEIN: No, OCR has been spared a recommendation.
MS. GREENBERG: This is something the Privacy Council, actually I would mention it to them, because they should be thinking ahead to this. And it could be that they would ask AHRQ to coordinate it, but they can figure that one out.
MR. ROTHSTEIN: Ok, so are we now satisfied that three, defensive practices, is ok?
MR. GREENBERG: Yes, you can put this evaluation thing wherever you want but I think it should be it's own thing so it stands out.
PARTICIPANT: Well, we're not bolding things now but one of the things I think is that we still somehow want to highlight what we think, and I think it's very close because of the things that are numbered now and underline with a very slight change, they're all saying sort of a major thing that should be done and then the bullets become details of how to accomplish that thing and so in this case, for instance, with number three, to make it symmetrical you would just take like the first sentence and leave it up there and then put the rest of it under a bullet and then it would be symmetrical with the rest of the things. And with some of these others all you would need to do is just add, sort of take the first sentence and say this is the recommendation, so that if you didn't have time you'd go down and you'd say oh, ok, we want to establish the office, we want to take care of covered entities, we want to do the web-site, we want to do frequently asked questions, etc. And so I think in number three I would leave the first sentence as sort of the charge and then put starting with there is considerable misunderstanding, just put that as a bullet underneath there.
MR. ROTHSTEIN: Except all the bullets are action items.
MS. GREENBERG: Are things to do, this is more an explanation. I don't know if there are things we want them to do under defensive practices, maybe you'd need a bullet like, but you already said should address.
MS. KAMINSKY: It wouldn't hurt to put a bullet of what exactly we're asking for there, FYI.
MS. GREENBERG: I think that's a good idea to have a bullet, but I don't think this verbiage is really the bullet.
DR. LOCALIO: We should say we want them to monitor defensive practices as the bullet, that's the direction we want them to monitor in it's practice, that's not what we're --
MR. ROTHSTEIN: They should assess the extent to which defensive practices are undermining compliance.
MS. KAMINSKY: I thought the goal of this was to do a better job at getting the word out --
MS. GREENBERG: On education, it's really an education thing.
MS. KAMINSKY: What's permissible so that folks will stop clamming up if it's ok for the disclosure to happen, especially since this chilling can be hurting the health care system in other ways, so I thought it was an action item, but I was hoping maybe the Committee could think of a specific about that education but leave it just that broad.
MS. GREENBERG: I think you could have a bullet that says something about outreach and education should make it clear what is permissible and, where was that one about, that I liked, that balancing all the privacy needs with the recognition that uses of PHI in an appropriate manner does, is important for public health, for research, for da, da, da. There was a sentence, that was one that I had said to bold in my comments I remember. It's somewhere here but I don't know where, I assume you didn't take it out. You know the one I mean? It's probably under consumer maybe, I don't know.
MS. KAMINSKY: Yes, I know which one mean. It is under consumers.
MS. GREENBERG: Yes, OCR's consumer education must include communicating the value of health information interchange including better health outcomes of reduced costs.
MR. ROTHSTEIN: Ok, so, we're adding bullets to number three, are we ok with that now?
MS. KAMINSKY: I'm not sure we're going to get the parallelism that --
MR. ROTHSTEIN: We'll work on it.
MS. KAMINSKY: Next, web-site, I just pulled two of the recommendation on web-site under this concept of revamping and then I didn't know where to put the decision tree diagrams and matrixes and since we've got the covered entity flow chart on our web-site I just threw it under web-site, I don't know if that works or not. Visual aids.
DR. COHN: You probably don't want to summarize the complexities but you probably want to, summarize isn't the right word, visual aids to summarize the complexities of privacy rule?
MR. ROTHSTEIN: Explain.
MS. KAMINSKY: Ok, FAQ's, I put two under this concept, posting answers within 30 days and targeting the FAQ's to specific professional groups, etc.
PARTICIPANT: Somewhere in there put frequently asked questions. I mean not every --
MS. KAMINSKY: Oh, yes, no, we can put that right up front, that's better. As was requested we deleted the sentence if OCR begins conference calls we'll have seminars and other outreach efforts detailed in this document and will not need the FAQ mechanism to learn what issues are of concern to covered entities. I think we stated that sentence in the old draft was a little bit confusing and not helpful.
DR. HARDING: Does the last sentence have to be there? The current arrangement has created a great deal of bad will.
MR. ROTHSTEIN: I think we can take that out because that's a point that was made explicitly in the letter.
MS. GREENBERG: It is true, but maybe it's sort of --
MR. ROTHSTEIN: It's certainly true, but it's piling on terms.
MS. KAMINSKY: And then guidance on privacy rules in relation to other laws, I put the two recommendations that we've previously called the preemption recommendations, the first being about coordinating preemption analysis. The second being about publishing stand-alone analysis of the intention of the various federal laws.
MS. GREENBERG: Do you really want to say, I mean I think the question submission feature on the OCR web-site needs to become a timely meaningful part of outreach. I would just put a period there because I don't think they should, it should be dropped altogether. That's in a sense kind of gratuitous I think.
MS. KAMINSKY: I'm not sure where you are.
MR. ROTHSTEIN: Back to FAQ's, the first bullet.
MS. GREENBERG: I'm backing up. I just think you could put a period there. I don't think you really want them to drop the FAQ's, we want them to --
MR. ROTHSTEIN: Not, but they might make a, I think if you can't answer the questions, don't ask for questions.
MS. HORLICK: No, but they're saying that they're going to use that to --
MS. GREENBERG: And then we're telling them to tailor FAQ's.
MS. HORLICK: To develop the FAQ's.
MR. ROTHSTEIN: What we also said in the letter, we specifically addressed that.
MS. KAMINSKY: Neither Kepa nor John are here today, but if you just think back a moment to an innocent day in June where this whole project was launched, I would say that this FAQ issue was the single most --
MS. GREENBERG: I wouldn't drop the FAQ thing at all --
MS. KAMINSKY: Particularly that Kepa and John talked about back then.
MS. GREENBERG: I'm just wondering if we want to say or it could be dropped altogether. Because I think it's a useful --
MS. KAMINSKY: You mean or it should be dropped altogether is a little bit like kind of too strong a statement.
MR. ROTHSTEIN: It is a strong statement and I think that's what we heard. And there is some other place and I couldn't find it where I think we said, it may have been taken out, that if OCR does web conferences and tele-conferences --
MS. GREENBERG: People didn't like that sentence, that's why we took it out.
MR. ROTHSTEIN: Well, mention it. It's only for oral use. They won't need the FAQ's, if you have these teams, the teams are going to find out what questions people have and they'll feed that back.
MS. GREENBERG: But you're still going to put them up maybe on the web-site as FAQ's.
MR. ROTHSTEIN: Absolutely you're going to put the answers to the questions, but you won't need to solicit them via the web and get questions that you're not going to answer.
MS. GREENBERG: That's true. What you're saying is the question submission feature.
MR. ROTHSTEIN: Correct.
MS. GREENBERG: Oh, alright, you're not saying consider just dropping the FAQ's, alright, I've got it now.
I agree.
MS. KAMINSKY: Moving right along, so are people ok with putting those guidance on privacy rules relationship to other laws stacked together? It seemed to make sense.
We did delete the paragraph 11 from the old letter which was the business about AdminSimp saving 10 percent of costs, that was one of the things that went yesterday. Training, now here's something. Somehow in these various drafts, that first bullet got completely dropped and I can't remember when that decision was made and it might have been an accident.
MS. GREENBERG: Blame it on Bill Gates.
MS. KAMINSKY: Thank you. But this was a key recommendation I thought that we wanted to have the minimum training standards idea, this is definitely one of John's favorites and also, in fact John made a comment yesterday about tailoring --
DR. COHN: Can I ask a question, isn't that John's business to do training on all this? Isn't there some sort of a point where maybe he, is this self-serving or? I put it that way but I'm --
MS. GREENBERG: It won't affect him any differently than all the other people who do training and do it through John's company. Generally there's something about the ones it doesn't affect any different than as other similarly situated people.
MR. ROTHSTEIN: Excuse me, Dan did you want to comment?
PARTICIPANT: I don't disagree with what you're trying to write here but to put this in would require a little change. It would have to be added to your implementation specifics in the regulation. And you've got a very good example of similar requirements in the Medicare compliance rules, which define how much training needs to be done at a facility. So if that's what you're attempting to do here, then you want to make a recommendation that the next time the rule is modified, put that requirement in. I don't think it helps you with your immediate --
MR. ROTHSTEIN: Ok, I don't think that's what we want to do, I think we want to provide guidance on training --
MS. GREENBERG: Exactly. Provide guidance on minimum standards. Should provide guidance, that's a good point.
MS. KAMINSKY: Well this was always a back and forth whether this belongs here or in the guidance section, because we have a piece on training in the guidance section. So it could go --
DR. COHN: Why don't we stick it there?
MS. KAMINSKY: Keep the other here for training for regional staff and sponsors train the trainers, but move this business about what we're specifically asking for in guidance on training back to the guidance section.
MR. ROTHSTEIN: Ok, so the second two bullets would sty and the first bullet would go to the guidance section.
MS. KAMINSKY: And then compliance assistance, this has three I think segments, four actually, the only one that's new is the second bullet that was, whose point was that yesterday?
PARTICIPANT: That's sort of one of the defensive practices I thought, correct?
MS. KAMINSKY: I don't think so. Well, maybe. I thought defensive practices was not sharing information, not completely retreating from being a covered entity altogether.
PARTICIPANT: I thought some of the discussion came up in that regard also.
MR. ROTHSTEIN: It's a kind of strategy.
MS. KAMINSKY: I think that the commonality was that we were talking about things for the cover letter that should be inserted into the recommendations. I'm not disagreeing --
PARTICIPANT: Not that complex, I'm making to me, the three defensive practices in that I argue you could put the two together though and it would be just as easy to --
MS. KAMINSKY: I don't think that's how it came up but I think --
MR. ROTHSTEIN: Move that second bullet into the defensive practices, as sort of the ultimate defensive practice.
MS. GREENBERG: I think it kind of dilutes the fact that you are, then it mixes it up with people not sharing information that can be shared, and then it dilutes that point I think.
MR. ROTHSTEIN: I think what we're worried about in the defensive practices is defensive practices that have adverse consequences, to public health, to research, etc., etc,. etc. This is a kind of a defensive practice but the results are different and we don't, it's different. I don't know that the answer, that's going to resolve it.
MS. GREENBERG: I think this is an area where OCR and CMS need to work together to, because this is absolutely the linkage thing. CMS is trying to get people to do everything in a standard way electronically and OCR is trying to implement privacy and if one is counteracting the other than --
MR. ROTHSTEIN: But we need to go back to the reasons why the people who said they're going back to paper are going back to paper. And the reason is they have no guidance, nobody is answering their questions, they have no model forms, it's too expensive, all these other things.
MS. KAMINSKY: Now that was not the full extent of it and as Simon pointed out in the full Committee meeting yesterday, because that came up, a big piece of that particular testifier that we're sort of basing this on was problems with the black hole, not being able to do the electronic standard, the transmissions electronically because I guess there was sort of vacation issues, didn't Simon raise this yesterday? Don't you remember Richard?
It went beyond privacy.
MR. ROTHSTEIN: But it was also, remember, we didn't only hear this in Baltimore. We heard it in Boston as well, the social workers testified that they are staying in paper and not going to electronic because they didn't want to be covered entities, etc., etc., etc. So it's clearly part of it --
MS. KAMINSKY: I agree with you. I agree with Marjorie though that it is broader than an OCR issue, the covered entity issues are definitely --
MS. GREENBERG: Well you know it could go under this covered entity thing I suppose. I think you want to add, OCR should, or OCR and CMS or the Department should take steps to address the practice, because it really, OCR isn't supposed to be monitoring who's doing paper or electronic, should take steps to address the practice of some providers to abandon electronic transactions in favor of paper transactions to avoid being a covered entity. Isn't that what we're talking about? So add that phrase and it should be the Department, and then, it could still be here but I think it really is the Department because OCR has it's hands full dealing with those who are covered entities.
MS. KAMINSKY: Exactly.
MR. ROTHSTEIN: So we would just add, I just want to make sure we have the language right. We're going to move it to the covered entity section. Have at the end of the first sentence, in favor of paper transactions to avoid being covered entities, and what about just dropping the second sentence and let them figure out how to do that?
MS. GREENBERG: I agree. Didn't they ask that we find a different example or get rid of this example about placing charts face down in racks, Clem McDonald was afraid he was going to be inoculating the wrong patient.
MS. KAMINSKY: I'm sorry, I didn't delete that.
MR. ROTHSTEIN: Theoretically, actually look at the chart before you --
MS. KAMINSKY: Ok, I did make that change to the third bullet which will now become the second bullet in the section. In the third sentence instead of although it would be possible to have OCR certify members, I said it is difficult in a practical way to have OCR certify vendors and consultants.
MR. ROTHSTEIN: That's fine. I just want to go back up to the rack. Bullet number one, do we want to come up with a different example or was that just Clem's idiosyncratic view?
MS. KAMINSKY: I don't think that's idiosyncratic, I think it's debatable, sort of under minimum necessary and incidental disclosures, etc. whether that particular practice is --
MR. ROTHSTEIN: Alright, well, let's just take that whole such as out. Publishing lists of no cost and low cost measures should promote at least some, how's that?
MS. GREENBERG: Yes, let them think about.
MR. ROTHSTEIN: Ok, anything else on eight?
MS. KAMINSKY: For outreach, I didn't know if this is the right heading but I said leverage technology and I put together the conference call and the web-based seminar suggestion together. And then again we have one of these sort of weird non-parallel situations, because the next one doesn't have any bullets under it. State-wide coalition building didn't seem to clump very well with anything for outreach.
MR. ROTHSTEIN: Well we could put the second, we could make the first sentence a bullet and make the second sentence a text, the second and third sentences the text.
MS. GREENBERG: After state-wide coalition --
` MR. ROTHSTEIN: After state-wide coalition building the next sentence could be a bullet and then take that out separately and have just the sentence OCR coordination as the text.
MS. KAMINSKY: So just move the first sentence down as a bullet underneath the topic is what you're saying.
MR. ROTHSTEIN: Correct. Is that alright?
MS. KAMINSKY: And then targeted mailing, I kind of was thinking that this could mean paper or electronic, but we have the monthly newsletter suggestion and the contacting individuals filing extension suggestion. And then toll-free hotline didn't seem to have, again it didn't clump very well.
MR. ROTHSTEIN: How about targeting communications?
MS. KAMINSKY: Ok, but then would you say toll-free hotline is a targeted communication?
MR. ROTHSTEIN: Sure, it's just in reverse.
MR. HOUSTON: Then you could argue that you could take leverage technology and make conference calls, regular conference calls as well web-based seminars to be targeted communications.
MR. ROTHSTEIN: That's true.
MR. HOUSTON: And you'd throw all of those under one bullet.
MS. KAMINSKY: I don't see conference calls or web-based seminars as targeted, nor do I see the toll-free hotline as targeted, but again, that's your call. Well the whole thing is outreach, every single one of the bullets, it doesn't even have to be segmented. But this was the very section that people said it cried out for bullets, quote, unquote, of the Committee members yesterday.
MS. GREENBERG: I wouldn't want to have the state-wide coalition building though just be a bullet. I think it's too, we mentioned it in the letter, I think it's --
MS. GREENBERG: No, I think we need that separate for sure.
MS. KAMINSKY: We could put that separate and everything else together as I don't know what.
MS. GREENBERG: I think you could.
MR. ROTHSTEIN: So you want to combine nine and 11, keeping ten together.
MS. KAMINSKY: Nine, 11 and 12 it sounds like.
MS. GREENBERG: Probably 12, too.
MR. ROTHSTEIN: And 12, yes, I'm sorry. Keep nine, 11 and 12 --
MS. GREENBERG: Those could all be bullets and then keep ten by itself.
MR. ROTHSTEIN: Ok, the title for that is what?
DR. COHN: Improved outreach.
MR. ROTHSTEIN: Strategies.
MS. KAMINSKY: Communication vehicles. Okey dokey, moving right along if we're ok with that. The consumer section, I added to the concept of a one-page handout a sentence which I'm not keen on, but such a handout should be appropriate to low literacy levels, I'm not sure that's how you phrase that, and should be translated into other commonly spoken languages based on Vicky's and others comments.
MR. ROTHSTEIN: Appropriate reading levels?
MS. GREENBERG: Yes, it should be at appropriate reading levels.
MR. ROTHSTEIN: Or at the appropriate reading level.
MS. KAMINSKY: Ok. Then the next one we had a kind of question raised again by our Subcommittee member actually, about what we were suggesting should go into this Medicare mailing.
DR. HARDING: It's a privacy notice in simplified form now, is that what we think should be?
MR. ROTHSTEIN: Right. Do you remember Kepa in Baltimore kept coming back to that?
MS. KAMINSKY: Yes, but I guess the question is they already get this notice in their Medicare and You handbook, and I know that the idea was to kind of take advantage of this mailing that's going out already, although I also know that there are probably some cost constraints on that mailing. But nonetheless, if in fact budget were not an issue and the weight of the mailing were not an issue, what is it that we're suggesting should also be stuffed in there?
MR. ROTHSTEIN: Ok, the reason we want to do that is because what Medicare puts, or what CMS puts in the guide is the notice that they're required as a covered entity. What we want to do is take the opportunity to provide more general patient education so that when they go to their provider and get their notice, etc., it's not totally out of the blue. And so I think that was the thinking.
MS. GREENBERG: So should it be this one-page handout that we want them to include?
DR. SIMON: Probably it's actually a final sentence after that one-page handout is that that one-page handout could be sent to a wide variety of Medicare and Medicaid members, or whatever. I think unfortunately we're beginning to reflect on the futility of this news in the information practices. We're all aware even though everybody is spending zillions of dollars writing and sending out to all patients, that we know that nobody is going to read it or if they do they aren't going to understand it. Isn't that what we're really talking about?
MR. ROTHSTEIN: Right.
MS. GREENBERG: But it's alerting them and Medicare patients are particularly likely to have a lot of different providers and this is kind of like an overview.
MR. ROTHSTEIN: Exactly. It's not a formal notice, just something like a new law has recently gone into effect and when you see your health care provider you may be provided with blah, blah, blah, blah, this is what's it's all about.
MS. HORLICK: I think it wasn't clear during the discussion yesterday whether we were actually talking about the notice or a separate, because I had some note on that, is this the note, I forget where it is now.
MS. GREENBERG: Someone said well gee, if you did this then maybe we wouldn't have to do our notices, and said no, there's no way you can make that one page.
MS. HORLICK: Right, so I think that we didn't make that clear in the way we've written it. I have written down what's different than what's already happening because people were thinking that was the notice.
DR. COHN: This question with the Medicaid is are we, really what we're talking about is we're also encouraging state Medicaid directors to send this out to Medicaid recipients? Is that what we're talking about as opposed to a CMS mailing to state Medicaid directors advising them of the privacy rule obligations? Which I can imagine as a state Medicaid Director I would love to get one of these in this from CMS, and then just sort of, is that what we're talking about? Or are we talking about something else?
MR. ROTHSTEIN: I'm not sure.
MS. KAMINSKY: I'm not sure, I mean the distinction being that there should be a one-page handout going to Medicaid beneficiaries versus some kind of technical advice to state Medicaid directors? Is that what your question is?
DR. SIMON: Obviously we started talking about the state Medicaid director thing yesterday and we were sort of wondering what it is exactly we're advising them --
MR. ROTHSTEIN: No, no, no, I think Simon you're reading it wrong. OCR should pursue with CMS and I think this is what we need to, is to say, OCR should pursue with CMS and state Medicaid directors a method for similarly informing Medicaid beneficiaries.
DR. SIMON: Mark, you're making it up as we go along, so whatever you think is making sense.
MR. ROTHSTEIN: Well, that's what I'm making up. What do you think of what I just made up?
DR. SIMON: I think that sounds fine.
MS. GREENBERG: Are we talking about the same one-page, come up with some kind of simplified thing to let consumers know and then this same thing should be provided to the Medicare beneficiaries and also work with state Medicaid directors to provide it to their beneficiaries?
MR. ROTHSTEIN: It's the written version of the 30-second explanation you would give to your mother about what the HIPAA privacy rule is all about.
DR. SIMON: And I guess Mark reflecting on that one, I think we need to simplify this area because I think the big news is number one that we're, when you think a one-page thing needs to be developed, and number one it needs to be widely distributed. That's somehow what we're really saying here.
MR. ROTHSTEIN: Correct. What about the specific bullets then which we make suggestions about how that might be done? Are you suggesting that we take that out?
DR. SIMON: One suggestion would be to include it in the distribution to the state Medicare or Medicaid directors should also be encouraged to submit it to others, I think that's what we're sort of talking about there.
MR. ROTHSTEIN: Ok, we can do that. Stephanie are you?
MS. KAMINSKY: Yes, that's great. So I don't think there were any changes to the consumer education approach section. I mean little things, the only thing was, again, the same person came up to me after, somebody from the public mentioned that there was an emphasis on physicians in that first bullet and asked that I change it to clinicians in certain cases, just some tiny things.
MR. ROTHSTEIN: In which one?
MS. KAMINSKY: The first bullet under consumer education.
MR. ROTHSTEIN: How about providers? We've always used that as --
MS. KAMINSKY: That's fine.
DR. COHN: Can I ask a question about the second bullet in 14 which I looked at yesterday? I remember the discussion we had in Baltimore and I'm still sort of scratching my head about. I think there's no question that special efforts need to be focused on the most difficult to reach people and I mean certainly homeless are going to be hard to find, substance abusers I doubt are going to be reading their mail on a regular basis, though as I say that that's a very, that's really not true, but certainly they would be, I guess, the way I read this is it seems to me sort off track from the rest of the discussion in the sense that we're talking about, everybody needs to be informed and then this seems to say well no, we need to be primarily focusing on this group, these groups, all of which are going to be, chronically ill are obviously not going to be difficult to get to, but I guess the question is is what are we saying there? Are we saying that there needs to be some focus --
MS. GREENBERG: Want to say special efforts should be addressed to those most vulnerable to discrimination and hardest to reach rather than beginning with? Just say, I agree with you.
MR. ROTHSTEIN: But we also want to include the notion that education efforts need to be segmented, even among the people who are relatively easier to reach, that was the message that these experts gave us.
MS. GREENBERG: Ok, we could just say OCR's consumer education efforts need to be segmented to different populations or something and then special efforts should --
MR. ROTHSTEIN: Yes.
DR. SIMON: Ok, great.
MS. KAMINSKY: And I added in low income persons into our example list as was requested.
MR. HOUSTON: Can I ask a question regarding, you say to begin with those most vulnerable to discrimination or hardest to reach, chronically ill, mentally ill, substance abusers, homeless, low income persons. Are chronically ill individuals hardest to reach? Or are those people that typically have more interactions with the health care industry and therefore would have more of an interest in some of these issues.
MS. KAMINSKY: Well, they are most vulnerable to discrimination.
MR. ROTHSTEIN: I think that's a group whose confidentially we want to be --
MR. HOUSTON: So it's or hardest to reach.
MR. ROTHSTEIN: Yes, good point.
MR. HOUSTON: And also maybe you want to put in there also elderly.
MS. KAMINSKY: Elderly?
DR. COHN: Well, that and chronically ill, it's not quite the same, but --
MR. HOUSTON: But I think elderly are a huge populations that are probably going to be very difficult to reach as well as understand their rights and likely to be discriminated against.
DR. COHN: Well, do you want to replace that Medicare piece above or is that different?
MR. ROTHSTEIN: We're in good shape on this I think. And then it's still our thought that we're going to have 15 as the evaluation correct? And now on to --
MS. KAMINSKY: The only thing is that you see in 17 I have in bold brackets something about just technically, technical change there because it's not just OCR that would be making any change on enforcement. Then under guidance, Roman IV, there was a question about that last sentence that in a way this was redundant I guess with the one-pager, or that we were just sort of asking for the same thing in a 100 different ways, or that this should be an outreach issue, not a guidance, but because it is originally worded to be for both employees and consumers, I'm not sure why we chose that now, it just didn't really seem to fit into the technical assistance category or the consumer category, I didn't know where to put it, I didn't know what to do.
DR. COHN: You mean the summary of the privacy rule? Why are we doing that if we're doing a one-pager? How many different things do we need?
MR. ROTHSTEIN: So we should just delete it? And in what is currently 20 the specific guidance topics, were there any changes that were?
MS. KAMINSKY: The only thing is we're going to make that training piece a little different from our earlier conversation.
MR. ROTHSTEIN: Ok, so that would be J.
MS. GREENBERG: That's for the guidance on the minimum standards.
MS. KAMINSKY: And a request was made to make Roman Numeral VI a different title, instead of Congressional measures, resources need to implement the privacy rule, I can't recall why right now.
DR. COHN: There's two Roman number VI's by the way. I think the issue, which personally I didn't bring up, but I think is more of a generic issue to relate to resources rather than just things that Congress may want to do.
MS. GREENBERG: Except the whole thing is resources needed to implement the privacy rule.
PARTICIPANT: Can I just comment on number 24? Why does it have to be, why couldn't you just not add, or put a period after or HIPAA compliance instead of singling out as an example rural providers? The subject of this is small providers, it's a great idea, but just leave it at HIPAA compliance instead of saying at least for a subset, suggest that somebody could discriminate and say well, you're not exactly the type of small provider we have in mind. Physicians don't have any ability to get money out of the federal government to help pay for HIPAA, there is nothing in the sustainable growth rate calculation that would help them get a payment out of Medicare or Medicaid or anybody else that's going to help pay for it.
MR. ROTHSTEIN: Well, I think it's a good point. The reasoning as I remember was because this was such a sort of audacious proposal that we wanted to have a back-up plan but if, I think that was the reasoning, that we didn't want to recommend something that would be DOA.
PARTICIPANT: Well, tax credits is certainly something the Administration favors and supports and if you leave it at that, rather than trying to carve it out only for small, for the rural provider, you've already said small earlier, don't make it so that it's only going to be interpreted as it's only available for rural providers.
MR. ROTHSTEIN: Ok, so your recommendation is just to delete the parenthetical, I have no problem with that.
MR. HOUSTON: Can I make a, Simon and I were sort of talking on the side and I think it's actually relevant. I don't think it's just even small providers, we've talked about a group of fragile providers previously and the argument I guess I would have is that those fragile providers are actually the list of people that you want to assist through potential tax credits.
MS. GREENBERG: They would be small providers.
MR. HOUSTON: Not necessarily. I was watching on the news this morning, what's the DC Hospital that has massive layoffs going on because it can't meet, it's not a small provider but yet it's going through the throes of serious financial trouble, so I would argue that you have large inter-city or large hospitals that are equally --
MR. ROTHSTEIN: I'm persuaded that we will have performed a service by raising the issue and maybe the best thing would be to put a period after the word compliance.
MS. GREENBERG: Well you could say though for small and fragile providers. Why couldn't you add that?
DR. COHN: Well, how about fragile? I think fragile is probably a much better descriptor because if you're a small provider --
MR. ROTHSTEIN: If we do that then people will want to go back to our discussion of fragile providers and take up the issue of who is in there and who we left out.
MS. GREENBERG: I'd keep small.
MR. HOUSTON: I just don't think that small necessarily completely encompasses the people that need assistance.
MS. GREENBERG: I'd say small and fragile, I wouldn't just say fragile.
MR. ROTHSTEIN: Small, fragile, over burdened, under funded --
PARTICIPANT: I think you could argue that a large bulky specialty practice that has a computerized patient record system might have more cost associated with complying with privacy than a single physician practice that's paper, you turn the paper down, they lock up their files, that's about it. But if you have to add new software to the computer system, things like that, that's going to be more expensive. So I think you could argue that a large practice might have more costs than a small practice.
MS. GREENBERG: They might, but they might have more resources, too.
DR. HARDING: I think I like your period, compliance period.
MR. ROTHSTEIN: This sounds like a great debate for, relieve financial burden of compliance.
MS. KAMINSKY: We'll get rid of small, the question is are we just talking providers or are we talking about all covered entities? How expansive are we?
DR. COHN: I think we've heard that health plans are having a big problem.
MS. KAMINSKY: So how about relieve financial burden for providers?
DR. SIMON: I think one of the things that if you looked at the cost benefit on all of this stuff, you saw that the costs were associated with providers, benefits accrued a lot to the insurance entities and federal government, so there is actually a case here about why it should be providers as opposed to financial benefits for everyone in the world. And that goes back to the cost benefits in the rules.
MS. HORLICK: So you would omit small altogether and just say providers, and let them figure out --
MR. ROTHSTEIN: We we're just going to take out small and put a period after compliance. And I think that's a very interesting proposal and we'll let the details be worked out in the normal method.
MS. KAMINSKY: Two more points here. One is that the $42.5 million under ASCA, I learned yesterday, and I think this is correct, was really just for AdminSimp not for privacy so I added and further some of the funding should be allocated to privacy rule implementation. I don't know if that's possible if it wasn't really authorized for such by Congress under ASCA but it just seemed like if we were going raise it then we should focus it.
MS. GREENBERG: I hate to go back there but I'd be more comfortable now since we've taken small out of providers if it would say the Secretary should consider recommending. Is the Committee really prepared to say the Secretary should recommend that Congress provide tax credits to all providers for HIPAA compliance?
MR. ROTHSTEIN: And recommending that they recommend it and then they'll consider whether they want to follow our recommendations.
DR. HARDING: I see, you just don't want to tell them, tell the Secretary what to do, so they should consider --
MR. ROTHSTEIN: How do we have the others worded?
DR. COHN: Well we started out saying it should consider --
MS. HORLICK: And right above it though we say should recommend the compliance --
DR. HARDING: We're an advisory body so everything we send is --
MS. KAMINSKY: So it that you're just not comfortable now that it's gone wider than just small providers and fragile providers, suddenly it's a different kind of rec that the quality of recommendation has shifted significantly or somewhat to you?
MS. GREENBERG: You have letters emphasizing how the bigger groups are doing pretty well but the small providers are the ones that are really having the problem, and the fragile providers may have to drop patients, and then suddenly we've got tax credits for everybody.
MR. ROTHSTEIN: It's the American way. I think you make a good point but I don't know that we want to make that cut here because it's going to be so --
MR. HOUSTON: Why don't we say relieve financial burden for certain providers who are somehow characterized that there's still some discretion but that there's a group of providers that need to be defined who need assistance?
MR. ROTHSTEIN: Providers unable to comply with?
DR. COHN: Well this actually relates to on page three this issue about providers abandoning electronic transactions, which actually I think that whole paragraph needs to be removed anyway if you want to go back there. Maybe this is the piece that helps encourage people to implement.
MR. HOUSTON: Right, incentivizing compliance. The tax credit is incentivizing compliance.
MR. ROTHSTEIN: Financial incentives for compliance.
MR. HOUSTON: I don't know if it's an incentive, there's two different issues. The incentive is one thing, they might be incapable I think is the point. Why don't we say this, if you change the sentence, this recommendation to say, the Secretary should recommend, or consider recommending that Congress provide tax credits or other mechanisms for HIPAA compliance, at least for a subset of providers that are financially unable to comply. Let them define it, but at least it says if you're big, fat and happy, we're not going to give you incentives. But we don't have to define who that subset is here because I think that's probably, that might be a big part of what needs to be determined by, for at least a subset of providers that are financially unable to comply.
MS. GREENBERG: With the fewest resources to comply or something. Something at least that doesn't just make it everybody. Because it's not consistent with the rest of the letter.
MR. HOUSTON: And it's not just small providers.
MR. ROTHSTEIN: What about this last paragraph? Had we reached agreement that we were going to, we've already incorporated part of that into the letter.
MS. HORLICK: The first two sentences?
MR. ROTHSTEIN: Correct. But the full paragraph we were also going to repeat someplace --
MS. GREENBERG: Right at the beginning of the recommendations.
MR. ROTHSTEIN: Ok, so that's acceptable before Roman I?
MS. KAMINSKY: But with the same verbiage?
MR. ROTHSTEIN: No, we'll revise it. So a couple comments, I'll recognize Simon.
DR. COHN: I actually think it's overall a good letter. I will apologize because I was out of the room on the piece under compliance assistance, the second bullet, which I think got modified, the recommendations with compliance assistance. I actually think and reflect on this one, I think the whole bullet ought to be struck. I think it's a fascinating, providers abandoning electronic transactions, and I would just that this is a little bit off the point. The reality is is that in our testimony, unless we were hearing a lot of the Salt Lake City, what we heard was anecdotally from one provider and the big issue here was the fact that vendors would not certify that their systems were going to be HIPAA compliant.
MR. ROTHSTEIN: We also heard in Boston and in written testimony about this issue and there have been a number of press reports of this. I'm willing to take it out of the recommendation because we mentioned it in the letter but in the letter we didn't say there's a groundswell, in the one paragraph where we mentioned it we recounted a series of singular comments and like one comment that we also included was I can't do this let them catch me. I mean that's not everybody's view, this is one person testifying.
MS. KAMINSKY: This was inserted, this was not here yesterday, this was inserted in response to --
DR. COHN: No, that's not true, it was here yesterday. The second bullet in compliance assistance.
MR. ROTHSTEIN: No, that's new.
MS. GREENBERG: I think it is new.
MS. KAMINSKY: That was from the discussion yesterday. Remember I said I have trouble with that suggestion because the statute gives latitude for providers to maintain paper transactions if they want, it was always written so that it was not forcing providers to come into compliance among, the concept was that the industry was going to sort of adopt at its own pace I thought. I was a little uncomfortable yesterday when it was raised because I wasn't sure --
MR. ROTHSTEIN: I'll be more than happy to take it out because it wasn't in the original letter, it just came up yesterday.
DR. COHN: Really, ok, I thought I saw something that looked in the letter yesterday that we saw.
MR. ROTHSTEIN: It's still in the letter.
DR. COHN: Oh, now it made it in here. I'm sorry, I guess I've seen too many versions of this.
MR. ROTHSTEIN: It was always in the letter but now it's been added to the attachments.
MS. KAMINSKY: You don't like it in the letter either?
DR. COHN: Actually I apologize, nine pages you sort of keep reading and reading. Let's talk about this one and then we'll talk about this piece in the letter. I guess to my view this is something that could be said nicely verbally but certainly in the recommendations, the recommendation is so milk toast as to be somewhat absurd.
MR. ROTHSTEIN: I'm persuaded.
DR. COHN: Now let's take a look in the letter and see where it's in the letter.
MR. ROTHSTEIN: Alright on page two, it’s in the last full paragraph.
MS. GREENBERG: Last sentence, one witness.
DR. COHN: Ok, one witness in oncology said defer the expense of HIPAA.
MS. GREENBERG: It kind of gets to it.
DR. COHN: I think that's probably ok the way it's described there.
MR. HOUSTON: Under eight, the second bullet that we're talking about it could be when you look at number five is frankly is just simply a specific FAQ that should be added, so it really is a specific point that could be added as an FAQ which means we really don't need to make it as a recommendation.
MS. KAMINSKY: Well that was also yesterday when I said what are you suggesting here? And that was the solution.
MR. ROTHSTEIN: Ok, I don't want to hold up the meeting. Did you want to say something?
PARTICIPANT: On your commendation 22 after Roman Number IV, you ask if $42.5 may never see the light of day in discussions. I mean given your discussion about resources early on this section, you may want to add a sentence encouraging the OCR and the Secretary to identify amounts for the 2004 budget because that may be our next budget discussion if we never get past, we don't have a 2003 budget this year, we've got a Continuing Resolution. I think what you want to do is make sure that the Secretary and OCR are working on budget monies to accomplish all these things that we want them to do, going through the five months we have left as well as in the future, so you may just want to add a sentence to make sure that this is a recognized budget item.
MR. ROTHSTEIN: Additional resources should, as needed, should be included in future budget proposals?
DR. HARDING: [Comment off microphone.]
MS. KAMINSKY: They're in the middle of working on it now, I know that.
PARTICIPANT: It's being reviewed by the Office of Management and Budget and will be presented to the Congress in early January for a budget hearing, or an Appropriations hearing to go on for the 2004 period. You're talking about a lot of money that's going to have to spent by the Office of Civil Rights and the question is how well funded is the government going to be to take on all these initiatives? I think they're worthwhile recommendations that are being suggested.
MR. HOUSTON: And there is an immediacy issue to ensure that that recommendation is acted upon if possible to amend the budget, so you want to make that a very strong recommendation.
MR. ROTHSTEIN: Are there other matters? I want to thank all of you for your suggestions, and I especially want to thank Stephanie for transforming this useful document into a great document.
[Whereupon, at 11:00 a.m., the meeting was adjourned.]