Hubert H. Humphrey Building
Room 405A
200 Independence Avenue, S.W.
Washington, D.C.
MS. COLTIN: -- comfortable with it. I left it very broad and I think, you know, myself in reading it over, I think the only comment that I had that kind of struck me was, perhaps, to change "American" to "U.S." But let's see what other people say about that.
DR. MOR: U.S. I was conscious of that this morning with the Canadians and --
MS. COLTIN: So, I can easily make that change.
I will give you a moment, if you have any other suggestions.
DR. MOR: This is substantially broader than my career, which has been highly idiosyncratic.
MS. COLTIN: You know, I debated doing it, but I thought to myself, well, that to me is the difference between a charge and a work plan. The work plan is what we are intending to accomplish in a relatively short period of time, you know, one to two years; whereas, the charge kind of covers activities that we may get into over a much longer period of time.
DR. NEWACHECK: This also suggests that we will not actually implement them or --
MS. COLTIN: We are not committed to solutions.
Is there anything in there that people -- anything missing that you would like to see in there, in the charge? I know it is pretty broad.
DR. MOR: The Work Group on Quality is not just a creature of the Subcommittee on Populations. Is that correct?
DR. IEZZONI: John Lumpkin is -- I don't know whether with his new responsibilities, he is going to want to continue to be the work group.
DR. MOR: The only question is whether there should be at least one clause about vulnerable populations.
DR. IEZZONI: Or in the work plan --
DR. MOR: -- oh, yes, fine.
DR. IEZZONI: It is synergistic with like the full subcommittee as being, you know, like 1 and 2, I think. Obviously, very derivative, but directly related to what the full subcommittee is doing.
It says "Subcommittee on Populations" at the top of the page.
DR. MOR: I know. I wasn't -- it was not my impression that the work group was a creature exclusively of the Population Subcommittee.
[Multiple discussions.]
MS. COLTIN: All right. Now, the work plan itself really just covers the four items that we had talked about at our last meeting, just putting them into some coherent language, I hope. I don't know if people feel a need to review specific wording or if you are just comfortable that we had agreed to what these were and -- anybody see anything that throws a red flag up or can we go with this pretty much the way it is?
DR. MOR: Four seems somewhat bigger, but then my memory is not always the best.
MS. COLTIN: Four is bigger than -- this is a work plan that goes through 2001. I go off the Committee in 2001. So, that is as far as I was willing --
DR. IEZZONI: Can't you be reappointed, Kathy?
MS. COLTIN: No, I have already been reappointed.
So, you know, in my role as chairing this and thinking about the work plan, I took that as my sort of end point, which would be June 30 of 2001. However, that is not, you know, to say that these are all things we will get done in one year. This really is a multi-year work plan.
I don't know that we need to take a vote. We are okay. Thank you, all. I will just change "American" to "United States" and we will be all set.
So, let's move to the second agenda item, then, which is to discuss a proposal for the post acute care work plan. Lisa and I had a telephone conversation about this, which I am going to let her tell you about. But just to say that our goal in this was to try to make the work of this work group and the full subcommittee as synergistic and as interwoven as we could.
DR. IEZZONI: Okay. Kathy and I did talk last Friday. It wasn't a phone call that needed to be recorded in the Federal Register. It was just a working phone call, just the two of us. It was all perfectly above board.
We basically were trying to think through what should be our proposals for the work plan for the full subcommittee and for the work group. I will talk about what I thought of for the full subcommittee and then Kathy will talk about what you thought about for the work group. Okay?
But let me just say how I kind of viewed my proposal. Frankly, I am a little tired. I feel like the full subcommittee has been doing a lot. It is doing the Medicaid managed care report. It is doing the insular islands report and we also haven't been as good as we need to be about tracking some of the ongoing issues.
We used to at our breakout sessions have at least one group, a panel, reporting on something that we would just like to keep track of, like the OMB Directive 15 revisions or the disability reevaluation for SSA. We are going to, hopefully, have David Takeuchi's immigrant children talked about at the June meeting.
So, I thought for the full subcommittee let's bite off a very nicely narrow defined piece that we could do relating to this continuum of care notion. And I am transitioning to calling it continuum of care. And have that be what the subcommittee is going to do and then have Kathy reach for the moon a little bit more, okay, in her ideas.
So, this was my straw person proposal for you all to shoot down or help me think about. One of the things that goes way back to the original core data elements was that there has been a place holder for functional status and the one piece of information that we do not get consistently from every single setting of care, going all the way from the hospitals to the outpatient, doctor's office, we do get it in spades in certain areas, but is functional status and that that is the one piece that could tie things altogether if you want to track people longitudinally throughout the health care system to see how they are doing, not to see what their diagnoses are, but to see how they are doing, you know, in their daily life.
I thought that maybe what our subcommittee should do is look at how that place holder for measuring, capturing, quantifying, classifying functional status should be done. I mean, there are all these different proposals ranging from ICIDH to an SF-36 type of thing. I thought that it was particularly pertinent because we need to think about issues for children and we need to think about functional status as a multidimensional concept, looking not just as physical functioning, but sensory, cognitive functioning as well as kind of the more physical dimension of functioning.
I thought that is a contribution that we can make that would be narrow enough that it would be -- there will be perimeters around it, but it is still pretty big, you know, coming up with a proposal about how we might think about recommending that people fill that place holder for functional status.
When I say "place holder," it can be multidimensional. So, people, tell me what you think about the idea.
DR. NEWACHECK: I have a question and a comment.
We are going to have two projects then on the continuum of care, one that will be focused on quality and one that will be focused on, perhaps, measurement or some other issue?
MS. COLTIN: I guess the way I was trying to conceptualize it is if you thought about -- I don't know if there is anything to write on that marker board around -- but if you thought about a matrix where you had all of the issues that you were interested in knowing about, whether it was clinical quality, access to care, cost of care, are on what all of your issues were as columns and then down the side, you had sources of information, administrative data, electronic medical records, surveys of patients and so forth, that what Lisa was proposing -- and talking about this all within the context of the continuum as we will agree to define it -- that what Lisa was talking about for the work of the subcommittee really is a row in that, which is the administrative data row since all of the core data elements come from administrative data at this point, of one sort or another, not necessarily billing data, but administrative data of one sort or another.
Whereas, as what I saw the work group doing would be to take a column that had to do with some aspect of quality -- and we can decide how broad we want to be. Do we want to include access or do we want to focus -- which gets you into the survey piece more because it is population based, or do you want to start with something like clinical quality, which is at least looking at data sources for people who are using the system?
Do you want to also move on to things like acceptability, which is also a survey issue? So, what I was proposing is that in the first year, we think about taking the clinical quality column. There would be an intersection with administrative data, which the subcommittee is looking at, but it would also get us into looking at the electronic medical record and where it could and should enhance our ability to look at clinical quality and it would get us into surveys around what patients can tell us about clinical quality.
And that in the second year, we would think about taking on perhaps some of the other columns in that matrix, looking at access issues, looking at some of the perhaps acceptability issues or satisfaction, whatever people want to, you know, use to call it, which will take you much more into an analysis of the surveys.
DR. NEWACHECK: Functional status data isn't going to come from -- currently come from administrative records, though, are they?
DR. MOR: It depends on what you mean by administrative records.
DR. NEWACHECK: Well, but you are differentiating, say, surveys from administrative records when you were --
MS. COLTIN: No. Well, what I was saying is that the work group would take the column of clinical quality, which cuts across all the data sources. So, functional status may come from patient reports and patient surveys. It may come from administrative data. It may come from medical records. It may come from some combination of those. And one of the things we would need to talk to talk about is where is the best place to get that information, where should it come from, how does it fit in.
DR. NEWACHECK: I think this would be very important; that is, the notion of doing something on functional status would be very valuable to do.
DR. IEZZONI: There is no agreement on -- well, something about ICIDH(?), I mean, the CDC -- Gail, you are here -- the CDC people -- Dan Lawlor has been agitating for requiring physicians to report the ICIDH codes, you know, and we have heard distinct disinterest in the field whenever we have had presentations about ICIDH.
I just think that we need to air this issue because I think function is the one piece of information about people's health that we have no clue about.
David.
DR. TAKEUCHI: I am not part of the work group but I just wanted to support your ideas in exploring the issue of trying -- at least in the mental health field, that is the direction that it is going. There is a lot of dissatisfaction with using dichotomous variables of, you know, psychiatric disorder and I think people will lean more towards trying to measure getting better measures.
DR. MOR: Let me just respond. I am a hundred present focusing on this. After our last hearings in January, I walked away sort of thinking to myself it was very intriguing. It was very interesting, but why is our subcommittee doing this. What are we going to say at the end of this? I thought, well, there are really two things we can say.
One, we had this place holder from this core data set and we are ready to make some kind of recommendation to fill it. Okay? Secondly, HCFA, with regard to the whole continuums of care is that they have an opportunity to use whatever we are suggesting is something that is core across a variety of different settings and they are not taking
that --
DR. IEZZONI: They are not doing it, right.
DR. MOR: They are taking advantage of that and they are dropping the ball. I think both of those are things that I wouldn't want to do the former to the exclusion of the latter, although I did see, again, that we wrote a letter formally to HCFA and it was in the report, the annual report, but not that it really did a hell of a lot of good because the OASIS(?) is going to go through and, more importantly, they are about to do something else for hospitals and they are going to do something else for other kinds of settings.
But they are in a position to deal with this. Is the same kind of information going across the settings?
DR. IEZZONI: Well, that is -- I just thought that our committee is a really good forum to air the issues. Again, HCFA is the, you know, 10,000 pound gorilla or whatever the metaphor is, but private plans are also beginning -- David, are you leaving?
DR. TAKEUCHI: Yes, but I vote "yes."
DR. IEZZONI: Thanks for weighing in on this. We are going to just be the two of us in a few minutes.
So, I guess since we do have about ten more minutes left for all of us to be kind of be around the table, do we have a kind of consensus about the first piece? We still have to figure out how we are going to do it, who we would include, what the initiative would look like.
DR. MOR: I would like a better understanding of
-- I mean, I go back to the core data set and --
DR. IEZZONI: We are talking about the core data set from --
DR. MOR: 1996.
DR. IEZZONI: 1996, the main one.
DR. MOR: It has got a hole there.
The same code set definitions that we used for the other things should be fillable in, perhaps, a more creative, you know, one for one, but rather -- option this or option that or option the other and recommending some issues of study, but that is what I think we should do, something very specific.
DR. IEZZONI: That is what I am hoping for because I --
MS. COLTIN: That is what the product looks like.
DR. IEZZONI: That is what the product looks like. It is filling that place holder and it can be multidimensional. We are going to have to think about that. You know, David brought up the mental health issue, but, okay. So, that is --
DR. NEWACHECK: I want to caution, at least in the area of children, this would be very difficult to do because none of the adult measures work for kids. There is controversy about what among the children's developments can work and there is really no agreement at all when you get down to about under three years old because of the difficulty in measuring. It is so subjective and difficult to tell --
[Multiple discussions.]
-- because of the development and all that, that there is sort of no --
DR. IEZZONI: Well, but we will have to just make that clear and I think those are issues we should definitely have a pediatric day, frankly, I think, because adolescence and, you know, if we are going to talk about having patients self-report rather than the provider reporting what it is, issues around adolescence and, you know, I mean, there are just so many --
DR. MOR: Cognitively impaired, the developmentally disabled. But I really would like us to think about this in the same kind of way -- the connection to ICIDH, for example, is one of the columns or one of the code dimensions, which is untranslatable or highly reliable, whatever --
DR. IEZZONI: Unfathomable.
DR. MOR: -- could actually be greatly enhanced by much more operationalized behavioral criteria. That is the linkage between a specific behavioral measure of function and this sort of much more conceptual ICIDH. I don't have a clue how ICIDH cross walks into children, except for the fact that it is sort of normed in some intuitive way. But that, I mean, I would see the strength here as having basically recommending code sets.
If the ICD-9 guys can do it and the HL7 whatever it is people can do it, I think we are ready.
DR. NEWACHECK: Do we all get copies of the core data set that we have been discussing --
DR. MOR: There is a lovely book.
DR. IEZZONI: It seems like not every member of the Committee has a copy of the core data elements report. We need to get that for everybody.
[Multiple discussions.]
I want Kathy to have time with you guys before --
MS. WARD: That is the part that I don't get yet is how that -- I mean, I understand the matrix and going down. It is still so big, I don't know how --
MS. COLTIN: Well, let me tell you what I am thinking. If we started by looking at measures of clinical quality that are relevant to these care settings and are relevant to transitions among these care settings, you would say if you are going to construct measures of clinical quality, what are the kinds of data that you need to have to be able to do that and what is the current state of the art with regard to where those data reside or don't reside at all? What are the quality of those data in the sources where they currently do reside? And what can we recommend in terms of improving the range of information that we have on which you can base quality measures and where those measures should be captured, by whom? How should they be coded?
So, let me give you an example. We are going to be seeing an NPRM on claims attachments soon. Should there be a claim attachment for laboratory results and, if so, what should it look like? Because laboratory results, I would posit, are very important data items for constructing clinical quality measures.
MS. WARD: Whether it is in a continuum of care we are looking at or --
MS. COLTIN: No matter where it is for monitoring patients' status.
MS. WARD: If people are moving out of settings, it is maybe even more important.
MS. COLTIN: So, I mean, that is the way I see approaching it, is to take a column like "Clinical Quality" and say what are the kinds of data elements and then walk through the different sources so that you are going down the rows.
And a good part of the work that we would do around clinical quality, and I am not just talking about process measures, you know, and what elements you need for that, but what elements you need for outcome measures and that is where the functional status overlap really is the greatest.
There would be a whole piece of work that would overlap with the subcommittee around the core data elements and data that would be captured in administrative systems, where we believe that is the best source for that data to be captured and then to move on to those data that perhaps can't easily be captured in administrative systems or where there isn't an existing vehicle to do that right now that you could add a data element onto or whatever and look at whether or not that is an item that could be captured directly from patients and, if so, what are the options for doing that?
DR. IEZZONI: Can I just bring up one thing?
We might have a possibility of having a contractor help us to a little extent. You know, we have to be frugal, but there is a possibility of a contractor to help us with some of this. So, I can see some immediate uses that we could make of a contractor on the piece that I have described.
Kathy, I think -- do you want to talk about it?
MS. COLTIN: Well, I thought that it would be helpful just to have someone help us identify and summarize the existing data needs for quality assessment and improvement because there have been a lot of panels and others that have looked at these sorts of things, but to take this more -- rather than a breadth focus, a depth focus on the clinical quality and saying what have people said about that.
You know, I am aware of several review articles or other types of articles on that topic in different settings, but I by no means know the full range of what has been done. I think it would be helpful to have a contractor kind of pull that information together for us so that we can more quickly and efficiently zero in on those areas that -- sort of the ground that hasn't been well trod yet because there is a lot of work that has been done in some of these areas. What we may want to do is review it and see whether we want to try to lend our weight to whatever recommendations are being made in that area or have been made in that area.
But if there is an area that really has not been well-examined, we might want to delve into that area further to know sort of where is the best place to start, it might be helpful to have a contractor do some of it for us.
DR. MOR: When you talk about quality and quality measures, are you thinking at the aggregate level or at the individual level? Because that will determine a lot about which way your contractor looks because I am in the midst of doing this for certain sectors right now and it is a radically different search engine when you go for individual measures versus those that are already contemplated to have an aggregated expression.
MS. WARD: What is an example of an aggregated expression?
DR. MOR: Pressure, also rate. Rate of such and such. Somebody has already thought about problems of the variance of the measure, the sample size needed to have it be somewhat stable, as opposed to the precision of measurement in one case, where that one case is very important clinically.
MS. COLTIN: I think it may need to be both because let's take the example, there is a new HEATUS measure called control of blood pressure. Well, that requires the longitudinal measurement within a given patient, but a roll up to a population rate of controls.
DR. MOR: Right. Exactly.
MS. COLTIN: So, most of these population-based rates start out with individual level measures of, yes, they had it or, no, they didn't in terms of a service.
DR. MOR: But my point, Kathy, is the literature is just replete with observations about individual measures and it is much more scarce about how those individual measures perform and behave at the aggregated level. That is all.
MS. WARD: Should the nursing home that has an ulcer rate, skin ulcer rate, of x be considered good or bad?
DR. MOR: Right. What does that mean? What does that rate mean?
MS. COLTIN: Or what does it tell you about other aspects of quality --
DR. MOR: Or that aspect itself in terms of variability, stability, those kinds of things. It is just a different way -- I find, at least, for me, thinking about it, and I know that the --
MS. COLTIN: That was not the way I was thinking of it. I was not thinking about how predictive one type of measure is of over another type of measure or overall from overall --
DR. MOR: At least in the worlds that I know it is going to have to be very clear to make directions to the contractor. Otherwise, it is an absolutely huge undertaking.
DR. IEZZONI: I was thinking for our piece that a contractor could look at OASIS defines function, how the NDS defines function, how, you know, maybe some private plans define function, how DNHIS(?) defines function, how it defines function for -- and kind of look at all the different definitions, look at how the ICIDH does it and kind of come of come up with a synthesis for us of where the differences are and what the issues are, self-report versus provider report, performance versus capability or whatever that, you know --
DR. MOR: With regard to MDS and OASIS and the home care setting, there exists a data set. Someone will have to tell HCFA, who will allow me to do something with it, that actually combines both sets of data in a very, very large data collection effort.
So, it would not be impossible to do a whole series of cross walking analysis but right now, HCFA --
DR. IEZZONI: HCFA won't --
DR. MOR: Well, I can do them, but it is just a question of whether I can tell anybody about it.
DR. IEZZONI: We will not have you do anything illegal with data. That would look very bad for us. We will not sanction that kind of behavior.
MS. WARD: Kathy, I would also hope -- and because you are chair, I am feeling confident that it would become very practical based in terms of our not saying this -- if the world looked like this, it would be great, but we are recommending something that not a single facility in the continuum of care would ever be able to afford to collect.
MS. COLTIN: And, in fact, I would encourage us to focus on short term small gains that fit in with some of the timeliness of other things that are happening, like, for instance, looking at the claim attachment and working with John's other committee through John as a, you know, intermediary, too, to say here is an opportunity. Can we make a recommendation around the claim attachment that might help with this? Or with Simon and Jeff, to say, you know, as you start thinking about defining some, you know, common content areas within an electronic patient record, think about idle times or something like that that we may think, you know, if we want to monitor blood pressure over time, shouldn't the record system tell us something about when and how the blood pressure reading was taken.
MS. WARD: Because I think that is the biggest criticism about the core data set is that it said this is what it ought to be but no one ever took it and figured out whether it is feasible to actually collect that stuff. Anyone who does data modeling will say I don't care if you have a core data set. You can't -- it is worthless to me until you can prove to me I can go collect it within my constraints. I think we have got to get away from that kind of NCVHS hypothetical sort of almost academic exercise.
DR. IEZZONI: That is why when Barbara has raised the issue about class, social class, I don't even join the argument because I think the feasibility issues are so huge. I think the function -- we still might have that same issue but I think it is going to be such a pressing kind of piece of information that payers and quality monitors are going to be demanding that people are going to begin to have to think about how to capture it.
MS. WARD: That would be the part that the contractor -- we would need to keep reorienting that we want to look at what is currently happening but to which we can attach a little bit morning, it is a meaningful activity.
DR. IEZZONI: Right. Exactly.
MS. COLTIN: It may be that we recommend our options to for more than one way that it could be done. I mean one of the things that came up around the lab results was that the national standard format, which is the Medicare professional services claims format, their equivalent of a HCFA 1500, basically, had fields on there for very specific tests for which they wanted lab results. There was a field for hematocrit and a field for erythropoietin and things like that. Whereas, what was recommended in the standard was the generic field called test results with a companion field, which would contain the T code that tells you which test result was in that other field. That opens up just tremendous flexibility for capturing that information, but it is one option for doing it.
So, there are different ways things can be done and one of the things we may want to do is, you know, in working with the other appropriate subcommittees, explore what the options are for collecting pieces of information so that we can make it practical. So, if you can't do it this way, you know, here are three different ways to figure out with the industry which way would work best for everyone.
DR. IEZZONI: We are done, I think.
MS. COLTIN: With regard to Item 2, I think we are done, which is the proposal for the post acute care work plan.
We are moving on now to --
[Multiple discussions.]
Did you have a chance to look at what I have given you?
DR. STARFIELD: Yes, I do and I have some comments on it.
MS. COLTIN: Why don't we give you just a couple of minutes to make your comments and see if they are in conflict with anything --
DR. STARFIELD: I guess we either have to decide whether we are interested in settings or interested in the continuum.
MS. COLTIN: I think we decided we were interested in the continuum.
DR. STARFIELD: I think that is great. So, if we are interested in the continuum, then it doesn't make sense to discuss this stuff by settings, which is what we did in the core data elements, which we may have to revisit because the core data elements is by settings in patients --
MS. COLTIN: Let me just recap for you what you missed. We had talked about taking the core data elements and trying to look at how to define them independent of settings so that if you looked at the functional status field, which is the one that there seemed to be the most interest in, right now different settings are defining it differently.
Is there a way to look at that field and define it in a way that it would work across settings? So that might be, you know, an example of what you are talking about and that lines up with what we were --
DR. STARFIELD: Okay. So, I gather we really didn't have to decide what was excluded or included because these are settings.
MS. COLTIN: Yes, but I think we were trying to not necessarily have to get into things like looking at these to say which is the emergency department data set, which has things that have to do with, you know, with whether the patient is conscious or unconscious or whether they are -- how their eyes look and, you know, I mean, there are some very detailed measurements that are unique to certain settings and that we were just going to basically take a look at the settings that we have been referring to as post acute care perhaps inappropriately, plus the acute hospitals because of the transition.
DR. STARFIELD: I guess I am not sure. Were any of the -- have you decided to exclude any of these? I mean, the subunits is fine, excluding them.
MS. COLTIN: Specifically excluding them, but I think --
DR. STARFIELD: I mean, I can see the subunits being --
MS. COLTIN: -- we can also look at subunits within a facility but rather ICUs and EDs and things like that, but rather to look at the whole --
DR. STARFIELD: So, that is the only one that is definitely excluded right now.
MS. COLTIN: In terms of outpatient and physician offices and things like that, I think that was something we wanted to throw open to a group. Right now, the core data elements are clearly pertinent to those settings. But whether we want to include that or not, we haven't included it when we were talking about post acute care. So, it is an open question I think.
DR. IEZZONI: I think for this functional status measure we do want to include it because that is where Don Lawlor, for example, from the CDC is saying we should have ICIDH codes on all outpatient encounter records.
MS. COLTIN: Certainly my preference from looking at clinical quality, it would be a huge gap not to look at outpatient care in doctors' offices or clinics and so forth. So, I am comfortable with that. I think it does leave us with having to go back and reframe a lot of the documents that we have created around the work plans of the subcommittee, the earlier documents where we talked about post acute care and I think we were really much more limited in what we were thinking about at that time in some of those documents.
So, it may mean, you know, going back and revisiting them to try to change the focus from post acute care to the continuum of care and to recognize these other settings as within the scope of the project.
DR. STARFIELD: Well, thank you for going over that for me.
MS. COLTIN: We rushed through because they had planes to catch and we weren't going to have a quorum. So, we were hurrying.
Okay. There are two other items, one of which is a very specific request that I got from Work Group on the CPR to consider whether we wanted to take advantage of -- they are proposing a two-day set of hearings at the end of March, I believe it is the 29th and 30th of March. And on the 30th, they had time open on their agenda for a panel and were interested in whether we might want to sponsor a panel on data quality as related to the electronic patient records, computer patient records.
Also if -- or even if not, whether we wanted to help craft some questions that they might include in the questions that they would send out to the people they invited for their panel that relate to quality and completeness of data within electronic medical records.
So, in keeping with what we have now defined as the scope of the work group's work, where we are talking about clinical quality now as opposed to access and acceptability, the electronic medical record becomes a really important source of information. So, this, I think, is an opportunity to take a look at what kinds of data quality issues come up around moving to an electronic environment. What kinds of data get lost, for instance, when you move to situations where there are stock phrases as opposed to, you know, customized information or -- any of you who use computerized records probably have some ideas about where the tradeoffs are.
There are certainly a lot of areas where quality gets better. There are a lot of areas where, you know, in my opinion I don't see them as being any more complete than paper records. They have a lot of the same deficiencies, things like recording information about pertinent negatives, as opposed to positives.
DR. IEZZONI: [Comment off microphone.]
MS. COLTIN: Maybe, but there are ways to make recommendations about -- you know, if there are check lists, do they set the defaults to "no" so that, in fact, you have the negative on record, that sort of thing.
DR. IEZZONI: Well, the question is can we get together some ideas for this March meeting?
MS. COLTIN: Yes. And I think we need to hear a little bit more from them about what they were hoping to get out of it as well.
MS. WARD: I really like the idea of having us set their time where we can ask a quality question so that it is not seen as sort of an add on or a separate -- if you are interested in quality, we will talk over here on Thursday, but if you are interested in just the regular old patient record, that --
MS. COLTIN: Well, what Simon and I talked about was possibly doing both, that, in fact, there might be a couple of key questions that we would want every panel to address, but there might be some very specific questions that the generalists that might be sent from vendors or whatever, to talk about other topics might not be able to address and where we might want to have some people who focus in that, but it would be a joint hearing.
DR. STARFIELD: Could you clarify the dates for me because Simon said something about hearings on the 16th and 17th and then on the 30th, there is a work group for Dan Friedman's effort?
MS. COLTIN: I don't know. I can try to resolve that and Simon thought he might --
[Multiple discussions.]
The dates that I got -- I got a call from Mike Fitzmaurice, who is the lead staff and it was March 29th and 30th that they were having hearings. The one that he was asking me about was the 30th of March. That I am clear on.
That is not to say that if we pass up the opportunity for the 30th of March, there might not also be an opportunity in May, but it will depend on how they are structuring those hearings; you know, what constituencies and what the topic areas are because it might not be the right people to discuss the issues that we would have discussed.
So, unfortunately, Simon was not going to come until 5:00. We thought we would be going until 5:30, but we are not even going to have a quorum. So, I don't have enough specifics. I think I can talk to him and maybe try to catch each of you tomorrow --
DR. IEZZONI: Let's do it by e-mail.
MS. COLTIN: Or do it by e-mail and try to get back to him. But, in general, how would people feel
about -- oh, there he is.
[Dr. Cohn enters meeting room.]
We are ahead of schedule and we were just talking about you.
DR. COHN: I almost didn't -- I almost went upstairs and thought I would come back here in half an hour, but I wanted to find out what you were doing.
MS. COLTIN: Good. Well, we were just talking about -- now, it is the 30th of March that we were talking about. That was the date Mike had given me. He said it was the 29th and 30th that you had the hearings.
DR. COHN: If you can give me just a second, I can pull out the date, as well as talk about the plan for a second. Actually, you are right. It is the 29th and 30th of March. So, I apologize. It is May 17th and 18th.
Should I just talk a little bit about what it is were are --
MS. COLTIN: Yes. Why don't you talk about what you are trying to accomplish with your hearings and where you think it might fit in.
DR. COHN: Okay. I apologize. I am just looking at Version 7 of our work plan. It is just about driving us crazy at this point.
Let me tell you about first that hearing that was in December and an issue that came up that we thought we needed to look at further and it had to do with the whole issue of data quality. As you know, the whole point of our Work Group on Computer-Based Patient Records had to do with the federal legislation.
Now, as we began to query the vendors, the public at large about the issues that we needed to be exploring and especially groups such as data warehouse groups and analytic types, such as MedStat and others, it became very clear to us that there was a whole issue of data quality that sort of runs through this issue because you can't get to uniform data unless you have some issue -- without having good quality data. In other words, you can do all the work you want to up front on uniform data standards, but if you don't at least take a look at what it is we need to do to assure the data that we are capturing is of also high quality, you don't get the comparable data or anything else we are all seeking.
So, we thought that that was worthy of some focus and we actually identified that as one of the focus areas that we wanted to begin to talk to people about. So, one of our focus areas is identifying and recommending standards for data quality related to patient medical record information and we are looking at data quality issues beginning with issues of initial capture, recording the data, communications data, translating, including the data transformation, recognizing that all of this is required for us to have good quality data and eventually have good quality to identify and measure quality,, which is I think where this work group comes into play.
Now, at our hearings in March we were going to get, as I said, a representative group of people, including groups that have to do with -- we had actually thought that we would begin to talk to some people about those issues, as well as perhaps more concretely the issue having to do with message format standards that contain patient medical record information and that we might add on some questions, as well as get some insight from people that are dealing with the data quality issue to also be part of some of the sessions.
We were thinking rather than -- we have all traditionally had hearings where we have got the vendors and we have got the thises and the thats all together sort of linearly to talk about things. We were trying to think of mixing groups up, maybe from standards groups, maybe some people who have quality concerns or data quality issues, some data warehouse people, you know, once again, sort of a mixture of people on each of the panels to perhaps go into this more exhaustively and discuss it.
We have two questions for this work group. Number one is assistance with framing the right questions for the people, as well as we thought -- two is you may have some suggestions on people that we ought to have come to testify and, thirdly, you might want to either participate, come -- I don't know whether you would want to -- you could certainly also cosponsor the hearings if you want to, but this is sort of short notice for that.
But I thought it made sense for us to have this discussion. A lot of this, I think, is -- I am reminded, Kathy, of your presentation to the committee, was it six or eight months ago, where you talked about the --
MS. COLTIN: Almost a year now. It was March, I think.
DR. COHN: Okay. But when you went through and talked about the various steps having to do with the data quality.
MS. COLTIN: Can I ask a couple of --
DR. COHN: You sure can. And you can tell that this is not well thought out and I am not working from a script here.
MS. COLTIN: So, maybe we can create answers to these questions as we go if you don't have them.
It is not clear to me. Most of the data quality issues that I spoke about related to administrative data rather than data that comes from electronic medical records. So, there are issues around data quality and administrative data where we have high hopes that should in the future the data contained in administrative records actually be a function of just transferring information that is captured in an electronic medical record into an administrative claims format.
There is this view that all those problems will go away because now you will have accurate diagnoses and complete information in making that transition. So, that is one set of questions is, you know, are we right or is that correct in thinking that once we move to electronic medical records as the source of administrative data, at least in some settings, that the quality of the administrative data will actually improve and that some of the problems that have been identified will go away.
The second thing that I see is that we know a lot about some of the inadequacies and problems in paper medical records, from a quality measurement standpoint, kinds of information that just isn't there, that you can't reliably get; information about counseling to the patients, what they were told or certain kinds of cognitive screening questions that are asked. It just isn't reliably recorded anticipatory guidance for kids.
We just found that we really can't get that information very well when we do medical record reviews. It is not reliably recorded in the medical record. Is the electronic medical record going to solve that problem or is that still going to be a problem in the electronic medical record? And are there ways to fix that, to try to draw attention to it in the design of the medical record to make sure that, you know, information of that type actually does get captured?
Another thing in terms of paper records that I see over and over again as an inadequacy -- and I have mentioned it before -- is pertinent negatives. You know, often what does get done is well recorded. What didn't get done, even if there was a clear reason for it, often doesn't get recorded. So, if you were looking at compliance with the guidelines and you expected something to happen but it didn't, there may be a very good reason why it didn't, but often you won't find that in the record.
So, you know, why something wasn't done or documenting that something wasn't found, wasn't present, you know, no review of systems -- often times you will see the things that were found. You won't see anything that documents that the rest was normal. You know, just make an assumption that if there is nothing there, it must have been normal. So, if you were looking for normal GYN exams or normal eye exam, you know, if they just wrote "ROS," you know, and there was nothing else --
DR. COHN: Negative.
MS. COLTIN: Negative. Is it that -- so, those are some of the things that come to my mind. Are those the kinds of things that you were thinking about or am I off base?
DR. COHN: No, I think that those are some of them. I mean, I think you have gotten a lot more specific. I think we are all aware of just saying we are going to computerize X and even have standards -- as I commented, I have created exquisite data models or I should -- not personally, but I have authorized the creation of wonderful data models where a great deal of standardization is in the models. But then you have to fill in the field and sometimes the data is of high quality and accurate and sometimes it isn't.
I don't think it is either a "yes" or "no" issue, but I think it is an issue that needs to be addressed as we talk about patient medical record information. So, I guess, I am saying that -- I think I am agreeing with what you are describing as some of the issues and the issues that need to be addressed and understood better, as well as see if there are solutions as we approach the whole issue of the standardization that maybe can take some of this into account so we deal with it because, clearly if we just go, gee, are we referring to standards, but we don't have any good data in our systems, that doesn't meet our needs. I don't think it meets your needs either.
DR. IEZZONI: I was just thinking about our transcription budget right now for our practice; $300,000. We have to cut $10,000 from our budget. We can cut $10,000 if each primary care doctor would dictate one line less in their record, you know, and, so, I think that when I hear people talking about completeness and so on and I see what it is like to care for patients now and I see what the costs of doing business are around having complete medical records, it is just hard for me to kind of figure out exactly what the solution is that people will be heading towards.
I also note -- and, Barbara, I think you might have participated in some of this research years ago that the research evidence on completeness of medical records is very difficult to document because you basically need to have a fly on the wall in the room to see what the doctor and the patient talked about and then compare that to what got recorded. So, there have been studies that have videotaped encounters. There have been studies that have audiotaped encounters and then gone back to look to see what was documented in the medical record and identified areas.
But from my review of the literature, there has only been maybe a handful of studies like that and they are quite old. So, it is hard -- Kathy, we talked about this last Friday when we had our phone call and I have been thinking about it since then as to who I might recommend who would be a good person to come and seek and it is not at all obvious to me who -- at least from my knowledge -- I mean, other people around the table might have a better sense of this as to who would be good to come to talk about data quality of electronic medical records or medical records in general.
DR. COHN: And be aware that we are really -- we have all described the name of the work group as somewhat of a misnomer because we are not talking about just electronic medical records. We are talking about lab data. We are talking about pharmacy data. We are talking about anything that is a patient medical record.
DR. IEZZONI: Well, some of the issues for lab and pharmacy, I can't even begin to comment on.
MS. WARD: For those states that are doing -- I mean, Clem could probably -- I could from what we are doing in terms of electronically trying to do laboratory reporting for the portable conditions that are library diagnosed -- we have proven that it is not only -- it costs less and it is more effective data. If you get it sooner, it is correct. When you don't have a piece of paper, I mean, there are isolated things that are going. I mean, that is probably one of the few where you can -- those of us who have now tested that idea of having laboratory data moved electronically have begun to prove that.
If you wait for the laboratory to call the physician, someone writes it down on a piece of paper, someone in the physician's office either faxes it to the health department or calls the health department, it takes a lot longer than when the laboratory gets the results and electronically sends it to the health department and it is more accurate.
The health department gets it in 24 hours rather than 72 to in some cases never showing up because the data is inaccurate because the laboratory will not send it electronically because the fields have to be filled in to send it electronically that says what is the patient's address. And they fill that in. They find out and send it because what happens with a piece of paper is they don't care whether all the items are filled in. They call it in and say, Joe Blow, whose doctor was in King County, has gonorrhea, but, in fact, the patient is not from King County. He is from Pierce County and the health department at Pierce County has to track down the patient and do the contract trade thing. That county never got the report because the piece of paper is still wandering through King County, trying to figure out where the patient was.
DR. STARFIELD: Yes. I mean, we showed the effect of this by comparing PKU screening and -- the mean number of days to get the patient record, 30 days in the U.S. It was of the order of four or five days in the other countries because of the centralized data systems they have.
MS. WARD: I think what you are also talking about, Lisa, isn't any different for a recorded, handwritten record on electronic ones, whether it is -- whether the person knows how to record what happened in the incident. If you could have someone watching and encounter, whether that person is recording electronically or on a piece of paper, whether they are actually recording what happened in the encounter.
DR. IEZZONI: Or whether they can afford to do the electronic --
MS. WARD: Aren't institutions that are implementing electronic medical records having to justify the cost?
DR. COHN: Certainly. I spend probably 30 percent of every year doing that.
MS. WARD: You must be proving a cost effectiveness to somebody.
DR. COHN: Oh, certainly.
MS. WARD: So, why are you implementing a medical record because it is going to be less expensive --
DR. IEZZONI: No, we are completely electronic. These transcriptions are into an electronic medical record.
DR. STARFIELD: Are you talking about inpatient?
DR. IEZZONI: No, we are talking about outpatient.
Our doctors can't type.
DR. STARFIELD: So, they are dictating.
DR. IEZZONI: They dictate.
[Multiple discussions.]
One of the things that we are talking about is an incentive for physician system -- you know, getting them a dollar. With doctors, sometimes that is all it takes, right?
[Multiple discussions.]
We have that, too, but you need to have dedicated machines that recognize individual -- we need to kind of come to closure, I think, about this particular meeting to see whether it is -- whether we can help or whether there is any synergy.
MS. WARD: The only thing that was really missing from what we were talking before you came in, I think we could -- I still like the idea of a joint meeting, giving you some questions. What we had moved onto was not data quality but data for quality.
[Multiple discussions.]
DR. COHN: And I hadn't seen your work plan before and I was quickly scanning that --
MS. WARD: It is a matter of whether that would push your group far beyond where you are.
DR. COHN: I think probably doing data for quality, which I think is a very important issue -- I keep saying, gee, we all seem to be running in different directions and we need to be getting back together on some of these issues. Maybe something that we do want to plan out -- that probably doesn't need to be done in six weeks from now.
MS. COLTIN: And I don't know that we could get our thoughts together in time --
DR. COHN: We had started planning on this -- as I said, this issue came up in December. The other piece that you are describing is a very appropriate fit and I would -- I think I speak for Jeff and myself when I say it would be very appropriate probably for after the June meeting. Is that what you are thinking about?
MS. COLTIN: That timing might work right because what we are proposing to do first is to make sure that we understand what the data are that we think are most critical to be able to measure clinical quality and, so, you know, it would be types of data, things like laboratory data, vital signs, things like that and then looking at the data sources and saying, you know, where is the best place to get this information right now. Is it available from some of the standard formats, the administrative formats or are these data elements -- like, for instance, could you get laboratory data from the standard claims attachment? Is there a claims attachment with an HL7 lab result?
Then you could use that as a vehicle right now and maybe it originates in an electronic patient record or maybe it originates directly at the lab. Who knows? But I don't think we are at the point yet of having, you know, said these are the data elements that we are most interested in and that we think really have to come from an electronic medical record, whether directly or indirectly and then to try to work through your group to say how do these fit into what you are recommending around standards for electronic medical record, particularly around content, as well as thinking about format, but more around content, I think, from our interest.
DR. COHN: You probably would have appreciated one of our speakers who was at the December meeting to talk about the issue of evidence-based terminology. What he was referring to was sort of akin to what you are describing is, in fact, some things within the medical record are important for evidence-based outcomes, quality measurement and others. Others don't matter. Probably, you know, if you describe eye tint in three ways versus 300, it probably isn't going to have a lot of implications for either outcomes or quality or elsewhere. So, you begin to move into some of the standards pieces, recognizing that some of these things have quality implications and, therefore need to be looking like this because of it versus others not, probably has a lot of significance.
MS. COLTIN: I think it would be helpful for us
-- to begin to finalize your work plan, for us to get a copy of it so that we can perhaps identify where we think the overlapping interests lie and think about maybe the May -- the period after June rather as a time to do something like that.
DR. COHN: Does that work with all of your timing?
DR. IEZZONI: We can't do anything more before that.
DR. COHN: That is the way I am sort of feeling, too. I really don't have a lot of energy right now.
DR. IEZZONI: None of us do.
DR. COHN: Can I ask one question then? As we begin to come up with some questions around data quality -- I guess I am looking at Kathy just because I know she will be able to talk on this -- whether you might be willing to critique some of that and suggest some other additions. I was wondering if anybody else feels that they want to venture in that area.
MS. COLTIN: I think everybody had an interest in asking the questions that you were thinking of asking and perhaps suggesting questions and we could do that by e-mail. If you just wanted to copy all of us with, you know, what you are intending to ask and we might suggest some additional questions.
DR. COHN: You might actually have some speakers on some of those particular areas. You might say, gee, I know X, Y and Z person and he said we have been very impressed, for example, with the MedStat groups that -- I mean, the things they have told us. They are not impressive with what they tell us, the results, but their experiences going to people who have data and even data that people think is pretty good, what they have had to do to make it good quality data. I think there is a lot of learning to that.
You may all have other sources that you can --
DR. IEZZONI: Our research colleagues have to do this all the time. It takes 95 -- even when you buy data from MedStat, to be quite honest with you, even once you buy it from sort of big warehousing groups, I mean, it -- I am sure Jonathan Wyner(?) would have a lot to say about that.
DR. COHN: As you see the questions, if there are people that would have something to say about these things, that would be great.
Okay. That is what we will do.
MS. COLTIN: Okay. So, you will e-mail us and we will reply individually, as opposed to as a group with suggestions --
DR. COHN: I think that would be great.
MS. COLTIN: And then we will think about where the possible intersections are after June. We will think about it before then, but we will think about planning something for after June.
DR. COHN: Yes, I think that that -- and we will have some e-mails and discussions about that.
Thank you.
MS. COLTIN: Our last agenda item actually is a good lead in to that and that was to think about whether we want to do something either in May -- we talked about possibly having a two-day meeting in May.
DR. IEZZONI: We need to wrap up the insular areas and the Medicaid managed care stuff in May.
MS. COLTIN: Do you think that will take both days?
DR. STARFIELD: We have two days in May?
DR. IEZZONI: We asked staff yesterday to poll people about it. We were going to do the usual kind of like day and a half, come in late in the day, you know, 10 o'clock in the morning start and then the full day and then maybe the morning the next day.
Didn't you get the fax that we were -- because we have to do the contract language. We have to do the final report. We have to do the insular areas.
MS. WARD: Yes, I think it is going to take that to do that.
DR. IEZZONI: Because it is going to be the final final task that we have and I am sure Sara Rosenbaum alone will take up, you know, several hours going through --
DR. STARFIELD: But we need to have stuff well ahead of time. I mean, that is the whole point is to get ahead of time so that we can minimize the impact of time in meetings.
MS. COLTIN: All right. So, then, if May is not an option, then there are two potential options around June, well, maybe three. But if we said we didn't want another meeting in June, working with the meeting we already have, there is an option of putting together a panel for the full Committee or there is an option of asking for enough subcommittee time, half a day or whatever, out of that meeting to have a panel.
What I was thinking about is bringing in people who have done a lot of work with trying to develop and create measures of clinical quality to talk about what some of the issues are around data limitations and the kinds of data they wish they had, but don't have.
DR. IEZZONI: I think apropos of the comment earlier about not wanting to marginalize quality, that that might be something that the full Committee should hear. I know Don had talked about maybe having a quality panel come and talk to the full Committee.
MS. COLTIN: My only concern with doing it that way is that when we put items on the full Committee agenda, the most you ever get is two hours.
DR. IEZZONI: Maybe it could be -- like I thought the way the things worked today with the international folks was really nice, that they presented in the morning and then there was more kind of opportunity in the afternoon --
[Multiple discussions.]
MS. COLTIN: -- I agree with you. We have so many of these panels with these superb people --
[Multiple discussions.]
DR. IEZZONI: You know, like the risk adjustment panel is just super.
Remember that I did promise David Takeuchi that we would have something as a breakout session in June about immigrant children.
DR. STARFIELD: Well, I did, on your instruction, talk to him this morning about thinking about the data issues. So, you really should try to get some feedback from him before you commit yourself.
DR. IEZZONI: But, you know, to be respectful of the kind of sense of obligation here, we need to at least factor that in until we get a sense on the data issues.
MS. COLTIN: I think we are going to have to talk about trying to strike a balance between time for the subcommittee and time for the work group because that is a subcommittee agenda, not a work group agenda; whereas, what I am proposing is a work group agenda.
I don't think it is at all unreasonable to expect the work group to be able to get two hours, to me, at a full Committee meeting. If that means that four hours have to be set aside out of every full Committee meeting, so you can at least have two for the subcommittee and two for the work group, I think that is fine, but I don't think that this work group can be hamstrung by the agenda of the subcommittee. It has to have its own independent concept.
DR. IEZZONI: This is a natural tension that was just built into the way that this was structured because there are only so many hours --
MS. COLTIN: But it may mean how the full Committee time gets sliced up into full Committee time versus subcommittee and work group time.
DR. IEZZONI: It is something that we are going to have to deal with at the Executive Committee, I think, because it is an issue certainly I think for Simon.
[Multiple discussions.]
DR. COHN: I am well aware of the problems we are all having. It is really a manpower issue. There are 16 of us. We all want to be everywhere.
DR. STARFIELD: And we are going to be faced with new members, who have to be brought up to --
MS. COLTIN: I think that in order to bring in some of the kinds of people who I think would be good speakers around, you know, measurements of clinical quality, we may have to pay to bring them in and we want to get the most out of it when they are there.
DR. IEZZONI: Lynnette will tell you we need to get a hold of that really quickly.
MS. ARAKI: I think your suggestion about bringing them in --
MS. COLTIN: So, if it is a two-day meeting, it could be that the subcommittee is on one of the days and the day that this panel has is the day the work group meets.
DR. IEZZONI: Although, let me just tell you, I was watching the body language of our international guests. They were tired. So, I think that having their presentation in the morning and then deferring their small group breakout until 3:30 is not fair to them as human beings.
So, it would be nice if we could think about the breakouts starting at 1:00.
DR. STARFIELD: What we will have left for the subcommittee in June? I mean, we will have done the Medicaid and the insular territories in May. Right? What is that in June for the subcommittee?
DR. IEZZONI: We have to present --
[Multiple discussions.]
We should be thinking about our work plan.
MS. ARAKI: You need to start formulating what it is you want so that I think at the next Executive Subcommittee, there should be some decisions made so that we can start -- the contractor process takes a lot of time. So, we need to -- I mean, if we are going to go by the task order --
DR. IEZZONI: We wanted to have a subcontractor for the functional status piece, to, two separate ones.
MS. ARAKI: I will mention that to Marjorie and Kathy because -- and Jim --
MS. COLTIN: And it may make sense to have the same contractor.
[Multiple discussions.]
MS. ARAKI: But the thing is that we need to start earmarking some plans and just sort of passing --
MS. COLTIN: The baton?
MS. ARAKI: Right and I want to make sure that I at least have -- I actually did factor in the possibility of contracts. But I need to --
DR. STARFIELD: The functional status and what is the other one?
MS. COLTIN: I will catch you up.
DR. STARFIELD: You did a lot in a half an hour.
DR. IEZZONI: We did because we had people leaving.
MS. COLTIN: Okay. So, we said we are going to defer to June. In terms of planning the panel itself, I presented an idea, which is to get people who have been trying to develop clinical quality measures or have developed them to talk about some of the limitations and various data sources and what they would like to have but don't, what some of the data quality issues are around the data that they depend on to develop those kinds of measures and so forth.
Does that sound like that fits everyone's interest? Okay. And that this would be people who are developing these kinds of measures across the continuum or they may be setting specific, but we will get representatives from different settings as well.
We heard David Zimmerman, but we didn't hear as much about what he would have liked to have, you know, as opposed to what he worked with that -- you know, from the MDF.
Okay. I think what I will try to do then is see if we can maybe steal an hour from the May meeting somewhere, sometime, to just talk about a straw proposal for that panel because we are going to have to get people lined up to come and talk and I would like to finalize that.
DR. IEZZONI: You should be lining them up now
MS. COLTIN: Then we are going to have to do it by e-mail basically. If you have ideas of people that you think would be good for a panel like that, but we are also going to have to come up with some questions, something to send them that says this is what we would like you to address. So, I think that what I will do is ask everybody to just send me what they think the questions are.
DR. IEZZONI: It would be good to have something on post acute care sites.
DR. STARFIELD: We had a panel on quality in the full committee about a year ago or something.
MS. COLTIN: We have had smatterings of people talking about quality issues at a number of meetings. I mean, we had data quality. We had Ann Page talk about QSMC(?), for instance. We had an hour of time and brought her in.
DR. STARFIELD: We had a whole panel on clinical quality, if I am not mistaken about a year ago, didn't we?
MS. COLTIN: It was around the data standards stuff.
DR. STARFIELD: Yes, it was around the data standards.
MS. COLTIN: It was much more focused, I think. Yes, we did have one because we had some people from NCQA, JCHO. But that is really one group, one constituency. I think it would be interesting to --
DR. STARFIELD: So, we should beyond that constituency.
MS. COLTIN: Yes, I think so.
MS. WARD: Particularly, I mean, we want to really, I think, focus on that continuum of care part.
MS. COLTIN: I think we need to get an update on what is going on with the Forum. I mean, John Eisenberg said he just came from a meeting of the Forum. You know, we haven't heard lately about what is going on with them. Obviously, something is going on with them now and maybe there will be something to report on that comes out of that meeting that is being held today.
So, I think, you know, we want to have some updates on what is going on generally but then we also want to have some topical focus discussion.
DR. STARFIELD: Of course, we don't know how broad that Forum is either. It may just be on the more narrow -- or we just don't know.
MS. COLTIN: No, we don't know.
DR. COHN: I would sort of comment from the CPR side, one of the things that we are looking at very hard we have described as fragmentation. I think the question is how well that is happening and --
MS. COLTIN: For those of you who are interested, on the JCHO Web site -- and I think it should be on the NCQA Web site as well -- there is a press release that announced AMAP(?), JCHO and NCQA announced plans to merge performance develop -- measure development efforts. They had announced this performance measurement coordinating council, but they have decided to go further than that and they have hired a staff director and they are actually going to merge the development effort so that, for instance, all the measures advisory panels that feed into HEATUS, they recognize that they are drawing on the same technical expertise and asking the same people to help them develop measures and why not pool this and jointly fund it and, you know, go to foundations together to get the money to fund the measurement development efforts.
I have a copy of it here. Maybe I can get it copied for all of you for tomorrow, but this is just the press release that talks about it. So, it is a move in the right direction and, you know, maybe something that we want to hear more about it.
Okay. I think we are adjourned.
[Whereupon, at 5:10 p.m., the work group meeting was adjourned.]